Joanne Jones. Patient: Joanne Jones. Class of Assessment: Intake Interview Was Conducted: In person. Interviewer:

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1 Patient: Joanne Jones Admission Date: 1/12/ :25 PM Assessment Begun:1/12/ :25 PM Assessment Ended: 5/29/ :52 PM NOTE: This report contains an automated narrative summary of the patient s condition, derived from selected structured interview items. This instrument is not a replacement for individual provider assessment and sound clinical judgment. ASAM and FEi Systems assume no direct or indirect liability for improper care or negative outcomes that may ensue from the use of this instrument. Consider your patient's needs carefully, using this instrument as one of many clinical tools in your determination of proper care. The Criteria may not encompass all levels and types of services which may be available in a changing health care field. Therefore, the Criteria may not be wholly relevant to all levels and modalities of care. Class of Assessment: Intake Interview Was Conducted: In person This summary is based on the patient's self-report regarding lifetime and recent Medical, Employment, Alcohol, Drug, Legal, Family/Social and Psychiatric involvement and/or problems. Included in each of these sections is the interviewer's severity rating, suggesting the client's need for treatment (or additional treatment beyond what the patient is already receiving). This is based on the information provided by the client and other sources as available at the time.

2 INDENTIFYING INFORMATION Name: Joanne Jones DOB: 2/5/1959 Gender: Female Ethnicity: Caucasian GENERAL INFORMATION SECTION The following is a clinical summary based on an in-person interview with Joanne, on 1/12/2017. Joanne is a 57 year old female who did not specify a racial category. She states she is Caucasian. She states her religious preference is Protestant. She has lived at her current address for approximately 2 years. Neither the client nor her family owns this residence. Joanne has not spent any time in any kind of a controlled environment in the past 30 days. Therefore her ability to use alcohol, or other drugs and have interaction with her family and/or others has not been compromised for the reporting period of the past 30 days. MEDICAL SECTION Medical History Joanne was hospitalized once for medical problems. This hospitalization was 3 years ago. She has a chronic medical problem and is prescribed medications for this problem. Joanne specified "Headache" as the chronic medical problem(s).she specified " Ibprofen" as the prescribed medication. She does not receive any financial compensation for physical disabilities. Client Perception of Severity of Medical Problems and Desire for Treatment Although Joanne experienced symptoms on 15 of the past 30 days, she is not at all troubled or bothered by them. Help obtaining treatment is not important to her at this time. Interviewer Impressions and Recommendations Medical It is my impression that Joanne understood all of the questions, and that she did not deliberately misrepresent her medical information. Joanne has a medical problem of substantial concern, and help obtaining appropriate treatment is necessary at this time. Interviewer Comments The interviewer did not have any comments for this section.

3 EMPLOYMENT SECTION Employment History She has worked full time (40 hours per week) for most of the past three years. Joanne's longest full time job lasted for 5 years. She specified "The patient is a claims reviewer at insurance company." as the usual or last occupation. Current Financial Resources Joanne reports working 30 days and making $3, income in the past month. She either does not remember or will not discuss whether she has received any income from welfare, unemployment compensation, or pensions/benefits/ssi in the past 30 days. She either has not received any money or will not discuss whether she received any cash from family or friends in the past month. Joanne says that she has not made any money illegally in the past month. Joanne has no dependents that she supports financially. A friend or family member contributes some form of support. Education, Training and Resources She completed 14 years of traditional schooling, obtaining a high school diploma and taking some college courses. Joanne has the skill base necessary to acquire a job. She has a valid drivers license and access to a car which may help her in maintaining employment. Client Perception of Severity of Employment Problems and Desire for Treatment Overall, she reports experiencing no employment related problems, however, she does report that employment issues are moderately troublesome for her. Obtaining treatment for employment difficulties is moderately important to Joanne. Interviewer Impression and Recommendations-Employment It is my impression that Joanne understood all of the questions, and that she did not deliberately misrepresent this information. She appears to have a moderately severe employment problem, and treatment is needed. Interviewer Comments Patient worries her boss will freak out if she requires a work absence for inpatient detox.

