CORE letter to the DA

From:
Mr. Kerry Hanley - potential client
504.605.8928
DOB: 05/25/1960
tequila.mockingbird.44@gmail.com

    Note: Mr Hanley responds more quickly to phone calls and texts.

Attached:
SUBSTANCE USE ASSESSMENT REPORT
related to DUI
(Klonopin & Adderall.
  BAC: 0.00.)
 
Assessment Date: 10/22/2020

Written by Ms Nicole Goldin
CORE Startup Founder 2020
>>>>[Not by the counselor in my "session" - Megan Loos]

Assessment Location
CORE (Startup 2020)
306 West Judge Perez
Chalmette, LA 70043
(504) 656-4325

Assessment Performed by
Megan Loos

Referral Source: St. Bernard District Attorney’s Office – Attn: Lesli Marengo

Reason for Referral: OWI 1st Offense & Vehicular Hit and Run

~~~~~~~~~

Reason for Referral: OWI 1st Offense & Vehicular Hit and Run

Overview
Kerry Hanley, age 60, was assessed on October 22, 2020 at CORE: Louisiana Counseling & Recovery Center as a result of a OWI that took place on February 12, 2020.

Client arrived on time to his scheduled in-person appointment and was dressed in appropriate attire.

  Client’s mood and affect were appropriate during his assessment appointment;

>>>  However, client’s comments and behaviors
>>> bordered with
inappropriate towards the end of his appointment.
>>>>>
1. "Comments"
1.a In response to the above statement that [... client’s comments and behaviors bordered with inappropriate...]
    This is in direct opposition to the previous paragraph which clearly states that, "Client’s mood and affect were appropriate during his assessment appointment."

Q-1.a What defines a clinically inappropriate comment during a clinical session - other than comments about plans to harm self or others?
    In a therapeutic session - other than the two examples of inappropriate comments above - all other comments must be deemed as important data and informational to the therapist in order to properly diagnose the client.
If a clinical patient were under the assumption that he or she could only say certain things - and I'm assuming that you do have some list of clinical words, or topics, or sentences, that are deemed appropriate and inappropriate - then the client would be hesitant to fully speak his or her thoughts to the clinician in a forthcoming manner, or hesitant to trust the clinician -  therefore refraining from speaking openly.
The agreement that a client can speak freely to the therapist during a clinical session, without being shamed in some manner, is imperative to an accurate diagnosis.

Q-1.b What defines a comment in a clinical setting "Bordering With" another type of comment?
   Please provide examples of inappropriate comments along with Mr. Homments that "border with" these examples.

3. Behavior
Also, in response to the above statement that [... client’s comments and behaviors bordered with inappropriate...]
    Which is also in direct opposition to the previous paragraph which clearly states that, "Client’s mood and affect were appropriate during his assessment appointment."

3.a What defines a clinically inappropriate behavior during a clinical session (other than behavior consisting of making contact with the counselor in any way, or damaging property in the therapist office or greater environment, or damaging the therapist personal property, are harming the therapist, or harming himself during the session, or stating that he or she is going to harm themselves or the therapist during this session)?

    In a therapeutic session - other than the examples of inappropriate behavior above - all other behavior traits must be deemed as important data and informational to the therapist in order to properly diagnose the client.
If a clinical patient were under the assumption that he or she could only say certain things - and I'm assuming that you do have some list of clinical words, or topics, or sentences, that are deemed appropriate and inappropriate - then the client would be hesitant to fully speak his or her thoughts to the clinician in a forthcoming manner, or hesitant to trust the clinician -  therefore refraining from speaking openly.
The agreement that a client can speak freely to the therapist during a clinical session, without being shamed in some manner, is imperative to an accurate diagnosis.

2.b What defines a comment in a clinical setting "Bordering With" another type of comment?
   Please provide examples of inappropriate comments along with comments that "border with" these examples.

>>> as well as during client’s post-assessment interactions with CORE’s clinicians [plural?].

Client reported being ‘a little sleepy’ during the beginning of his assessment, and after drinking coffee, client presented alert, awake, and oriented in all spheres throughout his evaluation.

Client participated in an in-depth clinical interview with a licensed counselor. The ASI (Addiction Severity Index), SASSI-4 (Substance Abuse Subtle Screening Inventory), and Revised COJAC Screening Tool were administered during client’s
