Complete the intake assessment form you developed earlier in the course. Fill in as much of the data as you can from the facts of the case. Then, create your diagnostic impressions, selecting at least three possible diagnoses you would consider for this case. (NFL Star Brandon Marshall)

Finally, write a brief assessment plan that would enable you to gather further evaluation data. It should include at least four separate sources or methods of data collection.

Client Intake Questionnaire

Please fill in the information below and bring it with you to your first session.

Please note: information provided on this form is protected as confidential information.

Personal Information

Name:________________________Brandon Marshall ________________________ Date: ______________________

Parent/Legal Guardian (if under 18): ___________________________________________________

Address: _________________________________________________________________________

Home Phone: ___ _______________________________ May we leave a message? □ Yes □ No

Cell/Work/Other Phone: _________________________ May we leave a message? □ Yes □ No

Email: ________________________________________ May we leave a message? □ Yes □ No *Please note: Email correspondence is not considered to be a confidential medium of communication. DOB: ______________________________ Age: _______ Gender: ________________ Martial Status:

□ Never Married  □ Domestic Partnership  □ Married

□ Separated □ Divorced   □ Widowed

Referred By (if any): ________________________________________________________________

History

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?

□ No □ Yes, previous therapist/practitioner: _________________________________________

Are you currently taking any prescription medication? □ Yes □ No

If yes, please list:

__________________________________________________________________________________

__________________________________________________________________________________

Have you ever been prescribed psychiatric medication? □ Yes □ No

If yes, please list and provide dates:

_________________________________________________________________________________ _________________________________________________________________________________

General and Mental Health Information

1. How would you rate your current physical health? (Please circle one)

Poor  Unsatisfactory  Satisfactory   Good  Very good

Please list any specific health problems you are currently experiencing: _____________________

_____________________________________________________________________________

2. How would you rate your current sleeping habits? (Please circle one)

Poor  Unsatisfactory  Satisfactory   Good  Very good

Please list any specific sleep problems you are currently experiencing:

__________________________________________________________________________________

__________________________________________________________________________________

3. How many times per week do you generally exercise? ___________________________________What types of exercise do you participate in? ____________________________________________

4. Please list any difficulties you experience with your appetite or eating problems: ______________________________________________________________________________________________

5. Are you currently experiencing overwhelming sadness, grief or depression? □ No □ Yes

If yes, for approximately how long?___________________________________________________

6. Are you currently experiencing anxiety, panics attacks or have any phobias? □ No □ Yes

If yes, when did you begin experiencing this? ___________________________________________

7. Are you currently experiencing any chronic pain?  □ No □ Yes

If yes, please describe: _____________________________________________________________

8. Do you drink alcohol more than once a week? □ No □ Yes

9. How often do you engage in recreational drug use?

□ Daily  □ Weekly  □ Monthly  □ Infrequently □ Never

10. Are you currently in a romantic relationship? □ No □ Yes

If yes, for how long? _______________________________________________________________

On a scale of 1-10 (with 1 being poor and 10 being exceptional), how would you rate your relationship? ______________________________________________________________________________

11. What significant life changes or stressful events have you experienced recently? _____________

______________________________________________________________________________ ______________________________________________________________________________

Family Mental Health History

In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (e.g. father, grandmother, uncle, etc.)

Please Circle  List Family Member

Alcohol/Substance Abuse yes / no _______________________

Anxiety yes / no _______________________

Depression yes / no _______________________

Domestic Violence yes / no _______________________

Eating Disorders yes / no _______________________

Obesity yes / no _______________________

Obsessive Compulsive Behavior yes / no _______________________

Schizophrenia yes / no _______________________

Suicide Attempts yes / no _______________________

Additional Information

1. Are you currently employed?  □ No □ Yes

If yes, what is your current employment situation? _________________________________________ __________________________________________________________________________________

Do you enjoy your work? Is there anything stressful about your current work? ___________________

__________________________________________________________________________________

__________________________________________________________________________________

2. Do you consider yourself to be spiritual or religious?  □ No □ Yes

If yes, describe your faith or belief: _____________________________________________________

__________________________________________________________________________________

3. What do you consider to be some of your strengths? ______________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

4. What do you consider to be some of your weaknesses? ____________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

5. What would you like to accomplish out of your time in therapy? ____________________________

__________________________________________________________________________________

Case Diagnostic Exercise Template

Case Name: Anxiety Disorder

Diagnoses Considered:

1.

2.

3.

Assessment Plan:

Sources of Clinical Data:

University of Phoenix user name claudiarangel pass Zion@2011

Applying Career Counseling Theories Role-Play Session Transcript

Assignment Content

Write a 350-word case scenario for a client who is seeking career guidance and counseling. Present this scenario and role play in class.

Write a 350-word transcript of a 5- to 10-minute career counseling session with this client. Include the following:

(I will need a intro and conclusion to this)

Demonstrate the use of career counseling theory to determine decision-making processes.

Demonstrate the use of theory-based counseling strategies to assist the client in developing career, educational, and life-work planning and management skills.