4 ALCOHOL & DRUG SECTION Lifetime and Recent Alcohol Use In her lifetime, Joanne drank regularly for a period of 30 years. For approximately 20 years, her drinking was regular and heavy (generally defined as 5 or more drinks in one day). In the past 30 days, she drank 30 days, and has drank heavily, having more than five drinks per day, on each of those days. She reports having spent $ on alcohol in the past 30 days. She has never experienced alcohol delirium tremens. Lifetime and Recent Drug Use Joanne does not appear to have any lifelong problems with heroin or methadone, and she reports no periods of ongoing use. Joanne has used other opiates habitually for a period of approximately 15 years, and she has no history of ongoing use of barbiturates. She has no history of regular or ongoing use of sedatives, hypnotics, or tranquilizers. Joanne has never regularly used cocaine or amphetamines. Joanne has no history of ongoing or problematic cannabis or hallucinogen use. She has no history of regular or ongoing use of inhalants. Joanne has a history of using multiple substances, on an ongoing basis, for a period of approximately 10 years. She has never overdosed, either intentionally or unintentionally, on drugs. Joanne has not used any heroin or methadone in the past 30 days. Joanne has not used sedatives in the past 30 days, but has used other opiates on 15 days this month, and either will not discuss or cannot remember if she has used any barbiturates during this time. Joanne has not used any cocaine or amphetamines in the past 30 days. Joanne has not used any cannabis or hallucinogens for the past 30 days. She has not used any inhalants in the past month. In the past 30 days, Joanne has used two or more drugs together (or drugs and alcohol) on 15 days in the past month. In the past 30 days, Joanne reports that she spent $ on alcohol and $20.00 on other drugs. Alcohol and Drug Treatment History Joanne has received treatment 8 times for alcohol problems, all her treatments were limited to brief withdrawal management. Joanne has never received treatment for her drug problems. Joanne's last period of continuous abstinence from alcohol lasted for 3 months, ending approximately 3 months ago. She has not received any outpatient treatment, including attendance at AA, NA, or CA, for any drug or alcohol problems in the past 30 days. Client Perception of Severity of Alcohol and Drug Problems and Desire for Treatment Joanne experienced alcohol related problems on 30 of the past 30 days, and is profoundly bothered by these problems. Obtaining alcohol treatment is of profound importance to Joanne. Joanne experienced drug related problems on 5 of the past 30 days, and is slightly bothered by these problems. Obtaining drug treatment is of some importance to Joanne. Interviewer Impressions and Recommendations - Alcohol and Drugs

5 It is my impression that Joanne understood all of the questions, and that she did not deliberately misrepresent information about her drug or alcohol use and history. It is my belief that alcohol use is her most significant substance use problem. She has an alcohol problem of substantial concern, and help obtaining appropriate treatment is vital at this time. Joanne has a drug problem of substantial concern, and help obtaining appropriate treatment is necessary at this time. Interviewer Comments Already in some withdrawal, has elevated blood pressure, chronic headaches with opioids in some withdrawal, and hasn't continued into rehab in past. LEGAL SECTION History of Charges and Arrests Joanne's participation in this substance use evaluation was not prompted by the criminal justice system. Joanne has never been arrested and charged with any drug charges. However, she either cannot remember or will not discuss if she has ever been charged with driving while intoxicated. She was never charged with a weapons offense, and she has never been arrested and charged with assault. Joanne has never been arrested and charged with shoplifting or vandalism, however, she either cannot remember or will not discuss any probation/parole violations. She has never been charged with burglary, larceny, or breaking & entering, however, she either cannot remember or will not discuss if she has ever been charged with robbery. She has never been charged with attempted homicide, homicide or manslaughter, however, she either cannot remember or will not discuss if she has ever been charged with rape or attempted rape. She has never been arrested and charged with forgery, however, she either cannot remember or will not discuss if she has ever been charged with arson. She either cannot remember or will not discuss if she has ever been arrested and charged with prostitution. She either will not discuss or does not know if she has been arrested and charged with any other crime. Joanne has never been arrested and charged with disorderly conduct, vagrancy, or public intoxication, however, she either cannot remember or will not discuss if she has ever been charged with contempt of court. She either cannot remember or will not discuss if she has ever been arrested and charged with any type of major driving violation. Current Legal Involvement In the past 30 days, Joanne has not engaged in any illegal activities for profit, nor has she been detained or incarcerated. She is not awaiting any type of charges, trial, or sentencing. She is not on probation or parole. Client Perception of Severity of Legal Problems and Desire for Treatment Joanne reports that her legal problems are not serious, and that help obtaining counseling for legal problems is not important to her.

6 Interviewer Impressions and Recommendations - Legal It is my impression that Joanne understood all of the questions, and that she did not deliberately misrepresent her legal information. She appears to have no need of help obtaining legal counseling at this time. Interviewer Comments The interviewer did not have any comments for this section.

