The document provides a comprehensive case conceptualization template for counseling students to develop their treatment plans. It includes various sections for detailing background information, presenting concerns, triggers, protective factors, cultural considerations, and the mental status exam. The final project is divided into parts for submission, ensuring that students systematically present their assessments, diagnoses, and treatment objectives.

1. MHC 610 Comprehensive Case Conceptualization Template
Instructions: Complete this template by replacing the bracketed
text with the relevant information. Do not delete any boxes from
this form, and be sure to remove the Guidance sections from
your treatment plan before submitting the final version of your
project.
Student Name: [Insert text]
Final Project Part One
Theoretical Orientation and Integrated Personal Approach
[Describe your integrated personal approach or single
theoretical orientation. If you use a model such as nondirective
vs. directive play therapy, the adaptive information processing
model, or another method for structuring your sessions and
counseling goals, please specify this.]
Guidance
In this section, describe (1) how you use your theory to help
you conceptualize the client’s problems, and (2) how you use
your theory to guide you in developing a treatment plan and
providing counseling to the client.
Background Information
[Include demographics, age, disability, religion, social class,
sexual orientation, indigenous background, national origin,
gender identity, family unit, highest level of education,
employment, military background, current and past legal issues,
relationship status/social history, and substance abuse and
treatment history if applicable.]
Guidance
Provide an overview of the client’s history, including
demographics, family dynamics and history, work and education
history, cultural considerations, key moments in the client’s life

2. (both positive and negative), early childhood memories, medical
history, career, and any other relevant information that will help
you better understand the unique person who is your client. For
example, some clients may have a military background, current
or past legal issues, and/or other unique experiences.
Comprehensive Overview of Presenting Concerns
Presenting Concerns: [Describe the problem, explain the
symptoms, note the intensity and frequency of the symptoms,
identify potential harmful behavior, and note if there is family
history.]
Current Triggers: [Describe triggers that activate the pattern,
resulting in the presenting problem.]
Guidance
Based on the client’s history from the Background
Informationsection and the history of the client’s problems,
describe the triggers (e.g., events, behaviors, sights, sounds,
smells, etc.) that activate or intensify the client’s problems.
Promoters:(Triggers (e.g., events, behaviors, sights, sounds,
smells, etc.) that activate one’s patterns of behavior, resulting
in the presentation)
Maladaptive Patterns: [Describe inflexible, ineffective manner
of perceiving, thinking, acting.]
Guidance
Based on the Background Informationand Current Triggers
sections, describe the client’s current and past responses
(thinking, feeling, and behaving) to the problem that have been
ineffective.
Developmental Influences: [Describe factors fostering adaptive
or maladaptive functioning; be sure to reference the human
development theory you used to guide your information
gathering.]
Guidance
Include the past history of the issues that brought the client to

3. counseling, and use a timeline or your human development
theory stages to organize the background: theories of individual
and family development across the lifespan.
Protective Factors: [Describe biopsychosocial/s piritual factors
that mitigate risk and support adaptive management of stress.]
Guidance
Based on the Background Information and Current Triggers
sections, describe the client’s current and past responses
(thinking, feeling, behaving) to the problem that have been
effective. Describe any other client strengths that could be
developed into protective factors for current and future
problems.
Co-occurring Disorders: [Describe issues with addictions and
mental health issues, if applicable. Assessment of the issues
that includes neuro-bio factors organized with the stages of
change is required.]
Mental Status Exam: [Note whether the client was on time; their
behavior, attitude, and orientation to person, place, time, and
situation; their mood, affect, tone of voice, rate of speech,
judgment, and memory; their suicidal or homicidal ideation; and
any observable symptoms/behaviors.]
Guidance
Summarize the results of the mental status evaluation of the
client, including the following: Note whether the client was on
time; their behavior, attitude, and orientation to person, place,
time, and situation; their mood, affect, tone of voice, rate of
speech, judgment, and memory; their suicidal or homicidal
ideation; and any observable symptoms/behaviors.
Cultural Considerations
Cultural Identity: [Describe sense of belonging to a particular
group (i.e., race, ethnicity, gender, sexual orientation, etc.).]
Cultural Stressors:[Describe level of adaptation to the dominant
culture, and stress-rooted acculturation including psychosocial

