2007-2012
// Jane Doe's Counselor (2007-2012)
Here is Document B rewritten to match the tone and format of Document A—dated, third-person, neutral, clinical progress-note style, with cleaned structure but no added interpretation:
SOCIAL HISTORY:
Jane Doe was born in the US and lives with her father, mother and twin sister. Her father and mother met in the US and were married here. After their marriage, her father's five older children joined the family from Jordan.
01/10/07
"I met with Jane Doe's mother first, at her request. She reported that the family has had ongoing problems because of her the five children from his previous marriage in Jordan have lived with them for the past five years and have caused conflict between her and her husband. She and her husband are currently In marriage counseling to deal with the issues.
Jane Doe processed at length her distress about body image and low self esteem which began when her parents signed her and her twin up for modeling when they were very young. When she was about 7 she began being pressured to lose weight and her sister actually became anorexic last year. Jane Doe said that her parents did not notice that her sister was eating one meal (a salad) a day and spending two hours at a time on the treadmill. She thinks she herself is fat and worries about it but also feels that by not being skinny, she is taking control of her own life. Jane Doe's abuse was traumatic because he took pictures and had her pose which she connected with the modeling and poor self esteem. She has a lot of confusion about her self image at this point.
02/08/07
Jane Doe's last appointment was cancelled because of Inclement weather. In the last two weeks her father and mother have separated and are in the process of divorce. Prior to the separation Jane Doe told both parents about the suicidal thoughts/gesture she made right after the sexual abuse Incident and she also had her sister tell them that she had been anorexic for a year. Jane Doe feit like they had not taken the Information very seriously. She said that her grades have Improved a lot and she finds herself feeling happy at school, although she feels sad at home.
03/01/07
Jane Doe's mother called me before the appointment to tell me that she and her husband are considering reconciliation and want to tell the girls this Sunday.
03/01/07*
Jane Doe is having some Issues with her mother today. Her mother has grounded her from going to the skating rink this weekend and Jane Doe complained that her mother insisted on staying at the skating rink when they do go.
03/14/07
Jane Doe's mother has been talking with the girls about her feelings and anxletles about their father. She has asked Jane Doe to call him and explain why she wants to talk to him in a therapy setting because "he'll only belleve it from her". Jane Doe feels very conflicted and upset and states that she knows far too much about her mother's feelings about her father and about their relationship. I met with her mother separately and asked her not to discuss the separation or her feelings about her husband with her daughters. We have arranged for her to have her own therapist here so that she has a venue to process what is going on.
03/29/07
Jane Doe said she tried to talk to her mother but her mother related it to her own relationship with Jane Doe's father and then sald she couldn't give very good advice because she did not do well with men. Jane Doe feels very frustrated because she thinks her mother is too obsessed with her father.
05/10/07
Jane Doe wonders if her parents might be getting back together because her mother has told her that she and her father are going on a trip for four days in a couple of weeks and the girls will need to stay with friends.
05/24/07
We rescheduled for two weeks because her parents will be on a trip together next week and the girls will be staying with friends.
06/07/07
Jane Doe reported that her weekend with her friend went well. Her parents went gambling together. She talked about her older sisters returning to Jordan and the oldest one is getting married there soon.
06/14/07
Jane Doe said that her father has begun moving his clothes and other belongings back Into the home and she assumes that he is moving back.
08/09/07
Jane Doe reports she continues to do well and that her father has Integrated back into the family without any problems for her. He is still not working and her mother tells the children they are poor and cannot afford school clothes this year. She is also starting high school in several weeks.
09/06/07
Jane Doe was disappointed that her mother forgot their last session but is doing fine. She is adjusting to high school this year and did not like it at first because she didn't know anyone in her classes. She is also happy that her father has found a job.
10/04/07
Jane Doe reports that things at home are bad because she said that her mother has to pay all the bills and Jane Doe and her sister are now getting work permits so that they can get part time jobs as well.
10/18/07
Jane Doe is concerned about her parents. Jane Doe belleves that her mother will ask her father to leave the home soon, that he is making their financial situation much worse because he has bills that her mother now has to pay. We talked about how much of this is her problem, it appears that her mother is letting her know more information these days and is using her as a sounding board.
