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BROWSE COUNTY OF LOS ANGELES / INTERNAL SERVICES DEPARTMENT (CA) FORMS

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Mail: Substance Abuse Prevention and Control Website: http://publichealth.lacounty.gov/sapc/
1000 S. Fremont Ave, Bldg. A9 East, 3rd Floor, Alhamabra, CA 91803 Fax: (XXX) XXX-XXXX
To check submission status call: (XXX) XXX-XXXX
Name (Last, First, and Middle) Date:
Address: Phone Number:
Date of Birth (MM/DD/YYYY) Age: Gender: Okay to Leave a Message?
Yes No
Race/Ethnicity: Preferred Language: Medi-Cal Identification Number: Other ID# (Plan):
Insurance Type: None MyHealthLA Medicare Medi-Cal Private Other
(Plan): (Plan): (Plan): (Plan):
Living Arrangement:
Homeless Independent living Other (specify):
Explanation of why client is currrently seeking treatment: Current symptoms, functional impairment, severity, duration of symptoms (e.g., unable to work/
school, relationship/housing problems):
1. Substance use history:
Client Name: Medi-Cal ID:
Treatment Agency:
SUBSTANCE ABUSE PREVENTION AND CONTROL
FULL ASAM ASSESSMENT - ADULT
DEMOGRAPHIC INFORMATION
Duration
(Length of Use)
Date of Last Use
Based on the ASAM Criteria [3rd Edition] Multidimensional Assessment
DIMENSION 1: SUBSTANCE USE, ACUTE INTOXICATION AND/OR WITHDRAWAL POTENTIAL
Alcohol and/or Drug Types
Recently Used?
(Past 6 Months)
Prior Use?
(Lifetime)
Route
(Inject, Smoke, Snort)
Frequency
(Daily, Weekly, Monthly)
Opioid Pain Medications
Misuse or without prescription
Sedative
(Benzos, Sleeping Pills)
Misuse or without prescription
Hallucinogens
Inhalants
Over-the-Counter
Medications
(Cough Syrup, Diet Aids)
Amphetamines
(Meth, Ice, Crank)
Alcohol
Cocaine/Crack
Heroin
Marijuana
This confidential information is provided to you in accord with State and Federal laws and regulations including but
not limited to applicable Welfare and Institutions Code, Civil Code and HIPAA Privacy Standards. Duplication of
this information for further disclosure is prohibited without the prior written authorization of the patient/authorized
representative to who it pertains unless otherwise permitted by law.
Nicotine
Other:
ASAM Full Assessment-Adult Revised 5/24/2016
1
Draft
Additional Information:
2. Do you find yourself using more alcohol and/or drugs than you intend to? Yes No
Please describe:
3. Do you get physically ill when you stop using alcohol and/or drugs? Yes No
Please describe:
4. Are you currently experiencing withdrawal symptoms, such as tremors, excessive sweating, rapid heart rate, blackouts, anxiety, vomiting, etc.?
Please describe specific symptoms and consider immediate referral for medical evaluation:
Yes No
5. Do you have a history of serious withdrawal, seizures, or life-threatening symptoms during withdrawal? Yes No
Please describe and specify withdrawal substance(s):
6. Do you find yourself using more alcohol and/or drugs in order to get the same high? Yes No
Please describe:
7. Has your alcohol and/or drug use changed recently (increase/decrease, changed route of use)? Yes No
Please describe:
8. Please describe family history of alcohol and/or drug use:
Client Name: Medi-Cal ID:
Treatment Agency:
Please circle one of the following levels of severity
Severity Rating - Dimension 1 (Substance Use, Acute Intoxication and/or Withdrawl Potential)
Based on the ASAM Criteria [3rd Edition] Multidimensional Assessment
FULL ASAM ASSESSMENT - ADULT
This confidential information is provided to you in accord with State and Federal laws and regulations including but
not limited to applicable Welfare and Institutions Code, Civil Code and HIPAA Privacy Standards. Duplication of
this information for further disclosure is prohibited without the prior written authorization of the patient/authorized
representative to who it pertains unless otherwise permitted by law.
