Assessment and Report Writing in Counselling

Part A: Case Notes

Client Name: Robin

PRESENTING PROBLEM/S: Robin is experiencing an awareness about her current state of autonomy and is eager to learn more about herself. She is 29 year old woman who has a young son of 2 years old and her constant clashes with her husband regarding household and church have left her overwhelmed. She is in a state of rationalizing everything that is happening around her and is extremely tolerant of her husband’s temper and mood swings. Even though she is an opinionated woman, her views are pretty traditional and archaic.

History of Problem/s:

Robin is an extremely positive and bubbly individual who has an optimistic view of life. Perhaps, the only place where she is passive with her intellect is in questioning these age-old norms that limit her. Even though she is trying her best at being a new mom, she often feels guilty because according to her husband she is just sitting at home and not doing anything. Robin believes his perception over her own.

Relevant Personal and Family History:

Despite coming from a low to middle income family that constantly moved, Robin does not complain and is well aware of the reality. Her father is the minister at the local church and she has grown up with extremely orthodox views and perceives them to be true in all cases.

She was the eldest of all her siblings and knows how to compromise without being to nit-picky. But this has led to an increase in her tolerance that can often lead problematic situations about her emotional boundaries ( Bergoffen, D. B. (1999). Robin is extremely tolerant of her husband’s temper simply because she had seen her father in the similar manner while growing up.

Social and Occupational Factors:

Before she gave birth to her baby boy robin used to work at a bank. Robin says that she misses her colleagues and friends and not the work. A lack of ambition or purpose can be noticed which explains why she feels the end to discover herself (Dattilo, J et al ,1994). Other than the social constraints it is important for an individual especially a married woman who has only know orthodox views all her life, to find a sense of self.

Client Goal/s for Counselling (for Session And/or for Counselling, as Agreed with Counsellor):

The client wants to develop a sense of autonomy and self-worth to discover herself. To find her functions other than that of a mother and a wife are of extreme importance as robin has been rationalizing all that has been happening to her for the longest time. Robin is extremely clear about wanting appreciation and validation for the work she does which means she is ready to value herself and start being valued (Shackelford, T. K. 2001).

Other Details:

Finding an occupation or a part time job that she would like to do would help her gain control over her independent aspect of life. This will help immensely in self-discovery and help her find autonomy.

Summary/outcome of Session:

Self-discovery and engagement in activities that will help her understand her social and individual context with regard to society is of utmost importance. The client wants to develop a sense of autonomy, so the first step will be to remove the shackles of her current situation to get an insight about her likes and dislikes (Kandpal, E., & Baylis, K. 2019). It can be noticed that once robin is introduced to new ideas and perceptions, she can actually become curious about her she as an individual is supposed to evolve. To discover the utmost potential of oneself other than hats expected of them is the amin objective here.

Part B: MSE

  1. Appearance

    :The individual is well groomed and neatly dressed. She is of a large built has a friendly face and an extremely pleasant personality.
  2. Behaviour/psychomotor activity

    :The individual is alert. their attention span is good and they are able to focus and follow the conversation.
  3. Attitude toward examiner (interviewer)

    : extremely polite and agreeable. The individual had a jovial mood and can communicate about difficult things without getting too uncomfortable.
  4. Affect and mood

    : The individual is in a calm and conversational mood. She is indulgent and excitable without ever going overboard. She has a good sense of humour and extremely involved in a conversation.
  5. Speech and thought

: the individual has clarity of speech and thought. She was confident and opinionated without being impolite.

  1. Perceptual disturbances

    : The client uses rationalization and understanding to make sense of the orthodox family traditions she partakes in. She does try to make advances as a woman with regard to her career and roles but it is still deep rooted in old fashioned ideas. The stereotype and personal prejudice around gender discrimination affects her perception.
  2. Orientation and consciousness

    : The individual has certain vies that are bound by orthodox ideals. She has an active conscience but sometimes feels guilty for having her own opinion. She believes in gender roles and is comfortable with the loss of power and perceives it as normalcy.
  1. Memory and intelligence

: The individual is smart with a good sense of knowledge about things. She is intelligent and has a sharp memory where she can remember stories and details from her earlier years.

