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MC08: Assessment & Case Conceptualisation1CASE STUDY REPORT GUIDELINESAssessment Task 1These guidelines should be used as a follow up to the explanations on writing the casestudy report given to you on HELP and the assessment requirements listed in the yourstudy guide. The aim of these guidelines is to assist you in developing a frameworkwithin which to summarise various types of clinical information, present assessmentdata in a concise manner, and build a client profile based on syntheses of allassessment results. You should present information in past tense and avoid makingdirect references to yourself (the exception for this is section VIII SELFREFLECTION ON ASSESSMENT of the report). Remember that you are writing thisreport for the benefit of another clinician who will be using it to make therapy decisionsabout the client you have assessed.The case study report should begin with a title (brief heading) which states the type ofassessment conducted and the addresses the issue of confidentiality. One example ofsuch a tile is:“CONFIDENTIAL REPORT OF COUNSELLING ASSESSMENT”You will be required to present your assessment procedures and results under thefollowing six headings:I REASON FOR PRESENTATIONThe purpose of this section is to introduce the client, list key demographic information(e.g., age, and gender client identifies with) and to present the main reason for theclient seeking services. You might also present key observations of the client insession.II RELEVANT BACKGROUNDThe purpose of this section is to provide relevant factual details which assist indescribing your client. Examples of such details include relationship types andemployment or study status. Consideration should also be made for any historical orbackground information which helps to contextualise the reason for presentation (orpresentation issues).III ASSESSMENT PROCEDURESThe purpose of this section is to provide the methodology used in assessing the clientand collecting the relevant data which will be outlined in the report. You need tocommunicate how you selected and administrated assessments to demonstrate thatyour evaluation is a professional integration of information from a variety ofsources. Be sure to also note who gave the tests and how long it took. These issuesare important if you ever need to report officially (for example if your assessments arebeing reported in court).IV ASSESSMENT RESULTSThe purpose of this section is to present a summary of the procedures used to assessclient functioning usually in the sequence in which these were applied to the client.Each assessment procedure is given a heading and data from the four assessmentprocedures you used should be summarised separately.1) Interview Results: This is a clinician-constructed (you are the clinician here) protocolused to gather background information on current status and identify any clientconcerns. It is usual for the clinician to begin this section by commenting on theMC08: Assessment & Case Conceptualisation2purpose of the interview and the conditions under which it was conducted (e.g., timetaken). The qualitative information obtained from the structured interview issummarised in relation to domain of performance. It is important that you demonstratethe ability to discriminate between different types of information. Your capacity todevelop a structured interview with clear prompt- and follow up questions will beimportant in gathering relevant information.2) DASS-42 Results: It is usual for the clinician to begin this section by stating thepurpose of this test (i.e., the performance area the test is

designed to measure).TheDASS is a standardised self-report inventory which is formally scored. These scoresare used to classify and measure the client’s coping strategies. You will need topresent all scores and state what these suggest about client performance (i.e., interpretthe scores).3) Modified WHODAS 2.0 Results: This is a non-standardised self-report questionnairewhich identifies the key stressors that can have an adverse impact on the functioningof individuals. In addition to stating the purpose of this scale, you should review clientresponses in order to identify the items which have been endorsed as being relevant“a good part of the time” and “most or all of the time”. These items will allow you toestablish which stressors are exerting the greatest impact on your client during theperiod of the assessment. You will need to present a table showing items whichreceived a “a good part of the time” and “most or all of the time” endorsement and drawconclusions on the classes or categories of stressor which would require attentionduring an intervention.4) One student selected assessment/ self-monitoring tool or one clinician-constructedtool: This assessment is clinician-selected (you are the clinician here). Thisassessment should provide relevant information which relates to: the presenting issue,or gaps identified in the assessment data.V CONCLUSIONSData obtained from different assessment procedures are minimally effective to thetesting process if they are only interpreted separately. It is important to review allresults together in order to construct a detailed assessment profile which tells a clearstory about client functioning. You will need to draw together the major trends obtainedfrom all assessment procedures, highlight areas in which there was consistencybetween various data sources, and identify any areas of inconsistency. Your aim is towrite a coherent summary that helps in drawing valid conclusions about clientperformance.VI RECOMENDATIONSThe purpose of this section is to provide an end point or conclusion to the report byproviding future directions. In this instance recommendations could refer to either theimplementation of further assessments or recommendations for the next phases oftherapy. Please note that for this task you are not required to discuss treatment orintervention options as it is unlikely you will have enough information to make suchrecommendations.VII SELF-REFLECTION ON ASSESSMENTThe purpose of this section is to provide you with the opportunity to review theassessment process you applied, your client’s reactions to this process and the rolesand responsibilities you undertook to ensure that you conducted client-centred andvalid testing. It is clear that assessment occurs within the context of an interactionbetween client and therapist and demands that the latter adopt particular behavioursthat might feel unnatural. In completing this section of the report, include a discussionMC08: Assessment & Case Conceptualisation3of whether you might include formal assessment in your day-to-day practice and thereasons for your response. This is the only section of the report that you can write infirst person.VIII REFERENCE LISTThe reference list should be presented in APA style format.IX APPENDICESThe appendices should contain all de-identified copies of:• the client confidentiality form• the questions you asked during the interview,• your notes on client interview responses,• the completed DASS-42 test form,• the completed modified WHODAS 2.0 self-report questionnaire,• and any other supplementary information.