Client Name: Penelope PepperClient ID#: 999999999
TANF#: H000000Referring DHS Worker: John Wayne
Date of SASSI: 3/19/16Date of ASI: 3/21/16
Assessing Clinician: Jane WayneDate of Admission: N/A
Date of Report(due 3 business days post-assessment):3/23/16
Report Submitted To: John Wayne
Method of Submission:☐SecureEmail: Click here to enter text.;☒Fax#: 000-000-0000
Assessment Summary based on ☒ ASI☐ASI-MV☐BHI-MV
Presenting Situation/Problem:Ms. Pepper is a 30 year-old Caucasian referred for TANF Screening, and if needed, substance use assessment and urinalysis. Ms. Pepper’s SASSI Score of Invalid due to high defensiveness indicates a need for further assessment. Based on Ms. Pepper’s Addiction Severity Index scores, she does not meet criteria for admission for substance use disorder treatment. Her defensiveness might be attributed to the substance use of the father of her children.
Living Situation:Ms. Pepper and her two children live with her parents at this time. She expressed frustration regarding this living situation and shared that she wants to get a place of her own for herself and her children. She reported that she has lived with her parents for the past 18 months. Prior to moving in with her parents, she lived with the father of her children. She stated that she “had to move away from him because he’s an angry drunk and started doing some drugs.”
Medical History/Current Status:Ms. Pepper reported that she was a “healthy kid” and only needed medical care for typical childhood illnesses. She shared that she has only been hospitalized two times; each time was to give birth; both children were caesarian births. She stated that she currently feels “stressed and tired a lot of the time” and attributes those feelings to living with her parents and not having her own place to live. She reported that she “probably needs to see a dentist” as she is having toothaches “off and on.” She shared that she does not have a primary care physician and has never had one on a regular basis because “overall I feel pretty good and I don’t have money to go to the doctor or the dentist.”
Drug & Alcohol History/Current Status: Ms. Pepper shared that her first use of alcohol occurred when she was 18 years old when she moved in with the father of her children. She said, “I was afraid to drink before then; my parents would have killed me.” She reported that she never drank as much as her children’s father did and that seeing him get drunk made her not want to drink. She acknowledged that she hoped that if she didn’t drink alcohol he would stop drinking too. During her time with him, she tried marijuana a “couple of times” and stated that she “never liked the way pot made me feel.” She denied having tried other illegal drugs. She stated that the only time she had used pain medication was following the birth of her two children due to pain associated with the caesarian incision. Ms. Pepper shared that her most recent use of alcohol was about a month ago and acknowledged, “I did get drunk then because my husband was drunk and I wanted to show him what it was like to be with a drunk.” She shared that since she is living with her parents again, she has not been drinking and wants to quit it “all together.” She reported that she has “really bad hangovers; it’s not worth it.”
Legal History/Current Status:Ms. Pepper stated that she has no current legal problems and has never had criminal charges; “not even a speeding ticket.” She reported that, “I called the cops once when my man was drunk and beating on me. He got arrested for assault and battery but I dropped the charges because I was afraid of him and what he would do if I didn’t.”
Family/Social Relationships:As reported in the legal section, Ms. Pepper shared, “my man beat on me when he was drunk and sometimes he would get really angry and throw things at me; the longer we were together the worse things got. I wanted to stay with him because of the kids but it got so bad that I moved out when my parents told me to come live with them for a while. I’m hoping he will miss me and the kids and will change and want us back.” She reported that he calls her off and on and talks to the children and they tell her that they miss him but that they don’t want to go back unless he “is nicer.” Ms. Pepper shared that she is a “loner” and doesn’t get out much and that she would like to have friends but isn’t sure where to find “safe” people for friends.
Psychiatric History/Current Status:Ms. Pepper reported that she has never seen been diagnosed with any mental health disorders. She shared that she feels depressed and sad because of her current living situation and being away from the children’s father. She stated, “I might want to see someone who could help me with that and the stress I feel and not be afraid of people so I can make friends.”
Case Management Needs: Ms. Pepper shared that she might want some case management services “to help me find a job that I can do so I can start making some money and maybe get into Section 8 Housing. Maybe the case manager could help me with housing too.” An appointment was made for 03/24/16 with the Case Manager for a complete case management assessment.
☒ Drug ScreenA Drug Screen is required for all TANF referrals following completion of the assessment
☒Negative
☐Positive for:
☐Illegal Drugs:
☐Marijuana
☐Methamphetamine
☐Heroin
☐Cocaine/Crack
☐Hallucinogens: Click here to enter text.
☐Other:Click here to enter text.
☐Alcohol
☐Prescription Drugs: Click here to enter text.
☒ Recommendations based on Assessment/UA and ASAM Patient Placement Criteria:
☐Treatment; Level of Care: Choose an item.
If Interim Services - describe: Click here to enter text.
If Other - describe: Click here to enter text.
☒Client does not meet criteria for admission to outpatient level of care
☒ Referrals: Offered Ms. Pepper a referral for depression and stress and she refused it at this time. She stated, “I’m just too busy right now with everything that is going on.” I gave her my numbers and told her she could contact me again if she changes her mind.
Other Comments/Recommendations: Ms. Pepper seems to be very interested in doing what is needed to receive her TANF benefits and expressed a hope that “TANF will help me get better.”
Client Name/ID#: Penelope Pepper
Screenings/Assessments are not forensic in nature and rely on the self-report of the person being screened/assessed.
* REDISCLOSURE NOTICE TO RECIPIENT OF INFORMATION
“This information has been disclosed to you from records that are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F. R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. Pts. 160 & 164, and cannot be disclosed without written consent unless otherwise provided for in the regulations. The Federal Rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains 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. “The information disclosed may only be redisclosed to carry out the recipients official duties with regard to the client’s criminal proceeding in reference to which the consent to release confidential information was made by the client.” 10/16