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Where did you find us?
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Which specialists do you see?
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Who referred you?
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Anything special we need to know
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Therapist(s)
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Are you able to understand written materials.
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What brought you to treatment
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What do you want to gain from treatment
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In your words, what do you think is the problem
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Others, please specify
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Do you have a Legal Guardian?
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Evaluation Date
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Admission date
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How was this service provided?
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Sexual Orientation
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Gender Expression
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Others, please specify
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Highest level of education
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Highest Level of education?
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Do you require any assistive technologies.
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Assistive technology Comments
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Are you a veteran or current military?
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Are you a combat veteran?
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Employment History
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Type of Employment
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last employment
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how long
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last time working
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How many months in the past 12 months have you been employed?
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Previous Treatment
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How many times in treatment
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Previous Treatment
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Name of last treatment facility
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Completed
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last date in prior treatment
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length in previous Treatment
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Prior to Treatment
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Where were you just before coming to treatment?
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Describe daily living prior to treatment
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comments:
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History of Withdrawal DIM 1
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Current Withdrawal Symptoms
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Past Withdrawal Symptoms
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How many times OD in past?
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What substance(s)
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Intentional overdose
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Initial Risk Rating Dimension 1
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When
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Withdrawal management levels
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Dimension 1 Severity summary
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Substance Abuse/Abuse History
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Symptoms of chemical use
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types of drugs used since use began
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Age of drug use begin
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Age of last use
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Alcohol
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amount,route,frequency
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AGE OF ONSET
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DATE LAST USE
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Cocaine
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amount,route,frequency
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AGE OF ONSET
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Last Use (date )
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Marijauna
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amount,route,frequency
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Marijuana
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Last Use (date )
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AGE OF ONSET
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amount,route,frequency
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Opiates
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amount,route,frequency
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AGE OF ONSET
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Last Use (date )
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Hallucinogens
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amount,route,frequency
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AGE OF ONSET
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Last Use (date )
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Inhalants
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amount,route,frequency
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AGE OF ONSET
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Last Use (date )
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benzodiazepines
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amount,route,frequency
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AGE OF ONSET
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Last Use (date )
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Sedatives
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amount,route,frequency
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AGE OF ONSET
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Last Use (date )
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Stimulants
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amount,route,frequency
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AGE OF ONSET
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Last Use (date )
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Steroids
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amount,route,frequency
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AGE OF ONSET
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Last Use (date )
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Amphetamines
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Last Use (date )
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AGE OF ONSET
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amount,route,frequency
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Do you use tobacco products?
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Last Use (date )
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AGE OF ONSET
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amount,route,frequency
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Caffeine
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amount,route,frequency
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Caffeine
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Last Use (date )
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AGE OF ONSET
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Others
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Others, please specify
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AGE OF ONSET
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Last Use (date )
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amount,route,frequency
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Current cravings on a scale of 1-10
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Dimension 2: Biomedical Conditions and Complications
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How would you rate your overall health?
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Medications
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Primary Care Provider
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Last doctor visit?
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May we contact your PCP?
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Medical conditions
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Family medical conditions
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Allergies
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How much weight have you lost in last 6 months?
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Was your substance use a consequence of a medical condition or injury?
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Medical Conditions
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Do you have a living will and/or Advance Directives?
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Initial Risk Rating Dimension 2
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Dimension 2 Severity summary
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Dimension 3: Emotional/Behavioral/Cognitive Conditions
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Mental Status Exam
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Appearance
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Appearance
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Behaviors
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Behaviors
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mood
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Mood
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Affect
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Affect
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Thought process
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Thought Process
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oriented
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Oriented
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memory
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Memory
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cognitive functioning
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Cognitive functioning
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insight
• • •
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Insight
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judgement
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judgement
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Speech and Language Quantity
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Speech and Language: Quantity
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Speech and Language Volume
• • •
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Speech and Language: Volume
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Speech and Language rate
• • •
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Speech and Language: Rate
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Speech and Language rhythm
• • •
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Speech and Language: Fluency and Rhythm
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eye contact
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Eye Contact
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impulse control
• • •
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Impulse Control
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Sleep
• • •
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Sleep
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appetite
• • •
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Appetite
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Summary and mental health observations
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Have you made any specific adjustments to your Mental Health Diagnoses, social behaviors.
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Have you ever experienced any auditory, visual, and/or tactile hallucinations?
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Mental Health Services
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Facility Name
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Type of Service
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Start Date
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End Date
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Do you have any family members who have a mental health diagnosis?
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Before age 18
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Did you feel loved growing up?
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Did any adult ever hit you, swear at you, threaten you, or make you feel afraid?
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Was there any physical violence, name calling or abuse to you or a parent?
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Did a parent ever go to jail/prison?
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Did a parent ever have a problem with drugs or alcohol?
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Did an adult or person 5 years or older than you, touch you inappropriately, or try/actually have sex with you?
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High risk behaviors over your Lifetime
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Gambling
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Have you ever had a DVO (domestic violence order) or an EPO (emergency protective order)?
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Have you or your family ever had any involvement with social services or had a caseworker?
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Have you ever wished you were dead?
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Have you ever thought about suicide or attempted suicide?
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Have you ever intentionally cut/burned yourself?
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Do you have homemade (or Jailhouse) tattoos or piercings?
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Have you ever driven while using any type of illicit substances?
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Have you ever exchanged sex for drugs or drugs for sex?
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Have you ever reused or shared needles or had unprotected sex with someone that did?
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How would you describe your sexual or romantic relationships?
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SI/HI/SSI/Trauma
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As an adult have you ever been verbally or emotionally abused?
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As an adult, have you ever been physically abused?
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Have you ever been sexually abused or experienced sexual trauma?
