Relentless (Elisabeth Reinhardt Book 1) by Nancy Alexander Page A

while and at that time I changed my last name to the foster family’s name, it was Baker. I was called Regina Baker, Gina for short. Then when I went to college and was more on my own, I changed my whole name .”
    “ I see,” said Dr. Reinhardt, “so when did you become Gina Reynolds?”
    “ Well, that was more of an internal identity thing I think,” Gina said.
    “I see ,” said the therapist slowly.
    “After the name change I evolved into this identity. I sort of left Reggie Lee Raines and Regina Baker behind and grew to become who I am now.”
    “ Okay, so become represents an identity evolution? You moved from one name/identity to another over time. Is that what you mean? It’s not just a name change which represents some kind of external identifier, it’s deeper than that. Is that it?”
    “ Well, I think that’s mostly it,” Gina smiled.
    The therapist started to nod when she saw a momentary expression fla sh across her patient’s face.
    That’s interesting , Dr. Reinhardt thought, making a mental note. There’s something else going on here. I’ll have to keep my eye on that. But not now, she thought. 
    “Okay, good,” she said. Taking a deep breath she repositioned herself in her chair and re-focused the session.
     
     

Elizabeth A. Reinhardt, PhD
    Great Lakes Bank Building
    Suite 315
    Chicago, Ill   60601
     
    CLINICAL PROGRESS REPORT
     
    Patient’s name:              Gina R                                                                      Date of Contact: ___11/10/2012___________
    Nature of Contact:              Office Visit _X___ Phone Call ______Email ______Other __________
     
Reason For Contact:              Scheduled_____ Practical _____Update _____Emergency __X___ Other _______
Presentation:               Normal _____Depressed/Low Energy _____ Upset/Agitated __X___ Frustrated/Angry ______ Dissociated/Detached ___X___ Anxious/Panicky __X____ Obsessive/Worried ____X___ Overwhelmed __X____ Desperate/Dependent ______ Confused ______ Guarded/Defended ______ Aloof/Distant _____
Urgency:                             Suicidal _______ Self-Destructive ______ Homicidal ______Other _______
Requires hospitalization:               a) Yes_____ specify plan_______________________________________
    b) No ___ X_____________________
Appearance:               Neat __X_____ Disheveled _______  Inappropriate ______________________________
Substance Use/Abuse:               Yes ______ No ___X____ Specify ____________________________________
Orientation:               Oriented:    X                Disoriented:               Time ________ Place ________Person _________
Areas of Concern :               Self/Symptoms ___X__ Personal Relationships ________ Work __X____
    Finances ______ Health _______ Safety _______ Functioning __________ Moral/Spiritual ____________
Session Narrative:               Flashback at work, traumatic content, worried about her ability to function on job, worried that her mental health is deteriorating, some information about family history/relatives, it appears there was legal action taken to emancipate or name change during teen years; patient reluctant to discuss, avoidant and anxious about past information.
Diagnosis:               Axis I: PTSD, GAD_______________
    Axis II : none
Recommendations:                   self-management techniques discussed. Suggested readings on PTSD and its treatment
Referrals if necessary: ____________________________
Clinical Impression:     Continue to evaluate dissociation, degree of fear/anxiety vs real world safety considerations
Treatment Plan:               Begin trauma work and support coping strategies at work.
Appointment Scheduled: