IF YOU DO NOT KNOW ANYTHING ABOUT PSYCHOLOGY DO NOT TRY TO DO THIS, PLEASE!

Running Head: CLINICAL REPORT 1

Iman A . Student Clinical Intake Report Liberty University CLINICAL REPORT 2

CLINICAL INTAKE REPORT 1. CLIENT DEMOGRAPHIC INFORMATION Mrs. M is a 31 -year -old, married, white female who lives with her husband of three and a h alf years. They currently have no children. Her primary language is English , and her religious affiliation (which she reports as important to her) is Christianity. As an LPC, Mrs. M reports earn ing an a nnual income of approximately 50 K. 2. INITIAL/GENE RAL IMPRESSIONS Mrs. M is approximately 5’3” and moderately overweight. Her general appearance was neat and professional (dress pants and blouse). She was very friendly and open in her interactions, both verbally and with her body language. Mrs. M . was actively engaged in the interview process, and seemed interested and attentive throughout the entire length of the interview . She was well -spoken and appeared to be intelligent. Mrs. M ’s facial expressions, body language and tone of voice indicated a eu thymic and reasonably positive mood t hroughout the interview . Of part icular note , however, is that Mrs. M . seemed to laugh at inappropriate times (e.g., when describing some of her current frustration s with her husband, when describing the loss of her old er sister, and when discus sing her experiences with sexual abuse as a child). 3. REASON FOR COMING/PRESENTING CONCERNS Mrs. M has been married for 3.5 years. She reports that the marriage “is not working”, and that she is “very unhappy in the marriage.” Her dissatisfaction began within the first month of marriage when she began to feel like she “made a mistake” and “rushed into something that [she] was not ready for.” When asked how she might be contribut ing to her current marital unhappiness, she repl ied, “I said ‘I do’ before I realized what I was getting into.” Mrs. M . went on to report that she felt deceived by her husband because he did things while they were dating that stopped within the first month after they were married. When asked for exa mples, Mrs. M said, “going to church together, praying together, going out with friends together, and even holding a steady job. ” Mrs. M reported that when they were dating, her husband presented himself as “a motivated, well -rounded person with peer supp ort.” Mrs. M said that after they married, Mr. M dropped all of his friends , and she became his “sole relationship .” She reports feeling pressured to stay at home with her husband when she would like to be going out with friends. Further, she says that Mr. M is resentful when she does go out with her friends. She says it feels like her husband “wants her home —all to himself.” Mrs. M also reports that her husband quit his job soon after they married, and hasn’t earned a steady income throughout their ma rriage. She is deeply unhappy and frustrated with being the sole financial supporter of the household. Mrs. M reports that her marital unhappiness is a severe concern to her, and it is the primary reason that she is coming in for counseling. Her marital issues could end up as a legal issue if the marriage ends in divorce. Timeline/History of presenting concern(s) : Mrs. M ’s marital dissatisfaction began nearly 3.5 years ago, about 1 mo . after she married. It was at that time that her husband started act ing differently than when they were dating. Over the first year of the marriage, her husband began working less and less, until he finally just quit his job and stopped contributing entirely to the financial and practical facets of the marriage relationsh ip. Mrs. M reports that her husband’s apparent lack of drive and self -respect has caused her to lose respect for him. According to Mrs. M , the marriage lacks physical attraction and emotional intimacy. Her level of personal commitment to her husband is very low, and the only thing tying her to the relationship is her desire to “honor God ” by upholding her “marriage covenant.”

Comment [K1]: This sample assignment is provided only as a guide as you complete your clinical intake report. This sample document is a comprehen sive clinical report that includes a summary of all of the typical, major elements of a full clinical interview . Your report will NOT be as long as this sample! Your report will include only 8 sections —the 4 required sections and 4 optional section s that you chose .

