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ASSIGNMENT INSTRUCTIONS
CASE PRESENTATION ASSIGNMENT

The case presentation will be in oral and written formats across the program. In some courses,
you will only have to focus on certain aspects of the case presentation (e.g., assessment,
diagnosis, treatment planning, case conceptualization, etc.). This assignment is derived from the
Switzer and Rubin (2015), which is a required book across the curriculum. Your written paper
should be 10-15 pages not including title or reference pages, double-spaced (except in the
treatment plan chart), and follow APA professional guidelines format. You should have at least
five (5) academic sources, specifically in the diagnosis, case conceptualization, treatment
planning, and integration sections. Please be concise yet thorough in covering the information
requested.

Identifying Data

Date of Initial Assessment: Sexual Orientation:

PSEUDO Name (DO NOT use actual Race & Ethnicity:
client’s real name): Marital Status:
Age: Employment Status:
Gender:

Part I – Intake Information – 1-2 pages

Reason for Referral/Presenting Problem

In this section, offer the referral status (i.e., self-referred, school referral, court-ordered) and
provide the initial reason for the referral. This may be a triggering event such as a divorce, death,
pandemic, loss of employment, bullying, or client reported increase in signs, symptoms,
impaired functioning, etc. Ideally, offering direct quotes on how the client describes the reason.
This is one short paragraph in length. To protect the confidentiality of your client, please refer to
them by a pseudo name in your case presentation. This section should include a statement
indicating that you reviewed confidentiality and the limitations therein.

Confidentiality
This section should include a statement indicating that you reviewed confidentiality and the
limitations therein.

Source of Information
Provide the source and manner in which data was obtained in the preparation of this report. This
includes both formal and informal assessments in the summary as well as throughout the case
presentation as necessary to support your conclusions. A semi-structured interview is necessary
in this section, but you should also include a battery of formal and other assessments (e.g., DSM-
5 cross-cutting measures, GAD-7, PHQ-9, PCL-5, etc.).
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ASSIGNMENT INSTRUCTIONS
Part II: Assessment - 5-8 pages

Offer clinically relevant background information on the client. Write this out in paragraph format
– no bullet points. The section should include the following in this order:

Observational Data/Mental Status Exam

This section should include all components of the Mental Status Exam, including observations,
mood, speech, affect, cognition, perception, thoughts, behavior, insight, and judgment.

Psychometric Assessment
This section should include which, if any, assessments, inventories, or psychological scales were
used to assess the client along with their scores and results.

Biological Assessment
 Demographic Information: age, gender, sexual orientation, ethnicity, marital status,
children, etc.
 Sleep
 Diet
 Exercise
 Medical History
 Medication – include the reason for the medication.
 Other pertinent information (this could include history of developmental milestones,
sexual adjustment, pornography use, menstrual cycle for women, number of
pregnancies/births, fertility issues, testosterone levels for men, etc.)

Psychological Assessment
 Historical assessment – including whether the client has been to counseling in the past,
any psychiatric hospitalizations, or any previous mental health diagnoses
 Trauma history
 Addiction Screening, including substance use history: Description of client’s
alcohol/drug use, patterns of use, and last use; as well as how often client uses and how
much.
 Risk Assessment – include how you assessed the client’s risk.
 Family Mental Health History
 Piaget’s Theory of Cognitive Development

Social Assessment
 Cultural Factors - Does the client have any factors such as acculturation, discrimination,
etc. that impact the client and may be source of signs, symptoms? How would the client
explain the problem from their cultural lens?
 Family of Origin - identifying information about the client, parents, and siblings (i.e.,
ages, occupations, etc.). Client’s perception of the home environment and relationships
within the family. Critical family incidents may be included.
 Romantic partner dynamic – include any information about the client’s current
relationship that would be helpful.
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ASSIGNMENT INSTRUCTIONS
 Current Living Arrangements
 Academic History - Description of pertinent information in relation to educational
background including academic achievement, school instances that were significant for
understanding the individual and the client’s attitude toward education. Any assessment
information would be helpful.
 Occupational History: A description of the client’s vocational history. Emphasis should
be placed on current occupational functioning, history of work problems and reason for
change. Quality of work and satisfaction and interests.
 Erikson’s Psychosocial Stages – what stage is the client currently in and what stage
should the client developmentally be in according to Erikson’s theory?
 Current Social Support

