New Service Provider Provider Type Provider Name Phone Ext

Transcription

1 Substance Abuse Adult Assessment AST022 Assessment Information Assessment Number Assessment Date Assessment Type Contact Type Assessment Site Referred by Client Issue Presenting Problem Expectations Service Preferences or Objections to Treatment Interventions Literacy or language barriers? Other Current Service Providers New Service Provider Provider Type Provider Name Phone Ext MH Test MH Test MH Test MH Test MH Test Edit Remove

2 Staff Info Interviewer Primary Counselor General Education Information Is the client enrolled in School? What type of School What type of attendance has the client had in the last 90 days? Current GPA? What grades has the client completed? Has the client received special education services? How many months has the client completed in training or technical education? Employment Information What is the client s employment status? What is the name of the clients current employer? What is the reason the client is not in the labor force? name of the client s current employer? How many months has the client been employed by current employer? How many months was the client employed during the last 12 months? How many days was the client paid for working in the last 30 days? What is the longest time the client has held a full-time job? Usual or last occupation? What is the client's usual employment pattern for the past 3 years? Is the client a veteran? Millitary discharge status? Does the client have a valid driver's license? Does the client have reliable transportation available? What is the client's source of income/support?

3 How many people are dependent on client for the majority of their food, shelter, etc.? Client Rating How many days has the client experienced employment or school problems in the past 30 days? How troubled or bothered has the client been by these employment or school problems in the past 30 days? How important to the client now is treatment for these employment or school problems? Interviewer Impressions Is the above information significantly distorted by the client's misrepresentation? Employment Status Severity Is the above information significantly distorted by the client's difficulty understanding? Living Situation What is the client's current living situation? What is the client's usual living arrangements (for past 3 years)? How many years has the client lived at the current address? Is the client a resident of the Colonias? Is the client satisfied with these living arrangements? Indifferent Family Profile Are there people in your life that significantly influence the way you think, feel or behave?

4 Adult Profile ( 18 and above ) Relation Name Age Gender Race Ethnicity Caregiver Employed Household Member Rate Quality Of Relationship Problematic Substance Use Mental Health Abuser Legal Medical Problems Problems Problem Youth Profile ( Below 18 ) Relation Name Age Gender Race Ethnicity Grade in Residence Caregiver School Rate Quality Of Relationship Problematic Substance Use Mental Health Abuser Legal Medical Problems Problems Problem Support System What is the client s marital status? Is the client satisfied with these living arrangements? Indifferent In what social, community and/or leisure activities does the client participate? What are the client's and/or the client's family's religious and/or spiritual beliefs? How often does the client practice or participate in the rituals of religion or spiritual beliefs? With whom does the client spend most of their free time? Is the client satisfied spending their free time this way? Indifferent Children Does the client need childcare services in order to participate in services? Is the client formally seeking to regain custody of children?

5 Client Rating How troubled or bothered has the client been in the past 30 days by the family problems? How troubled or bothered the client been in the past 30 days by social problems? How important to the client now is treatment or counseling for these family problems? How important to the client now is treatment or counseling for these social problems? Extremely Extremely Extremely Extremely Interviewer Impressions Is the above information significantly distorted by the client's misrepresentation? Is the above information significantly distorted by the client's difficulty understanding? Family/Social Status Severity 0= real problem, treatment not indicated General Legal Information Was this assessment prompted or suggested by the criminal justice system? What is the client's legal status? Has client ever been arrested? Has client ever engaged in illegal activities for profit? Civil Is the client involved in any civil action?

