Age Race, ethnic identification Socio-economic status Marital status Family constell
- Identifying information: (this section should be brief – simply give the reader a “snapshot” of who the client is)
- Age
- Race, ethnic identification
- Socio-economic status
- Marital status
- Family constellation
- Gender
- Education/Occupation
- Religion
- Nature of presenting problem: (In the first sentence state succinctly what the presenting problem is; then continue describing the details of the problem.)
- History
- Duration
- Frequency
- Exceptions to the problem
- Consequences
- Antecedents
- Other problems which contribute to the presenting problem
- Client functioning:
- Physical/medical
- Emotional/Behavioral
- Roles & adjustment to roles
- Social/Interpersonal
- Cognitive/Intellectual
- Client strengths & resources: Identify assets possessed by the client that could assist them in resolving problems (think “strengths-based perspectives; Saleeby, 1992).
- Interpretive Summary: Student’s impressions/hypothesis re: the problem based on the data (This is where you synthesize or put all of the information together for your analysis—not simply regurgitate the facts. Look for themes, underlying issues, explanations, etc. Critical thinking is important here!)
- Treatment goals and objectives: Include 1-2 goals and 3-4 objectives for how those goals are to be met. Make sure that these are consistent with your interpretation of the problem and with evidence-based practices for that problem.
- Evaluation: “Goal attainment scaling” is a common approach to measuring client outcomes in relation to a client’s subjectively chosen treatment goals. Identify an appropriate “goal attainment” measure to introduce to the client and describe your chosen scales’ properties. As part of this effort, please also describe how your chosen measure will be deployed to assess the effectiveness of the intervention from both the assessment to post treatment. As part of your response, please also discuss how you would use a single subject design to meet your evaluation ends.
- Rationale for treatment objectives: Explain to the reader why you are using particular objectives to meet treatment goals (hint: go to the literature and cite evidence-based practices and/or describe the unique circumstances of the client).
- Self-reflection: Briefly describe what you believe to be the strengths and weaknesses of your assessment skills. This should include professional demeanor, rapport building, insight, flexibility, judgment, etc. Also address any ethical issues that arose or could potentially arise in this case (i.e. personal biases, boundaries, etc.)
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