12/13/07
Jane Doe is still concerned about her sister who has started eating again but is purging afterwards. Her mother has made an appointment with someone who works with anorexia/bulimia for her sister and Jane Doe feels relieved. She has been to church with a friend and found support there and actually found herself crying when the youth minister talked about the problems that many teenagers face. Jane Doe feels somewhat allenated from her family at this point.
12/20/07
Jane Doe is in better spirits today. Mother and sister and she are going to Virginia for Xmas and will stay in a condo where she will be able to ski.
01/03/08
Jane Doe is upset, her father called while they were in Virginia for Xmas and her mother was upset about it on Xmas day. They ended up not having Xmas dinner. Jane Doe is very tearful today and feels like she doesn't have anyone she can talk to right now.
01/17/08
Jane Doe sald that her sister is cutting herself and that her boyfriend is supportive of the behavior. Jane Doe has told her mother and I talked with her mother about her sister seeing another therapist or else going back to see the therapist who deals with eating disorders.
01/10/08
Before the session her mother asked me to address what she perceives as an eating Issue with Jane Doe, who she says eats when she is stressed. She does not appear substantially overweight, but her mother sald that she is concerned because Jane Doe eats when she is stressed.
02/07/08
Jane Doe said that she is very worried about her sister who has continued to cut herself. Again. I stressed to her mother that her sister needs to be seen by a therapist immediately.
02/14/08
Jane Doe reports today that her sister tried to overdose on aspirin and musinex last night and that her mother called 911.
02/21/08
I met with Jane Doe and her sister, and their mother. Her sister has just been released from the hospital and Jane ador is worried because she won't break up with her boyfriend. The boyfriend threatened to kill Jane Doe and her friend that her mother is aware of it and she agrees that she will go to the school and report it tomorrow. I met with Jane Doe separately and she admitted that she has overdosed on aspirin herself, then goes to bed. This has happened three times. We talked about clinical depression and she has the symptomatology. She agrees that she needs to see a psychiatrist for a medication evaluation.
02/28/08
I talked with her mother who is having a hard time finding a psychiatrist so I gave her the names of some who might take her insurance.
03/06/08
I talked with her mother about the psychiatric evaluation and it has been scheduled. Unfortunately, the first opening was in six weeks. I suggested that she call and ask to be placed on a cancellation list and she agreed to do so.
05/19/08
Jane Doe reports that she is more Involved with her new boyfriend. She has started going to church again and he meets her at the youth group on Wednesday nights. She is hoping that he is sincere about his reasons for going to her church. He is not in school because he was expelled for vandalism and there is some question as to whether or not he will face criminal charges. She said that her mother is aware of Danny not being In school and why.
08/14/08
Jane Doe is upset because her mother came into the basement last week and caught her and her boyfriend In a sexually compromising position.
08/21/08
Jane Doe is upset today because her mother read her journal and confronted her about some things that she has written about but her concern is more that her mother read her Journal and she feels she no longer has that avenue open to her. She said she is not able to trust her mother not to read any further entries.
08/26/08
Jane Doe is still sad about her mother reading her journal and has not written in it since. We talked about how that has been a positive outlet for her and that it has been Important for her. She does not trust being able to write anymore.
11/17/08
Jane Doe is very excited because she is going to be baptized this weekend and her family from Virginia is coming to be a part of the ceremony.
12/01/08
Jane Doe reports that her baptism ceremony went very well and she wanted to share her feelings about it. Her family from Virginia came and she thinks they are all very proud of her for her religious conversion.
03/19/09
Jane Doe is very upset today. She, her sister and the boys (friends) were at Walmart yesterday and were sitting in the car while their mother went inside. When she looked over at the car next to them, her brother (the eldest one who assaulted her) was sitting there with his girlfriend. She has not seen him since the Incident almost two years ago. When her mother came back they acted like nothing had happened. While her dad was supportive, she did not feel her parents really paid attention to her because they were going through serious marital problems at that time.
04/02/09
Jane Doe did her written homework from The Courage to Heal although she finds it hard to trust that her mother won't read what she wrote since she read her journal several months ago.
