Contents of an Assessment
nPresenting Problems identified by client
nMedical and Psychiatric History
nCultural Aspects identified by client and/or noted by clinician
nLanguage/Interpreter Needs
nSocial History
n
nMental Status Exam
nMedical Necessity Statement
nPreliminary (Initial)  Plan
nOther information you or the client thinks is important nFive-Axis DSM IV Diagnosis
n
n