September 2015

Sample Case Presentation Template

1) Demographics: Sheila Tucker is a 30-year-old Caucasian female who
presents with challenges with controlling anger. Sheila is of low-income
socioeconomic status. She resides in a rooming home.
2) Reason for Initiating Services:
Sheilas presenting problem is emotional dysregulation. She reports having challenges in
maintaining her relationships with others, as people do not often receive her verbal expressions
or outbursts well. Sheila describes an uncertainty about how her verbal expressions can affect
others, yet admits that she often is angry for no apparent reason. She further has concerns
regarding mood regulation as she often is sad and retreats to her bedroom to be alone when not in
daily interactions with others in her home.
3) Chief complaint(s) include onset of problem(s), duration, and impact on
quality of life:
Client presents with saddened mood and emotional dysregulation. Client states that her mood has
been imbalanced for years as she often tries to cover up her hurt by pretending to smile and be
normal. Client identifies circumstances that have played a role in her depressions such as being a
victim of sexual abuse at the age of 13 years old to her maternal uncle for multiple years; being
neglected by her mother; having shallow relationships with her family; and her boyfriend being
recently incarcerated for murder. Client presents with low-self-esteem, saddened mood, social
isolation, self-care challenges, irritability, and abuse/trauma.

4) Developmental History family relationships/dynamics, significant events,

relationship history, educational history, etc.
Client was sexually abused by her maternal uncle during adolescent years. Client reports having
been molested for several years starting at the age of 7 up until the age of 13 years old when
removed from her mothers home where her uncle resided. Client experienced emotional abuse
and physical neglect when her mother failed to adhere to court recommendations for parenting;
client subsequently was placed in foster care at the age of 13 years old when her mother refused
to move from the home. Between ages of 7-13 years old, client resided between foster care and

her grandmothers home. Client reports no significant traumatic losses of family members that
further affect her functioning.
Client reported that she has had poor relationships with family members for as long as she can
remember. Clients paternal grandmother, aunt, and her boyfriend are sources of close
relationship. Clients biological mother now resides in Petersburg, Virginia along with her
clients younger siblings. Client has a poor relationship with her mother, limited to rare telephone
conversations via text and social media, especially when in disagreement. Client reports having
made multiple attempts in the last four years to have a relationship with her mother. Client is the
eldest girl of two siblings, none of which who client reports were victims to abuse in the home
when she was younger. Client reports no relationship with her uncle to date and his whereabouts
are unknown. Client reports being often isolated from her family interactions, being left out of
important events such as her cousins funeral, not being told about family gathering events, etc.
5) Family medical history include family MH history, if known
Clients mother was diagnosed with major depression when client was a child. She reports them
having to coach her mother out of bed and interact with her growing up in her formative years.
6) Personal medical history allergies, hospitalizations, illnesses, head
injuries
Client had gynecological issues contributing to the history poor hygiene in the last year. Client
was diagnosed with HIV in October 2002.
7) Trauma history sexual assaults, molestation, domestic violence,
accidents, natural disasters, etc.
Client was molested by her biological father up until the age of 10 years old when removed
from her home. Client had no consistency in living situation after that of which she was between
her grandmothers home and ultimately placed in adoption as grandmother could not care for
C.C. maladaptive behaviors in high school.

8) Psychiatric history any prior history of MH treatment, psychiatric

hospitalizations, etc.

Sheila has been receiving some form of clinical mental health services since
the age of 13 years old when taken from her mother and uncles home for
sexual abuse. She began receiving outpatient therapy for self-injurious
behaviors exhibited during early high school. She was hospitalized for
suicidal attempts in 2002, 2006, 2009, and 2010. All attempts were of Sheila
cutting her wrists. Sheila was diagnosed as major depressive in 2002 during
her first hospitalization.
9) Mental status at intake orientation, grooming, affect, speech, mood,
thought processes, perception, cognition, suicidality, homicidally, selfinjurious tendencies
Sheila presented in a pleasant mood with congruent affect. Sheila appeared
oriented x 4 and was able to identify her goals for wanting to be in
counseling services. Sheila appeared to be neatly groomed as evidenced by
her combed her and neat dress. S.T. speech was within normal limits. S.T.
thought processes were normal as she addressed some possible insight to
her attitude playing a role in her ability to sustain relationships with others,
even her mother. S.T. perception was within in normal limits as she
addressed her feelings on the lack of relationship she has with her mother
being a part of her sadness at times. She was unable to process how
something that occurred over 15 years ago, being sexually abused and then
neglected, still affects her anger. S.T. presented with no HI or SI behaviors.
10) Current mental status (if different from the above)
Same as above
11) A list of all current medications with name and dosing instructions
Depakote 200mg 1x/day
12) Results of any psychological testing (if available)
NA
13) Complete multiaxial diagnosis
Borderline Personality Disorder
14) Conceptualization why is the client struggling with these problems at
this particular time? What biological factors might be contributing?
Environmental? Social? Spiritual?

