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The client has a significant history of sexual abuse starting at age 7, leading to PTSD and self-harm behaviors.
The client exhibits symptoms of major depression, including poor appetite, sleep difficulties, and feelings of emptiness.
The client is an only child living with her mother, who has a history of domestic violence involving previous partners.
Currently in 9th grade, the client typically earns C's but has recently failed Algebra I and frequently misses school due to migraines.
The client reported trying alcohol once at age 13 but does not engage in regular substance use; she avoids smoking and drinking due to past trauma.
The client's support system includes her mother, her mother's boyfriend, and a close friend, which she identifies as crucial for her well-being.
Cognitive behavioral therapy is recommended to address depression and self-harm behaviors, along with a safety plan for ongoing support.
