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Comprehensive Case Conceptualization Template

Comprehensive Case Conceptualization Template

Comprehensive Case Conceptualization Template

Attached you will find the requirements to complete this assignment.  Use the template provided in order to complete the assignment.  Please read all attachment you will only complete the first section as described in the rubric. Comprehensive Case Conceptualization Template

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    MHC610ClientCaseFileCharlesCJJones.pdf

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    MHC 610 Client Case File Charles “CJ” Jones You are a counselor in an on-campus counseling center. Charles “CJ” Jones is a 21-year-old, single, straight, African American and Lakota man who sought treatment because he “feels lost,” withdrawn from friends, and “worried about money.” He said he had been feeling increasingly depressed for two months, and he attributes this to two essentially concurrent events: the end of a three-year romantic relationship (four months ago) and being unable to find his ideal employment situation. Mr. Jones has been on a job search for around five months. Mr. Jones has supported himself financially since high school and is accustomed to feeling nervous about making ends meet. He has become more worried after breaking up with his longtime live-in girlfriend, so he approached a family friend for financial help. He was turned down, leading him to feel alone in his financial struggles. This disappointment revived long-standing anger and sadness about not feeling close to and supported by either of his parents. His friends taunted him for “falling apart” over wanting to be financially stable saying, “We’re young. You have time to figure this out!” Mr. Jones is a full-time undergraduate student in his final year of college studying computer science; he also works full-time as a midnight-shift warehouse worker. When he finishes his early-morning shift, he finds it hard to “slow down,” and he has trouble sleeping. He has been looking for work daily and applies for jobs that are less physically demanding, with more flexible hours, but never gets past the phone call or interview. His appetite is unchanged, and his physical health is good. His grades have recently declined, and he has become increasingly discouraged about money and about being single. He has not previously sought mental health services, but a supportive cousin suggested seeing a counselor. Mr. Jones was raised as an only child by his mother and her extended family who all identify as African American. Mr. Jones reports that his extended family identifies as Baptist and, in his youth, he spent some time with family members at church; however, he now identifies as spiritual rather than religious. Mr. Jones describes that he has been drawn to exploring the spiritual beliefs and practices of the Lakota Nation. Mr. Jones regularly keeps in touch with his maternal extended family. Growing up, Mr. Jones mentioned he was a “good student and popular kid.” High school was complicated by his mother’s two-year period of unemployment and his experimentation with alcohol and marijuana. He recalled several heavy drinking episodes at age 14 and first use of marijuana at age 15. He smoked marijuana daily for much of his junior year and stopped heavy use under pressure from a girlfriend. At the time of the evaluation, he had “an occasional beer” and limited marijuana use to “being social” several times a month. Mr. Jones described his childhood as “normal,” and that while he had a very close relationship with his mother, it deteriorated in his adolescence. Mr. Jones’s mother decided that he should move out when he finished high school. She was dating a man she subsequently married and wanted time alone with this man. She was clear about her feelings that he needed to be more independent from her and that it was “finally her turn.” Mr. Jones’s father left shortly before his birth, telling his mother, “I didn’t sign on for this.” She relayed this story to him often in his childhood. On examination, Mr. Jones is punctual, cooperative, pleasant, attentive, appropriately dressed, and well groomed. He speaks coherently. He appears generally worried and constricted, but he did smile

     

     

     

    2

    appropriately several times during the interview. He has a quiet, dry sense of humor. He denied suicidality, homicidality, and psychosis. He’s cognitively intact, and his insight and judgment were considered good. In your first session, Mr. Jones communicated to you that as a young biracial man, he is generally expected to be strong and independent, and norms of masculinity have made him hesitant to attend counseling. He further expressed that his family views counseling as something that is only for “crazy people.” He informs you that there may be individuals in his family struggling with addiction and other mental health concerns who are not receiving treatment. Comprehensive Case Conceptualization Template

     

    • MHC 610 Client Case File Charles “CJ” Jones
  • attachment

    MHC610ComprehensiveCaseConceptualizationTemplate.docx

    MP_SNHU_withQuill_Horizstack

    MHC 610 Comprehensive Case Conceptualization Template

     

    Instructions: Complete this template by replacing the bracketed text with the relevant information. Do not delete any boxes from this form, and be sure to remove the Guidance sections from your treatment plan before submitting the final version of your project.

