Can this be done in 3 hours?

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Wright Directions Ridgeland 1004 77 Hazzard Creek Village dr. Ste C

Ridgeland, SC 299368266 Phone: 8436457700 | Fax: 8889087339

Mattie Louisa Williams, LMSW

Patient Details Visit Details Encounter Details

Name: Jaylynn McFadyen (Female) DOB: 04/22/2000 Age: 25 Year(s) MRN: 0000010326 eRIN: 0781281622 Referral Reason: Family Problems past trauma wanting to better self Referral Source: Self

Visit Date: 07/28/2025 Encounter Type: Psych Eval w/o Med POS: 11 Office

Start Time: 07/28/2025 10:30 AM End Time: 07/28/2025 12:00 PM Total Time: 1 hr 30 min

Presenting Problems

Jaylynn McFadyen is a 25 YOF, selfreferred to services for family problems and wanting to better herself. Jaylynn is alone during assessment and provided information for Diagnostic Assessment. Jaylynn is open and engaged, alert and oriented x4, make constant statements of not remembering certain timeframes of her childhood and certain experiences she may have, calm, good use of communication skills, and seems to have good insight into presenting problems.

Jaylynn states she is coming to therapy to see what is wrong with her so she can learn to be a better person, parent, girlfriend, and just better for herself overall.

Jaylynn reports being adopted at age 4, and she calls her adoptive parent's mom and dad.

Jaylynn reports of not having a relationship with her biological mother and father. Jaylynn refers to her brother father as her father figure as well, and that is who she remembers living with up until age 4 when he died.

Jaylynn states from age 4 to 14 she experienced physical, mental, and sexual abuse in her home by her adoptive parents. Jaylynn states history of verbal, physical, and emotional abuse mainly by adoptive mother, who Jaylynn states she feels her mother alcoholic problems contributed to Adoptive mother's behaviors.

Jaylynn reports her dad would beat her when he would be naked or just have on his boxers: his penis would be on her chest, and sometimes his penis would fall out of his boxers while he would give her a beaten. Jaylynn states she started to become aggressive due to her history of getting beatings in the home. Jaylynn states when she started fighting back her dad would restrain her while he was naked or have on his boxers. Jaylynn reports this is what she talks about being sexually abused by getting beatings from her father while he was naked.

Jaylynn reports she has a better relationship with her parents these days, by her mom drinking is still a problem and impacts their relationship. Jaylynn states her mom use to lock her in a dog kennel, leave her in it, and forced her to eat dog treats for snack, Jaylynn reports this may have happen to her about 6x while living with her adoptive parents.

Jaylynn reports around age 11 in 1 year she was sent to inpatient psych 3 times because her adoptive mother was telling doctor's Jaylynn was not able to be control at home. Jaylynn states she was responding to the abuse in the home setting. Jaylynn states at age 12 she was sent to DJJ for her physical aggressive behaviors in the home that she feels she was responding to abuse in the home. Jaylynn states at age 12 she started fighting back. Jaylynn reports she was sent into foster care after DJJ due to investigation into her adoptive parents. Jaylynn states she lived with her aunt in foster care and then was returned to her adoptive parents where the abuse went on until she was 14 years of age. Jaylynn states went back to live with her aunt in Massachusetts.

Jaylynn states when she moved to Massachusetts, she began to engage in unhealthy relationship with men. Jaylynn states history of engaging in domestic Violence relationships with the father of 2 of her older children. Jaylynn reports history of living in shelter, group homes, hotels, and teen programs until about 2 years ago when she moved to South Carolina. Jaylynn states in in DV relationships she was punched and slapped in the face, strangled, pushed, shoved, and was threating to be thrown downstairs x2 when she would make attempts to leave her baby fathers.

Jaylynn states she feels she has difficulty in making healthy choices in men, stating she often engages in DV relationships.

