CDT Meeting Tool

CDT Date: 11/23/18

Case Name: Sharlyn Atacio

WMS Case Number:S7255265


Current Phase CDT Phase Change to Phase Change Effective
Initial Baseline 12/1/18
Measure/Evaluation Participant(s) & Date Completed
DV Screening Sharlyn Atacio – 11/20/18
Evaluation (MH/SA, Psychosocial) Sharlyn Atacio intake at Postgraduate Mental Health Center 11/7/18
Modified Mini Screen Sharlyn Atacio 11/1/18 (score = 1)
UNCOPE (Adults) Sharlyn Atacio 11/1/18 (score = 2)
CRAFFT (Teens) N/A
ASSIST Sharlyn Atacio 11/1/18 (score = 19/cannabis)
CASAC Assessment Sharlyn Atacio: CASAC evaluation 11/15/18
Toxicology 10/24/18 positive for cannabis (at hospital) 11/1/18 results pending

Case Planner:

Adults in the home:NameRelationshipSharlyn AtacioSAMomAltagracia TorresATMGMJuan TorresJTMGF Children in the home:NameAgeGenesis AstacioGA16Sharlize AtacioSA3 weeks old
Parents outside of the home:NameRelationshipJose AstacioJABio momYahairaTorresYTBio dad External supports (out of the home):NameRelationship

CDT Participants:

Name Title/Role
Melissa Ramrattan, PhD Director, FTR-COS
Tiffany Rodriguez, PsyD Supervisor, FTR-COS
Leticia CorderoBA Case Planner, FTR-COS

Case Planner:

Referral Details (Referred by? Reason and date? When did family sign 2921):· The case was referred to University Behavioral Associates’ Family Treatment and Rehabilitation Court-Ordered Supervision (FTR-COS) program through the Bronx Field Office on 10/26/18, with allegations of substance use against Ms. Atacioclient related to her child, Sharlize. Ms. AtacioClient tested positive for marijuana at the birth of Sharlizebaby. Sharlize baby was born on 10/24/182018 at Columbia Presbyterianhospital. She tested negative for all substances.Housing (all family members; describe housing situation, stability of housing, rental arrears and amount):· Sharlyn client currently lives with her maternal grandparents. Family has lived there for over 20 years and there are no reported rental arrears.Home Environment (cleanliness, accessibility, food in the home, beds, CO/smoke detectors, window guards, rodents, other):· A home assessment was conducted on 10/29/18; based on this initial assessment, the home appeared clean, there is sufficient food, and properly functioning CO/smoke detectors. There were appropriate sleeping arrangements for everyone in the home, including Sharlize baby was has a crib and a bassinet. Safe sleep practices have been discussed on an ongoing basis.Financial/ Public Assistance/ Employment (type and amount of entitlements; if employed – job title, wages; other financial resources):· Ms. AtacioClient received financial support from her father and maternal grandparents. She receives $192 in food stamps on a monthly basis and $91.50 in cash on a biweekly basis. She also receives WIC.Education/Early Intervention (for all children; school name, grade, attendance, behaviors, academics ):· Genesis Sister is currently in 11th grade. There have been no reported behavioral or academic concerns.Medical (for all children; immunizations, most recent physical, known medical concerns ):· The medical care for Sharlize baby is up to date. She was last seen for a well-baby visit on 10/30/18. Follow up is needed on the medical care of Genesissister, however there are no known medical concerns and maternal grandparents reported that medicals are up to date.Strengths:· Ms. AtacioClient is willing to engage in MH services and substance abuse treatment.· Ms. AtacioClient has identified sources of support in her community and family· She exhibits a sense of self-awareness and the function of substances in her life.· Ms. AtacioClient has been observed to exhibit warm and appropriate interactions with her child· Sharlize baby was observed to be well cared for during the evaluation and during home visits.Family Functioning (Interactions between adults in the home, children, adults and children, custodial and non-custodial parents; DV?):· Family appears to be supportive of Ms. Atacioclient. Ms. AtacioClient appears to have a good relationship with her maternal grandparents, her biological father (whom she sees frequently), and her biological mother (who she speaks to on the telephone frequently). Ms. Atacioclient has reported that she has a good relationship with her younger sister. Ms. Atacio. Client has appeared attentive to babySharlize’s needs during home visit and has been observed interacting with her in a loving manner. She is struggling to manage the relationship between herself and Justin, Sharlize’s baby reported father. There are questions surrounding paternity and therefore both parties are interested in completing a DNA test.


