Diagnostic Assessment Sample

Client System:

  • Mya (she/her), 36, Burmese refugee, works two jobs

  • Carl (he/him), 35, Black U.S.-born veteran

  • Child: Rolan (AMAB), 10

Referral/Identified Client (IC):
School reports anxiety and increasing school avoidance; teacher notes “parents need to be more involved.” Carl reports he is involved and disagrees with that feedback.

Administrative notes:
Intake completed in English by Susan S.; interpreter was declined by front desk. Clinic intake form defaults to “Mother/Father”; no language-preference field.

I. Presenting Concerns & Initial Goals

  • Rolan (per caregiver report): Morning stomachaches/tearfulness before school, requests to stay home, worries about teacher/peer evaluation; impairment likely in attendance and participation (duration/severity TBD).

  • Family goals (initial): (1) Reduce school-day distress and absences; (2) Establish consistent morning routine; (3) Improve home–school communication; (4) Clarify if learning/attention issues are contributing.

II. Relevant History

  • Developmental/medical (Rolan): No known conditions provided; clarify sleep, appetite, growth, GI issues; coordinate with PCP to rule out medical contributors.

  • Educational: Obtain attendance, grades, behavior notes; clarify any prior evaluations (504/IEP, RTI supports).

  • Psychiatric history: No prior diagnoses or services reported for child or parents (to be confirmed).

  • Family/role demands: Mya works two jobs; Carl reports active involvement with child’s schooling.

III. Current Functioning

  • Routines: Morning transitions appear dysregulated; probable avoidance is reinforcing anxiety.

  • School: Anticipatory anxiety; possible performance or social worries; unknown peer climate.

  • Home: Parents motivated to help; communication with school perceived as strained.4) Mental Status Examination (updated)

  • Rolan (10): Appeared comfortable in session with caregivers present; cooperative; speech normal in rate/volume; mood “okay”; affect neutral-to-pleasant; thought process linear; no SI/HI/psychosis reported; orientation and attention grossly age-appropriate.

  • Mya (36): Appearance mildly disheveled; behavior cooperative; psychomotor WNL; speech soft, coherent; mood “tired/stressed”; affect constricted but appropriate; thought process goal-directed; no SI/HI/psychosis reported; insight/judgment intact for routine decisions.

  • Carl (35): Wearing camo “Blue Lives Matter” apparel; well groomed; cooperative; speech clear, normal rate/volume; mood “frustrated” when discussing school; affect appropriate; thought process linear; no SI/HI/psychosis reported; insight/judgment intact.

IV. Mental Status Examination

  • Rolan (10): Appeared comfortable in session with caregivers present; cooperative; speech normal in rate/volume; mood “okay”; affect neutral-to-pleasant; thought process linear; no SI/HI/psychosis reported; orientation and attention grossly age-appropriate.

  • Mya (36): Appearance mildly disheveled; behavior cooperative; psychomotor WNL; speech soft, coherent; mood “tired/stressed”; affect constricted but appropriate; thought process goal-directed; no SI/HI/psychosis reported; insight/judgment intact for routine decisions.

  • Carl (35): Wearing camo “Blue Lives Matter” apparel; well groomed; cooperative; speech clear, normal rate/volume; mood “frustrated” when discussing school; affect appropriate; thought process linear; no SI/HI/psychosis reported; insight/judgment intact.

V. Intake Interactional Observations

  • Family engagement: All three participated throughout intake; no escalation or raised voices observed; overall cooperative with evaluation tasks.

  • Parent–child fit: Rolan appeared at ease in proximity to both caregivers and responded to prompts without visible distress or withdrawal.

  • Turn-taking: Parents allowed space for Rolan to answer when addressed; clinician did not observe interrupting that impeded information gathering.

  • Affect/tone: Carl’s tone became firm when describing school concerns but remained redirectable; Mya spoke briefly (maybe 4-5 sentences) and appeared fatigued; Rolan’s affect stayed neutral-to-pleasant.

  • Nonverbal: Postures open/forward; no overt agitation noted; eye contact within expected range for age/adults.

  • Process impact: Presentation (Mya disheveled; Carl’s stated frustration; Rolan comfortable) did not impede rapport; adequate conditions for baseline assessment were present.

  • Safety/behavior: No aggression, threats, or acute risk behaviors observed during intake.

VI. Notes

  • Unable to complete intake due to Mya and Carl getting into negative interaction cycle about Rolan being a ‘fag.’