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Comment [K4]: Required Section CLINICAL REPORT 3

4. CURRENT AND RECENT SITUATION As stated above, Mrs. M . currently lives with her spouse. She also lives with her 2-year -old Sta ffordshire terrier , Cooper , who m she calls her “ sweet heart ” and “baby boy .” Mrs. M states that she receives much needed love and affection from her dog. On a typical day , Mrs. M starts work early at home. She manages emails and she catches up on paperw ork from her job at counseling agency. About 2 hours before she needs to report to the agency, she begins “getting ready.” During that time, she showers, gets dressed, listens to music, and reads scripture. She usually arrives at her agency job between 10:00 and 11:00 a.m. depending on her client schedule, and she usually remains there until between 6:30 and 8:00 p.m. On most days, the people she interacts with most are: colleagues , associate counselors whom she supervises, and her site manager (with wh om she “consults regularly”), representatives from other agencies/service providers, and her clients and their families . On “less full ” work days, Mrs. M communicates more with friends and family. She reports that at least twice a week, she goes out for lunch, coffee, etc. with friends, and at least once a week she goes out with a family member (mom, dad or brother). Mrs. M ’s husband does not like to do social things and refuses most of her requests to go out. Mrs. M reports that, at most, he will agree to go out for a quick dinner, and then wants to rush back home. Over the past year, Mrs. M has experienced several significant changes that may have contributed to her current marital dissatisfaction . First, Mrs. M has been promoted at her job from an i ntensive , in- home counselor to a n outpatient, on -site counselor. This promotion has affected her marriage in several ways. She wants to go on vacation to celebrate, but her husband refuses, which frustrates Mrs. M . An increase in workload has resulted i n a decrease in communication, and the remaining communication “completely lacks intimacy ” and is mostly about the business end of marriage . Second, Mrs. M and her husband have experienced the loss of loved ones. Most of the loss has been on Mr. M ’s side of the family so it has affected him more than Mrs. M . As a result of the loss, Mr. M has become increasingly depressed (e.g., he sleeps all day, and plays video games or watches TV at night). Finally, Mrs. M just bought a house and moved. This change contributes to the financial stress on the marriage. Mrs. M says that she is resentful because she carries all of the financial “stress/burden” for the couple because Mr. M doesn’t work. She has purchased everything for the new house, and “supports all o f his needs and w ants.” She goes on to say that he doesn’t even take initiative to take care of the new house. In addition to working, she takes care of almost all household chores. Mrs. M has to ask her husband repeatedly to take care of a chore (e.g., cutting the grass), and he usually only will follow through when she “threatens” to turn off the cable or internet. Since buying the house, Mrs. M reports that being married is more like “having a child than a husband.” When asked how she has tried to h andle the problem so far , she said that she has separated from him multiple times. Once, she even lived in her car for 2 months. During those time s, she tried talking to him about her dissatisfaction. He would promise to change if she came back. Things would change for a week or so, but then the situation would be “worse than before —like a downward spiral.” Mrs. M also has tried “threatening” with loss of privileges (e.g., cable, internet, car use), but that only works for the immediate. She said she has tried “encouraging, inspiring and uplifting,” but he did not respond. She also reports trying prayer, but is discouraged because she has seen no change. When asked what strengths she has that have helped her to manage this difficulty so far she liste d several. She said that she enjoys work, so she will go to work to increase her happiness. She says that she is patient because “3.5 years is a damn long time.” She says that she tries to stay optimistic and think positively, but she says she also needs to be realistic. Mrs. M has several sources of support for her current problem. She reports that most of the time when she is feeling upset about her marriage, she goes off by herself and “takes some time” to be

