Case Presentation

COUC 694

Date of Initial Assessment:

PSEUDO Name (DO NOT use actual client’s real name):

Age:

Gender:

Sexual Orientation:

Race & Ethnicity:

Marital Status:

Employment Status:

Part I – Intake Information – 1-2 pages

Reason for Referral/Presenting Problem

In this section, offer the referral status (i.e., self-referred, school referral, court-ordered) and provide the initial reason for the referral. This may be a triggering event such as a divorce, death, pandemic, loss of employment, bullying, or client reported increase in signs, symptoms, impaired functioning, etc. Ideally, offering direct quotes on how the client describes the reason. This is one short paragraph in length. To protect the confidentiality of your client, please refer to them by a pseudo name in your case presentation. This section should include a statement indicating that you reviewed confidentiality and the limitations therein.

Confidentiality

This section should include a statement indicating that you reviewed confidentiality and the limitations therein.

Source of Information

Provide the source and manner in which data was obtained in the preparation of this report. This includes both formal and informal assessments in the summary as well as throughout the case presentation as necessary to support your conclusions. A semi-structured interview is necessary in this section, but you should also include a battery of formal and other assessments (e.g., DSM-5 cross-cutting measures, GAD-7, PHQ-9, PCL-5, etc.).

Part II: Assessment - 5-8 pages

Offer clinically relevant background information on the client. Write this out in paragraph format – no bullet points. The section should include the following in this order:

Observational Data/Mental Status Exam

This section should include all components of the Mental Status Exam, including observations, mood, speech, affect, cognition, perception, thoughts, behavior, insight, and judgment.

Psychometric Assessment

This section should include which, if any, assessments, inventories, or psychological scales were used to assess the client along with their scores and results.

Biological Assessment

· Demographic Information: age, gender, sexual orientation, ethnicity, marital status, children, etc.

· Sleep

· Diet

· Exercise

· Medical History

· Medication – include the reason for the medication.

· Other pertinent information (this could include history of developmental milestones, sexual adjustment, pornography use, menstrual cycle for women, number of pregnancies/births, fertility issues, testosterone levels for men, etc.)

Psychological Assessment

· Historical assessment – including whether the client has been to counseling in the past, any psychiatric hospitalizations, and any previous mental health diagnoses.

· Addiction Screening, including substance use history: Description of client’s alcohol/drug use, patterns of use, and last use; as well as how often client uses and how much.

· Risk Assessment – include how you assessed the client’s risk.

· Family Mental Health History

· Piaget’s Theory of Cognitive Development

Social Assessment

· Cultural Factors - Does the client have any factors such as acculturation, discrimination, etc. that impact the client and may be source of signs, symptoms? How would the client explain the problem from their cultural lens?

· Family of Origin - identifying information about the client, parents, and siblings (i.e., ages, occupations, etc.). Client’s perception of the home environment and relationships within the family. Critical family incidents may be included.

· Current Living Arrangements

· Academic History - Description of pertinent information in relation to educational background including academic achievement, school instances that were significant for understanding the individual and the client’s attitude toward education. Any assessment information would be helpful.

· Occupational History: A description of the client’s vocational history. Emphasis should be placed on current occupational functioning, history of work problems and reason for change. Quality of work and satisfaction and interests.

· Erikson’s Psychosocial Stages – what stage is the client currently in and what stage should the client developmentally be in according to Erikson’s theory?

· Current Social Support

Spiritual Assessment

· Spiritual/Religious History

· Present Spiritual/Religious Beliefs - Does client believe in God? Attend church? What role does religious affiliation play in the client’s life? Are spiritual resources or issues important to client? How does client describe God? What is the state of the client’s spiritual awareness?

· Fowler’s Stages of Faith Development – What stage is the client currently in?

· Integration Assessment – Did you assess whether the client would like their spiritual beliefs to be incorporated into the counseling process? In what specific ways would the client like their beliefs incorporated (prayer, Scripture, spiritual discussion, etc.?)

History of Presenting Problem

Offer historical as well as present signs, symptoms, onset, duration, frequency, severity, areas of dysfunction, and other relevant data that will be needed for diagnosis and case conceptualization. Write this out in paragraph format – no bullet points. Do not include a diagnosis here.

