CASE STUDY FACE SHEET
(Please attach to your major case study)
STUDENT NAME:
TITLE OF CASE:
DATE:______________
Gender: ________________________________________
Sexual Orientation:_______________________________
Racial Identity: __________________________________
Ethnic Identity: __________________________________
Cultural Identity: _________________________________
Primary Language: _______________________________
Immigrant/Refugee: ______________________________
Ableness: ______________________________________
Socioeconomic Class:_____________________________
Religion/Spirituality: _____________________________
Other: _________________________________________
Client Identity
information
Relevant
Student
Identity
factors
Additional
Case
Information
Age:
Major
Issues:
(identify up
to three)
PLACEMENT: __________________
Your response to this section is optional and not required.
1. Child
4. Older Adult
1. Establishing
Relationship
4. Physical
disability/illness
7. Transference/
Countertransference
10. Ethnicity
13. Legal/Advocacy
16. Environmental
19. High Risk Behaviors
22. Immigration
2.
Adolescent
3.
Adult
2.
Developmental
Task/Life Stage
Adjustment
5.
Separation/Loss
3.
Communication/ Interpersonal
Conflict
6.
Termination Issues
8.
9.
Trauma
Use of Self
11. Race
14. AIDS/HIV Status
17. Financial Stress
20. Violence
23. Refugee
12. Sexuality
15. Homelessness
18. Gender
21. Other
Clinical
Diagnosis:
(tentative)
1. Neurodevelopmental
disorders
4. Depressive Disorders
7. Personality Disorders
10. OCD Disorders
2.
Psychotic Disorders
Treatment
13. Dissociative Disorders
1. Individual
5.
Anxiety Disorders
8.
Somatic Disorders
11. Substance Related
Issues
14. No Diagnosis
2.
Couples
Duration:
4.
1.
5.
2.
Placement
Setting:
Conjoint
Short Term
1. Child & Family
Services
4. Day Treatment
(IOP/PHP)
7. Medical/ Hospice
10. College Counseling
Services
Group
Long Term
2.
Domestic Violence
Program
5.
Outpatient Mental
Health
8.
School Based
Program
11. Residential
Treatment
3.
Bipolar Disorders
6. Trauma Disorders
9. Eating Disorders
12. Disruptive Disorders
6. Other
3.. Brief/ Crisis
15. Other (describe):
3. Family
3.
Inpatient Psychiatry
6.
VA or Military Setting
9.
Community Outreach Team
12. Crisis Team
Please select and sign for one of the options below:
I hereby authorize the Smith College School for Social Work to use this case study for educational
purposes.
________________________________________
Signature
I hereby authorize the Smith College School for Social Work to use this case study for educational
purposes but only after I have graduated from the program
______________________________________________
I do not authorize the Smith College School for Social work to use this case study for educational
purposes
_____________________________________________