Case Study: Behavioral Health Inc.

GENERAL FORMAT FOR CASE PRESENTATIONS AND DISCUSSION

The purpose of these presentations and discussions 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 document includes a brief outline of the case presentation and then a longer document detailing what needs to be in each part of the case.

BRIEF OUTLINE OF CASE PRESENTATION

(this provides the general format - details of each area are provided starting on page 2)

I Demographic description of client

II Presenting problem and reason for referral

A. Client's perspective

B. Family perspective

C. Referring agency (or individual's) perspective (school, legal, other agencies, etc.)

D. A summary of differences between these sources if applicable.

III The problems you are addressing in your treatment

IV History of the presenting problem

VI. General description of Client

A. Appearance

B. Behavior and psychomotor activity

C. Attitude toward examiner

VII Mood and affect

A. Mood

B. Affect

C. Appropriateness

VIII Speech (rate, quality, etc.)

IX Perceptual disturbances (hallucinations - visual, auditory, tactile, olfactory)

X. Thought

A. Process or form of thought

B. Content of thought

XI. 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

XII. Impulse control

XIII. Judgment and insight

XIV Reliability

XV Results of psychological tests (if administered)

XVI Your assessment of what lead to and maintains the client's problem (s). That is, what is your etiological/theoretical conceptualization of the client's problems.

XVII Current diagnostic formulation:

DSM-5

XVIII Your clinical (theoretical) conceptualization of the case:

XIX Summary of services provided to date:

XX Clients response to these interventions:

XXI Future intervention changes and plans:

XXII Other information you want to present about this case:

Information related to above question is enclosed below:

Attachment:- Cliniical_Case_Summary_and_Presentation.rar