6 Client Rating How serious does the client feel the present legal problems are? How important to the client now is counseling or referral for these legal problems? Interviewer Impressions Is the above information significantly distorted by the client's misrepresentation? Is the above information significantly distorted by the client's difficulty understanding? Legal Status Severity

7 General Health Does the client suffer from a chronic painful condition? Sleep Pattern? How many meals does the client eat each day? Does the client have any difficulty eating? Explanation Does the client use emetics, diuretics or laxatives for the purpose of losing weight? Has the client experienced a significant change in weight during the: Describe the client's medical conditions ne Last 30 days? Last 3 months? Allergies and Adverse Drug Reactions ne Substance Description of reaction Current Medications ne Medication Form Type Strength Route Frequency

8 Medical Treatment History How many times in the past 12 months has the client been in a general hospital including the emergency room? How many times in the client's life have they been in a general hospital including the emergency room? Number of times Number of times Briefly describe the reason for each hospitalization and the length of stay How many days in the past 30 days was the client in an environment supervised by a doctor, physician's assistant or nurse? Number of days Type of Medically Controlled Environment? Disability Does the client receive financial support for a disability? What is the disability? How does the disability interfere with the activities of daily living (ACL)?

9 Risk Assessment for Communicable Diseases Hepatitis-B/C and or Human Immunodeficiency Virus(HIV) Has the client ever injected drugs? Has the client ever shared injecting equipment? Has the client ever shared equipment for snorting drugs? Does the client have tattoos and/or piercings? Has the client ever had unprotected sex (vaginal/oral/anal penetration) without condoms or latex barrier? Has the client ever had unprotected sex with someone known to inject drugs? Tuberculosis (TB) Has the client had a persistent cough (longer than three months) for which they have not seen a physician? Has the client been tested (screened for TB) within the past year? Client Rating How many days has the client experienced medical problems in the past 30 days? How troubled or bothered has the client been by medical problems in the past 30 days? How important to the client now is treatment or counseling for medical problems? Extremely Extremely Interviewer Impressions Is the above information significantly misrepresentation? Is the above information significantly distorted by the client's difficulty understanding? Medical Status Severity

10 Psychiatric Treatment History How many times has the client has been treated for psychological problems in a hospital/residential environment? Has the client ever been treated for psychological problems in an outpatient setting? Please provide the following information for each outpatient treatment: 1) Name/location of treatment facility? 2) Reason for treatment? 3) Diagnosis given? 4) Diagnosing professional? Current and Historical Symptoms Unrelated to substance use, has the client ever: Symptom Never Experienced feelings of sadness that were unbearable Lost pleasure in all or almost all activities Felt worthless or have excessive or inappropriate guilt Been unable to make decisions, concentrate, or think Had difficulty managing anger Last 30 Days Last 6 Months Last 12 Months Lifetime Feel full of energy and ideas come rapidly Talked nearly non-stop Engaged in pleasurable activities with high potential for painful consequences Experienced preoccupation with sex Engaged in uncontrollable or compulsive behaviors Experienced excessive anxiety and worry Had difficulty managing day to day life Believed that almost anything is doable Heard voices that no one else hears Seen objects or things no one else sees Felt that people had something against the client without them necessarily saying so Believed that some group or individual may be trying to influence the client's thoughts or behaviors Experienced serious thoughts of harming behavior such as burning, cutting, or carving

11 Experienced self harming behavior such as burning, cutting or carving Risk of Harm Has the client ever: Item Response Comment Had recurrent thoughts of killing self Made plans for killing self Attempted to kill self Had recurrent thoughts of killing someone Made specific plans with intent to kill someone Attempted to kill someone Has the client ever had friends, family or significant others who have committed suicide? Risk of Harm Comment Current Affect Clinical Observations Abnormal Affect ne Slight Moderate Considerable Extreme Abnormal Appearance ne Slight Moderate Considerable Extreme Abnormal Behavior ne Slight Moderate Considerable Extreme Abnormal Speech/Language ne Slight Moderate Considerable Extreme Abnormal Thought Processes and/or Content ne Slight Moderate Considerable Extreme Anxiety ne Slight Moderate Considerable Extreme Delusional Symptomology ne Slight Moderate Considerable Extreme Depressed Mood ne Slight Moderate Considerable Extreme Difficulty With Alertness ne Slight Moderate Considerable Extreme Dissociative Symptomology ne Slight Moderate Considerable Extreme