substance use assessment. Client also submitted to a 12-panel point of care urine analysis.

Presenting Problem
Client reported that he was referred to complete a substance use evaluation due to a OWI and Vehicular Hit and Run that
took place on 02/12/2020. He explained that on the day of his arrest, he was in his vehicle and was attempting to back up after accidently pulling out ‘a little too far’ into traffic when attempting to make a right turn. Client reported that as he was
backing up, his vehicle ‘bumped’ into the vehicle behind him. Client stated that since he was going at a very low speed, he did not assume any damage was done. Client reported he heard the driver in the other car “blaring their horn” at him, and assumed this meant they wanted him to turn. Client stated he then drove off, unaware that the other individual in the car was attempting to get his attention. Client continued that after a few minutes had passed, he was ‘almost surrounded’ by several cop cars, where client was then arrested and taken into custody. Client stated that during this time he gave

>>> a blood test which came back positive for amphetamines and benzodiazepines. Client stated he is prescribed medications that contain
amphetamines and benzodiazepines.
>>> Proof of prescriptions was not provided at the time of client’s assessment.

Client denied the presence of any other prescribed or illicit substances in his system at that time of the incident.

ASAM Dimension Ratings
Dimension 1 – Acute Intoxication/Withdrawal Potential
Risk Rating: 1 (Mild)

>>> Client is at a low risk for withdrawal.

Client reported that his last use of alcohol was 1 night prior to his assessment

>>> and his last use of marijuana was 2 nights prior to his assessment.

Client reported he has ‘one or two’ drinks a night and

>>> uses less than a gram of marijuana ‘a few times a week’.

Client’s reported patterns of current use do not suggest dependence; however,
are
>>> currently regular and problematic,
>>> especially pertaining to
>>> continued illicit use while attempting to enroll into the diversion program.
>>>> [What's a diversion program?]

Client did not appear to be experiencing any withdrawal symptoms during his assessment, nor did he appear to be intoxicated at the time of his interview.

Dimension 2 – Biomedical Conditions and Complications
>>> Risk Rating: 0 (Low)
Aside from a hospitalization in 2018 due to a broken bone from a skateboarding injury, client denied experiencing any biomedical conditions in his lifetime and denied current prescription medications for medical purposes or physical conditions.
Client reported that he is currently prescribed medications for non-physical conditions (see Dimension 3).

Client denied experiencing any other biomedical conditions or complications in his lifetime. Client appeared to his appointment fully functioning and demonstrated no physical discomfort. No biomedical signs or symptoms were present, and client

Dimension 3 – Emotional, Behavioral, or Cognitive Conditions and Complications
Risk Rating: 2 (Moderate)
Client reported that he is currently emotionally stable and denied experiencing symptoms of serious depression or anxiety
within the past six months. Client reported he has been diagnosed with Major Depressive Disorder (MDD), Generalized Anxiety Disorder (GAD) and Attention Deficit Disorder (ADD). Client stated he was diagnosed with MDD when he was 27 years old and has been taking an antidepressant for that diagnosis since that time. Client reported he was diagnosed with GAD in 2000 and was prescribed Klonopin (benzodiazepine) at that time, and was diagnosed with ADD in 2015, where he was then prescribed Adderall (amphetamine). Client stated he takes his antidepressant once a day in the morning, and his Klonopin and Adderall prescriptions twice a day, once in the morning and once in the afternoon.

Client denied emotional/psychiatric problems that were caused by or worsened by his substance use. Client denied serious thoughts of
suicide and/or suicide attempts in his lifetime. Client denied hospitalizations for psychiatric or emotional conditions in his lifetime.

Dimension 4 – Readiness to Change
Risk Rating: 3 (Moderate-High)
Client appeared willingly engaged in the assessment process. Client appears to have awareness of the seriousness of his offense; >>>> however, appeared to minimize the seriousness of the original accident
>>>>[Appeared to Minimize? How so? No explanation? No evidence? Just appeared? What does "Appearance to minimize" look like?]

>>> nor did he recognize the role of his prescription medications and use of marijuana on the incident that led to his arrest.

Client’s post-assessment behaviors (see clinical impression) also determined this moderate-high risk within Dimension 4. Client expressed that he is eager to complete all requirements for diversion. Client denied using substances problematically and reported that if he were to discontinue marijuana use, he would not go through withdrawals symptoms, nevertheless “it would suck”.

