Clínica de la Albizu
Case Conceptualization and Treatment Plan
Evaluation Form Guidelines
Below we list a number of professional competencies that we will like you to evaluate. Please evaluate
only the competencies that apply.
1= Very low competence: Significant remediation needed; deficits in knowledge/skills.
2= Low competence: Minor conceptual and skill errors; in process of developing.
3= Basic competence: Understanding of concepts/skills evident.
4= High competence: Strong mastery of skills and thorough understanding of concepts.
5= Very high competence: Skills and understanding significantly beyond development level.
CASE CONCEPTUALIZATION
Contextual Material
1. Client Identifying Data:
Description of at least seven socio-demographic variables such as:
Age, gender, race/culture, marital status, education, occupation, living conditions, religion or spiritual ___/5
orientation.
The student misses many significant identifiers or has difficulty 1-Very low
integrating them into the conceptualization. competence
Misses several identifiers. 2-Low competence
Includes basic information related to age, race, gender & 3-Basic competence
education.
Identifies many of the identifiers, such as: client age, gender, 4-High competence
occupation, education, marital status & education background.
Clearly identifies and includes all the socio-demographic variables. 5-Very high
competence
1
2. Presenting Problem:
Description of client’s chief complaint, reasons of referral, and relevant information of client’ social, ___/5
cognitive, physical, and emotional adjustment.
Does not identify client’s chief complaints and cannot identify 1-Very low
client’s social, cognitive, physical and emotional problems competence
associated with his/her symptomatology.
The student identifies few relevant problems associated with the 2-Low competence
client’s psychological functioning and adjustment.
The student doesn’t include information about client’ behaviors,
thoughts, feelings and physical symptomatology.
Identifies relevant problems associated with the client’s 3-Basic competence
psychological, and social adjustment.
Includes general information about client’s behaviors, thoughts,
feelings, and physical symptomatology.
Identifies many problems associated with the client’s psychological 4-High competence
functioning and adjustment.
Includes accurate information about client’s behaviors, thoughts,
feelings and physical symptomatology.
Identifies in clear and coherent way clients’ problems, associated 5-Very high
with his/her psychological, developmental and social adjustment. competence
Includes precise information about client’s behaviors, thoughts,
feelings and physical symptomatology.
2
3. Child/Adolescent Psychosocial history:
The student includes client’s developmental and psychosocial history. At least nine minimum areas N/A
are described:
Developmental History
Fine and Gross Motor Development
Adaptive Socio-Emotional Development
Interpersonal History
___/5
Medical History
Educational History
Family History
Sexual History
Psychiatric History
Significant information is missing; unable to identify relevant 1-Very low
developmental & psychosocial history. competence
Insufficient, minimal or missing relevant developmental & 2-Low competence
psychosocial history.
Includes only basic information, such as basic developmental 3-Basic competence
information, educational, and family history.
Includes useful and relevant developmental & psychosocial 4-High competence
history.
Includes detailed yet succinct description of the client’s relevant 5-Very high
developmental and psychosocial history. Selected information competence
helps to develop a coherent case conceptualization.
Adult psychosocial history:
N/A
The student describes at least nine minimum areas of client’s history such as:
___/5
Developmental History of the Current Problem, Family or Couple Relationship,
Interpersonal/Social Functioning, Academic/Work History, Medical History and Medications,
Drug Abuse History, Sexual History, Prior Mental Health Treatment, Previous
Evaluations/Interventions (If applicable).
Significant information is missing, unable to identify relevant 1-Very low
developmental and psychosocial history. competence
Insufficient, minimal or missing relevant developmental & 2-Low competence
psychosocial history.
3
The student includes only basic information, such as basic 3-Basic competence
developmental information, educational and family history.
Includes useful and relevant developmental & psychosocial 4-High competence
history.
Includes detailed yet succinct description of the client’s relevant 5-Very high
developmental and psychosocial history. Selected information competence
helps to develop a coherent case conceptualization.
4. Clinical Observation and Mental Status Examination of Client:
The student describes objective behavioral observations as well as information elicited through ___/5
selected questions. The content of mental status examination includes: appearance, behavior and
attitude, characteristics of speech, mood & affect, orientation and intellectual capability, memory,
thought process/content, hallucinations, judgment, insight, perceptions, impulse control and suicidal
or homicidal ideations.
Describes three or less characteristics of client’s mental status. 1-Very low
competence
Provides few descriptions (between four and seven characteristics) 2-Low competence
of client’s mental status examination.
Provides a partial description of client’s mental status examination. 3-Basic competence
(Between eight and twelve characteristics).
Provides many characteristics of client’s mental status 4-High competence
examination. (Between thirteen and fifteen).
