Clinical Formulation Summary:
Using DSM 5: Primary Diagnoses1: Major Depressive Disorder
Using DSM V
Primary Diagnoses:
Prioritized Problem List
Axis I
Major Depressive Disorder 296.20-296.36
1
Coping with grief (the loss of her son)
Axis II
None
2
Managing her anger
Axis III
None
3
Lack of sleep
Problem # ___Coping with grief_____
#
Overall Goals
#
Objectives
Services to Address Goals and Objectives
(Who is responsible for this task)
1
Janet will increase her understanding of grief and how to cope.
1
Janet will verbalize at least 1 stage of grief four times a week for one week.
Client
2
Janet will be less isolated.
2
Janet will initiate two or more social contacts three times a week for one week
Client
Problem # __Anger Management____
#
Overall Goals
#
Objectives
Services to Address Goals and Objectives
(Who is responsible for this task)
1
Janet will learn ways to communicate verbally when angry.
1
Janet will verbalize at least 3 anger skills to her therapist two times a week.
Therapist and Client
2
Janet will learn positive anger management skills.
2
Janet will attend two therapy sessions per week.
Client
Problem # ___Lack of Sleep_____
#
Overall Goals
#
Objectives
Services to Address Goals and Objectives
(Who is responsible for this task)
1
Janet will get more sleep.
1
Janet will report at least 6 hours of restful sleep each day for a week.
Client
2
Janet will practice relaxation.
2
Janet will do 2 mindfulness exercises each morning, such as yoga and meditation.
Client
Client signature _____________________________________________
Therapist signature____________________________________________