     

    Student Name: [Insert text]
    Final Project Part One
    Theoretical Orientation and Integrated Personal Approach
    [Describe your integrated personal approach or single theoretical orientation. If you use a model such as nondirective vs. directive play therapy, the adaptive information processing model, or another method for structuring your sessions and counseling goals, please specify this.]

     

    Guidance

    In this section, describe (1) how you use your theory to help you conceptualize the client’s problems, and (2) how you use your theory to guide you in developing a treatment plan and providing counseling to the client.
    Background Information

    [Include demographics, age, disability, religion, social class, sexual orientation, indigenous background, national origin, gender identity, family unit, highest level of education, employment, military background, current and past legal issues, relationship status/social history, and substance abuse and treatment history if applicable.]

     

    Guidance

    Provide an overview of the client’s history, including demographics, family dynamics and history, work and education history, cultural considerations, key moments in the client’s life (both positive and negative), early childhood memories, medical history, career, and any other relevant information that will help you better understand the unique person who is your client. For example, some clients may have a military background, current or past legal issues, and/or other unique experiences.
    Comprehensive Overview of Presenting Concerns
    Presenting Concerns: [Describe the problem, explain the symptoms, note the intensity and frequency of the symptoms, identify potential harmful behavior, and note if there is family history.]
    Current Triggers: [Describe triggers that activate the pattern, resulting in the presenting problem.]

     

    Guidance

    Based on the client’s history from the Background Information section and the history of the client’s problems, describe the triggers (e.g., events, behaviors, sights, sounds, smells, etc.) that activate or intensify the client’s problems.
    Promoters: (Triggers (e.g., events, behaviors, sights, sounds, smells, etc.) that activate one’s patterns of behavior, resulting in the presentation)
    Maladaptive Patterns: [Describe inflexible, ineffective manner of perceiving, thinking, acting.]

     

    Guidance

    Based on the Background Information and Current Triggers sections, describe the client’s current and past responses (thinking, feeling, and behaving) to the problem that have been ineffective. Comprehensive Case Conceptualization Template
    Developmental Influences: [Describe factors fostering adaptive or maladaptive functioning; be sure to reference the human development theory you used to guide your information gathering.]

     

    Guidance

    Include the past history of the issues that brought the client to counseling, and use a timeline or your human development theory stages to organize the background: theories of individual and family development across the lifespan.
    Protective Factors: [Describe biopsychosocial/spiritual factors that mitigate risk and support adaptive management of stress.]

     

    Guidance

    Based on the Background Information and Current Triggers sections, describe the client’s current and past responses (thinking, feeling, behaving) to the problem that have been effective. Describe any other client strengths that could be developed into protective factors for current and future problems.
    Co-occurring Disorders: [Describe issues with addictions and mental health issues, if applicable. Assessment of the issues that includes neuro-bio factors organized with the stages of change is required.]
    Mental Status Exam: [Note whether the client was on time; their behavior, attitude, and orientation to person, place, time, and situation; their mood, affect, tone of voice, rate of speech, judgment, and memory; their suicidal or homicidal ideation; and any observable symptoms/behaviors.]

     

    Guidance

    Summarize the results of the mental status evaluation of the client, including the following: Note whether the client was on time; their behavior, attitude, and orientation to person, place, time, and situation; their mood, affect, tone of voice, rate of speech, judgment, and memory; their suicidal or homicidal ideation; and any observable symptoms/behaviors.
    Cultural Considerations
    Cultural Identity: [Describe sense of belonging to a particular group (i.e., race, ethnicity, gender, sexual orientation, etc.).]

     
    Cultural Stressors: [Describe level of adaptation to the dominant culture, and stress-rooted acculturation including psychosocial difficulties. Focus on minority stress, marginalization…What does this mean to you?]

     

    Guidance

    What are present stressors affecting your client’s cultural identity? Consider the impact of multiple minority statuses, marginalization, stress-rooted acculturation, psychosocial difficulties, institutional and social barriers, biases, power, and privilege.
    Cultural Influencers: [Describe beliefs regarding cause of distress, condition, or impairment.]

