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Client Case Presentation

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by

Tonya Lewis

on 1 December 2012

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Transcript of Client Case Presentation

Tonya Lewis Case Presentation Gender: Male
Race: Caucasian/Philipino/Latino
Session Length: 45 Minutes
Age: 13-years-old
Education: 8th grade Reason for Referral: Client: John Keen Anxiety
Short temper at home
Trouble focusing
Feeling overwhelmed at times
Frequent lying (eg. homework)
Declining grades
Migraines
There seems to be a pattern... 1. John will lie about completing his homework ->
2. Leading to anxiety the next morning when realizing the homework is due ->
3. This causes unnecessary stress to the situation->
4. Which onsets a migraine. The client presents.... Family History Client was adopted at the age of 3-years-old. Was left at a church by his birth parents with his infant sister. The two were taken in by a foster family who decided to kept the client's infant sister. However, they did not want to keep the client. Three days later, the client's current adoptive parents were contacted. What does this mean? There seems to be a communication problem within the family. The identified client feels the need to lie to his parent to avoid homework. The client needs to be able to express his wants and needs openly within his family to avoid anxiety and stress. Treatment Plan Experiential Family Therapy us being used on this family to help change communication between family members and increase self-esteem for the identified client.
Goals: Build rapport, gather more history, have each family member speak about their personal experience within the family, Identify functional and dysfunctional communication styles, help family to express themselves more directly and develop open communication.
End goal: Develop a family care plan to maintain progress made in sessions.
Continuous movement: finger playing, finger tapping, paper shuffling, foot tapping, minimal eye contact, and shifting in seat.
Well -groomed
Shy, spoke very little in session
Interacts well with peers
No problems staying on task in class (observation was conducted).
Full transcript