Fillable ADULT Initial Level of Care Assessment

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ADULT Initial Level of Care Assessment

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Client Name: _______________________________ Client ID #:_________________________
BHS/SUD, F104c Adult Page 1 of 8 July 2019
ADULT
Initial Level of Care Assessment
Staff completing the form: __________________________________ Place of interview: ________________________
Date of screening: ____________ Referral source (Name & Phone #) ________________________________________
PERSONAL INFORMATION
First Name: ____________________________ M.I. ___ Last Name: ____________________________ Age: ______
Social Security Number: _______________________ Birth Date: ____/____/____
Phone Number: (____) _____________ OK to leave message? ☐ YES ☐ NO Preferred Language: __________________
Address: ____________________________________________________________________________________________
Street City State Zip Code
What are the main reasons you are seeking help here today? _________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Gender Identity: ☐ Male ☐ Female ☐ Transgender (M to F) ☐ Transgender (F to M)
☐ Questioning/Unsure ☐ Other ____________________ ☐ Decline to state
Sexual Orientation: ☐ Heterosexual/Straight ☐ Lesbian ☐ Gay ☐ Bisexual
☐ Questioning/Unsure ☐ Other ____________________ ☐ Decline to state
Are you a veteran? ☐ YES ☐ NO
Are you pregnant? ☐ YES ☐ NO Due Date: _______________ # of Children under 18: _________
Do you have Medi-Cal? ☐ YES ☐ NO Medi-Cal Card #: ______________________________________________
Do you have Health insurance? ☐ YES ☐ NO Insurance Company: ____________________________________________
Are you on Medically Assisted Treatment (MAT) (i.e., Methadone, Vivitrol, Suboxone)? ☐ YES ☐ NO
If YES, list the medication: ___________________________ Where do you obtain this? _________________________
Have you ever been arrested/charged/convicted/registered for arson? ☐ YES ☐ NO
Have you ever been arrested/charged/convicted/registered for a sex crime(s)?
☐
YES
☐
NO
EMERGENCY CONTACT
Na
me: ___________________________________ Relationship: _____________________ Phone # (_____)_____________
Na
me: ___________________________________ Relationship: _____________________ Phone # (_____)_____________
Clear Form
Client Name: _______________________________ Client ID #:_________________________
BHS/SUD, F104c Adult Page 2 of 8 July 2019
ALCOHOL AND/OR OTHER DRUG USE
Primary Drug
# of Days used
in past 30 days
Route of Admission
Age at first use
Secondary Drug
# of Days used
in past 30 days
Route of Admission
Age at first use
Tertiary Drug
# of Days used
in past 30 days
Route of Admission
Age at first use
Have you used needles in the past 12 months? ☐ YES ☐ NO ☐ Decline to state/NA If yes, last used: ___/____/____
Da
te you last used any drugs including alcohol: _____/_____/_____ Number of days in a row you have been using: _____
Ho
w long do you think you have had a problem with alcohol and/or other drugs? _________________________________
ASAM Dimension 1: Acute Intoxication and/or Withdrawal Potential
Do you have a history of serious withdrawal, seizures, or life-threatening symptoms during withdrawal? ☐ YES ☐ NO
If yes, please describe:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Are you currently experiencing withdrawal symptoms, such as tremors, excessive sweating, rapid heart rate, blackouts,
anxiety, vomiting, etc.? ☐ YES ☐ NO
If yes, please describe:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
ALCOHOL AND/OR OTHER DRUG TREATMENT HISTORY
Have you received treatment for alcohol and/or other drugs in the past? ☐ YES ☐ NO
If yes, please give details:
Type of Recovery Treatment
(Outpatient, Residential,
Detoxification)
Name of Treatment Facility
Dates of
Treatment
Treatment
Completed
(yes or no)
Client Name: _______________________________ Client ID #:_________________________
BHS/SUD, F104c Adult Page 3 of 8 July 2019
Severity Rating – Dimension 1 (Substance Use, Acute Intoxication, Withdrawal Potential)
COUNSELOR: Please Check one of the following levels of severity
☐ 0: None
☐ 1: Mild
☐ 2: Moderate
☐ 3: Significant
☐ 4: Severe
Fully functioning, no signs of
intoxication or W/D present.
Mild to moderate
intoxication interferes
with daily functioning,
but does not pose a
danger to self/others.
Minimal risk of severe
W/D.
Intoxication may be
severe, but responds to
support; not posing a
danger to self or
others. Moderate risk
of severe W/D.
Severe signs/symptoms
of intoxication indicate
an imminent danger to
self/others. Risk of
severe but manageable
W/D; or W/D is
worsening.
