Inhoudsopgave
1. Diagnostssh rapport..........................................................................................................................3
Personalia..........................................................................................................................................3
Aanmelding........................................................................................................................................3
Formulieren...................................................................................................................................3
Algemene indruk................................................................................................................................3
Inventarisate van de klashten...........................................................................................................4
Klashten.............................................................................................................................................5
Hulpvragen........................................................................................................................................5
Onderzoek.........................................................................................................................................5
Cliënt lijdt aan:...............................................................................................................................5
Klashten worden in stand gehouden door:....................................................................................6
Lijst van hypothesen..........................................................................................................................7
Testresultaten....................................................................................................................................7
Klashtenlijst SCL-90........................................................................................................................7
NPV-2.............................................................................................................................................7
Hypothesetoetsing.............................................................................................................................9
Differentaaldiagnostek.................................................................................................................9
Conslusie (Totaalbeeld).....................................................................................................................9
Plan van aanpak.................................................................................................................................9
Lijst van mogelijkheden om dit probleem aan te pakken............................................................10
Vergelijking van de belangrijkste mogelijkheden.........................................................................10
Tabel verwasht nut......................................................................................................................10
Conslusie......................................................................................................................................11
Advies..............................................................................................................................................11
Afspraken.....................................................................................................................................11
Doorverwijzing.............................................................................................................................11
DSM-5 of ICD-10 diagnose...............................................................................................................11
Geldigheidstermijn en ondertekening.............................................................................................11
Bijlagen............................................................................................................................................12
Bronvermelding...............................................................................................................................12
2. Refesteverslag................................................................................................................................13
Trainingsdagen................................................................................................................................13
Inzisht..............................................................................................................................................13
Mijn eigen kwaliteiten.....................................................................................................................13
1
, Toets uitslag.....................................................................................................................................14
Literatuurlijst.......................................................................................................................................15
Bijlage 1. Informed sonsent en biografsshe vragenlijst......................................................................16
Bijlage 2. SCL-90 en NPV-2...................................................................................................................22
2
, 1. Diagnostisch rapport
Personalia
Namen van de cliënt: Martin de Groot
Geboortedata: 26-06-1968
Adres:
Telefoon:
Mobiele nummer:
Emailadres:
Aanmeldingsdatum: 09-05-2018
Aangemeld door: Zelf
Verwijzer:
Contactgegevens verwijzer:
Reden van verwijzing: Depressie, lusteloosheid, paniekaanvallen
Opdrachtgever: Zelf
Aanmelding
Cliënt meldt zich aan vanwege depressieve gevoelens, lusteloosheid en paniekaanvallen.
Hij heeft weinig zin en motivatie om te werken en heeft geen zin meer in seks met zijn
partner.
Algemene indruk
De cliënt zit er netjes en goed verzorgd uit, kleed zich naar leeftijd. Geeft de indruk een
kantoorbaan te hebben, maar heeft ook een sportief gebouwde fysiek. Heeft een stille
houding, beweegt nauwelijks tijdens het gesprek en de gezichtsuitdrukking is neutraal, toont
weinig emoties, maakt weinig oogcontact. De cliënt valt stil wanneer er onderwerpen aan bod
3
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