Clinical Vignette Review Template

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Clinical Vignette Review Template
Introduction to the Theoretical Model
In this section summarize the previous ONE Individual Theory AND ONE Family Theory Model that you selected from the list that was indicated above. Describe the main points of these theories, using the language of these theories alone (don’t borrow concepts from other theories, stay focused on the one Individual Theory and one Family Theory you select and be like an expert). This should be a minimum of a one page and no more than 3 pages (one and a half pages to describe the first Individual Theory and one and a half pages to describe the second Family theory you selected.
Client ID:_______________________ Education:______________________
Age: _____ Gender: _____________ Session Date: ___________________
Culture/Ethnicity:________________ Therapist Name: ________________
Reason for Referral
A brief description of the client/patient, explanation as to the reason(s) the client has been referred to you and why they are entering treatment now.
History of the Present Illness
A detailed chronological description of problems and concerns experienced by the client, including onset, frequency, intensity, and duration of symptoms.
DSM-5 Diagnosis (including use of V-Codes) (list the diagnosis and rationale / should match symptom presentation listed above). Take this information straight from the DSM-5 and list criteria related to the diagnosis you selected.
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Social and Family History
Describe family constellation and family relationships for current family and family of origin. Discuss any outstanding events or abnormal situations in family, relationships with peers, authority figures and community supports.
Birth Order:
Family Atmosphere: (describe if it was warm and nurturing or cold and distant)
Developmental Problems: birth defects etc. (if there are no developmental problems than indicate that patient denied these problems)
Education (grades, problems in school?):
Legal History and/or Financial Issues
Include any serious encounters with the law and/or any current financial stressors. Indicate how this information about the client might impact your work together in treatment?
Religious/Spiritual Practices (Current and Historical)
Indicate religious/spiritual belief system(s) if any. Reveal if different from family of origin and why. Indicate how this information about the client might impact your work together in treatment?
History of Employment and Education
Discuss employment and education history. How might having this information about the client impact your work together in treatment?
Psychological/Counseling / Psychiatric History
Include reasons for past treatment, type, outcomes, suicide attempts, hospitalizations and diagnoses. How might this information impact creating and achieving treatment goals?
Medical History/ Medications/ Psychological History
Discuss date of last physical, present state of health and any medical conditions. Indicate current medications, reason for usage and reported client side effects. Include sexual history, special diets, eating or sleeping problems. How might this information impact creating and achieving treatment goals?
History of Addictive Behavior
Discuss the nature of addiction(s) and impact on emotional, physical, relational health. How might this information impact creating and achieving treatment goals?
Mental Status & Behavioral Observations- N/A
Provide behavioral observations and mental status of client. How might this information impact creating and achieving treatment goals?
Ethical Considerations
Address 2-3 specific ethical and/or legal considerations for this case. Choose one of these issues addressed, to review in depth using a specific ethical decision making model. Indicate the model used. How might this information impact creating and achieving treatment goals?
Cultural Factors/Multicultural Competence
Discuss the multicultural considerations (e.g., gender, age, ability, sexual orientation, ethnicity, socioeconomic status, religion, class, and/or culture) that are evident for this case. Describe and apply the tenets of a relevant multicultural theory or model as it pertains to this case. Discuss what counselor factors comprise multicultural competence. How might this information impact diagnosis, treatment and creation of treatment goals?
Assessment
What assessment measures would you decide to conduct to enhance your understanding of the client(s) in order to direct your diagnostic formulation?
Theoretical Formulation: Family Theory/Therapy (Case conceptualization)
a. Name a specific family theory you would use to treat this case and why you would choose this theory.
b. Describe the specific and fundamental tenets of your chosen family theory.
c. Apply the family theory to your case, specifying hypotheses based on your theory.
Theoretical Formulation: Individual Theory/Therapy (Case conceptualization)
Note: You must use a separate theory from the family theory section.
a. Name a specific individual theory you would use to treat this case and why you would choose this theory.
b. Describe the specific, fundamental tenets of the individual theory.
c. Apply the individual theory to your case, specifying hypotheses based on your theory.
Diagnostic Impressions
Differential Diagnosis:
Develop a differential diagnosis. Indicate why you are considering these possible diagnoses by providing specific evidence from your case.
Treatment Plan
Using the template below, create a treatment plan for the theory you discussed in your family theory theoretical formulation section (make sure the language you use in this section is consistent with the theory you chose. Read the book and power points prior to completing this section).
