CASE PRESENTATION FORM
| Counselor’s Name: | Date: | ||
| Client Session#: | |||
| Counseling Setting: | |||
| Client Identities (e.g. youngest sister, individual client): | |||
| Client’s Initials and Role (e.g. GL = mom, FL = dad): | |||
| Race or Ethnicity: | Sex Assignment: | Age: | |
Background Information
Demographic background information (e.g., academic level, employment status, family constellation information, other information relevant to the presenting problem).
Presenting Problem
Why did the client enter counseling (this is the client’s or referring person’s narrative of the rationale for seeking counseling)? How long have the symptoms been present, what is their intensity, etc. (i.e., a mini Mental Status Exam)? What are the initial client goals (these will be used to create a working treatment plan)?
Subjective Observations and Case Conceptualization
What is your initial clinical impression, based on your developing theoretical orientation, of the client and his or her presenting problem(s)? How do you intend to incorporate your theoretical approach(es) to support this client?
Narrative Summary
Describe your view of the client’s problem? What are the relevant theoretical themes you noticed (e.g. types of self-talk, behaviors, emotional states/qualities)? What are the client’s barriers to growth and coping skills; what are the client’s areas in need of additional development/improvement? What is the etiology of the client’s present psychological capacity or incapacity?
Family Diagram
Provide a three generation genogram, family map, structural diagram, or other visual representation of the client’s familial constellation.
DSM-5 Diagnosis
Mental disorders, medical disorders, and other conditions that may be the focus of clinical attention (ICD-9 V codes and ICD-10 Z codes, etc.).
Select a Symptom Measure from Section III of the DSM-5 (begins on page 733)
The selected measure must be client-appropriate.
Examples:
- Level 1 Cross-Cutting Symptom Measures
- Level 2 Cross-Cutting Symptom Measures
- Clinician-Related Dimensions of Psychosis Symptom Severity
- WHODAS 2.0 Scoring
- Cultural Formulation Interview
Treatment Planning
- Counseling Goals (3 total):
- Short-term Objectives (2 per goal):
- Therapeutic Interventions
What evidence-based approaches do you intended to use, have used, or are using? Describe their intended purpose, current impact, or result.
Multicultural Considerations
Discuss any perceived multicultural struggles or considerations, including a plan of how you intend to address them, as well as implication on your current and future practice?
Ethical and Legal Considerations
Discuss potential ethical and legal issues, as well as the impact they may have on the client, the session, and the overall outcome of the treatment plan. Do you have ethical of legal concerns related to the diagnosis or diagnostic process (e.g. Are you legally able to diagnose in your state? Is diagnosis accurate or has it been enhanced for reimbursement purposes?, etc.)? What was done to address these concerns or issues?
Plans for the Next Session
What are your intentions for the next and future sessions? What issues and concerns must be explored with more depth?
Feedback
What feedback would you like? What areas would you like to develop further? How can we support your continued growth?