PLEASE READ CAREFULLY Two Separate Assignments in One

Case Development

Information to collect when conducting an initial interview or include when developing a sample case. This information would be gather doing the assessment phase. The guide was gather from http://www.become-an-effective-psychotherapist.com/Case-Presentation.html on 8/27/17

1. Demographics

Demographics include the client’s name, age, gender, relationship status, ethnicity, occupation, length of employment, age and gender of any children.

Example: Mary T. is a 25 year old married bi-racial female who has worked for City Savings and Loan as a teller for the last 2 years. She has been married to her husband for 4 years. They have no children and no previous marriages.

2. Presenting problem

The presenting problem is the reason why the person is receiving your services. The presenting problem can also be called the client’s chief complaint.

Example: Mary presents with multiple concerns related to an unfulfilling marriage, potential loss of employment, and concerns over her husband’s gambling.

3. Goal

Clients come to therapists to accomplish something. I think it is a good idea to find out what the client’s goal is. What do they want to get from your agency?

Example: Mary would like to first focus on concerns related to her husband’s gambling. Mary states that her husband told her last week that he is approximately $45,000 in debt. Mary is also worried about her job security.

4. Legal/ethical

This is a one of the most critical categories. Not addressing your legal and ethical responsibilities can be legal problems for you.

· You must indicate your status as an intern, if this is the case. · You must provide the name of your supervisor. · You must provide a written Informed Consent that usually includes information about the limits of confidentiality, your responsibilities in reporting abuse, your fee, your cancellation policies, and what the client should do if an after-hours clinical emergency happens. · Provide proper HIPAA notification, if you or your office is considered a “covered entity.” · If seeing a couple, it is always a good idea to discuss your “secrets” policy.

Make sure you know what your legal and ethical responsibilities are at all times. If you have any questions, please ask your supervisor or someone licensed in your field of study.

Generally, your legal and ethical responsibilities include:

Example: Mary signed the Informed Consent. She was notified of my status as an intern and the name of my supervisor. She was verbally informed of the limits of confidentiality, cancellation policy, and office fees. Mary signed the Acknowledgment of HIPAA Guidelines form.

5. Crisis/safety

Is the client in crisis? If so, describe the type and severity of the crisis and your interventions to address this concern. You must be exact.

Example: While her situation is difficult, Mary does not appear to be in crisis at this time. She denied any thoughts or feelings related to self harm. She denied any past history of self harm. There are no reporting responsibilities present. She seems to have an active and extended support system.

6. Diversity

What are the differences between you and the client? These differences can be about age, gender, education, socioeconomic status, sexual orientation, marital status, religion, stage of life, and should be noted.

The concern is whether or not these differences pose a difficulty for the helper to remain objective and focused on the client’s concerns. If the differences between the client and therapist are too great for the helper, it should be noted how the helper will handle this problem.

Example: There are some differences between Mary and myself. While we are of the same gender, she is married and I am not. Mary is of a different ethnicity than I am and she is a few years younger than I. There may also be some differences in our educational background, as well. I do not feel these differences will impede our working together. If I felt otherwise I would discuss my concerns with Mary to see if she had any similar concerns. Secondarily, I would seek consultation from my supervisor or a clinician skilled in working with someone from her culture. If the differences between us were too great and I was not of optimal service to my client, I would provide her with an appropriate referral.

It is a good idea to state that despite the differences between you and the client you feel confident you can be of service. If the differences were too great you should discuss your limitations with your supervisor and get consultation from a clinician of more similar backgrounds. Or you can refer the client to a therapist with more similar demographics to the client than you have.

7. Assessment

Your assessment is your impression of the client based on the assessment questions you asked.

Example: Mary is devoted to her husband and family, but is clearly struggling with their financial difficulties. She complains about increased anxiety, decreased sleep and some disruption in concentration. She notes a change in mood as she is “worried all the time” and finds herself crying when she feels hopeless. Mary does not describe herself as a person who worries a lot. Her acute symptoms seem particular to her husband disclosing the extent of his debts. She states her appetite is stable and has not experienced any recent gain or loss of weight. She is oriented to person, place and time. Thinking is linear and her memory appears good. Affect matches content. She states her performance at work is affected by her personal worries, but there is no current disciplinary action against her. She denies any suicidal or homicidal ideations or actions in the past or present. She states a social use of alcohol. She apparently has a strong support system which includes a large extended family and strong ties to her church community. She states her husband is generally supportive, they are effective parents, but has been less available due to his own worries. He has been avoiding her.