Psychotherapy case summary sample

COUN6331 CASE STUDY TREATMENT PLAN
Instructions: Please type directly into this template as you develop your Treatment Plan. Your submitted assignments in Unit 5 and Unit 9 must be completed within this template in order for you to receive credit for your paper.

Unit 5 Assignment: Complete the first six sections of the template, plus your reference list, for the Unit 5 assignment. After you have completed the final draft of these sections, save the template as a Word document with your name (for example, Smith Unit 5 assignment) and submit it to the courseroom assignment area by the deadline for the Unit 5 assignment.

Unit 9 Assignment: Complete the last five sections of the template, plus your reference list, for the Unit 9 assignment. Although your instructor will only be reviewing the last five sections to score your paper for Unit 9, please retain the information you have already written in the first sections within the template so your instructor can refer back to this when reading your Unit 9 assignment. When the full template is completed, save it as a Word document with your name (for example, Smith Unit 9 assignment) and submit it to the courseroom assignment area by the deadline for the Unit 9 assignment.

Case Study Treatment Plan

Your Name

COUN6331

Mental Health Counseling Clinical Internship 1

Case Study Treatment Plan

Unit 5 assignment sections: The Assessment Process (4–5 pages plus references)

Section 1: Identifying Information

Describe the client in your own words. Include demographic data and relevant context (living situation, employment, current functioning, et cetera). Your description should be concise.

Section 2: Presenting Problem

Describe the key concerns that have brought the client to counseling at this time. Include a brief description of any relevant history (for example., previous incidents of concern, length of time issues have been going on, prior trauma, or other critical events related to the presenting problems).

Section 3: Previous Treatments

Summarize the client’s previous experience in therapy. Include hospitalizations as well as any community resources or other medical/mental health services the client has used. Include the degree to which previous treatments were successful; has the client had any experiences with previous treatments that may have a negative impact on the current counseling process?

Section 4: Strengths, Weaknesses, and Support Systems

· Describe the client’s areas of strength and resilience.

· Describe the client’s limitations, challenges, or areas in which the client lacks knowledge, awareness, or specific skills.

· List the support systems the client currently has access to, such as family, friends, community groups, et cetera, and the extent to which the client is currently able to utilize these supports.

· Describe the impact of a co-occurring substance use disorder on the client’s medical and psychological disorder.

· Identify the key factors that may impact this client’s successful progress in therapy, how and why these factors may have an impact on treatment success, and how you will take these factors into account as you develop your treatment plan.

Section 5: Assessment

Describe the process you will use to complete a clinical assessment of this client. If you intend to use specific instruments (such as self-report instruments, structured interviews, or psychological tests), state what they are and why you have selected them. Discuss any concerns you will need to address regarding the relevance and biases of assessment tools with multicultural populations. Also discuss the methods you will use to arrive at an accurate DSM diagnosis for this client.

Section 6: Diagnosis

Present a DSM-5 diagnosis for the client. Provide a description of your rationale for making this diagnosis (for example, what information did you consider?). Discuss other possible diagnoses that you ruled out (or will need to rule out once you have additional information).

References for Unit 5 Assignment

Support your decisions and ideas for the Unit 5 assignment with a minimum of two references to articles from current professional journals in the field of counseling. Use correct APA format.

Unit 9 assignment sections: Treatment Goals (4–6 pages plus references)

Section 1: Treatment Plan Literature Review

Review the current research and best practices presented in the professional literature that relate to types of clients and presenting issues that are similar to the case you have selected. What does the literature have to say about the most effective types of counseling approaches used with clients who share similar social-cultural backgrounds, history, current situations, and/or presenting problems? Be sure to address the impact of diversity when selecting approaches and interventions. Summarize your review of the literature so it provides clear support for your choice of counseling approach, goals, and interventions that you will be presenting in the sections below. Keep direct quotes to a minimum; you should paraphrase the information you’ve reviewed in your own words. Remember to use correct APA format for all citations.