CASE WRITEUP

Date

I. CASE HISTORY

A. Identifying Information:

B. Chief Complaint: (For which the client came now)

C. History of Present Illness: (Detailed history plus)

Emotional symptoms:

Cognitive symptoms:

Behavioral symptoms:

Physiological symptoms:

D. Psychiatric History:

E. Personal and Social History:

F. Medical History:

G. Mental Status Check:

H. DSM V Diagnoses:

II. CASE FORMULATION:

A. Precipitants: (what current event led to the initiation of the problem)

B. Cross-Sectional View of Current Cognitions and Behaviors: (Current problematic

situation and relevant thoughts and behaviors)

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C. Longitudinal View of Cognitions and Behaviors: (Thoughts and behaviors from the

time when problem initiated/started)

D. Strengths and Assets (Client’s qualities helpful in problem resolution)

E. Working Hypothesis (summary of Conceptualization)

III. TREATMENT PLAN:

A. Problem List:

B. Treatment Goals:

C. Plan for Treatment:

IV. COURSE OF TREATMENT

A. Therapeutic Relationship: (Rapport Building)

B. Interventions/Procedures: (Applied along with aspect of client’s problem to which it is

applied)

C. Obstacles: (In Treatment)

D. Outcome: