Name: Maria Rasheed

Roll no: L1F20MSSY0029

Child Placement

Mam Momina
Biodata:
Name of client: M.S
Father’s name: M.S
Gender: Female
Age: 21
Birth order: 1st
Education: Nil
Marital status: Single
Case: 3
Date of assessment: 8,10,12,14,16,20-9-2021, 1,4,6,8.11,13-10-2021
Examiner: M.R

Identifying Information:
M.S is 21 years old, unmarried female. Her birth order is 1st. She has 2 younger sisters. Her
father is a government employ. Her mother is housewife. She lives in Lahore. She belongs to
middle socio-economic status. She is Sunni Muslim.

Referral source:
The client was referred for the purpose of assessment and management.

Presenting Complaint:
Headache
Stubborn
Problem in learning
Loss of interest in activities
Hesitant
Communication deficit

Interview Information:
The client had some problem by birth. She was admitted for more than 2 weeks in hospital.
Later on, when she was 3 months old, she got typhoid which her affects badly. She is
stubborn, hesitant and deficit in learning and remembering. Her mother reported that her
pregnancy period was normal and her milestones were not normal. Her mother also reported
that they consulted physiotherapist and speech therapist also after which she was able to get
admission in school of special needs and now, she is able to do her daily living things to
some extent without help.
According to her teacher, she is stubborn and has learning deficits. She is unable to learn
alphabets even. She does not socialize with people and has communication deficits. She
listens attentively but has deficit in learning and memory. She sometimes fails to reason some
points, in problem solving and abstract thinking.

Test Administration:
Informal:
The client was somehow cooperative & speech of the client was poor. Her appearance was
untidy and her sitting posture was appropriate. Client was hesitant very much. Her orientation
according to time, date and place was not appropriate.

Formal:
She was unable to perform neurological test because her visual motor index was very poor.
Adaptive scale shows that her score in daily living domain was average and in socialization
and communication domain she was low.

Tentative diagnosis:
319 (F70) Intellectual Disabilities, Mild,

Recommendations:
Follow up sessions
Activity participation
Reassessment after 6 months
 Case Formulation

Personal factors: M.S Family Factors:

By birth issue Supportive Family

Psychological
Assessment:
Management:
Presenting Complaints:
After assessment the
strengths and weaknesses Therapies used:
Headache
that concluded are as  Behavior therapy
follows: Stubborn  Group therapy
Weakness: Problem in learning Following skills were
 Socialization worked:
Loss of interest in
 Poor memory  Cognitive skills
Strength: activities  Socialization skills

 Motivation Hesitant
 Cooperation
Communication deficit
Case Conceptualization:
Client is 22 years old, female who lives in Lahore. Presenting complaints were Headache,
Stubborn, Problem in learning, Loss of interest in activities, Hesitant, Sleep Disturbance.
According to psychological evaluation, the client was suffering from Intellectual Disability
(Mild).
According to bio-psychosocial perspective, there are biological, psychological and social
aspects that leads to mental health problems and complaints. In this case, the biological factor
as a predisposing factor is that there was some complication at the time of birth. Her delayed
milestones were considered as precipitating factors. Very low IQ served as perpetuating
factor.
Treatment Plan:
Name of client
Age
Presenting complaints
Test administered
Tentative diagnosis
Goals of therapy
Main therapy
No. of sessions planned: 12
M.S
21
Headache
Stubborn
Problem in learning
Loss of interest in activities
Hesitant
Sleep Disturbance
Communication deficit
no
319 (F70) Intellectual Disabilities, Mild,
Short Term Goals:
To build rapport
To make client interact with others
Long Term Goals:
To make focus on work
To make client able to socialize
CBT
Play therapy
Rapport building
Psycho-educate client and family
Clinical interview
Test administration
Work focusing
Termination phase
Engaging in therapy interventions
Follow up sessions
Session Plan:
Session 1
Target Client’s interview
Rapport building
Therapeutic intervention Rapport was developed through active listening &
unconditional positive regard. Client’s history and data was
taken.
Outcomes Initiate rapport building and history taking

Session 2
Target Client’s interview
Rapport building
Therapeutic intervention Rapport was developed through active listening &
unconditional positive regard. Client’s history and data was
taken
Outcomes Rapport was built and history was fully taken
Session 3
Target Psycho educating the client
Therapeutic intervention Client was psycho educated about his disorder involving
awareness regarding triggers, coping with stress & about the
nature and types of worries that causes this condition.
Outcomes Client got aware of her stress and triggers.