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Bio-Psychosoical Assessment

 

            
             The client has an extensive sexual abuse history beginning at age 7 which led to the development of PTSD. She reports flashbacks of being frightened in the dark, has a history of self-harm, problems with socializing, and low self-confidence, difficulty sleeping well, sever migraine headaches, and complaints of depression. She has strong urges to self-harm which began last year. The most recent episode led to hospitalization at Fairview Medical Center from July 29, 2014 to August 05, 2014. For suicidal ideations after a possible suicide attempt which required 7 sutures for a cut on her left wrist. She wishes to begin outpatient therapy; per the client, she would like to "feel normal for once in my life", end self-harming, address her trauma issues, and improve her self-esteem.
             Social History .
             The client is a 17 year old African-American, born in Chicago Illinois now living in Coon Rapids Minnesota, Her primary language is English. She lives with her mother. The client is enrolled in 11th grade at Robert E Lee High School. She takes regular classes and has not been identifies for special education. The client's mother reported, the client typically earns grades of "B's", however, within the last year she has failed English and Geometry. Her parents Divorced when she was 8 due to her mother's discovery that her husband was sexually abusing the client. Her mother moved them back to Chicago from Minnesota in fear for her daughter's safety. The first year in Chicago in the client and her mother lived in the basement of a cousin's home until enough money was saved for the deposit on an apartment. From the age of 9 to the present, she has lived with her mother in a small two-bedroom apartment in the Coon Rapids area of Minnesota. Although the building was old, the client describes her mother as "a clean freak" and their place as always clean and neat.
             Family Dynamics.


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