Provides a full description of client’s mental status examination. 5-Very high
competence
5. Theoretical model:
The student demonstrates mastery of at least one theoretical evidence based model to conceptualize ___/5
the case and applies mayor components of this model to case material that is congruent with the
client’s history and the presenting problem.
4
Fails to demonstrate basic knowledge of at least one theoretical 1-Very low
evidence based model as required for the accurate diagnostic competence
formulation or treatment plan recommendations.
Demonstrates some basic knowledge of at least one theoretical 2-Low competence
evidence based model but it is insufficient for the accurate
diagnostic formulation or treatment plan.
Manifests basic knowledge of at least one theoretical evidence 3-Basic competence
based model sufficient for the diagnostic formulation and treatment
interventions.
Demonstrates general knowledge of one or more than one 4-High competence
theoretical evidence based model sufficient for the diagnostic
formulation and treatment interventions.
Demonstrates mastery in one or more than one theoretical evidence 5-Very high
based model (integrative framework) sufficient for establishing a competence
diagnostic formulation and treatment interventions.
TREATMENT PLAN
6. Diagnosis:
The student demonstrates clinical judgment when exploring relevant data for making a
___/5
differential diagnosis; the differential diagnosis rests on the manifestation of the symptoms and
expression of the problem; avoids over diagnosing and is accurate in the characteristics of
duration and remission of symptoms.
Displays ambiguity and lack of data to summarize a diagnosis. The 1-Very low
student doesn’t take into consideration the criteria of duration and competence
remission of symptoms.
Demonstrates low competence in differential diagnosis by partially 2-Low competence
exploring the symptoms and its duration, partially exploring the
personal and family history, over-diagnosing, and demonstrating
deficiencies in clinical judgment.
Identifies and provides follow up on the hypothesis conducting a 3-Basic competence
differential diagnosis in an organized way.
Gives a clear and comprehensive diagnosis as to the duration or
manifestation of symptoms.
Manifests good clinical judgment and explores relevant data of the 4-High competence
client to make a differential diagnosis avoids over diagnosing and
takes into consideration the characteristics of duration and
remission of symptoms.
5
Demonstrate outstanding clinical judgment, includes relevant data 5-Very high
for the formulation of the diagnosis, the differential diagnosis rests competence
on the assumption of the problem; avoids over diagnosing and
includes duration and remission of symptoms.
7. Therapeutic Goals:
Student collaborates with the client to select achievable goals,. The clinician chooses realistic ___/5
goals that are clearly defined and measured.
Doesn’t collaborate with the client to select achievable goals for 1-Very low
change that are causing the client distress or dysfunction. The goals competence
are not realistic and are not clearly defined and measured.
Partially collaborates with the client to select achievable goals for 2-Low competence
change that are causing the client distress or dysfunction. The goals
are not realistic and are not clearly defined and measured.
Collaborates with the client to select goals to attain change and 3-Basic competence
decrease client’s distress or dysfunction. The clinician chooses
realistic goals but they are not clearly defined and measured.
Collaborates with the client to select achievable goals to attain 4-High competence
change and decrease client’s distress or dysfunction. The clinician
chooses realistic goals that are clearly defined and measured.
Collaborates with the client to select achievable goals to attain 5-Very high
change and decrease client’s distress or dysfunction. The clinician competence
and the client chooses realistic goals that are clearly defined and
measured and discusses them with clients.
8. Treatment Plan:
The student develops and presents a logic and consistent evidence based treatment plan. Student ___/5
can explain clearly the treatment plan during the process of supervision.
Develops and presents a treatment plan that is not consistent with 1-Very low
the case conceptualization. The student cannot discuss a coherent competence
treatment plan during the process of supervision.
Develops and presents a plan for treatment that follows logically, 2-Low competence
but not consistently from the case conceptualization. Student can’t
explain this process during the supervision.
Develops and presents a plan for treatment that follows logically 3-Basic competence
but not consistently from the case conceptualization. Student
explains this process during the supervision.
6
Develops and presents a plan for treatment that follows a general 4-High competence
approach from the case conceptualization. Student explains this
process during the supervision.
Develops and presents a plan for treatment that follows logically 5-Very high
and consistently from the case conceptualization. Student explains competence
this process during the supervision.
9. Treatment formulation and implementation:
Student is empathic with the client and validates with him/her the application of the evidence
___/5
based treatment in response to the client’s needs and the resolution of the current problems.
Student isn’t empathic with the client and doesn’t validate with 1-Very low
client the application of the treatment in response to the client’s competence
needs.
Student is empathic with the client, but doesn’t validate with client 2-Low competence
the application of the treatment in response to the client’s needs.