     

    Guidance

    Using a cultural lens, what are your client’s beliefs regarding the cause of their distress, condition, or impairment?
    Personality Patterns: [Describe operative mix of cultural and personality dynamics.]
    Summary
    Theory-Driven Case Summary: [Outline the history of the client’s problems, referring to the overview of the client’s history, including the client’s strengths and barriers (from the Background Information section) and your theoretical orientation (from the Theoretical Orientation and Integrated Personal Approach section), including both counseling and human development theories.]
    Summary of Conceptualization Presented to the Client: [Write the script of what you will say to the client to offer a brief explanation of the conceptualization, and present the conceptualization to the client in language free from jargon so that they can correct and confirm the summary. Also add your theoretical orientation and integrated personal approach and focus on the object of change. For this section, you need to write up an explanation about the counseling process. You are informing the client about the steps you will take to assist them in addressing their objects of change.]
    Final Project Part Two
    Diagnosis
    Primary Diagnosis and Justification: [List both the ICD and DSM-5 codes. What is the overall descriptor of the diagnosis? What criteria are met, and what behaviors are used to meet diagnostic criteria? What are the cultural considerations?]
    Assessments: [List all of the assessments you used to justify this diagnosis.]
    Secondary Diagnosis and Justification: [List both the ICD and DSM-5 codes. What is the overall descriptor of the diagnosis? What criteria are met, and what behaviors are used to meet diagnostic criteria? What are the cultural considerations?]
    Assessments: [List all of the assessments you used to justify this diagnosis.]
    Tertiary Diagnosis and Justification: [List both the ICD and DSM-5 codes. What is the overall descriptor of the diagnosis? What criteria are met, and what behaviors are used to meet diagnostic criteria? What are the cultural considerations?]
    Assessments: [List all of the assessments you used to justify this diagnosis.]
    Additional Diagnosis and Justification: [What is the overall descriptor of the diagnosis? What criteria are met, and what behaviors are used to meet diagnostic criteria? What are the cultural considerations? This is where you will list all applicable V codes that are related to the complete diagnosis.]
    Assessments: [List all of the assessments you used to justify this diagnosis.]
    Final Project Part Three
    Client-Centered Goals
    Goal 1: [List long-term goal targeting an element of the presenting problem and/or part of the diagnosis that is agreed upon between the client and counselor using the SMART format.]
    Objective 1 of Goal 1: [List a short-term goal that is a smaller element of the stated long-term goal that is agreed upon between the client and counselor.]
    Intervention 1: [Describe what specific intervention the counselor will use and what is expected of the client to promote growth toward the objective (e.g., “Will use early recollections from Adlerian theory; Lifestyle Assessment to assist the client in discovering the guiding fictions they decided at an early age”).]
    Intervention 2: [Describe what specific intervention the counselor will use and what is expected of the client to promote growth toward the objective.]
    Intervention 3: [Describe what specific intervention the counselor will use and what is expected of the client to promote growth toward the objective.]
    Objective 2 of Goal 1: [Insert text]
    Intervention 1: [Insert text]
    Intervention 2: [Insert text]
    Intervention 3: [Insert text]
    Objective 3 of Goal 1: [Insert text]
    Intervention 1: [Insert text]
    Intervention 2: [Insert text]
    Intervention 3: [Insert text]
    Goal 2: [Insert text]
    Objective 1 of Goal 2: [Insert text]
    Intervention 1: [Insert text]
    Intervention 2: [Insert text]
    Intervention 3: [Insert text]
    Objective 2 of Goal 2: [Insert text]
    Intervention 1: [Insert text]
    Intervention 2: [Insert text]
    Intervention 3: [Insert text]
    Objective 3 of Goal 2: [Insert text]
    Intervention 1: [Insert text]
    Intervention 2: [Insert text]
    Intervention 3: [Insert text]
    Prognosis
    Guidance

    [In this section, summarize the likely course, duration, and outcome of the mental health condition with and without treatment.]
    Reevaluation of Treatment Plan
    Guidance

    [In this section, identify the importance of assessing the goals you developed for your client. Also, describe how you will reevaluate your treatment plan and how often this reevaluation process will happen.]
    SOAP Note
    Guidance

    [In this section, you will have to use your imagination on the likely progression of a session and objective behavioral presentation of your client. SOAP notes describe subjective observations, objective observations, assessment, and plan.]

