Cove AI

Is this an expedited assessment (i.e., scheduled on an accelerated timeline out of the Kickoff Session due to risk and safety concerns)?

Review Required

Full name of client

Session was attended by:

Session was conducted via

Address of physical location of client during session:

Needs More Info

Actual session length:

Did you discuss confidentiality / your role as a mandated reporter?

Review Required

Is consent for care on file from all required parties, including documentation of attempts to obtain consent from additional legal guardians?

Needs More Info

Review Required

Child's name

Child's age

Child's gender identity

Needs More Info

Child's preferred pronouns

Child's sex assigned at birth

Child's state of residence

Caregiver name(s) & relationship(s) to child

Child's school

Child's grade

Review of initial screening measures

Review Required

Primary presenting concerns

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Impact of child's symptoms on child and on whole family functioning

The child's symptoms result in significant impairment across multiple domains. Regarding eating, she exhibits restrictive eating patterns and significant distress surrounding meals, leading to parental concerns about her nutrition. In the school setting, she avoids the cafeteria, frequently visits the nurse for nausea, requests to go home, is described as quiet and reserved in class, and avoids group activities. Socially, she avoids parties, sleepovers, and has limited playdates, primarily engaging with one friend (Maya) at home. Her sleep is impacted by difficulty falling asleep due to worry about nocturnal nausea. Emotionally, she reports hating to feel worried and describes significant distress. The phobia significantly influences family routines, meals, activities, and travel plans, contributing to high reported family stress, described as 'overwhelming' and 'exhausting.' There is notable tension and disagreement between parents regarding the management of the phobia, specifically concerning accommodation versus encouraging the child to face her fears. Contextual stressors include cultural adjustment, financial pressures, and a lack of extended family support, which contribute to a sense of isolation.

Review Required

Past and present attempts to address child's presenting concerns and barriers to progress

Review Required

Reporters denied the presence of the following concerns:

Based on pre-assessment forms, reporters denied the following: On the MFQ, endorsements related to feeling no good, hating oneself, being bad, feeling unloved, not feeling as good as others, or doing everything wrong were denied. On the Spence Children's Anxiety Scale, fears of the dark, dogs, heights, and insects/spiders were denied. On the FMHC, concerns related to bullying, fighting, impulsivity, lying, overactivity, or stealing were denied. Regarding medical history, adoption, birth complications, hospitalizations/surgeries, various specific medical conditions (including asthma, allergies, hearing/vision issues), ADHD, Depression, Disruptive Behavior Disorders, Tics, and Learning/Speech disorders were denied. Concerning family history, known genetic disorders, Intellectual Disability (ID), Autism Spectrum Disorder (ASD), Depression, Bipolar Disorder, Schizophrenia, Trauma-related disorders, body image-related Eating Disorders, and suicide were denied. During direct questioning in the session, Eliza denied thoughts of not wanting to be alive or thoughts of hurting herself. Her parents also denied any concerns regarding suicidality or self-harm.

Any additional details regarding concerns denied

Family and client strengths

Is the child present in session?

Appearance

Needs More Info

Speech

Mood

Review Required

Behavior

Review Required

Affect

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Eye Contact

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Impulse Control

Attention

Review Required

Motor

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Insight

Judgment

Thought Content

Review Required

Orientation Impairment

Hallucinations

With whom does the child reside

Other important adults in child's life

What are the relationship dynamics between all family members

Review Required

Social relationships

Review Required

Describe your child's functioning in school

Review Required

Does your child have any of the following supports in school?

Needs More Info

Additional details on school supports

Past history of mental health treatment and diagnoses

Review Required

Current mental health treatment and diagnoses

Review Required

Current and past psychotropic medications

Family psychiatric history

Review Required

Current and prior medical diagnoses

Review Required

History of medical hospitalizations & surgeries

Current healthcare providers for child

Eating challenges

Review Required

Sleeping challenges

Review Required

Additional details on sleep

Review Required

Describe any significant stressors experienced by the child and by the family

Review Required

Trauma history for client

Review Required

Trauma history in any member of the immediate family

Review Required

Is the family experiencing any of the following social needs?

Review Required

Concerns during pregnancy or birth

Developmental milestone achievement

Did or does your child receive any Early Intervention (EI) services?

Needs More Info

Describe any factors that impact the risk and safety status of the client and family system beyond those documented elsewhere in the note (e.g., aggressive or unsafe behaviors when escalated, substance use, sexual activity).

Review Required

Is the client 8 years and older?

Lifetime:

Review Required

Past Month

Review Required

Lifetime:

Review Required

Past Month

Review Required

Lifetime:

Review Required

Past 3 Months:

Review Required

Lifetime Score (Highest numbered "Yes" in questions 1 -5)

Review Required

Past Month Score (Highest numbered "Yes" in questions 1 -5)

Review Required

Have you ever hurt yourself on purpose without intending to end your life, like cutting, biting, burning, or hitting?

Review Required

When someone feels very upset, they may have thoughts about hurting the person who has upset or hurt them. Have you ever had a thought like this?

Needs More Info

Review Required

Using the C-SSRS reference tables as a guide, select the client's SI risk acuity category:

Review Required

What was the client's response to item 6 of the C-SSRS regarding preparatory acts and suicidal behavior?

Review Required

Please select which risk domain(s) was positive:

Review Required

What are the most important aspects of the family's cultural identity?

How has this cultural identity influenced the presenting problem?

Needs More Info

Review Required

Clinical Global Impressions Severity of Symptoms (CGI-S) Based on your clinical experience with this particular population, to what degree does the client's symptoms in the past 7 days reflect deviations from typical development.

Review Required

Clinical formulation

Eliza is an 8-year-old female who presents with a severe Specific Phobia, Emetophobia subtype, and features consistent with Generalized Anxiety Disorder (GAD), as previously diagnosed by her PCP. Her symptoms reportedly emerged and significantly escalated following a gastrointestinal illness approximately one year ago. The core fear involves vomiting (either herself or others), with associated fears related to the physical sensation, potential judgment from others, loss of control, and choking. These fears manifest as intense anxiety (with described physical symptoms), intrusive thoughts and images, significant avoidance behaviors (related to food, the school cafeteria, parties, and travel), concerns about contamination, and safety behaviors (such as reassurance seeking, handwashing, and checking). The impairment resulting from these symptoms is severe across eating, school, social, and family domains. The family context is characterized by significant stress related to managing the phobia, conflict between parents regarding their approach (i.e., protection/reassurance versus encouraging exposure), immigration and acculturation stress, and a lack of local support. The mother has a reported history of anxiety. Client strengths include intelligence, creativity, articulateness, and the family's motivation for treatment. The proposed treatment plan involves Cognitive Behavioral Therapy (CBT) with Exposure and Response Prevention (ERP), integrated with parent coaching.

Review Required

Diagnostic summary

Review Required

Proposed plan for care

Review Required

Inviting LO Collaborators

Disposition

Recommended support & next steps

Review Required

Assessment Note: Eliza Petrova