Harlem United Prevention, Education and Policy Department Clinical Supervision Project CASE PRESENTATION FORMAT
The following format is to be used when presenting a case for group discussion. Please feel free to modify the format based on the particular type of intervention you provide. Additionally, it might be useful to think of 1-2 questions you would like the group to address during the discussion. I. Background Information Type of Intervention (e.g. 1:1 counseling, outreach, group, testing, etc..) The intervention was counseling with testing. Participant Name (use the first name or a pseudonym) or Group Name. Darnell Ellis Descriptive Information - Participant History o Age: 23 o Gender: Male o Sexual Orientation: Heterosexual o Race/Ethnicity: African American o Medical History/HIV Status: HIV Neg o Education Level: Some College o Work status: Currently unemployed. o Relationship Status (single, married, partnered, divorced, etc..): Girlfriend. o Social/Family History: Client is in contact with some family but is pretty much to himself. o Substance Use History: Client indicated NO substance usage other then "weed" and alcohol. o Psychiatric History: Client indicated that he tried to commit suicide when he was much younger, but nothing recient. II. Presenting Problem(s) What were the initial presenting problem(s) (from the participant’s perspective)? Clien t was a little upset with the state of "Black America". Client spoke very passionately about what he preceived as a downward spiral of our community. The client looked out the window and signed at how HIV is killing our community. Client initial just walked up to the van indicating that he wanted to be tested for "everything" and sounded slightly paniced. Any relevant events leading up to the presenting problem(s)? I tested this client serveral months ago and he seemd to be a totally different person. Client was more subdued and relaxed the first time I tested him. His appearance was even different. RCI Case Presentation Format Adapted from: E. Short Brooklyn College Handout and UCSF AIDS Health Project
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Any notable similarities/differences between the client’s description of their problem(s) and your own formulation?: Client indicated that people didn’t wanted to hear other peoples problems which why initially client was non responsive to pretest questions. There was a point where I put down the pen and just gave the client my full attention, which is when he really began to open up and we had a real conversation.
RCI Case Presentation Format Adapted from: E. Short Brooklyn College Handout and UCSF AIDS Health Project
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III. Goals and Service Plan
Review your intervention goals and service plan. Client was given our online contact information so that he could schedule follow up testing as well as get the results from his STD screening. Client also was given contact information about the youth group uptown.
Describe the steps (your rationale) that led you to develop the specific service plan. W hen the client initially entered the van he seemed paniced. He was also a little high from marijana. (I could smell it as well as the client stating it). The client also indicated that he had a main girlfriend that he has unprotected sex with but that he also has sex with men for money. Client mentioned that he wanted to find people to socialize and talk with because he didn’t like coming to the village.
IV. Course of Service Delivery – Intervention Impact Length of time working with the participant/group. 2 C & T Approx 40 mins. Summarize overall content of your sessions with the participant(s)/group: (e.g., what usually happens during the sessions?) The client got the standard HIV 101 and infor mation regarding STD screening and delivery of Rapid HIV screenings and STD screenings. Description of your interpersonal interactions with the participant/group (e.g. How do you think your client feels about you and Is the way your client reacts to you similar to the way she/he reacts to others in their life? How do you feel about your client? T he client told me how good he felt to see ME doing this type of work. He said how comfortable he felt talking with me and not a "white doctor". Client indicated through out the the session how honest he was going to be with me in talking about his risk factors. I really liked this client because he reminded me how important this work is and why I continue to do this work. Client even cried when he got his results.
How do you feel before, during, and after a session with this client? Does your relationship with your client have similarities to other relationships in your life?) Wh en the client first enter the van he seemed 'hyped-up' and in a paniced. The client struck me as a little strange but typical of the type of clients I usually see in the village. The client was very engaging and I enjoyed our conversation. There was a point when he had to exit the van to provide a urine sample for the std screening and I thought he wasn't coming back. When did eventually come back and I was actually glad to see him. I wanted to help the client as much as I could and gave
RCI Case Presentation Format Adapted from: E. Short Brooklyn College Handout and UCSF AIDS Health Project
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him the contact information to our office so that he could check in from time to time. I really wanted to know what happened in his life that cause such a drastic change in appearance/behavior.
Describe any salient themes related to this participant/group (e.g. similar issues keep presenting themselves in each session). there no matching themes. As state d before I tested this client prior, but he seemed completely different.
What challenges have you faced with this participant/group? my primary challenge was to not get too caught up in conversation with this one client because we had other people waiting to be tested.
What do you feel that you have accomplished with this participant/group? I helped this client see that there are people who are actually willing to listen to him.
What would you like to accomplish in the future with this participant/group? client enrolled in the youth group.
RCI Case Presentation Format Adapted from: E. Short Brooklyn College Handout and UCSF AIDS Health Project
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