PCN-610 Eliza D Psychosocial Example Name: Eliza Doolittle Date: ********* DOB: ******** Age: 18 Start Time: 1:15p End Time: 2:00p Identifying Information: The client is a Caucasian female with average height and slender build. The client stated that she is currently a freshman in college, majoring in engineering. The client also stated that her family resides in a small town approximately two hours away. Presenting Problem: At the onset of the session, the client statedthatshe had come to counseling as a result of being caught in a campus dorm with alcohol (it is an alcohol-free campus). Concerning the incident, the client stated “the RAs were called because my friends were being too loud in my dorm. When they arrived, they saw us with alcohol, and we got in trouble.” The client stated that her friends in the dorm were intoxicated but she was not, adding, “I was just buzzed” and adding that she was drinking “because they were” and “it’s just something to do.” Life Stressors: The client identified school as a life stressor, adding “things came easy to me in high school, I just figured it would be the same in college”. The client went on to state that, in addition to the difficulty in increased study requirements, she had struggles in making friends, stating, “a lot of my friends from high school have either gone to college somewhere else or are doing other things,” although the client denied feeling lonely. Substance Use: |X| Yes |_| No The client denied having a drug or alcohol problem, adding that she tried marijuana once in high school but “I didn’t like how it made me feel” and had not taken it since. The client stated that she was introduced to alcohol in HS when “friends asked me to drink it with them.” The client stated that “I sometimes drink on the weekends with friends,” denying drinking in excess or ever suffering symptoms of being hungover. Addictions (i.e., Gambling, pornography, video gaming) The client stated that she occasionally plays a Massive Multiplayer Online game. When asked how often the client played, the client stated “one or two times a week” for approximately “three to five hours” at a time. The client denied gambling or pornography issues. Medical/Mental Health Hx/Hospitalizations: Any past mental health history or hospitalizations denied. Abuse/Trauma: The client denied any current or past abuse, although stating in passing that she did experience some level of teasing in HS, although the client denied discussing specifics. Social Relationships: The client stated that she had quality relationships, but added that she felt as though she was, at times, being taken advantage of. When asked for details, the client stated that her friends oftentimes pressure her to complete their homework, as well as often push her to “party in my dorm.” When asked if the client had ever talked with her friends about said issue ...

1. PCN-610 Eliza D Psychosocial Example
Name: Eliza Doolittle Date:
********* DOB: ********
Age: 18 Start Time: 1:15p
End Time: 2:00p
Identifying Information:
The client is a Caucasian female with average height and
slender build. The client stated that she is currently a freshman
in college, majoring in engineering. The client also stated that
her family resides in a small town approximately two hours
away.
Presenting Problem:
At the onset of the session, the client statedthatshe had come to
counseling as a result of being caught in a campus dorm with
alcohol (it is an alcohol-free campus). Concerning the incident,
the client stated “the RAs were called because my friends were
being too loud in my dorm. When they arrived, they saw us with
alcohol, and we got in trouble.” The client stated that her
friends in the dorm were intoxicated but she was not, adding, “I
was just buzzed” and adding that she was drinking “because
they were” and “it’s just something to do.”
Life Stressors:
The client identified school as a life stressor, adding “things
came easy to me in high school, I just figured it would be the
same in college”. The client went on to state that, in addition to
the difficulty in increased study requirements, she had struggles
in making friends, stating, “a lot of my friends from high school
have either gone to college somewhere else or are doing other
things,” although the client denied feeling lonely.
Substance Use: |X| Yes |_| No
The client denied having a drug or alcohol problem, adding that

2. she tried marijuana once in high school but “I didn’t like how it
made me feel” and had not taken it since. The client stated that
she was introduced to alcohol in HS when “friends asked me to
drink it with them.” The client stated that “I sometimes drink on
the weekends with friends,” denying drinking in excess or ever
suffering symptoms of being hungover.
Addictions (i.e., Gambling, pornography, video gaming)
The client stated that she occasionally plays a Massive
Multiplayer Online game. When asked how often the client
played, the client stated “one or two times a week” for
approximately “three to five hours” at a time. The client denied
gambling or pornography issues.
Medical/Mental Health Hx/Hospitalizations:
Any past mental health history or hospitalizations denied.
Abuse/Trauma:
The client denied any current or past abuse, although stating in
passing that she did experience some level of teasing in HS,
although the client denied discussing specifics.
Social Relationships:
The client stated that she had quality relationships, but added
that she felt as though she was, at times, being taken advantage
of. When asked for details, the client stated that her friends
oftentimes pressure her to complete their homework, as well as
often push her to “party in my dorm.” When asked if the client
had ever talked with her friends about said issues, the client
stated that she had not, adding, “it’s not that big of a deal.”
Family Information:
The client stated that she was the only child in her family,
describing her mother as “kind of controlling” and her father as
“a good guy.” The client went on to state that her mother
required her to call approximately once a week “or else she gets
worried,” adding that during HS her mother “was always asking
where I was going or what I was doing.” The client stated that
her parents seemed to have a strained relationship at times,
stating, “when I call, I talk to my mom first, and then she hands

