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STIPS Case Notes

Can you provide a case note about a client session? Use the STIPS (Signs and Symptoms, Topics of Discussion, Interventions, Progress and Plan, and Special Issues) format. Maintain confidentiality by altering all names or specific identifying information.

Please use theoretical, empirical, or professional literature to support your views and writings. Reference your sources using standard APA guidelines.

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A format for organizing case notes is presented that could increase counselor trainees' case conceptualization skills (Prieto & Scheel, 2002). The STIPS format of case note writing consists of 5 major sections, including documenting clients' current Signs and symptoms, Topics discussed in counseling, counseling Interventions used, clients' Progress and counselors' continuing plan for treatment, and finally, any Special issues of importance regarding clients (e.g., suicide ideation). According to Prieto and Scheel, the structure and design of a STIPS format is intended to enhance trainees' ability to acquire relevant facts about clients, better understand clients' presenting problems, better monitor counseling processes, and better evaluate and adjust treatment intervention.

Utilizing a cognitive developmental approach, the aim of case notes is to build trainees' case conceptualization skills in order for supervisors to help trainees recognize, understand, and integrate discrete facts about clients (Scott & Michelle Scott (2007). In addition, counselors are able to identify what additional facts are needed to acquire additional information about clients, and make plans to implement and adjust their counseling intervention. In this process, case documentation and record keeping could serve as a useful tool for the supervisor in accomplishing cognitive-developmental goals for the client. The case note in STIPS format is as follows:

STIPS format

(1) Signs and Symptoms

Ms. X, a 27-year old African American woman entered the session with some in trepidation. She appeared nervous and unsure of herself. She was dressed in neat, fashionable attire--a dark pleated skirt and white blouse. Her affect was cool as her ...

Solution Summary

This solution provides the writing of a case note in the STIPS format.

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