CCT

Children's Counseling & Therapy — Case File

Individual Assessment & Session Notes — Child & Adolescent Services

Izabel Warren  (DOB: 17 Oct 2000)
Age at assessment: 11 years (2011)
Custody: Maternal grandmother
Presenting Concerns: Bereavement (loss of both parents in 2011); social withdrawal at school; hostile/antagonistic interactions with identified online peers "Bradley" and "Brian".

Assessment Summary

Initial intake completed 21 Oct 2011. Izabel demonstrates symptoms consistent with grief along with social withdrawal and guarded behavior in peer settings. She presents a restricted affect during face-to-face sessions and reports online interactions with two contacts ("Bradley" and "Brian"). Teacher feedback indicates refusal for group participation and avoidance during social tasks.

Clinical impression:

  • Social anxiety with defensive hostility
  • Online hostile exchanges; monitor for escalation

Session Notes (selected)

21 Oct 2011 (Intake): Izabel was quiet and guarded. Showing refusal to participate or speak. Grandmother present; reports poor sleep. 28 Oct 2011 (Session 3): Play-based approaches introduced. Izabel pushed away a puppet representing a school peer during a social exercise. 04 Nov 2011 (Session 6): Coping skills (breathing, worry box) introduced. Drawing exercise showed mixed affect — longing and anger. Online hostility discussed; boundaries reviewed.

Treatment Plan

  1. Weekly sessions focusing on grief processing with expressive modalities.
  2. Family support sessions with grandmother, including routines and online boundaries.