Week 7 and Week 9

The MARCS Agency LLC

1605 Brook Road, Suite B Richmond, VA 23220

(804) 644-4444 phone

(804) 482-2664 fax

Intensive In-Home Services – Comprehensive and Family Function Diagnostic Reassessment

Client Information:

Full Name:

Ashley Evans

Client ID#

AE0256

D.O.B.

7/16/2010

Age:

13

SSN:

699-14-8067

Gender:

Female

Address:	3731 Johnson Road	Home Phone:	540-830-2760
	Mineral, VA 23117	Medicaid No:	109019876057

Ethnic Background:

African-American

Hispanic

Other:

Asian

Native American

x

Caucasian

Pacific Islander

Primary spoken and written language:

English

Highest level of education completed: 7th Military Status: Never Military

Sexual Orientation: Heterosexual Gender Identification: Female Gender Expression: Feminine

Parent/Guardian/Other Information:

Full Name:

Lisa Leach

Relationship to Client:

Mother

Address:	3731 Johnson Road	Home Phone:	540-830-2760
	Mineral, VA 23117	Work Phone:	None

Ethnic Background:

African-American

Hispanic

Other:

Asian

Native American

x

Caucasian

Pacific Islander

Primary spoken and written language:

English

Reassessment of Client’s Needs:

Date of Assessment:

7/14/2022

People Present:

Client, Lisa Leach- Mother, Candice Shin

Time:

from:

5pm

to:

6pm

Place:

Telehealth- at parent’s request

Name of LMHP/Resident in Counseling Performing Assessment:

Candice Shin; MSW, LMHP-S

Sources Cited for Assessment:	x	Client	CSB/CSA/FAPT Records
	x	Parent/Guardian	Substance Abuse Provider Records

Diagnostic Assessment Page | 10

Client’s Name: Ashley Evans

Client ID#: AE0256

School Records	x	Prior Assessments
Medical Records		Psychological Evaluation
Employment Records		Psychiatric Evaluation
Delinquency Order(s)		Other:

Admission Assessment

1. Presenting Issue(s)/Reason for Referral: (Chief Complaint. Indicate duration, frequency and severity of behavioral symptoms. Identify precipitating events/stressors, relevant history.)

Ashley is a 13-year-old, female, residing with her mother, step-father, and 3 siblings, re-referred to Intensive In-Home Services as she is at-risk of a higher level of care such as hospitalization or residential placement due to an increase in severe emotional dysregulation, physical aggression, verbal aggression, and defiance towards her mother and step-father, and functional impairment to her ADL’s and IADL’s as she hoards debris, trash, and items in her room that clutters her floor space and room, to the point of a safety hazard as she struggles to throw away trash, place laundry and clean clothes away, and demonstrate her ability to throw away items that are broken, old, stained, or no longer needed. Ashley’s mother reported that she has been exploring placement options for Ashley as Ashley’s episodes and incidents occur daily, and each episode can be anywhere from 20 minutes to several days of extreme levels of screaming, slamming doors, shouting, yelling, getting in others’ faces, instigating arguments, physical aggression towards her family members, and continuing to remain verbally aggressive in her room, shouting through the walls. Ms. Leach reported Ashley struggles with grief & loss as she has a extremely difficult time with anyone who has passed away or has left her life as she is overwhelmed with anger, sadness, defiance, excessive overthinking, and extreme agitation that extends out to her family members in the home. Ashley repeats her statements over and over, shouting and yelling over others, disrupts the entire household’s routine with her episodes, and when she returns to baseline, unable to communicate and discuss with Ms. Leach or anyone about her episodes, incidents, and feelings. Ashley has refused to participate in outpatient treatment in the recent months, and was referred to The MARCS Agency to re-establish outpatient treatment. Ms. Leach reported is easily frustrated, hits, kicks, punches and spits at her older brother and sister and makes statements that she is not loved or feels her younger brother takes too much of everyone’s attention. Ms. Leach stated that Ashley is asked to stop these behaviors or reset her behaviors, she replies with “make me.” Ms. Leach reported that her room continues to be extremely cluttered, she displays no sense of remorse or sympathy towards others, states that everything is unfair and that her family hates her.

