Assess and diagnose:
A crucial objective is to conduct a thorough assessment to gain a comprehensive understanding of the client’s psychological and emotional state. This involves gathering information about their presenting concerns, personal history, and any relevant factors contributing to their current difficulties. A precise diagnosis, when applicable, helps guide treatment planning and interventions. Disclose any history of substance use that may contribute to the presenting problems and complicate therapy. Provide behavioral, emotional, and attitudinal information toward an assessment of specifiers relevant to a DSM diagnosis, the efficacy of treatment, and the nature of the therapy relationship. Your counselor will work with you to assess for any issues of age,
gender, or culture that could help explain your currently defined “problems, symptoms, and behaviors” and factors that could offer a better understanding of your circumstances.
This is important to remember:
In order for me to file claims with your insurance and get reimbursed or credit toward your deductible, services must meet the requirement for medical necessity, and your current problems have to be causing mild, moderate, or severe impact on your daily functioning in one or more of the following life domains: social, educational/academic, occupational, relationships. I have to provide a diagnosis, adhere to a treatment plan, track your progress, and measure the outcomes of therapy in order to justify the services I am providing to you.