Briefly summarize the problems you and your client are addressing in treatment
The purpose of creating a case presentation is to allow you to demonstrate an example of your current field work experience and to simulate the process of collegial psychological case consultations and the professional treatment planning process.
General Format for Clinical Case Presentations
This format is for your use in creating a case presentation for 8871 – Practicum. The purpose of creating a case presentation is to allow you to demonstrate an example of your current field work experience and to simulate the process of collegial psychological case consultations and the professional treatment planning process. This format should help you summarize your case in an organized and sequential manner such that your readers can develop a solid sense of the case you are presenting and the work you have been doing in you field experience.
NOTE: Please assure that all matters associated with confidentiality are strictly adhered to in your case presentation.
1. Demographic description of client
This section should be brief but it should leave your audience oriented to the basic demographic information about your client. For example: age, gender, SES, ethnicity.
2. Presenting problem and reason for referral
A. Client’s perspective
B. Family perspective (if applicable)
C. Referring agency (or individual’s) perspective (school, legal, other agencies, etc.)
D. A summary of differences between these sources if applicable.
3. Focus of treatment
Briefly summarize the problems you and your client are addressing in treatment. These may not include ALL of the problems listed in the reason for referral, or all of the presenting problems. However, if you are not addressing them yourself, be prepared to tell us what the disposition of those problems has been. In other words, did you make community referrals for other services, etc.
4. History of the presenting problem
Think in terms the course of the problem(s) over time:
Remember that you are telling a kind of a story about your client. The events of the client’s problems unfold in a specific sequence. This sequence is referred to as the clinical time course or chronology. Think of it as the scaffold on which all the other details of the history of the problem(s) will hang. Elements of the time course should include:
· When did the problem(s) start? (Onset)
· How has it progressed over time?
· What is its current status?
Once you’ve established the time course, note any factors that :
· make the condition worse
· relieve the condition, or make it improve
· Also – Note any prior treatments for the condition(s) and the condition’s response to those treatments
5. Brief initial mental status exam results
This is critical for inpatient clients. It is optional for other clients unless there are clear problems in certain areas that need to be delineated for your audience in order to have a more complete picture of you client.
I. General description
A. Appearance
B. Behavior and psychomotor activity
C. Attitude toward examiner
II. Mood and affect
A. Mood
B. Affect
C. Appropriateness
III. Speech (rate, quality, etc.)
IV. Perceptual disturbances (hallucinations – visual, auditory, tactile, olfactory)
It any of these are present or suspected – please provide details about content, context and frequency.
V. Thought
A. Process or form of thought
B. Content of thought
VI. Sensorium and cognition
A. Alertness and level of consciousness
B. Orientation
C. Memory
D. Concentration and attention
E. Capacity to read and write
F. Visuospatial ability
G Abstract thinking
VII. Impulse control
VII. Judgment and insight
IX. Reliability
6. Results of psychological tests (if administered)
Provide us with an overview of the results of these tests and the conclusions arrived at by the examiner(s). We are particularly interested in hearing about cognitive (including achievement), personality, and clinical diagnostic test results capable of providing us with an understanding of the client’s cognitive, affective, interpersonal, and behavioral assets, limitations, and motivational dynamics. Career or vocational test results may also be helpful.
7. Current diagnostic formulation: (if applicable)
DSM–5.
8. Your clinical (theoretical) conceptualization of the case:
What is your theoretical framework for this case? What theories have you employed to explain the presence of this condition in your client’s life? What theoretical model(s) has driven your treatment interventions? Please include your assessment of the cultural issues that play a role in explaining and treating this case.
9. Summary of services provided to date:
Please summarize the various types of individual, group, family, classroom, pharmacological, and other interventions as appropriate to this case. Explain your rationale for selecting the therapeutic model(s) you have employed with your client. Also, explain your rationale for any additional services you have requested for your client (e.g., a psychiatric or medication consultation).
10. Client’s response to these interventions:
Give a solid sense of what progress is being made – or not being made.
Tell your readers about any particular problems you have encountered or continue to encounter in the treatment process with this client.
11. Future intervention changes and plans:
Are there modification anticipated at this point in time. How will you and the client know when treatment is no longer required?
12. Other information you want to present about this case: