- Sex: female
- Age :22
- Marital Status : Single
- Education: College and living with parents.
- Setting: Private office
- Chief Complaint: I want to cut myself or stab my dog with a knife yesterday. Patient complained she was feeling angry had an emotional breakout and began screaming and punching the walls of her bedroom. My mother try to calm me down and convince me to come for my therapy sessions and I agree. Every time I get like this I have flashbacks of a man that almost rape me at a parking lot 2 years ago.
- At this time patient denied suicidal ideation, plan or intention. The patient was able to contract for her safety and the safety of others
- Brief psychiatric History: prior psychiatric history and previews hospitalizations
- Medical History: The patient denies medical history
MEDICATION HISTORY: GEODON 80 MG AT BEDTIME
- The patient is aware of surroundings and is alert to person, place, time, and situation, lack of energy and fair eye contact
HELLO WRITER I GAVE YOU INFORMATION ABOUT THE CASE, THE REST YOU CAN COME OUT WITH SOME IDEAS. I WILL LEAVE YOU THE SCHOOL SAMPLE SO YOU CAN GUIDE YOURSELF. THIS IS A VISIT TO A MENTAL HEALTH COUNSELOR, IT IS JUST A THERAPEUTIC VISIT