Give a brief summary of the approach discussed in your theoretical formulation for family therapy, then reveal the following:
Beginning
Pertinent interventions that will be use at this stage. Include:
Goals: Provide a minimum of 3 specific to chosen family theory.
Objectives: Indicate how goals will be accomplished, specific to chosen family theory.
Interventions: Strategies to accomplish goals/objectives based on chosen family theory, from a multi-culturally competent perspective.
Middle
Pertinent interventions that will be use at this stage. Include:
Goals: Provide a minimum of 3 specific to chosen family theory.
Objectives: Indicate how goals will be accomplished, specific to chosen theory.
Interventions: Strategies to accomplish goals/objectives based on chosen theory, from a multi-culturally competent perspective.
End
Pertinent interventions that will be use at this stage. Include:
Goals: Provide a minimum of 3 specific to chosen family theory.
Objectives: Indicate how goals will be accomplished, specific to chosen theory.
Interventions: Strategies to accomplish goals/objectives based on chosen theory, from a multi-culturally competent perspective.
Treatment Plan
Using the template below, create a treatment plan for the Individual theory you discussed in your theoretical formulation section (make sure the language you use in this section is consistent with the theory you chose. Read the book and power points prior to completing this section).
Give a brief summary of the approach discussed in your theoretical formulation for family therapy, and then reveal the following:
Beginning
Pertinent interventions that will be use at this stage. Include:
Goals: Provide a minimum of 3 specific to chosen family theory.
Objectives: Indicate how goals will be accomplished, specific to chosen family theory.
Interventions: Strategies to accomplish goals/objectives based on chosen family theory, from a multi-culturally competent perspective.
Middle
Pertinent interventions that will be use at this stage. Include:
Goals: Provide a minimum of 3 specific to chosen family theory.
Objectives: Indicate how goals will be accomplished, specific to chosen theory.
Interventions: Strategies to accomplish goals/objectives based on chosen theory, from a multi-culturally competent perspective.
End
Pertinent interventions that will be use at this stage. Include:
Goals: Provide a minimum of 3 specific to chosen family theory.
Objectives: Indicate how goals will be accomplished, specific to chosen theory.
Interventions: Strategies to accomplish goals/objectives based on chosen theory, from a multi-culturally competent perspective.
Pertinent Resources/Referrals
What referrals might benefit the client’s treatment (list specific referrals in the community with addresses and phone numbers and explain the referrals offered? Why are these good resources for this client?
Psychopharmacology
b. Group
c. Medical
**Please Note: Your Clinical Case Review will take into account Organization and Writing
Correct use of APA format and all proper writing mechanics is expected. Plagiarism is forbidden. Scholarly writing includes: APA format, thoughtful and clear responses, and critical thinking befitting a graduate level student.
Grading Criteria
CO: 1, 4
Assignment Components Proficient Max Points
One Individual Theory identified
One Family Theory identified
Student presents two theories and applies the theoretical
models to the understanding and conceptualization of the
vignette provided. Student thoroughly explains both
theories using the language of the theory.
40/pts.
40/pts.
Treatment Plan for
One Individual Theory identified
One Family Theory identified
Student presents two treatment plans for the vignette
provided and the treatment plans are consistent with the
theoretical models identified. Both treatment plans should
have a beginning middle and an end.
35/pts.
35/pts.
Diagnosis
Assessments
Resources
Student properly diagnoses the vignette patient and
presents symptoms accurately from the DSM-5. Student also
provides rationale for differential diagnosis.
Student properly identifies assessments that are needed to
adequately assess the client and rationale.
Student properly identifies resources that the patient would
benefit from and articulates the name, address, and phone
number of the referrals. Also provides the list of services
that the agencies offer.
40/ pts.
40/pts.
40/ pts.
Academic Writing
Write in a clear, concise, and
organized manner; demonstrate
ethical scholarship in accurate
representation and attribution of
sources (i.e. APA); and display
accurate spelling, grammar, and
punctuation. References the
textbook.
Written in a clear, concise, and organized manner;
demonstrated ethical scholarship in appropriate and
accurate representation and attribution of sources; and
displayed accurate spelling, grammar, and punctuation. Use
of the textbook as a scholarly source aligns with specified
assignment requirements. Follows APA guidelines for use
of unbiased language.
30/pts.
Total /300 pts

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