THERAPY NOTE: CS} a Opy ye Pt Name: Rikki Dombrowski Case Number: 4351 awe Date: 3/3/04 Time: 10:00 AMEGPM|_] oa Length of Session: (_} 30min J 60 min [ Toher Type of Session: (Ind. (] Group (_) Fan/Coup (lOther: Clinical Information/Deseription: ‘One contact with Mother. Report that se came ter mactial ats class and apparetly ot int argent with instructor who was insisting that she left. Indicted that fiend Ralph was with her. Expressing rastation and ager aot her doin thi te safe be instructor was there. Lneated that Mother also appavently showed up at school although se was gone and aed with principal. Expressing that she does not want (osce Mather right now. Sees her a ou of control. Expressing dhat she misses her when other kids have parents at school. Also worries aboot er be sees ber a8 not making good decisions when she is ike thi. She {cknovleles that she enjoys these times somewhat when with Mother be she cam fll her what to do and be a parent but alse Sels tunsaffinsecure when shes ike this. Medication: Problems _ Yes} No Wealth Changes: Yes[] Nob If Yes explain: _ Mental Status: Lot nese al TT Pressured = | iid posure [appeiae Speed x a Wa, {or oat Rearled Che ct Emotional Disordered Dir: cI Anson TET rari — a Tabi [Depressed | z Fiat ‘ther: Seems ope abi | er foingvthoghte tier: al Or: Tse [rie | Judgment Deere: ie good insight into her fealing reactions RT is} arte ‘ners WNL inser Dips ihe (ar Tncreva Deron Other: tant (aenepel 1 ena mee a a ot TE] Ballucinations ‘Delusions { a meee hae ar = SO mame ASAE [ae “ilsent TL edenion VC Pani Pn aa [htuti-level style % Teal rere: none za DIAGNOSIS: Avis Adjustment Reaction, Mived Mood and Conducte Avis fz Change: No © Yes © Ifyes, New Diagnosis: PROGRESS: [7] Good [x] Fair (] Stow [7] Complications [] Poor ] Regression INTERVENTIONS: Processing her reactions and feelings about her mother and the situation. Working with her to sce the varied fetings that she has and her enjoyment of control and direction. Expressing that she usualy feels safe with Father except that she is worried that Mother and/or friends might hurt him, Noting with me that she scems to reach out for seeurity by touching, e2, tapping her foot against ‘mine as we talk. PLAN: RTOIN(]1 wk 2wk [Jt mo[] others__ Referral: Yes] No] ifs, whom Define Qo SAV Che- Semen © io oy We thas