There are parts to the case conceptualization

1. Evaluation & Assessment- identify precipitating problems/symptoms,provide a comprehensive biopsychoscial assessment/history, Identify indivdual & relationship functioning

2. Case Conceptualization- Diagnosis & Treatment Planning,Integrate client assessment & observational data to form a conceptualization, Utilize clinical judgment,formulate a differential diagnosis, Develop a treatment plan.

3.Clinical Practice-Determine & identify other services that could meet the client’s needs, identify and discuss applicable ethical and legal issues,Discuss the scope of practice parameters and any foreseen limitations. APA format.

Paper #1 Outline

 

A.                  Presenting Problems/Symptoms

Include here a thumbnail sketch of the client.  Presenting problems are what brings them to therapy; who referred them; why?  What is their understanding of the problem?  Symptoms are terms used by clinicians to arrive at a diagnosis.  Include a statement about Suicidal and Homicidal ideation. 

B.                 Comprehensive psychosocial assessment/history

1.                  Family history

Who is in their immediate family? What are the family dynamics?

2.                  Current living situation

Where do they live? Who do they live with? Have there been changes in living arrangements recently?

3.                  Health

Client’s health history as well as significant health issues in the family

4.                  Education/Employment

Relevant educational and employment information

5.                  Spirituality

Relevant cultural and spiritual context and issues

6.                  Legal

Current and past legal issues; including probation; divorce or custody issues

7.                  Mental Health

Include mental status exam results; suicidal/homicidal ideation; previous diagnoses, treatments; family history of mental health

8.                  Substance Abuse

Include previous diagnoses of substance abuse; previous treatment attempts; age of first use; amount of last use; frequency of use; drugs of choice; family history of substance abuse

9.                  Violence

Own history of violent behavior and family history of violence

10.             Individual and relationship functioning*

The individual’s level of functioning as well as a description of their significant relationships and their ability to maintain those relationships.  Include information about their interpersonal relationships as well as their intra-personal functioning.

11.             Strengths/Limitations

Not only what the client reports, but what you observe about the client; what about social strengths?  This is really an opportunity for a summary paragraph.

C.                  Any assessment scores or measurement tools

Not necessary but if you use any instruments this is when you would report it.

II.                 Diagnosis and Treatment Planning

A.                  Integrated client assessment and observational data to form a conceptualization

Two paragraphs here…  First, give an explanation of the client’s problem in keeping with their psychosocial history using your theoretical orientation.  Second, justify your diagnosis based on the client’s problems and symptoms, include the logic of your reasoning to arrive at this diagnosis and not another.  This is the more academic aspect of your paper.

 

 Paper #1 Outline

 

A.                  Presenting Problems/Symptoms

Include here a thumbnail sketch of the client.  Presenting problems are what brings them to therapy; who referred them; why?  What is their understanding of the problem?  Symptoms are terms used by clinicians to arrive at a diagnosis.  Include a statement about Suicidal and Homicidal ideation. 

B.                 Comprehensive psychosocial assessment/history

1.                  Family history

Who is in their immediate family? What are the family dynamics?

2.                  Current living situation

Where do they live? Who do they live with? Have there been changes in living arrangements recently?

3.                  Health

Client’s health history as well as significant health issues in the family

4.                  Education/Employment

Relevant educational and employment information

5.                  Spirituality

Relevant cultural and spiritual context and issues

6.                  Legal

Current and past legal issues; including probation; divorce or custody issues

7.                  Mental Health

Include mental status exam results; suicidal/homicidal ideation; previous diagnoses, treatments; family history of mental health

8.                  Substance Abuse

Include previous diagnoses of substance abuse; previous treatment attempts; age of first use; amount of last use; frequency of use; drugs of choice; family history of substance abuse

9.                  Violence

Own history of violent behavior and family history of violence

10.             Individual and relationship functioning*

The individual’s level of functioning as well as a description of their significant relationships and their ability to maintain those relationships.  Include information about their interpersonal relationships as well as their intra-personal functioning.

11.             Strengths/Limitations

Not only what the client reports, but what you observe about the client; what about social strengths?  This is really an opportunity for a summary paragraph.

C.                  Any assessment scores or measurement tools

Not necessary but if you use any instruments this is when you would report it.

