Possible Couple/Family Clinical Case Study Outline for Couple and Family Psychology^®

I. Describe Couple/Family Background Information and Referral Concern

II. Overview of Assessment Process and Methods

• Describe measures selected and rationale
• Describe assessment process

III. Pre-Intervention Assessment Results and Interpretation

• Describe data and interpretation
• Provide formal DSM diagnoses (all that apply: Axis 1, Axis II, Axis IV, and Relational V codes)
• Provide relational diagnoses and systemic hypotheses contributing to and maintaining referral concern

IV. Treatment Goals, Plan, and Model

• Short-term goals, long-term goals
• Couple/family goals; therapist goals
• Briefly describe therapeutic approach and rationale

V. Process of Change

• Describe therapy process
• Describe progress towards goals
• Techniques used to achieve specific goals
• Include revisions of hypotheses and treatment plan (if applicable)
• Verbatim clinical vignettes
• Describe visible and reported change in thoughts, processes, behaviors, and mood
• Decision to terminate

VI. Post-Treatment Outcome Data

• Report outcome data
• Calculate RCI
• Determine outcome classification

VII. Discussion

• Implications for clinical theory and practice