4. difficulties. Focus on minority stress, marginalization…What
does this mean to you?]
Guidance
What are present stressors affecting your client’s cultural
identity? Consider the impact of multiple minority statuses,
marginalization, stress-rooted acculturation, psychosocial
difficulties, institutional and social barriers, biases, power, and
privilege.
Cultural Influencers:[Describe beliefs regarding cause of
distress, condition, or impairment.]
Guidance
Using a cultural lens, what are your client’s beliefs regarding
the cause of their distress, condition, or impairment?
Personality Patterns: [Describe operative mix of cultural and
personality dynamics.]
Summary
Theory-Driven Case Summary: [Outline the history of the
client’s problems, referring to the overview of the client’s
history, including the client’s strengths and barriers (from the
Background Information section) and your theoretical
orientation (from the Theoretical Orientation and Integrated
Personal Approach section), including both counseling and
human development theories.]
Summary of Conceptualization Presented to the Client: [Write
the script of what you will say to the client to offer a brief
explanation of the conceptualization, and present the
conceptualization to the client in language free from jargon so
that they can correct and confirm the summary. Also add your
theoretical orientation and integrated personal approach and
focus on the object of change. For this section, you need to
write up an explanation about the counseling process. You are
informing the client about the steps you will take to assist them
in addressing their objects of change.]
Final Project Part Two

5. Diagnosis
Primary Diagnosis and Justification:[List both the ICD and
DSM-5 codes. What is the overall descriptor of the diagnosis?
What criteria are met, and what behaviors are used to meet
diagnostic criteria? What are the cultural considerations?]
Assessments: [List all of the assessments you used to justify
this diagnosis.]
Secondary Diagnosis and Justification:[List both the ICD and
DSM-5 codes. What is the overall descriptor of the diagnosis?
What criteria are met, and what behaviors are used to meet
diagnostic criteria? What are the cultural considerations?]
Assessments: [List all of the assessments you used to justify
this diagnosis.]
Tertiary Diagnosis and Justification:[List both the ICD and
DSM-5 codes. What is the overall descriptor of the diagnosis?
What criteria are met, and what behaviors are used to meet
diagnostic criteria? What are the cultural considerations?]
Assessments: [List all of the assessments you used to justify
this diagnosis.]
Additional Diagnosis and Justification:[What is the overall
descriptor of the diagnosis? What criteria are met, and what
behaviors are used to meet diagnostic criteria? What are the
cultural considerations? This is where you will list all
applicable V codes that are related to the complete diagnosis.]
Assessments: [List all of the assessments you used to justify
this diagnosis.]
Final Project Part Three
Client-Centered Goals
Goal 1: [List long-term goal targeting an element of the
presenting problem and/or part of the diagnosis that is agreed
upon between the client and counselor using the SMART
format.]
Objective 1 of Goal 1: [List a short-term goal that is a smaller
element of the stated long-term goal that is agreed upon
between the client and counselor.]
Intervention 1: [Describe what specific intervention the

6. counselor will use and what is expected of the client to promote
growth toward the objective (e.g., “Will use early recollections
from Adlerian theory; Lifestyle Assessment to assist the client
in discovering the guiding fictions they decided at an early
age”).]
Intervention 2: [Describe what specific intervention the
counselor will use and what is expected of the client to promote
growth toward the objective.]
Intervention 3:[Describe what specific intervention the
counselor will use and what is expected of the client to promote
growth toward the objective.]
Objective 2 of Goal 1: [Insert text]
Intervention 1: [Insert text]
Intervention 2: [Insert text]
Intervention 3: [Insert text]
Objective 3 of Goal 1: [Insert text]
Intervention 1: [Insert text]
Intervention 2: [Insert text]
Intervention 3: [Insert text]
Goal 2: [Insert text]
Objective 1 of Goal 2: [Insert text]
Intervention 1:[Insert text]
Intervention 2:[Insert text]
Intervention 3:[Insert text]
Objective 2 of Goal 2: [Insert text]
Intervention 1: [Insert text]
Intervention 2: [Insert text]
Intervention 3: [Insert text]
Objective 3 of Goal 2: [Insert text]
Intervention 1: [Insert text]
Intervention 2: [Insert text]
Intervention 3: [Insert text]
Prognosis
Guidance
[In this section, summarize the likely course, duration, and
outcome of the mental health condition with and without

