Case Presentation Method (CPM):

Directions for Preparing the Written Case Presentation

Please Note: Your Case Presentation Must be Typed
1. The case you present must be related to the certification you are seeking.
2. Use an actual client from your case files, on who has completed treatment or is no
longer obtaining your services. Use a fictitious name for the client. Do not use
abbreviation.
3. Complete the entire first page (cover sheet) of the case presentation including
demographic information which is provided to you in this section of the manual.
4. Do not use photocopied pages, charts or reports directly from the client file in the
case presentation.
5. Sign the Counselor's Statement on the cover sheet. Your supervisor must sign the
Supervisor's Statement.
6. Give the completed case presentation to your supervisor for his/her review and
signature.
7. Make five (5) copies of the completed case presentation. Keep one copy for your
file, mail the original and four (4) copies to MAPCB along with the $100 testing fee.
8. By submitting this case presentation, you are pledging that you have prepared the
written case presentation independently on an actual client.

The Case Presentation Must Include All Of The Following Information

A. Substance Abuse History
1. Substances Used
2. Frequency
3. Progression
4. Severity/Amount Used
5. Onset - When Started
6. Primary Substance
7. Route of Administration
8. Effects - Blackouts, Tremors, Tolerance, DTs, Seizures, Other Medical Complications
(some of these can be included in the Physical History Section)
B. Psychological Functioning
1. Mental Status - Oriented, Hallucinations*, Delusions*, Suicidal*, Homicidal*,
Judgment, Insight -- *to include both present and past
C. Education/Vocational/Financial History

1. Educational and Work History

2. Educational Level
3. Disciplinar4y Action (at school or work)
4. Reasons for Termination
5. Current and Past Financial Status
D. Legal History (associated with or not associated with mood-altering chemicals)
1. Charges, Arrests, Convictions
2. Current Status
3. Pending
E. Social History
1. Parents
2. Siblings/Rank
3. Psychological Functioning in Family
4. Substance Use in Family
5. History of Social Functioning from Childhood to Present
6. Family Functioning - including Physical, Sexual, and Emotional Abuse
7. Relationship History
8. Children
F. Physical History
1. Both Alcohol and Drug, Non-Alcohol and Drug Problems
2. Past and Present Major Medical Problems, i.e. Disabilities, Pregnancy and Related
Issues, STD, Alcohol and Drug Related Problems
G. Treatment History
1. Both Alcohol and Drug and Psychological History
H. Assessment - NOTE: The Assessment is the counselor's perception of the client,
utilizing the data collected on the client and the counselor's perception of the client in
the interview.
1. Identify and evaluate the client's strengths and weaknesses, problems and needs for
the development of the treatment plan.
I. Treatment Plan
1. Identify and rank problems needing resolution.
2. Identify the short and long term treatment goals.

3. Describe the process used to determine the treatment goals.

4. Describe the process used in deciding upon treatment approach.
5. Identify the resources to be used in treatment.
J. Course of Treatment
1. Describe the counseling approach (Reality Therapy, RET, Behavioral Therapy, TA,
Systemic, etc.)
2. Describe the rationale for the counseling approach selected.
3. Identify the context of counseling (individual, group, family).
4. Identify the frequency of counseling (daily, weekly, bi-weekly).
5. Describe any changes in the approach, context or frequency of counseling.
K. Discharge Summary
1. Describe the client's reaction to the treatment process.
2. Describe the outcome of treatment, including client's status and substance
use/abuse.
3. Describe whether the goals and objectives were attained and, if not, why not.
4. Describe the after-care and follow-up plan.
Provide the information for items A through K. Begin by typing "A" Substance Abuse
History as a subheading. Follow with a narrative (story style) on this section. Then go
on to the next heading which is "B" Psychological Functioning. Complete this section
and all succeeding sections through "K" in the same manner.