                                                    Intake Note

Larch Counseling PLLC                                                           Date and Time: 10/14/2024 1:00 ᴘᴍ - 2:00 ᴘᴍ
Clinician: Danielle Smith, LMHCA                                                Duration:       60 minutes
Patient:   Raina Soleil Goodnight-Ralidak, DOB 6/3/2018                         Service Code:   90791
                                                                                Location:       Duvall Office
                                                                                Participants:   Client, mom



dummylink
Presenting Problem
Client has experienced trauma and the weight of parents divorce. Client has difficult time following directions and mother is concerned
that client could possible gave ODD. Client's mom would like client to learn more tools for self-soothing instead of thumb sucking

Current Mental Status
Orientation:                               X3: Oriented to Person, Place, and Time
General Appearance:                        Appropriate
Dress:                                     Appropriate
Motor Activity:                            Unremarkable
Interview Behavior:                        Appropriate
Speech:                                    Normal
Mood:                                      Euthymic
Affect:                                    Congruent
Insight:                                   Excellent
Judgment/Impulse Control:                  Excellent
Memory:                                    Intact
Attention/Concentration:                   Good
Thought Process:                           Unremarkable
Thought Content:                           Appropriate
Perception:                                Unremarkable
Functional Status:                         Intact

Risk Assessment
Patient denies all areas of risk. No contrary clinical indications present.

Objective Content
Covered informed consent, confidentality.

Biopsychosocial Assessment
Identification:                           6, she/her
History of Present Problem:               since seperation
Psychiatric History:                      none
Trauma History:                           seperation of family
Family Psychiatric History:               will update later
Medical Conditions & History:             speech therapy
Current Medications:                      none
Substance Use:                            none
Family History:                           1 older sister, 1 older brother. Parents seperated, messy divorce. Child cries when at dads.
                                          Client behaves out of the ordinary when coming home from dad according to mom
Social History:                           friendly, has friends at school.
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                                                    Intake Note

Larch Counseling PLLC                                                             Date and Time: 10/14/2024 1:00 ᴘᴍ - 2:00 ᴘᴍ
Clinician: Danielle Smith, LMHCA                                                  Duration:       60 minutes
Patient:   Raina Soleil Goodnight-Ralidak, DOB 6/3/2018                           Service Code:   90791
                                                                                  Location:       Duvall Office
                                                                                  Participants:   Client, mom



 dummylink
Spiritual/Cultural Factors:               Christian
Developmental History:                    all normal. speech delayed
Educational/Vocational History:           1st grade, smart, does well in school
Legal History:                            none execpt the divorce for parents
SNAP:                                     Funny, smart, and kind
Other Important Information:              reviewed paperwork

Plan
Create treatment plan, meet with mom privately

Diagnosis
F43.25         Adjustment disorder with mixed disturbance of emotions and conduct


   Danielle Smith, LMHCA, Licensed Mental Health Counselor Associate, License MC61294206, signed this note and declared
   this information to be accurate and complete on 10/24/2024 at 2:05 ᴘᴍ.




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