Spiritual Assessment
 Spiritual/Religious History
 Present Spiritual/Religious Beliefs - Does client believe in God? Attend church? What
role does religious affiliation play in the client’s life? Are spiritual resources or issues
important to client? How does client describe God? What is the state of the client’s
spiritual awareness?
 Fowler’s Stages of Faith Development – What stage is the client currently in?
 Integration Assessment – Did you assess whether the client would like their spiritual
beliefs to be incorporated into the counseling process? In what specific ways would the
client like their beliefs incorporated (prayer, Scripture, spiritual discussion, etc.?)

History of Presenting Problem

Offer historical as well as present signs, symptoms, onset, duration, frequency, severity,
areas of dysfunction, and other relevant data that will be needed for diagnosis and case
conceptualization. Write this out in paragraph format – no bullet points. Do not include a
diagnosis here.

Barriers to Treatment/Success
Are there personality factors, stages of change influences, or contextual factors that would
influence the success of treatment?

Part III: Diagnosis – 1-2 pages

Principal Diagnosis – Primary diagnosis, including ICD-10 code, severity, specifiers, etc.
Diagnosis 2 or z-code – Diagnosis, ICD-10 code, severity, specifiers, etc.
Diagnosis 3 or z-code - Diagnosis, ICD-10 code, severity, specifiers, etc.
Differential Diagnosis - Be sure to include diagnoses that you are still assessing for to rule them
out (For example, you may be ruling out Generalized Anxiety Disorder, but the client has not yet
had anxiety for 6 months or longer, so you’re keeping it as a provisional diagnosis)

Offer all your diagnoses and z-codes in order of priority. Include the ICD-10 code, severity,
specifiers, etc. for each disorder. The first diagnosis is called the principal diagnosis. If the client
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ASSIGNMENT INSTRUCTIONS
does not meet all the criteria for a disorder and it is likely that they will if you had more
information, offer that it is provisional – ex: Generalized anxiety disorder (provisional).

Diagnosis Rationale

When writing up this section, make sure to offer each disorder criteria with case data to support
the diagnosis. For each diagnosis, offer a separate paragraph in the diagnostic
impression/rationale. Below are examples of incorrect and correct ways to write it up:
- Not correct– The client has marked fear about one or more social situations. The
individual fear that he will act in a way or show anxiety symptoms that will be negatively
evaluated (offered DSM criteria only).

- Not correct – The client is depressed and noted sadness during the interview. The client
isolated herself at home (problem, did not connect to DSM criteria).

- Correct – The client has marked fear in several social situations as evidenced by her fear
when presenting in class, turning in a paper, and speaking with classmates (A1). She is
fearful to speak up when feeling wronged by her supervisor, avoids chatting with co-
workers, and isolates herself at home when asked to attend social events (A2). Her fears
are founded on that she will act in ways that will be perceived negatively by instructors,
classmates, and coworkers(B3). Offer criteria and case study data to support it.

Make sure to use Z codes as needed that are found in the back of the DSM-5. At times if no
disorder is appropriate, a z-code may be what is principal diagnosis.
Make sure to offer a paragraph of z-codes in the diagnostic impression/rationale.

The first paragraph is only for the principal diagnosis, the next paragraph is on the second
disorder, and then additional paragraphs are for the other disorders. Each paragraph is to focus
on only one disorder. It is like building a court defense. If your records are subpoenaed or you
transfer a client to another counselor, they are not questioning your diagnosis as being incorrect,
inconclusive based on the diagnostic discussion. For the final paragraph, discuss your differential
diagnosis.

This section should include a concise rationale for each diagnosis, differential diagnoses, and Z
codes provided above.