     

     

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  • attachment

    MHC610ComprehensiveCaseConceptualizationSectionOneDraftGuidelinesandRubric.pdf

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    MHC 610 Comprehensive Case Conceptualization Section One Draft Guidelines and Rubric

    Overview: This activity will allow you to reflect on past work regarding case conceptualization. These final projects are complex, so it’s essential that you have time to digest these materials. This draft is an opportunity for you to have your questions and concerns addressed by the instructor. Prompt: In this activity, you will begin exploring and working with the Comprehensive Case Conceptualization Template (CCC Template). In Week Two, you will provide a draft of the following components of the first section: theoretical orientation and integrated personal approach, background information, mental status exam, comprehensive overview of presenting concerns, cultural considerations, theory driven case summary, and summary of conceptualization presented to the client. Include questions or requests for specific feedback. Specifically, the following critical elements must be addressed:

    I. Theoretical Orientation and Integrated Personal Approach: Summarize your integrated personal approach or single theoretical orientation to counseling and describe the background information of the client.

    II. Comprehensive Overview of Presenting Concerns: Describe the client’s presenting concerns, triggers, promoters, maladaptive patterns, developmental influences, protective factors, co-occurring disorders, and MSE.

    III. Cultural Considerations: Describe the client’s cultural identity, cultural stressors, cultural influencers, and personality patterns. IV. Theory Driven Case Summary: Provide a theory driven case summary, and summarize the conceptualization and address the level of care and advocacy

    the client will need. V. Review additional components of the CCC Template and treatment planning form and identify any sections that remain unclear. Identify questions or

    requests for specific feedback related to that component.

    Rubric Guidelines for Submission: Please use the Comprehensive Case Conceptualization Template for this assignment. You can find this template in the required resources for Week One.

    Critical Elements Proficient Needs Improvement Not Evident Value

    Theoretical Orientation and Integrated Personal Approach

    Describes the integrated personal approach or single theoretical orientation and background information of client (100%)

    Describes some but not all of the integrated personal approach or single theoretical orientation and background information of client (70%)

    Does not describe the integrated personal approach or single theoretical orientation and background information of client (0%)

    25

     

     

     

    2

    Critical Elements Proficient Needs Improvement Not Evident Value

    Comprehensive Overview of Presenting Concerns

    Describes the client’s presenting concerns, triggers, promoters, maladaptive patterns, developmental influences, protective factors, co-occurring disorders, and MSE (100%)

    Describes some but not all of the presenting concerns, triggers, promoters, maladaptive patterns, developmental influences, protective factors, co-occurring disorders, and MSE, but lacks detail or contains inconsistencies (70%)

    Does not describe the presenting concerns, triggers, promoters, maladaptive patterns, developmental influences, protective factors, co-occurring disorders, and MSE (0%)

    25

    Cultural Considerations Describes the client’s cultural identity, cultural stressors, cultural influencers, and personality patterns (100%)

    Describes some but not all of the client’s cultural identity, cultural stressors, cultural influencers, and personality patterns (70%)

    Does not describe the client’s cultural identity, cultural stressors, cultural influencers, and personality patterns (0%)

    25

    Theory Driven Case Summary Provides a theory driven case summary, and summarizes the conceptualization and addresses the level of care and advocacy the client will need (100%)

    Provides a theory driven case summary and summarizes the conceptualization and addresses the level of care and advocacy the client will need, but lacks detail (70%)

    Does not summarize the conceptualization and address the level of care and advocacy the client will need (0%)

    10

    Questions or Requests for Specific Feedback

    Identifies questions or requests for specific feedback related to the chosen component (100%)

    N/A Does not identify questions or requests for specific feedback related to the chosen component (0%)

    5

    Articulation of Response Submission has no major errors related to APA citations, grammar, spelling, syntax, or organization (100%)

    Submission has major errors related to APA citations, grammar, spelling, syntax, or organization that negatively impact readability and articulation of main ideas (70%)

    Submission has critical errors related to APA citations, grammar, spelling, syntax, or organization that prevent understanding of ideas (0%)

    10

    Total 100%

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    MHC610FinalProjectPartOneGuidelinesandRubric.pdf

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    MHC 610 Final Project Part One Guidelines and Rubric: Assessment