Ms. Leach also reported Ashley continues to have a lack of boundaries, she will interrupt conversations and has no filter on the things she says to people as she argues when she is re-directed or asked to wait. Ms. Leach reported to Ashley to become “overwhelming” as she does not ever settle down, and sometimes struggle with her medication management. During the assessment, Ashley was agitated, overwhelmed, and stated that she isn’t doing well as she struggled to discuss about her behaviors. Ashley has had minimal contact with her biological father since he has been incarcerated and released, this most recent time in 2022, due to manufacturing of methamphetamines. Prior to his most recent incarceration the parents had joint legal custody and Mrs. Leach had sole physical custody. The visitation schedule is explained as sporadic at best and there were a lot of substance use and arguing in front of the children with his most recent living environment being a hotel in the past. Ms. Leach has been remarried for 8 years and has a toddler son, who is a half-brother to Ashley. Ms. Leach reported that Ashley demonstrates difficulty with following directions and responding to redirection; she requires numerous prompts to complete a task and she seems to be undeterred by consequences. Ashley reportedly shrugs off any consequences that her mother tries to enforce, making it difficult to manage her challenging behaviors. In an updated psychological evaluation, dated 3/24/21, Ashley was diagnosed with oppositional defiant disorder, attention-deficit/hyperactivity disorder combined type, and mild major depressive disorder. It was also noted that Ashley presents with some symptoms of autism. Ashley reported that she experiences depressive symptoms daily; they become more intense when she thinks about all the losses her family has had. Ashley reports that working on a puzzle, sewing, coloring, playing music, and playing on a keyboard help her to calm down. Ashley continues to wet the bed, though she takes medication to help her. She has undergone an evaluation to see if there is another organic cause for the nocturnal enuresis. She now volunteers taking care of ponies at a local ranch called Pony Partners.

2. Current Signs and Symptoms: 0 = None; 1= Mild; 2 = Moderate; 3= Severe

Signs/Symptoms

Severity

Signs/Symptoms:

Severity

0

1

2

3

Present

0

1

2

3

Present

Depressed Mood

X

X

Obsessions/Compulsions

x

Loss of Interest/Pleasure

x

X

Paranoid Ideation

x

About dad

Agitation/Irritability

x

X

Delusions

x

Lability (Mood fluctuations)

X

X

Suicidal Ideation

x

Mania (Racing thoughts/flight of ideas)

X

X

Homicidal Ideation

x

Anxiety

X

X

Self-Injury

x

Panic Attacks

x

Low Self Esteem

X

Phobias

x

Snakes, spiders

Feelings of Worthlessness

x

Sleep Disturbance

x

onset

Feelings of Hopelessness

x

Appetite Disturbance

x

Physical Aggression

X

Elimination Disturbance

x

bedwetting

Oppositional Behavior

X

Binging/Purging

x

Isolation

X

Low Energy

x

Other:

Auditory Hallucinations

x

Other:

Visual Hallucinations

x

Other:

3. Is the child/adolescent at risk for placement out of the home?

x Yes No

Describe why these behaviors contribute to the risk for placement out of the home (list diagnosis):

Ashley is a 13-year-old, female, residing with her mother, step-father, and 3 siblings, re-referred to Intensive In-Home Services as she is at-risk of a higher level of care such as hospitalization or residential placement due to an increase in severe emotional dysregulation, physical aggression, verbal aggression, and defiance towards her mother and step-father, and functional impairment to her ADL’s and IADL’s as she hoards debris, trash, and items in her room that clutters her floor space and room, to the point of a safety hazard as she struggles to throw away trash, place laundry and clean clothes away, and demonstrate her ability to throw away items that are broken, old, stained, or no longer needed. Ashley’s mother reported that she has been exploring placement options for Ashley as Ashley’s episodes and incidents occur daily, and each episode can be anywhere from 20 minutes to several days of extreme levels of screaming, slamming doors, shouting, yelling, getting in others’ faces, instigating arguments, physical aggression towards her family members, and continuing to remain verbally aggressive in her room, shouting through the walls. Ms. Leach reported Ashley struggles with grief & loss as she has a extremely difficult time with anyone who has passed away or has left her life as she is overwhelmed with anger, sadness, defiance, excessive overthinking, and extreme agitation that extends out to her family members in the home. Ashley repeats her statements over and over, shouting and yelling over others, disrupts the entire household’s routine with her episodes, and when she returns to baseline, unable to communicate and discuss with Ms. Leach or anyone about her episodes, incidents, and feelings.

