Assessment
Discuss background characteristics, presenting complaints, history of the problem, and social and cultural considerations.
Describe the differential diagnosis, including any related diagnoses that were considered and ruled out.
Explain the legal and ethical considerations that are relevant to the client situation.
Case Conceptualization
Use your theoretical orientation to provide a concise summation of the client’s psychological strengths and difficulties. Integrate your client’s history with the theoretical orientation you have selected to support your explanation.
Treatment Plan
List two long-term treatment goals for client issues with at least two short-term objectives that are steps in how you plan to meet each goal. The objectives need to be specific and measurable and are driven by your theoretical orientation and the element you are asking the client to change (e.g., thoughts, feelings, actions, etc.)
Interventions
Discuss how you will work toward the treatment plan goals. Base your interventions on the theoretical orientation you discussed in your case conceptualization. Be sure to use evidence-based practices that are supported by your research. Describe any referrals that you believe will be beneficial.
