COUNSELLING 19: Counseling Assessment Report on Valerie and Caiden

This report presents a thorough counseling assessment of two case studies: Valerie, a client with potential health and family issues, and Caiden, a client struggling with homosexuality, school reluctance, and suicidal ideation. The report is divided into two parts, the first focuses on gathering information, communication techniques, and applying Egan's model to Valerie's case, while the second part addresses risk identification and its impact on young clients, including Valerie. Furthermore, it explores the impact of risks in Valerie's case, considerations influencing decisions and actions, and relevant CareShore policies and procedures. The second case study on Caiden focuses on developing a counseling plan, including goal setting, trauma-informed care, and person-centered practice. The report outlines the client's needs, expectations, and commitment to counseling, as well as potential anxieties and a comprehensive counseling plan. This report provides a valuable resource for understanding the complexities of counseling assessment and intervention strategies.

Running head: COUNSELLING 1
MODULE 6 COUNSELLING ASSESSMET
Student’s Name
University Affiliation
Course
Date

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VALERIE’S SCENARIO
PART 1: GATHERING INFORMATION FROM CLIENT
A. Open and non-leading questions of gathering information
1. Could you kindly share with me the reason as to why you have come here at
CareShore Community services Office?
2. Have you been visiting the school nurse for blood sugar level checkup in the last
one month?
3. Have you had any challenges in getting insulin medications for your health
problem?
4. What are some of the challenges you have encountered while trying to seek health
care for your health problem?
5. What are the reactions of your family towards your health problem and how have
they influenced this problem?
B. Communication techniques used during the initial session to gather information in
counselling
1. Greeting the client and welcoming the client to the facility and explaining the
counselling process and proving ad overview of all the services provided at you the
facility.
2. Actively listening to the client and maintaining good body language such as eye
contact, expression of positive emotions and avoid distractions.

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3. Asking open-ended questions to seek clarification where I may not have
understood well. Open –ended questions enables the client to hold back and filter
her opinions or thoughts.
C- Behaviours and their indications
1. Keeping eyes low-show that she is resentful about the session of counselling
2. Sitting at the edge of the chair-Shows that the client is uncomfortable and anxious.
3. Hiding her face using her hands-indicates fear, shyness and lack of confidence
4. Crying when asked some questions-indicates that there is a very psychologically
traumatizing story that the client does not want to be reminded about.
5. Sleeping or yawning in the session-shows boredom and lack of interest in the topic
of discussion.
D- Key elements to consider in the school’s referral report
Some of important elements to consider in the referral letter from the school include client
identification which includes name, age and the level of studies. Reason for writing the letter,
detailed information on the problem and how it has impacted on her are also important. A
detailed history of the presenting issue and any remedies or effort had been made towards the
problem. Additionally, her personal history, clinical assessment, social history and differential
diagnosis should be considered.

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E- Stages of Egan’s model and their application to counselling in Valerie’s case.
Stage 1(What happening) -involves provision of safe environment for the client to narrate his
or her story in their own format, be fully listened and acknowledged. This stage can be applied in
Valerie’s case to encourage her narrate her story with good listening skills to enable her unfold,
explore and reflect the tale.
Stage 2 (What do I want instead?)-Involves problem-solution approach where the client
applies skills such as imaginative thinking and brainstorming in order to generate hope and
energy. It can used in Valerie’s Case to help her open a mental picture of what she wants and the
betterment of things.
Stage 3 (How will I get there?)- This focuses on how to achieve the goals identified in stage 2.
It focuses on specific actions and possible techniques or strategies to ensure change. This stage
can be applied in Valerie’s case to help generate solutions to her problem in order to achieve
what she wants and make things better for her.
F- Client special needs and their impact on counselling approach.
1. Age (below 18 years)-this impacts on decision making in counselling because the case
manager has to be very careful and follow some policies to avoid violating their rights.
2. Some special requirements such as adolescence. Adolescents are associated with certain
behavioral patterns which should be dealt with in a special manner, hence it impacts on a
counselling approach used.
3. Disabilities-This impacts on counselling approach because the counsellor must employ
special techniques of handling them to ensure successful counselling session.

