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‘Compass
Health
Billing Name: Elora Ralidak Name Elora Ralidak-Goodnight
Pronouns She/Her Gender Female
Client ID: 153056 DOB: 3/21/2015,
Employee Name: Liana Peeples , CMHS , LICSW, MSW, MHP __ Date/Time - Duration: 5/2/2024 9:04 AM to 10:25 AM - 81
Service Type: Assessment
TELEHEALTH

Was this session provided via telehealth? (Telehealth includes phone, audio without camera, and video): No
CLIENT INFORMATION

Client's Chosen Name:
Elora Ralidak-Goodnight

Client's Pronouns:
She/Her

Client's Gender (as identified by client):
Female

PRESENTING PROBLEM

County of service: *Snohomish
Are other participants present in this session: Yes

Presenting Problem

Click here to enter notes

Client is a 9 year old female presenting for an assessment in the Child Advocacy Program following disclosure of sexual
abuse allegedly perpetrated by a peer, Makayla Woodle, age 10. Client was accompanied to the assessment by her mother,
Veronika Goodnight, and her father, Mathew Ralidak. The parents both reported that they are currently in the middle of a
contentious custody battle. Because of this, clinician met with all parties separately.

Clinician initially met with client's mother 1:1. Regarding the allegations, mother stated: "On March 24th or 25th, she went to
dad's for the weekend. | got her Sunday night. Monday night, | put the kids to bed. She came out of bed and said, ‘There's
something that | want to talk to you about. | went over to my friend Makayla's house.’ She said, 'I was playing with Makayla
on Sunday but she's come over to my house before." | asked if there was something concerning about the playdate. She
said, 'We were playing in the backyard, and she tried to kiss me. Then she pulled up my shirt to try to see my belly button.’ |
asked if she (client) liked it, and she said no, 'I was just really uncomfortable.’ I said thanks for telling me, and I told her you
could use your voice."

Mother continued, "I said | need to write your dad an email. | need to let your father know that that was happening during his
weekend and that you felt uncomfortable." Mother reported that they made a plan and sent client back to bed. Mother stated,
"She later came back out and said, 'I can't sleep because there's more." Mother reported that client then described a
situation where client's friend, Makayla reportedly told her own father that she and client were going to draw. Mother stated
that she felt Elora had a strange look at that, so asked, what does drawing mean? Mother stated, "She (client) said it means
that she (Makayla) was going to start kissing [client] and touching [client]. She said, 'I felt really uncomfortable and just
froze.' She said, ‘Makayla told me to touch her pussy. She told her to touch her pussy and let her touch my pussy.’ She said
there was another time when Makayla pulled her pants and underwear down. She demonstrated that somehow Makayla
was holding her wrists to keep her from pulling her pants back up. She said, | really don't like that she said that she was
drawing. We didn't do any drawing." Mother expressed concern about the use of the word "pussy" and stated that she
believed this indicated "learned behavior."

Mother stated that after the disclosure, mother sent father an email detailing the allegations of the abuse. Mother stated that
she felt the client's father did not take adequate steps to follow up on the concerns, and therefore made a police report.
Mother provided the police report to this clinician, confirming a report was made to King County Sheriffs Office (Case
#C24010592). The report by Officer Mark Walker-Rittgers indicates a similar incident is alleged to have occurred involving
Makayla and another child.

Mother also noted a source of stress in the family's life is the ongoing custody battle. Mother stated that the parents have
another trial for custody that is set for May 28th, 2024, and that this will be the second trial.

When asked how she believed Elora was impacted by the alleged incidents with Makayla, mother stated, "There aren't any
big changes. She's kind of gone into a shell a little bit. She just froze. She keeps saying 'I didn't know how to get out of the
freeze.”

 

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Clinician then met with client's father 1:1. Regarding the allegations, father stated, "On March 24th, Elora was under my
residency. Sunday we go to church. Usually Elora asks to have a playdate with usually Mercy or Makayla. After church
usually Makayla comes over to our house or Elora goes over to Makayla's house. That week, Elora [went to Makayla's
house] came home to me at 3. Makayla's dad dropped Elora off, Makayla's dad came up and talked to me because Elora
had scraped her toe and...banged her finger because the brother jumped on her finger on the trampoline. She also bit her lip
while playing. She told me all those things, and Makayla's dad said the same things. They left, and then from about 3-5:45,
Elora was with us at our home. | didn't notice anything different about her. There wasn't anything cause for concern. She's
pretty good about saying to us (father and his wife, Monica), 'Hey guys, | need to talk to you.’ She really trusts Monica. They
go to their mother's Sunday evening, Monday passes, then Tuesday morning, | read an email from Veronika about some
things that happened at Makayla's house with Elora. | found that concerning because Elora didn't say anything about it.”

Father continued, "There was an incident a few summers ago, with a friend she met where the friend tried to kiss her, and
she was uncomfortable about it. She came back to the camp and told us right away." Father reported that because of this,
he found it odd that client did not disclose the alleged abuse with Makayla to father or father's partner, Monica.

Father continued regarding the email sent by Veronika: "The email was alleging that Makayla molested her or held her down
or forced her to do stuff. Makayla is the same size or slightly smaller than Elora. Some of the stuff just felt very...l don't know.
There was a lot there. So when I read that, | reached out to Veronika and said thanks for this info, Elora didn't mention any of

this, and I'll reach out to Doug and find out what the story is. | think that's what should happen at 9 years old, so that's what |
did.”

Father reported that he called Makayla's father and expressed the allegations. Father reported that he hadn't had a chance
to talk with client at that point because client was in mother's custody at that time. Father reported that Makayla's father
stated that his wife would talk with Makayla once Makayla's mother came home.

Father stated, "During that time was when Veronika called the police to file something. | only say that | think that was too far
at some point because | didn't have all the information. And that was my same thing with [the intake appointment at Dawson
Place]. | didn't have all the information. | called Doug and talked to him, but she (Veronika) thought that wasn't enough. She
called the police and didn't give me any information, and this goes back to the parenting plan with unilateral decision making.
| would hope that both parents would be involved with something like this.”

Father continued, "Karla (Makayla's mother) called me back about a day later, and said that she had a conversation with
Makayla, and said that maybe they were playing just a little too handsy. | had lunch with Elora later that week, and she said
that she felt uncomfortable with the game they were playing because Makayla was grabbing her hips and that Makayla was
maybe trying to kiss her. Veronika said that Makayla held her down and touched her pussy. Veronika used some words in
her email that our daughter doesn't know and doesn't use in her verbage. Veronika was saying that she (Makayla) was using
code words, and saying ‘don't tell anyone.”

Father also noted, "Veronika has also used a lot of the same language in other allegations against me."

When asked how he feels client has been impacted by the events, father stated, "I feel like something happened. Nine or 10
year old girls explore their bodies and there could be some inappropriate behavior that happens. The way Elora has acted
after, at our house there's no difference. When we've gone to church, she uses language that her mother uses (referencing
client and her family). She says that person is unsafe. She says that whole family is unsafe. She's being told things that |
think are too heavy and too above her in my opinion.”

Clinician then met with client 1:1. When asked if she knew why she was talking with this clinician, client stated, "Because of
Makayla." Clinician asked client if she could say more about Makayla. Client stated, "We were going to do drawing. But she
didn't do drawing. She just wanted to kiss me and touch me inappropriately. | just froze and didn't know what to do." When
asked what she meant by "touch me inappropriately,” client stated, "Like she was touching me where she wasn't supposed
to. My privates and my butt." Client reported that Makayla had allegedly tried to kiss her on more than once occasion, but
stated, "She didn't touch me inappropriately [before], this was the first time she touched me inappropriately.”

When asked where this happened, client stated, "Her house. We were in her room because now she gets her own room.
She was lying to her parents because she was like, ‘We're drawing up here, and she would go out to see if the coast was
clear. Then she would bring me up to her bed and lay on top of me and kiss me. She was pulling my pants down with my
underwear down sometimes. She would pull my underwear off me when she was on top of me. And she got mad at me.
when | wanted to go play with her brothers, because she just wanted to go to her room and touch me and kiss me
inappropriately." When asked how she felt about this, client stated, "It was uncomfortable and | didn't know what to do and |
froze, so | just let her do it. | don't want to be friends with Makayla.

When asked how she felt now, client reported that she felt unsure and "unsafe" and also stated, "I also feel like | can't trust
her brothers," but was unable to express a reason why she did not feel safe with them.

Problem List

Anxiety (general, panic, phobia, OCD)
Client reported that she feels anxious when going to church, stating that she does not want to be around Makayla or be.
friends with her, and that Makayla continues to attend the same church as her.

 

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Isolation/Withdrawal
Mother reports that client has been more withdrawn since the alleged incidents.

School or work challenges

Father expressed some developmentally appropriate challenges with friends, stating, "She very much takes to heart what
people say and do in class. She comes home and she's upset about this girl in class taking another friend from her. | think
it's all age appropriate things. She has a lot of friends. School-wise, she's done a good job making up in the past couple
years. She's under grade level in reading and writing. | have some additional help for her on Thursdays after school.” Mother
also reported that client has previously had tutoring help while in her care.

Father stated that client has "a lot of unexcused absences when at mother's home. Last year she had almost 30 days of
missed school. Elora has about 14 absences this year."

Sleep
Client stated that she occasionally has trouble falling asleep.

Trauma/Abuse/DV
See presenting problem.

Other major life events/past events that are still affecting client
Client's parents are in an ongoing custody dispute.

ADDITIONAL HEALTH INFO

Behavioral Health Treatment History

Previous Diagnostic History (Enter the diagnoses here and the dates and places of previous/current treatment in Service
Information below.)

Service Information

Outpatient Mental Health Treatment

Provider/Agency: Father reported that client has previously attended some therapy with a school based provider.
Requested ROls for treatment occurring within the last 5 years: N/A

The following sections cover much more than a client's mental health. Clients may wonder why we are asking
questions about areas of their lives beyond their mental health and may find the questions sensitive in nature
and/or uncomfortable to discuss. It may be helpful to take a moment to explain to clients that in order to have better
mental health, it is important to ensure overall well-being and that their physical health, relationships, living
situation, etc. may be impacting and/or impacted by their mental health. Gathering this additional information can
help us gain better understanding and provide more effective services. Even if the client indicates there is not a
relationship between their mental health and other areas of their lives, we may be able to offer resources that they
may find helpful.

HEALTH & MEDICAL

 

Allergies: No allergies reported

Primary Care Physician: Dr. Bowker, Cedar Avenue Integrative Medicine

Medications: No medications reported

Medical Conditions: No medical conditions reported

Any additional information regarding medical conditions or concerns with physical health (e.g. aches, pains)?: No
For youth, Any concerns with wetting/soiling?: No

Is this client currently enrolled in Developmental Disabilites Administration (DDA)?: No

 

Sexual/Reproductive Health
Nutrition
Eats at least 2 nutritious meals, including fruits and vegetables, each day?: Yes

**2 or more irregular responses indicate a need for further assessment. Irregular responses = No on Question 1,
Yes on Question 2-5.

Strengths/Resources or Obstacles to Recovery - Health: Accesses healthcare when needed, Desires to lead a healthy
lifestyle, Positive engagement with health care providers, Refrains from high risk health behaviors, Able to articulate healthy

 

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lifestyle goals
DEVELOPMENTAL HISTORY

Developmental History

Age Range: Child/Youth

Complete for the current age range of the child/youth.
Ages 6-12

Reads: Yes

Socializes w/ children: Yes

Follows rules: Yes

Problem-solving skills: Yes

Personal hygiene: Yes
PSYCHOSOCIAL

Culture:

Select here to enter Cultural Information

All parties reported that client attends church with her father weekly. Client is the oldest of two siblings who all reside in a
split household.

Strengths/Resources or Obstacles to Recovery - Ethnic/Cultural: Utilizes religious/spiritual support, Tolerant of
individual differences, Able to access ethnic/cultural activities

Current Family/Living Situation:

Name and/or Relationship: Veronika Goodnight (mother)
Living with Client?: Yes

Name and/or Relationship: Colin Derieg (mother's fiance)
Living with Client?: Yes

Name and/or Relationship: Aidan (brother), Raina (sister)
Age (if a minor): 7,5

Living with Client?: Yes

Name and/or Relationship: Mathew Ralidak (father)
Living with Client?: Yes

Name and/or Relationship: Monica Galarneau (mother)
Living with Client?: Yes

Current housing situation (safety, type of housing, length of residence, and any risk of displacement)? (Select to expand and

enter narrative response.)
Client lives in two different homes.

Are there any visitation/custody issues? For children/youth, if there is a parenting plan, request a copy.: Yes
Parents report that there is an ongoing custody dispute, and that the second custody trial is set for May 28th. Mother stated
that she is requesting full decision making at this trial. Parents reported that the current custody arrangement is 50/50 during
the summer. Father noted the children spend the 1st, 3rd, and 4th weekends from Thursdays after school until Sunday
evenings with him.

Strengths/Resources or Obstacles to Recovery - Family: Supportive, Engaged in client's treatment, Participates in
activities in support of client, Talks or visits with on a regular basis, Accepting of client's illness

Education and Employment

Currently in school?: Yes
Which school?: Cascadia Elementary

 

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Client/natural support perception of how they are doing in school (attendance, completion of assignments, any
behavioral or learning challenges): Both parents noted that client is behind grade level in math and reading and has
received extra support in those areas.

