Provide the full DSM-5 diagnosis for the client. Remember, a full diagnosis should include the name of the disorder, ICD-10-CM code, specifiers, severity, and the Z codes (other conditions that may need clinical attention). Keep in mind a diagnosis covers the most recent 12 months.
Explain the diagnosis by matching the symptoms identified in the case to the specific criteria for the diagnosis.
Describe the assessment(s) you would use to validate the client’s diagnosis, clarify missing information, or track her progress.
Summarize how you would explain the diagnosis to the client.
Explain how you would engage the client in treatment, identifying potential cultural considerations related to substance use.
Describe your initial recommendations for the client’s treatment and explain why you would recommend MAT or ABT.
Identify specific resources to which you would refer the client. Explain why you would recommend these resources based on the client’s diagnosis and other identity characteristics (e.g., age, sex, gender, sexual orientation, class, ethnicity, religion, etc.).
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