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alone. She also relies on God for comfor t through prayer and worship. When she wants to “bitch and complain” or when she feels like she is “about to explode,” she talks to family and friends. So for her day -to-day frustration and sadness, she turns to God, but when things come to a head, she t urns to family and friends. Since the problems with her marriage began, Mrs. M has experienced changes in functioning . Physically, she feels exhausted and has no energy. Emotionally, she often retreats into herself, and if she “hyper -focuses” on her mar riage situation, then she will feel depressed. Cognitively, she has a difficult time concentrating. Behaviorally, she says that she has to work extra hard to compensate for her husband. Mrs. M added that she is “in a beautiful place personally and profe ssionally” so she doesn’t feel depressed overall. She is simply unhappy about a specific aspect of her life. So outside of her marriage, everything appears to be going well for Mrs. M . 5. PREVIOUS ASSESSMENTS AND COUNSELING EXPERIENCES Mrs. M reports t hat she received vocational testing and educational testing while she was a junior in college. Testing indicated that she has a “reading comprehensi on disability” and that she was “comprehending at a 7 th grade level.” Mrs. M also reports having psycholog ical testing at that time to assess for clinical syndromes like personality disorders, mood disorders, and anxiety disorders. She did not recall which specific tests were administered. Mrs. M reports that she has been in counseling before. She sought ou t counseling on her own because she was distressed by how she felt and because she had decided to pursue counseling as a career, and “knew that [she] needed to make significant changes in her life” in order to do so. She started in counseling in 2006, and she currently is still in counseling with the same therapist. With her therapist, she has tried CBT techniques (e.g., relaxation, meditation), reality therapy, art/music therapy, Sand Tray therapy, and behavior modification techniques. In addition, she has agreed to increase s in level of care (i.e., in -patient treatment) when needed. Regarding the outcomes of these interventions, she believes that her mood and functioning have improved significantly overall, though she still feels that she has work to d o. Mrs. M has received several diagnoses in the past, including: ADD, PTSD, MDD, GAD, and Substance Use Disorder (alcohol, marijuana, nicotine and caffeine). She also has been prescribed various medications to threat these disorders. ADD  Concerta and Focalin; MDD  Abilify, Lexapro, Celexa, Wellbutrin, and Seroquel; GAD  Klonopin, Xanax, Ativan, Paxil and Zoloft. None of these medications helped with her symptoms, and she experienced severe side effects including auditory hallucinations and suicidal ideations. In 2007, Mrs. M made a suicide attempt (that resulted in a coma) using a benzodiazepine that she had been prescribed. She began by taking one pill to control feelings of anxiety, but ended up taking the entire bottle in order to “drown out the voices in her head.” 6. BIRTH AND DEVELOPMENTAL HISTORY When Mrs. M was born, her mother was 23 years old and her father was 27 years old. They were married at the time, but divorced when Mrs. M was a child . The pregnancy was not planned, as Mrs. M’s mother actually had a tubal ligation after the birth of her second child. The pregnancy went to term and was uncomplicated. Mrs. M believes that her mom received prenatal care, but she is not sure. Before she knew she was pregnant, Mrs. M ’s mother smoke d cigarettes and marijuana. When she found out she was pregnant, she stopped smoking marijuana, but continued smoking cigarettes. At birth, Mrs. M was 6 lb. 12 oz. At birth, Mrs. M had both a heart murmur and an atrial septal defect (i.e., a hole in the part of the septum that separates the upper chambers of the heart). Because of this

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Comment [K7]: Optional section CLINICAL REPORT 5

