Clinical Evaluation Portion of Case Study DSM Diagnosis
This is only a 2 page clinical evaluation which is the start to a full case study, being written
portion by portion.
The clinical evaluation should include:
Each case study must begin with an introduction to the client and their presenting problem.
Description of the client should include demographics (e.g., age, marital status,
race/ethnicity/nationality/immigration status, place of residence, living arrangements) and the
presenting problem for which they are seeking help. Who referred the client, couple, or family,
why they were referred, and whether the court mandated treatment should be also mentioned.
Prior psychological treatment, diagnosis, and history of psychiatric mediation use should also be
included in this section. The clinical evaluation begins with the psychosocial history, mental
status exam, results of any assessment tools used and concludes with a DSM diagnosis. The psychosocial history will vary somewhat based on whether this is an individual (child, adolescent
or adult), couple, or family but should include the following: history of the problem,
developmental, family and social history, and the medical or psychiatric history. It is easy to focus
only on the client’s problems but we want to be sure to include the client’s, couple’s or family’s
strengths. These strengths can be identified by the therapist, client, and/or their family members.
For example, what is working, what they do well and what you can build on in the course of
Given the rubric up above, this is the case and everything that should be included in these 2
pages, plus added information by you written as a clinical evaluation:
~Client Description +Psychosocial History-
• Adam Perez
• 31 years old
• Lives in an apartment in LA with his mom and younger brother.
• His parents are divorced. Has older sister who lives on her own. Doesn’t maintain too much
contact with his dad. Would explain his relationships with his family members as “Cold.”
• Reports being “rejected” from all relationships he’s had.
• No suicide history
• No psychiatric hospitalization
• Completed high school but dropped out of college
• Worked in sales and as a cook until laid off
• Loss of employment due to COVID-19
• Wants to better communication skills with his family members and “improve on weak spots”
• Feels “not good enough”, “not disciplined enough”, “disappointed with level of
• Wants to be better at “discussing certain things”
Referred by Sister Miriam who thought he could benefit from therapy.
Prior Psychological Treatment
• Diagnosed with ADHD in the second grade.
• Not taking medication for it
• Was in therapy from 2nd-12th grade for ADHD
• Reports his experience with therapy as positive
Mental status exam
• Does not have eye contact
• Thoughts are all over the place
• Jumps from one topic to another