Date of Assessment: Source of Referral: Choose an item. Persons Present: Client and Provider only Transportation Assistance Needed: Yes No Member has a Primary Care Physician (PCP)? Yes No If yes PCP, has member signed a release of information to PCP? Yes If no PCP, does member want help finding a PCP? Yes No Letter sent to PCP? Yes No No PCP Name: PCP Phone Number: PCP Address: PRESENTING PROBLEM: (Describe what the client sees as the substance use problem in emotional and behavioral terms) PRECIPITATING FACTORS OR EVENTS: (What prompted the request for substance use treatment now?) RISK FACTORS HISTORY: Suicide Homicide SUD Involuntary Commitment Elopement Trauma Medical Issues Other None CURENT RISK FACTORS HISTORY: Suicide Homicide Recent discharge from SUD Involuntary Commitment Unsafe living environment Elopement Other None SAFETY PLAN NEEDED: Yes No (If yes, what is the plan?): MENTAL STATUS: (Check all that apply) Appearance: Age Appropriate Younger than Age Older than Age Eye Contact: Good Fair Poor Grooming: Good Fair Poor Attentiveness: Attentive Distracted Resistant Preoccupied Disinterested Alertness: Alert Drowsy Stupor Motor: Normal Slowed Agitated Abnormal (tics, tremors, grimaces, other) Speech: Normal Slowed Pressured Loud Quiet Inarticulate Affect: Stable/Appropriate Labile Constricted Flat Blunted Inappropriate to content & Circumstance Other Page 1 8
Mood: Neutral Pleasant Happy Sad Euphoric Irritable Anxious Fearful Angry Apathetic Other Thought Content: Normal Worthless/Hopeless Self-Deprecating Threatening Obsessions Ruminating Phobias Ideas of Reference Paranoia Magical Ideation Delusions Grandiose Other Thought Process: Normal Associations Illogical Incoherent Tangential Flight of Ideas Word Salad Other Perceptions: Normal Auditory Hallucinations Visual Hallucinations Tactile Hallucinations Depersonalization De-realization Other Intelligence: Average Below Average Above Average Insight (for age): Good Fair Poor Judgement (for age): Good Fair Poor Describe any Mental Status Concerns: CULTRUAL FACTORS THAT MAY IMPACT TREATMENT: (May include age, values/beliefs, preferred language. Communication needs, gender, sexual orientation, relational roles, others). PSYCHOSOCIAL HISTORY: (Include living arrangements, financial problems, family problems, abuse/assault victim history, military service, combat veteran, legal problems, school adjustment, significant events, trauma history, etc.) MEMBER STRENGTHS: (Include personal characteristics, attitudes/beliefs, resources, social and abilities that will help client achieve goals of treatment) PSYCHIATRIC TREATMENT HISTORY: (Include dates, provider, diagnosis, medications, effectiveness) There is no history of psychiatric treatment. SUBSTANCE USE: The member denies any history of substance abuse problems and the professional has no collateral information to support a substance abuse problem. Yes No If yes go to family history of mental health or substance use problems. If no complete the below substance use table. Page 2 8
SUBSTANCE Alcohol Heroin Methadone Opiates Barbiturates Cocaine Amphetamines Cannabis Hallucinogens Inhalants Prescription Poly-substance use Other DATE OF FIRST USE AVERAGE AMOUNT USED FREQUNCY OF USE DATE OF LAST USE AVERAGE HIGHEST AMOUNT USED FREQUNCY OF USE METHOD OF USE (IV, INHALE, ETC.) Substance Use Disorder Treatment History: Longest period of recovery dates: How was the period of recovery achieved? Outpatient Treatment? Yes No (If yes, Include dates, provider, diagnosis, effectiveness): Co-occurring Treatment? Yes No (If yes, Include dates, provider, diagnosis, effectiveness): Detoxification Treatment? Yes No (If yes, Include dates, provider, diagnosis, effectiveness): Medication Assisted Treatment? Yes No (If yes, Include dates, provider, diagnosis, medication, effectiveness): Inpatient Treatment? Yes No (If yes, Include dates, provider, diagnosis, effectiveness): Therapeutic Community Treatment? Yes No (If yes, Include dates, provider, diagnosis, effectiveness): Self-Help Programs? Yes No (If yes, Include dates, type of program i.e AA, NA, CA, any history of having or being a sponsor (don t ask for the sponsor s name)): Page 3 8
DSM/ICD-10 SUD DIAGNOSTIC CRITERIA: Has the member has taken the substance in larger amounts and for longer than intended? Yes No (If yes, give behavioral examples of current, last 90 days, functional impairment with Has the member wanted to cut down or quit but not been able to do it? Has the member spent a lot of time obtaining the substance or recovering from using the substance? Has the member experienced cravings or a strong desire to use substances? Yes No (If yes, give examples with Has the member repeatedly been unable to carry out major obligations at work, school, or home due to substance use? Has the member continued use despite persistent or recurring social or interpersonal problems caused or made worse by substance use? Has the member stopped or reduced important social, occupational, or recreational activities due to substance use? Has the member had recurrent use of substances in physically hazardous situations? Page 4 8
Has the member had consistent use of substances despite acknowledgment of persistent or recurrent physical or psychological difficulties from using substances? Has the member developed tolerance as defined by either a need for markedly increased amounts to achieve intoxication or desired effect or markedly diminished effect with continued use of the same amount. (Does not apply for diminished effect when used appropriately under medical supervision)? Has the member experienced withdrawal manifesting as either characteristic syndrome or the substance is used to avoid withdrawal (Does not apply when used appropriately under medical supervision)? ASAM DIMENTIONS: (Gather information in the below sections to support the DSM/ICD-10 diagnosis and the current level of care) (Also document information related to high risk histories or situations such as pregnancy with a history of substance use). Dimension 1 Intoxication and Withdrawal Potential: The member presents as currently intoxicated? Yes No The member presents as currently experiencing withdrawal symptoms? Yes No Referral to social detoxification? Yes No Referral to a medical provider for assessment? Yes No Notes related to above yes responses in Dimension 1: Dimension 2 Biomedical Conditions: The member reports having a current medical condition? Yes No The member reports needing medical treatment? Yes No Page 5 8
Referral to emergency medical provider? Yes No Referral to a medical provider or PCP for assessment? Yes No Notes related to above yes responses in Dimension 2: Dimension 3 Emotional, Cognitive, Behavioral Conditions The member reports having a current mental health condition? Yes No The member reports needing mental health treatment? Yes No Referral to emergency mental health provider? Yes No Referral to a mental health provider for assessment? Yes No Notes related to above yes responses in Dimension 3: Dimension 4 Readiness to Change The member is court ordered to attended treatment? Yes No Estimated stage of change to reduce or stop substance use: Choose an item. Dimension 5 Relapse Potential Estimated risk of relapse within the next 30 days: High Moderate Low Relapse factors, stress mediators vs stressors (List potential triggers and coping mechanisms related to relapse potential): Dimension 6 Recovery Environment Estimated support for recovery in the member s living environment: Good Fair Poor Factors in member s living environment that may impact the member s recovery efforts: (Document factors in the members home, work and social network that support recovery or increase risk of relapse): FAMILY HISTORY OF MENTAL HEALTH OR SUBSTANCE USE PROBLEMS: The member denies any family history of mental health or substance use problems. DEVELOPMENTAL HISORY for members <21: (Include perinatal events, physical/intellectual/social development levels, behavioral issues, school adjustment, etc.) The member is > 21 years of age? Yes No Page 6 8
If yes, go to Concerns of Aging conditions section. The member or member s family reports developmental challenges such as autism or learning disabilities etc.? Yes No The member or member s family reports that the member has had an EPSTD/well-child examination within the past twelve months? Yes No If no referral made for EPSTD/well-child examination? Yes No CONCERNS OF AGING for members > age 60: (Include loss of hearing, vision, mobility, physical functioning and other factors related to aging) The member is < 60 years of age? Yes No If yes go to medical conditions section. MEDICAL/DENTAL CONITIONS that may impact presentation or functioning: (Include allergies) The member denies any medical/dental conditions. CURRENT MEDICATIONS: (Include name, dose, frequency, provider, effectiveness include over the counter medications) The member denies currently taking medication? Yes No Referral for medication assessment made? Yes No If yes, the member referred to: CLINICAL FORMULATION AND THERAPEUTIC RECOMMENDATIONS: Demographics/referral source Presenting problem/member s reason for seeking treatment at this time Testing instruments used and results of tools. Summary of symptoms/behaviors that explain diagnosis Diagnosis rule-outs if any, plan to gather additional information Assess member/family s willingness and ability to participate in treatment Prioritized problem list, which symptoms, behaviors. Skill or functional deficits, or services/supports needed will be addressed or deferred at this level of care? What level of care is recommended and why? (Including how and what has or has not worked in the past affected the decision) Summary of client/family strengths & supports that will help move treatment forward INITIAL SUD CO-OCCRUING DIAGNOSIS (DSM/ICD-10): (Include all relevant conditions, including above substance abuse DSM/ICD10 criteria and ASAM dimension information if gathered) PRIMARY DIAGNOSIS: Choose an item. SECONDARY DIAGNOSIS: Choose an item. Page 7 8
ASAM RECOMMENDED LEVEL OF CARE: Choose an item. ACTUAL ASAM LEVEL OF CARE PROVIDED: Choose an item. MODE OF DELIVERY: Choose an item. FREQUENCY OF CONTACT: Choose an item. ADDITIONAL NOTES/COMMENTS: (Right click below to set up signature ) Date Signed: X Counselor Signature CACII Page 8 8