Posted: August 24th, 2022

Provide pertinent details of the client’s medical history

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College of Social and Behavioral Sciences
School of Counseling

CES Practicum
CASE CONCEPTUALIZATION and PRESENTATION FORM
Field Experience Student’s Name:
Date:

# of sessions with client at presentation # of sessions with client at final submission

Field Experience Course:

Identified Client (e.g., individual client, couple, family):

Client’s Initials and Role (e.g., GL = mom, FL = dad):

Race or Ethnicity:
Self-identified Gender:
Age:

Directions: Students will complete the case conceptualization and presentation form throughout the quarter as part of the weekly discussion posts. For each domain of the form, students should review the identified week to have each requirement completed. Students should review all of the required domains and the weekly rubrics before participating in the weekly course activities. A final form that synthesizing all of your learning, feedback, and insights form the quarter is also due at the end of the quarter.
Students should complete this form on their counseling experience with a client/couple/ family who is/are long-standing client/s. Some students may not have a client/couple/family for a significant amount of time; if not, select a client/couple/family, you are working with and complete the required domains of the case conceptualization form.

Counseling Setting:
Provide a summary of the clients, agency, and services provided. If applicable, describe the agency or site supervisor’s theoretical orientation.

Theoretical Case Conceptualization:
Describe your counseling theoretical orientation. Justify how your theoretical approach explains wellness, positive growth, and change, development issues, challenges, and problems in general. (NOTE: to some degree, you may integrate more than one theory, but you must explain how you synthesize various elements. “Eclectic” or “Integrative” are insufficient.) Please site the original theorist(s) to justify the theoretical approach (i.e. Rogers for person centered, Jean Baker-Miller for relational cultural theory, Ellis for REBT, Bowlby/Ainsworth for attachment, etc.). Include primary resourced, cited details.

Medical History:
1. Provide pertinent details of the client’s medical history (for instance, clients with anxiety disorders may have hypertension, major depression may be associated with persistent illness, etc.)
2. Provide the client’s medication regimen or previous regimen, detailing her or his level of compliance (NOTE: some medications not typically considered psychopharmacologic agents may have psychotropic effects; for instance, levothyroxine may improve symptoms of depression)
3. Provide any significant side effects or contraindications.

Presenting Problem or Intent
1. Why did the client come to you (from the client’s perspective or other referring stakeholder)?
2. How long has the problem(s) persisted? Note the, duration, intensity, and frequency of any symptoms.
3. What have you and the client, family, or couple agreed to work on (minimum of 3 long-term treatment goals)?

Family Diagram:
1. If your identified client is a family, please provide a diagram of family structure or organization. This could include a simple genogram, family map, structural diagram, or other visual representation of how the relational system is organized. (The diagram may be attached as an appendix)
2. What is your preliminary Assessment of the family system based on the initial family genogram?

Multicultural Considerations:
1. Analyze the client’s cultural identity.
2. Design culturally and contextually relevant strategies for competent multicultural care for this client.
Include reference to relevant codes of ethics and primary resources.

Theoretical Approach Application to Case:
1. Explain how your above described theoretical approach explains why the client developed the presenting problems.
2. Explain how your above described theoretical approach explains how the client developed the presenting problems, including any issues of development.
3. What are the past or present patterns of thoughts, emotion, and behaviors you noticed based on your theory (e.g. types of self-talk, relational style, behaviors, emotional states or qualities)?
4. What present life elements that support or perpetuate the client’s problems?
5. What is the purpose of the past and present patterns and life elements in relationship to how your client functions?
6. What is the general guiding philosophy or path, based on your application of theory,) for how you would intervene to Help the client or system attain their 3 long term goals described above?
Include reference to relevant codes of ethics and primary resources.

