Case Study Format
I. Presenting Complaint
What is the client saying about the presenting problem/complaint
A. Subjective symptoms expressed
B. Observed Symptoms
C. History of the problem including family history of the problem
D. Any previous treatment for this complaint/problem
E. Clinical observations during session
II. Developmental History
Did client meet developmental milestones as a child related to walking, speech, social interaction etc.
III. Social and Family History
A. Family of Origin
1. Parents Living or deceased/married or Divorced/when
3. Extended Family
4. History of psych or medical disorders in the family
B. Current Family
1. Married or Divorced/Partner
3. History of psych or medical disorders in family
4. Any current marital and/or family dysfunction
a. domestic violence
b. child or elder abuse
c. sexual abuse
d. extramarital relationships
C. Vocational/Educational History
1. Current Occupation and job if any
2. Disability? State, Federal or Military
3. Academic history and highest grade achieved
4. Certifications, licenses, special skills etc.
1. Discusses friends and interactions
2. Social outlets: Church, Clubs, Hobbies involving others etc.
E. Medical History- any medical issues including childhood medical problems, difficult pregnancy etc.
IV. Mental Status Exam
A. Follow one of the outlines passed out in class
B. Include dual dx. Information
VI. Treatment Plan
A. Treatment Problems
B. Treatment Goals/Objectives (related to presenting complaint/problem)
C. Planned Treatment Modalities (Individual, Group, Family, Marital)
1. Modality, Frequency, Estimated Duration
2. Referral for
3. Neurological/Medical evaluation
4. Psychological or Neuropsychological testing indicated
5. Other social service resource needed and referrals made
VII. DSM-5 Diagnosis (DX)
A. Principle DX.
B. Any Provisional DX.
C. Z codes
D. ICD 10 code
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