7. treatment.]
Reevaluation of Treatment Plan
Guidance
[In this section, identify the importance of assessing the goals
you developed for your client. Also, describe how you will
reevaluate your treatment plan and how often this reevaluation
process will happen.]
SOAP Note
Guidance
[In this section, you will have to use your imagination on the
likely progression of a session and objective behavioral
presentation of your client. SOAP notes describe subjective
observations, objective observations, assessment, and plan.]
5
1
MHC 610 Final Project Part One Guidelines and Rubric:
Assessment
Overview
The final project for this course is the creation of a treatment
plan, also known as a comprehensive case conceptualization.
The final project is broken into four
smaller submissions. The assessment portion of the treatment
plan is the first submission for your final project. It is suggested
that you use what you have
developed using the client’s case study in the assessment course
to now fill in the sections of the treatment plan due in Week
Three. Your next submission is due
in Week Four and will consist of the diagnosis portion of the

8. treatment plan. You will need to apply feedback from both of
those submissions to submit the final
treatment plan in Week Nine. Please note that Part One and Part
Two of the final project will need to be submitted in Week Nine
to inform the treatment, but
they will not be regraded.
In this assignment, you will demonstrate your mastery of the
following course outcomes:
-610-01: Evaluate legal, ethical, and contemporary
issues as they relate to treatment planning
-610-02: Apply principles of advocacy toward
promoting culturally competent counseling as it supports
treatment planning
-610-07: Evaluate culturally specific assessment
strategies to inform client-centered treatment goals
Prompt
Specifically, you must address the critical elements listed
below. Most of the critical elements align with a particular
course outcome (shown in brackets).
I. Presenting Concerns [MHC-610-07]
A. Identify the presenting problem and characteristic response
to precipitants.
II. Current Triggers and Promoters [MHC-610-07]
A. Determine the client's current triggers that activate the
pattern, resulting in the presenting problem.

9. III. Maladaptive Pattern [MHC-610-07]
A. Determine the maladaptive pattern that causes the inflexible,
ineffective manner of perceiving, thinking, acting.
IV. Developmental Influences [MHC-610-07]
A. Determine the developmental influences that create factors
fostering adaptive or maladaptive functioning.
V. Protective Factors
A. Identify protective factors that are presented in the
information collected.
VI. Cultural Identity [MHC-610-07]
A. Describe the sense of belonging to a particular ethnic group
in the client.
VII. Cultural Stressors [MHC-610-07]
A. Identify the level of adaptation to the dominant culture and
stress-rooted acculturation, including psychosocial difficulties
the client is
demonstrating.
2
VIII. Cultural Influencers [MHC-610-07]
A. Describe the beliefs regarding cause of distress, condition, or
impairment the client is describing.
IX. Mental Status Exam [MHC-610-01]
A. Describe the operative mix of cultural and personality
dynamics that the client is experiencing.

10. X. Summary of Conceptualization Presented to the Client
[MHC-610-02]
A. Summarize the conceptualization and address the level of
care and advocacy this client will need.
Final Project Pathway
Final Project Part One Submission: Assessment
In Week Three, you will submit the assessment portion of the
treatment plan. It should be a complete, polished artifact
containing all the critical elements of the
final product. This submission will be graded with the Final
Project Part One Rubric.
Final Project Part Two Submission: Diagnosis
In Week Four, you will submit the diagnosis portion of the
treatment plan. It should be a complete, polished artifact
containing all the critical elements of the
final product. This submission will be graded with the Final
Project Part Two Rubric.
Final Project Part Three Submission: Treatment Plan
In Week Nine, you will submit your finished treatment plan. It
should be a complete, polished artifact containing all the
critical elements of the final product,
along with the assessment and diagnosis portions completed in
Parts One and Two. Note that the assessment and diagnosis
portions will not be graded in Week
Nine, but they will inform the treatment plan. This submission
will be graded with the Final Project Part Three Rubric.
Final Project Part Four Submission: Reflection
In Week Ten, you will submit your reflection on the treatment
plan. This will be done using the Q&A tool within Bongo. This
submission will be graded with the
Final Project Part Four Rubric.

