The document outlines the key elements that should be included in an assessment report, including the client's details, the reason for and goal of the assessment, a summary of the client's history with their problem and prior treatment, the assessment process and tools used to evaluate the client, the diagnosis or identified issue, and the recommended treatment plan based on the diagnosis.
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ELEMENTS OF AN ASSESSMENT REPORT.docx
1. ELEMENTS OF AN ASSESSMENT REPORT
ο· Clientβs details
ο· The /Reason for/goal/purpose of assessment: Indicate the specific purpose for which
assessment was requested and by whom.
ο· A summary of essential details related to the history of the client, both before you were
the therapist (if relevant) as well as during your work with the client(s) including:
ο· Duration.How long you have met the client?
ο· What was the initial presenting problem? History of the problem, treatment history
(Counseling, psychiatric medication, other medical issues).
ο· Assessment process : Assessment tools and methods used and scoring interpretations.
(Making judgment).
ο· Diagnosis: What is your judgment of the issue (issues?)
ο· Treatment: What is your recommended way of supporting the client based on your
diagnosis?