Comprehensive clinical case assessment & summary

Students will write a case study of a chemically dependent client including diagnosis, history of substance use, current use and symptoms, and current lifestyle information. Discuss at length your treatment approach and recommendations, including your rationale for both. Please be sure to follow the structure provided for the case study. The clinical case summary should present the pertinent background & clinical information on a client which will be used to inform and guide the treatment process. The clinical case summary is important for several reasons. It sets the stage for the client’s treatment services while also demonstrating the clinician’s ability to assess and formulate treatment recommendations. Team meetings and case presentations are an important aspect of the counselor’s work. The clinical case summary should include following the format presented below.

Requirements for Clinical Case Assessment Assignment

PART ONE: BACKGROUND INFORMATION ON CLIENT (client should have primary SUD)

Briefly, provide the most relevant facts to the following areas:

1. General Information– Fictional name, age, sex, marital status, ethnicity, education, occupation,

residence, and referral source. (African American)

2. Mental Status Exam– Cognitive functioning, appearance, dress, mood, orientation, contact with reality, affect.

3. Chief Complaint/Presenting Problem– Conditions and situation precipitating admission/visit.

4. History of Presenting Problem and Treatment Episodes– Comprehensive substance use history and symptoms. Include time spent obtaining the substance, route of administration, presence of withdrawal symptoms, and level of current use.

5. Medical, Physical & Mental Health History– Hospitalizations, emergency room visits, treatment, diseases, preventive health care, and high-risk potentials.

6. Social Assessments.

a. Family of Origin: Description of family, functionality, ACOA, and generational issues.

b. Marriage: History, current, spouse’s chemical use, and functionality.

c. Sexual History/Development: Development, preference, function, abused or abuser, HIV/STD risk.

d. Trauma and Losses: Emotional, physical, and others.

e. Social/Peer Relations: Support network, degree of social involvement, and skills.

f. Religion/Spiritual Orientation: Attitude, involvement, attendance, values, beliefs.

g. Financial status: Problems, the impact of chemical use and socioeconomic status

7. Legal Problems– History, current status, and pending charges.

8. Vocation and/or Education– Problems, performance, attitudes, and plans.

9. Collateral Information– All information from sources other than the client and past treatment records.

PART TWO: SUMMARY OF DIAGNOSIS, TREATMENT RECOMMENDATION

Based on the data from your biopsychosocial assessment presented in Part One:

1. Assessment Summary- Identify and substantiate your assessment by including a rationale for each

element of the diagnosis.

a. DSM-V diagnosis presented in narrative format (include all aspect of diagnosis)

2. Discussion of assessment data provided (was the client trustworthy? Do you believe the information to be accurate? What collateral information did you use? Was there a dynamic between therapist and client that may have affected the assessment process? How did you or could you have overcome this?)

3. Identification of additional data needed by the counselor to plan treatment for the client, including the use of any standardized screening measures that could have been used

4. Discussion of differential diagnosis: identify the diagnoses that are confirmed and the diagnoses that must be ruled out

5. Identification of stage of change and defenses used by the client, with the rationale provided

6. Identification of 3 short-term goals for the client

7. Identification of 3 long-term goals for the client

8. Detailed and specific treatment plan for the client

9. Discussion of ethical and cultural issues that may influence the counseling of the client

10. Discussion of potential countertransference issues that might arise if the student were to counsel this client

11. Based on your assessment and treatment recommendations, locate a treatment center within Maryland which you believe fit the treatment recommendations you provided for the client. Discuss why you chose the treatment center and the necessary steps needed to gain admission into the treatment program and level of care. Provide detailed contact information for this referral.

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