Alternative Theoretical Application:
Provide a case conceptualization based on a theory other than the one you used above (for example, if you chose to employ a relational framework, a cognitive framework would be appropriate). Case Study Conceptualization:
Explain your theoretical orientation. Demonstrate how your theoretical approach explains general development concerns and problems. (NOTE: you may combine aspects from multiple theories, but you must explain how you do so. Insufficiently eclectic or integrative.) For each theoretical method, cite the original thinker (e.g. Rogers for Person-Centered, Jean Baker-Miller for RCT, Ellis for REBT, Bowlby/Ainsworth for Attachment, etc.). Include cited primary sources.

History:
1. Detailed medical history of the client (for instance, clients with anxiety disorders may have hypertension, major depression may be associated with persistent illness, etc.)
2. Provide the client’s current or former drug regimen, including compliance (NOTE: some medications not typically considered psychopharmacologic agents may have psychotropic effects; for instance, levothyroxine may improve symptoms of depression)
Include any major adverse effects or contraindications.

Problem or Intention
From the client’s or referring stakeholder’s perspective, why did they come to you?
2. How long have the issues lasted? Notate symptom duration, intensity, and frequency.
How will you and the client (minimum of 3 long-term treatment goals) communicate?

1. If your identified client is a family, please offer a family structure or organization diagram. This could be a genogram, family tree, or other visual depiction of the relational system. (The diagram can be an appendix.)
2. Based on the basic family genogram, how would you rate the family system?

1. Examine the client’s cultural identity.
2. Create culturally and contextually relevant multicultural care techniques for this client.
Mention applicable ethical codes and primary sources.

Theoretical Approach Case Study:
1. Explain how your theoretical approach explains the client’s problems.
2. Explain how the client developed the presenting problems, including any developmental challenges.
3. Based on your idea, what forms of self-talk, relationship styles, actions, emotional states or attributes have you noticed in the past or present?
In what ways does the client’s life support or perpetuate his issues?
5. How do the past and present patterns and life components affect your client’s function?
6. Based on your idea, how would you intervene to help the client or system achieve the three long-term goals listed above?
Mention applicable ethical codes and primary sources.

Provide a case conceptualization based on a theory other from the one utilized above (for example, if you chose to employ a relational framework, a cognitive framework would be appropriate).
Include reference to relevant codes of ethics and primary resources.

Resources:
1. Analyze the resources that are already available to the client or system.
2. Design a plan to incorporate additional resources that would benefit and foster wellness for the client or system.

Assessment:
1. Design a comprehensive assessment plan for your client, based on presenting concerns, contributing factors, etc. For any instruments to be employed, include justification of use for the client based on demographics.
2. Describe any previous assessments performed, justified by cited evidence, and the outcomes of that assessment. Include assessment of suicidality, aggression, abuse, and crisis and any actions necessary.
3. Describe your DSM-5 diagnosis and your complete process for developing the differential/dimensional diagnoses.
Include reference to relevant codes of ethics and primary resources.

Co-Occurring Disorder: (If applicable)
1. Describe previous and current history of drug use and treatment, and include any comorbid diagnosis.
2. Describe history of substance use and attempts to quit, cut back, etc.
3. Describe the current treatment model (i.e., serial, parallel, and integrated).
4. Evaluate your client using the Prochaska and DiClemente’s Stages of Change Model (Precontemplation, Contemplation, Preparation, Action, and Termination).
5. Evaluate your role and develop a plan for treatment related to comorbidity.

Implications for Group Counseling:
Should the client be likely to benefit from the addition of group counseling, describe the implications for how you would incorporate group counseling into the treatment of the client or system.
1. Describe the specific group counseling techniques and intervention that you would use with this client or system
2. How your recommendations relate to you theoretical approach described above
3. Describe the intent and goals behind this inclusion.

Ethical and Legal Considerations:
Evaluate any ethical or legal issues that pertain to the client or system and their impact.
1. Describe any ethical or legal considerations associated with providing a diagnosis (e.g. are you legally able to diagnose in your state, what are the issues related to assessment measures, etc.)
2. Evaluate the accuracy of any current or previous diagnosis. How will you address any disparities or how were these resolved?
3. Evaluate any additional ethical or legal implications for care of this client.
Include reference to relevant codes of ethics and primary resources.

