November 27th, 2020 
Requirements for Clinical Case Assessment Assignment for fictional client
PART ONE: BACKGROUND INFORMATION ON CLIENT (client should have primary SUD)
Briefly, provide the most relevant facts to the following areas:
1. General Information- Fictional name, age, sex, marital status, ethnicity, education, occupation, residence, and referral source.
2. Mental Status Exam- Cognitive functioning, appearance, dress, mood, orientation, contact with reality, affect.
3. Chief Complaint/Presenting Problem- Conditions and situation precipitating admission/visit.
4. History of Presenting Problem and Treatment Episodes- Comprehensive substance use history and symptoms. Include time spent obtaining the substance, route of administration, presence of withdrawal symptoms, and level of current use.
5. Medical, Physical & Mental Health History- Hospitalizations, emergency room visits, treatment, diseases, preventive health care, and high-risk potentials.
6. Social Assessment.
Family of Origin: Description of family, functionality, ACOA, and generational issues.
b. Marriage: History, current, spouses chemical use, and functionality.
c. Sexual History/Development: Development, preference, function, abused or
abuser, HIV/STD risk.
d. Trauma and Losses: Emotional, physical, and others.
e. Social/Peer Relations: Support network, degree of social involvement, and skills.
f. Religion/Spiritual Orientation: Attitude, involvement, attendance, values, beliefs.
g. Financial status: Problems, the impact of chemical use and socioeconomic
status
7. Legal Problems- History, current status, and pending charges.
8. Vocation and/or Education- Problems, performance, attitudes, and plans.
9. Collateral Information- All information from sources other than the client and past treatment records.
PART TWO: SUMMARY OF DIAGNOSIS, TREATMENT RECOMMENDATION
Based on the data from your biopsychosocial assessment presented in Part One:
1. Assessment Summary- Identify and substantiate your assessment by including a
rationale for each element of the diagnosis.
a. DSM-V diagnosis presented in narrative format (include all aspect of diagnosis criteria)
2. Discussion of assessment data provided (was the client trustworthy? Do you believe the information to be accurate? What collateral information did you use? Was there a dynamic between therapist and client that may have affected the assessment process? How did you or could you have overcome this?)
3. Identification of additional data needed by the counselor to plan treatment for the client, including use of any standardized screening measures that could have been used
4. Discussion of differential diagnosis: identify the diagnoses that are confirmed and the diagnoses that must be ruled out
5. Identification of stage of change and defenses used by the client, with the rationale provided
6. Identification of 3 short-term goals for the client
7. Identification of 3 long-term goals for the client
8. Detailed and specific treatment plan for the client
9. Discussion of ethical and cultural issues that may influence the counseling of the client
10. Discussion of potential countertransference issues that might arise if the student were to counsel this client
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