1 MHC 610 Client Case File Charles “CJ” Jones You are a counselor in an on-campus counseling center. Charles “CJ” Jones is a 21-year-old, single, straight, African American and Lakota man who sought treatment because he “feels lost,” withdrawn from friends, and “worried about money.” He said he had been feeling increasingly depressed for two months, and he attributes this to two essentially concurrent events: the end of a three-year romantic relationship (four months ago) and being unable to find his ideal employment situation. Mr. Jones has been on a job search for around five months. Mr. Jones has supported himself financially since high school and is accustomed to feeling nervous about making ends meet. He has become more worried after breaking up with his longtime live-in girlfriend, so he approached a family friend for financial help. He was turned down, leading him to feel alone in his financial struggles. This disappointment revived long-standing anger and sadness about not feeling close to and supported by either of his parents. His friends taunted him for “falling apart” over wanting to be financially stable saying, “We’re young. You have time to figure this out!” Mr. Jones is a full-time undergraduate student in his final year of college studying computer science; he also works full-time as a midnight-shift warehouse worker. When he finishes his early-morning shift, he finds it hard to “slow down,” and he has trouble sleeping. He has been looking for work daily and applies for jobs that are less physically demanding, with more flexible hours, but never gets past the phone call or interview. His appetite is unchanged, and his physical health is good. His grades have recently declined, and he has become increasingly discouraged about money and about being single. He has not previously sought mental health services, but a supportive cousin suggested seeing a counselor. Mr. Jones was raised as an only child by his mother and her extended family who all identify as African American. Mr. Jones reports that his extended family identifies as Baptist and, in his youth, he spent some time with family members at church; however, he now identifies as spiritual rather than religious. Mr. Jones describes that he has been drawn to exploring the spiritual beliefs and practices of the Lakota Nation. Mr. Jones regularly keeps in touch with his maternal extended family. Growing up, Mr. Jones mentioned he was a “good student and popular kid.” High school was complicated by his mother’s two-year period of unemployment and his experimentation with alcohol and marijuana. He recalled several heavy drinking episodes at age 14 and first use of marijuana at age 15. He smoked marijuana daily for much of his junior year and stopped heavy use under pressure from a girlfriend. At the time of the evaluation, he had “an occasional beer” and limited marijuana use to “being social” several times a month. Mr. Jones described ...

1. 1
MHC 610 Client Case File Charles “CJ” Jones
You are a counselor in an on-campus counseling center.
Charles “CJ” Jones is a 21-year-old, single, straight, African
American and Lakota man who sought
treatment because he “feels lost,” withdrawn from friends, and
“worried about money.” He said he had
been feeling increasingly depressed for two months, and he
attributes this to two essentially concurrent
events: the end of a three-year romantic relationship (four
months ago) and being unable to find his
ideal employment situation. Mr. Jones has been on a job search
for around five months.
Mr. Jones has supported himself financially since high school
and is accustomed to feeling nervous
about making ends meet. He has become more worried after
breaking up with his longtime live-in
girlfriend, so he approached a family friend for financial help.
He was turned down, leading him to feel
alone in his financial struggles. This disappointment revived
long-standing anger and sadness about not
feeling close to and supported by either of his parents. His
friends taunted him for “falling apart” over
wanting to be financially stable saying, “We’re young. You
have time to figure this out!”
Mr. Jones is a full-time undergraduate student in his final year

