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I dont think there is a particular best format. This is one way I’ve done it before (each professor has a different way they wanted it done).
Client Demographics Presenting Problem Location of treatment, timing & number of people in session Assessment: Appearance, demeanor, scores on questionnaires, any other sorts of assessments Diagnosis (on all the axes) Treatment: What developmental stage is the client at (erikson), case conceptualization using a specific theory, objectives (what changes you want to make, interventions (what specific treatment methods will you use), prognosis (this is more of a counseling thing, but we like to insert the positive and discuss protective factors as well).
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