    Overview The final project for this course is the creation of a treatment plan, also known as a comprehensive case conceptualization. The final project is broken into four smaller submissions. The assessment portion of the treatment plan is the first submission for your final project. It is suggested that you use what you have developed using the client’s case study in the assessment course to now fill in the sections of the treatment plan due in Week Three. Your next submission is due in Week Four and will consist of the diagnosis portion of the treatment plan. You will need to apply feedback from both of those submissions to submit the final treatment plan in Week Nine. Please note that Part One and Part Two of the final project will need to be submitted in Week Nine to inform the treatment, but they will not be regraded. In this assignment, you will demonstrate your mastery of the following course outcomes:

     MHC-610-01: Evaluate legal, ethical, and contemporary issues as they relate to treatment planning

     MHC-610-02: Apply principles of advocacy toward promoting culturally competent counseling as it supports treatment planning

     MHC-610-07: Evaluate culturally specific assessment strategies to inform client-centered treatment goals

    Prompt Specifically, you must address the critical elements listed below. Most of the critical elements align with a particular course outcome (shown in brackets).

    I. Presenting Concerns [MHC-610-07] A. Identify the presenting problem and characteristic response to precipitants.

    II. Current Triggers and Promoters [MHC-610-07] A. Determine the client’s current triggers that activate the pattern, resulting in the presenting problem.

    III. Maladaptive Pattern [MHC-610-07] A. Determine the maladaptive pattern that causes the inflexible, ineffective manner of perceiving, thinking, acting.

    IV. Developmental Influences [MHC-610-07] A. Determine the developmental influences that create factors fostering adaptive or maladaptive functioning.

    V. Protective Factors A. Identify protective factors that are presented in the information collected.

    VI. Cultural Identity [MHC-610-07] A. Describe the sense of belonging to a particular ethnic group in the client.

    VII. Cultural Stressors [MHC-610-07] A. Identify the level of adaptation to the dominant culture and stress-rooted acculturation, including psychosocial difficulties the client is

    demonstrating.

     

     

     

    2

    VIII. Cultural Influencers [MHC-610-07] A. Describe the beliefs regarding cause of distress, condition, or impairment the client is describing.

    IX. Mental Status Exam [MHC-610-01] A. Describe the operative mix of cultural and personality dynamics that the client is experiencing.

    X. Summary of Conceptualization Presented to the Client [MHC-610-02] A. Summarize the conceptualization and address the level of care and advocacy this client will need.

     

    Final Project Pathway Final Project Part One Submission: Assessment In Week Three, you will submit the assessment portion of the treatment plan. It should be a complete, polished artifact containing all the critical elements of the final product. This submission will be graded with the Final Project Part One Rubric. Final Project Part Two Submission: Diagnosis In Week Four, you will submit the diagnosis portion of the treatment plan. It should be a complete, polished artifact containing all the critical elements of the final product. This submission will be graded with the Final Project Part Two Rubric. Final Project Part Three Submission: Treatment Plan In Week Nine, you will submit your finished treatment plan. It should be a complete, polished artifact containing all the critical elements of the final product, along with the assessment and diagnosis portions completed in Parts One and Two. Note that the assessment and diagnosis portions will not be graded in Week Nine, but they will inform the treatment plan. This submission will be graded with the Final Project Part Three Rubric. Final Project Part Four Submission: Reflection In Week Ten, you will submit your reflection on the treatment plan. This will be done using the Q&A tool within Bongo. This submission will be graded with the Final Project Part Four Rubric. Comprehensive Case Conceptualization Template

     

     

    3

    Final Project Part One Rubric Guidelines for Submission: Use the Comprehensive Case Conceptualization Template, linked in the Resources section of Week One, to complete this assignment. The assessment portion of the treatment plan must be filled in using information from the client case study. You may use your final project from the assessments course, but you will need to transfer the information into the Comprehensive Case Conceptualization Template for submission.

    Critical Elements Exemplary (100%) Proficient (90%) Needs Improvement (70%) Not Evident (0%) Value

    Presenting Concerns [MHC-610-07]

    Meets “Proficient” criteria and provides keen insight into the precipitants presenting concerns

    Identifies the presenting problem and characteristic response to precipitants

    Identifies the presenting problem and characteristic response to the precipitants, but lacks detail or contains inconsistencies

    Does not identify the presenting problem and characteristic response to precipitants

    10

    Current Triggers and Promoters

    [MHC-610-07]

    Meets “Proficient” criteria and illustrates a sophisticated explanation of the client’s current triggers

