Application Assignment

Student Name: Case Name / #:

1. Problem identification & definition: [1–2 paragraphs]

[Primary and contributing concerns for the client]

2. Contextual considerations: [1–2 paragraphs]

[What ethical, legal, cultural, or other key considerations need to be considered with this client when creating a treatment plan?]

3. Diagnosis

Axis I: [be sure to provide full title and code]

Axis II:

Axis III:

Axis IV:

AXIS V: GAF =

Diagnostic Comments: [1 paragraph]

[Here, provide a brief—no more than 1 paragraph—comment on the justification for your diagnosis]

4. Theoretical Conceptualization: [1–2 paragraphs]

[How would your selected theoretical orientation explain the primary issues for this client, and thus which interventions / treatments would be best suited for this client?]

5. Treatment Plan

Presenting Issue #1:

Strengths:

Barriers:

Goals:

Interventions:

Modality / Duration:

Measure of Progress:

Presenting Issue #2:

Strengths:

Barriers:

Goals:

Interventions:

Modality / Duration:

Measure of Progress:

Presenting Issue #3:

Strengths:

Barriers:

Goals:

Interventions:

Modality / Duration:

Measure of Progress:

References from Empirically Supported Research