Requirements for Clinical Case Assessment Assignment
PART ONE: BACKGROUND INFORMATION ON CLIENT (client should have primary SUD)
Briefly, provide the most relevant facts to the following areas:
1. General Information- Fictional name, age, sex, marital status, ethnicity, education, occupation,
residence, and referral source.
2. Mental Status Exam- Cognitive functioning, appearance, dress, mood, orientation, contact with reality, affect.
3. Chief Complaint/Presenting Problem- Conditions and situation precipitating admission/visit.
4. History of Presenting Problem and Treatment Episodes- Comprehensive substance use history and
symptoms. Include time spent obtaining substance, route of administration, presence of withdrawal
symptoms, and level of current use.
5. Medical, Physical & Mental Health History- Hospitalizations, emergency room visits, treatment,
diseases, preventive health care and high-risk potentials.
6. Social Assessmenta. Family of Origin: Description of family, functionality, ACOA, and generational issues.
b. Marriage: History, current, spouse’s chemical use, and functionality.
c. Sexual History/Development: Development, preference, function, abused or abuser, HIV/STD risk.
d. Trauma and Losses: Emotional, physical, and other.
e. Social/Peer Relations: Support network, degree of social involvement and skills.
f. Religion/Spiritual Orientation: Attitude, involvement, attendance, values, beliefs.
g. Financial status: Problems, impact of chemical use and socioeconomic status
7. Legal Problems- History, current status and pending charges.
8. Vocation and/or Education- Problems, performance, attitudes and plans.
9. Collateral Information- All information from sources other than the client and past treatment records.
PART TWO: SUMMARY OF DIAGNOSIS, TREATMENT RECOMMENDATTION
Based on the data from your biopsychosocial assessment presented in Part One:
1. Assessment Summary- Identify and substantiate your assessment by including rationale for each
element of the diagnosis.
a. DSM-V diagnosis presented in narrative format (include all aspect of diagnosis)
2. Discussion of assessment data provided (was the client trustworthy? Do you believe the information to
be accurate? What collateral information did you use? Was there a dynamic between therapist and client
that may have affected assessment process? How did you or could you have overcome this?)
3. Identification of additional data needed by the counselor to plan treatment for the client, including
use of any standardized screening measures that could have been used
4. Discussion of differential diagnosis: identify the diagnoses that are confirmed and the diagnosesthat
must be ruled out
5. Identification of stage of change and defenses used by the client, with rationaleprovided
6. Identification of 3 short-term goals for the client
7. Identification of 3 long-term goals for the client
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8. Detailed and specific treatment plan for the client
9. Discussion of ethical and cultural issues that may influence counseling of the client
10. Discussion of potential countertransference issues that might arise if the student were to counsel this
client
11. Based on your assessment and treatment recommendations, locate a treatment center within Maryland
which you believe fit the treatment recommendations you provided for the client. Discuss why you
chose the treatment center and the necessary steps needs to gain admission into the treatment program
and level of care. Provide the detailed contact information for this referral.