Do I have to formulate a diagnosis?
You are not expected to formulate a full diagnosis. What you can do, is to make some suggestions and recommendations to points towards a “tentative diagnosis”, that is a preliminary hypothesis of a diagnosis. However, remember to state what kind of areas are to be explored and what kind of information you need to collect in order to confirm your tentative diagnosis.
You can use the DSM-V to help you guide through this process. However, remember that the DSM-V should not be used as a prescriptive box ticking tool for making a diagnosis.
How do I best extract the information from the clinical case?
There are several tools you can use to extract, categorise, analyse, and interpret the information from a clinical case. Some of these, such as the Five Ps model combined with the biopsychosocial model for clinical formulation, are available in the slides (models in clinical psychology file)