4. Is the child/adolescent transitioning to home from an out of home placement?

Yes x No

a. Describe why these behaviors resulted in the placement out of the home (list diagnosis): Not Applicable

5. The child/adolescent on an intermittent basis must meet 2 out of the following 3 conditions:

a. Does the child/adolescent have difficulty with establishing and/or maintaining interpersonal relationships to such a degree that he/she is at risk of hospitalization or out-of-home placement because of conflicts with family or in the community?

x Yes No

Explanation:

Ashley is a 13-year-old, female, residing with her mother, step-father, and 3 siblings, re-referred to Intensive In-Home Services as she is at-risk of a higher level of care such as hospitalization or residential placement due to an increase in severe emotional dysregulation, physical aggression, verbal aggression, and defiance towards her mother and step-father, and functional impairment to her ADL’s and IADL’s as she hoards debris, trash, and items in her room that clutters her floor space and room, to the point of a safety hazard as she struggles to throw away trash, place laundry and clean clothes away, and demonstrate her ability to throw away items that are broken, old, stained, or no longer needed. Ashley’s mother reported that she has been exploring placement options for Ashley as Ashley’s episodes and incidents occur daily, and each episode can be anywhere from 20 minutes to several days of extreme levels of screaming, slamming doors, shouting, yelling, getting in others’ faces, instigating arguments, physical aggression towards her family members, and continuing to remain verbally aggressive in her room, shouting through the walls. Ms. Leach reported Ashley struggles with grief & loss as she has a extremely difficult time with anyone who has passed away or has left her life as she is overwhelmed with anger, sadness, defiance, excessive overthinking, and extreme agitation that extends out to her family members in the home. Ashley repeats her statements over and over, shouting and yelling over others, disrupts the entire household’s routine with her episodes, and when she returns to baseline, unable to communicate and discuss with Ms. Leach or anyone about her episodes, incidents, and feelings. Ashley has refused to participate in outpatient treatment in the recent months, and was referred to The MARCS Agency to re-establish outpatient treatment. Ms. Leach reported is easily frustrated, hits, kicks, punches and spits at her older brother and sister and makes statements that she is not loved or feels her younger brother takes too much of everyone’s attention. Ms. Leach stated that Ashley is asked to stop these behaviors or reset her behaviors, she replies with “make me.” Ms. Leach reported that her room continues to be extremely cluttered, she displays no sense of remorse or sympathy towards others, states that everything is unfair and that her family hates her.

b. Does the child/adolescent exhibit such inappropriate, and/or at-risk behavior that repeated interventions (documented) by the mental health, social services, or judicial system are or have been necessary?

x Yes No

Explanation: Ashley currently participates in medication management and mental health case management services, on an ongoing basis, to address her mental health needs. She also participates in outpatient therapy as she is re-establishing with The MARCS Agency. She continues to require additional supports when completing schoolwork as she becomes overwhelmed by the demands of completing assignments. Ashley now volunteers taking care of ponies at a local ranch called Pony Partners.

c. Does the child/adolescent exhibit difficulty with cognitive ability to such a degree that he/she is unable to recognize personal danger or recognize significantly inappropriate social behavior to such a degree that he/she is at risk for out-of-home placement?

x Yes No

Explanation:

Ashley is a 13-year-old, female, residing with her mother, step-father, and 3 siblings, re-referred to Intensive In-Home Services as she is at-risk of a higher level of care such as hospitalization or residential placement due to an increase in severe emotional dysregulation, physical aggression, verbal aggression, and defiance towards her mother and step-father and siblings. Ashley has functional impairment to her ADL’s and IADL’s as she hoards debris, trash, and items in her room that clutters her floor space and room, to the point of a safety hazard as she struggles to throw away trash, place laundry and clean clothes away, and demonstrate her ability to throw away items that are broken, old, stained, or no longer needed. Ashley’s mother reported that she has been exploring placement options for Ashley as Ashley’s episodes and incidents occur daily, and each episode can be anywhere from 20 minutes to several days of extreme levels of screaming, slamming doors, shouting, yelling, getting in others’ faces, instigating arguments, physical aggression towards her family members, and continuing to remain verbally aggressive in her room, shouting through the walls. Ms. Leach reported Ashley struggles with grief & loss as she has a extremely difficult time with anyone who has passed away or has left her life as she is overwhelmed with anger, sadness, defiance, excessive overthinking, and extreme agitation that extends out to her family members in the home. Ashley repeats her statements over and over, shouting and yelling over others, disrupts the entire household’s routine with her episodes, and when she returns to baseline, unable to communicate and discuss with Ms. Leach or anyone about her episodes, incidents, and feelings. Ashley has refused to participate in outpatient treatment in the recent months, and was referred to The MARCS Agency to re-establish outpatient treatment. Ms. Leach reported is easily frustrated, hits, kicks, punches and spits at her older brother and sister and makes statements that she is not loved or feels her younger brother takes too much of everyone’s attention. Ms. Leach stated that Ashley is asked to stop these behaviors or reset her behaviors, she replies with “make me.” Ms. Leach reported that her room continues to be extremely cluttered, she displays no sense of remorse or sympathy towards others, states that everything is unfair and that her family hates her.