heart defect, Mrs. M had emergency heart surgery immediately after she was born. Mrs. M reports that her delivery was “normal,” but she needed oxygen, had difficulty brea thing, and turned blue because of her congenital heart defect. Regarding childhood developmental issues, Mrs. M reported the following: 1) overactive, 2) sleep problems, 3) anxious/perfectionistic, 4) depressed, 5) shy, 6) easily frustrated, 7) nightmares , 8) fears/ phobias, 9) poor appetite and 10) attention problems . When asked if there was any other information about her childhood that we did not cover and that she would like to share, Mrs. M disclosed that she was both physically and sexually abused b y multiple people when she was a child. When I asked if she would min d sharing some details about her experience s, she agreed. Mrs. M said that the sexual abuse began when she was 4 years old by her maternal grandfather . Next, she was abused when she wa s 5 years old by her maternal uncle who came to stay with Mrs. M ’s family for a short time. Also at age 5, a maternal cousin (though not the child of the uncle previously mentioned) also sexually assaulted her. The majority of the abuse was perpetrated b y her paternal grandmother who lived with the family and by her brother. Her paternal grandmother abused her from age 6 -14. The abuse stopped when her grandmother died. Her brother , at the prompting of their paternal grandmother , abused her from age 6 -16. The abuse by her brother stopped only when Mrs. M pulled a knife on him. 7. FAMILY OF ORIGIN/FAMILY CONSTELLATION Mrs. M ’s father is 59 years old. He has a high school education. He has no known academic problems and no diagnosed emotional problems . He does have various medical problems, including: a recent stroke, overweight, pre -diabetes, and high blood pressure. Mrs. M reports having “a weird relationship” with her dad because their “personalities are so much alike.” She says that she even loo ks like him. Mrs. M says that they get along fairly well because they both are “passive.” He often asks Mrs. M if he can borrow money, and she has always given it to him in the past when he has asked. Mrs. M stopped taking her father’s calls about two w eeks ago after she bailed him out of jail for writing bad checks. Mrs. M ’s mother is 55 years old. She has an Associate’s degree. She has no known academic problems and no diagnosed emotional problems. She does have various medical problems, including: heart attack, congestive heart failure, high blood pressure and emphysema (due to smoking). Mrs. M says that she and her mother have very different personalities. This difference caused relationship problems when Mrs. M was an adolescent, but now they a re “quite close, and talk about all kinds of stuff.” Mrs. M says that her mother is clingy and dependent. Mrs. M gets annoyed with her mother and they fight when Mrs. M ’s mom “plays the helpless victim role.” Her mom does not ask directly for money. In stead, “she hints around,” and if “you don’t give into her hint, then she gives a guilt trip and plays mind games” which annoys and exasperates Mrs. M . Mrs. M had a sister, Ms. T, who died at age 5. Ms. T would be 36 right now if she were living. When I asked if she would mind sharing details of her sister’s death, Mrs. M explained that their father had run Ms. T over with a truck while driving drunk. Mrs. M has no memory of her sister as she was an infant when Ms. T passed. Mrs. M says that her family never talks about Ms. T, and that there aren’t even any pictures of her at home or in albums. She says that they “swept it under the rug like nothing ever happened” which is “what [her] family does with everything.” (By this, I suspect that she might have been referring to the sexual abuse that she experienced.) Mrs. M has a brother, Mr. C., who is 34 years old. This is the brother who sexually abused Mrs. M at the prompting of their paternal grandmother. Mr. C has a Bachelor’s degree in accounting. He has no known academic difficulties (except for trouble with spelling), no medical problems, and no