2. of college studying computer science; he
also works full-time as a midnight-shift warehouse worker.
When he finishes his early-morning shift, he
finds it hard to “slow down,” and he has trouble sleeping. He
has been looking for work daily and applies
for jobs that are less physically demanding, with more flexible
hours, but never gets past the phone call
or interview. His appetite is unchanged, and his physical health
is good. His grades have recently
declined, and he has become increasingly discouraged about
money and about being single. He has not
previously sought mental health services, but a supportive
cousin suggested seeing a counselor.
Mr. Jones was raised as an only child by his mother and her
extended family who all identify as African
American. Mr. Jones reports that his extended family identifies
as Baptist and, in his youth, he spent
some time with family members at church; however, he now
identifies as spiritual rather than religious.
Mr. Jones describes that he has been drawn to exploring the
spiritual beliefs and practices of the Lakota
Nation. Mr. Jones regularly keeps in touch with his maternal
extended family.
Growing up, Mr. Jones mentioned he was a “good student and
popular kid.” High school was
complicated by his mother’s two-year period of unemployment
and his experimentation with alcohol
and marijuana. He recalled several heavy drinking episodes at
age 14 and first use of marijuana at age
15. He smoked marijuana daily for much of his junior year and
stopped heavy use under pressure from a
girlfriend. At the time of the evaluation, he had “an occasional
beer” and limited marijuana use to
“being social” several times a month. Mr. Jones described his

3. childhood as “normal,” and that while he
had a very close relationship with his mother, it deteriorated in
his adolescence.
Mr. Jones’s mother decided that he should move out when he
finished high school. She was dating a
man she subsequently married and wanted time alone w ith this
man. She was clear about her feelings
that he needed to be more independent from her and that it was
“finally her turn.” Mr. Jones’s father
left shortly before his birth, telling his mother, “I didn't sign on
for this.” She relayed this story to him
often in his childhood.
On examination, Mr. Jones is punctual, cooperative, pleasant,
attentive, appropriately dressed, and well
groomed. He speaks coherently. He appears generally worried
and constricted, but he did smile
2
appropriately several times during the interview. He has a quiet,
dry sense of humor. He denied
suicidality, homicidality, and psychosis. He’s cognitively intact,
and his insight and judgment were
considered good. In your first session, Mr. Jones communicated
to you that as a young biracial man, he
is generally expected to be strong and independent, and norms
of masculinity have made him hesitant
to attend counseling. He further expressed that his family views
counseling as something that is only for
“crazy people.” He informs you that there may be individuals in
his family struggling with addiction and

4. other mental health concerns who are not receiving treatment.
MHC 610 Client Case File Charles “CJ” Jones
1
MHC 610 Week Six Assignment Guidelines and Rubric
Overview: As you create your goals and objectives, they should
align with interventions chosen. The goals should be person-
centered—they should reflect what
the client wants to accomplish. The objectives include the steps
that are taken to achieve that goal. The interventions are the
tools, techniques, or modalities
that are utilized to help the client work toward the goal. Recall
the who, what, where, when, and why of interventions as you
work on specific interventions for
this assignment.
Prompt: This assignment is a draft of the goals, objectives, and
interventions section of the treatment plan. Specifically, the
following critical elements must be
addressed:
o Develop two long-term expected outcomes of treatment.
ment Objectives
o Develop three short-term expected outcomes of treatment.
-Based Interventions
o Develop specific change techniques and tactics related to the
treatment strategy for achieving treatment goals and pattern

5. change for each goal
and objective. Include one intervention for each objective.
Rubric
Guidelines for Submission: Use the Comprehensive Case
Conceptualization Template, linked in the Resources section of
Week One, to complete this
assignment.
Critical Elements Proficient (100%) Needs Improvement (70%)
Not Evident (0%) Value
Treatment Goals Develops two long-term expected
outcomes of treatment
Develops long-term expected outcomes
of treatment, but they lack detail or are
unproductive for the client
Does not develop long-term expected
outcomes of treatment
30
Treatment
Objectives
Develops three short-term expected
outcomes of treatment
Develops short-term expected outcomes
of treatment, but they lack detail or are
unproductive for the client

