1. Identifying information The client, “Julie,” is a white, 14-year-old female 9th grade student with no siblings and a single mother, “Anne.” She presents for this first counseling session well groomed, appropriately dressed, and reports being in a relationship with a 17-year-old boyfriend who is a senior at her school....
1. Identifying information
The client, “Julie,” is a white, 14-year-old female 9th grade student with no siblings and a single mother, “Anne.” She presents for this first counseling session well groomed, appropriately dressed, and reports being in a relationship with a 17-year-old boyfriend who is a senior at her school.
2. Initial Impression
The client is intelligent and articulate, but she is also shy and reluctant to make eye contact. Despite her apparent shyness, Julie was responsive to questions and gesticulated a great deal, including the use of “air quotes” and swinging her legs when speaking.
3. Presenting Issues and Concerns
When she was 2 years old, Julie’s father died in an automobile accident. Her mother, who is employed full-time as an accountant, subsequently remarried when Julie was 12 years old. Three months previously, Anne completed an ugly divorce from this spouse who had been physically abusive on occasion. Although the divorce relieved Julie it distressed her mother which also distressed Julie because they are very close. Since the finalization of the divorce, Julie reports that her mother has become increasingly depressed, has started using antidepressants and has come to count on her more for emotional support and household assistance than in the past. Consequently, Julie has also experienced increasing stress at home which she believes is harming her academic performance because her grades have dropped and she is having trouble concentrating in class. She also reports having trouble sleeping and states that she does not know how to assist her mother besides helping out around the house and is not certain she is the right person for the job.
4. Personal History
The client attends high school in a middle-class Midwestern high school and is an above-average student who has shown an interest in fashion design. Her childhood was uneventful except for the most recent domestic violence incidents involving her mother and former step-father. Although Julie reports have several friends, she denies having any close friends besides her boyfriend, “Francisco” and denies being sexually active. At present, Julie is a member of the yearbook committee at her school and she participated in volunteer activities at a local shelter the previous 2 years.
5. Initial Assessment of Functioning
The client is an otherwise well-functioning teenager who is experiencing problems at home in responding to her mother’s depression and increasing need for assistance.
6. Medical History and Health Related Issues
The client reports general good health except for trouble sleeping in recent weeks. The client denies tobacco or illicit drug use and has not been treated for any mental health disorders in the past.
7. Counselor Case Conceptualization
This case is can be conceptualized using Dorothea Orem’s self-care model that provides a number of strategies for helping young people cope with family-related problems.
8. Counseling Plan
The goals of the counseling plan were three-fold: (a) provide Julie with the information and resources she needed to better cope with her current problems and develop resiliency for the future; (b) engage mother and daughter in a group meeting to identify resources in the community that can assist Anne; and (c) have Julie assessed to ensure that there are no organic factors contributing to her trouble sleeping. Following the group meeting with her mother, the client was seen on a weekly basis and provided with several coping strategies using Orem’s self-care model.
9. Counseling Process to Date
Although Julie’s academic performance has not improved significantly, the client does report being able to better concentrate in class, that she has been sleeping a little better and her mother’s disposition has improved (Julie continues to help with the housework). In addition, Julie’s mother was referred to a family therapist in the community and has attended three counseling sessions to date. More importantly, the client reports being pleased with the coping strategies that were recommended and adds that she has shared them with her boyfriend.
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