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This week, students have the opportunity to share cases. Please take precautions to protect the identity of the client. Cases should follow the format found in the doc sharing area and you should review the comments from week 4 that indicate what is necessary for a “good case”.

I currently work with juveniles in Department of Juvenile Services. It’s called FFT Functional Family Therapy. You will find a lot of info on FFT if you google it. I guess you can make up a case the fits the criteria of working with this population.

Case Format

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:

DETAIL OF REQUIREMENTS FOR THE CASE PRESENTATION:

Note: Please assure that all matters associated with confidentiality are strictly adhered to in your case presentation.

Demographic description of client

This section should be brief but it should leave your audience oriented to the basic demographic information about your client.

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.

The problems you are addressing in your treatment

Tell your audience the problems you and your client are addressing in treatment. These may not include ALL of the problems listed in the reason for referral or all of the presenting problems.

History of the presenting problem

Think in terms the course of the problem(s) over time:
Remember that you are telling a kind of a story about your client. The events of the client’s problems unfold in a specific sequence. This sequence is referred to as the clinical time course or chronology. Think of it as the scaffold on which all the other details of the history of the problem(s) will hang. Elements of the time course should include:

· When did the problem(s) start? (Onset)

· How has it progressed over time?

· What is its current status?

Once you’ve established the time course, outline the factors that :

· make the condition worse

· relieve the condition, or make it improve

· Also – Outline any prior treatments for the condition and the condition’s response to those treatments

Initial mental status (Give your listeners an overall sense of these factors)

This is critical for inpatient clients. It is optional for other clients unless there are clear problems in certain areas that need to be delineated for your audience in order to have a more complete picture of you client.

I. General description

A. Appearance

B. Behavior and psychomotor activity

C. Attitude toward examiner

II. Mood and affect

A. Mood

B. Affect

C. Appropriateness

III. Speech (rate, quality, etc.)

IV. Perceptual disturbances (hallucinations – visual, auditory, tactile, olfactory)
*It any of these are present – please provide details about content, context and frequency.

V. Thought

A. Process or form of thought

B. Content of thought

VI. 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

VII. Impulse control

VII. Judgment and insight

IX. Reliability

Results of psychological tests (if administered)

Provide us with an overview of the results of these tests and the conclusions arrived at by the tester(s). We are particularly interested in hearing about cognitive (including achievement), personality, and clinical diagnostic test results that provide us with an understanding of the clients cognitive, affective, interpersonal, and behavioral assets, limitations, and motivational dynamics.

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.

Current diagnostic formulation:

DSM-5

Your clinical (theoretical) conceptualization of the case:

What is your theoretical framework for this case. What theories have you employed to explain the presence of this condition in your client’s life? What theoretical model has driven your treatment interventions? Please include your assessment of the cultural issues that play a role in explaining and treating this case.

Summary of services provided to date:

Please summarize the various type of individual, group, family, classroom, pharmacological and other interventions as appropriate. Explain your rationale for selecting the therapeutic model(s) you have employed with your client. Also, explain your rationale for the services you have requested for your client. For example, a psychiatric and medication consultation.

Give us a feel for the process of intervention as it has unfolded since you took responsibility for the case. Provide your listeners with some sense of the sequence of these intervention. In other words – tell the story of treatment for this client so far.

Clients response to these interventions:

Give a solid sense of what progress is being made – or not being made.

Tell your listeners about any particular problems you have encountered or continue to encounter in the treatment process.

Future intervention changes and plans:

Are there modification anticipated at this point in time. How will you and the client know when treatment is no longer required?

Other information you want to present about this case:

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