>>>> It is of significant
clinical concern that client has continued to use marijuana despite knowing that this is an illicit substance and that he wishes to enroll in the diversion program. [What's a diversion program?]

>>>>  Furthermore, client’s use of marijuana 2 days prior to his assessment
and
having been informed of the required urine analysis
>>>> (false!)
and nature of the assessment
>>>> (false!)
is also of significant clinical concern.

Client reported no other legal charges in his lifetime.

Dimension 5 – Relapse, Continued Use, or Continued Problem
Risk Rating: 2 (Moderate)
Client has a moderate potential for substance use problems, has a moderate relapse potential and displays some coping skills. This dimension rating was based on client’s history of substance use as reported below.

Client reported that he experimented with alcohol for the first time at age 18, and reported that he has been drinking regularly since yet. Client reported that he will consume “two martinis per day.”
Client also clarified that he usually consumes 10-12
ounces of alcoholic beverages per day. Client reported that when he and his wife separate[d], his drinking increased significantly.

Client reported that since then, his drinking has reduced to the current amount. Client reported that his last use
of alcohol was the night prior to his assessment.
Client reported that he experimented with marijuana for the first time at age 16 and has been smoking [less than one gram for the past 2 years]
>>>> daily. [ No. I said
2-3 evenings per week]

Client reported that his marijuana use is not problematic nor is he dependent on marijuana.

Client reported that he has been able to take breaks from marijuana use lasting 2 and 3 years in length.
  Client reported that he has been smoking daily, less than 1 gram >>>> per day [no. per 2-3 times per week].

  Client reported that if he were to discontinue marijuana use “I wouldn’t have cravings but it would suck.”
  Client reported that his last use of marijuana was 2 days prior to his assessment.
 
Client reported that he has been prescribed Klonopin and Adderall for 5 years, and Paxil for over 30 years. Client denied non-prescribed, recreational, problematic, or regular use of his medications.

Client denied experimental, regular, problematic, or dependent use of any other substa[nce].

Dimension 6 – Recovery/Living Environment
Risk Rating: 2 (Moderate)
Client reported that he has been divorced for the past 11 years and lives by himself. Client reported that he has been living by himself for the past 5 [>>> 11] years.

Client’s living environment poses a moderate-high risk to his use of substances due to using alcohol and marijuana primarily at home.

Client reported that he has been retired for the past 3 months. After his assessment,
client reported that he has been having a difficult time with his retirement and “COVID isolation.”

Client’s retirement,
increased idle time, and lack of employment pose a moderate risk to his use of substances, and a high risk for client’s emotional health.

USDiagnostics® Point of Care 12-Panel Urine Analysis

DSM-5 Diagnostic Impression
F12.10 Cannabis Use Disorder – Mild.

As evidenced by the presence of 2 or more DSM-5 diagnostic criteria in the past 12 months. [? Depression & Anxiety?]

Clinical Impression
The clinical impression below has been
determined by
- client’s substance use assessment appointment,
as well as
- further interactions between the client and CORE’s licensed
>> clinicians [plural?]
following client’s assessment.
Client’s history of substance use indicates that client meets criteria for a mild substances use disorder. On the other hand,
client’s SASSI-4 results supported the above statement, as it indicated a high risk of having a substance use disorder. Client
reported that this is the first time he is in trouble with the law. Client articulated that he is eager complete all of his diversion
requirements for enrollment. Furthermore, it is clinically concerning that client has a history of increased intake and coping
with alcohol use. Client acknowledged use of marijuana is illegal and reported it has ‘never caused any problems’ for him
mentally, socially or physically and does not have any prior charges and/or convictions related to marijuana use.
The day after his assessment, client appeared at CORE’s Chalmette office without an appointment; however, the office was
closed. Client left a present for his assessment counselor at the office door. Per CORE’s policy, clinicians are not allowed
to receive presents from clients, especially while a client is under an evaluation process. CORE’s director contacted client
to thank him for the kind gesture and explain CORE’s policy regarding client presents. During this phone call, client
