Case Presentation Form Assignment

1. Counseling interns name: Zoe Romero

2. Client/Students first name, age, grade, gender, sexual orientation (if known),
race/ethnicity, religion, economic class (free-reduced lunch), first generation, family
background (parents? Siblings?), and/or other basic relevant demographic
information.

Name: Abi
Age: 15
Grade: 10
th
Grade
Sexual Orientation: Unknown
Race/Ethnicity: White
Religion: Unknown
Class: Middle class
Family information: The student lives with her mother, father and little brother.
Her mother is physically disabled from a spinal injury, and little brother has been
diagnosed with ADHD.

3. Date session occurred; session number; length of session

This session occurred on January 9
th
and was 25 minutes in length. This was the 5
th

session with Abi.

4. Use S.O.A.P. (Subjective, Objective, Assessment, Plan) notes to capture the
presenting issue:
Subjective
The student spoke about school, crew, and family. She reflected on her accomplishments
and lessons she had learned over that last couple of months. She also disclosed issues
with her family and how she is coping with the added stress.

Counselor: How has the transition back to school been for you?
Student: Its been really difficult to get back into the groove of things. In the general
scheme of things, Im really impressed with how well Ive been doing. The fact that Ive
managed to come to school has been good.
Counselor: What kinds of things are you proud of?
Student: My grades, and my accomplishments at crew. Usually balancing those are
really difficult for me. Even though I have 2 Cs Im doing really well in Math and
Science. Im on the top 10 list in Algebra 2.
Counselor: Congratulations, I bet that feels really good.
Student: It really does.

Student: My mom took me to the doctor because I felt sick every morning, that is why I
couldnt make it to school. The doctor said there is absolutely nothing wrong with me as
far as health, expect for your daughter has anxiety. The doctor explained that when you
are stressed, it can place a lot of wear and tear on your body.
Counselor: What kinds of things do you do differently that you didnt do before to cope
with stress?
Student: Well, We have been doing yoga at crew which is niceIts a way for me to
calm down after being so amped up. Ive also realized that doing something is better
than nothing. I am a perfectionist and before I wouldnt turn something in if I didnt
think it was perfect.
Counselor: Im glad to hear that. I know we have talked about ways to cope with stress
and these seem to be working for you.

The objective:
Student appeared well groomed and in good hygiene. She reported her attendance had
improved and that she was decreasing on the number of times she had been late for
school. She conducted herself in a calm and relaxed manner. The student disclosed, she
was good, for the most part. She had an organized thought process and was able to
reflect on life experience as it related to who she was and her age group.

The assessment:
The root of the presenting issue is psychological. It appears the student is still suffering
from panic attacks and anxiety. She also experiences sociological issues with her family
but did not appear to be the root of her stress. These anxious episodes are primarily
induced by school stress. During the session the student was able to reflect on all the
accomplishments she has achieved since the begging of the year. She felt proud and
energized for the end of the semester. A recent doctor visit also helped her understand
her anxiety and the physiological effects the stress has on her body. In addition the
student had indicated large strides in coping skills for her anxiety. She reported that more
information about anxiety, yoga sessions, and realistic expectations have improved her
ability to manage the stress.

The plan:
The level of intervention for the student would be micro-level. This intervention would
include goal setting and bi-weekly check-ins. She had issues with attendance in the past
and would like to work on getting to school on time. She agreed that a goal of 3 times a
week was a good place to start. We will also do check-ins a couple of times a month to
see how she is coping with the stress from school and family.

5. What multicultural factors are at play? How multicultural factors influence the
client-counselor relationship?

As a (student) counselor at the high school, there is a different power dynamic. I am also
older than the student. However it does not appear to influence my counseling
relationship with Abi.

6. What counseling theories are you using in this session and what evidence do you
have to support this?

Counseling skills I employed were attending, paraphrasing, directing, and clarifying. I
focused on her accomplishments since she has improved her ability to cope with anxiety
over the last few months. During the session I did not employ any specific counseling
theory to the session.

7. List three things that you did well in the session with the client. List three things
that you can improve on in your session with the client.

Things I did well:
Empathy
Paraphrasing
Recognizing accomplishments

Things I need to work on:
Asking more open ended questions
Focus on emotions
Being more present