11. 3
Final Project Part One Rubric
Guidelines for Submission: Use the Comprehensive Case
Conceptualization Template, linked in the Resources section of
Week One, to complete this
assignment. The assessment portion of the treatment plan must
be filled in using information from the client case study. You
may use your final project from the
assessments course, but you will need to transfer the
information into the Comprehensive Case Conceptualization
Template for submission.
Critical Elements Exemplary (100%) Proficient (90%) Needs
Improvement (70%) Not Evident (0%) Value
Presenting Concerns
[MHC-610-07]
Meets “Proficient” criteria and
provides keen insight into the
precipitants presenting
concerns
Identifies the presenting
problem and characteristic
response to precipitants

12. Identifies the presenting
problem and characteristic
response to the precipitants,
but lacks detail or contains
inconsistencies
Does not identify the
presenting problem and
characteristic response to
precipitants
10
Current Triggers and
Promoters
[MHC-610-07]
Meets “Proficient” criteria and
illustrates a sophisticated
explanation of the client's
current triggers
Determines the client's current
triggers that activate the
pattern resulting in presenting
problem
Determines the client's current
triggers that activate the
pattern resulting in presenting
problem, but lacks detail or
contains inconsistencies
Does not determine the client's
current triggers that activate

13. the pattern resulting in
presenting problem
10
Maladaptive Pattern
[MHC-610-07]
Meets “Proficient” criteria and
illustrates a sophisticated
explanation of the client's
maladaptive pattern
Determines the maladaptive
pattern that causes inflexible,
ineffective manner of
perceiving, thinking, acting
Determines the maladaptive
pattern that causes inflexible,
ineffective manner of
perceiving, thinking, acting, but
lacks detail or contains
inconsistencies
Does not determine the
maladaptive pattern that
causes inflexible, ineffective
manner of perceiving, thinking,
acting
10
Developmental
Influences

14. [MHC-610-07]
Meets “Proficient” criteria and
provides keen insight as to how
those developmental influences
foster maladaptive functioning
Determines the developmental
influences that create factors
fostering adaptive or
maladaptive functioning
Determines the developmental
influences that create factors
fostering adaptive or
maladaptive functioning
Does not determine the
developmental influences that
create factors fostering
adaptive or maladaptive
functioning
10
Protective Factors
[MHC-610-07]
Meets “Proficient” criteria and
provides keen insight into how
the protective factors affect the
client
Identifies protective factors
that are presented in the
information collected

15. Identifies protective factors
that are presented in the
information collected, but
contains gaps or inaccuracies
Does not identify protective
factors that are presented in
the information collected
10
Cultural Identity
[MHC-610-07]
Meets “Proficient” criteria and
illustrates a sophisticated
awareness of how the client's
cultural identity influences the
client
Describes the sense of
belonging to a particular ethnic
group in the client
Describes the sense of
belonging to a particular ethnic
group in the client, but contains
inaccuracies
Does not describe the sense of
belonging to a particular ethnic
group in the client
10

16. 4
Critical Elements Exemplary (100%) Proficient (90%) Needs
Improvement (70%) Not Evident (0%) Value
Cultural Stressors
[MHC-610-07]
Meets “Proficient” criteria and
provides keen insight into how
the cultural stressors are
influencing the client
Identifies the level of
adaptation to the dominant
culture and stress-rooted
acculturation, including
psychosocial difficulties the
client is demonstrating
Identifies the level of
adaptation to the dominant
culture and stress-rooted
acculturation, including
psychosocial difficulties the
client is demonstrating, but
submission lacks detail or
contains inaccuracies
Does not identify the level of
adaptation to the dominant
culture and stress-rooted
acculturation, including

17. psychosocial difficulties the
client is demonstrating
10
Cultural Influencers
[MHC-610-07]
Meets “Proficient” criteria and
provides keen insight into how
the cultural influencers are
influencing the client
Describes the beliefs regarding
cause of distress, condition, or
impairment the client is
describing
Describes the beliefs regarding
cause of distress, condition, or
impairment the client is
describing, but lacks detail or
contains inaccuracies
Does not describe the beliefs
regarding cause of distress,
condition, or impairment the
client is describing
10
Mental Status Exam
[MHC-610-01]
Meets “Proficient” criteria and
provides keen insight into the

18. mental status evaluation of the
client
Describes the mental status
evaluation of the client
Describes the mental status
results of the client but lacks
details or contains inaccuracies
Does not determine the mental
status evaluation of the client
10
Summary of
Conceptualization
[MHC-610-02]
Meets “Proficient” criteria and
provides keen insight into how
to advocate for the client to
ensure they receive the care
they need
Summarizes the
conceptualization and
addresses the level of care and
advocacy this client will need
Summarizes the
conceptualization and
addresses the level of care and
advocacy this client will need,
but lacks detail