7 FAMILY/SOCIAL SECTION Marital and Living Situation for Majority of the Past Three Years Joanne is currently divorced, and is generally dissatisfied with this situation. Joanne has been divorced for about 10 years. Joanne has lived with a sexual partner alone for most of the past three years, and appears to feel fairly indifferent to this circumstance. Joanne has recently been in this living arrangement for about 2 years. Recovery Environment and Social Contacts Joanne states that her current living arrangement will promote treatment and recovery. Joanne currently spends most of her free time alone, and is generally dissatisfied with this situation. She denies currently having any close friends. Relationship Problems Lifetime Joanne reports that she has had a close, long lasting relationship with her sexual partner/spouse. In her lifetime, she has had significant problems getting along with her partner, but not her children. In her lifetime, she has not had or reported any serious problems getting along with either her mother or father (or this relationship is not applicable). She has not had or reported serious problems getting along with other significant family members in her lifetime (or this relationship is not applicable). She has not had or reported any significant problems getting along with either siblings or close friends (or this relationship is not applicable). She has had serious problems getting along with co-workers, but not her neighbors. Relationship Problems Past Thirty Days In the past 30 days, she has had significant problems getting along with her partner, but not with her children. In the past 30 days, she has not had or reported any serious problems with either her mother or father (or this relationship is not applicable). She has not had or reported significant problems getting along with either siblings or close friends (or this relationship is not applicable). She has not had or reported serious problems getting along with other significant family members (or this relations hip is not applicable). She has not had or reported serious problems getting along with either neighbors or co-workers recently (or this relationship is not applicable). Joanne has not experienced any recent emotional, physical, or sexual abuse. Client Perception of Severity of Family and Social Problems and Desire for Treatment Overall, she reports experiencing no family problems and is not troubled or bothered by difficulties with family. Consequently, help obtaining treatment for family related difficulties is not important to Joanne. She reports having 12 days of problems with other people in the past 30 days, and is troubled by these problems. Obtaining treatment for social difficulties is important to Joanne.

8 Interviewer Impressions and Recommendations - Family and Social It is my impression that Joanne understood all of the questions, and that she did not deliberately misrepresent this information. Joanne has family or social problems of substantial concern, and help is necessary at this time. Interviewer Comments note The interviewer did not have any comments for this section.

9 PSYCHIATRIC SECTION Serious Emotional and Psychological Problems - Lifetime Joanne has a past history of psychiatric symptoms in her lifetime, including serious problems with depression and anxiety. Joanne has thought seriously about suicide, she does not have a history of attempting suicide. Joanne has no history of difficulty understanding and concentrating and no history of difficulty controlling violent behavior. She does not have a history of being prescribed psychotropic medications. She does not have a history of treatment for psychological or emotional problems. She does not receive any financial compensation for a psychiatric disability. Client Perception of Severity of Emotional and Psychological Problem and Desire for Treatment Joanne has had problems with depression in the past 30 days, and she was clearly depressed at the time of the interview. Joanne has had serious problems with anxiety in the past 30 days, and she was clearly anxious at the time of the interview. Joanne has not experienced suicidal ideation in the past 30 days and did not appear to be having suicidal thoughts at the time of the interview. Joanne has not attempted suicide in the past 30 days. Joanne has not had trouble understanding or concentrating in the past 30 days and was not noticeably having trouble with memory/comprehension at the time of the interview. Joanne has not experienced any trouble controlling violent behavior in the past 30 days and was not hostile at the time of the interview. Joanne has not experienced hallucinations in the past 30 days and did not appear to be experiencing symptoms of a thought disorder at the time of the interview. Joanne has not been prescribed psychotropic medications in the past 30 days. Joanne experienced symptoms on 30 of the past 30 days, and is profoundly bothered by them. Obtaining psychological or emotional treatment is of considerable importance to her. Interviewer Impressions and Recommendations - Psychiatric It is my impression that Joanne understood all of the questions, and that she did not deliberately misrepresent her psychological/emotional information. She appears to have a moderately severe psychological or emotional problem, treatment is needed. Interviewer Comments The interviewer did not have any comments for this section.

