Integrated Counseling Report
For this assignment, you will conduct a third counseling session that integrates ongoing case data, evidence-based practice, socioculturally appropriate interventions, and ongoing assessment and intervention regarding potential ethical and legal issues, as presented by the client. You will specifically address termination issues consistent with the client’s presentation, sociocultural background, evidence-based practice, and core therapeutic or diagnostic issues. In addition to your counseling session, you will produce an integrated counseling report.
Conduct the counseling session with your practice client, which should be approximately 30â€“45 minutes long. Then develop a written report of approximately 8â€“10 pages that consists of a revised biopsychosocial assessment and diagnosis (2 pages), a revised treatment plan (1â€“2 pages), progress notes (1 page), an updated case conceptualization (1â€“2 pages), and self-reflection (1â€“2 pages).
As a Reminder:
Continue to work with the same assigned classmate for these practice sessions, and you will each serve as the practice client for each other. You will use Zoom to conduct the practice sessions and to record them for submission to the instructor. In the case of an odd number of students in the class, the instructor will assign you to work as a group of three and will give you additional instructions on how to proceed so that each of the three members will have an opportunity to enact the role of a practice client and a practice counselor.
Important Notes about the Practice Sessions with Classmates:
- For the Practice Client:
When you are the practice client, you will be expected to be authentic in your discussions with the classmate who is practicing his or her counseling skills, but please be aware that you have the right to choose what you will or will not share with the classmate. For example, when your background information is being gathered for the intake report, you may choose to share or not to share any significant mental health history, trauma, etc., and should only disclose what you feel comfortable to share. Keep in mind that these are not therapy sessions; they are very time-limited and serve as only a practice opportunity for skill development, so you should go into the sessions with real presenting concerns that would give you some benefit in discussing (e.g., the stress of being a graduate student and juggling multiple priorities) but not a topic with a high-intensity level (e.g., a current unresolved high-conflict situation with a significant other or a trauma history). If for any reason during the course, you find that you have feelings or issues emerge that require additional support, you are encouraged to seek mental health assistance or to contact the Talk One-2-One student assistance program that is available for all NLU students at no cost. To schedule an appointment, call student services.
- For the Practice Counselor:
You are expected to complete several written reports that are submitted only to the instructor for review after the practice sessions in this course. The instructor will not share these reports with your classmates, and you are not to share the reports or any specific content with the classmate who serves as your practice client. In some of the reports, you may be asked to develop a preliminary diagnosis for the practice client, depending on the information you have gathered, and this is simply an opportunity for you to practice your diagnostic skills. Because this is only a skills practice, it is not appropriate for you to share the content of the report with your classmates (or anyone else except the instructor).
Preparation Prior to Practice Session:
- Confirm the agreed-upon meeting time with your practice client for this assignment.
- Have the interpersonal process recall method ready.
- Review the instructions that were emailed to you prior to the course to learn how to set up and record your video session.
- Prepare to record the practice session, so you can see and hear yourself and review the effectiveness of your interventions.
- Prepare to take notes during the session. This will help you formulate your summary toward the end of the session.
Part I: Conduct a Counseling Session:
- Conduct the second recorded counseling session with your practice client.
- This session should be between 30 and 45 minutes in length.
- Turn in recorded intake session through digital upload in the course for your instructor’s review as needed.
- As part of your grade, your instructor will view a 10-minute portion of the tape. You may suggest a time-stamp where you would like the instructor to begin the review. Ultimately, any part of your tape may be reviewed.
- Use the interpersonal process recall method of self-supervision following the session and document notes regarding your self-supervision in the self-reflection session.
- Next, meet over the phone or via Zoom with your practice client whom you will consult regarding your previous session. This is in order to receive feedback from the practice client on his or her experience within the session and the counseling skills you used.
Part II: Write a Written Report:
Follow the details below pertaining to the report’s requirements.
Your written report should be 8- to 10-pages long and should follow APA guidelines for writing style, particularly chapters 3 (Writing Clearly and Concisely) and 4 (The Mechanics of Style). Clear documentation of services is a very important skill that can result in a client’s services being reimbursed or denied and, therefore, is a client welfare issue. You should have a title page and a header labeled “Midterm Your Name.”
A. Biopsychosocial Assessment:
Develop a 2-page revised biopsychosocial assessment integrating your instructor’s feedback from your original documentation of the assessment. You may update the diagnosis on the basis of information you have learned in your first sessions. Note that if the diagnosis changes, it should be supported by evidence in the documentation in your progress notes (this is how quality assurance [QA] officers audit files). Use the format identified previously.
B. Progress Notes:
Document your session in a 1-page progress note using one of the approved formats that you learned about in Module 2 of this course (Subjective, Objective, Assessment, Plan [SOAP], Data, Assessment, Plan [DAP], or Behavior, Intervention, Response, Plan [BIRP]).