Part IV– Case Conceptualization – 1-2 pages

Theoretical Orientation

This should be one paragraph where one theory is chosen, the major concepts are explained, and
shown to be evidence-based using peer-reviewed journals.

Narrative of the Case Conceptualization

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ASSIGNMENT INSTRUCTIONS
Use the key terms and constructs of your chosen counseling theory to explain (not describe as the
DSM-5 does) the clinical problems and maintaining factors. This section should bring together
your biopsychosocialspiritual assessment and explain your understanding of the client and the
underlying factors that are contributing to the problems. This section should not include new
information that is not already identified in your assessment. From your assessment, do you see
the presenting problem stemming from the client’s biological, psychological, social, spiritual, or
a combination of some of these factors? Explain that conceptualization in this section.

Based on your conceptualization, which theory of counseling will you be using with this client?
This section should reference and apply sources for application of theory such as counseling
theories books, journal articles, etc.

Part V - Spiritual Integration – 1-2 pages

This entire section should be a reflection about integration. It should include the following
subsections:

Personal Integration Approach

Which integration approach are you using with this client as described by Johnson’s (2010)
Psychology and Christianity: Five Views or Entwistle’s (2015) Integrative Approaches to
Psychology and Christianity. (This subsection can be the same for Practicum, Internship 1, and
Internship 2 if it has not changed.)

Implicit Integration
Include how you implicitly integrate faith into this client’s counseling in an ethical manner.

Explicit Integration
Include how you explicitly integrate faith into this client’s counseling in an ethical manner. If
the client does not desire their faith to be integrated, it would be appropriate to state this and cite
the relevant ACA Code of Ethics (2014).

Part VI – Treatment Plan – 1-2 pages

Include the following treatment plan table:

Treatment Plan

Problems
1. Write out the client’s problems by order of problem (1. GAD – anxiety, restlessness, etc.;
2. Major Depressive Disorder – depressed mood, trouble concentrating, etc.)
2. You may have more than one problem to write out. For example, if you used the
Descriptive-Diagnostic Approach (Switzer & Rubin, 2015, p. 91) with major depressive
disorder, generalized anxiety disorder, and Z62.820 parent-child relational problem, then
write out these three problems (1, 2, 3).

Goals for Change

1. First problem here
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ASSIGNMENT INSTRUCTIONS
 Write up specific, measurable (e.g., reduce, eliminate, increase, etc.) outcome goals.
2. Second problem here
 Write up the next set of specific, measurable outcome goals for this problem.

Objectives & Therapeutic Interventions

Offer your theory here and estimate treatment length based on the severity of the problems.
For example, mild depression may be resolving in 5 to 10 weeks, but personality disorder in 5
to 10 years. If the client was depressed and had a personality disorder, you would treat the
depression first and then the personality disorder. Also, within each problem you would tier
the approach (e.g., you would not attempt to do cognitive restructuring without first offering
education on the cognitive model, identifying the problematic situation, and conditional
assumptions). Offer citations here that are used to support the interventions used (e.g., Jones &
Jones, 2020) and offer full citations in references below. If the client has requested spiritual
integration, be sure to include those spiritually relevant objectives and interventions.
1. Offer the first problem here.
 Write the first objective (client will do…)
 Write your theoretically interventions (counselor will do…)
 Next intervention (as many interventions as needed to meet the objective).
 Write the second objective (client will do…)
 Write your theoretically interventions (counselor will do…)
 Next intervention (as many interventions as needed to meet the objective).

2. Second problem as needed

 Write up the next step of tiered objectives and theoretically based interventions.

Outcome Measures of Change

Offer what the changes would look like for the client (increased euphoric moods,
attentiveness, prosocial behaviors) as measured by…
 Offer how you will measure when the outcomes have been met.
 As practicum and internship students, you should be using both formal and informal
assessments (e.g., PHQ-9, GAD-7, PCL-5, self-report, etc.).

References
(on separate page per APA 7)