Clinical Summary:

includes the following pieces of information: Clinical formulation of cause of client’s mental health symptoms, prognosis, and likely consequences of the symptoms; How client meets criteria for the diagnosis (including symptoms, duration and functional impairment); Analysis of strengths, cultural influences, life situations, relationships, health concerns and how the diagnosis interacts/impacts with client’s life; Explain rule outs, other provisional diagnoses and why alternative diagnoses that were considered and ruled out