Client Initials: R.S.
Date of Admission: 1/12/14
General Appearance R.S appeared his age of 17 years old. He stood about 5”6’ and wore big framed Ray Ban glasses. He dressed in nice attire, wearing a polo plaid button up underneath a navy blue polo long sleeve sweater with tan corduroy pants. He walked over and introduced himself in a very friendly manner with a big smile on his face. R.S was very cooperative, sociable and confident. He was at times reserved around other patients that he stated he just didn’t get along with, but he kept his distance and didn’t start any trouble. R.S has great posture and attends every group offered. He does seem anxious and keeps chewing on a straw.
R.S loves to talk. He is very intelligent and loves to tell stories or ask questions to get to know others. He speaks at a normal pace and moderate tone so that those he is talking to can hear him and clearly understand what he is saying.
Emotional State R.S stated his mood today and being happy and anxious as he is being discharged. He hasn’t seen his family for a week and he is excited to have his mom and little brother pick him up today. He says he is in a good place now and realizes it’s okay to communicate your feelings with others instead of letting them build up. He feels as if he is in a better place and can control his angry impulses. He is set on his goal to better himself and not end up back here even though he has made good friends the week he has been here.
Thought Process R.S thought process was goal directed and rational. He had no auditory hallucinations, paranoia, compulsions, delusions or flight of ideas. He is very logical and knows what he wants to do once he is discharged. He has plans to join a sports team at school and complete high school on time. He denies any suicidal ideation or homicidal ideation.
Sensorium and Mental Capacity R.S is oriented times three. He knows why he is here and has no memory gaps or