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PART TWO: RISK IDENTIFICATION

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Signs Extent they fall into own role/referral
requirements
Alcohol and other drugs Giving guidance on the impacts of
substance abuse to change the attitudes
and habits. Can refer for further
assessment since drug intoxication leads
to mental disorders in an individual.
Financial Difficulty Lack of emergency savings,
payday loan and making
credit purchases
Offering guidance on financial
management techniques to avoid these
signs
Domestic and Family Violence Physical abuse, verbal abuse
and threats
Offering social support, engaging
family in a counselling session.
Providing tips of managing family
dynamics. Refer for management of
physical trauma.
Child Abuse Sexual abuse, reluctance to
go home and being
withdrawn
Offering psychological support then
referring for further management due to
the sexual abuse
Child Neglect Begging, unattended medical
problems and poor hygiene
Child neglect is a scope of counselling,
therefore it falls in my role. I can also
refer for management of unattended
medical problems.
Homelessness Poor health, attendance
problems, lack of basic
This falls on my own role due to the
issues of homelessness, I can integrate

COUNELLING 7
supplies the family in a counselling process to
find a solution.
Problem Gambling Lying, borrowing, addiction
to gambling, stealing to
gamble
Problem gambling leads to addiction,
this falls under my role because I need
to offer guidance on how to deal with it
Mental illness Illogical thoughts,
withdrawal, apathy, mood
variations, unusual behavior
Mental illness signs falls under referral
requirements where a patient needs to
be put on special psychotherapy and
medications.
B- Impact on the signs of abuse exhibited by a young client.
Age-a young client is not mature enough, therefore he may not exhibit the same signs as an adult
in a case of abuse. An adult can find other ways of dealing with the abuse but a young client may
not think of such things when abused (France et al, 2012
Gender- There are some disorders which are associated with a certain gender, for instance,
depression in females leads to suicidal ideations than it does to a male gender. This affects the
degree of signs exhibited.
Culture-It determines on the signs exhibited since some cultural beliefs do not allow some
behaviors while others do. Therefore, a client may exhibit some signs and may not exhibit others
due to cultural obligations (France et al, 2012
Disability-patients who are deaf and dumb may have difficulties exhibiting signs such as crying
or communicating, therefore signs exhibited may be impacted by these disabilities (France, 2012

COUNELLING 8
Sexuality- this affects the signs exhibited since some clients opt for the same sex while others go
for the opposite sex. Like in homosexuality, the client is attracted to people of the same sex
(France et al, 2012
C-Impact of risks in Valerie’ Case: These risks may impact the life of Valerie in a negative
manner. Unattended health problem shows child neglect. Additionally, the family shows less
concern for her health problem. This may psychologically impact the client through depression,
dissociation, low self-esteem and academic challenges. Physically, she may be affected by the
complicated of diabetes if it goes untreated to elevated sugar levels since she has been having
challenges to get insulin medications.
D- Considerations that impact my decisions and actions in relation to this case
1. Age of the client since she is a child who has not yet attained 18 years hence cannot make
decisions for herself.
2. Social support of the client, the family seems not to cooperate with the school in the care
of the child
3. Gender, she is a female gender, so I have to make a decision or take an action that fits a
female gender.
E- CareShore policies and procedures I would access to assist me in making decisions
regarding this case?
1. Federal laws that deal with child welfare realm
2. Policies on provision of community services with respect and dignity irrespective of age
of the client.

COUNELLING 9
3. Child protection plans for more information to avoid violation of child’s rights and
freedom.
CAIDEN’S SCENARIO
PART ONE: DEVELOPING A COUNSELLING PLAN
A. How to implement goal setting processes with Caiden as a Case Manager
1. Supporting Caiden to set goals: I can implement this by first defining what he
wants, why and when. Secondly, I would try to identify the congruence level
between the goal and his lifestyle, values, priorities, beliefs and self-ideal.
Thirdly, I will do a check on ecology to identify factors that might influence the
achievement of the goal. I will then develop a blueprint for achievement of the
goals and finish with drawing a plan of action for goal accomplishment.
2. Breaking down goals: I can help him by guiding him on some of the goals that are
client focused, achievable, realistic, easily understood and measurable. I can
schedule regular appointments with him for continuity in the goal setting process.
B-Trauma Informed Care and its applicate in Caiden’s Case
Trauma Informed Care refers to an organizational structure and a framework of treatment
involving recognition, understanding and response to effects of different types of trauma. It
emphasizes on psychological, physical and emotional safety for providers and consumers. It can
be applied in the case of Caiden to help him rebuild empowerment and sense of control. Caiden
has physical and psychological injuries. Application of TIC in this case would facilitate holistic

COUNELLING 10
care to him which hence improvement and healing. It focuses on past traumatic experiences of an
individual, which is very applicable in Caiden’s case (Clarkson and Cavicchia, 2013.
C-
Persons Needs Rights and
responsibilities
Impact of their values
and systems on
Caiden’s care plan
Caiden Physical and
psychological healing
Good human care and
treatment, privacy
and confidentiality
Good health
CareShore Personnel, equipment Provision of quality
and individualized
care services
Quality outcomes on
clients
I (Case Manager) Skills and Knowledge Right information,
handle clients with
respect and dignity
Proper flow of all
procedures and
activities in the
facility and patient
recovery.