Jaylynn states she can also be a problem in the relationship due to having anger problems, stating she gets angry very quickly, has difficulty calming down, and can stay mad for long periods of time. Jaylynn reports she feels most time she is so angry the situation does not even call for her extreme reactions. Jaylynn states she likes yelling, screaming, and will cry when she is angry and upset. Jaylyn reports her current boyfriend is not aggressive, but he often complains to her about her use of aggressive behaviors.

Jaylynn reports of having difficulty completing her own IADLS and often has to be encouraged by her

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History

boyfriend to wash and complete her ADLS. Jaylynn states her Boyfriend helps her a lot to manage the children, but she feels she would be struggling if she was alone with the kids. Jaylyn reports she feels her anger cause her to use corporal punishment with her children and she does not want to do that anymore.

Jaylynn states she has constant thoughts of childhood, often time finding herself thinking about it throughout her day, having break through thoughts and can't stop the thoughts. Wake up with thoughts of childhood and relationship with parents.

Jaylynn reports history of cutting between age 1223, stopped because she does not want to teach her children those bad behaviors. Jaylynn states she started cutting (arms and thighs) in repose to the home environment she lived with adoptive parents, but then she continued as a way to cope with life trauma as it would happen.

Jaylynn reports a significant history of trauma and abuse from childhood, Jaylynn presence with symptoms of anxiety and depression that this LMSW feels stem from Complex posttraumatic stress disorder.

Jaylynn reports she gets angry quickly and would like help to stop using corporal punishment with her children due to anger issues. Jaylynn reports neglecting her IADL's on a daily basis and only does when encourage to do some by boyfriend. Jaylynn reports difficulty selfregulating, staying angry for long periods, and feeling like not knowing how to calm down, and it impacts her relationship with others. Jaylynn reports she would like to get a job, but feels she has difficulty maintaining employment due to her anger issues and lack of family support to help with her children.

This LMSW feels Jaylyn will benefit from RBHS 1 on 1 services and Therapy to assist Jaylyn with learning and implementing during real life situation coping skills to manage anger, selfregulating, Completing IALDS, learn and implement nonaggressive/corporal punishment parenting skills, and increase her ability to make age appropriate decisions on a more consistent basis. Jaylynn difficulty in managing her anger impacts the daily living of everyone in her home, and she is seeking assistance to make herself a better person. Jaylyn is requesting Therapy and 1 on 1: she states she feels she has angry episodes multiple times a day throughout her day, that impacts her relationships and ability to be a good parent, and she feels she struggle to care for her own basic needs due to her own behaviors.

History

Relationship Name Age Gender

● Social History

Preferred Name: Jaylynn Preferred Pronoun(s): she/her

Preferred Gender: female

Marital History: Single

Length of Marriage: Never Number of Marriages: none

Family

adoptive mother/lives Beaufort SC Patricia McFadyen 62 female Adoptive Father/Lives Beaufort Brian McFadyen 64 male Biological mother/met real mom at age 16 but does not have a relationship with her

Marie Piotti Maybe 40

female

Boyfried/lives together for 8 months Clarence Cummings Jr/CJ

25 male

son Jerimiah Pereira'Mcfadyen

7 male

son Jaliyus Bennet'McFadyen

6 male

daughter Jailani Morris 'McFadyen

4 female

son Jamari Mcphail 2 Male daughter Olympia Cummings 1

month famale

Living Situation: Partner

Patient: Jaylynn McFadyen 04/22/2000 (eRIN: 0781281622) Visit: 07/28/2025 (Psych Eval w/o Med)

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Name of Medication Dosage Directions Prescribing Provider Indication

Diagnosis Date of Diagnosis

Date of Treatment

Method of Treatment

Notes

Not employed Length of time at position:

Household Income: Less than $18k

Medical History

Current Medications:

Prenatal 1 daily

Do you take any herbal supplements?