Incapacitated, with
severe signs/symptoms.
Severe W/D presents
danger, such as
seizures. Continued use
poses an imminent
threat to life (e.g., liver
failure, GI bleeding, or
fetal death).
Severity Rating – Dimension 2 (Biomedical Conditions and Complications)
COUNSELOR: Please Check one of the following levels of severity
☐ 0: None
☐ 1: Mild
☐ 2: Moderate
☐ 3: Significant
☐ 4: Severe
Fully functioning and
able to cope with any
physical discomfort or
pain.
Adequate ability to cope
with physical discomfort.
Mild to moderate
symptoms (such as mild to
moderate pain) interfere
with daily functioning.
Some difficulty tolerating
physical problems. Acute,
non-life threatening
medical symptoms (such as
acute episodes of chronic,
distracting pain, or signs of
malnutrition or electrolyte
imbalance) are present.
Serious biomedical
problems are neglected.
Poor ability to tolerate
and cope with physical
problems, and/or
general health condition
is poor. Serious medical
problems neglected
during outpatient or IOT
services. Severe
medical problems (such
as severe pain requiring
medication, or hard to
control Type 1 Diabetes)
are present but stable.
The person is
incapacitated, with
severe medical
problems (such as
extreme pain,
uncontrolled diabetes,
GI bleeding, or infection
requiring IV antibiotics).
*Note: For residential programs, if the risk rating on ASAM Dimension 2 is greater than “zero” (0), please submit the
completed Health Screening Questionnaire along with this form to assist with obtaining initial authorization.
ASAM Dimension 2: Biomedical Conditions/Complications
(Include review of Health Questionnaire and TB Questionnaire in your determination below)
Are you currently taking prescription medications for any medical conditions? ☐ YES ☐ NO If yes, please describe:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
If recently enrolled in Medi-Cal, have you received a health screening to identify health needs within 90 days of
Medi-Cal enrollment? ☐ YES ☐ No ☐ N/A
Client Name: _______________________________ Client ID #:_________________________
BHS/SUD, F104c Adult Page 4 of 8 July 2019
Severity Rating – Dimension 3 (Emotional, Behavioral or Cognitive (EBC) Conditions or Complications)
COUNSELOR: Please Check one of the following levels of severity
☐ 0: None
☐ 1: Mild
☐ 2: Moderate
☐ 3: Significant
☐ 4: Severe
Good impulse control,
coping skills and sub-
domains
(dangerousness/lethality,
interference with
recovery efforts, social
functioning, self-care
ability, course of illness).
There is a suspected or
diagnosed EBC condition
that requires
intervention, but does
not significantly
interfere with
treatment. Relationships
are being impaired but
not endangered by
substance use.
Persistent EBC
condition, with
symptoms that distract
from recovery efforts,
but are not an
immediate threat to
safety and do not
prevent independent
functioning.
Severe EBC
symptomatology, but
sufficient control that
does not require
involuntary confinement.
Impulses to harm
self/others, but not
dangerous in a 24-hr.
setting.
Severe EBC symptomatology;
requires involuntary
confinement. Exhibits severe
and acute life-threatening
symptoms (e.g., dangerous or
impulsive behavior or
cognitive functioning) posing
imminent danger to
self/others.
ASAM Dimension 3: Emotional/Behavioral/Cognitive Conditions/Complications
Review Risk Assessment and Co-Occurring Conditions Screening form for historical information relevant to this dimension.
Include as part of your assessment of severity, below.
Do you have any current thoughts of hurting yourself or others? ☐ YES ☐ NO If yes, please describe:
_______
____________________________________________________________________________________________
_______
____________________________________________________________________________________________
Are you currently being treated or sought help in the past for a mental health condition? (For example, depression,
bipolar disorder, anxiety, PTSD, psychosis, or other mental health condition). ☐ YES ☐ NO
If yes, please describe:
___________________________________________________________________________________________________
_______
____________________________________________________________________________________________
If yes to the question above, a
re you currently prescribed medications for the mental health condition(s) you described?
☐ YES ☐ NO
If yes, please describe: _______________________________________________________________________________
Do you feel like you are unable to care for yourself (hygiene, food, clothing, shelter, etc.)? ☐ YES ☐ NO
If yes, please describe: ________________________________________________________________________________
Do you currently have a therapist and/or psychiatrist? ☐ YES ☐ NO
If yes, provide name/contact information: ________________________________________________________________
Over the past 2 weeks, how often have you been bothered by any of the following problems?
• Feeling down, depressed or hopeless
☐ Not at all ☐ Several Days ☐ More Than Half the Days ☐ Nearly Every Day
• Needed much less sleep than usual and found you didn’t really miss it
☐ Not at all ☐ Several Days ☐ More Than Half the Days ☐ Nearly Every Day
• Feeling nervous, anxious, or on edge
☐ Not at all ☐ Several Days ☐ More Than Half the Days ☐ Nearly Every Day
• Had nightmares about a frightening, horrible or upsetting event you’ve experienced
☐ Not at all ☐ Several Days ☐ More Than Half the Days ☐ Nearly Every Day
• Seen things that other people can’t see or don’t seem to see
☐ Not at all ☐ Several Days ☐ More Than Half the Days ☐ Nearly Every Day
• Heard things that other people can’t hear or don’t seem to hear
☐ Not at all ☐ Several Days ☐ More Than Half the Days ☐ Nearly Every Day
Client Name: _______________________________ Client ID #:_________________________
BHS/SUD, F104c Adult Page 5 of 8 July 2019
Severity Rating – Dimension 4 (Readiness to Change)
COUNSELOR: Please Check one of the following levels of severity
☐ 0: None
☐ 1: Mild
☐ 2: Moderate
☐ 3: Significant
☐ 4: Severe
Engaged in treatment as a
proactive, responsible
participant. Committed
to change.
Ambivalent of the need to
change. Willing to explore
need for treatment and
strategies to reduce or stop
substance use. May believe
it will not be difficult to
change, or does not accept
a full recovery treatment
plan.
Reluctant to agree to
treatment. Able to
articulate negative
consequences (of
substance use and/or
mental health
problems) but has low
commitment to change.
Passively involved in
treatment (variable
follow through, variable
attendance)
Minimal awareness of
need to change. Only
partially able to follow
through with
treatment
recommendations.
Unable to follow through,
little or no awareness of
problems, knows very little
about addiction, sees no
connection between
substance use/consequences.
Not willing to explore
change. Unwilling/unable to
follow through with
treatment recommendations.
ASAM Dimension 4: Readiness to Change
How long do you think you have had a problem with alcohol and/or other drugs?
_________________________________________________________________________________________________
Have you tried to stop drinking/using before? If so, what interfered with your success with that goal?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Do you intend to reduce or quit drinking/using in the next 2 weeks?
☐ Definitely no ☐ Probably no ☐ Probably yes ☐ Definitely yes
Wh
at substance(s) are you willing to stop using?
_________________________________________________________________________________________________
Wh
at would be helpful for you now in order to change your drinking/using?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
What is the possibility 12 months from now you will not have a problem with alcohol and/or other drugs?
☐ Definitely not ☐ Probably not ☐ Probably will ☐ Definitely will
How important is it for you to receive treatment for:
Alcohol problems: ☐ Not at all ☐ Slightly ☐ Moderately ☐ Considerably ☐ Extremely
Drug problems: ☐ Not at all ☐ Slightly ☐ Moderately ☐ Considerably ☐ Extremely
Client Name: _______________________________ Client ID #:_________________________
BHS/SUD, F104c Adult Page 6 of 8 July 2019
Severity Rating – Dimension 5 (Relapse, Continued Use, or Continued Problem Potential)
Please Check one of the following levels of severity
☐ 0: None
☐ 1: Mild
☐ 2: Moderate
☐ 3: Significant
☐ 4: Severe
Low or no potential for
further substance use
problems or has low
relapse potential. Good
coping skills in place.
Minimal relapse potential.
Some risk, but fair coping
and relapse prevention
skills.
Impaired recognition and
understanding of
substance use relapse
issues. Able to self-
manage with prompting.
Little recognition and
understanding of relapse
issues, poor skills to
cope with relapse.
Repeated treatment
episodes have had little
positive effect on
functioning. No coping
skills for
relapse/addiction
problems. Substance
use/behavior places
self/others in imminent
danger.
ASAM Dimension 5: Relapse, Continued Use, or Continued Problem Potential
What’s the longest period of time that you have gone without using alcohol and/or other drugs? __________________
If you previously stopped using alcohol and/or other drugs, what are the reasons you started using again?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
“Triggers” are events, feelings, people, places or things that cause someone to justify using again. Are you aware of your
triggers to use alcohol and/or other drugs? ☐ YES ☐ NO
If yes, please list: __________________________________________________________________________________
_________________________________________________________________________________________________
What are some coping tools you have used in the past to avoid using?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Client Name: _______________________________ Client ID #:_________________________
BHS/SUD, F104c Adult Page 7 of 8 July 2019
Severity Rating – Dimension 6 (Recovery Environment)
COUNSELOR: Please Check one of the following levels of severity
☐ 1: Mild
☐ 2: Moderate
☐ 3: Significant
☐ 4: Severe
and/or able to cope in
environment.