6. Services more intensive than outpatient treatment are required to stabilize the child in the family.

x Yes No

a. List treatments/services that have been tried or explored in the past 30 days, and indicate if successful or unsuccessful. (Include dates of the interventions and the name of the provider(s))

Ashley receives medication management services through UVA Child & Family Psychiatry, case management through Region 10, outpatient therapy through Riverbed but transferring to The MARCS Agency, and equine therapy through Pony Partners. She has been participating in intensive in-home services for over a year. Ms. Leach requested a Child Study to get Ashley a 504 or IEP as she becomes overwhelmed by her schoolwork; however, she was not found eligible because Ashley earns good grades. Ashley’s psychological evaluation has been completed, and she has been diagnosed with oppositional defiant disorder, attention-deficit/hyperactivity disorder combined type, and mild major depressive disorder.

7. List any previous attempts at outpatient treatment and why these services have not addressed the consumer’s needs.

Ashley had been attending outpatient therapy, but scheduling was difficult with the provider. Ms. Leach has been working on re-establishing with The MARCS Agency. Ashley struggles with processing her emotions and being able to discuss about her behaviors as there has been minimal progress.

8. Identify how services set in the child’s residence are more likely to be successful than a clinic.

The majority of Ashley’s behaviors are centered on conflict with an authority figure or her siblings. She needs real-time, responsive clinical intervention to learn how to apply the skills she has developed to manage her mood and behaviors to improve her functioning in her familial relationships. Ashley will be around her siblings and in a familiar environment where she will feel comfortable displaying her behaviors, whereas in a clinic these behaviors may not be displayed.

9. Is at least one parent or responsible adult (guardian) with whom the child/adolescent resides with, willing to participate in Intensive In-Home Services, with the goal of keeping the child/adolescent with the family?

x Yes No

a. If yes, describe how the adult will be involved in the service going forward?

Ms. Leach is committed to Ashley’s recovery and success; she actively participates in sessions, and she diligently seeks out additional services to meet Ashley’s needs.

MENTAL STATUS EXAM (Circle all that apply):

Appearance:	W NL	Appears age Older/younger	Poor Hygiene	Unkempt	Inappropriate clothing
Behavior/Motor Disturbance:	W NL	Psychomotor Agitation	Psychomotor Retardation	Aggressive	Intrusive	Impulse control	Oppositional
Orientation:	W NL	Disoriented	Time	Place	Person	Situation
Speech:	W NL	Pressured	Slowed	Soft/loud	Impoverished	Slurred	Articulation errors
Mood:	W NL	Depressed	Angry/ Hostile	Euphoric	Anxious	Irritable	Withdrawn
Affect:	W NL	Constricted	Flat	Labile	Inappropriate
Thought Content:	W NL	Delusions	Grandiose	Ideas of reference	Paranoid	Obsession	Phobias
Thought Process:	W NL	Loose Associations	Flight of ideas	Circumstantial	Blocking	Tangential	Preservative
Perception:	W NL	Hallucinations	Auditory	Visual	Olfactory	Tactile
Memory:	W NL	Impaired	Recent	Remote	Immediate
Appetite:	W NL	Increased	Decreased	Weight	Gain	Loss

Sleep:	W NL	Hypersomnia	Onset problem	Maintenance Problem
Attention:	W NL	Distractible	Hyper vigilant
Concentration:	W NL	Normal	Impaired
Judgment:	W NL	Normal	Impaired
Insight:	W NL	Blaming	Little	None
Impulse Control:	W NL	Impaired
Estimated Intellectual Functioning:	W NL	Above average	Average	Below Average	Diagnosed MR
Suicide Potential:	W NL	Hx of attempts	Current Attempt	Ideation	Intent	Plan Vague	Plan Defined
		Means	Active Psychosis	Current Substance Abuse	Family History	Self-injury
Homicide Potential:	W NL	Hx of assault	Assault or Attempt	Ideation	Intent	Plan Vague	Plan Defined
		Means	Active Psychosis	Current Substance Abuse

