Primary Concern
Case Study Template
Date __________________________.
Student’s Fictitious Name _______________________________.
Counselor Intern Name _______________________________.
Student Demographics
Provide student’s age, ethnicity, grade level, gender, sexual orientation, religious or spiritual affiliation, and other identifying information.
Primary Concern
Provide a summary of the reasons for which a student is being seen. If student was referred, specify the source of the referral (parent, teacher, principal, and so on). Provide succinct history specifying dates and timeline of the primary issue.
Family
Provide a detailed description of the student’s family. Include immediate family members, siblings, primary care givers, socioeconomic status, housing, and primary language spoken in the home. Indicate occupations and marital status of parents. List additional information such as abuse or criminal history, if any.
Social Relationships
Describe current and past relationships with peers, teachers, and family.
Academic and Attendance History
Provide history of academic performance (grades) and attendance history, noting any recent changes (increased absence or decline in grades).
Mental Health and Medical History
Provide relevant information about the student’s mental health and medical history to include: diagnoses, medications, ongoing issues, and previous counseling services.
Support Plan Recommendation
Summarize the primary issues of concern, highlighting the student’s strengths, areas of concern, and counseling goals. Indicate recommendations for additional services such as outside referrals (individual and community support groups), school-based groups, or intervention services. Provide rationale to support recommendations.
Ethical and Legal Issues
Highlight all relevant ethical and legal issues as they relate to this case.
Interventions
List all relevant interventions that have been utilized to date.
Feedback
What specific feedback or support would you like from the group?
Capella Proprietary and Confidential