Pt is a 16 y/o white female presetting to NNBHC with mother due to suicidal statements. Pt mother reports the pt made suicidal statements about self-harm about a week ago, due to not getting her way or attention seeking behaviors. Pt mother stated she attempted suicide a year ago by overdosing on brother’s medication due to conflict between her boyfriend. Pt currently denies SI/HI. The pt states she has been depressed due to the transition of moving with biological mother. The pt states conflict with her mother, she refrained from going into detail. The pt states she feels hopeless, helpless and worthless. Pt states she isolates all day and does not interact with family. Pt states she has been having difficulty with …show more content…
She states her biological father is currently incarcerated and will be released when she turns 18 years old. Pt mother states she does not believe that she was sexually assaulted by her father, she believes she was being intimate with other males. Mother reports that the pt is currently in a relationship with a 19 year old male, which she forbids her to continue the relationship. She also states a history of promiscuity with older men.
Family Composition
Pt father is currently incarcerated. Pt is residing with her biological mother, brother (17) and her mother’s ex-boyfriend. She has been residing with biological mother for almost a month, prior to residing with paternal grandmother. Mother states she will have full guardianship of the pt in upcoming weeks; her grandmother is unwilling to take care of her due to her defiant and oppositional behaviors. Mother reports of obtaining a CHINS report once guardianship is granted.
Psychiatric History
Pt has had numerous outpatient providers, but currently under the care of Betty Eastman LLC. She was prescribed Zoloft in the past, but currently she is not prescribed any psychotropic medications. Mother reports she engages in AWOL behaviors which this causes inconsistency with