oO THERAPY NOTE: “ “ee Pt Name: Bi ombrowski Case Number YY si ie Date: 1/22/04 Time: 2:00 AM[_|/PMEX] ey EAN) Length of Session: [| 30min [| 60 min (_] other Type of Session: [x] Ind. (1 Group (“| Fam/Coup | JOther: Informe tion/Deseription: Father bringing Rikki Cocwerned about events on last tne with mother. eseribes mother as taking Rikki to KC to fins home who ke has not known. Deerhcs Kk ascoming hack tps snd in fears. Overhead mater tlk to re hon troup call BACA (ers Again Child Atuse) and elerences being made tothe comings reaking hha Wes” relate! otters accortins that he has abwed Rik Father also espressing concerns that Rkht is taken to KC and eft wth people that the des ot Know 25 well Medication: Problems Yes[] No Health Changes: Yes(] No Da 1 Yes expt Diieiation (Gite? | Appearance Speech Beavion Thinking ‘Mood “Affect as Memory ‘Consciowsnese Tmpolse control SJadgment f ‘Attention/Conceat | q ¢ ‘Na Comin to safes} | Wt {ext ot Level Z DIAGNOSIS: Axis E-Adjusiment Reaction, Mixed Mood and Conducte Axis H: C5 dyes, New Diagnosis: PROGRESS: [] Good & Fair (Stow (] Complications (] Poor 7 Regression [Other Sears Suid a ae A ee ‘Threat to Others | Bg | ‘Matlevel syle Tio Plan INTERVENTIONS: Exploring with Rikki her recall of weekend. She i in genera! (with open ended queries) very postive shout the weekend. Site describes enjoying her time with son of Mother's friend who is about her age. Describes playing video games and doing things with ‘She indieates that when left by her mother she was with a female friend of her mother’s witli whom she had around for seme time. Apparently this friend has relationship with friend they were visiting. Rikki describes she and son waking up bie of Friend's ing at her bedroom door (was son's bedroam). While awake on one of these occasions, she and Friend overheard parents a down below. She describes them laying/stting atthe top ofthe stirs and Tistenuing tothe conversation. She her mother describe a letter she wrote o BACA group. Rikki charaeterizes this eter as though it had been Lf niten by her describing Father as scaring her while she was aking a bath and eausing hee to fall. She denies that her Father scared ther but tht she slipped inthe bathtub but was not hurt. She overhears friend telling her that Mother will need {0 meet with them tomorrow and Mother makes references to comments that they will ust his knuekles referring to her father. She expresses anger that Mother would cai that her father is abusive when she states that he fs aot and that she would write a leter ax though she werewriting it the phease, “bust his knuckles” meant and indicated that she asked the son what this meant but that Mother's female Fricad came and shoged thers ack into their rooms PLAN: RTOINC] 1 wk 2wk [1 mo(] others, Referral: Yes] NoL} if Fes, to whom: Deft hd. Qo. Dsé ictbagp® = Licensed Psycholofi Cop, YY64 Cite ct ~ par Roald. Py