CASE CONCEPTUALIZATION Part 1: CLIENT INFO Client Information Demographic information and related consequences Presenting Problem Present a brief desсrіption of the client, including psychosocial information Current situation (including living situation, support systems, work and employment, and health). Part 2: THEORETICAL APPROACH Describe the specific theoretical approach you used when working with this client. o Identify a single theory as your main approach; if you integrated a second perspective into your work (such as integrating reality therapy into a cognitive therapy approach), you will need to identify how each theory contributed to your work with the client. Discuss your rationale for selecting this theoretical perspective, and why you believed it was the most appropriate and effective approach to use. Support your statements with a minimum of 3 articles from current journals in the professional counseling literature that support the use of this theory with the types of issues your client presented, and/or with clients similar to yours (in age, gender, ethnicity, background, or in other ways). Describe how using this theoretical approach influenced the information you collected about the client during the first sessions. (For example, was it important for you to take a detailed history that included information about the client′s parents and early childhood experiences?) Again, support your ideas with references to the professional literature. Part 3: COUNSELING GOAL List three specific goals that you developed for working with this client. o These should be goals in which you expected to see some progress during the time you were working with the client. Note how these goals incorporated the client′s current strengths (to your knowledge), as well as areas of limitation or challenge for the client. Discuss how you considered your client′s social-cultural background when selecting these goals. Discuss how each goal is reflective of your theoretical approach, drawing from the key concepts and assumptions of that theory. Discuss the process you used to formulate your assessment and diagnosis for this client. Did you rely on information collected from the client during the first sessions? o Information that cannot be obtained from the client clinical records can be obtained at intake, or first session if the client is not willing to disclose information at intake. For example, information from observing the client and from her psychosocial history (e.g., generational habits, patterns in the family of origin etc.), could be helpful in conceptualizing her case, and diagnosing the problem. Did you utilize any self-report instruments (such as mental status exam, symptom checklists, anxiety inventories, and depression scales)? Did you consult with any other persons about the client (with his or her written permission) such as parents, teachers, physicians, and past therapists? What social-cultural factors did you consider when approaching the assessment process and formulating your diagnosis? Describe how the assessment and diagnosis process was integrated into your theoretical approach for working with the client. Did the information you gathered, and the diagnosis you formulated, assist you in working from this perspective more effectively? If so, provide examples; if not, discuss the reasons why.