Mental Health (all family members):Ms. Atacioclient completed the Modified MINI, UNCOPE, and ASSIST, in addition to the clinical interview. She denies any mood or psychotic symptoms on the Modified MINI, and reports some symptoms of anxiety which are specific to worries about embarrassment in social situations. This is consistent with her self-report, during which she denied current mood, anxiety, and psychotic symptoms. However, she reported an increase in stress related to the paternity of babySharlize and the relationship with the probable father, Justin.Ms. AtacioClient also reports a history of trauma, including early separation from her mother due to her mother’s incarceration and subsequent deportation to Dominican Republiccountry of birth, attempted sexual assault by a stranger last year and physical altercations in the community. Nevertheless Ms. Atacioclient denies any current symptoms of Posttraumatic Stress Disorder.The client denies any current suicidal ideation, any past suicide attempts or any current non-suicidal self-injury. She reports a history of passive suicidal ideation as a teenager but did not have any plan, intent or previous attempts. She also reports a history of one event in which she engaged in non-suicidal self-injury in which she scratched herself superficially with her nails. She denies any current or past homicidal ideations.Substance Use (all family members):In terms of substance use, her reports on the ASSIST (Score = 19/Cannabis) and UNCOPE (Score = 2) are consistent with her clinical interview. She reports that she smoked one blunt one month prior to giving birth. However, prior to discovering she was pregnant, when she was 4 months along, she would smoke 3 “blunts” a day. She acknowledges that smoking cannabis helps her “forget” about the stressful aspects of her life.Ms. AtacioClient reports that she began smoking cannabis at the age of 18 and steadily increased to smoking three times a day. She states that she stopped when she was four months pregnant, prior to that she was unaware of the pregnancy. She reports that she then stopped smoking for the duration of the pregnancy with the exception of one month before delivery when she was upset about the uncertainty of the baby’s paternity. She indicates that her main triggers for use were negative emotions (e.g., anger, sadness).Ms. AtacioClient completed an observed saliva toxicology on 11/1/18 (results pending). She also completed a breathalyzer on this date (BAC = .000). She also denied alcohol use and did not exhibit any symptoms of intoxication.Legal (all family members):· There are no known legal concerns for this family.Culturally Relevant Factors:· Maternal grandparents as well as Ms. Atacio’sClient’s parents are Spanish speaking.Conceptualization:Ms. AtacioClient is a domiciled twenty year old woman who was born, raised and currently resides in the BronxNew York. She was referred to UBA for FT/R – COS services following an Initial Child Safety Conference as a result of testing positive for marijuana at the birth of her daughter, Sharlize. SharlizeBaby tested negative for marijuana and all substances at birth. At present, she denies any mood or posttraumatic symptom history, however is interested in seeking mental health services. She understands that she was using marijuana as a coping mechanism and is interested in learning healthier ways of coping with life stressors. She denies current substance use but has a history of cannabis use. She denies current S/H/V/I/I/P.Ms. AtacioClient reported a significant loss when her mother was incarcerated then subsequently deported to Dominican Republiccountry of birth. Ms. AtacioClient denies any negative feelings towards her mother and reports that her maternal aunt is to blame because she introduced her mother to criminal activities. Ms. AtacioClient reported that as an adolescent she initially used cannabis socially but then began using it more frequently. She often used cannabis to numb her emotions and no longer have to think about the stress that was going on in her life at any given moment. Ms. AtacioClient may be struggling with her identity as a mother given the history of her unexpected separation from her own mother. It is likely that she has attempted to fill that emotional void via substance use and poor relationships. Nevertheless, she appears motivated to engage in services that will support her and assist her in fulfilling her role as a new mother.During the interview, Ms. AtacioClient was generally forthcoming and pleasant. She denied feeling overwhelmed by the involvement of ACS and she reported feeling grateful that Sharlize baby was not removed from her care. Throughout the interview, Ms. AtacioClient presented with blunted affect and therefore at times it was difficult to ascertain her feelings or level of understanding on particular topics, especially related to the ACS process. Given Ms. Atacio’sClient’s history, it is a possibility that she lacks a sense of agency and therefore does not provide much input into decision making processes.

CDT Facilitator:

Purpose of the meeting (Initial Plan, Transition meeting, Safety & Risk concerns, Engagement challenges, Lack of progress etc.):· Initial plan/Transition Meeting (client will be moved from Initial to Baseline as of 12/1/18)Known Risk Factors (all family members):Risks (e.g., suicidality, homicidality, self-injury, aggression, psychiatric illness, substance abuse, risky sexual behaviors, weapon possession, gang involvement, community violence, domestic violence, medical problems, school related problems, home environment):· Ms. AtacioClient’s marijuana use· Ms. Atacio’sClient history of poor impulse control/lack of coping skills.Engagement-related concerns (e.g., frequent no-shows or cancellations, lack of engagement during sessions, refuses to meet with staff): Ms. AtacioClient has been engaged with services and communicative with staff.· No concerns have been noted related to engagement; Ms. AtacioClient has beenSteps to Close Case:· Ms. Atacio’sClient consistent engagement in MH services and substance abuse treatment.Recommendations/ Next Steps:WhatBy WhomWhen

Case Planner signature: __________________________________ Date:_______________

Supervisor Signature: __________________________________ Date:______________