    Determines the client’s current triggers that activate the pattern resulting in presenting problem

    Determines the client’s current triggers that activate the pattern resulting in presenting problem, but lacks detail or contains inconsistencies

    Does not determine the client’s current triggers that activate the pattern resulting in presenting problem

    10

    Maladaptive Pattern [MHC-610-07]

    Meets “Proficient” criteria and illustrates a sophisticated explanation of the client’s maladaptive pattern

    Determines the maladaptive pattern that causes inflexible, ineffective manner of perceiving, thinking, acting

    Determines the maladaptive pattern that causes inflexible, ineffective manner of perceiving, thinking, acting, but lacks detail or contains inconsistencies

    Does not determine the maladaptive pattern that causes inflexible, ineffective manner of perceiving, thinking, acting

    10

    Developmental Influences

    [MHC-610-07]

    Meets “Proficient” criteria and provides keen insight as to how those developmental influences foster maladaptive functioning

    Determines the developmental influences that create factors fostering adaptive or maladaptive functioning

    Determines the developmental influences that create factors fostering adaptive or maladaptive functioning

    Does not determine the developmental influences that create factors fostering adaptive or maladaptive functioning

    10

    Protective Factors [MHC-610-07]

    Meets “Proficient” criteria and provides keen insight into how the protective factors affect the client

    Identifies protective factors that are presented in the information collected

    Identifies protective factors that are presented in the information collected, but contains gaps or inaccuracies

    Does not identify protective factors that are presented in the information collected

    10

    Cultural Identity [MHC-610-07]

    Meets “Proficient” criteria and illustrates a sophisticated awareness of how the client’s cultural identity influences the client

    Describes the sense of belonging to a particular ethnic group in the client

    Describes the sense of belonging to a particular ethnic group in the client, but contains inaccuracies

    Does not describe the sense of belonging to a particular ethnic group in the client

    10

     

     

     

    4

    Critical Elements Exemplary (100%) Proficient (90%) Needs Improvement (70%) Not Evident (0%) Value

    Cultural Stressors [MHC-610-07]

    Meets “Proficient” criteria and provides keen insight into how the cultural stressors are influencing the client

    Identifies the level of adaptation to the dominant culture and stress-rooted acculturation, including psychosocial difficulties the client is demonstrating

    Identifies the level of adaptation to the dominant culture and stress-rooted acculturation, including psychosocial difficulties the client is demonstrating, but submission lacks detail or contains inaccuracies

    Does not identify the level of adaptation to the dominant culture and stress-rooted acculturation, including psychosocial difficulties the client is demonstrating

    10

    Cultural Influencers [MHC-610-07]

    Meets “Proficient” criteria and provides keen insight into how the cultural influencers are influencing the client

    Describes the beliefs regarding cause of distress, condition, or impairment the client is describing

    Describes the beliefs regarding cause of distress, condition, or impairment the client is describing, but lacks detail or contains inaccuracies

    Does not describe the beliefs regarding cause of distress, condition, or impairment the client is describing

    10

    Mental Status Exam [MHC-610-01]

    Meets “Proficient” criteria and provides keen insight into the mental status evaluation of the client

    Describes the mental status evaluation of the client

    Describes the mental status results of the client but lacks details or contains inaccuracies

    Does not determine the mental status evaluation of the client

    10

    Summary of Conceptualization

    [MHC-610-02]

    Meets “Proficient” criteria and provides keen insight into how to advocate for the client to ensure they receive the care they need

    Summarizes the conceptualization and addresses the level of care and advocacy this client will need

    Summarizes the conceptualization and addresses the level of care and advocacy this client will need, but lacks detail

    Does not summarize the conceptualization and address the level of care and advocacy this client will need

    5

    Articulation of Response

    Submission is free of errors related to citations, grammar, spelling, syntax, and organization and is presented in a professional and easy-to-read format

    Submission has no major errors related to citations, grammar, spelling, syntax, or organization

    Submission has major errors related to citations, grammar, spelling, syntax, or organization that negatively impact readability and articulation of main ideas

    Submission has critical errors related to citations, grammar, spelling, syntax, or organization that prevent understanding of ideas

    5

    Total 100%

  • attachment

    MHC610ComprehensiveCaseConceptualizationTemplate2.docx

    MP_SNHU_withQuill_Horizstack

    MHC 610 Comprehensive Case Conceptualization Template

     

    Instructions: Complete this template by replacing the bracketed text with the relevant information. Do not delete any boxes from this form, and be sure to remove the Guidance sections from your treatment plan before submitting the final version of your project.

