Case Presentation

Basic Data

Client Demographics

The client selected for this presentation will be referred to as Marcus to protect his identity. Marcus is a 33-year-old African American male who identifies as male and uses he and him pronouns. He comes from a lower socioeconomic background and is currently unemployed, which he noted as one source of his stress: Case Presentation.

Marcus completed high school but did not pursue higher education due to early substance use and imprisonment in his twenties. He seeks to build a more stable life and is interested in getting his general educational development and pursuing trading.

Presenting Problem

Marcus presented to counseling at Serenity Recovery Centers following a court-mandated referral due to a second driving under the influence (DUI) charge within five years. He stated that he initially did not feel he had a problem but began questioning his substance use after losing contact with his daughter and facing possible jail time. While he was resistant at first, he shared during the intake session that he wanted to make changes to stay out of jail and possibly regain custody of his daughter. His presenting problem is centered around substance misuse, strained family relationships, and low motivation.

Social Context

In our initial conversation, Marcus described a strained relationship with his family, particularly with his mother and younger sister, with whom he used to live. He has a four-year-old daughter but has not seen her in over a year due to a protective order filed by the child’s mother. He stated that he has no close friends and often feels isolated.

Marcus admitted that his former peer group consisted of individuals who also misused alcohol and drugs, which contributed to his behavior. He feels unsupported and is uncertain about rebuilding trust within his social circle.

General Impressions of the Client

Marcus presented generally untidily but was alert during the first session. He wore wrinkled clothing, had minimal eye contact, and seemed fatigued. His mood was subdued, and he often answered questions in a flat, almost detached tone, suggesting possible depressive symptoms.

His effect was restricted, and while he did not express strong emotions verbally, his body language indicated discomfort. He initially appeared guarded but gradually opened up as rapport was built. Marcus is a voluntary client who agreed to attend sessions to comply with court requirements, though his motivation for personal change is slowly emerging.

Initial Session Presenting and Underlying Problem

Client’s View of the Problem

Marcus disclosed that he believed he was attending counseling simply because the court required it. He mentioned that he did not see himself as someone with a serious substance abuse problem and expressed resentment about being labeled an “addict.” When asked why he thought the court-mandated counseling, Marcus said it was “just something they do to make it look like they are helping.”

However, when asked about how alcohol had impacted his life, he admitted that it contributed to his legal troubles and the loss of contact with his daughter. His perception of the problem was defensive but had hints of self-awareness.

Counseling Dialogue

Our discussion started with some intake questions and evolved into reflections. When asked the question, “What brings you here today”? Marcus said, “I have to be here”. I responded, “It seems you came here because someone decided that for you.” He nodded and said, “Exactly.”

When I asked, “Do you think counseling can help in any way?” he paused and shrugged. “Maybe. I suppose I have screwed things. Might be too late, though.”

With reflective skills, I said, “It seems that you are not quite sure about what can be done, but you are optimistic about a second opportunity.” This moment made him want to reveal extra information.

Presenting Problem

The most obvious presenting problem was alcohol dependence, which brought him repeated legal trouble and significant personal losses. His substance use problem had a direct effect on his legal situation and his negative relations with his daughter. Apart from this, Marcus also indicated symptoms of depression and low self-esteem. This was clear when he said, “ I am tired of losing everything,” thus an underlying emotional problem other than his substance use disorder.

Client’s Goals

When Marcus was initially asked about his goal for counseling, he was vague and noncommittal, stating that he wanted to finish probation and move on. His responses initially focused on fulfilling external requirements rather than personal growth. However, as the session progressed and rapport deepened, Marcus began to express a more profound desire to reconnect with his daughter and not mess up again.

Marcus also stated that he wanted to build a more stable life and was interested in getting his general educational development and pursuing trading. This shift indicated the emergence of internal motivation, which we identified as a key element to focus on in future sessions.