Student is empathic with the client and occasionally validates with 3-Basic competence
him/her the application of the treatment in response to the client’s
needs.
Student is empathic with the client and validates with him/her the 4-High competence
application of the treatment and the resolution of the current
problem(s).
Student is highly empathic with the client and constantly validates 5-Very high
with him/her the application of the treatment and the resolution of competence
the current problem(s).
10. Client’s Strengths:
Student highlights the qualities and virtues of the client to overcome the problem and to achieve ___/5
therapeutic change.
Doesn’t identify any client’s strengths to overcome the problem 1-Very low
and to achieve therapeutic change. competence
Identifies few clients’ strengths to overcome the problem and to 2-Low competence
achieve therapeutic change.
Identifies some clients’ strengths to overcome the problem and to 3-Basic competence
achieve therapeutic change.
7
Identifies many significant clients’ strengths to overcome the 4-High competence
problem and to achieve therapeutic change.
Elaborates in details clients’ strengths to overcome the problem 5-Very high
and to achieve therapeutic change. competence
11. Areas for Further Development:
Student highlights areas that require further development in order to achieve therapeutic change. ___/5
Student doesn’t identify any areas that require further development 1-Very low
in order to achieve therapeutic change. competence
Student identifies few areas that require further development in 2-Low competence
order to achieve therapeutic change.
Student identifies some areas that require further development in 3-Basic competence
order to achieve therapeutic change.
Student identifies significant areas that require further development 4-High competence
in order to achieve therapeutic change.
Student elaborates in details areas that require further development 5-Very high
in order to achieve therapeutic change. competence
12. Cultural Diversity:
___ /5
Areas of cultural or individual differences in the interpretation of 1-Very low
the case were not identified. competence
Areas of cultural or individual differences were identified but they 2-Low competence
were not appropriate.
Basic areas of cultural or individual differences were identified and 3-Basic competence
integrated in the interpretation.
Many areas of cultural or individual differences were identified and 4-High competence
clearly integrated in the interpretation.
Areas of cultural or individual differences were elaborated, 5-Very high
highlighted and integrated in the interpretation of the case. competence
8
13. Review of Evidence Based Scientific Literature Related To Clinical Case:
___ /5
No references were included. 1-Very low
competence
Very few references were included and not cited in APA style. 2-Low competence
Basic relevant references were presented and integrated. 3-Basic competence
References were correctly cited in APA style.
Many significant references relevant to the case were presented and 4-High competence
integrated properly.
References relevant to the case were presented and integrated with 5-Very high
the conceptualization of the case. competence
14. Writing Skills:
Student masters writing skills. ___ /5
Treatment plan contains numerous grammatical, punctuation, and 1-Very low
spelling errors. competence
Impossible for the reader to follow logical sequence from sentence
to sentence.
Treatment plan contains many grammatical, punctuation, and 2-Low competence
spelling errors.
Reader unable to understand or see connections between thoughts.
The Treatment Plan meets the basic rules of grammar, punctuation 3-Basic competence
and the appropriate use of language.
Treatment Plan contains excellent grammatical, punctuation and 4-High competence
spelling.
Language is clear.
Rules of grammar, usage, and punctuation are followed; spelling is 5-Very high
correct. competence
Language is clear and precise; sentences display consistently
strong, varied structure.
Created by: José Rodríguez-Quiñones, Ph.D. (October 2014).
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Clínica de la Albizu
Case Conceptualization and Treatment Plan Evaluation Summary
Student’s Name: ______________________________ Semester: _______________ Year ______________
Student ID :__________________________________ Supervisor:__________________________________
Case Number : ___________________________ Practicum Module:____________________________
Program: Psy.D._____ Ph.D._____ Practice Center: ______________________________
Contextual Material Minimum Threshold = 56
/5
1. Client Identifying Data
2. Presenting Problem /5
3. Child/Adolescent or Adult Psychosocial history /5
/5
4. Clinical Observation and Mental Status Examination of Client
5. Theoretical Model /5
6. Diagnosis /5
7. Therapeutic Goals /5
8. Treatment Plan /5
9. Treatment formulation and implementation /5
10. Client’s Strengths /5
11. Areas for Further Development /5
12. Cultural Diversity /5
13. Review of Evidence Based Scientific Literature Related To Clinical /5
Case
14. Writing Skills /5
Total Score
_______/70
Total Score Obtained Number of Total Items Considered Final Average Score
10
Comments:
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Student’s Signature: __________________________________
Supervisor’s Signature: ______________________________
Date of Rubric Discussion: ___________________________
Revised: Dr. José Rodríguez Quiñones – 12/06/2016
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