19. Does not summarize the
conceptualization and address
the level of care and advocacy
this client will need
5
Articulation of
Response
Submission is free of errors
related to citations, grammar,
spelling, syntax, and
organization and is presented in
a professional and easy-to-read
format
Submission has no major errors
related to citations, grammar,
spelling, syntax, or organization
Submission has major errors
related to citations, grammar,
spelling, syntax, or organization
that negatively impact
readability and articulation of
main ideas
Submission has critical errors
related to citations, grammar,
spelling, syntax, or organization
that prevent understanding of
ideas
5

20. Total 100%
1
MHC 610 Comprehensive Case Conceptualization Section One
Draft Guidelines and Rubric
Overview: This activity will allow you to reflect on past work
regarding case conceptualization. These final projects are
complex, so it’s essential that you have
time to digest these materials. This draft is an opportunity for
you to have your questions and concerns addressed by the
instructor.
Prompt: In this activity, you will begin exploring and working
with the Comprehensive Case Conceptualization Template (CCC
Template). In Week Two, you will
provide a draft of the following components of the first section:
theoretical orientation and integrated personal approach,
background information, mental
status exam, comprehensive overview of presenting concerns,
cultural considerations, theory driven case summary, and
summary of conceptualization
presented to the client. Include questions or requests for
specific feedback.
Specifically, the following critical elements must be addressed:

21. I. Theoretical Orientation and Integrated Personal Approach:
Summarize your integrated personal approach or single
theoretical orientation to
counseling and describe the background information of the
client.
II. Comprehensive Overview of Presenting Concerns: Describe
the client’s presenting concerns, triggers, promoters,
maladaptive patterns, developmental
influences, protective factors, co-occurring disorders, and MSE.
III. Cultural Considerations: Describe the client’s cultural
identity, cultural stressors, cultural influencers, and personality
patterns.
IV. Theory Driven Case Summary: Provide a theory driven case
summary, and summarize the conceptualization and address the
level of care and advocacy
the client will need.
V. Review additional components of the CCC Template and
treatment planning form and identify any sections that remain
unclear. Identify questions or
requests for specific feedback related to that component.
Rubric
Guidelines for Submission: Please use the Comprehensive Case
Conceptualization Template for this assignment. You can find
this template in the required
resources for Week One.
Critical Elements Proficient Needs Improvement Not Evident
Value

22. Theoretical Orientation and
Integrated Personal Approach
Describes the integrated
personal approach or single
theoretical orientation and
background information of
client (100%)
Describes some but not all of
the integrated personal
approach or single theoretical
orientation and background
information of client (70%)
Does not describe the
integrated personal approach or
single theoretical orientation
and background information of
client (0%)
25
2
Critical Elements Proficient Needs Improvement Not Evident
Value
Comprehensive Overview of
Presenting Concerns
Describes the client’s presenting

23. concerns, triggers, promoters,
maladaptive patterns,
developmental influences,
protective factors, co-occurring
disorders, and MSE (100%)
Describes some but not all of
the presenting concerns,
triggers, promoters,
maladaptive patterns,
developmental influences,
protective factors, co-occurring
disorders, and MSE, but lacks
detail or contains
inconsistencies (70%)
Does not describe the
presenting concerns, triggers,
promoters, maladaptive
patterns, developmental
influences, protective factors,
co-occurring disorders, and MSE
(0%)
25
Cultural Considerations Describes the client’s cultural
identity, cultural stressors,
cultural influencers, and
personality patterns (100%)
Describes some but not all of
the client’s cultural identity,
cultural stressors, cultural
influencers, and personality
patterns (70%)

24. Does not describe the client’s
cultural identity, cultural
stressors, cultural influencers,
and personality patterns (0%)
25
Theory Driven Case Summary Provides a theory driven case
summary, and summarizes the
conceptualization and
addresses the level of care and
advocacy the client will need
(100%)
Provides a theory driven case
summary and summarizes the
conceptualization and
addresses the level of care and
advocacy the client will need,
but lacks detail (70%)
Does not summarize the
conceptualization and address
the level of care and advocacy
the client will need (0%)
10
Questions or Requests for
Specific Feedback
Identifies questions or requests
for specific feedback related to
the chosen component (100%)