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Have you ever witnessed any abuse, neglect, violence, or sexual assault as an adult or child?
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Was your sexual activity impacted by your substance use?
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Have you ever had suicidal thoughts?
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Have you ever made an attempt to harm yourself?
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Have you ever made an attempt to harm someone else?
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Are you experiencing any suicidal thoughts now?
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Are you experiencing any homicidal thoughts now?
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Have you ever attempted to harm yourself while in treatment?
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Have you ever attempted to harm someone else while in treatment?
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Has anyone in your family or any friends ever attempted or committed suicide?
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Risk to self/others, anxiety, depression
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In the last 12 months have you had a period of time lasting at least 2 weeks where you felt depressed or uninterested in things
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Depression on Scale of 1-10
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12months period lasting at least 2 weeks where you felt restless, keyed up, irritable, or on edge?
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Anxiety Scale
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Clinical Impression of Anxiety/Depression Diagnoses
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Risk to self/others Clinical Impression
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Initial Risk Rating Dimension 3
• • •
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Dimension 3 severity summary
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Dimension 4 Readiness to Change
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Internal Motivation
• • •
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External Motivation
• • •
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How do your values, sense of meaning, and your behavior impact your day-to-day attitude?
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Has anyone required, ordered, coerced, or demanded that you to come to treatment?
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Do you feel that you have a problem with drugs or alcohol?
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Do you feel that treatment is a necessity for you at this time?
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Do you think you will use substances in the future?
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How do you feel to make changes that would support ready sobriety?
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Client readiness rating scale
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Importance of treatment
• • •
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Initial Risk Rating Dimension 4
• • •
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Dimension 4 severity explanation
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Dimension 5: Relapse Potential
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Longest period of sustained abstinence?
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How many times have you attempted to stop using?
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Prior Relapse Details
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Rate Current Cravings
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How do you currently deal with cravings or urges to use?
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what is likelihood of relapse if you left treatment today
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Which best describes your reason for substance use
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Legal History
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Include dates, types of charges, misdemeanor or felony
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Past DUI DUI in last 12 Months
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History of charges
• • •
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Total lifetime DUI Drug Arrests Possession or paraphernalia
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What would you estimate is the total time of incarceration for your lifetime?
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Has past behaviors impacted or influenced your substance use.
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Initial Risk Rating Dimension 5
• • •
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Severity summary Dimension 5
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Dimension 6: Recovery Living Environment
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What was your family and home life like growing up?
• • •
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Do you live with family members who are in active use?
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What support will you need for recovery?
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Who is your biggest source of support for recovery and how do they support you?
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Have you ever been homeless?
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What is your current living situation if you left treatment today?
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Are you currently in a relationship?
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Do you have any children?
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Does your significant other use?
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Have your relationships been affected because of your use?
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How would you describe your relationship with your friends (peer) group?
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Do you have any sober friends?
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Does past legal issues affect employment and housing?
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How would you describe your relationship with your sober friends?
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What are your current financial obligations?
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Do you have transportation of your own?
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Do you have a current valid Driver’s license?
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If no, do you have a valid state issued ID?
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Have you had a sponsor in the past?
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Do you currently have a sponsor?
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Have you ever or are you currently using any of the following community resources?
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Hobbies interests - How have your hobbies or interests influenced your SUD and/or desire to get treatment? Will they be impacted
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Spiritual/Religious beliefs
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Cultural considerations?
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How has your culture influenced your SUD and/or desire to get treatment?
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Has substance use affected the following
• • •
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Has substance use affected the following explanation
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Self-identified Strengths
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Initial Risk Rating Dimension 6
• • •
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Severity summary Dimension 6
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Discharge Planning
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How long do you plan to stay in treatment?
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Where do you plan to have aftercare substance use disorder treatment services?
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Where do you plan to live after treatment?
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What resources would you need in order to be successful with your plan?
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When do you plan to leave treatment?
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Active use In the past 12 months
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1. Taken in larger amounts over a longer period of time than planned
• • •
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2. Desire or unsuccessful efforts to cut down or control use
• • •
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3. Great deal of time is spent in activities to obtain, use or recovery from substances Craving or strong desire/urge to use
• • •
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4. Craving, or a strong desire or urge to use substance
• • •
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5. Obligations at work, school, or home being unmet
• • •
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6. Continued use despite social or interpersonal problems
• • •
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7. Activities or interests given up or reduced due to substance use
• • •
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8. Use in situations where it was physically hazardous
• • •
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9. Continued use despite knowing of persistent physical or psychological problems have been caused or been made worse due to use
• • •
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10. Tolerance, as defined by either of the following
• • •
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11. Withdrawal symptoms or use of other substances to alleviate withdrawal
• • •
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Diagnosis
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Substance Use Disorder
|
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Problems
|
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RELAPSE PRONESS
|
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Relapse Proneness Problems
• • •
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Relapse proneness explanation (if needed)
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Substance Use Disorder Problems
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Substance Use Disorder Problems
• • •
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Substance use explanation (if needed)
|
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TREATMENT RESISTANCE
|
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Treatment resistance problems
• • •
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Treatment resistance explanation (if needed)
|
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IMPUSILSIVITY
|
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Impulsivity problems
• • •
|
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Impulsivity explanation (if needed)
|
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OTHER PROBLEMS
|
|
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Other problems
• • •
|
|
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Explanation of other problems
|
|
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Interim Intervention/Plan for Treatment
|
|
|
CLINICAL SUMMARY
|
|
|
Recommended ASAM Levels of Care
• • •
|
|
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Clinical Recommendations based on Level of Care Placement
|
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Interim Goal for Treatment
|
Interim Objective for Treatment
|
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Clinical Summary
|
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ELECTRONIC SIGNED FIELD
|
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signed by pin#
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signed by pin#
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