Fiona Dava 1

Name: _______Eliza________ Date: __21st June 2021___ DOB: _____2003___________

Age: ____18________ Start Time: ______1:00 PM______ End Time: __2:30PM___

Identifying Information:

The client is a Caucasian female who has an average height and a slender body. The client was sent for treatment after she was found consuming alcohol in the campus. The client is a freshman taking an engineering course at the campus

Presenting Problem:

The client has problems with maintaining her school GPA and admits to taking alcohol because her friends do and also as part of unwinding from her stressful course work. The client has difficulties in increased study requirements in her semester and making friends. She admits to gaming as a way of unwinding and forgetting the stressful school life.

Life Stressors:

The client is stressed because she struggles to maintain her school GPA and illustrates her coursework being so demanding and therefore identified school life as a stressor. She illustrates her family as a stressor because her mother has a controlling attitude.

Substance Use: FORMCHECKBOX Yes FORMCHECKBOX No

The client admits to consuming alcohol. She also admits of using marijuana in her high school life and was introduced to alcohol in campus.

Addictions (i.e., gambling, pornography, video gaming):

The client is addicted to gaming to unwind and forget stresses as a result of school life. The client also admits to be an addict of c

Medical/Mental Health Hx/Hospitalizations:

The client illustrates that she has never been hospitalized although she is an addict of self-harm (cutting), primarily because of family pressures to achieve high grades. The client illustrates that cutting helps her in relieving pressures.

Abuse/Trauma:

The client has not been abused although she has been teased severally in high school

Social Relationships:

Although she had quality relationships, the client has no any close friends currently at the campus and hasn’t disclosed her problems to anyone because she trusts no one. She admits to mingling with people at parties but doesn’t extend relationships further. She has a good relationship with her parents and her brother rarely call. She struggles of having happy relationships

Strengths:

The client has good family that calls to check on her and acts as a support system. She is also smart given that she achieves B’s.

Legal History:

The client hasn’t any legal history except that her drinking incident was reported to the police and nothing has been done yet by the police.

Educational History:

The client is freshman student at a City Campus majoring in an engineering course. She joined the university after completing her high school studies where she got A’s.

Family Information:

The client lives with her family (father, mother, and two siblings). She has a good relationship record with her parents but illustrates her mother as controlling and her father as a cool person and both call to check on her. She illustrates of not having a close connecting with the brother because they rarely call and only meets them upon visiting home. The client’s mother takes wine each night before sleeping to unwind. She is the lastborn in a family of three. Her parents strain in their relationship.

Spiritual:

The client’s religious preference is agonistic but her parents are Irish Catholics.

Suicidal:

The client has never been involved in suicide related activities.

Homicidal:

The client is not violent but has been engaging in self-harming activities whereby she cuts herself.

Mental Status Exam (MSE):

The client is depressed and denies it (denial stage). She first denied of consuming alcohol and is stressed of school life. She also cuts herself as a way of dealing with pressure from parents. Her way of dressing (wrinkled clothes and unkempt hair) illustrates how depressed she is. She also suffers anxiety based on how she responds to stress by drinking and cutting herself and also gaming.

Clinical Justification (Provide clinical justification related to client symptomology along with a DSM and ICD diagnosis based on client assessment):

Eliza, a Caucasian female is of average height and a slender body and was sent for treatment after being found taking alcohol in the campus’s dorm. Eliza confesses of taking alcohol, gaming and making cuts in her body. These are some of the courses of concern for Eliza. The client explains of her school life struggles and what she does to overcome them. Eliza’s symptoms are stagnant and illustrates of being not able to meet the requirements of her major.

Initial Diagnosis (DSM 5):

It’s the initial belief of the counselor that the client is depressed and this would be further evaluated as a way of determining severity. According to the DSM-IV criteria, a person needs to experience more of five symptoms for diagnoses and this is evident in Eliza’s case. She has a depressive mood, feels tired, doesn’t sleep and fails to concentrate. She is even disorganized in terms of her dressing ways.

Initial Treatment Goals:

Goal: short-term including being out of the bed during a certain time, talk to some classmates, have a daily schedule in which she can stick to, and try finding sleep by reading books. Long-term goals include improve her relationship with classmates, change a course and find one that she enjoys, get in touch with the family regularly, and search for a decent person who can help her in studying and avoid peer pressure.

Objective: Ensure that the client finds something that changes her stressful life.

Intervention: Cognitive Behavioral Therapy to help change her moods, behavior and thinking patterns. Counseling will help her in ways she will employ to stop drinking and search for friends

Target Date: Five months

Discharge Plan:

The client needs to understand that drinking will not help her and should actively pursue change to overcome the situation. The client is Caucasian female and a freshman in campus majoring in engineering and school life has made her have a stressful life. She rarely contacts the family and come for counseling because she was caught consuming alcohol in the school dorm which is against the campus regulations. She has been struggling with creating new friends at campus and decided to use drugs to relief her school stresses. The client was diagnosed with depression and is trying to cope with the alcohol consumption. Having spent five months with the client working on ways to improve, she has improved relationship status with the family, found new friends who are more concerned. The client has been having a better sleeping pattern and has stopped taking alcohol.

Name: ______student’s name______________________ Date: ____21st June 2021______________