25. N/A Does not identify questions or
requests for specific feedback
related to the chosen
component (0%)
5
Articulation of Response Submission has no major errors
related to APA citations,
grammar, spelling, syntax, or
organization (100%)
Submission has major errors
related to APA citations,
grammar, spelling, syntax, or
organization that negatively
impact readability and
articulation of main ideas (70%)
Submission has critical errors
related to APA citations,
grammar, spelling, syntax, or
organization that prevent
understanding of ideas (0%)
10
Total 100%
MHC 610 Comprehensive Case Conceptualization Template
Instructions: Complete this template by replacing the bracketed
text with the relevant information. Do not delete any boxes from

26. this form, and be sure to remove the Guidance sections from
your treatment plan before submitting the final version of your
project.
Student Name: [Insert text]
Final Project Part One
Theoretical Orientation and Integrated Personal Approach
[Describe your integrated personal approach or single
theoretical orientation. If you use a model such as nondirective
vs. directive play therapy, the adaptive information processing
model, or another method for structuring your sessions and
counseling goals, please specify this.]
Guidance
In this section, describe (1) how you use your theory to help
you conceptualize the client’s problems, and (2) how you use
your theory to guide you in developing a treatment plan and
providing counseling to the client.
Background Information
[Include demographics, age, disability, religion, social class,
sexual orientation, indigenous background, national origin,
gender identity, family unit, highest level of education,
employment, military background, current and past legal issues,
relationship status/social history, and substance abuse and
treatment history if applicable.]
Guidance
Provide an overview of the client’s history, including
demographics, family dynamics and history, work and education
history, cultural considerations, key moments in the client’s life
(both positive and negative), early childhood memories, medical
history, career, and any other relevant information that will help
you better understand the unique person who is your client. For
example, some clients may have a military background, current
or past legal issues, and/or other unique experiences.
Comprehensive Overview of Presenting Concerns

27. Presenting Concerns: [Describe the problem, explain the
symptoms, note the intensity and frequency of the symptoms,
identify potential harmful behavior, and note if there is family
history.]
Current Triggers: [Describe triggers that activate the pattern,
resulting in the presenting problem.]
Guidance
Based on the client’s history from the Background
Informationsection and the history of the client’s problems,
describe the triggers (e.g., events, behaviors, sights, sounds,
smells, etc.) that activate or intensify the client’s problems.
Promoters:(Triggers (e.g., events, behaviors, sights, sounds,
smells, etc.) that activate one’s patterns of behavior, resulting
in the presentation)
Maladaptive Patterns: [Describe inflexible, ineffective manner
of perceiving, thinking, acting.]
Guidance
Based on the Background Informationand Current Triggers
sections, describe the client’s current and past responses
(thinking, feeling, and behaving) to the problem that have been
ineffective.
Developmental Influences: [Describe factors fostering adaptive
or maladaptive functioning; be sure to reference the human
development theory you used to guide your information
gathering.]
Guidance
Include the past history of the issues that brought the client to
counseling, and use a timeline or your human development
theory stages to organize the background: theories of individual
and family development across the lifespan.
Protective Factors: [Describe biopsychosocial/spiritual factors
that mitigate risk and support adaptive management of stress.]

28. Guidance
Based on the Background Information and Current Triggers
sections, describe the client’s current and past responses
(thinking, feeling, behaving) to the problem that have been
effective. Describe any other client strengths that could be
developed into protective factors for current and future
problems.
Co-occurring Disorders: [Describe issues with addictions and
mental health issues, if applicable. Assessment of the issues
that includes neuro-bio factors organized with the stages of
change is required.]
Mental Status Exam: [Note whether the client was on time; their
behavior, attitude, and orientation to person, place, time, and
situation; their mood, affect, tone of voice, rate of speech,
judgment, and memory; their suicidal or homicidal ideation; and
any observable symptoms/behaviors.]
Guidance
Summarize the results of the mental status evaluation of the
client, including the following: Note whether the client was on
time; their behavior, attitude, and orientation to person, place,
time, and situation; their mood, affect, tone of voice, rate of
speech, judgment, and memory; their suicidal or homicidal
ideation; and any observable symptoms/behaviors.
Cultural Considerations
Cultural Identity: [Describe sense of belonging to a particular
group (i.e., race, ethnicity, gender, sexual orientation, etc.).]
Cultural Stressors:[Describe level of adaptation to the dominant
culture, and stress-rooted acculturation including psychosocial
difficulties. Focus on minority stress, marginalization…What
does this mean to you?]
Guidance
What are present stressors affecting your client’s cultural
identity? Consider the impact of multiple minority statuses,

