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: Emily Gallagher/#29539#1500111Date of Assessment:2/16/2018Address:4100 Okeechobee Blvd. West Palm Beach, FL 33409TASC Assessor:Nicole Hermitt, M.S.DOB:1/1/2001Age:17Sex:Female Race/Ethnicity:Caucasian Date of Referral:2/16/2018Referred By:JPO Rebekah Wilson 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 OfficerA 5 panel urinalysisREASON FOR REFERRAL:Emily’s PACT screening indicated the following: Consistent feelings of anger/irritability Consistent feelings of depression/anxietyHas attempted to commit suicideEngages in self-mutilating behavior, cutting Diagnosed with mental health problems LEGAL HISTORY:Facesheet indicated Court Order- Prosecution previously deferred case reopened (MI). On 2/13/18, Emily was charged w/ Battery-touch or Strike (MI), with a previous battery charge. EDUCATIONAL/VOCATIONAL HISTORY:Emily is currently enrolled in the 9th grade at Indian Ridge High School. She shared that once she turns 18 years old, she has plans to get her GED and go on to community college. Emily denied every being expelled from school or suspended. She stated that she was retained in the 9th grade for not having enough credits to go onto the next grade. Emily shared that in summer of 2017, she was employed as a customer service representative at a local gym but had to resign because she was relocating. She denied having any vocational training. FAMILY HISTORY/ABUSE HISTORY:Emily is currently residing at The Grove group home. She shared that she lives at the home w/ 3 other females but “don’t really talk to them.” Emily disclosed that the reason she is in foster care is because her mother called the police on 9/29/2017 for shoving her. Emily admitted that she was drunk and does not remember every putting her hands on her mother but DCF got involved and removed her from the home. Emily reported that she was raised by both of her biological parents up until age 12 when her parents divorced. Following the divorce, Emily was sent to live w/ her father. Emily shared “at the group home we don’t do anything” but my family would go out to eat and go to the movies together. She shared that she does not have a curfew while at the group home because she is not allowed to leave the home without staff. Emily stated that her chores consist of washing the dishes and keeping her room tidy. She stated that when she lived at home she would be disciplined by not getting an allowance. Emily identified her parents as the most important people in her life. Emily admitted to running away from the group home last week “they called the police but I went back on my own.” She denied ever having been kicked out of her house. Emily shared that her siblings use drugs/alcohol. She denied any family history of mental health counseling/treatment. She shared that her sisters and brothers got arrested for drugs. Emily denied having been the victim of physical, emotional, sexual abuse.SOCIAL HISTORY:Emily reportedly enjoys doing makeup, drawing, and being outside. She denied having friends or acquaintances that use drugs or drink alcohol. Emily shared that she does not have much of a social life because she resides at the group home. She denied any gang affiliation past or present. She denied being in a romantic relationship. Emily disclosed that in the past she had sex for drugs and money. SUBSTANCE ABUSE HISTORY:Client was assessed for use of the following substances:TobaccoBegan smoking cigarettes monthly at age 14. Emily also smokes vapors, and black and milds, the frequency of which is unknown. AlcoholOnset at age 15 when she “drank a couple of beers” on a weekly basis. Last use was Sept 2017 when she drank a bottle of Irish Whiskey and a bottle of Chardonnay wine. Emily reported no cravings or withdrawal symptoms however, she stated that she was too drunk to remember the altercation she had w/ her mother in September 2017.CannabisOnset at age 15 when she shared a bowl w/ 4 other people. Frequency daily. Last use was one week ago when Emily smoked a couple of blunts w/ a group of people. No craving or withdrawal symptoms reported. Crack/CocaineExperimented w/ cocaine at age 16. Emily stated that she shared a couple of grams w/ 3 people in Aug 2017 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: Emily was administered a urinalysis at the time of assessment and tested positive for marijuana and negative for all other substances: Cocaine (COC), Opiates (OPI), Methamphetamines (MAMP), and Benzodiazepines (BZO).PHYSICAL HEALTH:Emily was last seen by a medical professional 1 month ago for