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Questions/Discussion Points

Provide the questions/discussion points you would like us to consider during your presentation. Placing them at the beginning, allows us to consider them as we read through the write up. Please have at least 3 questions/discussion points.

Demographic Information

In this section, provide the client’s age, gender, year in school (if applicable), race, ethnicity, marital status, sexual orientation, religion/spirituality, and past experience in counseling – and any other important demographic information. Include here, the number of sessions you have had with the client to date.

Presenting Concern

Describe the reason the client came to treatment. Provide enough information to give the readers a clear picture of the client’s concerns. Include symptoms, onset, and duration. Also provide client’s psychiatric history and any prior counseling. For example: John came to the Counseling Center expressing feelings of sadness following a break-up with his romantic partner. He stated that following the break-up he has had difficulty sleeping, has a decreased appetite, depressed mood, poor concentration, and has been irritable with his friends and family. He stated that the break-up occurred 2 weeks ago, and he reported that he has felt these symptoms since that time. He stated that he experienced similar symptoms when he was in high school; he denied having received any prior counseling and denied any prior psychiatric illness.

Family History and Diversity/Cultural Contexts

Describe the family – include who is in the client’s family, the dynamics within the family and the relationships between family members. Also provide any family history of psychiatric illness and substance abuse. Be sure to include significant events, such as deaths or divorces.

Interpersonal Pattern

Describe the client’s support system, intimate relationships, friendships, and their style of relating to others. Include how the client relates to you in session.

Behavioral Observations

Note any significant behavioral patterns (e.g. crying, showing up late, being disheveled, and poor hygiene). Describe any observations you notice about how the client reacts to interventions.

Conceptualization, Diagnosis, and Goals for Therapy

Provide your theoretical framework and how you use this theory to help describe and understand your client. Specifically state at least one theoretical orientation (e.g. Learning Theory, Psychodynamic, Client-Centered, or Behavioral). If you integrate ideas from more than one theoretical orientation, describe how this is done.

Provide a DSM-5 diagnosis. Make sure that your diagnosis is supported by your presenting concern/observations/conceptualization (do not provide the rationale next to the diagnosis – just list the diagnoses with appropriate codes).


Describe treatment strategies and how they relate to the goals. Describe any homework assignments, in session interventions, and progress to date.

Discuss how you are tracking progress in treatment.

Potential Areas to explore: (Discuss at least 2 of these)

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