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CASE FORMAT

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Subtain 7247
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18 views4 pages

CASE FORMAT

Uploaded by

Subtain 7247
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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CASE REPORT OUTLINE

 Summary
 Identifying Information
 Presenting problem
 Client’s verbatim
 Symptoms
 History of problems/present illness
 Personal History
 Medical History
 Family history
 Educational History
 Occupational History
 Social History
 Past psychiatric history
 Psychological Assessment
 Informal Assessment
 Behavioral Observation
 Mental Status Examination
 Clinical Interview
 Formal Assessment
 Standardized Psychological test
 Tentative Diagnosis
 Diagnosis according to DSM-V-TR criteria
 Differential Diagnosis
 Prognosis
 Therapeutic Recommendations
 Management plan (for MS)
 Post assessment (for MS)
 References
 Appendix

 NOTE: Strictly follow APA when preparing clinical case reports.


SAMPLE CASE IS GIVEN BELOW

Summary of the case


Identifying data
Source and reason of referral
Presenting complaints
Table
Presenting complaints reported by client’s mother
Duration Presenting complaints

Presenting complaints reported by psychologist


Presenting complaints Duration

Initial Observation

History of present illness

Personal History
Developmental Profile
Developmental task Achieved age of milestones Age when achieve
Family history
Education history
Pre- morbid personality
Medical history
Drug and forensic history
Psychological Assessment
Informal
Formal
Clinical interview
Subjective rating of the problem
Table
Subjective rating of the problem from teacher (pre& post- assessment)
Problematic behavior Pre Rating

6
10
8
10

Table
Table showing the functional level of the child:
Corresponding areas Functional age Deficits
Socialization 7 years 9 month 7 years 9 months
Self help skill 12 years 6 months 3 years 4 months
Cognitive area 3 years 6 years
Motor area 3 years 2 months 3 years 2 months
Language area 3 years 2 months 6 years 8 months

Diagnosis
Severe Autism Spectrum Disorder V299.00 (F84.0)
Prognosis
Case formulation
Case conceptualization
Management plan
Intervention plan for the child's behavioral and academic problems was based on:
 Short Term Goals.
 Long Term Goals.
Short Term Goals
 Psychoeducation (Chambers &Pinnock, 2011) Long Term Goals
 Short term goals will be continued for the enhancement of skills that therapist taught
to the client
 Follow up sessions will be done to sustain and improve the skills that client had
throughout the sessions.
Implementation of Therapeutic Strategies
Following strategies are used to teach the child new task,
Rapport building
Positive reinforcement (Miltenberger,2008)
………
…………
Post assessment
Subjective rating of the problem (pre& post- assessment)
Problem Pre Rating Post Rating
On seat behavior issue 6 3
Not follow command 10 8
lethargic 8 6
Poor speech 10 9

Graphical representation of Pre and Post management rating by client


Outcome
Limitations
Recommendation
References
Sessions Report
Appendix

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