6. Does not develop short-term
expected outcomes of treatment
30
Treatment:
Evidence-Based
Interventions
Develops specific change techniques
and tactics related to the treatment
strategy for achieving treatment goals
and pattern change for each goal and
objective. Includes one intervention for
each objective.
Develops specific change techniques and
tactics related to the treatment strategy
for achieving treatment goals and
pattern change for each goal and
objective, but submission lacks detail or
contains inconsistencies
Does not develop specific change
techniques and tactics related to the
treatment strategy for achieving
treatment goals and pattern change
for each goal and objective
30

7. 2
Critical Elements Proficient (100%) Needs Improvement (70%)
Not Evident (0%) Value
Articulation of
Response
Submission has no major errors related
to APA citations, grammar, spelling,
syntax, or organization
Submission has major errors related to
APA citations, grammar, spelling, syntax,
or organization that negatively impact
readability and articulation of main
ideas
Submission has critical errors related
to APA citations, grammar, spelling,
syntax, or organization that prevent
understanding of ideas
10
Total 100%
MHC 610 Comprehensive Case Conceptualization Template
Instructions: Complete this template by replacing the bracketed
text with the relevant information. Do not delete any boxes from
this form, and be sure to remove the Guidance sections from
your treatment plan before submitting the final version of your

8. project.
Student Name: [Insert text]
Final Project Part One
Theoretical Orientation and Integrated Personal Approach
[Describe your integrated personal approach or single
theoretical orientation. If you use a model such as nondirective
vs. directive play therapy, the adaptive information processing
model, or another method for structuring your sessions and
counseling goals, please specify this.]
Guidance
In this section, describe (1) how you use your theory to help
you conceptualize the client’s problems, and (2) how you use
your theory to guide you in developing a treatment plan and
providing counseling to the client.
Background Information
[Include demographics, age, disability, religion, social class,
sexual orientation, indigenous background, national origin,
gender identity, family unit, highest level of education,
employment, military background, current and past legal issues,
relationship status/social history, and substance abuse and
treatment history if applicable.]
Guidance
Provide an overview of the client’s history, including
demographics, family dynamics and history, work and education
history, cultural considerations, key moments in the client’s life
(both positive and negative), early childhood memories, medical
history, career, and any other relevant information that will help
you better understand the unique person who is your client. For
example, some clients may have a military background, current
or past legal issues, and/or other unique experiences.
Comprehensive Overview of Presenting Concerns
Presenting Concerns: [Describe the problem, explain the
symptoms, note the intensity and frequency of the symptoms,

9. identify potential harmful behavior, and note if there is family
history.]
Current Triggers: [Describe triggers that activate the pattern,
resulting in the presenting problem.]
Guidance
Based on the client’s history from the Background
Informationsection and the history of the client’s problems,
describe the triggers (e.g., events, behaviors, sights, sounds,
smells, etc.) that activate or intensify the client’s problems.
Promoters:(Triggers (e.g., events, behaviors, sights, sounds,
smells, etc.) that activate one’s patterns of behavior, resulting
in the presentation)
Maladaptive Patterns: [Describe inflexible, ineffective manner
of perceiving, thinking, acting.]
Guidance
Based on the Background Informationand Current Triggers
sections, describe the client’s current and past responses
(thinking, feeling, and behaving) to the problem that have been
ineffective.
Developmental Influences: [Describe factors fostering adaptive
or maladaptive functioning; be sure to reference the human
development theory you used to guide your information
gathering.]
Guidance
Include the past history of the issues that brought the client to
counseling, and use a timeline or your human development
theory stages to organize the background: theories of individual
and family development across the lifespan.
Protective Factors: [Describe biopsychosocial/spiritual factors
that mitigate risk and support adaptive management of stress.]
Guidance
Based on the Background Information and Current Triggers

