3298-CasePresentationOutlineRev819

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South America University *

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CASE PRESENTATION OUTLINE APA formatting, double spacing, and including a cover page, reference page, and running head is required for final document. Demographics Include age, gender, ethnicity, living situation, circumstances of your involvement, etc. For macro practice, include a brief description of the agencies, organizations, or groups involved. Key findings/Presenting Problem Give details of the current situation relevant to understanding why this situation is a case. For example, give signs and symptoms of illness, environmental factors that impinge on the situation, and actual or potential resources within the situation. Background Give relevant history. For example, events that happened years ago may help clarify the current situation, or the situation may have arisen suddenly without obvious historical causes. Diagnosis of Student/Client This assignment calls for extensive use of the DSM 5 manual. Diagnoses must be justified using specific DSM 5 standards. Please address each one. Consider Clinical Diagnosis(es): Include specific DSM 5 symptoms observed or reported-your answer must meet DSM 5 diagnostic criteria Provisional Diagnoses (if needed): Include specific DSM symptoms observed or reported, if any. Theoretical Application Describe your understanding of the reasons things are as they are. This should reflect one or more theoretical perspectives (cite resources) and how you are utilizing it in session. It may appropriately reflect uncertainty or ambivalence. Interventions and Plans Describe what you have done and what you plan to do with the client/student that is therapeutically relevant. Include formal (if accessible) and informal (ex. Likert scale of level of anxiety, anger, depression, etc.) assessments. You should be doing some sort of informal check in scale for the purposes of this assignment. Identify two goals with three client steps and three counselor steps under each goal. Identify how your interventions are theoretically based. Revised Summer 2019

Goal 1: Client Step One Client Step Two Client Step Three Counselor Step One… Ethical/Multicultural Considerations What are relevant ethical and legal considerations regarding client, assessment, and plan? Note at least three ACA ethical standards by specific codes and how those apply to your case and you specifically. Also, note three AMCD standards by specific codes and how those apply to your case and you specifically. Personal Limitations in Practice Consider your personal limitations as a counselor in training, dual relationships, self-care, etc. What are the limitations to your practice and your plan to address those limitations? Reason for Presentation Explain your rationale for selecting this case. Does it present a unique challenge or an unusual problem? Does it illustrate the effectiveness of an intervention? Do you need help with the case, or are you presenting it so others can learn from your experience? Three questions for the class. Questions can be with regard to the skills you are using, how you are approaching the client, next steps, possible interventions, etc. Questions may also be directed specifically to the portion of tape you are going to share. MUST INCLUDE AN APA FORMATTED REFERENCE PAGE Revised Summer 2019

SAMPLE CASE PRESENTATION Demographics J.J. is a 37 year old male with a Spanish surname referred to the program following a positive test for marijuana at his place of employment. He works on the crew of an oil rig. He currently lives alone after being kicked out of his apartment by his wife of five years. He has no children from the current relationship but has a 15-year-old son from his first marriage. He denies any particular religious or spiritual orientation but acknowledges having been raised in the Catholic Church. He speaks Spanish and English, and he reports associating primarily with people who speak Spanish. Key findings The client denies using marijuana. He says he was at a party where some people were smoking, and that he must have tested positive because of their use. He acknowledges drinking several beers at parties like these, but denies that alcohol is an issue for him. He says he does not know why his wife kicked him out other than that “she’s a bitch.” He does not see his son or his first wife. His longest employment is about two years—on his present job—and he acknowledges having been fired on “a few” occasions, but does not acknowledge why. He says he is willing to complete a CD program just “to get them off my back,” but insists that he does not have any problems that need attention. Background The client was raised primarily by his mother and older sisters after his father left the family when the client was about four. He did not see his father much after that. He reports average grades in school until he dropped out in the 10 th grade to hang out with his friends. He did not finish high school and has not completed a GED. He has had several jobs, all of which apparently involved manual labor. He reports “a few” arrests for alcohol related crimes; the most recent was five years ago for DUI. He has never been in treatment. Diagnosis from DSM: Client has met the DSM 5 diagnostic criteria for: F41.1 Generalized Anxiety Disorder. A) Ct. reported to have excessive anxiety and worry for over 6 months B) Ct. reported that the anxiety id difficulty to control C) Ct. reported that the worry is associated with being easily tired, having difficulty concentrating, and having trouble sleeping D) Ct. reported that the symptoms cause clinically significant distress in work areas of functioning E) The reported symptoms are not better explained but a medical condition or drug use F) The reported symptoms are not better explained by another mental disorder Revised Summer 2019

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Interventions and Plan Goal 1: I attempted to develop rapport through the use of active listening and reflection. The plan is to continue assessment, and through motivational interviewing, attempt to identify an area that the client considers a concern. Allow him to participate in an outpatient CD program to avoid adverse consequences at work, to enhance the likelihood that he will learn some new social skills, and to give opportunity to form a new social network. Ethical/Multicultural Considerations ACA specific Code 1: List Code and how it applies specifically to me and my case ACA specific Code 2: See above ACA specific Code 3: See above AMCD specific Code 1: List Code and how it applies specifically to me and my case AMCD specific Code 2: See above AMCD specific Code 3: See above Personal Limitations in Practice Reasons for Presentation Although this case appears routine, I am concerned that I may be overlooking something or that a different formulation of the case might produce a better chance for a positive outcome. Questions for the Class: Question 1: Question 2: Question 3: Revised Summer 2019

Revised Summer 2019

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