S.T. is a 30-year-old Caucasian female seeking assistance with managing her mood. She presents
with saddened mood, low self-esteem, self-care challenges, and sexual abuse, and trauma. S.T.
appears to harbor a lot of her anger without expressing it appropriately until she explodes. S.T.
on a weekly basis, reports having undesirable interactions with family and friends to triggers that
are disproportioned to her response of anger. Because she has a history of sexual abuse, trauma,
and neglect, it appears that she is vulnerable to many of her current situations. Presenting with
some borderline tendencies, S.T. affective instability fosters from her past. Her poor self-esteem
is paramount to the fact that she was sexually abused and has yet to be able to vent thoroughly
and work through the relationship with her mother or other members of her mothers family. S.T.
anger appears to be secondary to the hurt that she experienced over her life, as evidenced by her
reported constant arguments with her mother over small issues. S.T. in turn seeks companionship
and close nurturance from outside sources such as persons in her community to the extent that
she has engaged in multiple occurrences of risky sexual behaviors. When these relationships
prove to be superficial and not reciprocated, she admits to becoming explosive and upset. It
further appears that her poor self-care has become a defense mechanism as she is not bothered by
it, until she is embarrassed or called out by friends. S.T. would benefit from psychotherapy
interventions to work through and understand the origin to her anger, depression, and low selfesteem.
15) Client strengths:
S.T. has good leadership skills and a desire to work hard.
16) Treatment goals
1. Client will increase awareness of therapy interfering and avoiding
behaviors as she has a tendency to retract from things when they do
not go her way and with ease.
2. Client will increase awareness of triggers to swift mood changes
3. Client will lean and implement appropriate anger management skills to
avoid explosive behaviors.
17) Quality of therapeutic relationship is there a strong alliance, does the
client engage in testing of the relationship, is the client ambivalent, etc.

There appears to be a strong therapeutic relationship. S.T. is very receptive

to the advice. There are times in which S.T. participates in vivo tasks in
session to work on her anger shallowly. S.T. has been defensive at times,
inclusive of an event of walking out of session when prompted to address the
parallels between the relationships with friends, her boyfriend, and her
mother. S.T. admits to often being defensive when she is pushed to talk
about things that make her uncomfortable.
18) Central themes in treatment core beliefs for the client, statements that
recur throughout sessions such as no one will ever want me, or Ill never
get better. May include both explicit and implicit themes.
S.T.. feels that much of her behavior is only a response to the behavior of
others. Although often agreeing that her anger is irrational and many times
apologizing to others, she still will point blame. S.T. has high expectations for
others, and when disappointed will often resort to being explosive. S.T. is
able to develop insight sometime after, yet she will respond abruptly first.
There is a theme of being easily disappointed and explosive when S.T. does
not have control over a situation. Her many expectations of others, even her
mother to provide answers to why she neglected her, often unconsciously
frustrate her.
19) Your experience of the client what you feel and think when working with
the client
I feel that S.T. is easily angered, so often times tasks are adapted to lightly
to avoid pushing her into an explosive mood. I feel that she is aware of how
her own behaviors have played a role in the events of losing friends and
even some family members, yet she does not want to admit. I feel that if
there is an aspect for S.T. to use to point blame, then she will.
20) Questions you have about the case or challenges you wish to discuss
What are effective techniques to work with therapy avoiding clients who are
not susceptible to the truth of their behaviors and when attempted they run?