PART I (Due Day 7 of Week 4) 

Client age: 28

Client initials: KL

Client race or ethnicity: African American

Number of   sessions with client: 1

Self-identified gender: female

Presenting Problem

To understand the presenting problem, describe the client’s past and present. Be sure to address each of the following elements: 

· Demographic information KL is a 28 yr. old female who lives with her 8-year-old Daughter. 

· Employment History KL works part-time at Floor Décor as a helper.

· Relevant legal problems KL reports she does not have any legal issues.

· History of counseling KL shared that this is her first counseling session.

· Reason for seeking counseling, according to the client According to KL she reports having a mild intellectual Disability.

· Onset and duration of concern KL could not recall what age she was diagnosed.

· Frequency and intensity of symptoms of Mild Intellectual Disability.

· What the client wanted to improve KL is a concern with her daughter’s onset of ADHD. KL reports not having any concerns for herself, which she explains as being high functioning. 

Family Structure

Clients and their concerns are shaped by their family structure and stage of development. Be sure to address each of the following elements and their impact: 

· Family of origin and role within KL mention her mother, Father, Grandmother, Sister, Brother, Daughter, Aunt, and Grandfather.

· Family of choice if different and role within 

· Significant relationships/relationship patterns KL shared she and her siblings were raised by her grandmother and Grandfather.

· Children, marriages, and divorces KL has an 8-year-old daughter, and she did not report ever being married.

· Current living arrangements KL and her daughter reside in their own apartment.

· Major losses, and family traumas KL shared the death of an aunt in 2022 that she looked up to.

· Family mental health history Mother suffers from mental illness. But not her father.

· Family substance abuse history no history of substance abuse reported. 

· Family violence or abuse history no family violence reported.

· Stage of development impacts

· Developmental challenges KL has been diagnostic with mild intellectual disability.

Multicultural Considerations 

Clients and their concerns are shaped by a multitude of multicultural considerations and their intersectionality. Be sure to address each of the following elements and their impact: 

· Race or ethnicity KL identifies as an African American.

· Religion KL reports that as an adult, she does not identify with any religion but grew up as a Baptist.

· Ability/disability Intellectual disability

· Sexuality KL reports she is straight which is she identifies as a Heterosexual. 

· Socioeconomic status KL falls into the low Socioeconomic status.

· Military No military history reported.

· Criminal justice system No criminal justice system reported.

· Geographic influences KL has never lived anywhere else except Savannah in the South among African American people.

· Environmental factors KL’s environment is a contributing factor to the lifestyle she lives today as well as her decision making and the people in her community, she interacts with are of the same race.

· Experiences of oppression or marginalization KL reports she has experienced Oppression.

Narrative Summary 

Take a step back and, through the lens of your education to this point, work to conceptualize the big picture. Consider the influence of all the information in Part I. Consider how it has all culminated and impacted who your client is and their worldview. Within that context, consider the problem they presented with for counseling and address each of the following elements: 

· Describe your understanding of the problem. As a counseling student in training KL being diagnosed with an intellectual disability it clearly means she has limitations with her mental abilities which limits her intelligence, learning, and her everyday life skills. 

· Describe your observations of the client. I observed KL as being one of the higher-functioning individuals living with an intellectual disability she can handle her personal affairs with the help of others. 

· Describe your impressions of the client. To meeting KL, I did not know she had a mild intellectual disability because she articulates words very well, when communicating with her she held an intelligent conversation. KL loves her daughter and wants the best for her educational needs. 

· Describe any factors contributing to or reinforcing the problem. In denial about what she has been diagnosed with.

· Describe the purpose of the client’s behaviors. She fails to recognize she has a mild learning disability because KL states she can function with medication. She reported being on medication when she was younger.

· Describe themes and patterns that emerge or connect. KL Shared her mother has mental issues along with herself and her daughter. KL touched on one of her nephews but reported her sister is in denial and has not taken him to a doctor. KL described some of the symptoms she has been experiencing.

· Describe barriers to growth and coping. She fails to think she has a learning disability because KL reports she has ADHD which was not the case.

· Describe strengths, assets, protective factors, and signs of resilience. KL lives a long, respectful, independent, nurturing mother, and a good communicator. 

DSM–5 Diagnosis

It is of utmost importance to diagnose ethically and responsibly. You must consider all elements covered thus far not only in your understanding of the problem but in rendering a diagnosis. With this in mind, address each of the following elements: 

· DSM–5 diagnosis F70 mild intellectual disability

· Rationale for how the diagnosis was determined. When speaking with KL about her diagnosis and listening to her explain her own child’s diagnosis since she was recently diagnosed as I began to read my research I viewed the hypotheticodeductive style which involves proposing a differential diagnosis since KL thought she had ADHD but after viewing her assessment she exactly was diagnosis with mild intellectual disability therefore when reading hypotheticodeductive style it simply stated asking a question, using the answer to refine the differential diagnosis, asking another question, again refining the differential, and so on until a final working diagnosis is obtained. However, this could have been used to determine KL diagnosis. In addition, Clinical assessment by collecting information and drawing conclusions using observation with psychological testing. 

· Two other diagnoses considered, but not given I will have to say moderate Intellectual disability and borderline personal disorder. 

· Explanation for ruling out diagnoses not given. According to the text, Doctors rule out a diagnosis in order to determine the correct diagnosis.

· Mental health assessments or scales used. I feel KL was tested with the IQ score.

· Other assessments or scales that could be used. Neurological testing