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Describe the client (without violating HIPAA regulations) and identify any pertinent history or medical information, including prescribed medications.

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Paper Instructions:

select a client whom you observed or counseled this week. Then, address the following in your Practicum Journal:
•    Describe the client (without violating HIPAA regulations) and identify any pertinent history or medical information, including prescribed medications.
•    Using the Diagnostic and Statistical Manual of Mental Health Disorders, 5th edition (DSM-5), explain and justify your diagnosis for this client.
•    Explain any legal and/or ethical implications related to counseling this client.
•    Support your approach with evidence-based literature.


The client is a 27-year-old female white DX with psychotic disorder alone for the therapy session. She lives with her mother after her father passed away from a motor vehicle accident. Appear older than stated age, not well-groomed hair not made, alert orient to person place and time. Cooperative and maintained good contact. The client reports she still hears voices since her last session.  Client having difficulty concentrating and focusing on one task. Loss of interest in personnel hygiene and having any relationship. She reports that she still hears the voices of her father and not to trust them and tries to ignore them. Cognitive behavior therapy was used in the therapy session to help the client change his thinking behavior and make gradual permanent changes to better-managed symptoms and improve the quality of life. Follow up care was set for the next session

233 Words  1 Pages
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