Subjective

The patient is a 24-year-old female who was seen today for

initial evaluation via video session with her consent. She is
diagnosed with adjustment disorder. The patient stated, “I really
didn’t want therapy, it is my mom who wants us to see therapy
together”. She stated that she does not have a relationship with
her mother. She stated, “I agreed to see a therapist because that
is the only way to communicate with my mom”. She said that her
mother initiated for them to come to CLAY for therapy. She said
that her mother has lots of issues, that she is overbearing. The
patient said that her mother is very controlling and emotionally
discharges when she tries talking to her. The patient agrees to
do family therapy with her mother. The patient stated that she is
not on any medication currently, but stated, “I smoke marijuana a
lot regularly every day”. The patient stated that she tried to
commit suicide at age 13 because she took a whole bottle of
Adderall because her mother was pressing her to be taking it, but
she went to school, and she told the teacher what she did and the
teacher to her to the hospital. She said that she stayed in the
psychiatric hospital for a week. The patient stated that there is
a history of family mental illness in both the father and
mother's sides of the family. The patient stated that her parents
divorced when she was 7 years old. She said that her father was
very abusive. She said that she lived with her mother until she
turned 20 years old and moved out of the house. She stated, “I’m
currently living with my ex-boyfriend, and trying to find a place
for myself”. She said she was bullied in middle school, but for
high school, her mother was her bully. The patient said that she
graduated high school and worked as a property manager.

Objective:
The patient is alert and oriented x 4, to person, place, time,
and situation. She appeared very neat and clean. Her eye contact
is very intense. She is cooperative, her mood is euphoric, her
affect is labile, the thought process is intact, and goal
directed. Fair insight and judgment, cognitively intact. The
patient is not on any medication currently. She reports tried to
commit suicide when she was 13 years old by taking a whole bottle
of Adderall with intention of committing suicide but was taken to
the hospital on time by her teacher after she her teacher and she
was hospitalized for one week in the psychiatric hospital. The
patient denies visual or auditory hallucination currently. She
denies suicidal or homicidal ideation presently.

Assessment:
Diagnosis: Adjustment Disorder. The rating scale for PHQ-9 is
6/27 and she has little or no anxiety or depression. The patient
is a 24-year-old African American female, alert, and oriented x
4, to person, place, time, and situation. She was seen today for
initial evaluation via video conference with consent. She is
seeking family therapy to facilitate a healthy adult relationship
with her mother. The patient is not currently taking any
medication. This Patient is referred to individual therapy along
with family therapy with the mother to help facilitate building
their relationship. The patient stated that she is already seeing
a therapist and that she is willing to commit to this new therapy
with her mother, and she will be seeing each on different days.
The patient will be followed-up in 4 weeks. The patient stated
that she does not exercise, her eating is not that great, and her
appetite fluctuates. The patient is advised/encouraged to commit
to exercise to increase her natural serotonin, increase her
overall immunity and good health. Also, she is encouraged to
focus on positive coping skills like exercise, taking a walk,
finding an activity that she enjoys, and try to surround herself
with positive people. She is encouraged to slow down on cannabis
consumption. The patient agreed and verbalized understanding. The
patient denied visual or auditory hallucination. She denied
suicidal or homicidal ideation currently. She is instructed to
call 911 immediately if she experiences suicidal or homicidal
ideation, and she verbalized understanding.
Plan of care: The patient will have increased adjustment to her
mother in 90 days. The patient has been referred to individual
psychotherapy along with family therapy with her mother. The
patient was instructed to exercise daily to increase her overall
good health, immunity, and natural serotonin. She is encouraged
to start cutting down on cannabis intake. She agreed and
verbalized understanding. Follow-up in 4 weeks. Call 911 if
experiencing suicidal or homicidal. The patient verbalized
understanding.