expressed that he “loved” his assessment counselor and wanted to become friends with her. Despite CORE’s policy, and
that said gift would have tobe returned to him, client verbalized that he would attempt to give this gift directly to the
counselor. Client was redirected again, and CORE’s director explained that client could only have purely clinical
interactions with his assessment counselor. It was documented that during his assessment, client verbally suggested to
assessment counselor that she visit his home one evening, and the assessment counselor politely declined. During the
assessment, client also stated that he believed that he and the assessment counselor “would not be a good fit [for counseling]
unless you’re ok with me asking you out at the end of every session.” In response, assessment counselor thanked client for
his honesty and agreed that it would not be a good counseling fit. Assessment counselor recognized client’s need for
counseling services and offered a referral list of counseling service providers. During phone call with CORE’s director,
client denied the above-mentioned agreement with assessment counselor, and attempted to negotiate with CORE’s director
ways and reasons why he needed to enroll in individual counseling with his assessment counselor. CORE’s director denied
his request. Later during the call, client requested that CORE’s director send a picture of his assessment counselor’s face,
as he was unable to see her full face due to the mask she was wearing at the time of his clinical interview. Client also
suggested that, perhaps with this picture, he would be able to recognize her if he “ran into her one day.” CORE director
denied his request, and at this point, due to the inappropriateness of his request, instructed client that he was not to contact
his assessment counselor any further. Client was also instructed not to appear unannounced at CORE’s of

ll in-person interactions with clinicians were by appointment only. Client was informed that should he continue to
contact his assessment counselor, CORE’s director would be obligated to report the inappropriate behavior, per signed
authorization to release information. Client verbalized “I guess I have to take this as a restraining order from Megan.”
Despite the above-mentioned notice and client’s verbal acknowledgement, client continued to attempt to contact both his
assessment counselor via phone calls and text messages, as well contacted CORE’s director asking to be matched with said
counselor for counseling sessions. CORE’s director does not get involved with counselor-client interactions unless there is
a concern for a CORE clinician’s safety. Due to the above-mentioned interactions between client and CORE’s clinicians,
client’s readiness to change, perception of the seriousness of his arrest, and respect for enrollment into the diversion process
appear to be significantly lacking. Client’s behaviors, disregard of clear redirection, and attempts for inappropriate boundary
crossing with CORE’s clinicians are of significant clinical concern.
Clinical Recommendations
Client is recommended to discontinue marijuana use completely and submit to monthly drug screenings for a
minimum of 6 months to ensure that client becomes and remains substance free. Furthermore, client is recommended to
submit to a psychiatric evaluation with a psychiatrist (MD). Client is also recommended to attend a minimum of 12
individual counseling sessions with a licensed mental health professional (LAC, LPC, LCSW, LMFT, PhD, MD) to
address client’s emotional and psychological needs, as well as to explore the relationship between client’s mental health
and substance use (see referral list). Client is to submit a copy of all current prescriptions to referral source, as well as
proof of prescriptions (e.g. pharmacy print-out) from the time of his arrest. Client reported that he is prescribed Klonopin
(benzodiazepine) 2 times per day. Lastly, client is to submit a letter from his prescribing physician stating that client has
been informed about possible interactions of Klonopin and alcohol, as well as advised against driving after consuming
prescribed Klonopin, as benzodiazepines are known to cause impairment of functions vital to operating a vehicle. Be it
known that client is not to receive any of the above-mentioned services at CORE due to client’s display of inappropriate
behaviors towards CORE’s clinicians. Proof of completion is to be submitted to client’s referral source. Should any
problems arise, please refer for re-evaluation and treatment.
CORE is dedicated to serving your clients. Should you have any questions regarding this assessment report, please contact
our office at 504-656-HEAL (4325) or via e-mail at mycorecenter@gmail.com.
Megan Loos
Nicole Goldin, MMT, LAC, CCGC, AADC, MT-BC Megan Loos, NCC, LPC
Licensed Addiction Counselor Licensed Professional Counselor