Part 1 Assess the Client
You are seeing a client for the first time. This is called an initial assessment. Use FIDO to assess for symptoms (#1-5) below. Use open-ended questions to assess for other considerations, known as Z codes (#6-10). Copy and paste the list below. Write 1-2 questions for each item. The first and sixth are samples and have been done for you.
1) Sleep In a week, how many days do you have trouble falling asleep? When did you first begin having trouble staying asleep?
2) Mood
3) Concentration
4) Appetite
5) Fatigue
6) Relationships When did you and your partner first start experiencing communication problems? On a scale of 1-10, 1 being very mild and 10 being very extreme, how intense would a typical argument be?
7) Education/Occupation
8) Medical check up
9) Finances
10) Religious/Spiritual Beliefs
Part 2 Practice Writing a Diagnosis
Use your DSM-5. First, choose any disorder. Next, write the formal diagnosis including the code, name, specifiers, and severity. You can freely choose the specifiers and severity levels. If you chose a disorder that does not have specifiers and/or severity, then you do not have to include them. Last, write a brief explanation on what the diagnosis means.
F32.0 Major Depressive Disorder, Single Episode, Mild, with anxious distress
If a client is diagnosed with F32.0 MDD, it means that s/he meets five to six criterion. These symptoms lasted a minimum span of two weeks. The client has reported feeling this bout of depression once in his/her life. While depressed mood is the primary focus of attention, this client also demonstrates anxiety about feeling sadness
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