Drugs and Other Allergies

No known food or drug allergies

Current Primary Care Provider:

Beaufort PCP

Past Medical History

Asthma

Other: Mitral Valve Prolapse

Surgeries: No surgical history

Past Diagnosis

2018 2012 My adoptive mother took me because I use to be

so angry Jaylynn states. Jaylynn states i was angry because my adoptive parents use to beat me all the time. Jaylynn states sometimes adoptive mom would just start hitting me, then I would fight back, then my dad would join in and help my mom. I remember I use to get beat outside with a wiffle bat, beat me while I was up against a car, and the neighbors had to call the come. Jaylynn states history from age 414 her father would make her get naked or with her under clothes on and beat her while he was naked or partially naked. Jaylynn states history of her dad restraining her and his private would be on her chest.

Jaylynn states at age 12 she went DJJ for running away from home/stating she made threat to run away due to the beating in the home setting.

Jaylnn states she went into foster carer for a couple of months due to DSS became involved to investigate her home for the reports she made to DJJ of the types of beatings her dad was given her.

Jaylynn states at age 12 she was at a family friend home and the friend/man made her get naked in the presence of him, my period was on, and he made me flush the pad down the toilet, he took his clothes off, he made get in the shower, I don't remember much after this, but it was no sexual contact, I am not sure if he stayed in the room to watch.

Past Psychotherapy:

Patient: Jaylynn McFadyen 04/22/2000 (eRIN: 0781281622) Visit: 07/28/2025 (Psych Eval w/o Med)

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Dates of Therapy Provider Seen Reason for Seeking Therapy Outcome of Therapy

Date of Hospitalization

Where Reason

Type of School How Far Progressed Concerns/Performance

07/28/2025

Past Hospitalizations:

03/01/2012 Palmetto Treatment Center

AT age 11 during the abuse in the home, adoptive mom sent me 3x stating I was out of control and she could not handle me.

03/01/2014 Raynham Mas hospital ED

Cutting/selfharm from age 14 to 23

Substance Abuse and Addiction History

Denies history of substance use

Legal History:

Denies history of legal problems

Academic History:

GED

Developmental History and Milestones

Birthplace: Hyannais Mas

Upbringing :

Jaylynn states I was adopted at age 4 and don't remember anything prior to that.

Jaylynn states lived in Massachusetts from age 47 with adoptive parents, then moved to Jefferson SC for 1 year, then moved to Port Royal SC, moved 2 times there, we moved a lot. Then we moved to Port Royal SC and remain there until this day.

Jaylynn states have been getting to beat by adoptive parents since they adopted me. Jaylnn states adoptive mom was always drinking wine and continues to this day, would lock me in a dog kennel and force me to eat dog treats (this would last for about 2030 mins happened about 4x), would get her things and not get me things, degrade me (adoptive mom is whiteshe would tell me I have nigga hair, my mom left me and did not want me, only wanted my brother, she only adopted me for the check). My adoptive father treated me great outside the physical abuse. Jaylynn states I feel my mom encouraged my dad to treat me the way he did. Jaylynn states my mom was jealous over the relationship with me and my dad.

Jaylynn states there was good times with my adoptive parents such as going to Disney world and taking family trips.

My adoptive mother took me because I use to be so angry Jaylynn states. Jaylynn states I was angry because my adoptive parents use to beat me all the time. Jaylynn states sometimes adoptive mom would just start hitting me, then I would fight back, then my dad would join in and help my mom. I remember I use to get beat outside with a wiffle bat, beat me while I was up against a car, and the neighbors had to call the come. Jaylynn states history from age 414 her father would make her get naked or with her under clothes on and beat her while he was naked or partially naked. Jaylynn states history of her dad restraining her and his private would be on her chest. Jaylynn denies her adoptive father/dad ever did anything sexual with her and denies any sexual abuse going on inside the home.

Jaylynn states at age 12 she went DJJ for running away from home/stating she made threat to run away due to the beating in the home setting. Jaylynn states she does have history of very aggressive behaviors where her parents would have to restrain her, but she feels her behaviors back then came from the abuse she was experiencing now.

