As in Assessment and Formulation Case Presentation and additionally:

The interventions should be clearly described, have clear rationales and flow logically from formulation.  Outcome of the intervention should be described and evaluated. 

Adheres to word count.

As in previous Case Reports and additionally:

You will need to clearly identify and reflect on one or two key themes or issues that were apparent or relevant to this case and discuss these with reference to relevant research/literature.

It should demonstrate clear understanding of evidence base practice and provide a critical discussion of the research evidence base in relation to both the work carried out and the specific theme(s) chosen for the reflective analysis.

The intervention work must be complete.

Lacking in basic competence/knowledge of core material and absence or major flaws in critical analysis. 
Unethical practice, breaches in confidentiality**
Severe departures from APA referencing.

• Reason for referral and for seeking treatment at this point.
• Description of the presenting problem(s)/symptoms, diagnosis and co-morbidity including use of DSM 5 criteria and full consideration of differential diagnosis (all possible diagnoses which were considered/ruled out for this client based on their symptoms, experiences and measures)
• Relevant background/personal information, including development of the problem, predisposing, precipitating, perpetuating, protective factors and current social circumstances.
• Risk assessment.
• Identified treatment goals for therapy (focus on SMART goals).
• Issues relating to engagement and the therapeutic alliance.
• Issues of diversity and difference (or similarity) between client and therapist and the impact on the therapeutic relationship.
• Use of the relevant model to guide assessment, formulation and intervention (if it is not used reasons for this should be given). For depression cases, the Beck model should be used.
• A cognitive behavioural assessment of the presenting problem(s), including a description of identified situations/triggers, cognitions, emotions, physical symptoms and behaviours.
• Socialisation to the model and suitability for CBT.
• Scores on IAPT service outcome and assessment measures.
• Relevant disorder specific assessment questionnaires (if not a reason should be given).

• Where a particular model has been used to guide formulation this should be referenced and accurately described including an accurate description of the theory underpinning the model. 
• There should be a narrative description of the case conceptualisation within the text, and clarified, where possible, by a diagrammatic representation of the conceptualisation.
• The formulation should link and fully explain the maintenance factors of the client's presenting problem(s) and where relevant the development of the problem.
• Ensure that the arrows on any diagrammatic formulations make sense, flow accurately and reflect both the theory and actual experience of the client.
• The formulation should relate to the client’s goals and flow from the assessment.
• Ensure a focus on collaboration with explicit client contribution.

• Interventions (carried out or planned) should directly relate to and flow from the client’s identified goals and the case conceptualisation, to demonstrate how treatment was idiosyncratic
• A minimum of 5 sessions should have been completed, including treatment/interventions
• Clear rationales for the interventions carried out should be given based on the theory, goals and case conceptualisation.
• Enough detail should be given in the text so that it is clear what was done, but a blow-by-blow account of each session is not required.
• The relapse prevention plan should be included.
• Include reference to relevant NICE guideline(s).
• Identify any difficulties experienced and relate back to the case conceptualisation where possible.

• You need to evaluate the interventions as applied and the outcome of the case.
• You need to demonstrate evaluation over the course of therapy (not just at the end) so that you can demonstrate that you are on track with the intervention.
• Present IAPT service outcomes for the client (ideally also through depiction of a graph) and critically discuss scores, considering also fluctuations in scores and why these may have occurred
• You should re-administer and report on all measures that were used at assessment (if not a reason should be given).
• Outcomes should be clearly related back to the identified goals of therapy.
• You should critically evaluate the work and outcome to date; e.g. why you think the changes have occurred?  Or if no changes have occurred why this may be?  Where possible relate this back to the case conceptualisation and/or the theory/model.
• Where an intervention has not been completed you need to present the current outcome in relation to the identified goals. 
• Refer back to relevant NICE guideline(s), where possible.

This is covered to some extent in previous areas. 
Throughout the report you need to:

• Relate the clinical work carried out to relevant cognitive-behavioural theory and relevant models throughout.
• Use theory/research/literature to guide your assessment, formulation, intervention plan and critical evaluation.
• Refer to and make use of the relevant literature to show how this was guiding your thinking about this case.

• Issues of risk including how risks were managed and reviewed
• Ethical issues
• Power dynamics
• Issues of diversity and difference and the impact on the therapeutic relationship.
• **Client confidentiality; anonymised biographical data must be used throughout the report and there should be no identifiable information in relation to the client or service i.e. you need to change any names and identifying information and make it clear that this has been done

Marks will be awarded for a well-structured case report.  The case report should read well and flow in a logical manner.  Be mindful of your use of language both the use of colloquialisms and jargon. Trainees should refer to themselves as 'the author' rather than 'I' within academic writing.

Where appropriate you may use diagrams, tables and bullet points. These should be used to aid clarity of information in the main text.  Key information needs to be in the main body of the text and any information in tables/diagrams needs to be at least summarised within the main text. Key information such as each of the '5 Ps', risk, differential diagnosis, narrative description of the formulation, interventions, critical evaluation, and the theory underpinning the work all needs to be described within the text.

If used, subheadings should relate to subsequent material presented and help to structure your case report. If used, appendices and footnotes should be used appropriately and not to help with word count.  Appendices should be clearly referred to, labelled and follow the reference section.

A possible structure could be based on the marking criteria e.g.: Outline/introduction to the client and the case report, reason for referral, presenting problem(s), assessment, formulation, intervention plan and critical evaluation.  Theory to practice links, self reflectivity and professional issues could be covered throughout in the previous sections or as separate sections.

• Reason for referral and for seeking treatment at this point.
• Description of the presenting problem(s)/symptoms, diagnosis and co-morbidity including use of DSM 5 criteria and full consideration of differential diagnosis (all possible diagnoses which were considered/ruled out for this client based on their symptoms, experiences and measures)
• Relevant background/personal information, including development of the problem, predisposing, precipitating, perpetuating, protective factors and current social circumstances.
• Risk assessment.
• Identified treatment goals for therapy (focus on SMART goals).
• Issues relating to engagement and the therapeutic alliance.
• Issues of diversity and difference (or similarity) between client and therapist and the impact on the therapeutic relationship.
• Use of the relevant model to guide assessment, formulation and intervention (if it is not used reasons for this should be given). For depression cases, the Beck model should be used.
• A cognitive behavioural assessment of the presenting problem(s), including a description of identified situations/triggers, cognitions, emotions, physical symptoms and behaviours.
• Socialisation to the model and suitability for CBT.
• Scores on IAPT service outcome and assessment measures.
• Relevant disorder specific assessment questionnaires (if not a reason should be given).

• Where a particular model has been used to guide formulation this should be referenced and accurately described including an accurate description of the theory underpinning the model.
• There should be a narrative description of the case conceptualisation within the text, and clarified, where possible, by a diagrammatic representation of the conceptualisation.
• The formulation should link and fully explain the maintenance factors of the client's presenting problem(s) and where relevant the development of the problem.
• Ensure that the arrows on any diagrammatic formulations make sense, flow accurately and reflect both the theory and actual experience of the client.
• The formulation should relate to the client’s goals and flow from the assessment.
• Ensure a focus on collaboration with explicit client contribution.

• Interventions carried out should directly relate to and flow from the client’s identified goals and the case conceptualisation to demonstrate how treatment was idiosyncratic.
• The main body of the intervention must be completed (the client may still be seen for follow-up or relapse prevention). The relapse prevention plan should be included.
• Clear rationales for the interventions carried out should be given based on the theory, goals and case conceptualisation.
• Enough detail should be given in the text so that it is clear what was done, but a blow-by-blow account of each session is not required.
• Include reference to relevant NICE guideline(s).
• Identify any difficulties experienced and relate back to the case conceptualisation where possible.

• You need to evaluate the interventions as applied and the outcome of the case.
• You need to demonstrate evaluation over the course of therapy (not just at the end) so that you can demonstrate that you were on track with the intervention.
• Present IAPT service outcomes for the client (ideally also through depiction of a graph) and critically discuss scores, considering also fluctuations in scores and why these may have occurred
• You should re-administer and report on all measures that were used at assessment (if not a reason should be given).
• Outcomes should be clearly related back to the identified goals of therapy.
• You should critically evaluate the outcome; e.g. why you think the changes have occurred?  Or if no changes have occurred why this may be?  Where possible relate this back to the case conceptualisation and/or the theory/model. 
• Refer back to relevant NICE guideline(s), where possible.

• Relate the clinical work carried out to relevant cognitive-behavioural theory and relevant models throughout.
• Use theory/research/literature to guide your assessment, formulation, intervention plan and critical evaluation.
• Refer to and make use of the relevant literature to show how this was guiding your thinking about this case.

• The literature around these themes
• The work/intervention with reference to this literature.

• Issues of risk including how risks were managed and reviewed
• Ethical issues
• Power dynamics
• Issues of diversity and difference and its impact on the therapeutic relationship.
• **Client confidentiality - anonymised biographical data must be used throughout the report and there should be no identifiable information in relation to the client or service i.e. you need to change any names and identifying information and make it clear that this has been done.

Marks will be awarded for a well-structured case report.  The case report should read well and flow in a logical manner.  Be mindful of your use of language both the use of colloquialisms and jargon. Trainees should refer to themselves as 'the author' rather than 'I' within academic writing. 

Where appropriate you may use diagrams, tables and bullet points. These should be used to aid clarity of information in the main text.  Key information needs to be in the main body of the text and any information in tables/diagrams needs to be at least summarised within the main text. Key information such as each of the '5 Ps', risk, differential diagnosis, narrative description of the formulation, interventions, critical evaluation, the theory underpinning the work and critical appraisal of theme/s all needs to be described within the text.

If used, subheadings should relate to subsequent material presented and help to structure your case report. If used, appendices and footnotes should be used appropriately and not to help with word count.  Appendices should be clearly referred to and labelled and come after references.

A possible structure could be based on the marking criteria e.g.: Outline/introduction to the client, the case report and key themes that will be discussed; reason for referral; presenting problem(s); assessment; formulation; intervention plan; and critical evaluation and reflective analysis.  Theory to practice links, critical appraisal of theme/s, self reflectivity and professional issues could be covered throughout in the previous sections or as separate sections.  

Word count excludes: case report title, tables, figures, headings for tables/figures, the reference list, and appendices. All other words are counted. Work exceeding this limit will not be marked and will not receive credit.