Client Summary

Dates of Assessment: February 23, March 1st, March 8th, March 15th
Assessor’s Name: Amanda Collins
Client’s Name: Lulu (she/they)
Demographics: Lulu is a 25-year-old Chinese American, Latin-American, bisexual, nonbinary
woman assigned male at birth. She is currently employed by her father at a game development
business and is trying to “break into” the screenwriting industry. She is in an open relationship
with a trans male (Partner A) and a non-binary person (Partner B). Client reports that she is
atheist but will incorporate spiritual practices such as tarot card reading if she sees them as
beneficial. She is also interested in philosophy.
Referral Source: Client referred herself to the LGBT Center at the beckoning of Partner A.
Presenting Problem: Lulu reported distress at not knowing where she will be in five years and
wants to create long-term goals and motivation for herself. Lulu has a history of major
depressive disorder that includes symptoms of low motivation, low mood, and thoughts that she
would be better off dead.
History: Client reports that her symptoms of anxiety became more pronounced after the death of
her aunt last year. Client reports that her aunt’s death motivated her to reconnect with her family
while there is still time and live her life more authentically. The client also wants to move in
with Partner B and which is motivating her to care for her mental health.
Risk Factors:
● Lulu reported having suicidal ideations since she was a teenager. Specifically, she
reports martyr fantasies (e.g., getting caught in an explosion while saving a group of
underserved people “Terminator style”) and a belief that she will experience a violent
death like that of her grandfather who was shot in a gang shootout. During one session,
the client made mention of buying a firearm for protection and giving it to a friend so she
wouldn’t be tempted to hurt herself with it. The client later decided not to purchase a
firearm.
● Client also reports a history of self-harm in which she would deny herself physical safety
or comfort or expose herself to cold temperatures. Client denies current self-harm.
Client denies suicidal and homicidal intent or plan.
● Client was once escorted out of a college class by a police officer after she made a joke
about killing herself in class. Client originally described this event as a source of trauma
in her life, but she also denies that the incident had a significant impact on her.
Psychosocial & Family History
● Lulu had a previous diagnosis of Major depressive disorder. Client reports that her mom
has bipolar disorder and that she often feels as if she was “walking on eggshells” her
 entire life. Clients’ parents are divorced. Client describes her relationship with each
parent as “loving and anxious.”
● The client’s mother is a doomsday prepper and would often have the client help her
create disaster kits to ease her anxiety. Client continues to build disaster kits to ease her
environmental anxiety and fulfill her value of community service.
Psychiatric History
● Lulu started hormone replacement therapy in August 2021.
● Lulu has been on 50mg of Zoloft daily for depression and gender dysphoria since 2021.
She reports that Zoloft has lowered her libido which has caused her frustration. Client
reports that she stopped taking Zoloft at one point in the past and her anxiety increased.
Diagnosis
● Lulu has a moderate episode of recurrent major depressive disorder (F33.1) and
unspecified anxiety (F41.9). This was the diagnosis given to her by her psychiatrist. I
agree with her depression diagnosis as she exhibits symptoms of depressed mood,
fatigue, feelings of worthlessness, recurrent thoughts of death, and indecisiveness almost
every day for a two-week period, she is not currently using any substances, and her
symptoms have caused impairment in her social and work life. Lulu also shows
symptoms of anxiety, including the fear that something awful might happen, but she does
not meet full criteria for a specific anxiety disorder.
ORS/SRS (or C-ORS/C-SRS) Outcomes
Summary of Data Gathered and Client Responsiveness
Lulu was responsive and open to engaging with the ORS and SRS assessments. She
frequently asked questions regarding how to engage with the assessment and would write down
explanations for her scores in her journal. The client completed the assessments after each
session and emailed them to me the following day. In the following sessions, we’ll discuss the
results in depth. I eventually limited our assessment discussions to 15-minutes as our first
attempt to review the results took up an entire session leaving us little time to create action plans
for the client’s therapy goals. In the four assessments we reviewed together, the client scored 23,
30, 32, and 38 respectively on the ORS and 36.5, 38,38, and 38 on the SRS.
Clinical Hypothesis
My hypothesis for this client was that she was generally dissatisfied with most areas of
her life because she was dwelling on feelings of hopelessness and anxiety without mindfully
engaging in actions that aligned with her personal values. Before we started the assessment, our
sessions focused on Lulu’s belief that she was not taking full advantage of the opportunities that
came her way, that she was not contributing to creating a better society, and that the only way
she could add satisfying value to the world was through her death. In our first assessment
review, Lulu reported that their social life, which includes work and school in the context of the
ORS, felt boring and meaningless as they believed they weren’t using her talents to improve the
world. This information was reflected in her social score which was a 6 during the first two
assessments. Additionally, Lulu’s lowest score, a 5, was in personal well-being which reflected
her depressed and anxious state of mind at the time.
I also predicted that Lulu would score our sessions together as a 7 or 8 as she disclosed
that explaining her ideas to therapists frustrated her in the past, and I often found myself having
to ask her to re-explain her thoughts to me. I also believed that she would say that she had not
worked on what she wanted to work on as most of our sessions consisted of her musing about
life rather than action plans to create change in her life.
Implication for Client’s Progress
Over the course of our four sessions, Lulu’s scores in all areas of the ORS gradually
increased. Specifically, Lulu’s individual well-being had the greatest change from a 5 to a 9.
The implication for her progress and diagnosis is that once the client started planning a future
that aligned with her personal values, she felt more hopeful and confident in her actions.
Additionally, Lulu might feel more hopeful as she engages in actions that she finds meaningful.
Client-Therapist Working Relationship
There are a few implications that come to mind when the client and I are working
together. When I addressed our working relationship with Lulu, I noticed she tended to repeat
that she felt “generally heard” and that she was receiving tools she needed to solve her problems.
Specifically, she said listing out her top 5 personal values and defining them in her own words
gave her clarity when creating plans of action. Lulu also mentioned that she has a tendency to
resort to “people pleasing” when she believes her true thoughts will cause trouble for another
person. I addressed this directly in our session by asking Lulu if her high scores were an attempt
to appease my feelings. Lulu then elaborated her initial response saying that I confirmed
thoughts she hadn’t voiced in session and promised to tell me if I say something that upsets her.
Treatment Modalities
The implication of the treatment modality is that it works well with the client’s needs. I
initially expected Lulu to voice discontent with the structure of our sessions as I tended to make
them more free-flowing, and she had initially indicated she wanted more structure in therapy. In
our first two sessions, Lulu shared that she was satisfied with the structure of sessions because it
helped her sort out thoughts that had sat with her throughout the week. Then, in our fourth
session, which took place after Lulu asked to review her values and create action plans, she
voiced that she would like to change our sessions to a goal-oriented format. This shows that
Lulu is engaged with the therapy process and aware of the structure she needs for growth.
Personal Reflection
Using this assessment helped me open up conversations with my client about our sessions
and their personal progress in therapy. In particular, I found the scales helpful in visualizing
where the client’s state of mind and satisfaction with therapy was at that given moment. It also
pointed out certain areas of the client’s life that needed attention and strategize to support them
in therapy accordingly. If I were to do this assessment again, I think I would distribute it every
four sessions to serve as a “checkpoint” in therapy. I have one client in particular who shared
that he feels more motivated to follow through on tasks when he can visibly measure his
progress. I think the ORS and SRS would fill that need.