Written Case Study Format
Use the following sub-sections to organize your case study:
1. Identifying Information
Age, gender, race, physical appearance, marital/partnership status and history, ages and gender of children, occupation, number of (counseling) sessions.
2. Initial Impression
General appearance, mannerisms, behavior, speech, gestures at first meeting.
3. Presenting Issues and Concerns
Describe using the client’s language and way of understanding the situation.
4. Personal History
Developmental history, including childhood, adolescence and adulthood. Include personal, family, and community description. Describe relationships with others and group affiliations.
5. Initial Assessment of Functioning
Mental status, including problem symptoms. Note any recent crises and reports of psychotic symptoms.
6. Medical History and Health Related Issues
Current health, serious illnesses, injuries, surgery, medications. Eating, sleeping, and exercising patterns. Use of illegal drugs and legal drugs, including alcohol, tobacco caffeine, and sugar. History of previous mental health care - by whom, what issues, and for what duration.
7. Religious History and Spiritual Themes
Theological insights and Biblical themes which can be brought to bear in understanding the person. Spiritual/religious dynamics between counselor and client.
8. Counselor Case Conceptualization
How the counselor conceptualizes the case in terms of his/her unique counselor identity, to include counselor view of human nature and theoretical orientation, integrating faith, philosophy of life, and how counselor arrived at this understanding in view of his/her own history and experiences. This should directly reflect the specifics of the work that the counselor is seen to be doing in the videotaped presentation. In other words, this section should provide the answer to “the work you will see me doing with this client is a result of my following beliefs and views...”
9. Psychodynamic Formulation
Provides a professional overall statement of positive and problematic aspects of the situation. Name the intrapsychic and/or interpersonal conflicts. Identify the primary source of distress and what defenses are employed against the distress. Describe implicated relationships. Identify once again the theory you worked from (see Counselor Case Conceptualization), this time describing how it was applied to and integrated into the clinical work. Overall, this section provides a description of the strengths, limits, and sources of conflict of the client as integrated into the theory of choice.
10. Diagnosis
If appropriate, include DSM IV diagnosis.
11. Counseling Plan
If counseling is recommended, list goals, how often client will be seen, and type of counseling. Type of counselor (personality, gender, style of counseling) and the room arrangement or atmosphere which best suits the therapeutic needs of this person. How would your theoretical approach provide guidance.
12. Counseling Process to Date
Course of treatment. What has, or has not been, helpful. Major transitions observed. Client satisfaction with counseling.
13. Prognosis
Liabilities and assets for making use of counseling. Time frame and/or stages of projected growth.
14. Counselor Strengths and Limits
What this clinical experience has taught you and/or reinforced about yourself. Goals for subsequent clinical experiences.
15. Help
Difficulties and questions as a result of this clinical learning experience.
16. Reflections
As you reflect on this person, what does she/he evoke in you by way of image, metaphor, theological, religious, or Biblical theme? If it is music, write the words. If it is poetry, attach it. If it is a picture or drawing or photo, attach it to the paper. If it is a story or play or movie, name and describe briefly. If it is a scripture or other sacred reading, reprint it. If a character- famous in history, current in events, of Biblical stories, etc., name and briefly describe.
Please note that strict procedures are followed to safeguard confidentiality. Case studies must conceal all client identities, and will be kept on file as confidential material. All copies of the case study, other than the departmental copy, are destroyed after the case presentation. The program reserves the right to remove case studies from its files.
