THE DRUG ABUSE TREATMENT ASSOCIATION, INC.,



lefttop00THE DRUG ABUSE TREATMENT ASSOCIATION, INC., TREATMENT ACCOUNTABILITY FOR SAFER COMMUNITIES (TASC)Substance Abuse and Mental Health Assessment (SAMH - 3)Summary of Findings and RecommendationsClient Name/DATA ID:DJJ ID: Gregory RoyalDATA ID: 30181DJJ ID: 1397837Date of Assessment:2/26/2017Address:896 Pipers Cay Dr. West Palm Beach FL, 33415TASC Assessor:Nicole Hermitt M.S. DOB:1/18/2002Age:16Sex:Male Race/Ethnicity:African American Date of Referral:2/21/2018Referred By:JPO Vernon Jackson METHODOLOGY:The following assessment report is the result of an in-depth assessment process that included all of the following:Review of Positive Achievement Change Tool (PACT) screening instrumentReview of the offender’s legal historyA structured interview with the offender (SAMH-2)Consultation with the current Juvenile Probation OfficerConversation with offender’s parent/guardianA 5 panel urinalysisREASON FOR REFERRAL:PACT Screening indicated – further assessment as youth has or has had aggressive reactions to feelings of frustration or irritability, has witnessed violence at home, witnessed violence in the community, and diagnosed w/ mental health problems. LEGAL HISTORY:Gregory is on probation for 3rd degree felony burglary. He has previous charges that include: assault w/ intent to commit felony (F3), battery – touch or strike (MI), aggravated assault – weapon w/o intent to kill (F3). EDUCATIONAL/VOCATIONAL HISTORY:Gregory is in the 9th grade at John I. Leonard High School earning grades of A’s, C’s and currently has 2 F’s. He shared that he is taking regular and advanced classes. He likes some of his teachers, enjoys having a second lunch period, and loves his culinary class. He denied ever being expelled from school but admitted to being suspended approximately 10 times in middle school for fighting. He was retained in kindergarten twice. He desires to become a chef. He denied any history of employment and denied ever having received any formal vocational training. FAMILY HISTORY/ABUSE HISTORY:Gregory lives at home with his mother, step father, four sisters, and two brothers. He admitted to having a poor relationship w/ his step-father and reported that he does not like him. He shared that he gets along with most of his siblings and his mother but does not get along with his younger brother. Gregory was not raised by both his biological parents. He shared that his mother took care of him and raised him herself due to his father having been in prison for 12 years. Gregory shared that before he went to prison he would speak to him. Gregory and his mother shared that they enjoy celebrating holidays together, watching TV, playing cards and other games. Gregory denied ever having run away from home and or ever having been kicked out of his house. He has an 8 p.m. curfew but his mother reported that he does not abide by it. Gregory has assigned chores at home that consist of washing the dishes, and sometimes washing his clothes and cleaning the living room. He identified his grandmother and mother as the most important people in his life. Gregory shared a family history of substance use stating “my older brother and cousin smoke weed.” Gregory and his mother denied any family history of substance abuse treatment. His mother shared that Gregory and his siblings have participated in individual and family counseling. His mother also disclosed that her older son was diagnosed with Bipolar Disorder and her younger son with ADHD and Bipolar Disorder just like Gregory. Gregory disclosed that he suffered physical and emotional abuse at the hands of his father; reportedly his father would push him around when Gregory was about 13 y/o, as a form of discipline. This was reported and Gregory’s father was court ordered to stay away from him, his siblings and his mother. Gregory denied ever having been the victim of sexual abuse. SOCIAL HISTORY:Gregory enjoys being outside playing basketball and football, and he also likes playing video games. Gregory shared “my friends in the past would smoke weed.” He acknowledged that his friends are both a good and a bad influence on him. Gregory is reportedly involved in a romantic relationship. He denied ever having been a member of a gang. Gregory described himself as fun, athletic, and great cook. SUBSTANCE ABUSE HISTORY:Client was assessed for use of the following substances:TobaccoDenied Use. AlcoholDenied Use.CannabisOnset at age 15 when he smoked 2 joints, weekly, with last reported use on 2/3/2018. Gregory’s mother shared that unbeknownst