Assessment, Diagnosis & Treatment Planning

Biological/medical, psychological, social/environmental, and spiritual/cultural factors integrated to understand the whole client in context.

To gather comprehensive, multidimensional data that informs diagnosis, treatment planning, and an understanding of the client's strengths and needs.

Data obtained from sources other than the client—family, prior records, other providers, schools—used to corroborate and enrich the clinical picture.

Generally before contacting outside sources; the client must give informed, often written, consent except in emergencies or where law permits/requires disclosure.

They reveal past diagnoses, treatments tried, response patterns, hospitalizations, and risk history, improving accuracy and continuity of care.

Subjective data are the client's self-reported experiences and feelings; objective data are observable, measurable findings such as behavior, appearance, and test results.