Reason for Referral: The subject, a 14-year-old male, was referred for counseling by the school due to an inability to follow directions, distracting others in the classroom, and a tendency to act out in a violent manner towards himself and others. .

             Notification of Purpose and Limits of Confidentiality: The subject was notified that the school referred him for counseling in order to help him control his anger toward himself and others, be less distracting in the classroom, and help him to follow directions in a more appropriate manner, which would benefit both himself and the others in the classroom, as well as the teacher. The subject was also informed that the potential users of the report would include the school, the specific teacher, the parents of the subject, a social worker, and a nurse. While the parents would not be involved with giving referral information, the nurse, teacher, and social worker would. This was all explained in plain language to the subject, so that he would have a complete understanding of the nature of the referral and the amount of confidentiality that he could reasonably expect.

             Evaluation Instruments and Sources of Information: Three evaluation instruments were used. These included a standard IQ test which was age-appropriate, a test for depression and suicidal thoughts among adolescents (Gispert, Wheeler, Marsh, & Davis, 1985) and a test for other basic psychological problems, many of which are often seen in children and adolescents. In addition to this, observation referral information for the report also came from the teacher, a nurse, and a social worker. .

             Background Information: The subject is a white male, 14 years of age. The subject's birth was normal, and age-appropriate milestones were met, with the exception of a lack of willingness to play with or respond to others of the same or similar age. There is no evidence of sexual, emotional, or any other type of trauma in early childhood, and the subject showed no other developmental issues in early childhood.