Case Study
Patient Demographic: Initial Intake: Age: 28 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Couple
Mental Status Exam: The couple appear to be their stated ages with positive signs of self-care related to hygiene and dress. Both individuals appear overweight for height, and John appears to visually be categorizable as obese. Both individuals presented with congruent affect to their stated moods. Neither demonstrated retardation, spasticity, or hyperactivity of motor activity. The couple present as cooperative, open, and forthcoming, though each frequently looks at the other and confirms that the information they are presenting individually is accurate. Jane is noted to be caregiving of and highly empathetic to John. John is noted to respond appropriately to Jane’s statements. Neither presents with reports of suicidal ideations, thoughts of harm to self or others, or difficulties with memory, judgement, or concentration. 
Presenting Problem: You are a counselor in a private practice setting.  Your client, Jane, is 28 years old and presents with her spouse, John, a 24 year-old Hispanic male for “problems communicating.” The couple report that they have been married for one year after cohabitating for one year prior to marriage. Immediately after their marriage they began trying to become pregnant. They state they sought help from a specialist after several months and on learning that some degree of infertility existed, Jane began hormone therapy. Jane notes that it was soon after this time that the communication problems between them began. She tells you that it was at this point that she and John realized that they may not be able to have a biological child together. John acknowledges that Jane has tried many times over the last year to bring up this topic for discussion, but he chooses not to engage her.  He tells you that he tends to believe that “if I don’t think about it, it will probably go away.” Jane agrees with John and reports that over time, the couple have talked less and spend much less time together. John agrees and says that sometimes “I may not say more than five words to Jane in a day.”  Jane reports that they have not been intimate in over two months. When completing the intake paperwork, John endorsed no problems on any symptom criteria. Jane reported “serious” problems with “feeling sad, loss of interest in things she previously enjoyed, crying spells, and stress. She reported “moderate” problems with “feelings of worthlessness, anxiety, loss of appetite, and sleep disturbance. The couple states they were to sign divorce papers last week but made the decision to try counseling first. Neither has participated in counseling previously.
Other Contexts: Family History:
The couple currently live with Jane’s 10 year-old son from her previous marriage and Jane’s 75 year-old grandfather, for whom the couple provide care. Jane owns and operates a small shop, is completing her bachelor’s degree, cares for her grandfather, and parents her son, who is heavily involved in baseball. She describes a history of hypothyroid disease though is no longer taking medication as her disease is now controlled with diet and exercise. She reports taking an antidepressant for two years, approximately seven years ago. She currently is taking Provera and Clomid for infertility and states these have had a noticeable effect on her mood. John reports this is his first marriage and he has no children from prior relationships. He was laid off two years ago and has been working in his uncle’s business, but the family has no insurance. He is actively involved in caring for Jane’s son and grandfather. He reports a history of high blood pressure. Prior to their wedding, John states he experienced irritability, agitation, difficulty sleeping due to “thinking about things” and worry. He was prescribed an SSRI and took this for six months. He tells you it seemed to help but he discontinued it 8 to 9 months ago. He reports that his doctor said his anxiety might have been because of his high blood pressure.

Question: Which is the most appropriate action when referring a client to another provider?
(A): Make a copy of the client's full chart and give it to the client to take to the provider
(B): Have client contact referral and sign a release of records when completing intake forms
(C): Telephone the new provider and give client's name, contact information, and request provider reach out to schedule an appointment, but do not give diagnosis
(D): Have client sign release of records then send letter to referring provider with client summary

Correct Answer: Have client sign release of records then send letter to referring provider with client summary
Explanation: Having the client sign a release of records while your office facilitates connection between the referring and referral provider. The referring provider then can send a letter introducing the client, the reason for referral, and contact information. This minimizes miscommunication between the client and referral provider and may facilitate getting John into the provider more quickly. Confidentiality rules require that a counselor never divulges any identifying information about a client, even for referral, without a client's signed consent, so calling without that form would be inappropriate. You can have the client make an appointment and sign a release at the referral source's office, however, without the consent, the process could be delayed. Additionally, having signed the consent, the client is more likely to follow through with scheduling an appointment, particularly if contacted by the referred provider. Counselors do not provide clients with a complete chart. Upon request, clients may review their charts with a counselor and may request copies of progress notes. However, therapy notes are not shared with the client or when records are requested. Therefore, the correct answer is (C)
Competency: professional practice and ethics