COUNELLING 11
D- Process that can be used to clarify Caiden’s needs, expectations and commitment in
relation to counselling. This process involves a well-structured approach and techniques in
counselling which clearly explains the entire process of counselling to the client. Secondly,
establishment of health relationship will help him properly understand the nature of services
involved in the counselling process hence promoting client satisfaction. Confirming the
appropriateness of the relationship ensures use of appropriate counselling methods and resources
that meets the needs and expectations of the client (Clarkson and Cavicchia, 2013.
E- Person-centred practice and its application in Caiden’s case:
Person-centred care refers to a manner of doing things or thinking using social and health
services equally in planning, development and monitoring of care to ensure that they meet their
expectations and needs. It involves respect, integration of care, emotional support respect for
one’s values, and teamwork to ensure good education, information transmission and
communication. It can be applied in Caiden’s case to provide quality and individualized care,
meet his expectations and needs which promotes healing and good health (Mearns, Thorne and
McLeod, 2013).
F-Potential Anxieties with Caiden about the counselling process and how to explore them.
1. Social anxiety-client feels fearful to be in public places and he does not want to
interact with strange with people.
2. Diagnostic anxiety-sweating and shaking fearing the outcome of his condition
after assessment.

COUNELLING 12
G-Counselling Plan for Caiden
Current
Situation
Priorities Approaches Responsibilities Evaluation
Strategies
Client with an
issue of
homosexuality,
reluctance to go
to school,
withdrawing
from friends and
sitting alone and
suicidal
ideations.
Suicidal
ideations which
are associated
with increased
behavior of
isolating from
others and
feelings of
hopelessness in
life hence
wishing to die.
Physical
bruises,
Withdrawing
from friends,
Homosexuality
which could be a
disorder
associated with
adolescence,
Psychodynamic
approach,
Client-centered
Approach,
Humanistic
Approach
Behavioral
Approach
Gathering
information,
Assessing the
client, planning
and coordination
of the
counselling ,
provision of
quality services
to meet client’s
needs and
expectations
Planning for
referral of a
client to another
counseling
service center
for further
investigations in
order to get a
Observations to
monitor any
changes in the
behavioral
patterns of the
client in order to
determine the
levee of
intervention
required.
Interviews
Caiden and the
family member
on the progress
of the client to
obtain more
information
which will be
useful in further
planning.

COUNELLING 13
whereby he feels
more attracted to
the opposite sex.
This is part of
psychosexual
development
which should be
considered
among
adolescents.
detailed and
wide range of
information
regarding the
case of the
client.
Facilitating
implementation
of the
appropriate
interventions in
care of the
client.
Questionnaires
with both open
and closed-
ended
questionnaires to
gather
information that
tells whether he
has improved or
not.
H- Protecting Caiden’s rights
I can protect his rights by ensuring privacy and confidentiality of all the information obtained
from him and in any other services I provide to him. I do this by not discussing his case with any
other person without his consent. I will properly keep all hard copies of records to avoid access
by unauthorized persons. I will lock all the records with his names and other identification
information in locked cabinets or files (Clarkson and Cavicchia, 2013
I-Ethical Concerns applying in Caiden’s Case

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Some of the ethical concerns that may apply in the counselling process of Caiden include
confidentiality and privacy, dual relationships, professional competence, informed consent when
doing some procedures to him, ethical decision-making, disclosure statements, rights of the
client, multicultural counselling. Ethical concerns are very critical in all aspect of care to avoid
violation of client rights (Clarkson and Cavicchia, 2013).
PART TWO: GIVING CONTEXT TO THE COUNSELLING PROCESS
A-Scope and nature of a counselling relationship:
Scope of counselling comprises of three major areas. The first one is individual counselling
which involves adolescent concerns and identity, teen-parent relationships, peer relationships,
gender sexuality, identity and sexuality, anger and stress management, workplace relationships
and stress, family issues, children issues in families, interpersonal and personal relationships and
depression. Secondly, it focuses on pre-marital and marital counselling which involves infertility,
relational and marital dynamics and relationships in extended families. Thirdly, counselling
focuses on family counselling which involves life transitions and stages, divorce issues, family
dynamics such as communication, estrangement and conflicts, child behaviors and adolescents
and patterns of parenting (Clarkson and Cavicchia,2013) .
A- Purpose of counselling: Counselling plays an important in problem solving.
Counselling acts as an inspiration of successful endeavors for goal attainment. It
encourages and promotes development of interests and abilities. It helps clients in
achievement of their goals and gain high insights in the different aspects of their life.
Additionally, it empowers individuals, groups and families to accomplish education,
health, wellness and other goals such as career. It also enables clients to adequately deal