10. sections, describe the client’s current and past responses
(thinking, feeling, behaving) to the problem that have been
effective. Describe any other client strengths that could be
developed into protective factors for current and future
problems.
Co-occurring Disorders: [Describe issues with addictions and
mental health issues, if applicable. Assessment of the issues
that includes neuro-bio factors organized with the stages of
change is required.]
Mental Status Exam: [Note whether the client was on time; their
behavior, attitude, and orientation to person, place, time, and
situation; their mood, affect, tone of voice, rate of speech,
judgment, and memory; their suicidal or homicidal ideation; and
any observable symptoms/behaviors.]
Guidance
Summarize the results of the mental status evaluation of the
client, including the following: Note whether the client was on
time; their behavior, attitude, and orientation to person, place,
time, and situation; their mood, affect, tone of voice, rate of
speech, judgment, and memory; their suicidal or homicidal
ideation; and any observable symptoms/behaviors.
Cultural Considerations
Cultural Identity: [Describe sense of belonging to a particular
group (i.e., race, ethnicity, gender, sexual orientation, etc.).]
Cultural Stressors:[Describe level of adaptation to the dominant
culture, and stress-rooted acculturation including psychosocial
difficulties. Focus on minority stress, marginalization…What
does this mean to you?]
Guidance
What are present stressors affecting your client’s cultural
identity? Consider the impact of multiple minority statuses,
marginalization, stress-rooted acculturation, psychosocial
difficulties, institutional and social barriers, biases, power, and

11. privilege.
Cultural Influencers:[Describe beliefs regarding cause of
distress, condition, or impairment.]
Guidance
Using a cultural lens, what are your client’s beliefs regarding
the cause of their distress, condition, or impairment?
Personality Patterns: [Describe operative mix of cultural and
personality dynamics.]
Summary
Theory-Driven Case Summary: [Outline the history of the
client’s problems, referring to the overview of the client’s
history, including the client’s strengths and barriers (from the
Background Information section) and your theoretical
orientation (from the Theoretical Orientation and Integrated
Personal Approach section), including both counseling and
human development theories.]
Summary of Conceptualization Presented to the Client: [Write
the script of what you will say to the client to offer a brief
explanation of the conceptualization, and present the
conceptualization to the client in language free from jargon so
that they can correct and confirm the summary. Also add your
theoretical orientation and integrated personal approach and
focus on the object of change. For this section, you need to
write up an explanation about the counseling process. You are
informing the client about the steps you will take to assist them
in addressing their objects of change.]
Final Project Part Two
Diagnosis
Primary Diagnosis and Justification:[List both the ICD and
DSM-5 codes. What is the overall descriptor of the diagnosis?
What criteria are met, and what behaviors are used to meet
diagnostic criteria? What are the cultural considerations?]
After assessing Mr. Jones’ information, it is evident that he has
acute adjustment disorder with depression. According to the
DSM-V, Jones’ issues is acute adjustment disorder with

12. depression since his symptoms connect to the criteria. The
condition occurs for people exposed to stressful events in their
lives recently or even in their past (Sissons, 2020). The process
of generating the diagnosis involves assessment of situations in
Mr. Jones’ life to determine what triggered the recent feelings
of being lost, withdrawn socially, and having financial issues.
The main issues that Mr. Jones identified were ending his three-
year romantic relationship and lacking the appropriate
employment.
Assessments: [List all of the assessments you used to justify
this diagnosis.]
It is possible to assess the situation of Mr. Jones by apply a
dimensional approach which offers accurate assessment of his
behavior and impact between his personal life and finding an
effective method of collaborating with external conditions. Mr.
Jones was exposed to a lot of issues in his childhood that
resulted in him adjusting to social situations where he had to
form maladaptive behavior. The dimensional diagnosis approach
focuses on placing abnormal behaviors in a patient’s life and
connecting them to the frequency in occurrence and level of
severity when attempting to find effective solutions. There is a
connection between the abnormal behaviors in a person’s life
and their ability to form an agreeable personality based on their
social problems.
Secondary Diagnosis and Justification:[List both the ICD and
DSM-5 codes. What is the overall descriptor of the diagnosis?
What criteria are met, and what behaviors are used to meet
diagnostic criteria? What are the cultural considerations?]
The study of Mr. Jones’ condition requires analysis of his
behavior to determine an effective method of managing his
personal factors and ability to connected with proper social
development. The diagnostic criteria for depression are required
to determine the types of behaviors Mr. Jones displays and they
can lead to future solutions. A person with depression would

