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College of Social and Behavioral Sciences
School of Counseling
Counseling Masters’ Programs
CLINICAL MENTAL HEALTH COUNSELING
MARRIAGE, COUPLES, FAMILY COUNSELING
CASE CONCEPTUALIZATION FORM
This Case Conceptualization & Reflection Form will be used in conjunction with your recording assignment to analyze your skills demonstration. For these assignments, you will complete the case conceptualization on the client you have chosen for your skills demonstration. Ideally, this will be the same client for both Week 4 and Week 8.
FOR THE WEEK 4 CASE CONCEPTUALIZATION
PART I
FOR THE WEEK 8 CASE CONCEPTUALIZATION
PART II
PART I (Due Day 7 of Week 4)
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Counselor name: |
Client age: 12 |
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Client initials: IH |
Client race or ethnicity: Hispanic |
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Number of sessions with client: 4 |
Self-identified gender: Female |
Presenting Problem
To understand the presenting problem, describe the client’s past and present. Be sure to address each of the following elements:
· Demographic information: 12 year old female who lives with her father, mother, and two other siblings, one younger brother aged 8 and sister aged 19.
· Employment history: N/A
· Relevant legal problems: N/A
· History of counseling: First time in counseling
· Reason for seeking counseling, according to the client: Depression, isolation, no desire for socialization, feels guilty when parents argue and blames self, distrusts father from prior history of him cheating on her mother. Feels father is controlling and harsh towards she and her siblings. Reports of being rude and aggressive verbally. Hates to see mother cry, but wants to be there for mother. Self-reported cutting for 3 years. Denies suicidal ideation.
· Onset and duration of concern: About 2 years
· Frequency and intensity of symptoms:
· What the client wants to improve: Confidence, positive self image, bettering relationship between she and father, finding ways to cope with stress.
Family Structure
Clients and their concerns are shaped by their family structure and stage of development. Be sure to address each of the following elements and their impact:
· Family of origin and role within
· Family of choice if different and role within
· Significant relationships/relationship patterns
· Children, marriages, divorces
· Current living arrangements
· Major losses, family traumas
· Family mental health history: No reported history
· Family substance abuse history: Denied
· Family violence or abuse history: Denied
· Stage of development impacts:
· Developmental challenges:
Multicultural Considerations
Clients and their concerns are shaped by a multitude of multicultural considerations and their intersectionality. Be sure to address each of the following elements and their impact:
· Race or ethnicity
· Religion
· Ability/disability
· Sexuality
· Socioeconomic status
· Military: No history
· Criminal justice system: No history
· Geographic influences: El Salvadorien ethnicity
· Environmental factors:
· Experiences of oppression or marginalization: No prior reports.
Narrative Summary
Take a step back and, through the lens of your education to this point, work to conceptualize the big picture. Consider the influence of all the information in Part I. Consider how it has all culminated and impacted who your client is and their world view. Within that context, consider the problem they presented with for counseling and address each of the following elements:
· Describe your understanding of the problem.
· Describe your observations of the client.
· Describe your impressions of the client.
· Describe any factors contributing to or reinforcing the problem.
· Describe the purpose of the client’s behaviors.
· Describe themes and patterns that emerge or connect.
· Describe barriers to growth and coping. Not wanting to socialize
· Describe strengths, assets, protective factors, signs of resilience. Likes to journal, dance, play sports to cope.
DSM–5 Diagnosis
It is of utmost importance to diagnose ethically and responsibly. You must consider all elements covered thus far not only in your understanding of the problem but in rendering a diagnosis. With this in mind, address each of the following elements:
· DSM–5 diagnosis: Major depressive disorder, recurrent, moderate, F33.1 (ICD-10) (Active); Nonsuicidal self-harm, R45.88 (ICD-10) (Active)
· Rationale for how diagnosis was determined
· Two other diagnoses considered, but not given
· Explanation for ruling out diagnoses not given
· Mental health assessments or scales used: Patient Health Questionnaire-Adolescents, Children's Depression Rating Scale‐Revised (CDRS‐R)
· Other assessments or scales that could be used:
Rev: June 2020
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