Intake Assessment in Counselling

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Client’s Presenting Problem

C. claims to be “sad” and acting “not like me.” C. noted that she no longer engages in or performs activities that she once found enjoyable. Since the COVID-19 epidemic, C. has had difficulty leaving the house. Since the rules are relaxed and people are permitted to leave their homes, C. is having trouble returning to “normal.” C. claimed that she consistently lacks energy and experiences “slump-like” feelings.

Clinical Impressions

The client lacks energy, is worn out, unhappy, and has melancholy. C. stated that she occasionally feels “numb” and that her days are not filled with much joy.

Mental Status

C. appeared to be kept up and dressed nicely. During this session, C. was worn out. C. frequently avoided eye contact when asked about her feelings and looked down at the floor. When talking about her family’s history of mental illness, C. occasionally had a slumped-over appearance.

History of the Presenting Problem

Client symptoms emerge throughout the three classroom presentations that take place throughout the course. Now, she has symptoms every time she has presentations at work in front of people. She feels anxiety accompanied by dizziness and a feeling of paralysis.

Family History

C.’s relationship with her parents, brother, and other family members is close. C. said she and her brother would sacrifice anything for the other. C. claimed that before the epidemic, she spoke to her parents frequently on the phone and saw her brother pretty often. She has, however, cut back on her familial interaction since the outbreak. C. described having a close relationship with her father as a child because he oversaw some of her sporting endeavors. C. admitted that their relationship with her father was strained due to her mother’s “mood swings.” C. claimed that this has since lessened and that she and her mother now get along well.

C. claimed that her mother experienced frequent mood swings and frequently retreated to her bedroom to avoid having to interact with the rest of the family. In response to his observations that C.’s symptoms were worsening, C.’s father urged her mother to seek therapy, which she did. C.’s mother appears to have benefited from treatment because she is no longer bothered by these symptoms. C. is not aware of her mother’s medical condition.

C. indicated that her grandmother had anxiety and depression diagnoses. However, she did not know her grandmother and claimed to only be aware of these diagnoses through hearing from other family members.

Educational History

The client is a recent university graduate who is now enrolled in additional coursework. She describes herself as a high school achiever with high expectations for herself. She was having difficulty with her university classes. She answered, “Not very good,” when asked how she was doing with her schoolwork. She had trouble focusing in class due to her workload and worries about tests and homework. She expected to see improvement as she grew accustomed to academic life, but nothing had changed.

Work History

Working as a legal assistant is C. C. is currently working from home due to the impact of the pandemic. C. takes pleasure in her job and the coworkers she works with. She acknowledged that her career might occasionally be very demanding, which could lead to some mild stress. C. is currently engaged in a demanding “major” case. When working from home, C. is struggling to strike a balance between her personal and professional lives. Overall, C. cherishes her work and makes sure she consistently performs well.

Spiritual/Religious

C. made no mention of her family’s religious background. C. added that although her family is tight, they do not discuss sensitive subjects. They are “not an emotional family,” according to C., and if something were to happen in her life, she would want to deal with it on her own rather than “burdening” someone else with her problems.

Medical History

In her teenage years, C. had previously had symptoms like this. C. described feeling depressed, low energy, and a “slump.” C. did seek treatment when these problems first appeared, and she found it helpful. C. claims she enjoys counseling because it allows her to express her feelings without feeling burdened.

Alcohol/Drug

C. stated that drinking alcohol is her only means of coping. C. noted that she would often have 1-2 glasses of wine at the end of the day, but on very stressful days, she might consume more. C. does not view drinking alcohol as a problem she wants to address in treatment or as something she can’t control.

Legal

The client denies having any legal problems.

Abuse

C. made no mention of any past or present abuse. C. noted that her mother used to isolate herself from the family frequently and “snap” at C. and her family when she was a child. This might be a sign of minor emotional abuse or trauma. C. kept quiet about how she thought this was harmful. I want to discuss this more with C. so we can learn more about the circumstances surrounding these events and how they currently affect C..

Client Strengths

In her life, C. is supported by various people, including her family and friends. C. claims that while she still feels supported by these people, she does not always confide in them about her issues. On both a social and familial level, C. has a lot of positive and solid relationships. They want to return to a pattern that involves socializing and organization in her days, which is vital for C. C. is willing to participate in therapy to lessen her symptoms and is ready to return to her “regular” self. C. has stated that she wants to develop good coping skills.

Session Rating Scale Summary

The SRS outcomes in this session were good. The scores were as follows:

Relationship: 10
Goals and Topics: 10
Approach or Method: 9
Overall: 10

During this session, C. said she felt heard, understood, and cared about. Although we are still getting to know one another, she said that she already feels at ease during these sessions.

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