0
None
1
Mild
2
Moderate
3
Severe
4
Very Severe
Incapacitated. Severe signs and
symptoms. Presents danger, i.e.
seizures. Continued substance use
poses an imminent threat to life.
Severe intoxication with imminent
risk of danger to self/others. Risk of
severe manageable withdrawal.
May have severe intoxication but
responds to support. Moderate risk
of severe withdrawal. No danger to
self/others.
Mild/moderate intoxication,
interferers with daily
functioning. Minimal risk of
severe withdrawal. No danger to
self/others.
No signs of
withdrawal/intoxication present
ASAM Full Assessment-Adult Revised 5/24/2016
2
Draft
Additional Comments:
9. Please list known medical provider(s):
10. Do you have any of the following medical conditions:
Heart Problems Seizure/Neurological Muscle/Joint Problems Diabetes
High Blood Pressure Thyroid Problems Vision Problems Sleep Problems
High Cholesterol Kidney Problems Hearing Problems Chronic Pain
Blood Disorder Liver Problems Dental Problems Pregnant
Stomach/Intestinal Problems Asthma/Lung Problems Sexually Transmitted Disease(s):
Cancer (specify types[s]): Infection(s):
Allergies: Other:
11. Do any of these conditions significantly interfere with your life? Yes No
Please describe:
12. Provide additional comments on medical conditions, prior hospitalizations (include dates and reasons):
13. Question to be answered by interviewer:
Does the client report a medical symptoms that would be considered life-threatening or require immediate
medical attention? * If yes, consider immediate referral to emergency room or call 911
Yes No
14. List all current medication(s) for medical condition(s):
Client Name: Medi-Cal ID:
Treatment Agency:
FULL ASAM ASSESSMENT - ADULT
Based on the ASAM Criteria [3rd Edition] Multidimensional Assessment
Contact InformationPhysician Name Specialty
DIMENSION 2: BIOMEDICAL CONDITIONS AND COMPLICATIONS
Severity Rating - Dimension 2 (Biomedical Conditions and Complications)
0
None
1
Mild
2
Moderate
3
Severe
4
Very Severe
Please circle one of the following levels of severity
Medication Dose/Frequency Reason Effectiveness/Side Effects
This confidential information is provided to you in accord with State and Federal laws and regulations including but
not limited to applicable Welfare and Institutions Code, Civil Code and HIPAA Privacy Standards. Duplication of
this information for further disclosure is prohibited without the prior written authorization of the patient/authorized
representative to who it pertains unless otherwise permitted by law.
Fully functional/ able to cope
with discomfort or pain.
Mild to moderate symptoms
interfering with daily
functioning. Adequate ability to
cope with physical discomfort.
Some difficulty tolerating physical
p
roblems. Acute, nonlife threatening
problems present, or serious
biomedical problems are neglected.
Serious medical problems neglected
during outpatient or intensive
outpatient treatment. Severe medical
problems present but stable. Poor
ability to cope with physical
problems.
Incapacitated with severe medical
problems.
ASAM Full Assessment-Adult Revised 5/24/2016
3
Draft
Additional Comments:
15. Do you consider any of the following behaviors or symptoms to be problematic?
Depression/sadness Loss of Pleasure/Interest Hopelessness Irritability/Anger
Impulsivity Pressured Speech Grandiosity Racing Thoughts
Anxiety/Excessive Worry Obsessive Thoughts Compulsive Behaviors Flashbacks
Paranoia Delusions: Hallucinations:
Sleep Problems Memory/Concentration Gambling Risky Sex Behaviors
Suicidal Thoughts: please describe
Thoughts of Harming Others: please describe
Abuse (physical, emotional, sexual):
Traumatic Event(s):
Other:
16. Have you ever been diagnosed with a mental illness? Yes No Not Sure
Please describe (e.g., diagnosis, medications?):
17. Are you currently or have you previously received treatment for psychiatric or emotional problems? Yes No
Please describe (e.g., treatment setting, hospitalizations, duration of treatment):
18. Do you ever see or hear things that other people say they do not see or hear? Yes No
Please describe:
19. Question to be answered by interviewer:
Based on previous questions, is further assessment of mental health needed? Yes No
Please describe:
20. List all current medication(s) for psychiatric condition(s):
21. Please list mental health provider(s):
Client Name: Medi-Cal ID:
Treatment Agency:
FULL ASAM ASSESSMENT - ADULT
Based on the ASAM Criteria [3rd Edition] Multidimensional Assessment
DIMENSION 3: EMOTIONAL, BEHAVIORAL, OR COGNITIVE CONDITIONS AND COMPLICATIONS
Mood
Anxiety
Psychosis
Other
Medication Dose/Frequency Reason Effectiveness/Side Effects
Provider Name Contact Information
This confidential information is provided to you in accord with State and Federal laws and regulations including but
not limited to applicable Welfare and Institutions Code, Civil Code and HIPAA Privacy Standards. Duplication of
this information for further disclosure is prohibited without the prior written authorization of the patient/authorized
representative to who it pertains unless otherwise permitted by law.
ASAM Full Assessment-Adult Revised 5/24/2016
4
Draft
Additional Comments:
22. Is your alcohol and/or drug use affecting any of the following?
Work Mental Health Physical Health Finances
School Relationships Sexual Activity Legal Matters
Handling Everyday Tasks Self-esteem Hygiene Recreational Activities
Other:
23. Do you continue to use alcohol or drugs despite having it affect the areas listed above? Yes No
Please describe:
24. Have you received help for alcohol and/or drug problems in the past? Yes No
Please list treatment providers(s)
25. What would help to support your recovery?
26. What are potential barriers to your recovery (e.g., financial, transportation, relationships, etc.)?
27. 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
Please describe:
Client Name: Medi-Cal ID:
Treatment Agency:
Willing to engage in treatment.
Willing to enter treatment, but
ambivalent to the need to
change.
Reluctant to agree to treatment. Low
commitment to change substance
use. Passive engagement in
treatment.
Unaware of need to change.
Unwilling or partially able to follow
through with recommendations for
treatment.
Not willing to change.
Unwilling/unable to follow through
with treatment recommendations.
Good impulse control and
coping skills. No
dangerousness, good social
functioning and self-care, no
interference with recovery.
Suspect diagnosis of EBC,
requires intervention, but does not
interfere with recovery. Some
relationship impairment.
Persistent EBC. Symptoms distract
from recovery, but no immediate
threat to self/others. Does not prevent
independent functioning.
Severe EBC, but does not require
acute level of care. Impulse to harm
self or others, but not dangerous in a
24-hr setting.
Severe EBC. Requires acute level of
care. Exhibits severe and acute life-
threatening symptoms (posing
imminent danger to self/others).
Please circle one of the following levels of severity
0
None
1
Mild
2
Moderate
3
Severe
4
Very Severe
Severity Rating - Dimension 3 (Emotional, Behavioral, or Cognitive Conditions and Complications)
FULL ASAM ASSESSMENT - ADULT
Based on the ASAM Criteria [3rd Edition] Multidimensional Assessment
Please circle one of the following levels of severity
This confidential information is provided to you in accord with State and Federal laws and regulations including but
not limited to applicable Welfare and Institutions Code, Civil Code and HIPAA Privacy Standards. Duplication of
this information for further disclosure is prohibited without the prior written authorization of the patient/authorized
representative to who it pertains unless otherwise permitted by law.
