CASE NOTES AND REPORT
Part 1 of assignment – Case notes to be 500 words
In this assessment you are asked to complete a case note based on the transcript. Part 1 is to be soley based on the first session in this transcript.
Use the following as a guide:
? Presenting Problem/s
? History of Problem/s
? Relevant Personal and Family History
? Social and Occupational Factors
? Client Goal/s for Counselling (for session and/or for counselling, as agreed with counsellor)
? Other Details
? Summary/Outcome of Session
Part 2 of assignment – Client report to be 1500 words
This section is a training guide for preparing a report and familiarising yourself with the language, structure and style for professional report writing. This will enable you to confidently navigate the reference text and then construct professionally written reports. In this portion of the assessment you are to complete a report based on the client in the designated transcript. Your report is based on the entire counselling experience of the client in the video series. Your audience is a referring counselling colleague. You are to determine which headings to use based on the availability of the data from the interview and on relevance to help form as complete picture as possible within the word limits. The course readings will provide instructions for how to prepare the report, what to include, ideas on how to formulate and write impressions, and where to find relevant information within the text itself. Given the word limitations, you may not be able to address every heading, hence be selective to choose headings that will cover all of the most pertinent information that another therapist who is taking on this case might need to know.
Title: Assignment 2 CASE NOTES & REPORT
(Based on first session only)
HISTORY OF PROBLEM/S
RELEVANT PERSONAL AND FAMILY HISTORY
SOCIAL AND OCCUPATIONAL FACTORS
CLIENT GOAL/S FOR COUNSELLING (for session and/or for counselling, as agreed with Counsellor)
SUMMARY/OUTCOME OF SESSION
DATE OF REPORT:
(any other relevant statements i.e. confidentiality, consent, etc
It is recommended that you write this report as if you were reporting back to the referrer on the client’s progress/outcome in therapy. This is to include the content of the entire transcript i.e. all sessions. Note there is one heading that needs to be included that is not in the evaluation report format – that of the client’s personal treatment goals. In line with some of the underpinning values of this course, ensure you have a section called Client goals and treatment preferences
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