Multicultural Aspects and Conceptualization

Several multicultural considerations were noted, including Marcus’s experience as a Black man navigating systemic injustice, imprisonment, and stigma in accessing mental health services. He expressed mistrust of counselors, stating, “They all just want to write stuff down and judge.” Understanding the cultural and systemic context helped to guide my approach to building trust.

In conceptualizing his case, Marcus’s underlying problem may be unresolved trauma related to childhood neglect and his current feelings of social disconnection. While no formal diagnosis was made in the first session, symptoms aligned with alcohol use disorder and depressive features, which are to be explored further.

Interviewing, Informed Consent, and Confidentiality

 Agency Intake Process and Informed Consent Protocol

At Serenity Recovery Centers, the intake process begins when clients are referred or called to schedule an appointment. They are typically asked to provide basic demographic information over the phone. Upon arrival, they complete a handwritten intake form that includes medical history, substance use history, legal status, and emergency contact details (Serenity Recovery Centers, 2021b).

A clinician reviews this form before the session begins. As a student counselor, I was introduced to Marcus at the beginning of the session, and he was informed of my status as a trainee working under supervision. He was also informed of the confidentiality policies and signed a standard consent form with space for my personalized student disclosure.

Informed Consent

My approach to counseling is grounded in a person-centered framework that emphasizes emotional awareness, client autonomy, and empathy. I believe that people change through understanding their emotions and the thoughts that drive their behaviors. My focus is on helping clients explore their feelings, examine their beliefs, and set goals to develop healthier behaviors.

As a counselor in training, I strive to create a safe space where clients feel seen and heard without judgment. My goal is not to fix clients but to support them in making choices aligned with their values.

Counseling is a process that may bring up difficult emotions as clients begin to address things they may have avoided for years. While it is not always easy, I believe it can lead to meaningful change and personal growth. During sessions, clients may experience sadness, anger, or confusion (Muntigl, 2020). These emotions are part of the healing journey.

Sessions are a collaborative space, and clients are encouraged to speak openly. Participation is voluntary, and clients may choose to pause or end counseling at any time. The space we create together is confidential, supportive, and meant to promote positive change.

Confidentiality and Duty to Warn Based on Tennessee State

Confidentiality refers to the ethical and legal obligation of the counselor to protect client information shared during sessions. At Serenity Recovery Centres, clients are informed during intake that what they discuss in counseling remains private, which helps build trust and encourages openness (Serenity Recovery Centers, 2021a). However, according to Appel (2022), there are specific circumstances under which confidentiality may be lawfully breached. These include when a client discloses intentions to harm themselves or others, reports abuse or neglect of a child or vulnerable adult, or when legal authorities subpoena counseling records.

In Tennessee, licensed counselors are granted privileged communication, which protects client disclosures from being used in court (Rule 501: Privileges Recognized Only as Provided. Tennessee Administrative Office of the Courts, 2025). However, this privilege can be overridden in situations where there is a risk of imminent danger to the client or another person. As a counselor in training, I am bound by the same ethical obligations and must consult my supervisor immediately in such cases.

The duty to warn requires that if a client makes a credible threat against another person, steps must be taken to notify the intended victim and relevant authorities. Clients are informed of these limitations clearly at the beginning of counseling to ensure transparency and foster an environment of safety and mutual understanding.

References

Appel, J. M. (2022). Breach of confidentiality. In Springer eBooks (pp. 113–120). https://doi.org/10.1007/978-3-030-91975-7_15

Muntigl, P. (2020). Managing distress over time in psychotherapy: Guiding the client in and through intense emotional work. Frontiers in Psychology, 10. https://doi.org/10.3389/fpsyg.2019.03052

Rule 501: Privileges Recognized Only as Provided. | Tennessee Administrative Office of the Courts. (2025). Tncourts.gov. https://tncourts.gov/rules/rules-evidence/501

Serenity Recovery Centers. (2021a, March 17). Privacy policy. Serenity Recovery Centers. https://serenityrecovery.org/privacy/

Serenity Recovery Centers. (2021b, May 8). Admissions. Serenity Recovery Centers. https://serenityrecovery.org/admissions/

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Unit 3 Assignment: Case Presentation – Initial Session

Case Presentation Outline: Sections A through C
This assignment requires you to complete sections A through C of the case presentation outline. You will select from one of your cases to complete this assignment. We suggest that you discuss with your site supervisor, which client would be appropriate for this assignment.

