Case Presentation Model 2019

A Model of Case Presentation

for the Clinical Supervision of Psychotherapy

Date of presentation:

¡°Fabricated first name¡±

Referred by (source) on (date):

Client Description:

Age

Gender/Sexual Orientation

Ethnicity

Body type

Spiritual life

General appearance

Present living & working situations:

Mood

Stressors

Presenting complaints:

Issues presented by the client:

Issues presented by the environment: (workplace; significant others; criminal

justice system)

Previous counseling:

Precipitant:

Medications/amounts/frequency/beginning:

Prescribing physician & phone:

Diagnosis:

Central/Historical facts: simple background information that contributes to this

counseling event

Status of therapy to this point:

Process notes: some small portion of a session in which the two parties (therapist

and client) statements-reactions-thoughts are described in sequence, typically

written during or right after a meeting has concluded:

Therapist: ¡°(approximated quotation)¡±

Client: ¡°(approximated quotation & reaction)¡±

Therapist: ¡°(approximated quotation& reaction)¡±

Client: ¡°(approximated quotation & reaction)¡±

Therapist: ¡°(approximated quotation & reaction)¡± etc.

CARLTON F. ¡°PERK¡± CLARK, LCSW

PSYCHOTHERAPY & ORGANIZATIONAL DEVELOPMENT

5930 E PIMA ST STE 144 TUCSON, AZ 85712

VOICE: 520/519-8475

FAX: 520/519-8476

7/23/19

EMAIL: perk@

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