Chapter Two

Chapter Two
Freya’s Day: January 14 Grael 14
Adrienne Venet Vanessa McClain, MA, LAPC
DOB: 7-1-1982
Psychotherapy Note
Client displayed poor grooming habits as evidenced by strong body odor, disheveled hair, and dirty clothing. Client denies that others have noticed that she displays substandard grooming and hygiene. A.V. gave evidence of a failure to use basic appropriate hygiene techniques such as bathing, brushing her hair, and washing her clothes. Client’s poor hygine has caused medical problem. A.V. reports that “I cannot wash my hair because it is falling out.” Client is experiencing dental difficulties due to her poor hygine. A.V. reports that “my wisdom teeth are breaking off and I have constant pain in my jaw.” Due to Client’s inability to cook meals properly she has experienced deficiencies in her diet. A.V. makes poor food decisions, which has caused dificiencies in her diet. Client reports a history of eating disorder since the age of 14. Client reports hospitalizations for Anorexia Bulimia at ages 14, 16, 19, and 21. Clients’ impaired reality testing and bizarre behaviors cause problems with her performance of activities of daily living. Client’s inventory of positive and negative functioning regarding activities of daily living was reviewed within the session. The client prepared a poor inventory of activities of daily living and was redirected. Client was asked to identify a trusted individual from whom she can obtain helpful feedback regarding daily hygine and grooming. Next session with client scheduled for one week follow up.