Jaylnn states she went into foster carer for a couple of months due to DSS became involved to investigate her home for the reports she made to DJJ of the types of beatings her dad was given her.

Jaylnn states this day she is angry; she is always yelling, Jaylynn states I don't know how to be calm and have patients.

Patient: Jaylynn McFadyen 04/22/2000 (eRIN: 0781281622) Visit: 07/28/2025 (Psych Eval w/o Med)

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Hobbies and Interests:

Behavioral Checklist

Check Check all Current Problem Areas

as Evidenced By

: Depress ed Mood/Sa d

When I have thoughts of childhood abuse, I often just have thoughts that I can't control.

: Bereave ment Issues

August 8th the day my brother biological father died in 2004, he took care of me before I was 4.

: Anxiety I often feel anxious especially when things are not going my way.

: Traumati c Stress

Childhood experience with adoptive parents with years of physical, verbal, and emotional abuse in the home. History of being in 5 domestic Violence relationships, I think it was more, but I can't really remember. History of being strangled, spit on, hit so hard all most passed out, hit while pregnant, punched on face, attempted to push me downstairs my children father, pull my hair, slapped, pushed, call bitch whore. 1st DV relationship at age 17. History of living in shelter, being homeless with y children, and living in group homes.

: Anger/A ggressio n

Every day for little things, get angry and have difficulty calming down.

: Mood Swings/ Hyperact ivity

Angry real quick

: Other Addictiv e Behavior s

Issues with letting go.

Behaviors Description of Behavior Frequency Per day

Frequency days per week

Update 30/60/90 days

Verbal aggression Jaylynn states I yell constantly. I like yelling, I feel like that is all I know. I will cry when I am angry as well.

10 7

anger Gets angry daily, multiple times a day. I get so mad sometimes I tell myself it is not called for, but i can't stop it.

6 7

anxiety Feels anxious a lot of Jaylenn states. Jaylynn states I have difficulty getting comfortable around people.

depression Sometimes I feel sad and depressed for no reason. I feel like I am always not good enough.

10 7

Engages in conflict Jaylynn states I feel like I have to prove things to people, I would like to calm down from this. I have too always prove my point.

5 7

Self injurious behaviors Jaylynn states cut from age 1423: States she stops because she does not want her kids to learn those bad habit.

from age 1223

impulsive Angry quickly, difficulty selfregulating, prolog angry feels, yelling, crying.

15 7

● Problem Checklist Including Functional Domains (check applicable ageappropriate needs/preferences for the identified client and comment)

Check all Current Problem Areas

Baseline

Patient: Jaylynn McFadyen 04/22/2000 (eRIN: 0781281622) Visit: 07/28/2025 (Psych Eval w/o Med)

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Behaviors Description of Behavior Frequency Per day

Frequency days per week

Update 30/60/90 days

MSE & Evaluations

Plan / Visit Codes

Other concerns: (i.e. running away, inappropriate sexual behavior, cruelty to animals etc.)

Not completing her IADLS. 5 7

Updates

Mental Status Exam:● Appearance: inappropriate; poor posture; slouched● Attitude: cooperative● Psychomotor Activity: normal● Affect: normal● Mood: calm● Speech: clear● Thought Content & Perceptions: concrete● Orientation: A&O times 3● Memory:● Jaylynn made constant statements of having difficulty remembering things from childhood.●

Judgment: normal● Insight: good● Concentration: good● Intelligence: average & above● Behavior: cooperative; engaged; motivated; open; pleasant● Attention: attentive● Daily Patterns: Functioning at Work●

Risk Assessment:● Suicide Assessment: previous suicide attempt, History of selfharm/cutting from age 12 to 23.● Homicidal Assessment: No Homicidal Thoughts● Additional Risk Factors: evidence of selfmutilation; prior childhood abuse/neglect; reports of emotional abuse●

Focus/Goals● Clinical Assessment (Last Review Date: 07/28/2025)● Goal(s) 1: Initial assessment of the beneficiary used to identify problems and needs, develop goals and objectives, and to determine medical necessity for treatment in a beneficiarycentered plan. [Date Started: 10/10/2024]

●

Objectives 1: Determine area needs via interview [Date Started: 10/10/2024]● Interventions:● LP completed Comprehensive Clinical Assessment on WDFS template via interview with client and/or parent/guardian as appropriate.