Currently on IEP?; No

Currently employed?: No

Previous employment history?: No
Any employment concerns/needs?: No

If not attending school or employed, does the client feel productive and satisfied with current role (homemaking,
volunteering, caregiving, etc.)?: N/A

Daily Activities
Daily activities in the last 30 days. If documentation includes information beyond 30 days, document this clearly.
Time Management:

Follows a regular routine/daily schedule most days (e.g. follows schedule for bedtime, wakeup, meal times, getting
to activities/responsibilities on time)?: Yes

Sleeps 5-9 hours most nights?: Yes

Feels rested most days?: Yes

Hygiene/Grooming/Dress:

Independently/age-appropriately able to bathe/shower, brush teeth?: Yes

Able to eat, chew, drink without pain or discomfort?: Yes

General appearance is neat and clean (e.g., hair brushed, shaven, hands/nails clean)?: Yes

Clothing is weather appropriate, clean, and in good repair?: Yes

Money Management:

Regular source of income?: No

For adults - able to independently manage money, meet basic bills/expenses such as food, shelter, clothing?: N/A

For youth - able to independently/age-appropriately manage allowance/rewards/money earned and take care of
belongings/'their stuff'?: Yes

Problem Solving:

Strengths/Resources or Obstacles to Recovery - Daily Living & Role Performance: Stable Housing, Doing well
academically, Manages activities of daily living

SOCIAL

In the last 30 days; if documentation includes information beyond 30 days, document this clearly.
Communication:

Listens to others and understands what they are saying?: Yes

Able to express needs and wants in a positive manner?: Yes

Leisure Activities:

Activities or hobbies client is interested/engages in: Per father, "She loves talking about reading, talking about the
friends she has, she likes being on the student council, she's very involved at school.”

Energy/focus/interest in their favorite activities in the last month?: Yes
Community Resources/Involvement:

Utilizes resources in the community (e.g. church, school/community clubs and programs, support groups)?: Yes
Client attends church regularly.

Strengths/Resources or Obstacles to Recovery - Social: Involved in community activities/hobbies/sports, Utilizes natural
supports, Has supportive friends.

Legal History and Current Status
Is there a legal guardian/dependency?: No

Abides by laws and/or resides in community without conflict and/or respects the rights of others (last 30
days)?: Yes

Loss of control, aggression, or violence with others or property? In the last 30 days?: No
Any significant legal history?: No

 

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Charges pending?: No

On probation/parole/diversion?: No

Currently court-ordered to treatment? If yes, explain and request copy of court order.: No
History of Trauma

Has the client experienced trauma?: Yes

Sexual: Yes, explain below
See presenting problem.

SUBSTANCE USE DIS. SCREEN

Review GAIN-SS if applicable. If client did not complete GAIN-SS yet, complete with them. Score of 1 or more on the
SDS subscale indicates need for further assessment.

GAIN-SS SDS Subscale Score of 1 or greater?: N/A

Client is a Youth age 9 or older and GAIN-SS not completed and/or additional screening is warranted.: No

STOP if all above answers are ‘Never’. Otherwise, please CONTINUE:

Any responses other than Never need follow up (e.g., provide cessation advice, reduce use/risky behavior, and/or
facilitate linkage for substance use assessment).

History of Substance Use/Addictive Behavior
Distinguish between use within the last 30 days and history beyond 30 days
None

 

RISK ASSESSMENT
Clearly distinguish between factors within the last 30 days and history beyond 30 days

Danger (Risk Factors) to Self: (Must include details about when, how, where, etc.): None
Self-Harm: (Must include details about when, how, where, etc.): None
Danger (Risk Factors) to Others: (Must include details about when, how, where, etc.): None

Which of the following potential risk factors currently apply for this client (check all that apply): History of
trauma/victimization (sexual abuse, domestic violence, etc.), Stressors/triggering events

Protective Factors
Family involvement: Yes

Sense of hope: Yes
Prohibitive belief: No
Strong social support: Yes

No known risk factors requiring a referral for provision of emergency/crisis services consistent with WAC 246-341-0640.

RECOVERY ENVIRONMENT

Individual/Family Expectations:

Initial Treatment Plan - Include at least one goal for treatment as identified by client and/or family use quotes: +
Parents both agreed that therapy could be beneficial and would initially focus on increasing client's body safety and ability to
advocate for her personal boundaries.

Strengths/Resources or Obstacles to Recovery - Emotional: Expresses hope, Able to articulate goals, Working towards
meeting life goals (job, relations), Utilizes healthy coping skills

Recovery Readiness
Motivated for Change/Articulates Goal(s): Yes

Accepting of Treatment: Yes

 

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Positive Treatment History: N/A

Comments: (required for ALL yes answers): .
Client and family are accepting of treatment.

