Name: Maria Rasheed
Roll no: L1F20MSSY0029
Child Placement
Mam Momina
Biodata:
Name of client: M.A
Father’s name: A.M
Gender: Male
Age: 22
Birth order: 2nd
Education: 3rd class
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.A is 22 years old, unmarried male. His birth order is 2nd. He has 1 elder and 1 younger
brothers. His father is government employ. His mother is housewife. He lives in Lahore. He
belongs to middle socio-economic status. He is Sunni Muslim.
Referral source:
The client was referred for the purpose of assessment and management.
Presenting Complaint:
Stubborn
Aggressive
Problem in learning
Loss of interest in activities
Sleep Disturbance
Communication deficit
Interview Information:
The client had some problem by birth, his colour was blue at the time of birth due to oxygen
deprivation. According to mother, the client has major problem in learning. His milestones
were delayed. He does not show interest in activities. He is slow and stubborn and sometimes
becomes aggressive with younger brother. Most of the time he remains silent an uninterested
in talking or anything. Sometimes he plays with brothers only when he wants to.
According to teacher, the client sits silently in class. He also has some attention problem and
do not participate in any work or activity. Client respond to someone only when he wants to
other wise does not pay attention.
Test Administration:
Informal:
The client was not so cooperative & speech of the client was poor. His appearance was tidy
and his sitting posture was appropriate. Client was stubborn. His orientation according to
time, date and place was not appropriate.
Formal:
VABS
Psychological Evaluation:
Adaptive behavior composite indicates that the client is low.
Tentative diagnosis:
319 (F70) Intellectual Disabilities, Mild,
Recommendations:
Follow up sessions
Activity participation
Reassessment after 6 months
Speech therapist
Treatment Plan:
Name of client M.A
Age 22
Presenting complaints Stubborn
Problem in learning
Loss of interest in activities
Aggressive
Sleep Disturbance
Communication deficit
Test administered VABS
Tentative diagnosis 319 (F70) Intellectual Disabilities, Mild,
Goals of therapy 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
Main therapy BT
Play therapy
No. of sessions planned: 12 Rapport building
Psycho-educate client and family
Clinical interview
Test administration
Work focusing
Termination phase
Engaging in therapy interventions
Follow up sessions