Passive/disinterested social
support, but not too
distracted by this situation
and still able to cope.
Unsupportive
environment, but able
to cope with clinical
structure most of the
time.
Unsupportive
environment and the
client has difficulty
coping, even with
clinical structure.
Environment toxic/hostile to
recovery (i.e. many drug-using
friends, or drugs are readily
available in the home
environment, or there are
chronic lifestyle problems).
Unable to cope with the
negative effects of this
environment on recovery (i.e.
environment may pose a
threat to recovery).
ASAM Dimension 6: Recovery Environment
Are you homeless or at risk? ☐ YES ☐ NO Living Situation: __________________________
Are you currently employed? ☐ YES ☐ NO
Vocational/Educational Achievements (Highest grade level completed, any training or technical education, etc.):
___________________________________________________________________________________________________
Do
you have friends and/or family that are supportive of you seeking treatment for problems related to substance use?
☐ YES ☐ NO If yes, describe:
________________________________________________________________________
Do you have friends and/or family that might interfere with your treatment for problems related to substance use?
☐ YES ☐ NO If yes, describe:
________________________________________________________________________
PO Contact Name & Phone Number: __________________________________________________
Pending court date(s)? ☐ YES ☐ NO If yes, reason(s) and date(s):
_________________________________________
Are there any transportation, childcare, housing or employment issues that could interfere with your treatment for
problems related to substance use?
☐
YES
☐
NO
Client Name: _______________________________ Client ID #:_________________________
BHS/SUD, F104c Adult Page 8 of 8 July 2019
Recommended Level of Care: Enter the ASAM Level of Care that offers the most appropriate treatment setting given
client’s current severity and functioning: ______________________________________________________________
Actual Level of Care: If a level of care other than the recommended is provided, enter the next appropriate level of
care: ___________________________________________________________________________________________
Reason for Discrepancy (Clinical Override): Check off the reason for discrepancy between level of care determination
and level of care provided, and document the reason(s) why:
☐ Not applicable ☐ Service not available ☐ Provider judgment ☐ Client preference
☐ Transportation ☐ Accessibility ☐ Financial ☐ Preferred to wait
☐ Language/Cultural Factors ☐ Environment ☐ Mental Health ☐ Physical Health
☐ Court/Probation Ordered ☐ Other: ________________________________________________
Explanation of Discrepancy:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Designated Treatment Provider Name/Location: ________________________________________________________
______________________________ __________________________________ ____________
Counselor Name (if applicable) Signature (if applicable) Date
Provisional Diagnosis
All programs must provide a provisional diagnosis
Provisional Diagnosis DSM-5 Diagnostic Label(s) & ICD-10 Code(s): _______________________________________________
______________________________________________________________________________________________________
A face-to face interaction between the AOD counselor and the LPHA to verify the determination of medical necessity for the
client regarding this intake screening and related forms occurred on: ___/____/____ (
if applicable)
______________________________ __________________________________ ____________
LPHA* Name Signature Date
*Licensed Practitioner of the Healing Arts (LPHA) includes: MD, Nurse Practitioners, Physician Assistants, Registered Nurses, Registered Pharmacists,
Licensed Clinical Psychologist (LCP), Licensed Clinical Social Worker (LCSW), Licensed Professional Clinical Counselor (LPCC), and Licensed Marriage and
Family Therapist (LMFT) and licensed-eligible practitioners working under the supervision of licensed clinicians.
Level of Care Determination Instructions
After completing the screening (and determining the risk ratings) in each of the six
dimensions, review the “Levels of Care” document which describes the typical risk ratings
associated with each level of care and can help guide your level of care recommendation.
Onc
e the recommended level of care is determined, document it in the space below. Also
document the level of care to be provided. If there is a discrepancy between the two,
document the reason(s) for the discrepancy in the spaces provided.
If
the screening results indicate a level of care different than the one your program provides,
complete the “Designated Treatment Provider Name/Location” field with the information
from the program you will be linking the client to.
DMC-ODS regulations require that a “Licensed Practitioner of the Healing Arts” (LPHA)*
make level of care determinations. In the event an LPHA does not conduct the screening
(and an AOD/SUD Counselor does), the Counselor and LPHA must have a face-to-face review
of the information, and the LPHA must co-sign the form, indicating their agreement with the
level of care determination.
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ADULT Initial Level of Care Assessment

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Completed 31 August 2021

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