to him he smoked a joint that was laced with an opiate and since then he has not smoked marijuana. Crack/CocaineDenied Use. EcstasyDenied Use. BenzodiazepinesDenied Use. InhalantsDenied Use. OpiatesDenied Use. HeroinDenied Use. HallucinogensDenied Use. AmphetaminesDenied Use. Over The CounterDenied Use. FlakkaDenied Use. Other: N/AOther: N/AURINALYSIS RESULTS: Gregory was administered a U/A at the time of assessment and tested negative for all substances: Cocaine (COC), Cannabinoids (THC), Opiates (OPI), Methamphetamines (MAMO), and Benzodiazepines (BZO).PHYSICAL HEALTH:Gregory was last seen by Dr. Bernadette from multilingual Psychotherapy Center December 2017 for medication management. MENTAL STATUS EXAM/PREVIOUS PLACEMENT:Gregory’s mother stated that he has been Baker Acted 3 times due anger outbursts and was sent to JFK Hospital. He has been receiving services from Multilingual Psychotherapy since the age of 6-7; he was diagnosed with ADHD and Bipolar Disorder. He has been prescribed Trazodone and Focalin. Gregory’s psychiatrist is Dr. Bernadette. Mother stated that Gregory is scheduled to meet w/ his psychiatrist every month but missed his appointment in January 2018 because he was in the detention center. Gregory’s mother shared that he was previously being treated at South County Mental Health. Mother reported that Gregory was sent to Sandy Pines in March 2017 and successfully completed the program. SUMMARY AND RECOMMENDATIONS:Gregory is a 16 y/o African American male referred to TASC due to his PACT Screening having indicated further assessment needed as youth has or has had aggressive reactions to feelings of frustration or irritability, has witnessed violence at home, witnessed violence in the community, and diagnosed w/ mental health problems. Gregory is on probation for 3rd degree felony burglary. He has previous charges that include: assault w/ intent to commit felony (F3), battery – touch or strike (MI), aggravated assault – weapon w/o intent to kill (F3).Gregory is in the 9th grade at John I. Leonard High School earning grades of A’s, C’s and currently has 2 F’s. He shared that he is taking regular and advanced classes. He expressed that he has goals to become a chef. He lives at home with his mother, step father, four sisters, and two brothers. Gregory disclosed that he suffered physical and emotional abuse at the hands of his father; reportedly his father would push him around when Gregory was about 13 y/o, as a form of discipline. This was reported and Gregory’s father was court ordered to stay away from him, his siblings and his mother. Gregory denied ever having been the victim of sexual abuse.Gregory’s mother stated that he has been Baker Acted 3 times due anger outbursts and was sent to JFK Hospital. He has been receiving services from Multilingual Psychotherapy since the age of 6-7; he was diagnosed with ADHD and Bipolar Disorder. He has been prescribed Trazodone and Focalin. He sees his psychiatrist monthly and he is compliant with his medication.Gregory began smoking marijuana at 15, smoking weekly, with last reports use on 2/3/2018 when he smoked 1 joint. Gregory was administered a U/A at the time of assessment and tested negative for all substances: Cocaine (COC), Cannabinoids (THC), Opiates (OPI), Methamphetamines (MAMO), and Benzodiazepines (BZO).Given the information gathered at the time of assessment, Gregory is recommended to participate in outpatient substance abuse treatment to include anger management and random u/a testing. He is to continue taking his medications as prescribe and to see his psychiatrist as scheduled. TASC Assessor will refer and link Gregory to the appropriate service. By typing my name hereto, Nicole Hermitt, M.S., I hereby certify that the information contained within this document is true and correct to the best of my knowledge.2/26/2018 ___________________________________________________Staff Signature Date Nicole Playton, M.S., LMFT By typing my name hereto on this 28th day of February 2018, I hereby certify that I have reviewed and approved this document. _______________________________________Qualified Professional Signature This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR part 2). The federal rules prohibit you from making any further disclosure of information in this record that identifies a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose (see § 2.31). The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder, except as provided at §§ 2.12(c)(5) and 2.65. ................
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