Severity Rating - Dimension 4 (Readiness to Change)
DIMENSION 4: READINESS TO CHANGE
Provider Name Contact Information
0
None
1
Mild
2
Moderate
3
Severe
4
Very Severe
ASAM Full Assessment-Adult Revised 5/24/2016
5
Draft
Additional Comments:
28. In the last 30 days, how often have you experienced cravings, withdrawal symptoms, disturbing effects of use?
Alcohol:
None Occasionally Frequently Constantly
Drug:
None Occasionally Frequently Constantly
29. Do you find yourself spending time searching for alcohol and/or drugs, or trying to recover from its effects? Yes No
Please describe:
30. Do you feel that you will either relapse or continue to use without treatment or additional support? Yes No
Please describe:
31. Are you aware of your triggers to use alcohol and/or drugs? Yes No
Please check off any triggers that may apply:
Strong Cravings Work Pressure Mental Health Relationship Problems
Difficulty Dealing with Feelings Financial Stressors Physical Health School Pressure
Enviornment Unemployment Chronic Pain Peer Pressure
Other:
32. What do you do if you are triggered?
33. Can you please describe any attempts you have made to either control or cut down on your alcohol and/or drug use?
34. What is the longest period of time that you have gone without using alcohol and/or drugs?
35. What helped and didn't help?
Additional Comments:
Client Name: Medi-Cal ID:
Treatment Agency:
Low/no potential for relapse.
Good ability to cope.
Minimal relapse potential. Some
risk, but fair coping and relapse
prevention skills.
Impaired recognition of risk for
relapse. Able to self-manage with
prompting.
Little recognition of risk for relapse,
poor skills to cope with relapse.
No coping skills for relapse/
addiction problems. Substance
use/behavior, places self/other in
imminent danger.
This confidential information is provided to you in accord with State and Federal laws and regulations including but
not limited to applicable Welfare and Institutions Code, Civil Code and HIPAA Privacy Standards. Duplication of
this information for further disclosure is prohibited without the prior written authorization of the patient/authorized
representative to who it pertains unless otherwise permitted by law.
DIMENSION 5: RELAPSE, CONTINUED USE, OR CONTINUED PROBLEM POTENTIAL
Please circle one of the following levels of severity
Severity Rating - Dimension 5 (Relapse, Continued Use, or Continued Problem Potential)
0
None
1
Mild
2
Moderate
3
Severe
4
Very Severe
Based on the ASAM Criteria [3rd Edition] Multidimensional Assessment
FULL ASAM ASSESSMENT - ADULT
ASAM Full Assessment-Adult Revised 5/24/2016
6
Draft
36. Do you have any relationships that are supportive of your recovery? (e.g., family, friends)
37. What is your current living situation (e.g., homeless, living with family/alone)?
38. Do you currently live in an environment where others are using drugs? Yes No
Please describe:
39. Are you currently involved in relationships or situations that pose a threat to your safety? Yes No
Please describe:
40. Are you currently involved in relationships or situations that would negatively impact your recovery? Yes No
Please describe:
41. Are you currently employed or enrolled in school? Yes No
Please describe (e.g., where employed, duration of employment, name and type of school):
42. Are you currently involved with social services or the legal system (e.g., DCFS, court mandated, probation, parole)? Yes No
Please describe:
If on parole/probation:
Additional Comments:
Client Name: Medi-Cal ID:
Treatment Agency:
Please circle one of the following levels of severity
Severity Rating-Dimension 6 (Recovery/Living Environment)
0
None
1
Mild
2
Moderate
3
Severe
4
Very Severe
Able to cope in environment/
supportive.
Passive/disinterested social
support, but still able to cope.
Unsupportive environment, but able
to cope with clinical structure most
of the time.
Unsupportive environment,
difficulty coping even with clinical
structure.
Environment toxic/hostile to
recovery. Unable to cope and the
environment may pose a threat to
safety.
This confidential information is provided to you in accord with State and Federal laws and regulations including but
not limited to applicable Welfare and Institutions Code, Civil Code and HIPAA Privacy Standards. Duplication of
this information for further disclosure is prohibited without the prior written authorization of the patient/authorized
representative to who it pertains unless otherwise permitted by law.
