For Ann Harris

Initial Phase

· History assessment

· Gathering clinical information

· Identifying information about the client, presenting concerns and level of client distress, history of presenting concern, family background, personal history, previous counseling experience, risk assessment (suicidal or homicidal ideation), clinical impression and/or diagnosis, client’s goals for counseling.

· Establish rapport, build therapeutic relationship

· Determine risks, benefits, and alternatives

· Provide structure to the counseling process

· Help clients take initiative in the change process

· Develop initial case conceptualizations

Working Phase

· Examine cognitions and thinking patterns

· Recognize and explore emotions experienced

· Emotional, physical, or a combination, overt, covert, or a combination, positive negative or neutral, in or out of awareness, level of intensity, appropriateness for context and stimulus, congruence, helpful or harmful.

· Case notes

· Signs and symptoms, topics of discussion, interventions, progress and plans, special issues (STIPS format, from Prieto & Scheel, 2002)

· Documentation with high-risk clients (explain how the conclusion was reached, take action, and document the action (R.M. Mitchell, 2007).

Closing Phase

· End a learning experience properly.

· Closing gives clients opportunity to maintain changes achieved in counseling and generalize problem-solving skills to new ones.

· Closing serves as a reminder that the client has matured.

· Final Assessment:

· Has the client achieved behavioral, cognitive, or affective goals?

· Has the client developed better coping skills?

· Is the counseling relationship no longer helpful?

· Has the context of the original counseling relationship changed?).

References

Mitchell, R. M. (2007). Documentation in counseling records: An overview of ethical, legal, and clinical issues (3rd ed.). Alexandria, VAL American Counseling Association.

Newsome, D. W., & Gladding, S.T. (2014). Clinical mental health counseling in community and agency settings, (4th ed.). Boston, MA: Pearson.

Prieto, L.R., & Scheel, K.R. (2002). Using case documentation to strengthen trainees’ caseconceptualization skills. Journal of Counseling & Development, 80, 11-21.

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