Case Presentation Form Assignment for Individual Counseling Sessions

1. Counseling interns name: Ruth Howard

2. Client/Students first name: Valerie
Age: 13
Grade: 7th
Gender: Female
Sexual orientation: unknown
Race/ethnicity: Caucasian
Religion: unknown (her adoptive family is very Christian)
Economic class: unknown
Family background: She was adopted as an infant. She lives with her adoptive mother and
father, as well as a younger brother (biological son of her adoptive parents).

3. Date session occurred: April 20, 2015

Session number: ?
Length of session: 35 minutes
4. Use S.O.A.P. (Subjective, Objective, Assessment, Plan) notes to capture the presenting
issue:
* Subjective:
This clients current issues involve social interactions/conflict at school. In previous
sessions, this client has discussed past bullying incidents (involving serious physical harm) that
were also connected with her previous self-harm behavior (cutting). In the current session, the
client talks about a couple of conflicts that occurred in the past week, at school, with students
during the after-school program. One of the incidents involved her being teased by another
student because she is in foster care and her mom is in jail. The client, currently, viewed these
conflicts with other students being as resolved, and also talked about friends at school who are
supportive as well as strategies she uses to deal with negative social interactions. In previous

counseling sessions, issues of identity, surrounding the fact that she does not know her birth
mother have also come up as well. In the past, she has also expressed frequent communication
difficulties/conflict with her adoptive mother. Currently, she reports that communication with her
mom is improving and going well. The client is also struggling academically (Ds in 3 of her
classes) and reports that this is because she forgets to turn her completed work in.
*Objective should include things that are observable and measureable such as whether the client
is well-groomed, clients affect, attendance patterns, behaviors during the session, etc.
This clients affect is congruent with her expressed emotions. She often wears baggy,
dark clothes, and her hair (bangs) over her face, however, she is decently groomed and dressed
appropriately for her age.
This student maintains some average grades, while also struggling in some of her classes
(currently has Ds in 3 of her classes). She has good attendance. Her behaviors during the
session are open, cooperative, and expressive.
* Assessment is written from the counselors perspective regarding the clients presenting
problem. Identify whether the root of the problem is: (1) biologically (e.g., medical condition,
I.E.P.), (2) psychologically (e.g., low self-esteem, depression, mental illness), and/or (3)
sociologically (e.g., poverty, family dynamics, bullying, domestic violence, racism, etc.) based.
Also, identify whether the issue is impacting the clients academic, career, and personal/social
development.
I believe that the root of this clients presenting problem is mainly sociological. This
client has been the victim of bullying in the past. In addition, she struggles with identity issues
connected with being adopted and family dynamics. These issues have impacted her both
emotionally, socially, academically. She has a history of previous self-harm (cutting). Earlier in
the year, she was emergency excluded from school because of creating a kill list in her
notebook. Since her return, she is continues to be academically behind, however, socially seems
to have made some improvements in gaining some supportive friends with a new class schedule.
*Plan includes what the counselor and client will do to address the presenting problem. The plan
should be specific, measureable, attainable, realistic, and timely (S.M.A.R.T. goals). Be detailed
in your S.O.A.P. write-up. As you consider the intervention plan, identify which level of
intervention is needed and explain why (or if intervening on all three domains is necessary):
a. Counselor: This domain involves providing students individual and/or group counseling.
I will continue to meet with this student weekly. These weekly check-ins include ensuring that
she feels safe at school, as well as supporting strategies for communicating or dealing with
conflict, both with students at school and at home. I will also do an academic plan for success
with her, in order to focus on how she can bring up her current D grades. This will include a
plan for turning in work and staying organized. In addition, I plan to include her in a 7th grade

girls group that I am starting next week with the nurse. The purpose of this group is to foster
social connections, self-value, and positive self-care practices. I think this client would be an
ideal fit for this group.
b. Advocate: This domain involves out-of-office advocacy such as collaboration with families,
teachers, administrators, doctors, nurses, facilitating groups, or implementing school wide
guidance curriculum. It also involves helping to change systemic barriers.
I am currently collaborating with the school nurse in running a counseling group that this student
will be included in. This student was also referred to outside counseling, in order to return to
school after being emergency excluded. As we are a new school and counseling program this
year, we have not yet implemented a school-wide bullying curriculum, but I this is a very
important piece of intervention/prevention for students at the middle school level.
c. Scholar: This domain involves collecting data and using assessment.
Our counseling department, through a student needs assessment has collected data on
what students concerns are at school (including issues of safety, bullying, and harassment).
Ideally this information gained from this process will be used to guide school-wide curriculum,
as well as groups and individual intervention.
5. What multicultural factors are at play? How multicultural factors influence the clientcounselor relationship?
Both the client and I are White females. Although I do not see factors of race or gender at
play in influencing the client-counselor relationship, as an adopted child, this client has a very
different family experience than I do.
6. What counseling theory are you using in this session and what evidence do you have to
support this?
In this session, I use a lot of Reality Therapy. Because a lot of this clients issues have to
do with social interactions and peer/family conflicts, my goal is to get her to recognize what she
wants out of these relationships, what she is currently doing, how her responses are working for
her, and how she can plan for future social interactions. I think I do this in the session by having
her recognize what strategies she used during a conflict, talking about the result of this, and
coming up with a list of things that she thinks will work for her next time a similar situation
occurs.
7. List three things that you did well in the session with the client. List three things that you
can improve on in your session with the client.

I think I have good rapport with this student and am able to provide a space where she feels safe and
comfortable. I do a good job of tracking her story and clarifying themes. I believe I do well in keeping her
focused on solutions and strategies.
I think that I could do better in helping this student see the ultimate goals of her behavior and what she
wants in relationship with others. Also, I think there are times when it would be more beneficial to help
this student focus more on the academic piece and limit storytelling.