12 Elevated Mood ne Slight Moderate Considerable Extreme Hallucinations ne Slight Moderate Considerable Extreme Hostility ne Slight Moderate Considerable Extreme Hyperactivity/Distractibility ne Slight Moderate Considerable Extreme Impaired Insight ne Slight Moderate Considerable Extreme Impaired Judgment ne Slight Moderate Considerable Extreme Interpersonal Isolation ne Slight Moderate Considerable Extreme Impulsiveness ne Slight Moderate Considerable Extreme Intoxicated ne Slight Moderate Considerable Extreme Poor Eye Contact ne Slight Moderate Considerable Extreme Poor Grooming ne Slight Moderate Considerable Extreme Shame and/or Guilt ne Slight Moderate Considerable Extreme Uncooperativeness ne Slight Moderate Considerable Extreme Client Rating How much has the client been troubled by these psychological or emotional problems in the past 30 days? How important to the client now is treatment for these psychological or emotional problems? Interviewer Impressions Is the above information significantly distorted by the client's misrepresentation? Is the above information significantly distorted by the client's difficulty understanding? Mental Health Status Severity Suicidality Homicidality 4=Extreme problem, treatment absolutely necessary 4-High 4-High

13 Substance Use History Has the client ever used alcohol and/or other drugs? Primary Use Substance Used Route of Administration Frequency of Use Alcohol Injection Daily Age at First Use Last Date Used How many years (any use at all) Secondary Use Substance Used Route of Administration Frequency of Use Age at First Use Last Date Used How many years (any use at all) Tertiary Use Substance Used Route of Administration Frequency of Use Age at First Use Last Date Used How many years (any use at all) How much money did the client spend in the past 30 days on alcohol and/or other drugs? Has the client had any physical consequences because of alcohol and/or other drug use? Does the client frequently use more than one substance at a time? In the past 30 days, how many days has the client been abstinent from all substances? Number of days

14 Current and Historical Symptoms Due to their substance use, has the client ever experienced: Symptom Never Last 30 Days Last 6 Months Last 12 Months Lifetime Shakes/Tremors Blackouts Memory lapses Cravings Vomiting Nausea Profuse sweating Hallucinations (Visual, Tactile, Auditory) Seizures DT's Anxiety Headaches Substance Treatment History How many times has the client been treated for a substance use disorder? How many of these were detox only? How many days has the client been treated in an outpatient setting for alcohol and/or other drugs in the past 30 days? How many days has the client been treated in a residential or hospital setting for alcohol or drugs in the past 30 days? How many months has it been since the last discharge from any substance treatment program? How many days has the client attended communitybased mutual help groups for alcohol and/or other drugs in the past 30 days? Number of times Number of times Number of days Number of days Does the client use tobacco on a daily basis?

15 Client Rating How troubled or bothered has the client been in the past 30 days by Drug and/or Alcohol Problems? How important to the client now is treatment for Drug and/or Alcohol Problems? Interviewer Impressions Is the above information significantly distorted by the client's misrepresentation? Is the above information significantly distorted by the client's difficulty understanding? Substance Status Severity

16 Strengths and Limitations Client's Strengths Client's Limitations AXIS I # Axis I Diagnosis Justification AXIS II # Axis II Diagnosis Justification

17 AXIS III # Axis III Diagnosis Justification AXIS IV Diagnosis Other Diagnosis Problems with primary support group Economic problems Social environment Problems with access to health care Educational problems Problems in interaction with legal services Occupational problems ne Housing problems Other Psychosocial and Environmental Problems AXIS V Diagnosis Numeric only

18 Summary and Recommendations Stages of Change Priority Population Status Summary of Severity Scores Employment Status Severity Family/Social Status Severity Legal Status Severity Medical Status Severity Substance Status Severity Mental Health Status Severity Substance Abuse Calculated Severity Score Substance Abuse Calculated Level of Care Client Refused to Receive Services Client t Eligible for Treatment Substance Abuse Recommended Level Of Care Date of Substance Abuse Calculation Recommendation Document Status Draft Document Status Date 11/11/2009 Help Desk: Clinical Management for Behavioral Health Services (CMBHS), Texas Department of State Health Services. All rights reserved.