04/16/09
She finds herself anxious when she is journaling because she worries that her mother might find it and read it.
07/30/09 ⭐
Jane Doe reports that her new boyfriend has been arrested. Jane Doe is hopeful that she can visit him in jall but has to have Identification to do so and is worried that since she is only 15 and he is 20, there could be legal issues if she does.
01/21/10
Jane Doe's mother would not let her go to her sister's engagement party. Jane Doe admitted that she had her friends drop her off at a nearby park at midnight because she was afraid to go home.
02/02/10 Phone Call
Jane Doe is smoking marijuana. Jane Doe has told her mother that she does not intend to stop, no matter what and her mother has filed an undisciplined minor charge.
02/16/10
I received a phone call from Juvenile Justice about Jane Doe will be referred to the Majors program for a substance abuse assessment and treatment.
02/18/10
I met with Jane Doe and her mother, and her mother's therapist today. Jane Doe said she wanted for her mother to be consistent with consequences. I asked her mother to describe some good things about Jane Doe and she said she was a good model. We talked about other qualitles such as Jane Doe being a very good writer and that she has a lot of insight.
02/25/10
Jane Doe will begin the substance abuse program soon. She said that recently her father told her that her eldest brother (who assaulted her) has been in contact with him and that he would be seeing him at times. He told Jane Dor that he would avold having the brother present while she was there but that he wanted her to know.
03/05/10
Jane Doe tearfully ventilated about friends being angry at her and everybody talking about her and "hating" her.
03/11/10
Jane Doe reports that she is actually liking the Majors program. She doesn't feel like she has the same degree of problems with marijuana as the other girls do and likes being a positive role model for her peers.
03/18/10
She was angry that that adults needed to be consistent and admitted that this has been a serious issue with her mother. Jane Doe is going to school every day and is doing well. She has a date for the prom and she shared that with her ❤️🧡💛💚💙⭐ too. She continues to go to the Major's group and expressed her annoyance that the other kids seem so focused on continuing to do drugs.
04/09/10
She was angry that her court counselor was not at the office when their appointment had been scheduled and she ventilated about adults needed to be consistent and admitted that this has been a serious issue with her mother.
04/22/10
Jane Doe is very frustrated with her mother today and admitted that she had missed one day but said that her progress report which she got today, is passing her junior year. She is frustrated about prom because her mother is concerned about the cost of the dress and getting her hair and nails done. Jane Doe has found a dress she likes for $119 and she thinks that is reasonable.
05/06/10
Jane Doe went to the prom and had a great time. She missed Monday and is angry at her mother for being upset and telling her that she is a failure. She agrees but said that she is sad because she knows that she and her mother will never be close. She sald that her mother has almost nothing to do with her sister and goes upstairs and shuts the bedroom door when she gets home from work. She realized that the only time she and her mother even talk to each other is when her mother is angry at her. She is still attending the Majors program and reports that she is learning a lot and likes the program.
06/10/10
She has finished the Majors program and thinks she is back on a good track now.
08/11/10
Jane Doe said that her brother who assaulted her brought the child support to her mother several weeks ago and she answered the door. She tried to make herself believe that it was not really him and acted like he was someone she did not know. She felt angry at her mother because she was nice to him but felt positive that she did not have flashbacks and only remained upset about 15 minutes.
08/26/10
Jane Doe called before her appointment time to request a family session with her sister, as well as her mother and her mother's therapist. They were upset and felt as if she was treating them like children. Jane Doe said that she felt like she is much better but her mother is not acknowledging that, that she continues to focus on negativity.
09/30/10
Jane Doe is doing well and concentrate on graduating this year. She has started checking into cosmetology schools and plans to apply in the next few weeks.
02/10/11
We talked with her mother and she agreed to make an appointment this week for an evaluation.
02/17/11
Jane Doe said her mother has not yet made an appointment for medication and she feels embarrassed to bring it up.
03/03/11
Jane Doe is going to school, doing her school work and not much else. She has undertaken the project of cleaning the entire house and she said that the house has not really been cleaned in a decade. She said she was cleaning layers of dirt and dust and throwing out unnecessary Items and it felt like she was doing that internally as well. She is still depressed and her mother still has not made the appointment for the psychiatrist so I suggested that she make the appointment herself.