29. marginalization, stress-rooted acculturation, psychosocial
difficulties, institutional and social barriers, biases, power, and
privilege.
Cultural Influencers:[Describe beliefs regarding cause of
distress, condition, or impairment.]
Guidance
Using a cultural lens, what are your client’s beliefs regarding
the cause of their distress, condition, or impairment?
Personality Patterns: [Describe operative mix of cultural and
personality dynamics.]
Summary
Theory-Driven Case Summary: [Outline the history of the
client’s problems, referring to the overview of the client’s
history, including the client’s strengths and barriers (from the
Background Information section) and your theoretical
orientation (from the Theoretical Orientation and Integrated
Personal Approach section), including both counseling and
human development theories.]
Summary of Conceptualization Presented to the Client: [Write
the script of what you will say to the client to offer a brief
explanation of the conceptualization, and present the
conceptualization to the client in language free from jargon so
that they can correct and confirm the summary. Also add your
theoretical orientation and integrated personal approach and
focus on the object of change. For this section, you need to
write up an explanation about the counseling process. You are
informing the client about the steps you will take to assist them
in addressing their objects of change.]
Final Project Part Two
Diagnosis
Primary Diagnosis and Justification:[List both the ICD and
DSM-5 codes. What is the overall descriptor of the diagnosis?
What criteria are met, and what behaviors are used to meet
diagnostic criteria? What are the cultural considerations?]
Assessments: [List all of the assessments you used to justify

30. this diagnosis.]
Secondary Diagnosis and Justification:[List both the ICD and
DSM-5 codes. What is the overall descriptor of the diagnosis?
What criteria are met, and what behaviors are used to meet
diagnostic criteria? What are the cultural considerations?]
Assessments: [List all of the assessments you used to justify
this diagnosis.]
Tertiary Diagnosis and Justification:[List both the ICD and
DSM-5 codes. What is the overall descriptor of the diagnosis?
What criteria are met, and what behaviors are used to meet
diagnostic criteria? What are the cultural considerations?]
Assessments: [List all of the assessments you used to justify
this diagnosis.]
Additional Diagnosis and Justification:[What is the overall
descriptor of the diagnosis? What criteria are met, and what
behaviors are used to meet diagnostic criteria? What are the
cultural considerations? This is where you will list all
applicable V codes that are related to the complete diagnosis.]
Assessments: [List all of the assessments you used to justify
this diagnosis.]
Final Project Part Three
Client-Centered Goals
Goal 1: [List long-term goal targeting an element of the
presenting problem and/or part of the diagnosis that is agreed
upon between the client and counselor using the SMART
format.]
Objective 1 of Goal 1: [List a short-term goal that is a smaller
element of the stated long-term goal that is agreed upon
between the client and counselor.]
Intervention 1: [Describe what specific intervention the
counselor will use and what is expected of the client to promote
growth toward the objective (e.g., “Will use early recollections
from Adlerian theory; Lifestyle Assessment to assist the client
in discovering the guiding fictions they decided at an early
age”).]
Intervention 2: [Describe what specific intervention the

31. counselor will use and what is expected of the client to promote
growth toward the objective.]
Intervention 3:[Describe what specific intervention the
counselor will use and what is expected of the client to promote
growth toward the objective.]
Objective 2 of Goal 1: [Insert text]
Intervention 1: [Insert text]
Intervention 2: [Insert text]
Intervention 3: [Insert text]
Objective 3 of Goal 1: [Insert text]
Intervention 1: [Insert text]
Intervention 2: [Insert text]
Intervention 3: [Insert text]
Goal 2: [Insert text]
Objective 1 of Goal 2: [Insert text]
Intervention 1:[Insert text]
Intervention 2:[Insert text]
Intervention 3:[Insert text]
Objective 2 of Goal 2: [Insert text]
Intervention 1: [Insert text]
Intervention 2: [Insert text]
Intervention 3: [Insert text]
Objective 3 of Goal 2: [Insert text]
Intervention 1: [Insert text]
Intervention 2: [Insert text]
Intervention 3: [Insert text]
Prognosis
Guidance
[In this section, summarize the likely course, duration, and
outcome of the mental health condition with and without
treatment.]
Reevaluation of Treatment Plan
Guidance
[In this section, identify the importance of assessing the goals
you developed for your client. Also, describe how you will
reevaluate your treatment plan and how often this reevaluation