Demonstrate appropriate theory-based career counseling interventions.

Use a consistent theory throughout the role-play session.

Format your assignment according to appropriate course-level APA guidelines.

Submit your case scenario and role-play transcript .

Note: For Local Campus students, you will also conduct your role-play in class.

This might help you

The STEPs for Documenting Career Counseling Sessions

By Rhonda Sutton, Ph.D., LPC, LPC-S, is the author of “STEP notes TM: The Counselor’s Guide to Progress Notes” and president of STEP Notes TM, Inc. She also owns a private career and mental health counseling practice in Raleigh, North Carolina, where she provides career and mental health counseling. For more information, feel free to contact Rhonda via email at rhonda@stepnotesinc.com.

Progress notes are a vital aspect of any counselor’s work, and career counselors are no exception. The career counseling process builds upon itself, and it is important to see a client progressing. Client attendance can also be sporadic, so having a solid record of all counseling sessions helps career counselors better serve their clients. Additionally, even though career counselors do not directly address mental health issues, it is important to assess if a client needs to seek supplementary assistance for personal concerns. Take the following fictional case study as an example:

Ariana is a 26 year old undergraduate student in her junior year. She took time off from school when her mother was diagnosed with lymphoma. Her mother passed away two months ago, and Ariana’s father has “forced” Ariana to return to college to earn her degree, especially since there are three younger siblings at home. Ariana’s father needs her to get good grades and major in “something worthwhile” so that she can help support the family financially. Ariana originally wanted to major in history with the goal of becoming a history professor, but now she is changing her major to business administration. She is seeking career counseling to find out about the types of jobs she can get and what she should do to “make the most” of the next two years of college. When she meets with you, a career counselor at her university, Ariana appears unkempt in baggy sweatpants, an oversized t-shirt and uncombed hair. She barely looks you in the eye, shifts around in her chair a lot, and seems tearful when she briefly refers to the loss of her mother. Ariana shares that she is having a hard time concentrating in her business classes and does not sleep much given that she is working a full-time job to help pay for college.

The STEP notes TM method provides concrete “STEPs” for documenting this session:

“S” refers to the SUBJECTS the client discussed and the SYMPTOMS the client reported or exhibited. Subjects Ariana disclosed include: death of her mother, change of major, and stress. Symptoms can be emotional, behavioral, cognitive, and/or physical. Ariana’s emotional symptoms appear to be sadness and uncertainty. Behavioral symptoms to document for Ariana include loss of sleep, minimal eye contact, acting withdrawn, and agitation. Ariana’s difficulty concentrating is a cognitive symptom, and her disheveled appearance is a physical symptom. Seeing how the subjects and symptoms increase, decrease or change over the course of counseling help the career counselor better ascertain ways in which career counseling is progressing.

“T” refers to the actual THERAPEUTIC TOOLS the counselor utilized during the session with the client. For example, Ariana’s career counselor may utilize Holland’s theory of vocational choice or Super’s developmental self-concept theory. Also, the counselor may be person-centered or use solution-focused techniques with Ariana. In addition to the therapeutic approach, what the counselor actually does during the session should be documented in the progress notes by using action verbs. Words such as, “aligned, demonstrated, explored, reframed” are all examples of action verbs that can start a sentence describing how the counselor put a theoretical approach into practice. For example, “Explored Ariana’s reason for changing majors and what she hopes to accomplish by doing so.”

“E” indicates the EVALUATION section of the progress note. Evaluation involves the client’s level of engagement in therapy; for example, is the client minimizing, open, or guarded? In the example with Ariana, it appears she is somewhat guarded. Evaluation also needs to include an assessment of the client’s current level of functioning. Utilizing a scale of 1 to 10 is helpful, with “1” indicating an inability on the part of the client to engage in career counseling and a “10” signifying that the client has met her career counseling goals. Ariana is probably functioning at a “2” to “3” level given that she is dealing with the loss of her mother, pressures from her father, and uncertainty about her major. In this section, it would also be important for the career counselor to note if the client was referred to additional services to deal with deeper concerns, such as grief over the loss of a parent.

“P” is the last part of the progress note and references both the short- and long-term PLAN for the client. The plan may include the homework, assessments, and long-range goals. Examples of a plan for Ariana may include taking a career assessment of her interests and skills, exploring jobs one can get with a business major, and learning about resources to deal with the loss of her mother. The plan can also include topics or details that were not addressed in the current session but that the counselor wants to follow up on during the next appointment.

These “STEPs” provide career counselors with a format to efficiently and clearly document their counseling sessions. As one can see from the case study example above, using the STEPs format to document sessions can assist with systematically noting present concerns and planning future goals. The categories provide an organized structure for evaluating progress as well as assessing if career counseling interventions are meeting client needs. The goal of STEP notes TM is to provide a professional and thoughtful conceptualization of counseling sessions, and to be a useful tool for counselors to note the progress of their clients. More about STEP notes can be found at www.stepnotesinc.com.