10 Patient's Rating Joanne Jones PATIENT PERCEPTION The following is a graph showing the patient's perception of her problems, column A, and her desire for treatment, column B. Patient Perception of Problem and Need for Treatment 4 Medical 0 Employ 2 Alcohol 4 Drug 1 3 Legal 0 Family 0 Social 4 Psych 4 2 Medical 0 Employ 2 Alcohol 4 Drug 1 Legal 0 Family 0 Social 4 Psych Medical Employ Alcohol Drug Legal Family Social Psych Problem Area Patient's Rating of Problem Patient's Rating of Desire for Treatment Rating Scale 0-Not at All, 1-Slightly, 2-Moderately, 3-Considerably, 4-Extremely

11 ADDICTION SEVERITY INDEX COMPOSITE SCORES The ASI Composite scores rate severity in seven areas of the patient's life. Analysis of her ASI responses revealed the following composite scores: (NOTE: The same score in different ASI Composite Subscales does not necessarily denote a similar extent of severity.) ASI Composite Scores Category Value Medical Employment Alcohol Drug Legal Family and Social Psychiatric ASI Composite Scores

12 PROBLEM LIST ASAM DIMENSION 1 - ACUTE INTOXICATION AND/OR WITHDRAWAL POTENTIAL Item ID Item Statement ASId1-13b Substance(s) used within the past 3 days: Alcohol, Other Opiates. CIWA-Ttl Sum of CIWA items 1-10: 16 ASId99 Is the patient experiencing significant withdrawal, or is there evidence that withdrawal is imminent? Consider substance intake, age, gender, previous withdrawal history, symptoms, physical, emotional, behavioral and cognitive conditions. Withdrawal OR evidence of imminent withdrawal AND no risk of severe withdrawal syndrome AND moderate withdrawal is safely manageable at Level 3 ASAM DIMENSION 2 - BIOMEDICAL CONDITIONS AND COMPLICATIONS Item ID ASIm3 ASIm6 ASIm6q ASIm8a ASIm9 Item Statement Do you have any chronic medical problems which continue to interfere with your life? Headache Medical problems in past 30 days? Dental, teeth, gums, Digestive, stomach, bowel, liver, pancreas, diabetes,. Would the patient's continued substance use endanger his/her medical condition? Not sure or possibly How much medical or nursing care or physical rehabilitation do you need? 1 Visit per Month How would you rate the patient's need for medical treatment? Moderate problems require close outpatient follow-up (e.g. diabetes) ASAM DIMENSION 3 - EMOTIONAL, BEHAVIORAL, OR COGNITIVE CONDITIONS AND COMPLICATIONS Item ID ASIp4s ASIp10a ASIp12 Item Statement Trouble falling asleep, staying asleep, or sleeping too much? Considerably Are you currently receiving the psychiatric care and services that you need? (Don't include any alcohol or drug service needs with this item) No How much have you been troubled or bothered by the previously discussed psychological or emotional problems in the past 30 days? Extremely

13 ASAM DIMENSION 3 - EMOTIONAL, BEHAVIORAL, OR COGNITIVE CONDITIONS AND COMPLICATIONS Item ID ASIp12b ASIp13 ASIp13a ASIp20a ASIp20b ASIp20 Item Statement How difficult have these problems made it for you to work, take care of home, or get along with others? Moderately (some difficulty taking care of things) How important to you now is counseling for these psychological problems? Why? Considerably, has psychological needs that are in some conflict with recovery efforts How might your emotional problems affect your efforts in recovery? Will hinder treatment/recovery participation Does the patient's current behavior seem inconsistent with reliable self-care, safety, or ability to participate in treatment? Not sure or possibly Are current problem behaviors so severe as to require continuous limit-setting interventions? Not sure or possibly INTERVIEWER SEVERITY RATING: How would you rate the patient's need for psychiatric/psychological treatment? Moderate problems require close outpatient follow-up (e.g. suicidal thoughts) ASAM DIMENSION 4 - READINESS TO CHANGE Item ID ASIm8b ASId24w ASId24x ASId24z Item Statement How might your physical health and function affect your ability to address your substance problems? Some likelihood to hinder treatment/recovery participation Do you have any concerns about pursuing treatment...? Would anything possibly hold you back, such as money, insurance, schedule, attending groups, having to take medicines, drug tests, or drinking or drug-using friends? Ambivalent about important responses How do you think treatment will help? or, if rejects help, Why do you think treatment will not help? If entering or continuing treatment: Do you expect to be in treatment in 3 months? Over-confident or too reliant on program rather than self How do you plan to prevent relapses? After answer, if not mentioned, ask: How about counseling, meetings, a sponsor, or new activities or sober friends? How active have you been with any of these recently? Passive or vague