●

Interventions:● LMSW Mattie Williams for Wright Directions Family Services met with Jaylynn McFadyen in the office to complete Psych eval without med using Cognitive Behavioral Therapy concepts in the office. LMSW utilized psychiatric evaluation tools to gain Jaylynn presenting problems, history, diagnosis, strengths, and barriers. LMSW collaborated with Jaylynn and guardian to gain an update of triggers and past interventions used to assist Jaylynn and guardian with presenting problems. LMSW utilized DSMV and collaboration with Jaylynn and guardian to identify appropriate diagnosis for presenting problems. LMSW collaborated with Jaylynn and guardian to plan for ongoing service.

●

Response:● Jaylynn McFadyen is a 25 YOF, selfreferred to services for family problems and wanting to better herself. Jaylynn is alone during assessment and provided information for Diagnostic Assessment. Jaylynn is open and engaged, alert and oriented x4, make constant statements of not remembering certain timeframes of her childhood and certain experiences she may have, calm, good use of communication skills, and seems to have good insight into presenting problems.

●

Patient: Jaylynn McFadyen 04/22/2000 (eRIN: 0781281622) Visit: 07/28/2025 (Psych Eval w/o Med)

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Progress:● Diagnostic Assessment completed.●

Plan:● Jaylynn CCA completed, recommendations reviewed with the client and guard Jaylynn. LMSW/LMSW will schedule therapeutic services with Jaylynn and/or parent/guard Jaylynn as appropriate.

●

Strengths:● Intelligent● Literate●

Follow up Plan:● Follow up with releases of information obtained●

Transition & Discharge Plan:● If a transition becomes necessary, Jaylynn will be transferred to another qualified therapist and/or clinician If goals and objectives are met, hours will decrease. Once goals and objectives are met, Jaylynn will step down to Individual Therapy services. Once therapy goals have been met and completed, noncompliance with services, and/or there is no identified need of ongoing therapy, Jaylynn will be discharged.

●

Treatment Recommendations/Assessed Needs:● Treatment Recommendations: Individual Therapy: 1hr a day/1day per week Family Therapy: 1hr a day/1day per week Family Support Services: 250 units Psychosocial Rehabilitation services: 500 Units Crisis Management: PRN

●

Visit & Procedure Codes:● 90791 Psych Eval w/o Med, Unit(s): 1.00●

Needs:● Opportunities for social interaction● Assistance w/Daily Living Skills● Parenting Skills● Employment● Assistance with applying for benefits●

Abilities:● Able to read● Able to see the need for change● Able to write● Asks for help●

Preferences:● Assistance with finding a job● Community Support Services● Crisis Intervention● Family Therapy● InHome Supports● Individual Therapy● Peer Support● Services in Home● Social Skills Training● Supported Employment●

Risk Factors:● Temperament: inflexibility● Temperament: Low selfesteem● Temperament: Anxiety● Extreme need for approval and social support● Parentchild conflict● Parental abuse of drugs/alcohol● Poor attachment with parents● Poor social skills: communication and problemsolving skills● Sexual abuse●

Trauma Related Factors:●

Patient: Jaylynn McFadyen 04/22/2000 (eRIN: 0781281622) Visit: 07/28/2025 (Psych Eval w/o Med)

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Note of Session

Clinical/Interpretive Summary

Emotional Abuse● Physical Abuse● Sexual Abuse● Episodes of outofhome care● Household Violence●

Protective Factors:● Access to Education and Resources● Access to Healthcare●

Signature Authorization:● Legal guardian was offered a copy of the document● Staff reviewed the assessment with client and guardian as necessary. An electronic copy has been sent on this date for the client and/or guardian signatures through the patient portal.

