Post Traumatic Labyrinthinitis; Major Depressive Disorder / Anxiety Disorder

a) number of sessions with each client stated
b) reason for the referral, relevant background information, client or
organisational history given
c) presenting problems and symptoms (mood, affect, cognition, behaviour) or
organisational issues are identified and described in sufficient detail to
support the development of a formulation and diagnosis
d) risk is assessed and any identified risks are managed
e) formulation identifies and integrates the predisposing vulnerabilities, triggers,
and maintaining and protective factors that account for the client’s presenting
problem or target behaviour
f) relevant evidence-based theories and models are discussed, including how
these inform diagnosis, formulation, treatment plan and intervention delivery
43
g) formal diagnosis using standard diagnostic/classification systems relevant to
the area of practice is given; organisational diagnosis is based on
psychological tools and processes; any tests must be selected, used and
interpreted appropriately and results correctly integrated
h) discussion as to whether symptoms meet all diagnostic criteria is included
using examples from client’s presentation; organisational diagnosis is
justified; differential diagnoses should be explored; if the DSM diagnostic
classification system is used, the supervisee must demonstrate his or her
ability to establish whether each of the criteria for each of the Axis I and II
disorders have been met; if the DSM is not employed, the supervisee must
indicate which system or framework is being used and justify how the
diagnosis has been derived
i) intervention plans are succinctly described and clearly linked with the
diagnosis/formulation and relevant evidence based theories; plans are
realistic given the experience of the supervisee, the complexity of the issues
and the number of sessions available for treatment
j) intervention is consistent with plan; a succinct summary of the intervention
process (not a session by session account) demonstrating intervention skills
in implementing the plan is provided
k) a reflection on the case is provided, including lessons learnt and how practice
might be modified in light of the experience. The outcome of the intervention
is evaluated.