C. Treatment Plan Update:
Revise the 1- to 2-page treatment plan integrating your instructor’s feedback from your original treatment plan. You may update the plan on the basis of new information gathered if needed. Use the chart format previously identified.
D. Case Conceptualization:
Document your case conceptualization in 1â€“2 pages integrating diagnostic, developmental, sociocultural, interpersonal neurobiological, and theoretical concepts into your understanding of the client’s issues. Integrate feedback from your case consultation session. Integrate information you have learned from the research you have done on the client’s issues or his or her sociocultural or spiritual background, as relevant.
If you do not have any changes/updates to the case conceptualization, discuss evidence from the client’s session and your classmate/colleague consultation that supports your original case conceptualization.
Specifically, address your experience of the client’s resistance during the sessions with the understanding that resistance occurs on a continuum (i.e., from not wanting to attend mandated treatment, to avoiding any feelings or internal focus). Determine your conceptualization of the client’s resistance and/or reactance, integrating what you have learned in class.
Explain your conceptualization of termination issues related to the client’s therapeutic issues, interpersonal nature of the therapeutic relationship, and evidence-based practice regarding termination.
Integrate information from self-supervision and case consultation into your self-reflection in 1â€“2 pages in this module. Identify your strengths and challenges as a counselor. Specifically, note any ethical, legal, or sociocultural issues that might be a focus for supervision and any transference or countertransference issues that may be affecting the therapeutic relationship. Identify any vicarious trauma or other self-care concerns.
Explain your experience of being present and the impact it had on the client. Describe your experience as a participant-observer in the relationship. Discuss any specific advanced skills you utilized over the course of the previous four modules and how you felt in terms of self-efficacy applying those skills. Finally, explain your plan for working toward termination with this client. What challenges do you foresee? How will you address those?
Your final product will consist of your report in a Microsoft Word document (approximately 8â€“10 pages in length). Your report should be written in APA format in a clear, concise, and organized manner; demonstrate ethical scholarship in the accurate representation and attribution of sources; and display accurate spelling, grammar, and punctuation.
- By the due date assigned, save your document as M4_A2_Lastname_Firstname.doc and submit the document to the Submissions Area.
Signature Assignment 1 Grading Criteria
|Assignment Components||Proficient||Maximum Points|
|Conduct and tape a counseling session on any topic.||A clear and logical taped counseling session is completed. The content is appropriate for the assignment. Evidence of counseling skills related to addressing core therapeutic issues and termination issues are demonstrated.||24|
|Revise the biopsychosocial assessment based on your instructor’s feedback.||The biopsychosocial assessment is revised accurately based on instructor feedback from the initial biopsychosocial assessment. Many relevant details are included.||32|
|Revise the client’s treatment plan and risk assessment, per your instructor’s feedback.||The client’s treatment plan is revised accurately based on instructor feedback from the initial treatment plan. Many important details are included. The treatment plan and risk assessment is documented in behaviorally observable and measurable terms consistent with expectations of third party reimbursement entities and used in treatment teams.||32|
|Revise the progress notes, per your instructor’s feedback.||The progress notes are revised appropriately based on instructor feedback. Progress notes concisely and accurately reflect session activities, speak to treatment plan goals, and document risk management issues as relevant. Progress notes are documented in a consistent format approved by the instructor (Subjective, Objective, Assessment, Plan [SOAP], Data, Assessment, Plan [DAP], or Behavior, Intervention, Response, Plan [BIRP]). Many relevant details are included.||32|
|Revise your case conceptualization per your instructor’s feedback. Discuss evidence that supports your original case conceptualization. Include any termination and resistance issues.||All case conceptualization revisions are correctly made, per the instructor’s feedback. A logical discussion is included regarding evidence found from the client’s session and classmate/colleague consultation that supports the original case conceptualization. Resistance and termination issues are logically included. An accurate integration of new information gathered in subsequent counseling sessions is provided. If substantive changes are not needed in the case conceptualization, a logical analysis of the case conceptualization following subsequent counseling sessions is given.||32|
|Develop a self-reflection regarding your strengths and challenges. Specify any ethical, legal or sociocultural issues that may be affecting the therapeutic relationship.||The reflection clearly identifies many strengths and challenges as a counselor and includes details such as: ethical, legal or sociocultural issues that might be a focus for supervision and/or transference/counter-transference issues that may be affecting the therapeutic relationship. In addition, examples regarding vicarious trauma or other self-care concerns are adequately addressed. The models of self-supervision and peer supervision/case consultation used to assist in self-reflection are correctly identified.||24|
|Write in a clear, concise, and organized manner; demonstrate ethical scholarship in accurate representation and attribution of sources (i.e. APA); and display accurate spelling, grammar, and punctuation.||Written in a clear, concise, and organized manner; demonstrated ethical scholarship in appropriate and accurate representation and attribution of sources; and displayed accurate spelling, grammar, and punctuation. Use of scholarly sources aligns with specified assignment requirements, as appropriate.||24|