Case Report Format

1. Identifying Data. This section will include relevant demographic

information.
a. Age
b. Sex
c. Race
d. Educational level
e. Marital status, with or without children
f. Living situation
g. Manner of dress
h. Physical appearance
i. General self presentation

2. Presenting Problem. Include a listing of the client’s problem areas,

from the client’s perspective, noting particularly the client’s view of
their importance. Suggested items to focus upon are:
a. Was there a set of precipitating circumstances?
b. How long has/have the problem(s) persisted?
c. Has this problem occurred before? What were the circumstances
at the time?

3. Relevant History. This section will vary in comprehensiveness

according to depth and length of treatment, and will vary in focus
according to theoretical orientation and specific nature of the
problem(s).

4. Interpersonal Style. This section should include a description of the

client’s orientation towards others in his environment and should
include two sections:
a. Is there an overall posture he or she takes towards others?
What is the nature of his or her typical relationships? Karen
Horney’s conceptualization may be useful here:
i. Moving toward (dependency, submission)
ii. Moving against (aggressive, dominance)
iii. Moving away (withdrawal)
Is there a tendency toward one or the other polarity of dominance vs
submission, love vs. hate?

b. How is the client’s interpersonal stance manifested specifically

within the therapeutic dyad? What is the client’s interpersonal
orientation toward the counselor?

5. Personality Dynamics
a. Cognitive Factors: this section will include any data relevant to
thinking and mental processes such as:
i. Intelligence
ii. Mental alertness
 iii.Persistence of negative cognitions
iv. Positive cognitions
v. Nature and content of fantasy life
vi. Level of insight—the client’s “psychological mindedness”
or ability to be aware and observant of changes in feeling
and behavior, and ability to place his/her behavior in
some interpretive scheme and to consider hypotheses
about his or her own and others’ behavior.
vii. Capacity for judgment. Client’s ability to make decisions
and to carry out the practical affairs of daily living.

b. Emotional Factors
i. Typical of most common emotional states
ii. Mood during interviews
iii. Appropriateness of affect
iv. Range of symptoms
v. Cyclical aspects of the client’s emotional life

c. Behavioral Factors
i. Psychosomatic symptoms
ii. Other related physical symptoms
iii. Existence of persistent habits or mannerisms
iv. Sexual functioning
v. Eating patterns
vi. Sleeping patterns

6. Environmental Factors
a. Elements in the environment which function as stressors to the
client, both those centrally related to the problem and more
peripheral stressors.

b. Elements in the environment which function as a source of

support for the client. Examples are friends, family, living
accommodations, recreational activities, financial situation.

7. COUNSELOR’S CONCEPTUALIZATION OF THE PROBLEM/S. This

section will include a summary of the counselor’s view of the problem.
Include only the most central and core dynamics of the client’s
personality and note in particular the interrelationships between major
dynamics. What are the common themes? What ties it all together?
This is a synthesis of all the above and essence of the
conceptualization.

8. Treatment Plan. Based on the above information, describe the plan

you will follow to address the presenting and emerging problems.
Make it consistent with your theoretical orientation.

9. Summary of Counseling Sessions

 10. Client’s Status at Termination/ Recommendations.

Please include 1 page summary of Personal Counseling Philosophy