Student: Asika, Judith
Date: 3/3/2025 Academic Year: 2024/2025 Period: Spring
Course: PRAC 6645
Instructor: OYEWOLE, Daniel
Field site: KENYATTA BLACK COUNSELING TX
Date Saved: 3/5/2025 9:37:06 PM Last Edit: 3/5/2025 9:37:05 PM
Notes: Second Week: 3/3/2025 to 3/7/25
1.
Neurodevelopmental Disorder
C.N., a 16-year-old female diagnosed with ADHD with
Hyperactive Disorder, and her mother attended a counseling
session today. Supportive BTC psychotherapy was used to
address C.N.’s behaviors and hyperactivity symptoms. The
client reported experiencing several challenges, particularly
with difficulty concentrating in class and completing both
household chores and school assignments. A contract was
Student Notes created, along with specific strategies, to help C.N. manage
her ADHD and associated symptoms. Both C.N. and her
mother agreed to the proposed strategies. No medication
was prescribed at this time. A follow-up session is planned
for one month. The client and her mother were informed to
call 911 or visit the nearest emergency crisis center if
symptoms worsen, and they acknowledged their
understanding of this information.
2. Substance-Related & Addictive Disorder
3. F.J., a 65-year-old male with Opioid Use Disorder, participated in an
individual therapy session. Motivational psychotherapy was used to
address additional issues related to his opioid use. The client
shared that he faces multiple challenges, including back injury pain
Student Notes and unresolved childhood trauma, both of which are contributing
to his opioid use disorder. A treatment plan was developed,
including specific strategies to help F.J. manage his condition and
related symptoms. F.J. agreed to follow the treatment plan. A
follow-up session is scheduled for one month. The client was
, advised to call 911 or go to the nearest emergency crisis center if
his symptoms worsen, and he confirmed his understanding of the
information and the treatment plan.
4.
Diagnosis Anxiety Disorder
C.M., a 78-year-old male diagnosed with Generalized Anxiety Disorder (GAD), engaged in
an individual therapy session. Cognitive Behavioral Therapy (CBT) techniques were
utilized to address his anxiety and associated symptoms. The client reported
experiencing challenges such as insomnia and depression, which contribute to increased
Student anxiety at times. A comprehensive treatment plan was established, incorporating specific
Notes strategies to assist C.M. in managing his condition and related symptoms. C.M.
consented to adhere to the treatment plan. A follow-up session is scheduled for one
month. The client was informed to contact 911 or visit the nearest emergency crisis
center if his symptoms deteriorate, and he acknowledged understanding of this
information and the treatment plan outlined.
5.
Trauma & Stress-Related Disorder
T.D., a 12-year-old female diagnosed with Post-Traumatic Stress Disorder (PTSD)
stemming from childhood trauma, attended an individual therapy session
accompanied by her mother. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
techniques were employed to address T.D.’s PTSD and related symptoms. Both T.D.
and her mother reported challenges including social anxiety, panic attacks, and
Student depression, which at times exacerbate her PTSD symptoms. A comprehensive
Notes treatment plan was developed, incorporating specific strategies to assist T.D. in
managing her condition and associated symptoms. Both T.D. and her mother agreed
to adhere to the treatment plan. A follow-up session is scheduled for one month.
They were informed to contact 911 or visit the nearest emergency crisis center if her
symptoms worsen, and both acknowledged understanding of this information and the
outlined treatment plan.
6.
Anxiety Disorder
, J.J. is a 32-year-old Caucasian woman with generalized anxiety disorder. She participated
in individual therapy. She reported excessive and unrealistic worry, restlessness, fatigue,
shakiness, palpitations, shortness of breath, dry mouth, feeling on edge, trouble
Student concentrating, and difficulty sleeping. She practiced deep breathing exercises,
Notes progressive muscle relaxation, mindfulness meditation, and cognitive restructuring. She
was educated to call 911 or visit an emergency crisis center if her symptoms worsened or
if she had suicidal thoughts. She understood this information. J.J. accepted the therapy
plan and will follow up in four weeks.
7.
Personality Disorder
O.J. is a 44-year-old African American male diagnosed with borderline personality
disorder (BPD). He has persistent feelings of emptiness. He struggles with excessive
spending, substance misuse, reckless driving, and binge eating. He often feels unjustly
treated and believes others are untrustworthy. He has experienced childhood trauma.
Student
The patient and his family agreed to use dialectical behavior therapy (DBT) to help
Notes
regulate emotions and relationships. They also agreed to schema-focused therapy to
address negative thought patterns. O.J. was educated to call 911 or visit an emergency
crisis center if his symptoms worsened or if he had suicidal thoughts. He will be
reassessed in one month.
8.
Trauma & Stress-Related Disorder
The patient is a 17-year-old female diagnosed with PTSD and childhood trauma. She
visited the clinic with her mom for counseling. The patient is willing to work on
change and understands the problems caused by her mental disorder. Trauma-
Student focused therapy will be used as part of her treatment. This therapy involves talking
Notes about the traumatic event, addressing mistaken beliefs, and managing anxiety.