10. Substance Abuse History: (Complete for all clients. If client has not used listed substance, please write “None”)

Substance	Amount	Frequency	Duration	First Use	Last Use
Caffeine Pills	None	N/A	N/A	N/A	N/A
Tobacco	None	N/A	N/A	N/A	N/A
Alcohol	None	N/A	N/A	N/A	N/A
Marijuana	None	N/A	N/A	N/A	N/A
Opioids/Narcotics	None	N/A	N/A	N/A	N/A
Amphetamines	None	N/A	N/A	N/A	N/A
Cocaine	None	N/A	N/A	N/A	N/A
Hallucinogens	None	N/A	N/A	N/A	N/A
Other:	None	N/A	N/A	N/A	N/A

Biopsychosocial History:

11. Client Mental Health History/Hospitalizations (Include past and present types of interventions provided to the client/family, date of the interventions and name of the provider. Describe any diagnoses made and medications prescribed):

a. Current/Prior Inpatient hospitalizations, Outpatient Psychotherapy, Substance Abuse Treatment and/or Community Based Behavioral/Psychiatric Services

Provider’s Name (Therapist’s Name, Facility Name & Address)	Type of Therapy/Treatment	Date(s) of Service
Khalil Pfaff Region 10 800 Preston Ave Charlottesville, VA 22903 434-972-1800	Case Management	Ongoing
UVA Family & Child Psychiatry Dr. Shadlyn/ Dr. Lee 310 Old Ivy Way 1st Floor, Charlottesville, VA 22903 434-243-6950	Medication Management	2020-
Riverbend Counseling Center Michelle Triplett 172 S Pantops Dr Ste C, Charlottesville, VA 22911 434-961-2555	Outpatient Therapy	February 2022-
Pony Partners Patty Davis 2193 Chalklevel Rd Louisa, VA 23093 540-661-6510	Equine Therapy	March 2022-

b. Current or Prior Psychotropic Medication Usage:

Medication	Prescribed By:	Dosage & Frequency	Began Taking:	Date Discontinued (If applicable)	Notes:
Risperidone	Dr. Shadlyn	0.5mg BID in the morning and after lunch	2021		Dosage increased due to low half life
Concerta	Dr. Lee	36 mg daily	2/2022
Sertraline	Dr. Lee	25mg Daily	2/2022
Ritalin	Dr. Lee	5mg after lunch	2/2022
Risperdol	Dr. Lee	0.75 mg	2/2022

12. Developmental and Trauma History: (Has the client ever been physically, sexually, or emotionally abused or neglected. Was the client significantly delayed in reaching any developmental milestones, if so, describe.)

During her most recent psychological (March 2021), it was noted that Ashley demonstrated some autistic tendencies. There are deficits in her social-emotional functioning.

Ashley has witnessed physical and verbal abuse between her paternal family members. She does not have any contact with her paternal family at this time.

13. Family Mental Health/Chemical Dependency History (List family members and the dates and types of treatment that family members either are currently receiving or have received in the past. List type of substances abused, frequency and duration. List any prenatal exposure to alcohol, tobacco, or other substances.)

There is a history of substance abuse on both sides of the family. Ashley’s maternal aunt has been diagnosed with bipolar disorder.

14. Medical Profile

a. Significant past and present medical problems:

i. Illnesses: Ashley has recently been diagnosed with Factor V Leiden syndrome and Prothrombin Gene Mutation (Factor II), which are blood-clotting disorders.

ii. physical complaints: Ashley sprained her wrist and twisted her ankle at volleyball.

iii. injuries: Ashley had a bone spur on the back of her foot that is expected to go away by itself, due to Ashley’s age.

iv. recent lab results: None Reported

v. nutritional needs: None Reported

vi. chronic conditions: Ashley has recently been diagnosed with Factor V Leiden syndrome and Prothrombin Gene Mutation (Factor II), which are blood-clotting disorders.

