1) The counseling goal for the session (in terms of stages of the counseling or problem-solving process, i.e., to define client’s problem/concern, define goal(s), identify strategies for addressing problem, review progress and revise strategies as needed. Examples: The purpose of this first session with Mr. Graham was to obtain informed consent from Mr. Graham for counseling and to help him identify his current problems or concerns for our sessions.
The purpose of today’s session was to continue to review Alfonso’s progress in his job search.
2) Specific client problems, goals, strategies, progress, identified as counseling progresses
Examples: After several issues were discussed, Jeff stated he wanted to focus his counseling sessions on how to deal with his “dysfunctional marriage”.
Clara stated she was feeling “overwhelmed with her life right now” due to multiple home and work responsibilities.
3) Evidence of client progress through the problem-solving process, as obtained through client statements or other sources of progress data discussed during session (i.e., statement of client’s problem or goal from session, client report of progress on strategies selected, etc.)
Examples: Chu stated that he tried to tell his employer about his continuing difficulty understanding instructions in English, but his boss did not acknowledge Chu’s problem or offer any accommodations.
Larry reported today that for the first time, he was able to remain calm during the noon rush at his job site.
4) Counselor observations of client behavior during session or as reported between sessions
(i.e., “Joan was unable to give any specific examples of how her boss ‘abuses her’ at her job site.”; “John stated he forgot to follow-up on his job lead, as he agreed to do at our last session.”; “Rufus stared at the floor throughout the session and changed the subject when asked about his drinking problem.” “The counselor observed that Amy was smiling and energetic today as she entered the room; stated that she felt much happier in the past week.”
5) Specific “homework” assignments or recommendations/suggestions made by counselor (examples: “ It was agreed that Elmer will attend at least two social events during the next week.”; “Mark should continue following his physician’s recommendations for diet and medication for his hypertension.”; Leroy will bring his wife to the next session.”)
6) If relevant to session, incidents of client harm or harm to others and what actions/recommendations were taken to insure client/other safety.
Example: Pete stated he had been considering suicide. Counselor inquired about extent of his suicide planning and concluded a possible risk of suicide exists; obtained client’s agreement to a suicide contract (copy attached). Counselor telephoned client’s psychiatrist to discuss the suicide threat. Awaiting return call from psychiatrist.
1) Writing style for counseling session summaries:
2) Summary should be brief, concise, covering the main facts and events of session, but with adequate detail for another counselor to take over client session if necessary and to provide documentation of client progress. It is not necessary to report everything covered in the session, but the events/statements most relevant to session goal.
3) Write case summaries in the past tense and in third person (e.g., Counselor observed that client was 15 minutes late for her session.)
Statements should be written in behavioral/observable terms, using description of behavior, specific statements, etc. Counselor should avoid making judgments or giving own feelings about the client, especially negative ones. Observations or opinions about clients can be provided but should be backed up by observable behaviors or statements of client during session.
Example: Avoid such statements as, Yolanda was avoidant and paranoid when discussing her mother.
Instead, use statements such as, Matilda stated, “I don’t want to talk about that” when counselor asked about her relationship with her mother.
4) Emphasis should be placed on reporting client progress in defining their problem(s), goals, strategies, and progress toward goals/symptom reduction. Progress should be reported from client’s point of view, not counselor’s.
Example: Mahlia stated that she is pleased with the way her recent interview went.
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