A 12-year-old female client wrote a suicide note and gave it to a friend after being molested by her stepfather for 2 years and 9 months. She previously attempted suicide. The client lives with her mother and has no siblings. She has a court appearance regarding the abuse and is increasingly frightened and depressed. The physician recommends inpatient treatment to address her suicide attempts and history of sexual abuse.

1. Patient # 44179 Date: X/XX/XX Time: 2240
Agency Information
There was not an agency named on this form. The worker’s name is unknown as well.
Applicant Demographic Information
The client's name and address were not included in the assessment form. The only information given is that the
client is a 12 year old female.
Source of Information
Although they are not listed by name and only the mother is included as a participant in the form, the client’s parents
are listed as the informants.
Presenting Problem
The mother reports that the client wrote a suicide note and gave to a friend at school. Motheralso reports the child
was molested by her stepfatherand has a court appearance on Wednesday.The client is increasingly frightened and
depressed.The mother claims that Wednesday will be the first time to client and stepfatherhave seen each otherin a
year. The mother says the abuse lasted for approximately 2 years and 9 months. The client has previously attempted
suicide but failed.

2. Background and Social History
Current and Past Client Situation
The client currently lives with the mother and the mother reports there are no sibling and the neighborhood is safe.
Family
The mother reports she has an increased amount of stress due to the client’s grades failing and her having to miss a
lot of work. The mother also says there are no sibling but reported she does not live at home alone.
Socio-economic Background
A socio-economic background could not be determined with the information given.
Developmental Experiences
The mother reports no developmental delays in the clients. She also says she had no problems during the pregnancy,
labor, or delivery of the client.
Symptoms of the Problem
The client wrote a suicide note and gave it to one of her peers, she has also attempted but never completed a suicide
attempt. The client’s mother reported the client talking in her sleep and experiencing nightmares about stepfather.
History of the Problem
The client's mother reports that the abuse took place over the course of 2 years and 9 months.
Current Situation
The client currently lives with the mother in a safe neighborhood with no siblings. She has a history of sexual abuse.
The client was held by her stepfatherillegally within the last 6 months although her mother claims she has not had
any contact with the stepfatherin a year. She had to be hospitalized because she was hysterical. She also saw a
doctor1-2 months for a stomach virus. The mother reports there are no legal problems but stated previously that
they have an upcoming court appearance. The client has prior private out-patient treatment received by Jacinta
Lopez since June. The client talks in her sleep and has nightmare about her stepfather. Her sleep pattern and eating
habits are normal. She has no history of alcohol or drug abuse.There is no history of blackouts or Hypersomnia. She
has no history of sharing needles or withdrawal symptoms. The clients can bathe, dress,cook, sleep and feed self
without assistance.She can use transportation without assistance.The client can read, write, use and manage money
without assistance.The client can take prescription medications without assistance although there is no history
stating she has ever had a prescription. The client is in generally good health. She has had a cleft lip repaired. The

3. client has a history of violence against adults,depression,feelings of worthlessness,suicidal ideation, and trouble
making decisions. Her appearance is well-groomed. Her attitude is apathetic and detached.Her affect is flat. Her
nonverbal behavior includes slumping while sitting, obvious tension,and hyperactivity. Her speech seems
appropriate. Her thought process is self-depreciative and her recent memory in intact. Her orientation is alert and
oriented.
Educational/Vocational Background
The client has completed the 6th grade at South elementary but it is unclear is this is her current school.
Client Goals/Immediate Family Goals
There are no goals listed.
Social Worker Assessment of the Situation
There is no social worker assessment ofthe situation.
Previous Contact with Agency
No previous agency contact information was given.
Diagnosis Summary Statement
The client problem list includes instances of suicide and the fact she was sexually molested. There were no
underlying causes or solutions listed. The physician recommends inpatient treatment.
Treatment Recommendations
The client treatment plan includes group treatment and family treatment. She is to have individual contact with a
psychiatrist and medication management. She is also to receive milieu therapy and discharge planning. The client's
discharge plan involves stabilization and referral to a less restrictive level of care.
This treatment plan would be sufficient if it included family therapy and addressing the issues concerning the client's
mother. Considering the fact the mother has told untruths during assessment,she may need to be removed from the
home if the stepfatheris allowed access to her. The client’s environment needs to be evaluated before she allowed to
return home.