History of Presenting Illness and Chief Complaint

Jessica is a 16-year-old and identifies as cisgender straight white female. She was referred for treatment by her father after he received multiple texts from her "confessing" her sinful thoughts. Jessica and her father reported these confessions have been happening for the past two years, since she started high school. However, they noted they have become progressively more detailed in the past 6 months, to the point of dad feeling very "uncomfortable" knowing his daughters thoughts.

Histories

Family History:

Jessica lives with her biological father, 12-year-old brother Bill, and the family cat Pickles. She has lived in the same home in small town MA since she was born. She reports having a close relationship with her father, "he is like my best friend." She enjoys spending time with dad and noted they will often go hiking and camping together as a family. Her father is also the football coach in her school. She indicated a "decent" relationship with her brother. She stated they got along better when he was younger and feels that while their relationship is not "what it used to be" is still a positive relationship. She noted struggling sometimes with her brother due to his "embarrassing behaviors" around her female friends.

Jessica's mother died when she was 8 years old. She was diagnosed with stage 4 breast cancer and died one year after the diagnosis.Jessica reports she loved her mother and felt they had a good relationship prior to her death. Jessica indicated she misses her mother "terribly" at times and feels that if she was around she would feel less anxious about her thoughts and would have someone to "talk to about everything." Jessica says at times she doesn't talk about her mother and avoids the subject because it leads to overwhelming feelings of sadness.

Jessica reported a positive relationship with her paternal grandparents who live in the adjacent town. She stated they will often spend weekends over there or have dinner at their house a few times a week. She has a positive relationship with her paternal aunt but stated she does not see her much due to living in a different state. "We will spend holidays together and it is always nice to see her and my cousins, we just don't get to do it very often."

Jessica's maternal grandparents live in California. She stated she talks to them regularly but doesn't have much of a relationship with them. She indicated her mother had a strained relationship with her parents and didn't have much involvement with them when her mother was alive. She has no aunts or uncles on her mother's side.

Education/Work History:

Jessica is currently in the 10^th grade at Some Great High School. She reported her grades are generally A's. She does not have an IEP or a 504. She has been on the honor roll every semester since starting high school. She was asked to apply for the National Honors Society. She is taking advanced science and math courses. She reported some struggles at times with her advanced courses but overall feels she is handling the demands well. She indicated a desire to start her AP courses next year and has plans to take classes on the college campus. She is unsure what she would like to pursue for work upon graduation of high school but is interested in molecular biology or possibly stem cell research.

Jessica volunteers at a local food bank one day a week.She helps organize food baskets for families to pick up from the food bank. She also works the counter at the food bank distributing baskets. She started this volunteer work as part of a freshman assignment and found it to be rewarding and continued volunteering after the class was over.

Jessica works weekends at a local creamery when in season. She started the job last season and worked the counter; she plans to go back this year when they open again in a few weeks. Jessica stated she had a good relationship with her boss. She also had a good relationship with her coworkers that were also peers in her school.

There have been no reports of any disciplinary action either at school, work, or with volunteering.

Social/Peer:

Jessica reported a strong peer network. She has found individuals she has identified as close friends. She reported the five girls have been friends since early childhood.They will often have sleepovers at each other's houses. They have gone on vacation with each other's families. For fun, she and her friends will "hang at the house," go swimming, bike riding, shopping, and watch movies.

She also identified a number of other individuals that she is acquaintances with. She denied any problems with peers at school and indicated she is involved in a number of activities that keeps her active with the student body. She is currently applying for National Honors Society. She has been part of the debate team since her freshman year. She is also the captain of the girl's junior varsity team. While there is no indication of peer struggles, she reports feelings anxious at times due to her thoughts and fears that "if they only knew" they would reject her.

She has not been involved in a romantic relationship yet but expressed a desire to date. Her desires are what lead to confessions to her father. Jessica reports having a crush on a classmate and she will often have "sexual" thoughts that pop into her head that are unwanted, sometimes about the individual and sometimes just about the act. These thoughts lead to high levels of anxiety and despite her best efforts to suppress them, they often are perseverative, and only subside once she texts her father.

