Describe identifying characteristic of the client: age, biological sex, gender identity, relationship/marital status, sexual orientation, race, ethnicity, socioeconomic class, education, immigration status, religious or spiritual identification.
CASE STUDY: intervention and CBT treatment plan and treatment course
CLINICAL CASE WRITE-UP:
- a) Identifying characteristics: Describe identifying characteristic of the client: age, biological sex, gender identity, relationship/marital status, sexual orientation, race, ethnicity, socioeconomic class, education, immigration status, religious or spiritual identification.
- b) Presenting Complaint: In the client’s words, describe the reason for pursuing psychotherapy/treatment. Be sure to identify the source and context of the referral (e.g. parent, school, DCFS, self-referred, employer, correctional or judicial system, etc.), and for child cases, the guardians’ understanding for the need for treatment.
- c.Client History: A detailed history of the client’s life struggles and functioning must be provided. If no information is available, please state so and remark on actions taken to collect this information. Information in each domain below should be organized chronologically within that domain. Domains that must be addressed and require subheadings include: