FORMCHECKBOX Is in denial regarding substance use disorder and it’s implications, blames others for problems, rejects treatment. Is there a history of mental illness in your family? Have you ever been emotionally/verbally abused? FORMCHECKBOX FORMCHECKBOX Has a serious medical problem he/she neglects during outpatient or intensive outpatient treatment. 0000036568 00000 n FORMCHECKBOX Is not in imminent danger and is able to care for self 3 FORMCHECKBOX Exhibits inconsistent follow-through, shows minimal awareness of substance use disorder and need for treatment. FORMCHECKBOX The symptoms are not due to a general medical condition and are not better accounted for by another medical disorder. FORMCHECKBOX No FORMCHECKBOX FORMCHECKBOX Yes; if yes, when and by whom: ___________________________________ Have you received or participated in counseling for this issue FORMCHECKBOX No FORMCHECKBOX FORMCHECKBOX Yes, When and what was the outcome?________ ___________________________________________________________________________________________________2. Conduct multidimensional assessment (The ASAM Criteria, 2013, p124) Focus Assessment and Treatment (cont.) (e.g. Have you ever given up or reduced important social, occupational or recreational activities because of using alcohol or other drugs? óèÚÌÚÀ³¦œ¦ó�ó…óxójYóKjó h4] h;_ CJ \�^J aJ h4] h;_ CJ OJ QJ ^J aJ h4] h;_ 5�CJ ^J aJ h4] hCˆ CJ ^J aJ hCˆ CJ ^J aJ h4] h4] CJ ^J aJ hCˆ B* aJ ph ÿh4] h;_ B* aJ ph ÿh4] h4] B* aJ ph ÿhCˆ h;_ 5�^J aJ hCˆ h;_ 5�\�^J aJ hCˆ hCˆ 5�\�^J aJ hCˆ 5�\�^J aJ h4] h;_ CJ ^J aJ = § Ÿ í í Ô Ô » � ƒ Æ f¤( ¤( $„üÿ„Õ&P#$/„´ If gd;_ Æ ü ÂŞèf¤( ¤( $„üÿ„Õ&P#$/„´ If gd;_ $ Æ f$„üÿ„Õ&P#$/„´ If a$gd;_ $ Æ ğ$„üÿ„Õ&P#$/„´ If a$gd;_ $„üÿ„Õ&P#$/„´ If gd;_ Ÿ   ­ Ü ~ e Q ¤. 0000007651 00000 n (PR) 4. FORMCHECKBOX No FORMCHECKBOX Yes ROI signed on ____________________________ (date)8. 0000006802 00000 n Have you ever been involved with any self-help support group? FORMCHECKBOX Dysphoric mood and two (or more) of the following physiological changes, developing within a few hours to several days after Criteria A FORMCHECKBOX (1) fatigue, FORMCHECKBOX (2) vivid, unpleasant dreams, FORMCHECKBOX (3) insomnia or hypersomnia, FORMCHECKBOX (4) increased appetite, FORMCHECKBOX (5) psychomotor retardation or agitation FORMCHECKBOX Symptoms in Criteria B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Counselor’s observation of patient’s physical health: FORMCHECKBOX Poor FORMCHECKBOX FORMCHECKBOX Average FORMCHECKBOX Good FORMCHECKBOX FORMCHECKBOX ExcellentRisk Rating for Dimension 2 (from PPC-2R - Appendix A): 4 FORMCHECKBOX Incapacitated, with severe medical problems. 0000011538 00000 n FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. he “assessment” phase of treatment represents the early information-gathering phase, in which patient and physician work together to determine what signs and symptoms are present, and what they point to. CDP assessment of patient’s risk for relapse: Unknown FORMCHECKBOX High FORMCHECKBOX Moderate FORMCHECKBOX Low FORMCHECKBOX As evidenced by _________________________________________________________________________________________7.

Does not affect the placement decision. Do you need any help to understand written or verbal information?

): C. Cognitive Conditions/Complications1. FORMCHECKBOX No skills to cope with and interrupt addiction problems or to prevent or limit relapse or continued use but is not in imminent danger and is able to care for self. Are you currently under the supervision of the Department of Corrections? FORMCHECKBOX No FORMCHECKBOX Yes, If yes, explain:________________________________________ _______________________________________________________________________________________________________6. Tolerance, as defined by either of the following: a. Markedly increased amounts of the substance in order to achieve intoxication or desired effect; b. Markedly diminished effect with continued use of the same amount. FORMCHECKBOX No FORMCHECKBOX Yes, if yes, what kind of help do you need?

he criteria were developed by the American Society of Addiction Medicine (ASAM), FORMCHECKBOX 2 FORMCHECKBOX An acute or persistent emotional condition/complication requires intervention, with symptoms that significantly interfere with addiction treatment, as evidenced by ______________________________________________________________________. Do you have access to medical care? FORMCHECKBOX No signs or symptoms of intoxication or withdrawal are present, or signs/symptoms, if present, are resolving. FORMCHECKBOX No FORMCHECKBOX Yes, If yes, which? 0000066906 00000 n ________________________________________________________________________________________________________5. FORMCHECKBOX Severe mental health condition/complication requires residential intervention, with symptoms that significantly interfere with addiction treatment as evidenced by _____________________________________________________________________. “Assessing” with The ASAM Criteria. 0000043545 00000 n Demonstrates good ability to tolerate and cope with withdrawal discomfort.

0000012605 00000 n _________________________________________ Phone # __________________ Contact Person ________________ Name 2. endstream endobj 3514 0 obj <. FORMCHECKBOX 2 FORMCHECKBOX Reluctant to agree to treatment for substance use problems, as evidenced by _______________________________________. How would you describe your physical health? endstream endobj startxref FORMCHECKBOX No FORMCHECKBOX Yes, If yes: Name of Drug: __________________ Dose: _________________ Frequency: _________________ Duration: __________________ Name of Drug: __________________ Dose: _________________ Frequency: _________________ Duration: __________________ Name of Drug: __________________ Dose: _________________ Frequency: _________________ Duration: __________________8. FORMCHECKBOX No FORMCHECKBOX FORMCHECKBOX Yes; if yes, when and by whom:___________________________________ Have you received or participated in counseling for this issue? ASAM Six Dimensions Dimension 1: Acute Intoxication and/or Withdrawal Potential Past and current experiences of substance use and withdrawal. What was the reason you scheduled this appointment? No FORMCHECKBOX Yes FORMCHECKBOX if yes Does the patient need help accessing or selecting childcare? 0000031836 00000 n No FORMCHECKBOX Yes FORMCHECKBOX (e.g., legal mandates, logistical barriers, lack of available services, etc. No FORMCHECKBOX Yes FORMCHECKBOX if yes Referral information for child care services: _________________________________________________________________ HIV/AIDS Brief Risk Intervention conducted? FORMCHECKBOX FORMCHECKBOX No FORMCHECKBOX FORMCHECKBOX Yes, if yes, where/who? FORMCHECKBOX No FORMCHECKBOX Yes, If yes: Name of Medication: ___________________________Dose ______________________Prescribed by: ________________________ Name of Medication: ___________________________Dose ______________________Prescribed by: ________________________ Name of Medication: ___________________________Dose ______________________Prescribed by: ________________________7. 0000010471 00000 n 9. problems with legal system, school, work, at home, relationships, health, etc. 0000002526 00000 n 0000027389 00000 n _________________________________________ Phone # __________________ Contact Person ________________ Also recommended: FORMCHECKBOX Domestic Violence Perpetrator Program FORMCHECKBOX Anger Mgmt FORMCHECKBOX Vocational Rehabilitation FORMCHECKBOX GED FORMCHECKBOX Mental Health Counseling.



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