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PURPOSE FOR ASAM
• • •
Explanation of why patient is currently seeking treatment: Symptoms, functional impairment, severity, duration of symptoms:
Dimension 1: Acute intoxication and/or withdrawal potential.
Acute Intoxication and/or withdrawal potential. (LIFETIME USE) Mark all that apply.
• • •
Other Please Specify:
Do you find yourself using more alcohol and/or drugs than you intend to?
Do you get physically ill when you stop using alcohol and/or drugs?
Are you currently experiencing withdrawal symptoms, such as tremors, excessive sweating, rapid heart rate,blackouts, anxiety, vo
Do you have a history of serious withdrawal, seizures, or life-threatening symptoms during withdrawal?
Do you find yourself using more alcohol and/or drugs in order to get the same high?
Has your alcohol and/or drug use changed recently (increase/ decreased, changed route of use)?
Please describe family history of alcohol and/or drug use (if none, please say N/A):
SEVERITY RATING - (Substance Use, Acute Intoxication and/or Withdrawal Potential):
• • •
Dimension 2: Biomedical Conditions and Complications
Please list known medical provider(s), specialties, and contact information. If there are none, please state none.
Do you have any of the following medical conditions:
• • •
Other Please Specify:
Question to be answered by interviewer: Does the patient report medical symptoms that would be considered lifethreatening or req
Do any of these conditions significantly interfere with your life?
List all current medication(s) for medical condition(s) (Include name, dosage, reason for taking or not taking, and effectivenes
SEVERITY RATING - (Biomedical Conditions and Complications)
• • •
Dimension 3: Emotional/Behavioral/Cognitive Conditions
(Emotional, Behavioral, or Cognitive Conditions and Complications) - Do you consider any of the following behaviors or symptoms:
• • •
Have you ever been diagnosed with a mental illness?
Are you currently or have you previously received treatment for psychiatric or emotional problems?
Do you ever see or hear things that other people say they do not see or hear?
Question to be answered by interviewer: Based on previous questions, is further assessment of mental health needed?
If Yes, explain:
List all current medication(s) for psychiatric condition(s): Include name, dosage, reason for taking/not taking, and effectivene
Please list mental health provider(s) and their contact information: (if none, please state none)
SEVERITY RATING - (Emotional, Behavioral, or Cognitive Conditions and Complications):
• • •
Dimension 4 Readiness to Change
Readiness to Change - Is your alcohol and/or drug use affecting any of the following? Mark all that apply.
• • •
Do you continue to use alcohol or drugs despite having it affect the areas listed above?
Have you received help for alcohol and/or drug problems in the past?
What would help to support your recovery? (Must not be blank.)
What are potential barriers to your recovery (e.g., financial, transportation, relationships, etc.)? (Must not leave blank)
How important is it for you to receive treatment for: Alcohol Problems
• • •
How important is it for you to receive treatment for: Drug Problems
• • •
SEVERITY RATING - (Readiness to Change):
• • •
Dimension 5: Relapse Potential
Relapse, Continued Use, or Continued Problem Potential - . In the last 30 days, how often have you experienced cravings, ALCOHOL
• • •
Please describe alcoholic cravings, withdrawal symptoms, and disturbing effects of use
Relapse, Continued Use, or Continued Problem Potential - . In the last 30 days, how often have you experienced cravings, DRUG
• • •
Initial Risk Rating Dimension 5
• • •
Please describe cravings, withdrawal symptoms, and disturbing effects of drug use:
Do you find yourself spending time searching for alcohol and/or drugs, or trying to recover from its effects?
Do you feel that you will either relapse or continue to use without treatment or additional support?
Are you aware of your triggers to use alcohol and/or drugs?
Please check off any triggers that may apply:
• • •
Other Please Specify:
What do you do if you are triggered?
Can you please describe any attempts you have made to either control or cut down on your alcohol and/or drug use?
- What is the longest period of time that you have gone without using alcohol and/or drugs?
What helped and didn't help?
SEVERITY RATING - (Relapse, continued Use, or Continued Problem Potential)
• • •
Dimension 6: Recovery Living Environment
Recovery/Living Environment - Do you have any relationships that are supportive of your recovery? (e.g., family, friends)
What is your current living situation (e.g., homeless, living with family/alone)?
Do you currently live in an environment where others are using drugs?
Are you currently involved in relationships or situations that pose a threat to your safety?
Are you currently involved in relationships or situations that would negatively impact your recovery?
Are you currently employed or enrolled in school?
Are you currently involved with social services or the legal system (e.g., DCFS, court mandated, probation, parole)?
SEVERITY RATING - (Recovery/Living Environment):
• • •
OVERALL ASSESSMENT OF THE DIMENSIONS
SUMMARY - Dimension 1 - Substance Use, Acute Intoxication and/or Withdrawal Potential
• • •
SUMMARY - Dimension 2 - Biomedical Condition and Complications
• • •
SUMMARY - Dimension 3 - Emotional, Behavioral, or Cognitive Condition and Complications
• • •
SUMMARY Dimension 4 - Readiness to Change
• • •
SUMMARY - Dimension 5 - Relapse, Continued Use, or Continued Problem Potential
• • •
SUMMARY - Dimension 6 - Recovery/Living Environment
• • •
DIAGNOSIS: DSM-5 Criteria for Substance Use Disorder. Pick at least three (3) substances used in the last 12 months
• • •
DIAGNOSIS: List of Substance Use Disorder(s) that Meet DSM-5 Criteria and Date of DSM-5 Diagnosis (specify severity level):* The
ASAM LEVEL OF CARE DETERMINATON TOOL - WITHDRAWAL MANAGEMENT - D1 - Substance Use, Acute Intoxication, Withdrawal Potential
• • •
ASAM LEVEL OF CARE DETERMINATION TOOL - Other Treatment and Recovery Services Severity/Impairment Rating
• • •
ASAM LEVEL OF CARE DETERMINATION TOOL - Would the patient with alcohol or opioid use disorders benefit from and be interested in
• • •
PLACEMENT SUMMARY - Level of Care Provided: Enter number care provided:
PLACEMENT SUMMARY - If the level of care provided isn't the most appropriate, what are REASONS FOR DISCREPANCY (check all that a
• • •
Briefly explain discrepancies: If there are none, state none.
ASAM SUMMARY

ASAM PLACEMENT CRITERIA/SUMMARY NOTE Medical Form

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Published: Oct. 20, 2023, 4:37 p.m.
Doctor: Dr. History Physical
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