| Date | Type | Focus Area Statement |
| 03/02/2023 | Treatment | Client needs a relapse prevention plan to follow upon discharge and completion of treatment that will continue to support recovery efforts.
Client needs an effective discharge plan to follow upon completion of treatment that will support continued sobriety.
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| 02/13/2023 | Service | Client needs job interview appropriate clothing
Client needs undergarments
Client needs every day clothing items |
| 09/29/2022 | Treatment | Inability to identify positive things about self.
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| 08/10/2022 | Treatment | Concealing sexual identity from significant others (e.g., friends, family, spouse).
Depressed mood, diminished interest in activities.
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| 08/10/2022 | Treatment | Anxiety, depression, and preoccupation with somatic concerns.
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| 08/10/2022 | Treatment | Depressed mood.
Diminished interest in or enjoyment of activities.
Feelings of hopelessness, worthlessness, or inappropriate guilt.
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| 08/10/2022 | Treatment | Excessive and/or unrealistic worry that is difficult to control occurring more days than not for at least 6 months about a number of events or activities.
Hypervigilance (e.g., feeling constantly on edge, experiencing concentration difficulties, having trouble falling or staying asleep, exhibiting a general state of irritability).
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| 08/10/2022 | Treatment | Client needs an effective discharge plan to follow upon completion of treatment that will support mental health needs.
Client needs an effective discharge plan upon completion of treatment that will support identified treatment goals.
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| 06/23/2022 | Treatment | Client needs an effective discharge plan to follow upon completion of treatment that will support mental health needs.
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| 05/06/2022 | Service | learn how to use a bank account |
| 04/22/2022 | Treatment | xx |
| 11/29/2021 | Service | Client needs an effective discharge plan upon completion of treatment that will support identified treatment goals.
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| 11/08/2021 | Service | Ct is homeless is seeking permanent housing. |
| 11/08/2021 | Service | Ct is homeless is seeking permanent housing. |
| 09/12/2021 | Service | Client needs assistance completing education course applications
Client needs educational/vocational testing/evaluation
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| 08/21/2020 | Treatment |
Family member hiding client's sexual orientation from other family members.
Frequent conflict (e.g., arguing, yelling) with parents and/or siblings about sexual orientation.
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| 08/21/2020 | Treatment | A major event has occurred (e.g., natural disaster, crime victimization, employment loss, etc.), causing disruption and instability in the family.
A sense of disengagement occurs with family members, causing feelings of alienation.
Familiar family routines and rituals are disrupted.
A sense of disengagement occurs with family members, causing feelings of alienation.
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| 08/21/2020 | Treatment | Concealing sexual identity from significant others (e.g., friends, family, spouse).
Depressed mood, diminished interest in activities.
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| 08/21/2020 | Treatment | Remarkable
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| 07/10/2020 | Treatment | Absenteeism rate is above acceptable standards.
Displays flat or depressed affect.
Client reported, "I'm depressed." |
| 07/03/2020 | Treatment | Client reported she was hospitalized in 2004 for anorexia and reported bouts of depression since her teens. Client also talked about a history of self-harming behaviors on and off since age 13. Last reported incident of self-harm was "three weeks ago" and she indicated these are periodic episodes. |
| 07/03/2020 | Treatment | Client reported being sexually abused by her step-father at about age 7 and she believes her mother knew of the abuse. Client was uncertain how long the abuse was ongoing. Client also reported a history of spiritual abuse from her mother and the church, in which she was sent away to a religious camp (age/duration not obtained), and that it was related to her that they would "make your life hell to save you for eternity." |
| 07/03/2020 | Treatment | Client reported her mother and stepdad divorced when she was age 7. Client described her mother's love as conditional, her younger sister as the "golden child," and that she received positive attention from losing weight and exercising. See additional information in the Abuse History section. |
| 07/03/2020 | Treatment | Client reported she was in a relationship of 7 years up until about 2.5 weeks ago and had one other previous relationship. Client indicated she is still grieving the loss of her latest relationship. |
| 07/03/2020 | Treatment | Client reported spiritual abuse at a young age. Client reported she currently believes in "something" but is unsure what, and would like to do some of this spiritual exploration in therapy. |
| 05/11/2020 | Treatment | Feelings of hopelessness, worthlessness, or inappropriate guilt.
Depressed mood.
Social withdrawal.
Diminished interest in or enjoyment of activities.
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| 11/14/2019 | Treatment | Blaming victimization on characteristics of self (e.g., being gay/lesbian, weak, "flamboyant").
Confirmed self-report or account by others of physical assault (e.g., beating, stabbing, hitting) by stranger because of sexual orientation.
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| 09/09/2019 | Treatment | Hypervigilance (e.g., feeling constantly on edge, experiencing concentration difficulties, having trouble falling or staying asleep, exhibiting a general state of irritability).
Motor tension (e.g., restlessness, tiredness, shakiness, muscle tension).
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| 09/06/2019 | Treatment | Client does not have sufficient food to maintain weight
Client lacks financial resources to obtain basic food needs
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| 09/06/2019 | Service | Client lacks transportation generally
Client lacks transportation to medical appointments
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| 06/09/2019 | Service | Client needs furnishings
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| 04/01/2019 | Service | Client needs job interview appropriate clothing
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| 04/01/2019 | Service | Client is homeless
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| 01/25/2019 | Treatment | Complains of sleep disturbance when away from home and/or when away from the immediate presence of a parent.
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| 01/25/2019 | Treatment | Discovered denial of substance use.
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| 01/11/2019 | Treatment | Client needs an effective discharge plan upon completion of treatment that will support identified treatment goals.
Client needs an effective discharge plan to follow upon completion of treatment that will support mental health needs.
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| 01/11/2019 | Treatment | Becomes very anxious with any hint of perceived abandonment in a relationship.
Chronic feelings of emptiness and boredom.
Consistent pattern of burning, cutting, scraping flesh, hitting, or bruising self.
Uses self-injury to reduce negative affect.
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| 01/11/2019 | Treatment | Escalating isolation from significant other(s), family, and/or peers.
Increased moodiness.
Increased sleep and lethargy.
Serious unresolved grief issues.
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| 01/11/2019 | Treatment | Persistent preoccupation with body image related to grossly inaccurate assessment of self as overweight.
Recurrent episodes of binge eating (i.e., rapid consumption of large quantities of high-carbohydrate food).
Recurrent inappropriate compensatory behavior to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise.
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| 10/09/2018 | Treatment | Concealing sexual identity from significant others (e.g., friends, family, spouse).
Difficulty enjoying sexual activities with opposite sex partner because of low arousal.
Engagement in sexual activity with person of same sex which has caused confusion, guilt, and anxiety.
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| 07/25/2018 | Treatment | All family members experience tension and conflict due to the dysfunction in the home.
Boundaries weaken and issues of power and control surface, contributing to the decreasing effectiveness of the parents.
Children under the age of 13 have behavioral problems that cause conflict for the parents and the rest of the family members (e.g., acting out, destructive behaviors, refusal to go to school).
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| 07/05/2018 | Treatment | Deferred at client request. Provide referrals to housing as needed and identified by client. |
| 07/05/2018 | Treatment | Client reported issues with diet; provided referral to LCH for medical care. |
| 07/05/2018 | Treatment | Client needs an effective discharge plan to follow upon completion of treatment that will support continued sobriety.
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