Start with what brought the client in.
Describe why the client is seeking treatment, with specific symptoms and examples of how daily functioning is affected.
Course 1 · Diagnostic Assessment
Know what to include in your assessment.
Work through a diagnostic assessment from the presenting problem to treatment recommendations. Learn how to explain your findings and the reasons for your clinical decisions.
$37Self-paced course · lifetime access · 30-day guarantee
Presenting concernPersistent worry, sleep disruption, and difficulty concentrating.
Functional impactWork deadlines missed; withdrawing from friends; sleeping 4 to 5 hours.
DiagnosisF41.1 Generalized Anxiety Disorder, Moderate
Starting measureGAD-7: 16
Clinical directionOutpatient psychotherapy with measurable progress monitoring.
Course roleEstablishes
Is this a good fit?
This training is for…
Therapists who write diagnostic assessments and want more guidance on what to include and how to explain their findings.
Study at your own pace in Mini Course Generator. Download the PDFs from Google Drive to use alongside the lessons.
- You're writing assessments for the first time or want a refresher.
- You collect a thorough history but feel less certain about the formulation.
- You want to explain the diagnosis and need for treatment more clearly.
- You supervise clinicians and want specific examples for documentation feedback.
An assessment example
Explain how you reached your clinical conclusions.
Scroll through this shortened example to see how assessment findings inform the diagnosis and treatment recommendations.
Consider the relevant history.
Organize the client's history by domain. Use the formulation section to explain how that history relates to the current presentation.
Record what was observed and what was assessed.
The 11-domain MSE and risk findings make the clinical picture more complete. The course also separates routine monitoring from active reassessment.
Explain the diagnosis and your reasoning.
Explain the diagnosis and relevant differentials. Consider how strengths and protective factors may support treatment, and how motivation or barriers may affect progress.
Explain why you recommend this treatment.
Explain the recommended treatment and level of care. Include coordination needs and prognosis, with discharge planning begun at intake.
Use the findings to develop the treatment plan.
The symptoms and functional impairment documented at intake help you select treatment goals and establish a baseline for measuring progress.
Presenting problemEight months of excessive worry, poor sleep, tension, and difficulty concentrating.
Functional impactMissed deadlines, social withdrawal, and reduced daily follow-through.
MSE and riskAnxious mood; congruent affect; organized thought process; no acute safety concern identified.
FormulationF41.1 Generalized Anxiety Disorder, Moderate. Panic Disorder ruled out.
Rationale for careOutpatient psychotherapy is appropriate, with progress monitored against baseline.
Baseline for planningGAD-7 baseline 16. Treatment target and interventions can now respond to identified impairment.
The review test
Could another clinician follow the thinking?
Use these questions to review whether your assessment explains the diagnosis and your recommendations.
Why did treatment begin?
Symptoms and functional impairment establish the need for care.
How was the diagnosis reached?
The formulation connects reported history, observation, diagnostic criteria, and differentials.
Why does this level of care fit?
Treatment recommendations and medical necessity make the rationale explicit.
What should the plan address next?
Use the assessment findings and baseline measures when choosing goals. Consider the client's strengths and barriers when planning treatment.
Inside the course
You'll learn…
You'll study worked examples and practice writing each section. Later lessons use the findings from earlier parts of the assessment.
Presenting problem
Record identifying and referral information, then describe the clinical concern in enough detail to guide the assessment.
Biopsychosocial history
Organize the relevant history domains while keeping formulation and recommendations in their proper place.
Mental status examination
Use the 11-domain structure to document clinical observations and assessed mental status.
Risk assessment
Document current and historical risk alongside protective factors. Use monitoring language that matches the clinical situation.
Clinical formulation
Explain how the symptoms and impairment support the diagnosis, including relevant differentials. Consider strengths and motivation alongside barriers to treatment.
Medical necessity and prognosis
Explain your treatment recommendations and the rationale for care. Address coordination needs and discharge planning, with a prognosis supported by your findings.
Telehealth documentation
Cover the ten elements the course uses for telehealth records, including modality and place-of-service details.
Complex presentations
Apply the framework to multiple diagnoses, re-evaluation, high-risk situations, and adolescent assessment.
A look at the actual workbook
See what you'll work with.
These are pages from the Diagnostic Assessment Workbook PDF included with this course. Select a page to take a closer look.
Work with it
Handouts included
Use the completed examples to compare your responses, then review your assessment with the audit checklist.
- Diagnostic Assessment WorkbookWriting exercises and an answer key.
- Diagnostic Assessment templateA structure to reference while drafting your assessment.
- Diagnostic Assessment audit checklistQuestions to help you review the completed document.
Complex presentations
Assess clients with more complex needs.
The bonus material addresses more complex presentations and changes in risk. It also includes an example of adolescent assessment.
More than one diagnosis
Organize concurrent symptoms and differentials without losing the primary clinical argument.
High-acuity and re-evaluation
Document changes in presentation and explain how current risk findings affect your recommendations.
Adolescent assessment
Apply the framework to developmentally specific history and presentation.
Choose what fits
Start with the assessment, or learn the whole record.
Choose this course if you'd like help with intake documentation. The bundle also includes Treatment Plans, SOAP Notes, and Case Consults, Summaries & Discharges.
Write it Right: Diagnostic Assessment
Get help with your next assessment.
Work through the examples and compare them with your own assessment. Which section do you feel least certain about writing?