BROWARD SHERIFF’S OFFICE CHILD PROTECTIVE INVESTIGATION SECTION

SUBSTANCE ABUSE

MULTI-DISCIPLINARY ASSESSMENT TEAM REPORT

This following report is the result of a trans-disciplinary staffing review. This MAT committee is at a minimum comprised of substance abuse treatment provider(s); Health Start Coalition; women intervention specialist(s); children’s medical specialist(s); child protection & service provider(s) for purposes of inter-agency communication and service coordination focused on infant’s health, safety and wellbeing; caregiver(s) parenting capacities & treatment issues; service and safety needs for family. The resulting information is based on attending parties’ consensus for purposes of it being utilized for furtherance of safety & service delivery to the family.

FSFN # : / Date Report: / Date Staffing: / FAX: 954-327-2764
CPI: / Desk: / Cell #: / Email:
CPI Supervisor: / Desk: / Cell #: / Email:
A. Allegation Narrative:
B. Primary V/C
Primary V/C Last Name:
/ V/C First Name:
/ Age:
/ DOB:
/ Gender:
/ Race:
Primary V/C current address:
/ City:
/ Zip Code:
Hospital: / Delivery Type:
Natural Cesarean / Weight:
/ Length:
/ Apgar Scores:
Substance Exposed V/C
Yes No / Positive Toxicology:
Yes No Pending / If Yes Explain: / Type of Test:
Complications/Adverse Effects: Yes No If Yes Explain: / NICU: Yes No
Medical Diagnosis: / Referral Made to Early Steps:
Yes No
Pediatrician:
Yes No / If Yes Pediatrician Name:
/ Pediatrician Phone:
/ Receiving Healthy Start: Yes No / Healthy Start Agency:
Sheltered
Yes No / PAD
Yes No / Placement Type: / ChildNet CA Assigned: / OAG Assigned:
Home visit completed:
Yes No Pending / Date of HV: / Was SAFE SLEEP addressed with mother and father?
Yes No Explain: / Crib/Bassinet observed by CPI?
Yes No
C. Mother
Mother Last Name:
/ Mother First Name:
/ DOB: / Phone #:
Address (If different than Primary V/C):
/ City:
/ Zip Code:
Positive Toxicology:
Yes No Pending / If Yes Explain: / Pre Natal:
Yes No Unknown / Pre Natal Physical/Clinic:
Substance Abuse:
Yes No / If Yes Explain: / Drug Tested:
Yes No Pending / Referred to Substance Abuse Counseling:
Yes No If Yes Explain:
Mother Arrested?
Yes No / Law Enforcement Agency Involved: / Case Number: / LE Name
D. Mother’s other children (# of Children in Home? )
Name / DOB / Gender
-Race / Father / Current Placement
E. Mother’s History / Explain
1 / Relationship with Primary V/C’s Father? / Yes No Unknown
2 / Mother’s education level:
3 / Is the Mother employed? / Yes No Unknown
4 / Does the Mother have a history of substance abuse? / Yes No Unknown
5 / Does the Mother have a history of family/domestic violence? / Yes No Unknown
6 / Mother has history of sexual victimization? / Yes No Unknown
7 / Does the Mother have a history of instability? / Yes No Unknown
8 / Does the Mother have a history of anxiety and or depression? / Yes No Unknown
9 / Does the Mother have a history of suicidal ideation or involuntary hospitalizations? / Yes No Unknown
10 / Mother has history of physical abuse, neglect or abandonment as AP? / Yes No Unknown
11 / Mother has prior involvement with DCF? / Yes No Unknown / List Case Number, Maltreatment, and Findings:
12 / Mother has prior or current Dependency Judicial Intervention? / Yes No Unknown / List Case Number, Maltreatment, and Findings:
13 / Does the Mother have a service history? / Yes No Unknown
14 / Has or is the Mother involved in Drug Court? / Yes No Unknown
15 / Does the Mother have a criminal history? / Yes No Unknown / List Arrests and Convictions:
16 / Does the Mother have family/friend? / Yes No Unknown / Who is their support group/system?
17 / Is the Mother cooperative? / Yes No Unknown
Additional Findings/Summary:
F. Primary V/C Father
Primary V/C’s Father Last Name:
/ Primary V/C’s Father First Name: / DOB: / Phone #: / Father # of Children?
Address (If different than Primary V/C):
/ City:
/ Zip Code:
Substance Abuse:
Yes No / If Yes Explain: / Drug Tested:
Yes No Pending / Referred to Substance Abuse Counseling:
Yes No If Yes Explain:
Father Arrested?
Yes No / Law Enforcement Agency Involved: / Case Number: / LE Name
G. Primary V/C Father’s other children
Name / DOB / Gender
-Race / Mother / Current Placement
H. Father’s History / Explain
1 / Relationship with Primary V/C’s mother? / Yes No Unknown
2 / Father aware of the mother’s Substance Abuse? / Yes No Unknown
3 / Father’s education level:
4 / Is the father employed? / Yes No Unknown
5 / Does the Father have a history of substance abuse? / Yes No Unknown
6 / Does the Father have a history of family/domestic violence? / Yes No Unknown
7 / Does the Father have a history of instability? / Yes No Unknown
8 / Does the Father have a history of anxiety and or depression? / Yes No Unknown
9 / Does the Father have a history of suicidal ideation or involuntary hospitalizations? / Yes No Unknown
10 / Father has history of physical abuse, neglect or abandonment as AP? / Yes No Unknown
11 / Father has prior involvement with DCF? / Yes No Unknown / List Case Number, Maltreatment, and Findings
12 / Father has prior or current Dependency Judicial Intervention? / Yes No Unknown / List Case Number, Maltreatment, and Findings
13 / Does the Father have a service history? / Yes No Unknown
14 / Has or is the Father involved in Drug Court? / Yes No Unknown
15 / Does the Father have a criminal history? / Yes No Unknown / List Arrests and Convictions:
16 / Does the Father have family/friend? / Yes No Unknown / Who is their support group/system?
17 / Is the Father cooperative? / Yes No Unknown
Additional Findings/Summary:
I. Substance Abuse MAT Staffing recommendations:
Risk Factors /
Current Situation
Barriers to Services
Family
Service Recommendations

Participants multi-disciplinary staffing:

My signature below indicates that I attended & participated in the above noted multi-disciplinary staffing and assessment. The Confidentiality of all information, discussions and/or records referenced in this staffing is pursuant to FS 39.202. No notations or recordings from this staffing may be taken, unless the entity has prior authorization by the CPI and supervisor based on their permitted access due to being an authorized provider who has been granted charge of intervention or prevention services in the case.

Agency / Print Name / Signature
CPI Staffing Case
BSO/CPIS
Staffing Supervisor
BSO/CPIS
Other BSO/CPIS
ChildNet Representative
Children’s Diagnostic Treatment Center
Healthy Start Coalition Representative
Spectrum
Susan B. Anthony
Broward Health Department Representative

BSO CPIS DMST MAT Staffing Form – July 2012 1