GUIDANCE assessment

COLLEGE OF ARTS AND SCIENCES
DEPARTMENT OF BEHAVIORAL AND SOCIAL SCIENCES
TRINITY UNIVERSITY OF ASIA
STA. ISABEL, PAULO
4PSY01
-2012-

Paulo Z. Sta. Isabel
-Optimum Life Center-
“YourHealth isourSuccess!”
For Guidance and Counseling and Self-help Support
Burgos Rodriguez (Montalban) Rizal
Mobile Number: (0906)151-94-01 & (0933)498-89-54
Email Address: paulozata@yahoo.com
CASE HISTORY FORM
Place of Interview Trinity University of Asia
Case worker name Paulo Z. Sta. Isabel
Clients Name John De Leon
Nickname John
Age 19 years old
Gender Male
Place of birth Quezon City
Blood type Type O
Present address 122 K4th Kamuning Quezon City
Provincial address Nueva Ecija
Contact no. 09177618826
Marital status Single
Educational status College student

HEALTH AND MEDICAL BACKGROUND
Past medication Hospitalization
(Medical Problem)
No
Past head trauma: any seizure cases? No
Had EEG? No
Have changes in appetite/weight? Yes
How many meals normally do you eat per day? Four (4)
Any problems chewing, swallowing, digesting or
eliminating?
None
Do you exercise regularly? How/what? Yes
Any current physical complaints? None
Do you have any medical history of the following:
High blood pressure No
Diabetes No
Asthma No
Tuberculosis No
Ear problems No
Eye problems No
Hearth complications No
Blood sugar level No
Sinus problems No
Nose problems No
Urinary problems No
High cholesterol No
Fainting No
Breathing trouble No
Headaches Yes
Dizziness No
Cataracts No
Constipation No
Arthritis No
Chronic fatigue No
Bone or Joint problems No
Glaucoma No
Hepatitis No
Gastritis No
Hormonal problems No
Numbness No
Kidney problems No

BRIEF PSYCHOSOCIAL HISTORY
CHILDHOOD;
Where were you born and raised? Born: Quezon City Raised: Quezon City
Did your parents married? Yes
Did you reach your development
milestones, like walking, talking, and potty
training on time?
Yes
With whom did you live while you were
growing up?
Parents
Who did you fell closer to? Brothers and mother
Who in the family was affectionate to you? Brothers and mother
How did you get along with your family? Fine
Who made the rules and enforced
discipline?
Father
Do you think the rules were fair? Yes
How often did you get punished? Seldom
How did they usually discipline you? By talking
Did they ever spank or hit you? No
Did you see violence in the family? No
Did anyone sexually abuse you? None
At what age did you begin to go in school? Six (6) years old
Did you go to regular or special classes? Regular class
How did you do in school? (What were
your grades?)
Studying and have some fun (grades are
good)
Did you ever repeat a grade? Yes
Where did you involved in school
activities? IF YES: give example
Yes! Taekwondo
What did you do after you graduated? Work
What was your personality like as a child Approachable
Did you have many friends as a child? Yes
Did you have any really close friends? Best
friends?
Yes
Were you more of a leader or a follower? Leader
Diarrhea Yes
AIDS No

PRESENT HUMAN RELATIONSHIPS;
Do you have many friends, that is,
someone you can really trust with secrets?
Yes
Do you have many friends now? Yes
Do you tend to keep friends for a long
time?
Yes
How many romantic relationships have you
been involved?
Three (3)
Do you have romantic partner right now?
How long?
None
What happens when you and your partner
have disagreements?
Talk about the concern
Describe the most recent (or serious) time
that a disagreement happened?
When my Ex-girlfriend got jealous
How often does something like this
happen?
Seldom
Have you ever had to go to a doctor
because of injuries received during a fight?
No
Did this ever happen in prior relationships? No
CURRENT LIVING CIRCUMSTANCES;
Where do you live? Kamuning Quezon City
Do you live in an apartment? Or a
house?
House
How long have you been living there? More than ten (10) years
With whom do you live? With Mother, father and two (2) siblings
MENTAL HEALTH;
Previous psychotherapy None
Previous psychiatric hospitalization None
Family psychiatric history None
Mental/Behavioral status Normal
Orientation Normal
Psychomotor activity Normal

