Element of stigma/shame

Client Information
Name: Age: Date of birth:
I) Description of child and family (include individuals the client resides with and other frequent visitors. Include information relevant to clients’ physical appearance)
II) Presenting problem (Identify primary reason for referral to clinical counseling. Operationalize the problem).
III) History of problem (Create a timeline of the development of the problem).
IV) Element of stigma/shame associated with problem
V) Ego strengths and weaknesses
a) Identified goals and strengths (from client’s perspective):
b) Hobbies/special interests-
c) Frustration tolerance, ability to delay gratification:
d) Identified Barriers to Treatment
VI) Coping skills/Reaction to adjustments (This section refers to the client’s ability to respond to transitions or changes in different settings. Information may come from the client, caregiver, or teachers)
a) Home: ability to adjust to difficulties or changes at home (give examples)
b) School : ability to adjust to difficulties or changes at school (give examples)
c) Interpersonal/peers: ability to adjust to difficulties or changes in interactions with peers (give examples)
VII) Mental and Behavioral Functioning
a) Cognitive level: Piaget’s stages of cognitive development
b) Temperament: current temperament (sanguine, choleric, melancholic, phlegmatic
c) Medical history: describe serious illnesses, operation, and injuries since birth, with dates and outcomes. Consider requesting medical records from pediatrician.
d) Mental health history: Previous mental health concerns or diagnoses (include dates)
e) Suicidal or homicidal ideation (current/history):
f) Abuse history
i) Physical
ii) Sexual
iii) Emotional/Exploitative
g) Exposure to traumatic events (include specific ages/dates of traumatic events):
h) Sexualized behaviors/sexual activity:
VIII) Contextual Factors
a. Physical living situation-space? – Type of dwelling, number of rooms, conditions
b. Financial situation:
c. Community environment – SES, safety/crime, activities
d. Cultural factors: Ethnicity, race, etc.
e. Spirituality/Religion: Identified religion or spirituality. Does the child/family participate in religious services? If yes, how frequently does the child/family participate?

Developmental History Outline

Developmental Milestone Age Achieved Comments
Sat Alone
Crawled
Took First Steps
Said first word
Weaned
Fed Self
Dressed Self
Toilet Trained
Speaking in Full Sentences

IX) Specific developmental history (PAY ATTENTION TO TIME FRAMES)
A. Pre-natal Experience
a. Was pregnancy planned or unplanned?
b. Parental attitudes toward children- Perspectives of both parents prior to and at birth
c. Couple/Marital situation, financial status – marital status, quality of relationship at timing of clients birth, working status, ability to meet basic needs
B. Delivery

1. Abnormalities, difficulties, unusual procedures –
2. Gender of child (parental/sibling reaction)-.
3. Birth weight-
   C. Infancy (age 0-1)
4. Emotional responsiveness and sensitivity (child’s temperament – easy/difficult; ability to engage with others)-
5. Quality of parenting (maternal/paternal availability for positive, fulfilling relationship); who was the primary caretaker?
6. Stressor Events to Impact Client (at this age of development)
   D. Early childhood (age 1-4)
7. Stressor Events to Impact Client (at this age of development; sibling births, separation from parents; medical concerns)
8. Reactions to nursery school or other separation-
9. Discovery of anatomical sexual differences (reaction)-
10. Exposure to sexual activity or materials-
11. Fantasy life and play- parallel, independent or interactive play, imaginary friends
    E. Elementary Age (5-12)
12. Stressor Events to Impact Client (at this age of development; sibling births, separation from parents; medical concerns, etc.)
13. Separation Reactions: (to attending kindergarten)
14. Ability to learn, concentration :
15. Academic Performance: (grades, need to be retained or skip a grade, etc)
16. Superego formation/moral development – clear sense of right and wrong, expression of remorse
17. Any noted difficulties in behavior (disruptive behaviors, attendance, etc. )-
    F. Secondary School (12-18)
18. Stressor Events to Impact Client (at this age of development; sibling births, separation from parents; medical concerns)
19. Ability to learn, concentration, cognitive development-
20. Academic Performance: (grades, need to be retained or skip a grade,)
21. Superego formation/moral development – clear sense of right and wrong, expression of remorse
22. Any noted difficulties in behavior (disruptive behaviors, attendance, substance use, etc.)-
23. Employment/Vocational Experiences:
    Situational Factors in the Assessment of the Child
    A. Presence of loss factors
24. Separation from family members and/or changes in family structure -
25. Death of family members –
26. Loss of body part or function -
    B. Presence of Violence
27. Presence of life threat –
28. Presence of physical injury or chronic pain-
    C. Psychosocial and environmental problems:
29. Family History of Mental Health Issues:
30. Family History of Substance Use/Abuse:
31. Family Medical Concerns:
32. Involvement of others: involvement with other agencies (DCF, school, psychiatric services, APD, DJJ, etc)
    DSM-V diagnosis:

Clinical Impression:

Assessment of Child’s Support System

1. Close family members and/or significant social support

Mother: Age: Relationship Quality
Father: Age: Relationship Quality:
Sib: Age: Relationship Quality:
Sib: Age: Relationship Quality:
Other: Age: Relationship Quality:
Other: Age: Relationship Quality:

a. How responsive are they to child’s needs?
b. To what extent is the child included in discussions about the “problem situation”? How does the child respond to these discussions?
c. To what extent do the views of various members of the nuclear family differ on matters pertaining to the child?

1. Extended family members
   a. How frequently are they in contact with the child?
   b. Describe the nature of the relationships, including who is the most supportive relative to the child.
   c. To what extent do the views of the extended family differ or agree with those of the nuclear family on matters pertaining to the child?
2. School/peers/ social network
   a. Child’s friendship network: how many friends does the child have? Quality of these relationships? How many days after school, on the average, does the child play/interact with another child?
   b. Child’s desire to have more friends than he/she has? (child perspective)
   c. Client’s history of intimate or romantic relationships
3. Spirituality/Religion (Discuss the importance of religion/spirituality in child’s life)

Clinical Summary: (Identify most significant presenting concerns to be addressed in clinical counseling.)

Sample Solution