COUNELLING 15
with life circumstances, make rational and well-informed decisions and manage stress for
personal growth.
C-Evolution of counselling as a helping relationship:
Counselling as a helping relationship began when human beings got a realization that there is
more comfort and relive in sharing their own fears, feelings or problems and narrating their
stories to other specialized individuals who in turn offered psychological and emotional support.
When things get tough or seemed not to be working properly as per their expectations. As a
result of this, counselling emerged to be a helping relationship.
D-Place of counselling within the helping services: It helps to enable client perceive things and
situations from a different point hence enabling them focus on experiences, feelings or behavior
aimed at facilitation of positive change. As a helping approach, counselling helps to highlight the
intellectual and emotional experiences of clients, their feelings and their thoughts and views on
the problem they wish to be guided on.
E-Licensing –Licensing-Certified Case Manager Credential from the Case Manager
Certification Commission. Case managers can maintain these by obeying laws, rules and
regulations, maintaining the integrity of code of professional conduct, maintaining competency
in their practice, maintain objectivity with their clients and placing the interest of the public
higher than theirs. Additionally, they can maintain this by acting with integrity when dealing
with different individuals of different professions to facilitate achievement of maximum benefits
by their clients (Counselling, 2015.

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PART THREE: MAINTAINING COUNSELLING RECORDS
A.
Counselling contract
This is a mutual counselling agreement between ________Dr.
Obanor__________________________
(Counsellor) and ______Caiden______________________________ (client).
Confidentiality and
disclosure: All the information obtained from the client to be maintained
private and confidential. The information will not be disclosed
to any unauthorized person without consent from the client.
Sessions 5 session
Duration of
counselling:
2 hours
Issues to be
addressed during
counselling:
Homosexuality, physical injuries, withdrawal from friends
and family, suicidal ideation
Ending counselling:
Ask the client to summarize the session,
My inputs to the summary

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Taking notes after the client leaves
Fees: As agreed with the client
Client rights:
Privacy and confidentiality, humane treatment and care,
participation in decision making, information on legal
requirements of the session, review and amendment of his
medical records, copy of the charges and fees associated with
the session.
Cancellations:
Some fees and charges after agreement with the client
Counsellor name: Dr.Obanor
Counsellor
signature:
Iiooooii Date: 16-03-2018
Client name: Caiden
Client signature: Ci Date: 16-03-2018

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B. Referral Letter
Dr.Smith
CareShore Community
Services Office,
129 Skylight Street.
[e-mail]
March 15, 2018
To Dr.Martin, Jane Doe Community services
I am Dr.Obanor, a case manager at CareShore Community Services Office. Enclosed is a copy of
the client’s information.
Background Information
Caiden is a 16-year-old male client who stays with his parents and his young brother. He
disclosed his homosexuality to his parents and friends and he was brought to us 12 months age.
Reason for Referral
In the past two months, it was noticed by the parents that he was increasingly becoming
withdrawn. He was also noticed to have physical bruises on his body and he claimed that he had
been injured by friends while playing soccer. In the last one month, he has been so reluctant and
he does not go to school. The parents discussed with his teachers and it was reported that in
school he sits alone without interacting with his normal friends. Last week, Caiden was
discovered to have suicidal ideation whereby he told his mother he would rather die than live.

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Based on my working, I came up with a diagnosis depression.
I would appreciate your assessment. You can share your assessment and contact us anytime you
need any enquiries.
Thank You
Dr.Obanor.
B. Managing Caiden’s Records
I would show accountability and responsibility for all records regarding Caiden’s case. I
would record all the information obtained from the client since it is useful in the whole
process and also for communication purposes in the facility with other professionals. I would
ensure the information is confidential and private by avoiding discussions with unauthorized
personnel. I would put the records in lockable cabinets and files where they cannot be easily
accessed by unauthorized individuals. I disposal of the records, I would follow the
procedures and policies regarding disposal of a client’s records (Counselling, 2015).

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References
Burnard, P., 2013. Practical counselling and helping. Routledge.
Counselling, C. and Psychotherapy Association, 2015. Standards of practice.
Clarkson, P. and Cavicchia, S., 2013. Gestalt counselling in action. Sage.
France, M.H., del Carmen Rodríguez, M. and Hett, G.G. eds., 2012. Diversity, Culture and
Counselling: A Canadian Perspective, 2e. Brush Education.
Mearns, D., Thorne, B. and McLeod, J., 2013. Person-centred counselling in action. Sage.
Thapar, A., Collishaw, S., Pine, D.S. and Thapar, A.K., 2012. Depression in adolescence. The
Lancet, 379(9820), pp.1056-1067.
Trower, P., Jones, J. and Dryden, W., 2015. Cognitive behavioural counselling in action. Sage.
Van Deurzen, E., 2012. Existential counselling & psychotherapy in practice. Sage.