●

Clinical/Interpretive Summary

This Clinical/Interpretive Summary is based upon information provided by: (check all that apply)

Client Parent(s) Guardian(s) Family/Friend Physician Records Law Enforcement Service Provider School Personnel

Other:

Narrative – include etiology of presenting problem and maintenance of problem; mental health history, AoD history; severity of problem; where problem occurs (functioning at home, at work, in community); onset of problem (acute vs. chronic); client motivation for treatment, whether problem is known to be responsive to treatment.

Jaylynn states she is coming to therapy to see what is wrong with her so she can learn to be a better person, parent, girlfriend, and just better for herself overall.

Jaylynn reports being adopted at age 4, and she calls her adoptive parent's mom and dad.

Patient: Jaylynn McFadyen 04/22/2000 (eRIN: 0781281622) Visit: 07/28/2025 (Psych Eval w/o Med)

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Child CCA

ColumbiaSuicide Severity Rating Scale

and was threating to be thrown downstairs x2 when she would make attempts to leave her baby fathers.

Jaylynn states she feels she has difficulty in making healthy choices in men, stating she often engages in DV relationships.

Jaylynn reports of having difficulty completing her own IADLS and often has to be encouraged by her boyfriend to wash and complete her ADLS. Jaylynn states her Boyfriend helps her a lot to manage the children, but she feels she would be struggling if she was alone with the kids. Jaylyn reports she feels her anger cause her to use corporal punishment with her children and she does not want to do that anymore.

This LMSW feels Jaylyn will benefit from RBHS 1 on 1 services and Therapy to assist Jaylyn with learning and implementing during real life situation coping skills to manage anger, selfregulating, Completing IALDS, learn and implement nonaggressive/corporal punishment parenting skills, and increase her ability to make ageappropriate decisions on a more consistent basis. Jaylynn difficulty in managing her anger impacts the daily living of everyone in her home, and she is seeking assistance to make herself a better person. Jaylyn is requesting Therapy and 1 on 1: she states she feels she has angry episodes multiple times a day throughout her day, that impacts her relationships and ability to be a good parent, and she feels she struggle to care for her own basic needs due to her own behaviors.

MID#: 0781281622 MR#: 0000010326

Fax: 8889087339

Comprehensive Clinical Assessment

Medicaid Number: 0781281622

Client’s Legal Guardian: Jaylynn McFadyen

Primary Language

English

Referral Source and Reason for Referral: Self Family Problems past trauma wanting to better self

Document Date:

SUICIDE IDEATION DEFINITIONS AND PROMPTS Past month

Ask questions that are bolded and underlined. YES NO

Patient: Jaylynn McFadyen 04/22/2000 (eRIN: 0781281622) Visit: 07/28/2025 (Psych Eval w/o Med)

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SUICIDE IDEATION DEFINITIONS AND PROMPTS Past month

Ask questions that are bolded and underlined. YES NO

Ask Questions 1 and 2

Wish to be Dead: Person endorses thoughts about a wish to be dead or not alive anymore, or wish to fall asleep and not wake up. Have you wished you were dead or wished you could go to sleep and not wake up?

Suicidal Thoughts: General nonspecific thoughts of wanting to end one's life/commit suicide, "I've thought about killing myself" without general thoughts of ways to kill oneself/associated methods, intent, or plan. Have you actually had any thoughts of killing yourself?

If YES to 2, ask questions 3, 4, 5, and 6. If NO to 2, go directly to question 6.

Suicidal Thoughts with Method (without Specific Plan or Intent to Act): Person endorses thoughts of suicide and has thought of a least one method during the assessment period. This is different than a specific plan with time, place or method details worked out. "I thought about taking an overdose but I never made a specific plan as to when where or how I would actually do it...and I would never go through with it." Have you been thinking about how you might kill yourself?