She/Mom was educated to call 911 or visit an emergency crisis center if her
symptoms worsened or if she had suicidal thoughts with verbalized understanding.
Follow up appointment scheduled in a month.
9.
Trauma & Stress-Related Disorder
, The patient is a 62-year-old Vietnamese American male. He came to the clinic with a
diagnosis of grief and loss. He feels guilty that he didn’t do enough for his lost loved
one. He also believes unreasonably that he contributed to the death. The patient is
committed to being open and honest while working with the therapist to reach his
Student
therapeutic goals. Cognitive behavioral therapy (CBT) and art and memory books are
Notes
used to help him change negative thoughts and behaviors, process his feelings, and
remember the deceased. He was educated to call 911 or visit an emergency crisis
center if his symptoms worsened or if he had suicidal thoughts. The patient will
return in a month.
10.
Trauma & Stress-Related Disorder
M.Z. is a 55-year-old Asian American female grieving the loss of her spouse. She
attended counseling with her daughter. She struggles with loss, poor concentration,
tearfulness, and confusion about the future without her spouse. The patient and her
Student daughter agreed on the treatment plan. Empathetic listening and life review therapy
Notes were used to create a safe space for M.Z. to discuss her feelings and review past
achievements and conflicts. She was educated to call 911 or visit an emergency crisis
center if her symptoms worsened or if she had suicidal thoughts. A follow-up
appointment is scheduled in one month.
11.
Anxiety Disorder
1. T.C., a 40-year-old African American male, came in for a follow-up individual
counseling/therapy session to address difficulties with focus and heightened anxiety,
which are linked to family and work transition concerns. The client has a prior diagnosis
of anxiety disorder and is not currently taking any medication. Struggles with family
matters and adjusting to new responsibilities at work have contributed to increased
anxiety, difficulty concentrating, and challenges in decision-making. Several factors were
identified as contributing to conflicts both at home and in the workplace, and solutions
Student were developed. The client will continue individual counseling and therapy as planned,
Notes using Acceptance and Commitment Therapy (ACT) to manage the work transition and
improve cognitive functioning. The patient agreed to the treatment plan and expressed
understanding. A follow-up is scheduled in one month. MME: The client is a 40-year-old
African American male who appears his stated age. He is alert, awake, and oriented to
person, place, time, and situation. He reports feeling depressed and anxious, with
increased anxiety and focus issues related to job transition and family problems. The
client is neatly dressed and well-groomed. Speech is clear, coherent, and normal in tone
and volume, with no signs of abnormal motor activity. He expressed indecisiveness and
Date: 3/3/2025 Academic Year: 2024/2025 Period: Spring
Course: PRAC 6645
Instructor: OYEWOLE, Daniel
Field site: KENYATTA BLACK COUNSELING TX
Date Saved: 3/5/2025 9:37:06 PM Last Edit: 3/5/2025 9:37:05 PM
Notes: Second Week: 3/3/2025 to 3/7/25
1.
Neurodevelopmental Disorder
C.N., a 16-year-old female diagnosed with ADHD with
Hyperactive Disorder, and her mother attended a counseling
session today. Supportive BTC psychotherapy was used to
address C.N.’s behaviors and hyperactivity symptoms. The
client reported experiencing several challenges, particularly
with difficulty concentrating in class and completing both
household chores and school assignments. A contract was
Student Notes created, along with specific strategies, to help C.N. manage
her ADHD and associated symptoms. Both C.N. and her
mother agreed to the proposed strategies. No medication
was prescribed at this time. A follow-up session is planned
for one month. The client and her mother were informed to
call 911 or visit the nearest emergency crisis center if
symptoms worsen, and they acknowledged their
understanding of this information.
2. Substance-Related & Addictive Disorder
3. F.J., a 65-year-old male with Opioid Use Disorder, participated in an
individual therapy session. Motivational psychotherapy was used to
address additional issues related to his opioid use. The client
shared that he faces multiple challenges, including back injury pain
Student Notes and unresolved childhood trauma, both of which are contributing
to his opioid use disorder. A treatment plan was developed,
including specific strategies to help F.J. manage his condition and
related symptoms. F.J. agreed to follow the treatment plan. A
follow-up session is scheduled for one month. The client was
, advised to call 911 or go to the nearest emergency crisis center if
his symptoms worsen, and he confirmed his understanding of the
information and the treatment plan.
4.
Diagnosis Anxiety Disorder
C.M., a 78-year-old male diagnosed with Generalized Anxiety Disorder (GAD), engaged in
an individual therapy session. Cognitive Behavioral Therapy (CBT) techniques were
utilized to address his anxiety and associated symptoms. The client reported
experiencing challenges such as insomnia and depression, which contribute to increased
Student anxiety at times. A comprehensive treatment plan was established, incorporating specific
Notes strategies to assist C.M. in managing his condition and related symptoms. C.M.
consented to adhere to the treatment plan. A follow-up session is scheduled for one
month. The client was informed to contact 911 or visit the nearest emergency crisis
center if his symptoms deteriorate, and he acknowledged understanding of this
information and the treatment plan outlined.