     

    Student Name: [Insert text]
    Final Project Part One
    Theoretical Orientation and Integrated Personal Approach
    [Describe your integrated personal approach or single theoretical orientation. If you use a model such as nondirective vs. directive play therapy, the adaptive information processing model, or another method for structuring your sessions and counseling goals, please specify this.]

     

    Guidance

    In this section, describe (1) how you use your theory to help you conceptualize the client’s problems, and (2) how you use your theory to guide you in developing a treatment plan and providing counseling to the client.
    Background Information

    [Include demographics, age, disability, religion, social class, sexual orientation, indigenous background, national origin, gender identity, family unit, highest level of education, employment, military background, current and past legal issues, relationship status/social history, and substance abuse and treatment history if applicable.]

     

    Guidance

    Provide an overview of the client’s history, including demographics, family dynamics and history, work and education history, cultural considerations, key moments in the client’s life (both positive and negative), early childhood memories, medical history, career, and any other relevant information that will help you better understand the unique person who is your client. For example, some clients may have a military background, current or past legal issues, and/or other unique experiences.
    Comprehensive Overview of Presenting Concerns
    Presenting Concerns: [Describe the problem, explain the symptoms, note the intensity and frequency of the symptoms, identify potential harmful behavior, and note if there is family history.]
    Current Triggers: [Describe triggers that activate the pattern, resulting in the presenting problem.]

     

    Guidance

    Based on the client’s history from the Background Information section and the history of the client’s problems, describe the triggers (e.g., events, behaviors, sights, sounds, smells, etc.) that activate or intensify the client’s problems.
    Promoters: (Triggers (e.g., events, behaviors, sights, sounds, smells, etc.) that activate one’s patterns of behavior, resulting in the presentation)
    Maladaptive Patterns: [Describe inflexible, ineffective manner of perceiving, thinking, acting.]

     

    Guidance

    Based on the Background Information and Current Triggers sections, describe the client’s current and past responses (thinking, feeling, and behaving) to the problem that have been ineffective.
    Developmental Influences: [Describe factors fostering adaptive or maladaptive functioning; be sure to reference the human development theory you used to guide your information gathering.]

     

    Guidance

    Include the past history of the issues that brought the client to counseling, and use a timeline or your human development theory stages to organize the background: theories of individual and family development across the lifespan.
    Protective Factors: [Describe biopsychosocial/spiritual factors that mitigate risk and support adaptive management of stress.]

     

    Guidance

    Based on the Background Information and Current Triggers sections, describe the client’s current and past responses (thinking, feeling, behaving) to the problem that have been effective. Describe any other client strengths that could be developed into protective factors for current and future problems.
    Co-occurring Disorders: [Describe issues with addictions and mental health issues, if applicable. Assessment of the issues that includes neuro-bio factors organized with the stages of change is required.]
    Mental Status Exam: [Note whether the client was on time; their behavior, attitude, and orientation to person, place, time, and situation; their mood, affect, tone of voice, rate of speech, judgment, and memory; their suicidal or homicidal ideation; and any observable symptoms/behaviors.]

     

    Guidance

    Summarize the results of the mental status evaluation of the client, including the following: Note whether the client was on time; their behavior, attitude, and orientation to person, place, time, and situation; their mood, affect, tone of voice, rate of speech, judgment, and memory; their suicidal or homicidal ideation; and any observable symptoms/behaviors.
    Cultural Considerations
    Cultural Identity: [Describe sense of belonging to a particular group (i.e., race, ethnicity, gender, sexual orientation, etc.).]

     
    Cultural Stressors: [Describe level of adaptation to the dominant culture, and stress-rooted acculturation including psychosocial difficulties. Focus on minority stress, marginalization…What does this mean to you?]

     

    Guidance

    What are present stressors affecting your client’s cultural identity? Consider the impact of multiple minority statuses, marginalization, stress-rooted acculturation, psychosocial difficulties, institutional and social barriers, biases, power, and privilege.
    Cultural Influencers: [Describe beliefs regarding cause of distress, condition, or impairment.]

