Case Study Template
This activity is aligned with CACREP standard SC. H1: Assesses and interprets students’ strengths and needs, recognizing uniqueness in cultures, languages, values, backgrounds, and abilities.
Date __________________________
Student Fictitious Name _______________________________
Counselor Intern Name _______________________________
Student Demographics
Provide student’s age, ethnicity, grade level, gender, sexual orientation, religious/spiritual affiliation, and other identifying information.
Done Joe
17
American
Male
Catholic
Straight
highschool
Primary Concern
Provide a brief summary of reason(s) student is being seen. If student was referred, specify the source of the referral (parent, teacher, principal, and so on). Provide succinct history specifying dates and timeline of the primary issue.
Father has mental illness and anger problem. Student feels guilty for not taking care of father. manipulates son to care for him. Student has a close relationship with mom. Father doesn’t want student to see his mom. Father is upset because his mother has a boyfriend. Sister can’t care for the father because she has personal issues herself.
Family
Provide a detailed description of the student’s family. Include immediate family members, siblings, primary care givers, socioeconomic status, housing, and primary language spoken in the home. Indicate occupations and marital status of parents. List additional information such as abuse or criminal history, if any.
Social Relationships
Describe current and past relationships with peers, teachers, and family.
Academic and Attendance History
Provide history of academic performance (grades) and attendance history, noting any recent changes (increased absences or decline in grades).
Mental Health and Medical History
Provide relevant information regarding student’s mental health and medical history to include: diagnoses, medications, ongoing issues, and/or previous counseling services.
Support Plan Recommendation
Summarize the primary issue(s) of concern, highlighting student’s strengths, areas of concern, and counseling goals. Indicate recommendations for additional services such as outside referrals (individual and community support groups), school-based groups, or intervention services. Provide rationale to support recommendations.
Ethical and Legal Issues
Highlight all relevant ethical and legal issues as they relate to this case.
Interventions
List all relevant interventions that have been utilized to date.
Feedback
What specific feedback or support would you like from the group?
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