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diagnosed emotional problems. Mrs. M reports having a “good relationship” with her brother despite the years of abuse. They get together regularly for coffee or lunch. When discussing her brother, almost as a side note, Mrs. M laughingly told me that he is gay. When asked if there were difficulties at home not yet mentioned, Mrs. M explained that her parents divorced when she was a child, and both rema rried other people when she was an adolescent. Mrs. M’s mom “bailed out” on the family and left the state to go to college. Care for Mrs. M shifted to her dad and paternal grandmother (who abused her). When asked what changes at home would have made lif e easier for her she mentioned two things: 1) if her paternal grandmother never came to live with them and 2) if her parents/the family could have communicated better. She further explained that her family is “too secretive,” that nothing was ever talked about until it hit a “boiling point” when “anger came out” and “nothing was ever solved.” 8. EARLY RECOLLECTIONS Early Memory # 1: Mrs. M remembers being spanked by her paternal grandmother and being placed on the floor with a playpen over top of her so that she “could not get out.” She remembers sitting there crying and feeling angry because she “wasn’t sure what she did wrong, but didn’t deserve what happened.” Early Memory #2: Mrs. M remembers going to church as a child and “loving it.” She remembe rs being really involved. She remembers the pastor and his wife driving to pick her up and drop her before and after church on Wednesdays and Sundays after her parents “quit going.” She remembers feeling happy and feeling good learning about God. She al so remembers feeling sad that “her parents didn’t want to go with her.” 9. MARITAL AND FAMILY DATA Mrs. M is has been married to Mr. M (31 years old) for 3.5 years. Mr. M has a high school diploma. He had learning difficulties in school that were made worse by the medication that he took to manage his ADHD. Mr. M has asthma, and uses an albuterol inhaler. Regarding emotional problems, Mr. M was diagnosed with ADHD as an adolescent. Though he never has been diagnosed by a clinician, Mr. M has told Mrs . M that he feels depressed nearly all the time. 10. MEDICAL HISTORY Major Injuries, illnesses, and surgeries : Mrs. M was born with a heart murmur and with an atrial septal defect which required immediate, eme rgency surgery. In 2005 , Mrs. M had appendic itis/ appendectomy. In 2009 , Mrs. M deliberately overdosed with alcohol and 30, 0.5 mg Ativan tablets. Her heart stopped and she had to be resuscitated multiple times befor e she went into a coma. In 2011 , Mrs. M had her tubes tied. Medications : N/A Re garding current/past medical history, Mrs. M reports the following: 1) seasonal allergies, 2) extreme fatigue much of the time, likely d ue to overworking, 3) dizziness, 4) stomachaches, 5) tremors , 6) headaches, 7) sleep problems since adolescence (takes melatonin as needed), 8 ) memory problems that started after the coma in 2009, 9 ) kidney problems occurred as a result of the coma, she received dialysis twice, but ha sn’t had problems since then, 10 ) history of bronchitis and pneumon ia, perhaps because of asthma, 11) congenital heart problems, 12 ) ongoing attention

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Comment [K11]: Optional section CLINICAL REPORT 7

problems s ince childhood, 13 ) went into drug treatment rehab after overdose/coma. Other conditions include: carpal tunnel syndrome and ongoing heart issues. Regarding family medical history, Mrs. M reports: Brother : had repeated ear infections as child. Mom : seasonal allergies, heart disease, sleep problems, migraines, pneumonia, heart attack, tremors, and high BP. Dad : seizures, heart attack, heart disease, neurological issues, heart problem s, high BP, and attention problems. 11. EDUCATION AND TRAINING Mrs. M ’s educational history confirms my impression of her as intelligent, articulate and professional. She earned a B.S in Psychology and an M.A. in Community Counseling. Then she earned a n Ed.D. (highest degree earned) in Counseling Psychology with a concentration in Counselor Education and Supervision. Regarding her performance and preferences in school, Mrs. M . says that reading, writing, and science were the easiest subjects for her, a s well as the ones she enjoyed the most. The subject that was most challenging for Mrs. M was math. Her greatest source of pride throughout her schooling has been her writing performance. Mrs. M says that she always has had an “above average” attitude toward school. Given the turmoil of her home life as a child/adolescent, school was a place where she could “feel free” and “do well.” Mrs. M says that she was never retained in grade placement and that she never received an IEP, BIP or 504 accommodation plan. Although she was diagnosed with a “reading comprehension disability ” as a junior in college , she chose not to receive any accomm odations. 12. WORK BACKGROUND/HISTORY Right out of her M.A. program, Mrs. M had a job as a middle school guidance couns elor, and then as a high school guidance counselor. While she “loved” the middle school age group and “liked” the high school age group, she found that she wanted to do more clinical/counseling work. So she left her school job because she wanted to do mo re work directly in the community and because she decided to pursue licensure as a LPC (which she has completed at this point ). Mrs. M also worked as an In -Home Intensive Therapist and Team Lead. Mrs. M really enjoyed working with the families and helpin g people change for the better (especially children), but she “hated driving around.” As a team lead, she has good working relationships with the QP’s (qualified professionals) on her team, but she was concerned about how “ dependent ” they were on her and how they seemed to lack “confidence to make decisions on their own. ” She was promoted from this position to the clinical position that she currently holds. Mrs. M currently works as an Outpatient Therapist/Assistant Clinical Director , which she enjoys immensely . The aspects of her work that Mrs. M enjoys best are: 1) helping people and teaching clients new skills, 2) teaching future counselors how to be counselors, 3) feeling like she “is living [her] purpose and doing what God called [her] to do.” The aspects of her work that Mrs. M enjoys least are: 1) paperwork, 2) meetings, and 3) “basically all administrative tasks.”

