Written Case Material
Please use the following as a guide for your case write up. Address each of the catergories below and include as many of the suggested topics listed under each heading as possible. The finished document should be between 5 and 10 pages. Remember to carefully disguise the information so that confidentiality is maintained.
- Introduction: Describe the setting in which the treatment was conducted, the referral process that brought the client to you and how long you have been working together.
- Identifying Information: Include the client’s age, gender, sexual orientation, marital status, living situation, social economic status, ethnicity and religion as relevant. Describe how the client presented him/herself in the first meeting and what you observed and experienced.
- Presenting Problem: Present your understanding of the reasons that the client is seeking treatment at this time and the process/events that led to the decision to seek professional help.
- History, Relationships and Current Functioning: Present relevant aspects of the client’s personal history including: family of origin, significant health, development or adjustment difficulties from childhood to present. Discuss the nature of the client’s important relationships and relationship history. Also describe past performance in work and school and how the client functions currently.
- Development of Treatment Process: Discuss the development of the treatment relationship, i.e., how it has changed or not changed over time, prominent themes that have emerged in the treatment process, and the client’s response to the structure (attendance, promptness, fees, payment, etc). Describe internal and/or behavioral changes you have observed since the beginning of the treatment.
- Clinical Vignette: Please include a 1-2 page excerpt of actual dialogue between you and your client. Explain why you chose this piece of process and what you think the process demonstrates about the client and/or the therapeutic process.
- Dilemmas and Concerns: Identify a clinical dilemma or concern that you would present to a consultant. If this case is already in consultation, discuss how the consultation experience has influenced your understanding of and work with your client.