MHC 610 Comprehensive Case Conceptualization

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 Informationsection 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 Informationand 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]
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Intervention 3: [Insert text]
Goal 2: [Insert text]
Objective 1 of Goal 2: [Insert text]
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Intervention 3:[Insert text]
Objective 2 of Goal 2: [Insert text]
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Objective 3 of Goal 2: [Insert text]
Intervention 1: [Insert text]
Intervention 2: [Insert text]
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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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