Strengths:

Jessica is an insightful and intelligent individual. She is articulate and able to advocate for herself. She is athletic and involved in a number of activities. She is able to take on leadership roles and encourage others to perform well. She has the ability to establish and maintain peer relationships. She has a good relationship with her family. She is compassionate and has a desire to give back to her community. She is resilient. She is hardworking and determined.

Trauma History: (only include information if their trauma history is positive)

Jessica reported her mother died when she was younger from an aggressive form of breast cancer. She struggles with coping at times with her mother's death. She avoids talking about her and at times experiences intrusive thoughts and feels sad and depressed her mother will not be around to experience different milestones in her life.

Mental Health History:

There was no reported history of past treatment, diagnoses, or medication.

Substance Use History:

Jessica denied any substance use or treatment,

Medical History

Jessica reported an allergy to shellfish and bee's and carries an epi-pen. No other allergies were reported. She attends yearly PCP visits and is up to date on all required vaccines. She denied any chronic medical conditions. She was hospitalized once when younger following a bee sting, which is when they discovered her allergy. No other hospitalizations or surgeries were reported. She attends biyearly dental visits. She just started seeing the GYN for routine preventive care.

Family Medical/Mental Health/Substance Use History:

Family Medical History: Paternal - PGM diabetes; PGF skin cancer, high blood pressure, high cholesterol, diabetes. Maternal - Mom breast cancer, MGM unknown; MGF unknown.

Mental Health History: paternal - PGM undiagnosed anxiety; p-aunt anxiety, OCD. Maternal - unknown mental health history

Substance Use History: paternal - no reported substance related disorders. Maternal - unknown.

Mental Status

Jessica arrived for the session on time and was dressed appropriately for the occasion and weather. She appeared to have recently showered and denied any concerns with her hygiene. She reported showing daily but noted there are times she does not wash her hair due to breakage concerns and instead will use a dry shampoo.She reported her sleep at night was "good" which means she generally sleeps 7-9 hours a night and feels rested when she gets up. She did report occasionally having nightmares, she said the theme is always surrounding loss or being alone and scared. She indicated her appetite is "healthy" and said she eats 3 meals a day. There have been no reported weight fluctuations. She works out 7 days a week and her workouts include cardio and weight training. She often feels that her legs are "too scrawny" and focuses her workouts on increasing her leg strength. She stated she will measure her thighs weekly and keeps the measurements in her journal along with her weightlifting program. She indicated she will often "check" with her dad that she is on the right track with her weightlifting, since he is the soccer coach and was a former weightlifter. Her speech was WNL for rate and tone. Her thought process was logical, although at times she became repetitive and appeared stuck on certain topics. She described a time when she was walking down the stairs with her friend and they "walked down the wrong way" she indicated being stuck on the fact that she did it "wrong" and had to go back to the top of the stairs and walk down the "correct way." She reported intrusive thoughts specifically related to desires she has about others and struggles with stopping the thoughts and becomes preoccupied with them. There was no reports of auditory or visual hallucinations and she was not responding to internal stimuli. Jessica was alert and oriented to time and place. She did not appear to have any cognitive deficits, but there was no formal testing completed. She reported her mood overall as 'good' and her affect was bright in the session.

Risk Assessment

Jessica's level of risk is low. She denied suicidal ideation and homicidal ideation. She reported a past history of self-injury, cutting behaviors. However, the cuts she reported were superficial on her arms and never required medical attention.She indicated the last time she engaged in cutting behaviors was over a year ago. She denied any desire to engage in cutting behaviors currently.

Clinical Formulation

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Diagnostic Formulation

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Treatment Plan

Client Goal (take a guess as to what the client would want their goal to be)

Clinical Goal (take the clients goal and write it in clinical terms)

Objective (measurable step to get to the objective - what will be different?)

Intervention (name one intervention and how you would use it to work toward the objective)