Mood Normal
Thought process Good
Insight/Psychological Mindedness Good
Judgement/Impulse Control Fair
Behavioral attitude Guarded
Attention/Concentration Fair
LETHALITY ASSESSMENT;
Presence of current suicidal thoughts or
impulses
No
History of any previous suicide attempts No
Suicide risk level Low
Presence of thoughts or impulses to harm
others
No
Assessment of risk level Low
Remarks;
The client is very cooperative and attentive during the interview. Without hesitating
and other thoughts he reviled all his complaints and personal matters. He has an eye to
eye contact during the interviews and very straightforward with his responses and to
the questions. He is frankly about things and information when it comes to the topic
about his studying, living situation and needs and to his father. He is comfortable
talking about some circumstances and in sharing funny story but client is serious about
in issues in life. He have positive outlook to his future life and in studying. His
development during his childhood and with great support of his family helps him to
create his characteristic and boost his self-esteem. And help him to figure out what he
wants and don’ts in making decisions. For him the key of success is determination. The
client’s mental functioning is good and matured enough to understand things and
critical situations.
STA. ISABEL, Paulo Z
Evaluated by:

Mobile Number: (0906)151-94-01 & (0933)498-89-54
Clients Data Form
Nickname John
Age 19 years old
Gender Male
Birthday January 4, 1993
Citizenship Filipino
Blood type Type O
Ethnic Background Nueva Ecija
Place of birth Quezon City Philippines
Religion Roman Catholic
Provincial address Nueva Ecija
Contact no. 09177618826
Marital status Single
Educational status College student
Family Background

Name Age Status profession
Father Kennedy De Leon 52 Married Registered
Nurse
Mother Susan De Leon 47 Married Housewife
Children Sandy De Leon 28 Married Engineer
Roel De Leon 27 Married Seaman
Kingdi De Leon 25 Single Medic
Leonardo De Leon 24 Single None
John De Leon 19 Single College student
Roy De Leon 14 Single High school
student
Purpose for Evaluation:
The client is 19 years old from Kamuning Quezon City Philippines. The client is second
to the youngest from the six children of Mr. Kennedy and Susan De Leon. He is a
second year college student in Trinity University of Asia taking a Bachelor of Science in
Psychology. Single. Have fair complexion, brown eyes, 5’4” in tall and has masculine
physique. As my client I sought him to undergo from my guidance, psychotherapy
assessment, and counselling sessions to enlighten him about his condition and
behaviour because as his chief complaint, he is thinking that his endeavour in studying
is still not enough to achieve his aims and having lack of financial support from his
family in his studies and the pressure from social life as his other central conflicts that’s
affecting his major complain.
The client is not suffering from other remarkable diseases or illness. He is physically
fit and has an active lifestyle for having regular exercise especially body building and
taekwondo as his supplementary activity. He does not want to have commitment this
time to focus more in his studying and in building his career. He justify not having many
friends at school for being irregular student. He stated that he became lonely and feels
that he is the center of attention when he is by himself. Being an irregular student gives
him difficulty in studying sometimes and establishing good relationship among his other
classmates.
The client’s suffering from his chief complaint since last three (3) months, March of
this year. Sometimes his expectations from his venture gave him frustrations. He got
good grades from his previous subjects but still he thinks that this are not enough to
achieve his goals in his future life. As he sees in their family situation and status in life,

he engaged to work early on his young age in a firearms store in Quezon City to
support his needs and to help his family in financial problem.
The client is also complaining his father for its insufficient salary that leads of lack of
support from their needs. The client is close to his mother than to his father because he
often to talk and open-up some subject matters in life, about studying and having
bonding moments with his mother than to his father. Regarding to his siblings he have
a close-tie relationship among them.
As a previous assessment to the client he has a positive outlook in his life situation,
needs and to his self, moreover he has matured sense in handling/coping his problems
and complaints. That’s why as his case worker I ideally use Reality Therapy on our
sessions, in supporting him and resolving his complaints.
Evaluated by:
Mobile Number: (0906)151-94-01 & (0933)498-89-54
CASE SESSION FORM
Date of Session July 17, 2012
Case Session no. 1
Case Process