5.
Trauma & Stress-Related Disorder
T.D., a 12-year-old female diagnosed with Post-Traumatic Stress Disorder (PTSD)
stemming from childhood trauma, attended an individual therapy session
accompanied by her mother. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
techniques were employed to address T.D.’s PTSD and related symptoms. Both T.D.
and her mother reported challenges including social anxiety, panic attacks, and
Student depression, which at times exacerbate her PTSD symptoms. A comprehensive
Notes treatment plan was developed, incorporating specific strategies to assist T.D. in
managing her condition and associated symptoms. Both T.D. and her mother agreed
to adhere to the treatment plan. A follow-up session is scheduled for one month.
They were informed to contact 911 or visit the nearest emergency crisis center if her
symptoms worsen, and both acknowledged understanding of this information and the
outlined treatment plan.
6.
Anxiety Disorder
, J.J. is a 32-year-old Caucasian woman with generalized anxiety disorder. She participated
in individual therapy. She reported excessive and unrealistic worry, restlessness, fatigue,
shakiness, palpitations, shortness of breath, dry mouth, feeling on edge, trouble
Student concentrating, and difficulty sleeping. She practiced deep breathing exercises,
Notes progressive muscle relaxation, mindfulness meditation, and cognitive restructuring. She
was educated to call 911 or visit an emergency crisis center if her symptoms worsened or
if she had suicidal thoughts. She understood this information. J.J. accepted the therapy
plan and will follow up in four weeks.
7.
Personality Disorder
O.J. is a 44-year-old African American male diagnosed with borderline personality
disorder (BPD). He has persistent feelings of emptiness. He struggles with excessive
spending, substance misuse, reckless driving, and binge eating. He often feels unjustly
treated and believes others are untrustworthy. He has experienced childhood trauma.
Student
The patient and his family agreed to use dialectical behavior therapy (DBT) to help
Notes
regulate emotions and relationships. They also agreed to schema-focused therapy to
address negative thought patterns. O.J. was educated to call 911 or visit an emergency
crisis center if his symptoms worsened or if he had suicidal thoughts. He will be
reassessed in one month.
8.
Trauma & Stress-Related Disorder
The patient is a 17-year-old female diagnosed with PTSD and childhood trauma. She
visited the clinic with her mom for counseling. The patient is willing to work on
change and understands the problems caused by her mental disorder. Trauma-
Student focused therapy will be used as part of her treatment. This therapy involves talking
Notes about the traumatic event, addressing mistaken beliefs, and managing anxiety.
She/Mom was educated to call 911 or visit an emergency crisis center if her
symptoms worsened or if she had suicidal thoughts with verbalized understanding.
Follow up appointment scheduled in a month.
9.
Trauma & Stress-Related Disorder
, The patient is a 62-year-old Vietnamese American male. He came to the clinic with a
diagnosis of grief and loss. He feels guilty that he didn’t do enough for his lost loved
one. He also believes unreasonably that he contributed to the death. The patient is
committed to being open and honest while working with the therapist to reach his
Student
therapeutic goals. Cognitive behavioral therapy (CBT) and art and memory books are
Notes
used to help him change negative thoughts and behaviors, process his feelings, and
remember the deceased. He was educated to call 911 or visit an emergency crisis
center if his symptoms worsened or if he had suicidal thoughts. The patient will
return in a month.
10.
Trauma & Stress-Related Disorder
M.Z. is a 55-year-old Asian American female grieving the loss of her spouse. She
attended counseling with her daughter. She struggles with loss, poor concentration,
tearfulness, and confusion about the future without her spouse. The patient and her
Student daughter agreed on the treatment plan. Empathetic listening and life review therapy
Notes were used to create a safe space for M.Z. to discuss her feelings and review past
achievements and conflicts. She was educated to call 911 or visit an emergency crisis
center if her symptoms worsened or if she had suicidal thoughts. A follow-up
appointment is scheduled in one month.
11.
Anxiety Disorder
1. T.C., a 40-year-old African American male, came in for a follow-up individual
counseling/therapy session to address difficulties with focus and heightened anxiety,
which are linked to family and work transition concerns. The client has a prior diagnosis
of anxiety disorder and is not currently taking any medication. Struggles with family
matters and adjusting to new responsibilities at work have contributed to increased
anxiety, difficulty concentrating, and challenges in decision-making. Several factors were
identified as contributing to conflicts both at home and in the workplace, and solutions
Student were developed. The client will continue individual counseling and therapy as planned,
Notes using Acceptance and Commitment Therapy (ACT) to manage the work transition and
improve cognitive functioning. The patient agreed to the treatment plan and expressed
understanding. A follow-up is scheduled in one month. MME: The client is a 40-year-old
African American male who appears his stated age. He is alert, awake, and oriented to
person, place, time, and situation. He reports feeling depressed and anxious, with
increased anxiety and focus issues related to job transition and family problems. The
client is neatly dressed and well-groomed. Speech is clear, coherent, and normal in tone
and volume, with no signs of abnormal motor activity. He expressed indecisiveness and