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13. RECREATION, INTERESTS, AND PLEASURES Mrs. M enjoys a variety of recreational activities that appear to tend to her body, mi nd/emotions and spirit. She enjoys playing with and walking her dog, walking in nature, and going to the beach. Mrs. M also enjoys listening to encouraging messages by spiritual leaders, reading the Bible, listening to uplifting music, and pray ing /medita ting. She also works out, rides bikes, goes bowling, goes dancing, and plays recreational sports (e.g., volleyball, basketball, and kickball). While Mrs. M has many areas of pleasure/interest, she doesn’t get to engage in them as frequently as she would like because of her “busy work schedule.” She does try to make time for recreation at least once or twice a week. 14. SOCIAL SUPPORTS, COMMUNICATION NETWORK, AND SOCIAL INTERESTS Mrs. M says that she has several excellent sources of social support/socia l interest.

 She has two friends “from a distance who [she] loves and adores and speaks to quite frequently by text, phone and email.” They can talk about anything and everything —“good stuff, challenges, problems, whatever.”

 She has one local friend whom she talks to about some things.

 She has lots of colleagues, professional supports, and supervisors who are “able to help [her] with cases, job responsibilities, licensure requirements etc.

 She has a life coach that she has been seeing recently to help inc rease her self -esteem and to decide “what she wants and where she wants to go next” in life. She also is using coaching services in thinking about and planning for her own private practice.

 She has a therapist whom she has been seeing since 2006, and with whom she continues to work “quite frequently.” Mrs. M appears to be basically satisfied with the therapeutic relationship that she has created with her counselor as well as with the progress that she has made. I got the sense that Mrs. M wasn’t complete ly satisfied with the services she has received so far, but she indicated that it would be “too difficult to start [the process] again with someone else.” 15. SELF -DESCRIPTION When asked about her strengths , Mrs. M listed the following: 1) perseverance, 2) willingness to learn/ grow/change, 3) passion for her work and for serving other people, 4) being a good person, 5) being kind -hearted. When asked about her weaknesses , Mrs. M listed the following: 1) low self -esteem, 2) sometimes letting her “fears g et the best of [her],” 3) being a “work -a-holic.” Mrs. M then offered the following explanation for her tendency to be work -a-holic —“Work is a way for me to disconnect from the negative in my life and to connect with something positive.” Because Mrs. M enjoys her work and believes that she is g ood at what she does, it appears that work may function as a safe place amidst the chaos and sadness of her personal life. She also said that because of her health problems , she is afraid that she may not live long enough to accomplish all the goals that she has set her mind to. Mrs. M provided the following self -description: “I am very creative. I love music, art, dance, writing, and just playing like a kid. I also use creative interventions in my work with chil dren, adolescents, adults and families. I often visualize the beach or some kind of nature/water to help reduce anxiety and tension, or even to help me battle my depression from time to time. I also try to visualize what heaven might be like or what God might look like.”

