COUNSELING EVALUATION

Identifying The client was a 17-year old female, single and currently in an in-
Information: and-out relationship. The counselee is a Grade 11 student.

She was born in the Philippines until the family transferred to Riyadh
when she was 8 years old. She returned to the Philippines when
she was 15 years old. She was an adopted child of a well-to-do
family. She also has an adopted brother. Mother is a dentist and
father is a consultant Agricultural Engineer in Riyadh.

During Grade 10, the client studied at one of the prestigious private
Catholic high school in the area. However, client transferred to the
public school when she was in Grade 11.

Client was referred by the Assistant Principal to the Guidance Office

and the client submitted herself for a voluntary counseling.

Presenting Problem: The counselee was referred because of habitual watching and
sending of online sexual pornography to her classmates. It was
either some random sexual videos or her videos masturbating.
There was also an aggressive behaviour being directed to her
classmates in relation with her shared online sexual videos. She
would throw tantrums and punch her classmates because she said
that they are talking her down behind her back.

History of Difficulties: During initial assessment:

 Client seems to be silent and shy.
 Client does report of aggressive and risk-taking behaviors.
 Client does report fear, anxiety and worries.
 Client does report obsessions or compulsions.
 Client does report tendencies of bulimia.
 Client does report of suicidal ideation.
 Client does report of sexual fantasies and masturbation.

Past Psychiatric Previous psychiatric diagnoses:

History:  No reported psychiatric evaluation/diagnoses. But Client has
been reported by the mother to be given psychiatric medicine
before.
 Counselor has not validated the claim of the psychiatric
diagnoses.

Safety concerns:
 History of Violence to Self: YES
  History of Violence to Others: YES

Mental health treatment history discussed:

 History of outpatient treatment: no report
 Previous psychiatric hospitalizations: no report
 Prior substance abuse treatment: no report

Trauma history:
 Client does report history of trauma including witnessing
disturbing events (seen the nanny having online nudity and
sex).

Substance Use:
 Client denies use or dependence on nicotine/tobacco
products and alcoholic beverages.

Medications: No current medications.

Mental Status Client seems to be silent and shy at first.

Examination: But after sometime, she seems to be cooperative and conversant,
appears without acute distress, and fully oriented.

Psychomotor activity appears within normal.

Presents with appropriate eye contact.

Speech: spontaneous , normal rate, appropriate

volume/tone with no problems expressing self .

TC: no abnormal content elicited, denies suicidal ideation and

denies homicidal ideation. Process appears linear ,
coherent , goal-directed .
Cognition appears grossly intact with appropriate

attention span & concentration and average fund of knowledge.

Judgment appears fair . Insight appears
fair

Strengths/Limitations The client is able to articulate needs, is motivated for compliance

: and adherence to counseling plan. Client is willing and able to
participate with treatment, disposition, and discharge planning.
Assessment & Dx: -
Diagnoses: Dx: -
Dx: -

Informed Consent: Client has the ability/capacity appears to respond to

counseling sessions and appears to understand the need for
counseling and is willing to attend counseling sessions.

Reviewed potential risks & benefits, Black Box warnings, and

alternatives including declining treatment.