CASE STUDY FACE SHEET
(Please attach to your major case study)
NAME:
TITLE OF CASE:
Summary of Major Issues:
PLACEMENT:
Please indicate the appropriate
CODE
field(s) in each category
Date:
Gender:
______________________
__________________
Race: ___________________________________________________
Socioeconomic Class: ______________________________________
Religion: ________________________________________________
Sexual Orientation: ________________________________________
Age:
1.
4.
Child
Older Adult
2.
Adolescent
3.
Adult
Major
Issues:
(identify up
to three)
1.
Establishing Relationship
2.
3.
4.
7.
5.
8.
Communication/ Interpersonal
Conflict
Termination
Trauma
10.
13.
16.
19.
Physical disability/illness
Transference/
Countertransference
Ethnicity
Legal/Advocacy
Environmental
High Risk Behaviors
Developmental Task/Life
Stage Adjustment
Separation/Loss
Use of Self
11. Race
14. AIDS/HIV Status
17. Financial Stress
20. Violence
12. Sexuality
15. Homelessness
18. Gender
21. Other
Clinical
Diagnosis:
(tentative)
1.
4.
7.
10.
13.
Neurodevelopmental D/O
Depressive Disorders
Personality Disorders
OCD Disorders
Dissociative Disorders
2.
Psychotic Disorders
5.
Anxiety Disorders
8.
Somatic Disorders
11. Substance Related D/O
14. No Diagnosis
3.
6.
9.
12.
15.
Treatment
1.
4.
Individual
Conjoint
2.
5.
Couples
Group
3. Family
6. Other
Duration:
1.
Short Term
2.
Long Term
3.. Brief/ Crisis
Placement
1.
Child & Family Services
Setting:
4. Day Treatment (IOP/PHP)
7. Medical/ Hospice
10. College Counseling
Services
2.
Domestic Violence
Program
5.
Outpatient Mental Health
8.
School-based Program
11. Residential Treatment
6.
9.
3.
Bipolar Disorders
Trauma Disorders
Eating Disorders
Disruptive Disorders
Other (describe):
Inpatient Psychiatry
6. VA or Military Setting
9. Community Outreach Team
12. Crisis Team
I hereby authorize the Smith College School for Social Work to use this case study for educational purposes.
________________________________________
Signature
Case study used by:
Name
Date