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16. CHOICES AND TURNING POINTS IN LIFE In her senior year of high school, Mrs. M was robbed at gunpoint while at work as a cashier. At that point, she decided to go to college to “get out of that environment .” This decision complet ely changed the course of her life as she never even thought of going to college before then. College was not something that her family “modeled” or thought of as important. In the first two years as an undergraduate student, Mrs. M failed and re -took 14 classes. Because of these failures, Mrs. M realized that sh e had a learning disability which she began to work hard to overcome. She also changed majors, which “changed the course of [her] life,” and put her on a path “more in -line with [her] purpose an d calling.” After earning her BS is psychology, Mrs. M decided to “go lateral entry into teaching special education. When she started teaching, she realized that she had “a passion for teaching and helping others.” The work was “new, and hard, and [she] felt like [she] was totally out of [her] element.” She never had taught a single class in her life when she “stepped in front of a classroom full of 8 th graders. ” In her feelings of lack, she realized that “God could use her to amazing things” even when she “knew very little.” Mrs. M was very proud and excited to earn the “Rookie of the Year” teaching award her first year as a special education teacher. While in graduate school, Mrs. M decided to enter therapy. According to Mrs. M , therapy has had its “ups and downs, and at first it was all downs/bad.” After years of therapy and “a lot of hard work,” Mrs. M says that she is “starting to see the fruits of all the effort [she has] put in. Therapy has helped her develop as a counselor. After her suicid e attempt/ove rdose/coma in 2009 , Mrs. M entered rehab where she was able to see firsthand the consequences of a life of drug abuse. Both her roommate and another young man died right in front of her. At that poi nt, she realized that she did not want that outcome for her life. Being in rehab gave her to opportunity to distance herself from the negative influences and environments in her life and to really focus on herself instead of “trying to take care of the world.” Her experiences in rehab helped her to realize that she “was worth so much more” than she thought of herself and that she wanted to live. The choice to pursue a doctorate and to believe that she could contribute to the world by teaching future counselors has provided Mrs. M with a sense of both personal and professional fulfillment. Mrs. M says that she has overcome many obstacles to get to where she is now —a counselor and an assistant professor of counseling. She derives personal and professional satisfaction from the fact that she achiev ed her dream despite great adversity and that she is meaningfully contributing to society by teaching others to do the work about which she is so passionate. 17. PERSONAL GOALS AND VIEW OF THE FUTURE In the next year , Mrs. M would like to see the followi ng happen: 1) get the Distance Credentialed Counselor (DCC) certificate through the National Board of Certified Counselors (NBCC ), 2) look for new employment opportunities, 3) possibly take a new job offer, 4 ) possibly relocate to Portland, OR. In the nex t 5 years , Mrs. M would like to: 1) Obtain her Approved Clinical Supervisor (ACS) credential through the NBCC and begin supervising provisionally licensed counselors, 2) have her own private practice, 3) teach graduate school full -time. In the next 10 yea rs, Mrs. M would like to: 1) be a published author, 2) be teaching full -time, 3) have a thriving private practice, 4) be a motivational speaker, and 5) travel the world.

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Mrs. M believes that she already is taking the steps that she needs to in order to ac complish all of her goals. She says that she just needs to continue to do more of the same thing. Mrs. M also says that she believes her marriage relationship in its current state is an impediment to achieving all of her dreams and goals. She believes t hat her husband’s “complete lack of motivation” is holding her back from achieving her own goals. She “fears ” that severing the relationship might be a necessary step for her “to move forward with her life. ” 18. INITIAL TREATMENT RECOMMENDATIONS 1) Additi onal psychological testing is re commended to determine the continued presence and severit y of other symptoms/ clinical syndromes not revealed by the current case history and to further elucidate Mrs. M ’s presenting concerns . 2) Continued individual therapy on a once -weekly basis, with either her current therapist or a new therapist is recommended . Therapy should focus on Mrs. M ’s presenting concerns around her relationship with her husband and on increasing Mrs. M ’s ability to manage her negative cognitive and emo tional responses to her marital situation . 3) Couples’ therapy may be warranted in the future, b ut Mrs. M ’s husband presently refuses to attend counseling , and Mrs. M has little motivation to work on the relationship . 4) Because Mrs. M ’s spiritual beliefs play such a significant role in her life, effort should be made to incorporate these beliefs into treatment planning .

Comment [K19]: Required section IMPORTANT NOTE: It is here in your Clinical Intake Report that you w ill make at least one Biblically -based treatment recommend ation which you will logically support with the use of at least one relevant scriptural citation.