Case Study Analysis Part 2: Assessment and Diagnostic Formulation

Formatting Requirements

The assignment should be formatted in 12-point, Times New Roman font, with 1-inch
margins, double-spaced, with the use of headings to organize its contents. The entirety of the
paper should be formatted using the standards outlined in APA. A minimum of six pages of text
is expected. A maximum of eight pages of text is allowed. The paper should use complete
sentences in narrative form—do not use bullets or sentence fragments. Your paper should be
submitted in a MS Word (.doc or .docx) file format and use the headings provided in the
instructions below.

Instructions: Students will read a case study provided by the instructor to write a 6-8 page
report using the following headings to answer these questions.

This assignment calls for students to conduct a comprehensive and multidimensional mental
health assessment. Students will demonstrate their abilities to apply ethical decision-making
skills to mental health assessment; understand the spectrum of mental health functioning;
consider cultural factors in mental health assessment; and use sensitive, person-first language
free of negative labels or stereotypes.

For this assignment, you are expected to write a 6-8 page assessment (double-spaced) of a client
(Stephen). The case study for Stephen will be provided by the instructor. It is important to
conceptualize the case yourself and justify your assertions with explanations and examples – that
is, it is not sufficient to simply report what is already written in the case study.

Grading Criteria

Your assessment should contain the following components:

Identifying information (5 point possible)

 Client demographics (age, gender, race/ethnicity, job, marital status, etc.).
 Source of your information (client, family, records, etc.).

Presenting problem (5 point possible)

 Describe the problem that has caused the client to seek help. Use the client’s words when
possible.
o Symptoms, feelings, thoughts, behaviors, etc. that client reports.
o Any other information relevant to the presenting problem (e.g., if this has
happened before and how it was resolved).
Mental Status Exam (10 points possible)
 Please be succinct, illustrative, and present-oriented – What did you observe? What did
the client report to you that is relevant to what you observed (e.g., mood, thought
content)?

SOWK4338: Case Formulation

  Please base the MSE on a specific scene in which the character is in distress and provide
an explanation of that scene. *Students may take creative license for this portion of the
report. Students can make culturally-responsive assumptions about how the client will
respond.

Psychosocial History (10 points possible)

For this section, please use the following as a guide:
 Relevant history from childhood and beyond (including trauma, loss, and challenges).
 Relationship status and history.
 Educational level and intellectual abilities.
 Cultural factors, including religion/spirituality.
 Current home and vocational situation.
 Previous mental health or substance use problems (including treatment received, if any,
and outcome). If the client already has been assigned a diagnosis by another professional,
include that here; however, your own diagnosis will come later in the case formulation
 Health status and history.
 Strengths, resources, and other assets of client, including coping skills, external supports,
areas of mastery, and any other sources of pride for the client.
 Any other information pertinent to the client’s psychological and social functioning and
history.

Diagnostic Assessment (30 points possible)

 This section needs to include your process of differential diagnosis. What disorders did
you consider, and why? Which disorders did you rule out, and why? Which diagnosis (or
diagnoses) did you decide on, and why? Are there other diagnoses that need to be ruled
out pending further information, and why?
 Be sure to list specific symptoms that the client does or does not have in explaining your
rationale for a diagnosis or diagnoses.
 If the subject of your assessment has already received a prior diagnosis (or diagnoses),
explain why or why not you agree with the previous diagnosis.
 Note: In an actual assessment in the clinical practice, you will not need to go into such
detail about your diagnostic process. For this assignment, however, you are asked to
illustrate your diagnostic decision-making process, as a means for demonstrating your
competency in this skill.

Analysis (20 points possible)

 Your opinion of the client’s key issue(s) or problem(s) – this may or may not be same as
the client’s.
 Your assessment of the severity of the problem.
 Your assessment of environmental contributions to presenting problem.
 This is a chance to analyze how the person’s environment directly relates or
contributes to the presenting problem, as well as how the problem affects the
client’s interactions with the environment.
 Your identification of potential areas for empowerment.

SOWK4338: Case Formulation

Summary and recommendations for clinical practice (5 points possible)
 Your recommendations can be general.

Submitting the Assignment

The following must be submitted via 2DU within 24-hours after the Week 10 Live Session:
 Case Formulation Assignment in .doc or .docx file format.

SOWK4338: Case Formulation

Section/Criteria Points Possible Points Earned
Content
Identifying Information 5
Presenting Problem 5
Mental Status Exam 10
Psychosocial History (including Strengths) 10
Diagnostic Assessment 30
Analysis 20
Summary 10
Process
Depth of Analysis & Critical Thinking 5
Writing Quality and Professionalism of
5
Presentation
Total 100

SOWK4338: Case Formulation