Case Target Plans
 Set for a new schedule of interview and process
 Observe and analyzing the personality of the client
 Establish proximity and make each other feel more
better for the next sessions
Mobile Number: (0906)151-94-01 & (0933)498-89-54
CASE SESSION FORM
Case Session no. 2
 Getting to know each other
 Building rapport and knowing each personality
 Knowing each similarities and dissimilarities

Mobile Number: (0906)151-94-01 & (0933)498-89-54
Case Process
 Gathering more data and information about the
clients background by means of interviewing and filling-
up the case data form
 Knowing better more about personal subject
matters about the clients’ life
 Open my view in life especially in pursuing my
Masters Degree in Counselling in the near future to have
a chance to get the clients trust to start the case
management assessment
Case Target Plans
 Set for a new schedule of session to expand the
interest of the client about case management
 Focus to the course of therapy and influence of
the choice therapeutic procedures and strategies

CASE SESSION FORM
Case Session no. 3
Case Process
 Encourage (deceive) the client to help and be my participant in practicing
counselling case management as one of my requirements in Masters Degree
 The client open more about his personal life matter and prepared to be my client
 Filled up the Case history form; Health and Medical Background, Brief
Psychosocial History, Present Human Relationships, Current Living
Circumstances, Mental Health, and Lethality Assessment
Case Target Plans
 Finished the initial steps for establishing better relationship and empathy
between the client
 Proceed to the Psychotherapy that will used (Reality Therapy) for the
whole counselling support
“YourHealth is ourSuccess!”
Mobile Number: (0906)151-94-01 & (0933)498-89-54

CASE SESSION FORM
Date of Session August 03, 2012
Case Session no. 4
Case Process
 Applying the Reality Therapy to Mr. De Leon
 List down and make an assessment for major complaint and other
central conflicts that affecting his major complaint, behaviour, and
condition
 Challenge the client to look at his current behaviour to decide if he
want this behaviours make changes or eliminate
 Make decisions whether what the client and I will do to work this
Reality Therapy effectively
Case Target Plans
 Planning and making commitments to stick with the plans to really achieve what
Mr. De Leon want to make changes

Mobile Number: (0906)151-94-01 & (0933)498-89-54
CASE SESSION FORM
Case Session no. 5
Case Process
 Assisting in making plans to change specific behaviour that Mr. De Leon
determined that was not working for him
 Formulating concrete goals then utilize a variety of techniques that foster
modification of feelings, thinking processes, and ways he behave
Case Target Plans
 Help to achieve and challenge the client in the plans that he made for his change
 Be supportive and trust the client’s ability to cope-up with his complaints

Mobile Number: (0906)151-94-01 & (0933)498-89-54
CASE SESSION FORM
Case Session no. 6
Case Process
 Apply the specific plans for the development of the case management and for
the improvement of the clients’ condition and behaviour
 Start to eliminate and discuss the complaints in the list that Mr. De Leon wrote in
the covenant;
-LIST of GOAL-
 Retain his in-house determination on life
 Set a standard limitation in everything
 Do not give too much pressure to himself
 Balance the Lifestyle management not the Time management
 Be contented to what he is receiving or earning from his endeavour and to
what he have and;
 Just go with the flow to the things that will happen and to the results of
his accomplishments and to what life will offer
Case Target Plans
 Set in the client’s mind that this case management is an active,
directive, and didactic therapy

Mobile Number: (0906)151-94-01 & (0933)498-89-54
CASE SESSION FORM
Date of Session September 4, 2012
Case Session no. 7
Case Process
 Encourage Mr. De Leon to evaluate himself and what we are doing
to see if there are progress of changes
 Focusing the client and his accountability measure
Case Target Plans
 Stick to the plan, covenant, and to the commitment that we have
to follow things from beginning to end

Mobile Number: (0906)151-94-01 & (0933)498-89-54
CASE SESSION FORM
Date of Session September 14, 2012
Case Session no. 8
Case Process
 The client find out that the psychotherapy and case management
that we have conducted was very challenging to his part to have a
new persona
 Have realized the things and the behaviour that he acted before
from his past condition
 Contented to the results of the case management and to his new
behaviour
Case Target Plans/Recommendation/Status
 CLOSURE OF CASE
 Fulfil to the improvement and determination of Mr. De Leon
 Support!!! Guide... Support!!! Guide... Support!!! Guide...
Sta. Isabel, Paulo Z
Approved by:

GUIDANCE assessment

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