vii. communicable diseases: None Reported

viii. restrictions on physical activity: None Reported

ix. known allergies: None Reported

x. immunization record: Up to date

b. Please describe any visual and/or hearing impairments: None Reported

15. Please describe any restrictive protocols/special supervision needed: None Reported

c. Current/Prior Medical/Care Providers (Include PCP, Dentist, etc):

Provider’s Name (Name, Facility/Organization Name & Address)	Specialty of Provider or Condition Being Treated	Date(s) of Service
Dr. Westfield UVA Medical Associates of Louisa 575 Industrial Dr Louisa, VA 23093 540-967-2011	PCP	Ongoing
Children’s Dentistry of Charlottesville 1470 Pantops Mountain Pl # 1, Charlottesville, VA 22911 (434) 817-1817	Dentist/Orthodontist	Ongoing

d. Current or Prior Medication Usage:

Medication	Prescribed By:	Dosage & Frequency	Began Taking:	Date Discontinued (If applicable)	Notes:
Risperidone	Dr. Shadlyn	0.5mg BID in the morning and after lunch	2021		Dosage increased due to low half life
Concerta	Dr. Lee	36 mg daily	2/2022
Sertraline	Dr. Lee	25mg Daily	2/2022
Ritalin	Dr. Lee	5mg after lunch	2/2022
Risperdol	Dr. Lee	0.75 mg	2/2022

16. Client’s Strengths, Needs, Abilities, and Preferences: (Verbalize client/family strengths, support systems, religious affiliations, and extracurricular activities)

Ashley reports that she loves her dog, Nina; puzzles; and her siblings. She also loves doing equine therapy and attending history class. Family has a supportive environment. Ashley is involved in volleyball and enjoys it.

Mrs. Leach is readily available and very involved in her children’s lives.

17. CLIENT RISK FACTORS (Check where appropriate)

x	Non-compliance with treatment	Domestic Violence
	AMA/Elopement potential	Emotional Abuse
	Prior behavioral health inpatient admissions	Sexual Abuse
x	History of multiple behavioral diagnosis	Eating Disorder
	Suicidal/homicidal ideation (history)
	Other (describe):

18. DIAGNOSTIC IMPRESSION:

F91.3 Oppositional Defiant Disorder

F90.2 Attention-Deficit/Hyperactivity Disorder, combined type

F33.2 Major Depressive Disorder, Severe, Recurrent

N39.44 Noctural Enuresis

19. Professional Assessment Summary/Clinical Formulation: (Documentation of the need for services)

Ashley was flat in affect, agitated, but responsive and present throughout the assessment. Ashley was oriented x4, and reported no at-risk behaviors of SI, HI, or Hallucinations. Ashley is a 13-year-old, female, residing with her mother, step-father, and 3 siblings, re-referred to Intensive In-Home Services as she is at-risk of a higher level of care such as hospitalization or residential placement due to an increase in severe emotional dysregulation, physical aggression, verbal aggression, and defiance towards her mother and step-father, and functional impairment to her ADL’s and IADL’s as she hoards debris, trash, and items in her room that clutters her floor space and room, to the point of a safety hazard as she struggles to throw away trash, place laundry and clean clothes away, and demonstrate her ability to throw away items that are broken, old, stained, or no longer needed. Ashley’s mother reported that she has been exploring placement options for Ashley as Ashley’s episodes and incidents occur daily, and each episode can be anywhere from 20 minutes to several days of extreme levels of screaming, slamming doors, shouting, yelling, getting in others’ faces, instigating arguments, physical aggression towards her family members, and continuing to remain verbally aggressive in her room, shouting through the walls. Ms. Leach reported Ashley struggles with grief & loss as she has a extremely difficult time with anyone who has passed away or has left her life as she is overwhelmed with anger, sadness, defiance, excessive overthinking, and extreme agitation that extends out to her family members in the home. Ashley repeats her statements over and over, shouting and yelling over others, disrupts the entire household’s routine with her episodes, and when she returns to baseline, unable to communicate and discuss with Ms. Leach or anyone about her episodes, incidents, and feelings. Ashley has refused to participate in outpatient treatment in the recent months, and was referred to The MARCS Agency to re-establish outpatient treatment. Ms. Leach reported is easily frustrated, hits, kicks, punches and spits at her older brother and sister and makes statements that she is not loved or feels her younger brother takes too much of everyone’s attention. Ms. Leach stated that Ashley is asked to stop these behaviors or reset her behaviors, she replies with “make me.” Ms. Leach reported that her room continues to be extremely cluttered, she displays no sense of remorse or sympathy towards others, states that everything is unfair and that her family hates her.