Barriers to Treatment/Success

Are there personality factors, stages of change influences, or contextual factors that would influence the success of treatment?

Part III: Diagnosis – 1-2 pages

Principal Diagnosis – Primary diagnosis, including ICD-10 code, severity, specifiers, etc.

Diagnosis 2 or z-code – Diagnosis, ICD-10 code, severity, specifiers, etc.

Diagnosis 3 or z-code - Diagnosis, ICD-10 code, severity, specifiers, etc.

Differential Diagnosis - Be sure to include diagnoses that you are still assessing for to rule them out (For example, you may be ruling out Generalized Anxiety Disorder, but the client has not yet had anxiety for 6 months or longer, so you’re keeping it as a provisional diagnosis)

Offer all your diagnoses and z-codes in order of priority. Include the ICD-10 code, severity, specifiers, etc. for each disorder. The first diagnosis is called the principal diagnosis. If the client does not meet all the criteria for a disorder and it is likely that they will if you had more information, offer that it is provisional – ex: Generalized anxiety disorder (provisional).

Diagnosis Rationale

When writing up this section, make sure to offer each disorder criteria with case data to support the diagnosis. For each diagnosis, offer a separate paragraph in the diagnostic impression/rationale. Below are examples of incorrect and correct ways to write it up:

· Not correct– The client has marked fear about one or more social situations. The individual fear that he will act in a way or show anxiety symptoms that will be negatively evaluated (offered DSM criteria only).

· Not correct – The client is depressed and noted sadness during the interview. The client isolated herself at home (problem, did not connect to DSM criteria).

· Correct – The client has marked fear in several social situations as evidenced by her fear when presenting in class, turning in a paper, and speaking with classmates (A1). She is fearful to speak up when feeling wronged by her supervisor, avoids chatting with co-workers, and isolates herself at home when asked to attend social events (A2). Her fears are founded on that she will act in ways that will be perceived negatively by instructors, classmates, and coworkers(B3). Offer criteria and case study data to support it.

Make sure to use Z codes as needed that are found in the back of the DSM-5. At times if no disorder is appropriate, a z-code may be what is principal diagnosis.

Make sure to offer a paragraph of z-codes in the diagnostic impression/rationale.

The first paragraph is only for the principal diagnosis, the next paragraph is on the second disorder, and then additional paragraphs are for the other disorders. Each paragraph is to focus on only one disorder. It is like building a court defense. If your records are subpoenaed or you transfer a client to another counselor, they are not questioning your diagnosis as being incorrect, inconclusive based on the diagnostic discussion. For the final paragraph, discuss your differential diagnosis.

This section should include a concise rationale for each diagnosis, differential diagnoses, and Z codes provided above.

Theoretical Orientation

This should be one paragraph where one theory is chosen, the major concepts are explained, and shown to be evidence-based using peer-reviewed journals.

Narrative of the Case Conceptualization

Use the key terms and constructs of your chosen counseling theory to explain (not describe as the DSM-5 does) the clinical problems and maintaining factors. This section should bring together your biopsychosocialspiritual assessment and explain your understanding of the client and the underlying factors that are contributing to the problems. This section should not include new information that is not already identified in your assessment. From your assessment, do you see the presenting problem stemming from the client’s biological, psychological, social, spiritual, or a combination of some of these factors? Explain that conceptualization in this section.

Based on your conceptualization, which theory of counseling will you be using with this client? This section should reference and apply sources for application of theory such as counseling theories books, journal articles, etc.

Part V - Spiritual Integration – 1-2 pages

This entire section should be a reflection about integration. It should include the following subsections:

Personal Integration Approach

Which integration approach are you using with this client as described by Johnson’s (2010) Psychology and Christianity: Five Views or Entwistle’s (2015) Integrative Approaches to Psychology and Christianity. (This subsection can be the same for Practicum, Internship 1, and Internship 2 if it has not changed.)

Implicit Integration

Include how you implicitly integrate faith into this client’s counseling in an ethical manner.

Explicit Integration

Include how you explicitly integrate faith into this client’s counseling in an ethical manner. If the client does not desire their faith to be integrated, it would be appropriate to state this and cite the relevant ACA Code of Ethics (2014).

Include the following treatment plan table:

Treatment Plan

References

(on separate page per APA 7)