Required Components:
Identifying Client Information—
Addresses all of the following components succinctly and with sound clinical language; client name (fictitious), age, sex/gender, race/ethnicity, marital status, referral source, reason for referral.
Presenting Problem—
Succinct clinical presentation focusing on the presenting complaint; the client’s perception of the problem with limited quotations; the counselor’s perception of the problem; presenting signs and/or symptoms; onset, duration, and intensity of symptoms.
DSM-5-TR Diagnosis(es)—Required Components Advanced Competency
Identifying Client Information
Addresses all of the following components succinctly and with sound clinical language; client name (fictitious), age, sex/gender, race/ethnicity, marital status, referral source, reason for referral.
5 Points
Presenting Problem Succinct clinical presentation focusing on the presenting complaint; the client’s perception of the problem with limited quotations; the counselor’s perception of the problem; presenting signs and/or symptoms; onset, duration, and intensity of symptoms.
5 Points
DSM-5-TR Diagnosis(es)
Diagnoses are listed in order of treatment priority and include relevant codes and name(s). Applicable v/z codes are addressed. Includes brief discussion and rationale for diagnoses. Succinct, clinical language is utilized.
5 Points
Medications (s)
Thoroughly addresses medication dosage, frequency, purpose, and prescribing authority. Succinct, clinical language is utilized.
5 Points
Treatment Goals and Plan Items
Provides 2-3 measurable, directional, and time specific goals are identified. Plan items are connected to each goal and address appropriate evidenced-based interventions and strategies to reduce symptoms, maladaptive behaviors and negative patterns and increase positive coping skills and wellness strategies. Succinct, clinical language is utilized.
5 Points
Adjunct Services
Thoroughly addresses all of the following components: collaborative agencies and key constituents in the client’s care, a plan to assist with coordination of care, identifies future adjunct services. Succinct, clinical language is utilized.
5 Points
Client Strengths
Identifies at 3 well-articulated client strengths and adequately integrates those strengths to into client progress and treatment. Succinct, clinical language is utilized.
5 Points
Discharge Criteria
Thoroughly addresses criteria for reduction/termination of services and discharge procedures Succinct language is utilized.
5 Points
Presentation/Professionalism
(5 Total Points Possible) Advanced Competency
Paper is organized using APA (7th ed.) formatted headers, is substantive, and succinct. Paper demonstrates strong use of clinical language and is clinically consistent throughout.
5 Points
Formatting
(5 Total Points Possible) Advanced Competency
The following components are formatted according to APA (7th ed.) guidelines: Cover page, references page, body of paper with no/minimal errors. Paper has no spelling and grammatical errors.
5 Points
Diagnoses are listed in order of treatment priority and include relevant codes and name(s). Applicable v/z codes are addressed. Includes brief discussion and rationale for diagnoses. Succinct, clinical language is utilized.
5 Points
Medications (s)
Thoroughly addresses medication dosage, frequency, purpose, and prescribing authority. Succinct, clinical language is utilized.
5 Points
Treatment Goals and Plan Items
Provides 2-3 measurable, directional, and time specific goals are identified. Plan items are connected to each goal and address appropriate evidenced-based interventions and strategies to reduce symptoms, maladaptive behaviors and negative patterns and increase positive coping skills and wellness strategies. Succinct, clinical language is utilized.
5 Points
Adjunct Services
Thoroughly addresses all of the following components: collaborative agencies and key constituents in the client’s care, a plan to assist with coordination of care, identifies future adjunct services. Succinct, clinical language is utilized.
5 Points
Client Strengths
Identifies at 3 well-articulated client strengths and adequately integrates those strengths to into client progress and treatment. Succinct, clinical language is utilized.
5 Points
Discharge Criteria
Thoroughly addresses criteria for reduction/termination of services and discharge procedures Succinct language is utilized.
5 Points
Presentation/Professionalism
(5 Total Points Possible) Advanced Competency
Paper is organized using APA (7th ed.) formatted headers, is substantive, and succinct. Paper demonstrates strong use of clinical language and is clinically consistent throughout.
5 Points
Formatting
(5 Total Points Possible) Advanced Competency
The following components are formatted according to APA (7th ed.) guidelines: Cover page, references page, body of paper with no/minimal errors. Paper has no spelling and grammatical errors.
5 Points