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