The paper should be divided into three sections that are clearly labeled with the following headings:

1. Overview of Case, i.e. Client/Case Description, History: In this section, you need to provide a summarized overview of the case (including history, i.e. 15 year or otherwise stated), which should include a client/case description and history. You should include enough detail so that I/reader can fully understand the case/client without having read the chapter. The goal of this section is to provide an ACCURATE description of the case/client.

2. Case Conceptualization & Provisional 5-Axial Diagnosis: Provide a brief expository overview of the case/client and conceptualize it within the confines of the clinical diagnosis. This section should also include a Provisional 5-Axial Diagnosis in the following format:

Axis I: Clinical Disorders or Other Conditions That May Be a Focus of Clinical Attention Example: Axis I: 309.81 PTSD

Axis II: Personality Disorders/Mental Retardation
Example: Axis II: 318.1 Severe Mental Retardation or
Example: Axis II: Antisocial Personality Disorder

Axis III: General Medical Conditions
Example: Axis III: R/O Anorexia Nervosa
Example: Axis III: Hypothyroidism

Axis IV: Psychosocial and Environmental Problems (choose from the following categories)
Problems with primary support Group
Problems related to the social environment
Educational problems
Occupational problems
Housing problems
Economic problems
Problems with access to health care services
Problems related to interaction with the legal system
Other psychosocial and environmental problems

Example: Axis IV: Primary Support, Educational, Occupational

Axis V: Global Assessment of Functioning
Your report or judgment of the individual’s overall level of functioning (be advised that in order for the client to meet medical necessity for treatment, the GAF must be 50 or below).

Example: Axis V: GAF = 45

This section should be formatted to include a 5-axial diagnosis AND a paragraph explaining how or why you chose each of the diagnoses on each axis (provide support for your findings).

3. Treatment Plan: This portion of the paper should provide details of the most appropriate treatment plan, given the client’s/patient’s diagnosis. You may need to research treatment plans via the internet or other research based mediums (psychological journals) and only include those treatments that have been established as Empirically Validated Treatments (EVTs) or Evidenced Based Treatments (EBTs). Make sure you include enough information so that I can see that you clearly understand how the treatment plan applies to the client’s diagnosis.