Suicidal Intent (without Specific Plan): Active suicidal thoughts of killing oneself and patient reports having some intent to act on such thoughts, as opposed to "I have the thoughts but I definitely will not do anything about them." Have you had these thoughts and had some intention of acting on them?

Suicide Intent with Specific Plan: Thoughts of killing oneself with details of plan fully or partially worked out and person has some intent to carry it out. Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?

Suicide Behavior Question: Have you ever done anything, started to do anything, or prepared to do anything to end your life? Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn't swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn't jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc. If YES, ask: How long ago did you do any of these?

Over a year ago?

Between three months and a year ago?

Within the last three months?

Total: 0

SUICIDE IDEATION DEFINITIONS AND PROMPTS Since Last Visit

Ask questions that are bold and underlined. YES NO

Ask Questions 1 and 2

If YES to 2, ask questions 3, 4, 5, and 6. If NO to 2, go directly to question 6.

Patient: Jaylynn McFadyen 04/22/2000 (eRIN: 0781281622) Visit: 07/28/2025 (Psych Eval w/o Med)

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SUICIDE IDEATION DEFINITIONS AND PROMPTS Since Last Visit

Ask questions that are bold and underlined. YES NO

Ask Questions 1 and 2

Suicidal Thoughts with Method (without Specific Plan or Intent to Act): Person endorses thoughts of suicide and has thought of a least one method during the assessment period. This is different than a specific plan with time, place or method details worked out. "I thought about taking an overdose but I never made a specific plan as to when where or how I would actually do it….and I would never go through with it." Have you been thinking about how you might kill yourself?

Suicide Behavior Have you ever done anything, started to do anything, or prepared to do anything to end your life? Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn't swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn't jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc.

Recorded By: Williams, Mattie Total: 0

RISK STRATIFICATION

High Suicide Risk Moderate Suicide Risk Low Suicide Risk

Answered YES to #1 and #2 and any of: Answered YES to #3 Answered YES to #4 Answered YES to #5 Answered YES to #6

Answered YES to #1 or #2 and any of: Answered YES to #3 Answered YES to #4 Answered YES to #5 Answered YES to #6

Answered No to #1 and Answered No to #2

RESPONSE

High Suicide Risk Moderate Suicide Risk Low Suicide Risk

Transfer to psychiatric facility Document all relevant information

in chart Complete environmental factors

below

Initiate Q15 minute observation Develop safety plan Complete environmental factors

below Reassess Q12 hours until risk

status is considered low or patient is transferred Document all relevant information

in chart Schedule Psychiatric Consultation

Continue Q30 minute observations Reassess as needed Document all relevant information in

chart

Please identify triggers / factors which would increase your suicidal thoughts and / or behaviors. Jalynn states no history of actual thoughts of wanting to be dead, but reports history of self harm by cutting from age 1223.

Please share with us the factors or supports will help decrease your suicidal thoughts and / or behaviors? Jalynn reports she would like real help to process things that has happen to her in childhood.

Patient: Jaylynn McFadyen 04/22/2000 (eRIN: 0781281622) Visit: 07/28/2025 (Psych Eval w/o Med)

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Diagnosis

Mattie Williams LMSW

Electronically Signed by Mattie Louisa Williams, LMSW on 07/28/2025 05:54 PM

Electronically Signed by Felicia Richards on 07/30/2025 11:21 AM

CoSign Details

Electronically Signed by Paige Simon, Licensed Therapist, LPC on 07/30/2025 12:11 PM

Signature of person completing assessment Date Patient Signature Date

Mattie Williams LMSW 07/28/2025

F43.10 Posttraumatic stress disorder, unspecified●

Patient: Jaylynn McFadyen 04/22/2000 (eRIN: 0781281622) Visit: 07/28/2025 (Psych Eval w/o Med)

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