a physical examination. She denied having any past or current medical condition. MENTAL STATUS EXAM/PREVIOUS PLACEMENT:Emily was oriented to person, place, time and situation at the time of assessment. She was well groomed but appeared to be a bit irritated with the assessment process. Emily denied having any obsession w/ fire and or harming animals. She denied having any hallucinations, obsessions, and/or delusions. Emily admitted to past suicidal thoughts, attempts, plans, “I started cutting when I was 12 because my parents were divorced. Mom found out I was cutting and bought me to the hospital and they Baker Acted me. Then it became a sporadic thing. Family found out and I was Baker Acted a few times throughout the years and then my parents sent me to Sandy Pines. Last time was December 2017." Emily reportedly completed her episode of care at Sandy Pines and was diagnosed w/ depression, anxiety, and a mood disorder. She was prescribed Prozac, Lamictal, and Seroquel. Emily denied having any current suicidal thoughts attempts or plans however, collateral information obtained from her JPO, indicated that Emily was recently Baker Acted and taken to JFK Hospital. Emily reported, “the staff Baker Acted me because I left the house and went to my dealer’s house and they just wanted me locked up. I didn’t say or do anything." JPO stated that Emily was diagnosed with Bipolar Disorder as well. Emily has been attending outpatient substance abuse treatment with DATA since 12/8/2017. Emily admitted to having a history of anger and irritability stating, “I get angry when I’m trying to be controlled.” Emily is reportedly seeing an in-home onsite therapist provided by her group home The Grove. SUMMARY AND RECOMMENDATIONS:Emily is a 17 y/o Caucasian female who was referred to TASC due to the following indications on her PACT screening: Consistent feelings of anger/irritability, consistent feelings of depression/anxiety, has attempted to commit suicide, engages in self-mutilating behavior cutting, diagnosed with mental health problems. Her facesheet indicated Court Order- Prosecution previously deferred case reopened (MI). On 2/13/18, Emily was charged w/ Battery-touch or strike (MI), with a previous battery charge.Emily is currently residing at The Grove group home. She shared that she lives at the home w/ 3 other females. She disclosed that the reason she is in foster care is because her mother called the police on 9/29/2017 for shoving her. Emily admitted that she was drunk and does not remember ever putting her hands on her mother but DCF got involved and removed her from the home. Emily admitted to running away from the group home last week “they called the police but I went back on my own.” She is attending the 9th grade at Indian Ridge High School. Emily began smoking cigarettes on a monthly since age 14. She also smokes vapors, and black and milds. Onset of marijuana at age 15 when she “drank a couple of beers” on a weekly basis. Last use was September 2017 when she drank a bottle of Irish Whiskey and a bottle of Chardonnay wine. Emily reported no cravings or withdrawal symptoms however, she stated that she was too drunk to remember the altercation she had w/ her mother in September 2017. Onset of alcohol at age 15 when she shared a bowl w/ 4 other people. Frequency daily. Last use was one week ago when Emily smoked a couple blunts w/ a group of people. No craving or withdrawal symptoms reported. She admitted to experimenting w/ cocaine at age 16. Emily stated that she shared a couple of grams w/ 3 people in August 2017. Emily was administered a urinalysis at the time of assessment and tested positive for marijuana and negative for all other substances: Cocaine (COC), Opiates (OPI), Methamphetamines (MAMP), and Benzodiazepines (BZO).Given the information gathered at the time of assessment, Emily’s substance abuse diagnosis is secondary to her mental health. Emily is recommended to participate in a residential facility that can address her co-occurring disorder to include random u/a testing and anger management counseling. She is to continue with her current psychiatric services and she is to be compliant with taking her medication as prescribed. TASC Assessor will refer and link to the appropriate service(s). 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.2/16/2018 ___________________________________________________Staff Signature Date Nicole Playton, M.S., LMFT By typing my name hereto on this the day of 19th 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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