Demographics
Include age, gender, ethnicity, living situation, circumstances of your involvement, etc. For macro practice, include a brief description of the agencies, organizations, or groups involved.
Key findings
Give details of the current situation relevant to understanding why this situation is a case. For example, give signs and symptoms of illness, environmental factors that impinge on the situation, and actual or potential resources within the situation.
Background
Give relevant history. For example, events that happened years ago may help clarify the current situation, or the situation may have arisen suddenly without obvious historical causes.
Formulation
Describe your understanding of why things are as they are. This should reflect one or more theoretical perspectives. It may appropriately reflect uncertainty or ambivalence.
Interventions and Plans
Describe what you have done and what you plan to do about the situation.
Reason for Presentation
Explain why you selected this case when you could have presented several other cases. Does it present a unique challenge or an unusual problem? Does it illustrate the effectiveness of an intervention? Do you need help with the case, or are you presenting it so others can learn from your experience?
Sample Case Presentation
Demographics
J.J. is a 37 year old male with a Spanish surname referred to the program following a positive test for marijuana at his place of employment. He works on the crew of an oil rig. He currently lives alone after being kicked out of his apartment by his wife of five years. He has no children from the current relationship but has a 15-year-old son from his first marriage. He denies any particular religious or spiritual orientation but acknowledges having been raised in the Catholic Church. He speaks Spanish and English, and he reports associating