  1. Reliability, judgement, and insight

    :The individual has a lot of insights about gender roles and her judgment is clouded by old fashioned ideas bound by church and traditions. The individual appears to be responsible and reliable but her opinions on the role women can be a little demeaning due to lack of awareness and ignorance.

Part C: Case Formulation



Robin is 29 year old woman who is trying to find her individual identity outside the roles of a mother and a wife.

She is an extremely positive and sociable person who has somehow rationalised the orthodox ways of her family and life. her intelligences and opinionated nature are making her wonder about the limits of autonomy that she as a woman should cross.



Robin continues to rationalize and underplay the pressure of following gender roles as dictated by the male sin her family or the church. She believes in the pre conceived notions about how women should behave and continues to exercise a great amount of personal prejudice.


Predisposing factors

Her slightly sub servient nature that prevents her from look at things with a modern approach.


Precipitating factors

The work that comes with being a young mom , her idea of a good wife and an ardent church goer are leaving her overwhelmed. She is unable to get any personal time or to understand her own personality other than these roles that she is expected to perform.


Perpetuating factors

· Tendency to take up a lot more than she can handle

· Conformity to gender roles

· Tolerance when it comes to impolite behaviour from husband



The client is an intelligent individual in her late twenties who wants to discover herself without the pressure of reigns of family or church.


Potential (resources and protective factors)

Being married is potentially a protective factor, but we don’t have much information on the quality of her relationship.

Integrated and involved in her community and church

Strong family bonds

 motivated to change

Has good insight and observations

Part D: Treatment Plan

Client name: Robin

Summary of client’s overall presenting issue (single sentence):

  • The client is curious about her individuality and is trying to find a sense of autonomy different from hr family and church.

What are the client’s strengths that they can apply to their presenting issue?

  1. the client is extremely sociable and a very good conversationalist.
  2. the client is opinionated and strong headed about how she leads her life.
  3. the client has an optimistic temperament and can always see the bright side of things.

Treatment plan

Client issue/s – concerns, problem, mental health condition or risk e.g., abuse, suicidal ideation.

Client goals: what they want and when.

Intervention: how will you support the client to address their concerns, problem, mental health condition or risk e.g., abuse, suicidal ideation.

Rational for intervention: justify each intervention as a sound clinical practice.

1. Self-esteem issues

The client needs to develop more confidence about their roles and duties.

Suggestion for regular feminist therapy would be helpful.

A different perception that recognises the work she does on a daily basis will help her understand her stance and give her the confidence.

2. Development of individuality

The clients wants to understand her personality and discover who she is outside of the roles expected of her

The suggestion of getting part time job that gives her sometime to understand herself and her capabilities.

Finding some time in the day to sit by herself and journal even if it is for 15 minutes can be extremely helpful.

Recognizing one’s individual needs and requirements and their pursuit can be extremely empowering. This will provide the client some insight about who she is outside of her obligations and roles.





References for Assessment and Report Writing in Counselling

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Etc. etc.

Dattilo, J., Dattilo, A. M., Samdahl, D. M., & Kleiber, D. A. (1994). Leisure orientations and self-esteem in women with low incomes who are overweight. Journal of Leisure Research26(1), 23-38.

Bergoffen, D. B. (1999). Marriage, autonomy, and the feminine protest. Hypatia14(4), 18-35.

Kandpal, E., & Baylis, K. (2019). The Social Lives of Married Women Peer Effects in Female Autonomy and Investments in Children. The World Bank.

Shackelford, T. K. (2001). Self-esteem in marriage. Personality and Individual Differences30(3), 371-390.

Elliott, M. (1996). Impact of work, family, and welfare receipt on women's self-esteem in young adulthood. Social Psychology Quarterly, 80-95.

Remember, at the center of any academic work, lies clarity and evidence. Should you need further assistance, do look up to our Nursing Assignment Help

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