Stage of Change
Clinician's assessment of client's stage of change for:
Mental health issues: Might be a problem; might consider change (Contemplation)

Substance use issues: No problem and/or no interest in change (Pre-contemplation)

RECOMMENDATIONS

Recommendations: .
Client to begin services in the Child Advocacy Program with Clinician Anjali D'Souza.

The following services are medically necessary*:
Services Ordered/Referrals (if checked, include frequency)

Individual Psychotherapy/Behavioral Health Counseling
1x/week

Comprehensive Community Support
As needed

Family Therapy
2x/month or as needed, to involve both parents, separately.

Primary Care Physician - Name/Location
Client to continue with Dr. Bowker at Cedar Ave. Integrative Medicine.

*Medically necessary services are reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent
worsening of conditions in the client that endanger life, or cause suffering or pain, or result in an illness or infirmity,
or threaten to cause or aggravate a handicap, or cause physical deformity or malfunction. There is no other equally
effective, more conservative or substantially less costly course of treatment available or suitable for the client
requesting the service. ‘Course of treatment’ may include mere observation or, where appropriate, no medical
treatment at all.

Interactive complexity present in this service?: Yes

Type of interactive complexity: Evidence or disclosure of a sentinel event and mandated report to third party (e.g., abuse
or neglect with report to state agency) with initiation of discussion of the sentinel event and/or report with patient and other
visit participants.

ACPS call and police were made as a result of this assessment.

DX CAUTION: DO DX TAB 1ST
Diagnosis

Diagnosis:
Effective Date : 04/02/2024
4 (309.9 / F43.20) Adjustment disorders, Unspecified
Diagnosed By : Liana Peeples, MSW, LICSW, CMHS, MHP Diagnosed Date : 5/2/2024

Onset Date : Previous Onset Date :
Onset Prior to Admission: Yes
RIO: No

Notes: Client's symptom self-assessment scores were as follows:
Child and Adolescent Trauma Screen (CATS), client self-reported a score of 17, when 15 is considered clinically significant.
Screen for Child Anxiety Related Disorders (SCARED), client self-reported a score of 2 for anxiety, when 3 is clinically
significant.
Moods and Feelings Questionnaire (MFQ), client self-reported a score of 5, when 11 is considered clinically significant.

Client's symptom assessment scores completed by father were as follows:
Child and Adolescent Trauma Screen (CATS), caregiver reported a score of 10, when 15 is considered clinically significant.

 

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Screen for Child Anxiety Related Disorders (SCARED), caregiver reported a score of 1 for anxiety, when 3 is clinically
significant.

Moods and Feelings Questionnaire (MFQ), caregiver reported a score of 1, when 11 is considered clinically significant.
Pediatric Symptom Checklist (PSC-17), caregiver reported a score of 3 internalizing, 3 attention, and 6 externalizing for a
total of 12.

Client's symptom assessment scores completed by mother were as follows:

Child and Adolescent Trauma Screen (CATS), caregiver reported a score of 25, when 15 is considered clinically significant.

Screen for Child Anxiety Related Disorders (SCARED), caregiver reported a score of 2 for anxiety, when 3 is clinically
significant.

Moods and Feelings Questionnaire (MFQ), caregiver reported a score of 4, when 11 is considered clinically significant.
Pediatric Symptom Checklist (PSC-17), caregiver reported a score of 3 internalizing, 3 attention, and 0 externalizing for a
total of 6.

During assessment, client disclosed experiencing an incident of sexual abuse. Following the incident, client endorsed
avoidance of trauma reminders and occasional low mood. Mother also reported that client has "turned inward" and is
withdrawn at times. Client's symptoms impact social and familial functioning, are not better explained by another mental
health condition, and are not due to the effects of a substance. Client is therefore diagnosed with (F43.20) Adjustment
disorders, unspecified.

Date Updated: 05/03/2024

SNOMED: -
2 (Resolved)(F99) Mental disorder, not otherwise specified
Diagnosed By : Diagnosed Date :
Onset Date : Previous Onset Date :
Onset Prior to Admission:
R/O: No
Notes:

Date Resolved: 05/02/2024
Date Updated: 05/03/2024
SNOMED: -

WHODAS 2.0 General Disability Assessment Date:
Raw Score: Avg Score:

Cognition:
Mobility:
Self-care:
Getting along:
Life activities:
Participation:

 

 

Psychosocial/Environmental Problems - Primary: Problems related to the social environment

 

 

Employee Signature

Fipomploa

5/3/2024 3:19 PM
Liana Peeples - 2832
CMHS , LICSW , MSW , MHP

 

 

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