Sample Medical Diagnosis

Counselor: Roberta Jones, Charlotte, N.C.

Client Name: Elizabeth Smith
Age: 44
Presenting Problem: Depression related to long-standing marital distress, with physical and verbal abuse

Dates Seen: January 10, 2003; January 17, 2003; February 1, 2003

Counseling Technique used:
Natal and Marital Archetypal wheels with interpretation.

Outcome:
The client realized after these sessions that she was continuing a Rescuer and Victim role that has plagued her most of her life. She reported on February 15, 2003 that she had removed herself to a halfway house for abused women and was seeking a divorce.
I contacted her on October 19, 2003 for follow-up; she has completed her divorce and feels free of depression.

A copy of this form was sent to her for signature and returned.

Client Signature:
I agree that the above report is accurate.

Signed: Elizabeth Smith, 1708 S. Third Ave, Charlotte, N.C. 28201
Date:
October 22, 2003