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Provider Case Study Form
Please maintain HIPAA compliance by using pseudonyms and providing a secure email address.
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Email *
Provider Name: *
Provider Location: *
(city, state/province, country)
Provider Organization:
Provider Language: *
Required
Discipline/Credentials: *
Please list your discipline (practice area) and credentials (licenses, certifications, etc.)                                                                                                                                                            i.e. Occupational Therapist, OTR/L; Mental Health Provider, LPC, MSW, LMFT
Modalities:
Please list the modalities, interventions, and theoretical approaches you use or are trained in.                                                                  i.e Somatic Experiencing, EMDR, Sensory integration/processing, play therapy, art therapy, cognitive behavioral therapy.
Which Unyte-iLs products have been delivered? *
Required
What is your past experience delivering the Unyte-iLs product?
How many years/months have you delivered? With about how many clients?
CLIENT INFORMATION
Client Pseudonym: *
Please provide a pseudonym for your client to support HIPAA compliance and confidentiality.
Client Age: *
Client Gender: *
Client Presentation: *
Describe your client at the start of treatment. What conditions, symptoms or features were present?
CASE HISTORY
Background: *
What was the living and social environment, treatment history, and other context at start of treatment?
Reason for seeking services: *
What brought the client to you? What problem was being addressed? What were the treatment goals?
Intervention: *
How was the Unyte program delivered (in-person, remotely, or a hybrid)?  What was the length, pace, and structure of the sessions (co-listening and independent listening)?
Delivery and supporting activities: *
Were other modalities or therapeutic approaches were used in delivery? What, if any, psychoeducation, co-regulation, regulating activities, or other interventions were delivered?
If the SSP was delivered, which Pathway/Hour(s)?
Include partial and/or complete Hours.
Hour 1
Hour 2
Hour 3
Hour 4
Hour 5
SSP Connect
SSP Core
SSP Balance
If the Focus System was delivered, which program(s)?
Include partial and/or complete programs.
Outcomes: *
What changed for your client as a result of the intervention, especially relative to their clinical history? Please provide any supporting data, including assessment results, progress towards goals, or other.
Subjective: *
Describe your own reactions, the client's, and how family members, teachers, or colleagues responded to the changes.
Discussion: *
What do you think was different about this intervention? Why did it work? What have you learned (or what would you change) after working with this client? Consider how this case might inform delivery for other providers and their clients.
Case Study Title:
What would your headline be for this case study if it were an article in the newspaper or professional publication?
Additional info:
Please include anything else that supports your case.
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