Social Change Implications:
Discuss how your work with this client has informed your understanding of a larger social challenge/barrier. Offer recommendations for what you could do to effect positive social change at your site related to the social challenge/barrier you identified. Explain the steps you would take to implementing a social change project at your field experience site to address the social challenge/barrier you have identified.

Consultation:
Design a consultation plan with any psychiatrist or other physician, social worker, spiritual healer or advisor, or other resource that would support the wellness of your client.
Include reference to relevant codes of ethics and primary resources.

Self-Analysis:
1. What foundational and advanced counseling skills have you used or will you use with the client to address each of the following structural elements of the counseling session? (Rapport, Pragmatics (documentation), Focus, Resistance, Foreclosure, Impasse, etc. NOTE: see definition of terms for detailed explanation)
2. Justify how these skills have promoted or will promote consistency, rapport, and trust in the helping relationship.
3. Evaluate the application and effect of any interventions or techniques have you used that you listed on the above treatment plan.
4. How will you connect the previous sessions with the nest session to assure consistency in treatment?
5. Analyze the significant themes and patterns you observed in your own behavior, noting what you did that you considered especially effective and areas that were troublesome for you.
6. Analyze transference and countertransference; design strategies for attending to them. What have you done to apply self-care and plan for ongoing self-care?
7. Analyze areas for growth for you to competently, best treat this client. Design a plan to implement additional training and knowledge you need to expand you skills in working with this client.
Include reference to relevant codes of ethics and primary resources.

Treatment Planning:
Complete the Treatment plan template. Be sure to include:
1. a minimum of 3 presenting problems or areas for growth or positive change,
2. 3 long-term goals
3. 3 specific, measurable, attainable, realistic, and timely (SMART) goals for each long-term goal, and
4. at least 1 specific techniques and interventions to achieve the short term goals.
5. discuss plans and timelines for the designed assessment plan, evaluating treatment goals, or Assessments of goals based on progress
6. justification of goals and treatment strategies based on primary resources.
Refer to the “commonly misunderstood terms” to clearly understand the expectations for each of these elements.

ATTACH the Treatment Plan template

De-identified Progress Note (may be submitted as an appendix)
DAP, SOAP, or other justified case note structure

Plans for the Next Session:
How do you plan to follow up in subsequent sessions?
What issues and concerns do you think worthwhile to explore? What process goals will you try to accomplish?

Helpance and Feedback Requests:
Specifically what kind of Helpance or feedback would you like, from your practicum supervisor and from fellow students, about any or all of the elements of this case?
—-
Case Sample for Field Experience
Case of Walter

Walter is an 11 year old, white, Caucasian male. His mother brought him in reporting symptoms of difficulty sleeping at night, poor eating habits, low mood, and problems at school. She reported that she and Walter’s father were divorced when Walther was 9 years old. She stated that it was not a “messy” divorce. However, she reported that this was a very difficult period for Walter. He is an only child. She reported that he cried “for weeks” afterwards begging them not to go through the divorce. His grades suffered in school as did his behavior (classroom disruptions). His mother reported that he met with the school counselor numerous times and appeared to have “worked through it”. His behavior eventually improved as did his grades. Walter’s parents have joint custody; however, Walter only spends every other weekend with his father who now lives in Birmingham (45 minutes away).
Due to the divorce, Walter’s mother had to return to work, which meant she needed Helpance with child care. Her father, Walter’s grandfather, was retired and available to help take care of Walter after school each day and during the summer while his mother worked. She reported that the two of them grew extremely close. Sadly, the grandfather died of a heart attack four weeks ago. Walter’s mother reported that the symptoms and problems reported above have all returned. Walter’s teachers report to the mother that Walter is withdrawn and engages very little with them or his peers. His mother also reports that Walter no longer takes an interest in any of the things he normally enjoys such as completing school work, video games, watching television and playing with his neighborhood friends. He wants to spend all of his time in his room alone.

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