II.                 Diagnosis and Treatment Planning

A.                  Integrated client assessment and observational data to form a conceptualization

Two paragraphs here…  First, give an explanation of the client’s problem in keeping with their psychosocial history using your theoretical orientation.  Second, justify your diagnosis based on the client’s problems and symptoms, include the logic of your reasoning to arrive at this diagnosis and not another.  This is the more academic aspect of your paper.

 Paper #1 Outline

 

A.                  Presenting Problems/Symptoms

Include here a thumbnail sketch of the client.  Presenting problems are what brings them to therapy; who referred them; why?  What is their understanding of the problem?  Symptoms are terms used by clinicians to arrive at a diagnosis.  Include a statement about Suicidal and Homicidal ideation. 

B.                 Comprehensive psychosocial assessment/history

1.                  Family history

Who is in their immediate family? What are the family dynamics?

2.                  Current living situation

Where do they live? Who do they live with? Have there been changes in living arrangements recently?

3.                  Health

Client’s health history as well as significant health issues in the family

4.                  Education/Employment

Relevant educational and employment information

5.                  Spirituality

Relevant cultural and spiritual context and issues

6.                  Legal

Current and past legal issues; including probation; divorce or custody issues

7.                  Mental Health

Include mental status exam results; suicidal/homicidal ideation; previous diagnoses, treatments; family history of mental health

8.                  Substance Abuse

Include previous diagnoses of substance abuse; previous treatment attempts; age of first use; amount of last use; frequency of use; drugs of choice; family history of substance abuse

9.                  Violence

Own history of violent behavior and family history of violence

10.             Individual and relationship functioning*

The individual’s level of functioning as well as a description of their significant relationships and their ability to maintain those relationships.  Include information about their interpersonal relationships as well as their intra-personal functioning.

11.             Strengths/Limitations

Not only what the client reports, but what you observe about the client; what about social strengths?  This is really an opportunity for a summary paragraph.

C.                  Any assessment scores or measurement tools

Not necessary but if you use any instruments this is when you would report it.

II.                 Diagnosis and Treatment Planning

A.                  Integrated client assessment and observational data to form a conceptualization

Two paragraphs here…  First, give an explanation of the client’s problem in keeping with their psychosocial history using your theoretical orientation.  Second, justify your diagnosis based on the client’s problems and symptoms, include the logic of your reasoning to arrive at this diagnosis and not another.  This is the more academic aspect of your paper.

 Paper #1 Outline

 

A.                  Presenting Problems/Symptoms

Include here a thumbnail sketch of the client.  Presenting problems are what brings them to therapy; who referred them; why?  What is their understanding of the problem?  Symptoms are terms used by clinicians to arrive at a diagnosis.  Include a statement about Suicidal and Homicidal ideation. 

B.                 Comprehensive psychosocial assessment/history

1.                  Family history

Who is in their immediate family? What are the family dynamics?

2.                  Current living situation

Where do they live? Who do they live with? Have there been changes in living arrangements recently?

3.                  Health

Client’s health history as well as significant health issues in the family

4.                  Education/Employment

Relevant educational and employment information

5.                  Spirituality

Relevant cultural and spiritual context and issues

6.                  Legal

Current and past legal issues; including probation; divorce or custody issues

7.                  Mental Health

Include mental status exam results; suicidal/homicidal ideation; previous diagnoses, treatments; family history of mental health

8.                  Substance Abuse

Include previous diagnoses of substance abuse; previous treatment attempts; age of first use; amount of last use; frequency of use; drugs of choice; family history of substance abuse

9.                  Violence

Own history of violent behavior and family history of violence

10.             Individual and relationship functioning*

The individual’s level of functioning as well as a description of their significant relationships and their ability to maintain those relationships.  Include information about their interpersonal relationships as well as their intra-personal functioning.

11.             Strengths/Limitations

Not only what the client reports, but what you observe about the client; what about social strengths?  This is really an opportunity for a summary paragraph.

C.                  Any assessment scores or measurement tools

Not necessary but if you use any instruments this is when you would report it.

II.                 Diagnosis and Treatment Planning

A.                  Integrated client assessment and observational data to form a conceptualization

Two paragraphs here…  First, give an explanation of the client’s problem in keeping with their psychosocial history using your theoretical orientation.  Second, justify your diagnosis based on the client’s problems and symptoms, include the logic of your reasoning to arrive at this diagnosis and not another.  This is the more academic aspect of your paper.

