Case Assessment
Client’s Name: Paul (Pseudonym).
Date: March 4th, 2024
Non-Identifying Information
Paul is a 22-year-old male of Hispanic descent. He is average in height and body size, well
groomed and neatly dressed in neat official pair of trousers, nice shirt and a leather jacket. He is
eloquent, confident and articulate, well versed with diction. He’s cooperative, a keen listener,
attentive and responds to questions as asked. He’s however, seems a little anxious as can be
noted from his facial expression, a little stammering and downcast when our eyes meet.
Referral Information / Reason for Referral
The client’s appointment was a walk-in case. Paul’s case related to the concept of self-
determination. He conspired with the field instructor and failed to follow through his liaison’s
directives, leading to failure to hit deadlines in delivering key project outcomes. He has since
then endured terrible anxiety, which is affecting his concentration, energy, sleep and eating. He’s
nervous and worried on what to do to avoid landing in trouble with his liaison. He requires crisis
intervention and help to avoid harsh punishment, which may include suspension, probation or
other disciplinary actions from school, as it constitutes a case of academic ethics.
Background Information:
This may be the longest section of the Case Assessment because it contains all pertinent
information about the client, family, and environment of the client. It is the bio-psycho-social
background of the client, as reported to you by the client and, in the case of a child, the parent(s).
Use the following headings to organize the information in this section. Enter the pertinent
information under the headings in order to be thorough, present quantities of material in an
organized manner, to make it easier for you to write, and to make it easier for others to read.
Client’s Name: Paul (Pseudonym).
Date: March 4th, 2024
Non-Identifying Information
Paul is a 22-year-old male of Hispanic descent. He is average in height and body size, well
groomed and neatly dressed in neat official pair of trousers, nice shirt and a leather jacket. He is
eloquent, confident and articulate, well versed with diction. He’s cooperative, a keen listener,
attentive and responds to questions as asked. He’s however, seems a little anxious as can be
noted from his facial expression, a little stammering and downcast when our eyes meet.
Referral Information / Reason for Referral
The client’s appointment was a walk-in case. Paul’s case related to the concept of self-
determination. He conspired with the field instructor and failed to follow through his liaison’s
directives, leading to failure to hit deadlines in delivering key project outcomes. He has since
then endured terrible anxiety, which is affecting his concentration, energy, sleep and eating. He’s
nervous and worried on what to do to avoid landing in trouble with his liaison. He requires crisis
intervention and help to avoid harsh punishment, which may include suspension, probation or
other disciplinary actions from school, as it constitutes a case of academic ethics.
Background Information:
This may be the longest section of the Case Assessment because it contains all pertinent
information about the client, family, and environment of the client. It is the bio-psycho-social
background of the client, as reported to you by the client and, in the case of a child, the parent(s).
Use the following headings to organize the information in this section. Enter the pertinent
information under the headings in order to be thorough, present quantities of material in an
organized manner, to make it easier for you to write, and to make it easier for others to read.