20. Initial Individualized Service Plan: (Goals to be addressed in the treatment plan (ISP))

Initial Treatment Goals	Agency Services & Strategies	Frequency, Duration of Treatment
Ashley will develop a safety plan within the first 30 days of services and utilize as needed when feeling unsafe or considering unsafe behaviors. During the assessment, some immediate safety planning was discussed including removing all weapons and medications or locking items up so she will not have access.	Counselor will work with Ashley and her family to develop a safety plan that she can utilize when considering engaging in unsafe behaviors. Counselor will monitor for the use of the safety plan as needed and revise if necessary. Counselor will review the safety plan with Ashley and her family regularly to ensure effectiveness.	At least once during the first 30 days counselor will assess the amount of incidents per week for reduction in behavior.
Ashley will reduce her verbally and physically aggressive outbursts towards others to no more than 2 incidents per week and work towards eliminating these behaviors completely.	Counselor will work with Ashley to understand the importance of utilizing more positive words and behaviors when upset. Counselor will teach Ashley more positive ways to communicate other than using yelling, screaming, and profanity or becoming physically aggressive. Counselor will work with Ashley in sessions to practice these skills with activities including modeling and role play. Counselor will involve Ashley’s family in sessions to help establish a rewards system to help Ashley reduce her negative behaviors. Counselor will work with Ashley to understand consequences of her actions and help her family develop a rewards system for improving behaviors and utilizing learned skills to avoid aggression.	At least once during the first 30 days.
Ashley will identify at least 5 coping skills he can utilize to help manage her symptoms of mental illness and subsequent behaviors.	Counselor will work with Ashley to identify coping skills he can utilize when having difficulty managing her symptoms. Counselor will teach Ashley how to verbally communicate effectively when angry instead of exhibiting aggression. Counselor will educate Ashley on some relaxation techniques to utilize when feeling anxious or stressed.	2-3 times per week for the first 30 days.

21. Discharge Planning and Discharge Criteria: (Describe expected outcomes of the services. How will the client/family identify that the services have improved their lives?)

Client is expected to progress through in-home services as noted by a decrease in behaviors and symptoms that place client at risk of an out of home placement. Client is expected to remain in services a minimum of three months, with the counselor working to prepare the client for a step-down into outpatient counseling. Family would be assisted in locating community supports to assist them with maintaining whatever gains they are able to make. Client will be deemed appropriate for discharge at the time when any of the following conditions have been met:

1. The client is no longer at risk of being moved into an out-of-home placement related to his/her behavioral health symptoms and the client’s level of functioning has improved with respect to the following goals outlined in the ISP. The client can reasonably be expected to maintain these gains at a lower level of treatment:

a. Client has demonstrated competency in appropriate use and application of the following coping skills: (list skills)

b. Client has demonstrated 100% adherence to his/her current psychotropic medications as prescribed by his/her psychiatrist/PCP, for a minimum of 4 consecutive weeks.

c. Client has demonstrated competency in and the appropriate use of social and interpersonal skills to improve social interactions with others.

d. (List other skills developed and symptoms/behaviors that have improved)

2. The client is not making significant progress at this level of care and there is no reasonable expectation of progress at this level of care. An alternative plan of treatment has been explored and appropriate referrals have been made.

3. The client and/or a parent or responsible adult is no longer actively participating in services, despite multiple attempts to engage them to address nonparticipation issues.

4. Consent for treatment has been withdrawn and the client no longer agrees to participate in the services.

5. The client exhibits severe exacerbation of symptoms, decreased functioning, disruptive or dangerous behaviors and requires a more intensive level of service.

6. The client is no longer in the home and/or has moved out of the service area.

Admission to Services:

The client and parent/guardian have been informed and have agreed that there will be active family participation in the treatment, and services will be provided primarily in the home.

x YES NO

All of the following must be agreed upon prior to admission (please check):

x At least one caretaker is willing to participate in the Intensive In-Home Counseling Services.

x The caretaker and client are willing to commit to the recommended hours of counseling.

x The family problems and client’s behavioral problems have not improved with less intensive services.

I have completed this assessment, recommend Intensive In-Home Counseling services for this client, and approve this case to be opened:

Candice Shin, MSW, LMHP-S

Licensed Professional’s signature with professional degree and date

7/15/2023