CASE PRESENTATION:
SECOND CLIENT
Sarah English-Morrell
Liberty University
DEMOGRAPHIC INFORMATION
CLIENT INFORMATION
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8 years old Black female
Youngest of two children
Lives with mom and older sister
Close with older sister and mother
Parents are in the process of divorce
Goes to a private school
Father is a surgeon
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PRESENTING
CONCERNS/PROBLEMS
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The client's presenting problem is she has picked off a
majority of her left eyebrow
Sitting still in class
Maintaining focus
Relying on her older sister to advocate
Case presentation: second client 3
DIAGNOSTIC IMPRESSIONS
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Trichotillomania (Hair-Pulling Disorder) Diagnostic Criteria
312.39 (F63.3)
Z61.2 Altered pattern of family relationships in childhood.
V61.03 (Z63.5) Disruption of Family by Separation or Divorce
V61.29 (Z62.898) Child Affected by Parental Relationship
Distress
Case presentation: second client 4
SESSION DESCRIPTION &
THERAPEUTIC RELATIONSHIP
This is the second session. The client was brought into counseling by
their mother. The client's mother voiced concerns about the client's
eyebrow picking.
The client and their sister was told by their father that he was
divorcing her mother before he told the mother.
The client has since become easily distracted and having trouble in
class.
Case presentation: second client 5
ASSESSMENT OF THERAPEUTIC
RELATIONSHIP
Case presentation: second client 6
My impression of the therapeutic connection after this session is
positive.
The client was open with her body language and was excited about the
play therapy feelings game.
The client had waves of joy and sadness in the session discussing the
death of her dog.
Notes of concern are found in her strong feelings about her father
wanting to shoot her dog in the head and how she gets "grouchy"
when he "whoops" her.
COUNSELOR ASSESSMENT
Throughout the session I could have used better open-ended questions.
I used "yeah" too many times.
I was trying to let the client lead in the session but felt inadequate when she
brought up watching Youtubevideos of BTS abs. I felt Ishould have maybe asked
her more about that but instead jumped to the next part in the game.
Class feedback regarding the flow of the session.
Case presentation: second client 7
REFERENCES
V Codes (DSM-5) & Z Codes (ICD-10). (2021, November 25). PsychDB.
https://www.psychdb.com/teaching/dsm-v-icd-z-codes
Williams, J. B. W., & First, M. (2013b). Diagnostic and Statistical Manual of Mental Disorders. Encyclopedia
of Social Work. https://doi.org/10.1093/acrefore/9780199975839.013.104
