OUTLINE OF A CASE STUDY REPORT I.

Identifying Information Name of the Client Sex Age Civil Status Educational Attainment Religion Date of the Evaluation

II. Reason/s for Referral III. Assessment Procedures Testing Behavior Psychological Tests Administered Mental Status Examination

IV. Background of the Client Adaptation in life situations What are the major tasks in the clients life (work, school, family) and how well is he functioning? Does he seem to be at or below optimum? Symptomatic Behavior From the clients standpoint, what is troubling him? What are his presenting symptoms? As viewed by concerned others, family or coworkers, what deviant or disturbed behaviors does the client show? What bothers them? From the perspective of the assessing clinician, what evidence is there pf psychological disturbance? Are there thought disorders or failure of reality testing? Are negative emotions overly strong, uncontrollable, or painful? Anxiety? Depression? Are distressing conflicts visible? Obsessive thoughts? Specific dysfunctions, e.g., failures of memory, inept problem-solving, concrete thinking? Motivation for clinical care and preconceptions about mental health What does the client expect will happen in the clinic? Why did he come? What is hoped-for outcome? Symptom relief? More effective functioning? Personality change? Change in distressing external conditions? What does being a patient mean to him? How does he view mental illness, mental health? Is he psychologically minded?

Appearance and behavior in the clinic Is he anxious? Guarded? Trusting? Uncooperative and resistant?

V. Social Determinants and Current Life Situation Family What are the relationships between patient and spouse, parents or children? How does the present family system work? Is it like or unlike that of family origin? Education and work School and work history. Is the client satisfied with his work achievements, income, and conditions of work? Is leisure available? How is it used? Social ecology In what kind of community (physical and social) does the client live? Is it home or alien? Does he identify his welfare with community goals? Does he participate in community affairs, work for community improvement? Is the environment crowded, noisy, safe, and ugly? Does he commute or live close to work? Are desired facilities available?

VI. Personality Development Here the question is How the personality did come to be? the answer necessarily involves analysis of early life experiences, relationships to significant others, parents and peers. The critical identifications throughout life and major learning experiences. The history and sequence of social and interpersonal influences on the person. Of particular importance is the way in which the patient coped with successive developmental tasks. What alternatives were available to the client? How did he withstand new experiences and challenges? Did he hold to safe and established modes of behavior? Could he take new roles? VII. Summary of Impressions and Findings (based on the assessment tools and the personal background of the client) Cognitive Level Current intellectual and cognitive functioning (e.g. ideation, intelligence, memory, perception ) Degree of impairment compared to premorbid level Probable cause of impairment ( by end of this subsection, the evaluator should know whether the client has a thought disorder, mental retardation, organicity) Affective and Mood Level Mood, affect at present compare this with premorbid levels

Degree of disturbance ( mild, moderate, severe) Chronic VS Acute nature of disturbance Lability how well the person modulate, control affect with his/her cognitive resources? ( by the end of this subsection, the evaluator should know whether there is a mood disturbance, what the clients affects are and how ell controlled his/her emotions are?

Interpersonal- intrapersonal Level Primary interpersonal and intrapersonal conflicts and their significance Interpersonal and intrapersonal coping strategies (including major defense)

VIII. Diagnostic Impression Use the multi-axial system of making diagnosis IX. Recommendations Desired Outcomes What qualities pf the client and/or his situation requires change if the patient is to function in a more effective and comfortable way? What are his major growth needs which could provide goals for therapeutic intervention? Possible Interventions Environmental and social. Can the clients life conditions be change din ways to reduce stress and facilitate growth? For example, change of home living conditions, taking leave from school, new job, etc. Can counseling be done with relevant others, e.g. parents or friends, who might change their impact on the client? Might new social activities be of benefit, perhaps in the conjunction with people with similar problems? Psychotherapy. Might psychotherapy be helpful? Of what sort, with what kind of therapist, for how long, to what goals? Should it be individual, group, or family? Might other forms of psychological intervention be useful, instead of or in addition to psychotherapy; e.g. vocational or educational counseling, occupational therapy, music, dance or other activities? Other therapeutic interventions. Is hospitalization necessary? Are drugs required? Which? For what purpose? X. Signature APPENDICES Include all the test protocols, profile sheets of the test and any paraphernalia utilized in the conduct of the case study

A Case Study of ______________________ Name of the Client

Submitted to Prof. Hector M. Perez Faculty Department of Psychology Institute of Arts and Sciences Far Eastern University

In Partial Fulfillment of the Requirements in Psy 110 - Abnormal Psychology

Names (alphabetized)

March 12, 2008