Client has been diagnosed with: F33.9 Major Depressive Disorder, Recurrent, Unspecified F40.10 Social Anxiety Disorder F94.1 Reactive Attachment Disorder F84.0 Autism Spectrum Disorder Personal History of self-harm Background History on Client Jenny has an extensive history of instability, inability to cope safely when under stress, managing impulses in ways that put self and others at risk, poor self-care, dangerous and impulsive acts, and diminished ability to complete activities of daily living. Psychiatric symptoms that persist and require immediate therapeutic intervention include: threats, impulsivity, depression, anxiety, easily frustrated, explosive reactions, runaway behaviors, mood swings, disruption, manipulation, and sexual preoccupation. It has been reported that Jenny has engaged in a history of physical aggression toward peers and staff, suicidal ideation, binge-eating, scratching/cutting herself, burning herself, hiding sharps, poor boundaries, engaging in sexualized chatrooms, thoughts of causing sexual harm to children, and inappropriate contact with younger children. Some of these behaviors are attributed to Jenny’s extensive history of abuse/neglect, as evidenced by her biological mother and previous foster family, neglect by biological mother, and sexual abuse by previous foster family. Due to Jenny’s traumatic history, it is recommended that she be placed in a therapeutic group home where she can continue to receive the structure, support, and immediate therapeutic intervention she requires for continued stabilization.
