Behavior : [Counselor’s observation, include mood, affect, etc:]
Heidy was appropriately dressed and displayed good hygiene. She was able to establish good eye contact and looked happy and relaxed. She displayed good insight and good judgment. She was oriented times four and showed no suicidal or homicidal ideations during the session.
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o Heidy’s letter to Rafael (the perpetrator) had helped her to identify and verbalized her feelings in connection with the sexual abuse, which had helped to affirm to her that she is not responsible for the abuse and ease her feelings of guilt. o Counselor validated what Heydi is already doing well and invited her to keep doing what is working.
Plan (P): [Areas to be addressed in the next session, plan of action for client to achieve outstanding goals]: o Counselor would use a scale from 1 to 10 in each session to anchor problems, measure progress and to obtain a rating from the minor on where she perceives she is on the scale that day. o Counselor will work with minor on the ability to establish and maintain close interpersonal relationships. o Heidy will continue to attend weekly individual counseling sessions as well as weekly clinical group dynamic to reinforce life