- Client Name
- Presenting Concern: Include reason the client stated for coming to counseling.
- Case Conceptualization: Include specific information about client symptoms and presenting concerns. Include demographic information. Review biopsychosocial factors/considerations including biology, family, culture, environment, and other relevant systemic considerations; assess how the addiction impacts all major life areas).
- Assessment: Identify and describe one to two assessment tools to be used with this client and the rationale for selecting the assessment tool.
- Diagnostic Impressions: Include the provisional diagnosis for the client and any rule-out or alternative considerations noted.
- Rationale for Diagnostic Impressions: Use the DSM-5-TR to explain how the client’s symptoms are reflected in the diagnostic criteria for each diagnosis that you render.
- Therapeutic Approach: Identify the chosen therapeutic approach to be used with this client and rationale for your selection, including appropriate treatment setting.
- Treatment Goals: Identify three initial treatment goals you are considering in your work with this client, and note how you will measure/know when goals are obtained. Note: Significant issues will need treatment goals.
- Relapse Prevention and Continuum of Care: Describe relapse prevention needs and challenges for the client. Discuss a continuum of care plan and recommendations for client.
- Ethical Considerations: Note any ethical considerations or challenges associated with this case.
- References List