Please do not include the actual name of your client.

See the attached document for complete instructions and grading rubric.

HSV593 – Field Practicum I

Case Presentation Templates Guidelines
A. Basic Data (This section will accompany all of your case presentations.)

(Unit 1) Case Presentation: Initial Session -Clinical Skills and Interventions:

Relationship Building Skills

Include section A with your case presentation.
1. Pseudonym (Do not use client’s real name; you should be able to recall the name as you may use the same client later and we will need to be able to associate ongoing sessions and impressions.)
2. Age, Race, Gender. Social Economic Status
3. Grade level, education level

4. What brough the client into counseling. (Presenting Problem)
5. Information about the client’s social context-What does the client say about their relationship with family, friends, acquaintances.
6. General impressions of the client

a. Client appearance (physical appearance)
b. Client Mood (refers to sustaining overall presentation depressed, upbeat, melancholy. Can be concluded based on words, behaviors, and attitudes.)
c. Client Affect (refers to fluctuating changes in the client, i.e., happy, sad. It is a more subjective state based on observations)

d. Did the client feel at ease with counseling, apprehensive,
e. Voluntary or involuntary client. (Is the client attending of their own desire?) If not explain.

B. (Unit 2) Case Presentation: Initial Session-Presenting Problem and Underlying Problem
1. Provide a summary of the initial counseling session.
a. Discuss the reason for the client attending counseling. If involuntarily referral, discuss the client’s belief as to why they are at counseling. What is the client’s view of the problem or situation?
b. Provide an overall dialogue between you and the client.

c. What appears to be the presenting problem?
d. What goals did the client express about the problem? What would they like to achieve through counseling.
e. What are some multicultural aspects you believe may play a role in the counseling session?

f. Conceptualization: what underlying problem do you believe is the relevant factor here in the counseling session?
g. If relevant discuss the client’s diagnosis.

C. (Unit 3) Case Presentation: Initial Session-Interviewing, informed consent, confidentiality

Include section A with your case presentation.
1. Discuss your agency’s intake process. Do clients call over the phone first and provide basic information? Do you start with a questionnaire and work with clients?

How long is the form? Is this form automated or handwritten process?

Some forms are completed by clients online and the results are shared with the potential counselor. Is this a part of the process at your agency.

2. While the agency provides you with their form, there is a piece to informed consent that you can personalize. The client should know that you are a student or counselor-in-training.

You may have been introduced to this concept in the Professional and Ethics Orientation course. In the resource area is a few examples of informed consent.

3. Develop a two-paragraph informed consent about yourself. A) what is your theoretical approach or how do you believe people change

Do you focus on client’s: Affect (feelings) cognitions (thinking) or behavior (doing) B). What is your impression of counseling, does it work for everyone, is it a trusting process? C).

What should clients expect from counseling and during counseling sessions?

Will they experience various emotions? Will it be uncomfortable? How might they feel at the end of sessions? Can the client choose to stop at any time? Will this be a safe experience?

4. Confidentiality-What is confidentiality? Can clients talk about what occurs in the counseling session? Is it the same as privileged communication? Does your state give privileged communication to counselors?

Is it a legal provision given to clients, or an ethical behavior conferred upon our clients? Consider your state when answering this question. What are the limitations of confidentiality?

When can confidentiality be breached or broken? Discuss the duty to warn as it applies to your state. (Please indicate your state when you address this issue.)

Readings & Resources:

• Basic Counseling Skills
• Videos:
  • https://youtu.be/VD01e_k9m7Y
  • https://youtu.be/YQSxWEM3Q1M

Notes:

• field experience site:
  • Name of Agency: Serenity Recovery Centers
    • Full address: 1094 Poplar Avenue Memphis TN 38105
    • Website: serenityrecovery.org