Management

Case Conceptualization Summary Statement- this section should include your understanding of how you would ‘pull together’ the different aspects of the client’s presentation, along with the theoretical model that would benefit the client based on your understanding of the client’s presenting problems at this time. Please see the Sperry article these documents expand on the Integrative Model (Scott et.al, 2015). The Sperry article provides a more detailed explanation of how to implement this Integrative Model in the development of your case conceptualization summary statement.
Theoretical Orientation and Research/Evidence-based treatment- describe the theoretical orientation you are using to guide your work with this client (. Support your theoretical selection with evidence-based research as well as how this theory informs your treatment planning (5-7 citations from peer-reviewed literature should be listed in the reference section).
Ethical Issues- What ethical considerations were addressed or considered in this client’s case?
Multi-cultural Factors- this section should include multi-cultural considerations. Discuss cautions or perspectives that this culture might have. Provide information that indicates that you recognize the cultural diversity.
Assessment- This should include baseline data from scaling during session one on the presenting problem and a chart including the level on the scale in subsequent sessions, clients attributions of improvements and/or and the various treatment interventions used and content from assessments (such as a genogram, Beck Depression Inventory, etc.) if they are used. (Note: Helpful online assessments for your consideration include the Cross-Cutting Symptom Survey (Level One and Two); https://www.psychiatry.org/psychiatrists/practice/dsm/educationalresources/assessment-measures and WHODAS http://www.who.int/classifications/icf/whodasii/en/ ) termination and even during counseling such as community resources for housing, etc.
Referral/Access- this section should include additional resources for the client after
Prognosis- what is your prediction of the likely course, duration, severity, and outcome with or without treatment. Your prognosis may range from excellent, good, fair, guarded, to poor.