Family Vision: For Tina comply with parental directives/rules, learn how to express feelings appropriately, improve decision making skills and improve relationship among family members.
Family: Tina is an African American female, age 16 y/o who resides in Elizabeth with her mother Ms. Gilder, uncle, grandfather and cousins. Tina and Ms. Gilder continue to have a conflicting relationship. Tina and Ms. Gilder relationship are slowing improving. Tina has been out the home for a month now, she was placed in a Specialized Residential Treatment Program on 10/11/17. Since her admission into the program Tina and Ms. Gilder became closer. There is still a lot of family work that needs to be done but at this time, Tina and Ms. Gilder are able to communicate…show more content… Gilder attends weekly family sessions to assist the family with unresolved family issues, healthy communication and strengthening the family bond.
Psych/Mental Health: Tina is diagnosed with F91.3 Oppositional Defiant Disorder. Youth is not on any medication at this time. Tina was hospitalized back in Tina was hospitalized back in March 7th, 2017 for inebriated and out of control. She was discharged on March 23rd, 2017 from the CCIS unit. She then was stepping down to the Tina stepped down to the Trinitas Adolescent Full Day MICA program on 3/24/17. Tina successfully completed the MICA program and was step down to the Trinitas MICA group on 6/20/17. Tina continue to miss her weekly group sessions at the MICA program.
Due to youth’s non-compliance with MICA treatment contract resulted in an unsuccessful discharge from the MICA group. Samantha Lukenda (Trinitas Hospital OP Department clinician) recommended a higher level of care. CM made a phone referral to a specialized program for youth. She was scheduled for a telephonic interview for Friday 9/1/2017 at 11am. Youth missed the telephonic interview on Friday 9/1/2017. Youth refuses to attend a specialized program. At that time youth is not open to attending a specialized