3. the phone off to my dad, and he goes into another room to talk
with me.” The client also stated that the two frequently
complain to the client about the current status of their marriage.
In the conversation, the client also acknowledged sometimes
feeling as though she were “the middle man” when living at
home.
Spiritual:
The client identified as being an agnostic. The client also stated
that her parents are Irish Catholic, even though “they mostly
only go to church on Christmas and Easter.”
Suicidal:
Denied.
Homicidal:
Denied.
© 2015. Grand Canyon University. All Rights Reserved.
Week 8 Journal Entry The first client is a 25-year-old female
who presented to the facility one year after the death of the
mother. She reported having feelings of sadness and
hopelessness which have affected her social interactions. At the
time she presented, she reported difficulty in sleeping, and
recurrent thoughts of suicide. The patient had also lost interest
in activities which she previously found to be interesting. The
patient was diagnosed with major depressive disorder. The
diagnosis is supported by the DSM-5 criteria which state that
for this diagnosis a patient should present with five or more
symptoms of depression in the same two-week period (American
Psychiatric Association, 2015). 2 Of the presenting symptoms,
one of them should either be a loss of interest or a depressed
mood. The patient is under citalopram for the management of
symptoms.
The second client is a 28-year old male who presented to the
facility and was diagnosed with a generalized anxiety disorder.
The patient started developing excessive worry that he would
fail in his Post-graduate examinations. The worry has lasted for

4. seven months, and it has affected his ability to read and
understand school content. The patient found it difficult to
control the symptoms. He also explained that he was easily
fatigued, was highly irritable and was facing sleep
disturbances. 3 The symptoms are in line with the DSM-5
diagnostic criteria for generalized anxiety disorder. For a
positive diagnosis, the patient must present with excessive
worry or anxiety for a period exceeding six months and also
three of the six cardinal symptoms of anxiety (Er, 2015). The
symptoms include irritability, sleep disturbances, easy
fatiguability, concentration difficulties, restlessness, and muscle
tension (Er, 2015). Furthermore, the disturbances should cause
clinical distress and should not be attributable to the
psychological effects of a substance. The patient is administered
with alprazolam.
Cognitive-behavioral therapy would be effective for the group
of patients. 4 It has been shown to be effective in the
management of both generalized depressive disorder and
generalized anxiety disorder (Powers, de Kleine & Smits,
2017). The expected outcomes would be an improvement of the
symptoms of the patients and improved ability of the patients to
engage in social interactions. There are several ethical
considerations related to the counseling of each of the patients.
It is important to protect the patient information which may
have severe consequences on their social and personal lives if it
is made public. It is also necessary to promote the
confidentiality of the patient concerning the information they
share. Finally, any health care provider is obligated to provide
treatment with a favorable risk to benefit ratio.
Group Therapy Progress Note
American Psychological Association | Division 12

5. http://www.div12.org/ 1
Client:
__________________________________________________
Date: ___________
Group
name:________________________________________________
Minutes:________
Group session # ______ Meeting attended is #:______ for this
client.
Number present in group _____ of _____ scheduled Start
time:________ End time: ________
Assessment of client
1. Participation level: ❑ Active/eager ❑ Variable ❑ Only
responsive ❑ Minimal ❑ Withdrawn
2. Participation quality: ❑ Expected ❑ Supportive ❑ Sharing
❑ Attentive ❑ Intrusive
❑ Monopolizing ❑ Resistant ❑ Other:
_____________________________________
3. Mood: ❑ Normal ❑ Anxious ❑ Depressed ❑ Angry ❑
Euphoric ❑ Other: _______________
4. Affect: ❑ Normal ❑ Intense ❑ Blunted ❑ Inappropriate
❑ Labile ❑ Other:_______________
5. Mental status: ❑ Normal ❑ Lack awareness ❑ Memory
problems ❑ Disoriented ❑ Confused
❑ Disorganized ❑ Vigilant ❑ Delusions ❑ Hallucinations

6. ❑ Other:__________________
6. Suicide/violence risk: ❑ Almost none ❑ Ideation ❑ Threat
❑ Rehearsal ❑ Gesture ❑ Attempt
7. Change in stressors: ❑ Less severe/fewer ❑ Different
stressors ❑ More/more severe ❑ Chronic
8. Change in coping ability/skills: ❑ No change ❑ Improved
❑ Less able ❑ Much less able
9. Change in symptoms: ❑ Same ❑ Less severe ❑ Resolved
❑ More severe ❑ Much worse
10. Other
observations/evaluations:________________________________
________________________
In-session procedures:
_____________________________________________________
__________________________
_____________________________________________________
__________________________
_____________________________________________________
__________________________
_____________________________________________________
__________________________

7. _____________________________________________________
________________
Homework:
1.
2.
3.
Other Comments:
_____________________________________________________
________________________________
_____________________________________________________
________________________________
_____________________________________________________
________________________________
_____________________________________________________
________________________________
Signatures Date
Assignment 1: Practicum – Week 8 Journal Entry
Learning Objectives
Students will:
· Develop effective documentation skills for group therapy
sessions *
· Develop diagnoses for clients receiving group psychotherapy *
· Evaluate the efficacy of cognitive behavioral therapy for
groups *
· Analyze legal and ethical implications of counseling clients

8. with psychiatric disorders *
*
Select two clients you observed or counseled this week during a
group therapy session. Note: The two clients you select must
have attended the same group session.
Then, in your Practicum Journal, address the following:
· Using the Group Therapy Progress Note in this week’s
Learning Resources, document the group session (see
attachment).
· Describe each client (without violating HIPAA regulations),
and identify any pertinent history or medical information,
including prescribed medications.
· Using the DSM-5, explain and justify your diagnosis for each
client. (very important to use
· Explain whether cognitive behavioral therapy would be
effective with this group. Include expected outcomes based on
this therapeutic approach.
· Explain any legal and/or ethical implications related to
counseling each client.
· Support your approach with evidence-based literature.