13. have moody behavior, little interest in pleasurable situations,
weight loss, restlessness, fatigue, feeling of being worthless,
and reduced concentration (Truschel, 2020).
Assessments: [List all of the assessments you used to justify
this diagnosis.]
The appropriate assessments for Mr. Jones are substance abuse
assessment, psychological testing, and individualized treatment.
The process of performing substance abuse assessment is
imperative to connect to Mr. Jones since he reported that he had
been using alcohol and marijuana in his childhood. This issue is
detrimental in the case of Mr. Jones since it is difficult for him
to function properly yet he has not recently engaged in alcohol
abuse. Mr. Jones’ problem would have to get solved early to
ensure he does not resort to alcohol and substance abuse to
manage his feelings of low self-worth. Mr. Jones need to access
health improvement measures that target his mental balance.
Tertiary Diagnosis and Justification:[List both the ICD and
DSM-5 codes. What is the overall descriptor of the diagnosis?
What criteria are met, and what behaviors are used to meet
diagnostic criteria? What are the cultural considerations?]
Assessments: [List all of the assessments you used to justify
this diagnosis.]
Additional Diagnosis and Justification:[What is the overall
descriptor of the diagnosis? What criteria are met, and what
behaviors are used to meet diagnostic criteria? What are the
cultural considerations? This is where you will list all
applicable V codes that are related to the complete diagnosis.]
Assessments: [List all of the assessments you used to justify
this diagnosis.]
Final Project Part Three
Client-Centered Goals
Goal 1: [List long-term goal targeting an element of the
presenting problem and/or part of the diagnosis that is agr eed
upon between the client and counselor using the SMART
format.]

14. Objective 1 of Goal 1: [List a short-term goal that is a smaller
element of the stated long-term goal that is agreed upon
between the client and counselor.]
Intervention 1: [Describe what specific intervention the
counselor will use and what is expected of the client to promote
growth toward the objective (e.g., “Will use early recollections
from Adlerian theory; Lifestyle Assessment to assist the client
in discovering the guiding fictions they decided at an early
age”).]
Intervention 2: [Describe what specific intervention the
counselor will use and what is expected of the client to promote
growth toward the objective.]
Intervention 3:[Describe what specific intervention the
counselor will use and what is expected of the client to promote
growth toward the objective.]
Objective 2 of Goal 1: [Insert text]
Intervention 1: [Insert text]
Intervention 2: [Insert text]
Intervention 3: [Insert text]
Objective 3 of Goal 1: [Insert text]
Intervention 1: [Insert text]
Intervention 2: [Insert text]
Intervention 3: [Insert text]
Goal 2: [Insert text]
Objective 1 of Goal 2: [Insert text]
Intervention 1:[Insert text]
Intervention 2:[Insert text]
Intervention 3:[Insert text]
Objective 2 of Goal 2: [Insert text]
Intervention 1: [Insert text]
Intervention 2: [Insert text]
Intervention 3: [Insert text]
Objective 3 of Goal 2: [Insert text]
Intervention 1: [Insert text]
Intervention 2: [Insert text]
Intervention 3: [Insert text]

15. Prognosis
Guidance
[In this section, summarize the likely course, duration, and
outcome of the mental health condition with and without
treatment.]
Reevaluation of Treatment Plan
Guidance
[In this section, identify the importance of assessing the goals
you developed for your client. Also, describe how you will
reevaluate your treatment plan and how often this reevaluation
process will happen.]
SOAP Note
Guidance
[In this section, you will have to use your imagination on the
likely progression of a session and objective behavioral
presentation of your client. SOAP notes describe subjective
observations, objective observations, assessment, and plan.]
5