     

    Guidance

    Using a cultural lens, what are your client’s beliefs regarding the cause of their distress, condition, or impairment?
    Personality Patterns: [Describe operative mix of cultural and personality dynamics.]
    Summary
    Theory-Driven Case Summary: [Outline the history of the client’s problems, referring to the overview of the client’s history, including the client’s strengths and barriers (from the Background Information section) and your theoretical orientation (from the Theoretical Orientation and Integrated Personal Approach section), including both counseling and human development theories.]
    Summary of Conceptualization Presented to the Client: [Write the script of what you will say to the client to offer a brief explanation of the conceptualization, and present the conceptualization to the client in language free from jargon so that they can correct and confirm the summary. Also add your theoretical orientation and integrated personal approach and focus on the object of change. For this section, you need to write up an explanation about the counseling process. You are informing the client about the steps you will take to assist them in addressing their objects of change.]
    Final Project Part Two
    Diagnosis
    Primary Diagnosis and Justification: [List both the ICD and DSM-5 codes. What is the overall descriptor of the diagnosis? What criteria are met, and what behaviors are used to meet diagnostic criteria? What are the cultural considerations?]
    Assessments: [List all of the assessments you used to justify this diagnosis.]
    Secondary Diagnosis and Justification: [List both the ICD and DSM-5 codes. What is the overall descriptor of the diagnosis? What criteria are met, and what behaviors are used to meet diagnostic criteria? What are the cultural considerations?]
    Assessments: [List all of the assessments you used to justify this diagnosis.]
    Tertiary Diagnosis and Justification: [List both the ICD and DSM-5 codes. What is the overall descriptor of the diagnosis? What criteria are met, and what behaviors are used to meet diagnostic criteria? What are the cultural considerations?]
    Assessments: [List all of the assessments you used to justify this diagnosis.]
    Additional Diagnosis and Justification: [What is the overall descriptor of the diagnosis? What criteria are met, and what behaviors are used to meet diagnostic criteria? What are the cultural considerations? This is where you will list all applicable V codes that are related to the complete diagnosis.]
    Assessments: [List all of the assessments you used to justify this diagnosis.]
    Final Project Part Three
    Client-Centered Goals
    Goal 1: [List long-term goal targeting an element of the presenting problem and/or part of the diagnosis that is agreed upon between the client and counselor using the SMART format.]
    Objective 1 of Goal 1: [List a short-term goal that is a smaller element of the stated long-term goal that is agreed upon between the client and counselor.]
    Intervention 1: [Describe what specific intervention the counselor will use and what is expected of the client to promote growth toward the objective (e.g., “Will use early recollections from Adlerian theory; Lifestyle Assessment to assist the client in discovering the guiding fictions they decided at an early age”).]
    Intervention 2: [Describe what specific intervention the counselor will use and what is expected of the client to promote growth toward the objective.]
    Intervention 3: [Describe what specific intervention the counselor will use and what is expected of the client to promote growth toward the objective.]
    Objective 2 of Goal 1: [Insert text]
    Intervention 1: [Insert text]
    Intervention 2: [Insert text]
    Intervention 3: [Insert text]
    Objective 3 of Goal 1: [Insert text]
    Intervention 1: [Insert text]
    Intervention 2: [Insert text]
    Intervention 3: [Insert text]
    Goal 2: [Insert text]
    Objective 1 of Goal 2: [Insert text]
    Intervention 1: [Insert text]
    Intervention 2: [Insert text]
    Intervention 3: [Insert text]
    Objective 2 of Goal 2: [Insert text]
    Intervention 1: [Insert text]
    Intervention 2: [Insert text]
    Intervention 3: [Insert text]
    Objective 3 of Goal 2: [Insert text]
    Intervention 1: [Insert text]
    Intervention 2: [Insert text]
    Intervention 3: [Insert text]
    Prognosis
    Guidance

    [In this section, summarize the likely course, duration, and outcome of the mental health condition with and without treatment.]
    Reevaluation of Treatment Plan
    Guidance

    [In this section, identify the importance of assessing the goals you developed for your client. Also, describe how you will reevaluate your treatment plan and how often this reevaluation process will happen.]
    SOAP Note
    Guidance

    [In this section, you will have to use your imagination on the likely progression of a session and objective behavioral presentation of your client. SOAP notes describe subjective observations, objective observations, assessment, and plan.]

     

     

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