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Word Count: 2,118
The client is a 16 year old white female found wandering on the sideof the road by the Sherriffs Department with multiple self- inflictedsuperficial cuts to both forearms Upon questioning by the SherriffsDepartment she stated that she ran away from her foster home and thatvoices told her to kill herself She reported a history of repeatedsexual assault by her father who has been on the run since theincident and that her mother is on drugs She was removed from her homeand placed in foster care after the incident The only other familymember she has is an aunt that desires no contact with her and will noteven speak with her She openly expressed the desire to learn skills tocope with this traumatic situation and the voices she hears that tellher to kill herself however this is the third mental health facilityshe has been in within the past month She has admittedly manipulatedthe mental health facilities by doing what was requested of her withouthaving a genuine desire to get better As a result she would getdischarged only to find herself not being able to cope with thesituation again and ultimately ending up back at a mental healthfacility A vicious cycle that the client states she is ready to stop I met the client the day after her admission and she was anxious aboutthe color of the walls at the mental health facility stating that thecolor green triggers the voices in her head that tell her to killherselfAssessment DataThe Client was given a Mini-Mental Status Exam and scored a 30 out of apossible 30 A urine drug screen was done as well as a pregnancy testand she tested negative on both The clients psychomotor skills were within normal limits and her moodwas appropriate She was alert and spoke with a normal rate rhythm andvolume In addition she was cooperative and willing to shareinformation The client has no religious affiliationThe primary diagnosis for this client is Post
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