14 ASAM DIMENSION 5 - RELAPSE, CONTINUED USE OR CONTINUED PROBLEM POTENTIAL Item ID ASId14 ASId##Qa ASId18a ASId19a ASId19f ASId25e ASId22e ASId22f ASId22g ASId22h ASId22i ASId22k ASId23a ASId24a ASId25a Item Statement Which substance is the major problem? Alcohol Interviewer: Has the patient responded to appropriate recent efforts by the prescriber to maintain dose at therapeutic levels? No How many times in your life have you been treated for alcohol use problems? 8 Counting the times in your life you have been treated for alcohol use problems, how many of these were withdrawal management only? 8 After withdrawal management, have you usually entered continued treatment? No Is the patient manifesting any current serious escalation of relapse behaviors? Yes Imagine yourself in the environment in which you previously used drugs and/or alcohol. If you were living in this environment today, what is the likelihood that you would use? Extremely Rate how strong your urges are for a drug and/or alcohol when something in the environment reminds you of it. Extremely How strong is your desire to use any drug right now? Considerably How likely is it that you might relapse because of craving or need for opiates? Extremely Have your addiction symptoms increased recently? How...? (Ask about any items below not mentioned by the patient) Have you had more craving, risk behaviors, more frequent use, increased amount of substance or have you used a more rapid route of administration? Increased use or more acute route of administration than before Do you feel you are likely to continue using or, if not using, that you are in danger of relapsing? How soon...? Do you feel at risk, even if you have had some treatment previously? At risk today How troubled or bothered have you been in the past 30 days by the noted alcohol problems? Extremely How important to you is treatment for alcohol problems? Extremely How would you rate the patient's need for treatment for alcohol use problems? 7

15 ASAM DIMENSION 5 - RELAPSE, CONTINUED USE OR CONTINUED PROBLEM POTENTIAL Item ID ASId23d ASId24d ASId25d ASId28 Item Statement How troubled or bothered have you been in the past 30 days by these drug problems? Slightly How important at this time is treatment for your drug problem (if any)? Slightly How would you rate the patient's need for treatment for drug use problems? 6 Comments: Already in some withdrawal, has elevated blood pressure, chronic headaches with opioids in some withdrawal, and hasn't continued into rehab in past. ASAM DIMENSION 6 - RECOVERY/LIVING ENVIRONMENT Item ID ASIf1 ASIf3 ASIe7a ASIe20 ASIe21 ASIe22 ASIe25 ASIf8a ASIf8 ASIf9 ASIf9a Item Statement Marital Status: Divorced Are you satisfied with this situation? No Tell me about alcohol and drug use in your work (or school) How will your work (or school) affect your treatment and recovery? Will discourage or hinder treatment/recovery How troubled or bothered have you been by these employment problems in the past 30 days? Moderately How important to you now is counseling for these employment problems? Moderately How would you rate the patient's need for employment counseling? 4 Comments Patient worries her boss will freak out if she requires a work absence for inpatient detox. Tell me about alcohol & drug use in your free time activities... How will your free time affect your treatment & recovery? Will discourage or hinder treatment/recovery Are you satisfied with spending your free time this way? No How many close friends do you have? None Tell me about alcohol & drug use among your friends... How will your friends affect your treatment and recovery? Will often expose patient to substance use

16 ASAM DIMENSION 6 - RECOVERY/LIVING ENVIRONMENT Item ID ASIf9b Item Statement How will you deal with any problems with friends and acquaintances who put you at risk for relapse? What is it like for you to meet people who can help in your recovery? Reclusive or drawn to high-risk social contacts How many days in the past 30 have you had serious conflicts: ASIf10a ASIf14 ASIf19e ASIf19g ASIf19h ASIf21 ASIf23 ASIf24 with other people (excl. fam.) 12 In the past month, have you had significant periods, in which you have experienced serious problems with: Sexual parter/spouse Yes Did your neglect/abuse of family occur during your substance use? No Who is the person (or persons) with whom you have had contact during the past 4 months and who has been most important to you? Sexual partner/spouse How much help will this person (or these persons) need to assist in your treatment and recovery and how likely is it that he/she/they will get involved in your treatment? Not sure if willing to help or no one available How troubled or bothered have you been in the past 30 days by these: How troubled or bothered have you been in the past 30 days by social problems? Extremely How important to you now is treatment or counseling for these: How important to you now is treatment or counseling for social problems? Extremely How would you rate the patient's need for family and/or social counseling? 7