I.

Referral
a. Self-referral,
b. Getting distracted easily, has been alone, voluntary
II. Description of Client
a. Name: Jennifer McArdle
b. Age: 27
c. Gender Identity: She/Her
d. Marital Status: Divorced for 2 years
e. Race: White
f. Ethnicity: Caucasian
g. Sexual Orientation: Presumably Straight
h. Religion: N/A
i. Social Class: N/A
j. Income Sources: Alimony, savings, graduate assistantship, loans
k. Disabilities: N/A
l. Level of Education: Undergraduate in Psychology, pursuing Masters in Social
Work
m. Health Issues: change in sleep pattern
n. Medications: none
o. Substance Use: none
p. Legal Issues: none
III. Presenting Issues and Concerns:
a. Complaints: weight gain, feeling disconnected
b. Larger issues: seems a little depressed and disconnected, avoidance of social
interaction,
c. How does client view: is upset by them to the point of tears
d. Others view: N/A
e. When did they begin: when she moved to SC
f. Identifiable precipitant: appetite is weird not the same with old good foods
g. Why now: has class/field placement all day comes home tired
h. Similar past: when going through divorce (stress eating)
i. What want help for: yes
IV. Assessment of Relevant Contextual, Historical, and Intrapersonal Factors
a. Current Context
i. Issues relevant to understanding:
ii. Basic needs met: yes
iii. Strengths in meeting: money is well managed and is using combination of
savings, alimony, loans, and working on campus
iv. Culturally appropriate: yes
v. Income sources: Alimony, savings, graduate assistantship, loans
vi. Are they stable: yes: can they be improved: yes and no
vii. Strengths in meeting basic needs: good with finances/ savings
viii. Income obtained in culturally sensitive manor: yes
 ix. Language issues: no
x. Meeting basic needs: no
xi. In school/workplace: no
xii. Language training accessible if sought: N/A
xiii. Strengths / challenges: N/A
xiv. Disability accessibility of environment: N/A
xv. Communication needs: N/A
xvi. Transportation: N/A
xvii. Equipment: N/A
xviii. Training for devices: N/A
xix. Understood in cultural context: N/A
xx. Strengths related to disability: N/A
xxi. Medical/dental: N/A
xxii. Culturally appropriate: N/A
xxiii. Safety needs: yes
xxiv. Physical environment safe: yes
xxv. Hazard to self/others:
xxvi. Fire setting risk:
xxvii. Domestic/marital violence issue: N/A
xxviii. Safety plan: N/A
xxix. Child Protective Services/Adult Protective Services: N/A
xxx. Service Plan: N/A
xxxi. Services involved: N/A
xxxii. Services ignored: N/A
xxxiii. Legal issues: N/A
xxxiv. Court involvements/restraints/obligations: N/A
xxxv. Obligatory services/costs/settlements: N/A
xxxvi. Immigration status: N/A
xxxvii. Source of unsafe: N/A
xxxviii. Religion/spiritual beliefs: Catholic
xxxix. Level of involvement: was active in childhood and before moving, now
not involved due to distance
xl. Other connections: family
xli. Shape meaning of life: follows specific rules due to Catholicism
xlii. Recreational interest: farmers markets
xliii. How and where: one in Sandhills area
xliv. Barrios: not many she knows of
xlv. Key social supporters: N/A
xlvi. Accessible: N/A
xlvii. Important social policy/structural: N/A
xlviii. Has client joined others: N/A
xlix. How: N/A
b. Historical Influences
 i. Childhood: grew up in Catholic Church
ii. Relationship with family: very close (all in Maryland)
iii. School/work history: undergraduate degree in Psychology; worked at an
inpatient facility for adolescents
iv. Previous services: counselor during divorce proceedings
v. Intimate relationships: close to family; still checks in on ex husband
c. Coping Strengths and Weaknesses
i. Self-reported strengths: N/A
ii. Inferred strengths: N/A
iii. Process info: stress eats
iv. Protect self: stress eats
v. Turn to for support: family but has not done so
vi. Interactions with others: group projects she flakes on meeting
vii. Are they successful: no
viii. Routinely problematic: yes
ix. Flexibility in interaction style: not really
x. How do these fit with social and institutional resources: she is struggling
with a group project
xi. Resources and obstacles: can get help from therapy
xii. Current life cycle tasks: is doing school work and interacting with people
who have not been married while being matured due to a marriage herself
V. Formulation
a. Was raised in a tight nit family allowing for resiliency, but her divorce may have
caused some confidence issues especially with moving to a new state within 3
years of the divorce. She has yet to find a church she can regularly attend and is
missing a key part of her life leading to her being a less resilient person over all
due to not having the constant of the Catholic church in her routine every week
and not having a sense of community in her new home (person in environment).
She is also far from her tight nit family (family systems) and friends and is having
trouble making new friends. A main concern is her not having any of her supports
nearby and not having a stable point in her life besides her stressors, school and
work.
VI. Plan for Intervention
a. Find a long-term Catholic church near her (short term goal)
b. Try an on-campus group (short term goal)
c. Trying new farmers markets (short term goal)
d. Develop better self-perception and how she wants others to perceive her (long
term goal)
e. Explore eating/sleeping patterns
f. Client must come back to therapy and continue counseling and do “therapy
homework”
g. She may not want to try socializing as much
VII. The Best Research Evidence
 a. Mary Richmond’s Person and Environment perspective
b. Murray Bowen’s Family Systems theory
c. These would likely be accepted due to her involvement in social work and
psychology
d. They are there and available since they are simple interactions and support system
building which is usually funded by the client
VIII. Values and Ethics: The Worker’s Own
a. I do not like organized religion which makes me less knowledgeable on different
organizations around Columbia. I also want to give her her own self determination
and do not want to push unwanted social interactions on her which may lead to
undue stress.
IX. Organizational Issues
a. The organization must set up appointments and could put her with a different
counselor
b. Remote and in person interaction and immediate rebooking’s
c. If the counselor becomes her teacher, they must stop their professional
relationship (he is one of my teachers lol)
X. Social Change Goals
a. One social change goal is finding a new church and the counselor already promoted it by
suggesting they look into churches together
b. We could connecter her with a church that an associate goes to near her
c. Possibly encourage more social interactions and praise positive ones