Case Analysis Template
COUNSELLORS NAME
Date
Client
Occupation
Name
Date of
Address
Birth
Age
Gender
Relationship
Religion
Status
Additional Client
Client
Occupation
Name
Date of
Address
Birth
Age
Gender
Relationship
Religion
Status
How
Referral
assigned
Agency
Reason(S) For Seeking Help
(Presenting Problem)
Client 1
Presented
Information
1
Client 2
Presented
Information
Educational
Background
Mental Status
Examination
Current Issues Being
Faced as a Result of
The Problem
Historical
Context/Setting of
Problem(s)
Current Situation That
Triggered the Need for
Therapy
2
Consequences or
Dimensions of The
Problem (Aspect of The
Clients Life Now Being
Impacted)
Feature(s) Associated
with this condition
OTHER COMMENTS
OBSERVATION
DURING INTERVIEW
PERSONAL ASSETS
(is there anything about
the client now that could
positively influence the
client in getting better?)
THEORETICAL FRAMEWORK
Theory
Assumption
3
INTERVENTION METHOD
Intervention tools
Approaches
CONCLUSION
Declaration
I ……………………………………………. Do understand and was made aware that the contents of this
template contain my personal information. The ethical consideration was pointed out and I acknowledge that I
give / did not give permission for my information to use in a case study or other professional forum.
Sign: …………………………….
(client)
Date: …………………………….
Witness: ……………………………
(case worker)
Date: ………………..………………
4