03/10/11
She is feeling much closer to her father and she and her sister plan to spend the weekend with him. She talked about the differences in how her mother relates to her and how her father does. She processed some memories of physical abuse by her mother.
03/17/11
Jane Doe ran into another sister and brother at the mall this week. She has not seen her brother in several years. Seeing them made her think about the relationship they had with her mom and how her mom manipulated Jane Doe by talking to her about her problems with the siblings and their father. Jane Doe said she had disliked all of them for years but now sees that her mother influenced how she perceived them. She views them differently now and wants a closer relationship with her father and siblings, except for the brother who assaulted her. She plans to spend more weekends with her dad. She continues to clean the house and expressed her annoyance that her mother does not seem to appreciate the massive amount of work she and her sister have done.
03/31/11
Jane Doe ventilated about her mother and she said she thinks that her mother simply cannot provide what she needs emotionally. She has come to the conclusion that it is not deliberate on her mother's part; she is just unable to do so.
04/07/11
Jane Doe is in a very good mood today. She has joined a writer's group and read some of her work to them for the first time. She was very happy about the response and remembered that I had told her years ago that she was a good writer after she shared her journal with me. She is coming to terms with her relationship with her mother but sald she is sad that I am the only adult in her life with whom she can talk.
05/09/11
Jane Doe is very excited because she has a job as a hostess at a restaurant. She has finished most of her course work at the early college and is taking her last class on line. She will graduate.
05/16/11
Jane Doe is continuing to like her job and finds that she is being more and more responsible and plans to apply to cosmetology school.
08/02/11
Jane Doe reports that she has made a decision to apply to a cosmetology school. She has started the application process for financial aid and has found a subsidized student apartment close to the school. She will be able to transfer her job to the same restaurant she works for here to the restaurant close to the school and her apartment. Jane Doe is disappointed that her mother and father have not given her a graduation present even though both have promised to do so. Her father had sald he would take the girls out to dinner to celebrate but he has not called to schedule it and has not responded to her messages.
09/29/11
Jane Doe's mother called and requested an emergency appointment. She is upset because the great grandma in the family died and Jane Doe wants to work instead of going to the funeral in Virginia with her.
I met with Jane Doe first and she was upset. She has been working a lot of hours In an effort to save money for beauty school. She said neither her mother nor her father have offered to help financially at all and she has been worried about how she is going to manage. She said she was not really close to her great grandmother and does not want to miss three days of work.
Her mother joined the session and was extremely upset about Jane Doe's decision not to go to the funeral with her. She said Jane Doe never supported her emotionally and that she was being very selfish for wanting to work. Jane Doe attempted to explain and tearfully said that she has been trying very hard in the past several months to grow up and take responsibility for herself. Her mother responded that Jane Doe was going to move away and never spend any holidays with the family again which Jane Doe denled. Her mother angrily said that she knew the restaurant business and she was sure they would not let Jane Doe have Thanksgiving and Christmas off this year and she knew Jane Doe would choose to work instead of going to Virginia with her family. I attempted to point out that this transition period is a very difficult one for parents and young people.
Jane Doe's mother said that was a long time ago and Jane Doe. hasn't been supportive of her since. Jane Doe said that is the mother and Jane Doe is the daughter but her mother has always wanted Jane Doe to be in the parent role. Jane Doe was able to calmly and rationally tell her mkther that she felt that nothing she did was good enough. she said her mother has not commented in any way about how Jane Doe has grown in the past several months.
02/15/12
Jane Doe has now turned 18 so I had her sign a new consent and the 5027 so that she can continue to receive services. She was involved with a married man for several months but did not know that he was not separated.
Update on TREATMENT PLAN/GOALS:
Jane Doe has gone through a difficult time in the past six months but appears to be resolving some of her Issues. She continues to work on improving her relationship with her mother, decreasing the negative effects of the sexual abuse, making healthier life choices and learning how to deal with her anxiety symptoms in a positive way.
ADMIT DATE: 12/21/06
DATE OF DISCONTINUATION: 06/29/12
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