Sample - Recs Review for Counseling Eval

REVIEW OF RECORDS

Johnny is a 16-year-old student who is currently classified as a 9th grader, after not having accumulated sufficient high-school credits to move on to 10th grade. He is currently taking a combination of 10th and 9th grade classes, with 9th grade classes being recovered via the high-school's online credit recovery system.

Available records indicate Johnny initially qualified for special education services in 2015, when concerns regarding lack of academic progress were brought up at school. The specific suspicion was related to learning disabilities at that time. An Initial evaluation for special education services was conducted, which included an assessment of behavior (FBA). Johnny was non-compliant and engaged in physical and verbal aggression with peers and adults in his school environment (refuse to participate, fall to the floor, crawl under desks, put fingers in ears, break and/or throw items in the classroom, turn over chairs, kick teachers, hit himself, threaten to kill teacher, cry, yell, and scream). A Counseling evaluation was conducted in conjunction with this Initial FIE. It was noted that Johnny declined to discuss any issues and triggers related to his emotional outbursts, and he declined the option of engaging in the counseling process at school. Although there appeared to be a need for counseling at that time, the student’s refusal was taken into account and counseling was not recommended, in favor of a behavior plan that would allow his teachers to support him through difficult outbursts and moods.

At the time of this assessment, Johnny’s cognitive and academic functioning were assessed with standardized instruments that compared his functioning with that of thousands of same-age and grade peers across the nation. His intellectual functioning was found to be in the average range, with standard scores ranging from 80 in Long-Term Retrieval (ability to quickly retrieve and use information already known) to 103 in Fluid Reasoning (ability to reason with abstract information, such as that found in math and sciences). Johnny’s academic skills ranged from 40 (below the 1st percentile as compared to peers) in Writing to 80 (Low Average) in Math Reasoning. Based on data gathered through this initial evaluation, a recommendation for special education services under Specific Learning Disability was made for Basic Reading Skills, Reading Comprehension, Math Calculations, and Written Expression. He began receiving specialized instruction for reading, writing, and math, along with accommodations in the classroom and other specialized supports. A Behavior Intervention Plan was also developed and recommended, to address his tendency to engage in problematic behaviors when not wanting to or not able to perform well in the classroom.

It should be noted initial FIE information indicates a diagnosis of ADHD for Johnny. This was not follow-up on, and was not mentioned again at the next re-evaluation.

Johnny was re-evaluated in 2018. He continued to meet criteria for services. The evaluation noted that he did not have any office referrals for the school year 2016-2017 and for the school year 2017-2018 (Evaluation date was 01/26/2018). The evaluation noted the following teacher input at the time: Johnny could follow classroom directions pretty well and got along with peers with very little conflict, if at all. He was kind, polite, and respectful. He did struggle with academics and became frustrated easily with how difficult some tasks were, and he cried instead of asking for help. It was noted that he has the tendency to quickly say, “I can’t” or “I don’t know”. It was also noted that he had many friends in class and peers always tried to help him. Parent report was consistent with that of teachers.

By the time this re-evaluation occurred, Johnny was engaging in counseling services. Available data indicates that he participated well, was able to admit being frustrated with work, was able to state physiological symptoms he experienced when frustrated, he was able to state coping strategies, and he was able to regroup before shutting down.

Johnny was re-evaluated again in 2021. No new assessments were used for this re-evaluation, and all data was carried forward. However, updated information from teachers was obtained, and Johnny was rated as follows: Average for Generally cooperating and complying with teacher requests, for being pleased with his work, and for responding appropriately to praise and correction; and Below Average for Adapting to new situations without getting upset, accepting responsibility for his actions, working cooperatively with others, and initiating activities independently. His services continued.

In 2024, for the triennial evaluation required, Johnny’s academic skills information was updated with standardized assessment. All other information was pulled forward from the 2021 evaluation. He continued to demonstrate a need for specialized support in reading, writing, and math. Evaluation data indicates Johnny was not cooperative during testing; as such, his academic scores might have been higher.

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NOTE #1: A Counseling Evaluation has many different parts to it, the above is just one. Name, dates, and identifying information have been changed. Please keep in mind that different professionals write different evaluations from different perspectives, educational backgrounds, and work experiences. As such, mine might look vastly different than one written by a School Psychologist in WA State, for example (I'm in Texas). It will also look different than one written by a Licensed Professional Counselor (LPC) in a Louisiana parish. You get the point.

NOTE #2: A Records Review is important for any type of psychoeducational evaluation because the team trying to help the student must know what has been done before to help (this way, we don't end up suggesting the same things over and over). In addition, a review of available records provides a timeline of events and a history of the current problem that also helps the team when they determine what to do next. The way the review is written definitely depends on the purpose of the report, on the audience, and on the presenting problem.