Client is a 10 yo HM who has been in DFPS custody before, moved to FL for adoption of himself and siblings, 6 to 8 mos later, the adoption fell through and he is now back in the system. His mother died in a car accident while he was in DFPS custody. Client has frequent SI/HI verbalized threats with aggression towards others. Client continues to present with anxious affect and labile mood. Upon arrival, client could be heard outside (although he was indoors) having a verbally aggressive tantrum with yelling, screaming, crying, blaming and oppositional defiant behaviors. Despite the foster mom’s quiet calm tone and attempts to hear him out, he continued to lash out verbally. Foster mom informed me client has been picking at his fingernail bed until it bleeds and has been peeling the skin from around his toenail bed with his teeth until it bleeds. She is afraid of infection and discussed a doctor’s visit with the client, which appears to have triggered the outburst. Client became increasingly frustrated and agitated as took a seat. He continued the restricted disclosure until finally, therapist responded to the client in a quiet voice, “Okay, I’m listening. Tell me exactly what it is that you want.” Client began to escalate again, while whining and yelling, he began to blame again stating we were not listening to him. Therapist quietly again called him by name twice and stated calmly, “Just take a deep breath. Take another one, now another one. Now, I’m listening, just tell me what you want.” Client covered his ears with his hands then his eyes and yelled (but in a lower volume), I want my privacy! I don’t like people looking at my privacy!” Therapist asked client what he meant by his privacy. Client responded he didn’t want people looking at his pictures of his family or his younger self. He also stated he did not want to go to the hospital because she (FM) was just going to send him away to another home. Foster mom offered to put his photos in a photo album that he could access whenever he chose to do so. She also reassured him that he was not going to the hospital or going to be discharged from her home. She explained to him she was going to accompany him to the doctor so they could properly attend to his wounds and therapist supported her statement verbally. We discussed managing our emotions in healthy ways and using our coping skills including mindful/ deep breathing. Client shared some drawings he made and therapist encouraged him to utilize drawing to self-soothe. Client was given time to draw and color (about 10 minutes) and he offered another drawing to the therapist. Next session will focus on emotional regulation and mindfulness.
MINI SOAP NOTE
MUST BE OBGYN TOPIC/DIAGNOSIS MINI SOAP NOTES DO NOT INCLUDE DIFFERENTIAL DIAGNOSIS PLEASE ONLY INCLUDE WHAT IS ASKED FOR ON THE ATTACHMENT