32. process will happen.]
SOAP Note
Guidance
[In this section, you will have to use your imagination on the
likely progression of a session and objective behavioral
presentation of your client. SOAP notes describe subjective
observations, objective observations, assessment, and plan.]
5
1
MHC 610 Client Case File Charles “CJ” Jones
You are a counselor in an on-campus counseling center.
Charles “CJ” Jones is a 21-year-old, single, straight, African
American and Lakota man who sought
treatment because he “feels lost,” withdrawn from friends, and
“worried about money.” He said he had
been feeling increasingly depressed for two months, and he
attributes this to two essentially concurrent
events: the end of a three-year romantic relationship (four
months ago) and being unable to find his
ideal employment situation. Mr. Jones has been on a job search
for around five months.
Mr. Jones has supported himself financially since high school
and is accustomed to feeling nervous
about making ends meet. He has become more worried after
breaking up with his longtime live-in
girlfriend, so he approached a family friend for financial help.
He was turned down, leading him to feel

33. alone in his financial struggles. This disappointment revived
long-standing anger and sadness about not
feeling close to and supported by either of his parents. His
friends taunted him for “falling apart” over
wanting to be financially stable saying, “We’re young. You
have time to figure this out!”
Mr. Jones is a full-time undergraduate student in his final year
of college studying computer science; he
also works full-time as a midnight-shift warehouse worker.
When he finishes his early-morning shift, he
finds it hard to “slow down,” and he has trouble sleeping. He
has been looking for work daily and applies
for jobs that are less physically demanding, with more flexible
hours, but never gets past the phone call
or interview. His appetite is unchanged, and his physical health
is good. His grades have recently
declined, and he has become increasingly discouraged about
money and about being single. He has not
previously sought mental health services, but a supportive
cousin suggested seeing a counselor.
Mr. Jones was raised as an only child by his mother and her
extended family who all identify as African
American. Mr. Jones reports that his extended family identifies
as Baptist and, in his youth, he spent
some time with family members at church; however, he now
identifies as spiritual rather than religious.
Mr. Jones describes that he has been drawn to exploring the
spiritual beliefs and practices of the Lakota
Nation. Mr. Jones regularly keeps in touch with his maternal
extended family.
Growing up, Mr. Jones mentioned he was a “good student and
popular kid.” High school was
complicated by his mother’s two-year period of unemployment

34. and his experimentation with alcohol
and marijuana. He recalled several heavy drinking episodes at
age 14 and first use of marijuana at age
15. He smoked marijuana daily for much of his junior year and
stopped heavy use under pressure from a
girlfriend. At the time of the evaluation, he had “an occasional
beer” and limited marijuana use to
“being social” several times a month. Mr. Jones described his
childhood as “normal,” and that while he
had a very close relationship with his mother, it deteriorated in
his adolescence.
Mr. Jones’s mother decided that he should move out w hen he
finished high school. She was dating a
man she subsequently married and wanted time alone with this
man. She was clear about her feelings
that he needed to be more independent from her and that it was
“finally her turn.” Mr. Jones’s father
left shortly before his birth, telling his mother, “I didn't sign on
for this.” She relayed this story to him
often in his childhood.
On examination, Mr. Jones is punctual, cooperative, pleasant,
attentive, appropriately dressed, and well
groomed. He speaks coherently. He appears generally worried
and constricted, but he did smile
2
appropriately several times during the interview. He has a quiet,
dry sense of humor. He denied
suicidality, homicidality, and psychosis. He’s cognitively intact,
and his insight and judgment were

35. considered good. In your first session, Mr. Jones communicated
to you that as a young biracial man, he
is generally expected to be strong and independent, and norms
of masculinity have made him hesitant
to attend counseling. He further expressed that his family views
counseling as something that is only for
“crazy people.” He informs you that there may be individuals in
his family struggling with addiction and
other mental health concerns who are not receiving treatment.
MHC 610 Client Case File Charles “CJ” Jones