 Paper #1 Outline

 

A.                  Presenting Problems/Symptoms

Include here a thumbnail sketch of the client.  Presenting problems are what brings them to therapy; who referred them; why?  What is their understanding of the problem?  Symptoms are terms used by clinicians to arrive at a diagnosis.  Include a statement about Suicidal and Homicidal ideation. 

B.                 Comprehensive psychosocial assessment/history

1.                  Family history

Who is in their immediate family? What are the family dynamics?

2.                  Current living situation

Where do they live? Who do they live with? Have there been changes in living arrangements recently?

3.                  Health

Client’s health history as well as significant health issues in the family

4.                  Education/Employment

Relevant educational and employment information

5.                  Spirituality

Relevant cultural and spiritual context and issues

6.                  Legal

Current and past legal issues; including probation; divorce or custody issues

7.                  Mental Health

Include mental status exam results; suicidal/homicidal ideation; previous diagnoses, treatments; family history of mental health

8.                  Substance Abuse

Include previous diagnoses of substance abuse; previous treatment attempts; age of first use; amount of last use; frequency of use; drugs of choice; family history of substance abuse

9.                  Violence

Own history of violent behavior and family history of violence

10.             Individual and relationship functioning*

The individual’s level of functioning as well as a description of their significant relationships and their ability to maintain those relationships.  Include information about their interpersonal relationships as well as their intra-personal functioning.

11.             Strengths/Limitations

Not only what the client reports, but what you observe about the client; what about social strengths?  This is really an opportunity for a summary paragraph.

C.                  Any assessment scores or measurement tools

Not necessary but if you use any instruments this is when you would report it.

II.                 Diagnosis and Treatment Planning

A.                  Integrated client assessment and observational data to form a conceptualization

Two paragraphs here…  First, give an explanation of the client’s problem in keeping with their psychosocial history using your theoretical orientation.  Second, justify your diagnosis based on the client’s problems and symptoms, include the logic of your reasoning to arrive at this diagnosis and not another.  This is the more academic aspect of your paper.

 Paper #1 Outline

 

A.                  Presenting Problems/Symptoms

Include here a thumbnail sketch of the client.  Presenting problems are what brings them to therapy; who referred them; why?  What is their understanding of the problem?  Symptoms are terms used by clinicians to arrive at a diagnosis.  Include a statement about Suicidal and Homicidal ideation. 

B.                 Comprehensive psychosocial assessment/history

1.                  Family history

Who is in their immediate family? What are the family dynamics?

2.                  Current living situation

Where do they live? Who do they live with? Have there been changes in living arrangements recently?

3.                  Health

Client’s health history as well as significant health issues in the family

4.                  Education/Employment

Relevant educational and employment information

5.                  Spirituality

Relevant cultural and spiritual context and issues

6.                  Legal

Current and past legal issues; including probation; divorce or custody issues

7.                  Mental Health

Include mental status exam results; suicidal/homicidal ideation; previous diagnoses, treatments; family history of mental health

8.                  Substance Abuse

Include previous diagnoses of substance abuse; previous treatment attempts; age of first use; amount of last use; frequency of use; drugs of choice; family history of substance abuse

9.                  Violence

Own history of violent behavior and family history of violence

10.             Individual and relationship functioning*

The individual’s level of functioning as well as a description of their significant relationships and their ability to maintain those relationships.  Include information about their interpersonal relationships as well as their intra-personal functioning.

11.             Strengths/Limitations

Not only what the client reports, but what you observe about the client; what about social strengths?  This is really an opportunity for a summary paragraph.

C.                  Any assessment scores or measurement tools

Not necessary but if you use any instruments this is when you would report it.

II.                 Diagnosis and Treatment Planning

A.                  Integrated client assessment and observational data to form a conceptualization

Two paragraphs here…  First, give an explanation of the client’s problem in keeping with their psychosocial history using your theoretical orientation.  Second, justify your diagnosis based on the client’s problems and symptoms, include the logic of your reasoning to arrive at this diagnosis and not another.  This is the more academic aspect of your paper.

 Paper #1 Outline

 

A.                  Presenting Problems/Symptoms

Include here a thumbnail sketch of the client.  Presenting problems are what brings them to therapy; who referred them; why?  What is their understanding of the problem?  Symptoms are terms used by clinicians to arrive at a diagnosis.  Include a statement about Suicidal and Homicidal ideation. 

B.                 Comprehensive psychosocial assessment/history

1.                  Family history

Who is in their immediate family? What are the family dynamics?