FULL ASAM ASSESSMENT - ADULT
Based on the ASAM Criteria [3rd Edition] Multidimensional Assessment
DIMENSION 6: RECOVERY/LIVING ENVIRONMENT
Name of Parole/Probation Officer Contact Information
ASAM Full Assessment-Adult Revised 5/24/2016
7
Draft
Client Name: Medi-Cal ID:
Treatment Agency:
This confidential information is provided to you in accord with State and Federal laws and regulations including but
not limited to applicable Welfare and Institutions Code, Civil Code and HIPAA Privacy Standards. Duplication of
this information for further disclosure is prohibited without the prior written authorization of the patient/authorized
representative to who it pertains unless otherwise permitted by law.
Dimension 2
Biomedical Condition and
Complications
Dimension 3
Emotional, Behavioral, or
Cognitive Condition and
Complications
Dimension 4
Readiness to Change
None Mild Moderate Severe
None Mild Moderate Severe
None Mild Moderate Severe
None Mild Moderate Severe
0123-4
None Mild Moderate Severe
23-4
0123-4
SUMMARY OF MULTIDIMENSIONAL ASSESSMENT
Dimension Severity Rating (Based on Ratings Above) Rationale
Dimension 5
Relapse, Continued Use, or
Continued Problem Potential
Dimension 6
Recovery/Living
Environment
0123-4
None Mild Moderate Severe
0123-4
0123-4
01
Dimension 1
Substance Use, Acute
Intoxication and/or
Withdrawal Potential
FULL ASAM ASSESSMENT - ADULT
Based on the ASAM Criteria [3rd Edition] Multidimensional Assessment
ASAM Full Assessment-Adult Revised 5/24/2016
8
Draft
Please check off any symptoms that have occurred in the past 12 months.
List of Substance Use Disorder(s) that Meet DSM-5 Criteria and Date of DSM-5 Diagnosis (specify severity level):
* The prescense of at lease 2
of these criteria indicates a substance use disorder.
** The severity of the substance use disorder is defined as:
- Mild: Presence of 2-3 criteria
- Moderate: Presence of 4-5 criteria
- Severe: Presence of 6 or more criteria
Client Name: Medi-Cal ID:
Treatment Agency:
This confidential information is provided to you in accord with State and Federal laws and regulations including but
not limited to applicable Welfare and Institutions Code, Civil Code and HIPAA Privacy Standards. Duplication of
this information for further disclosure is prohibited without the prior written authorization of the patient/authorized
representative to who it pertains unless otherwise permitted by law.
11 Withdrawal, as manifested by either of the following:
- The characteristic withdrawal syndrome for the substance.
- Substance (or a closely related substance) is taken to relieve or avoid withdrawal symptoms.
Total Number of Criteria
9 Continued substance use despite knowledge of having a persistent or recurrent physical or
psychological problem that is likely to have been caused or exacerbated by the substance.
10 Tolerance, as defined by either of the following:
- A need for markedly increased amounts of the substance to achieve intoxication or desired
effect.
- A markedly diminished effect with continued use of the same amount of the substance.
7 Important social, occupational, or recreational activities are given up or reduced because of
substance use.
8 Recurrent substance use in situations in which it is physically hazardous.
5 Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or
home.
6 Continued substance use despite having persistent or recurrent social or interpersonal problems
caused or exacerbated by the effects of the substance.
3 A great deal of time is spent in activities necessary to obtain the substance, use the substance, or
recover from its effects.
4 Craving, or a strong desire or urge to use the substance.
Substance often taken in larger amounts or over a longer period than was intended.1
2 There is a persistent desire or unsuccessful efforts to cut down or control substance use.
FULL ASAM ASSESSMENT - ADULT
Based on the ASAM Criteria [3rd Edition] Multidimensional Assessment
DIAGNOSIS: DIAGNOSTIC STATISTICAL MANUAL, 5TH EDITION (DSM-5)
CRITERIAL FOR SUBSTANCE USE DISORDER
#3:
___________
#2:
___________
#1:
___________
Substance Use Disorder Criteria (DSM-5)
Name of Substance(s)
ASAM Full Assessment-Adult Revised 5/24/2016
9
Draft
FULL ASAM ASSESSMENT- ADULT
Based on the ASAM Criteria [3rd Edition] Multidimensional Assessment
None Mild Mod Sev Mild Mod Sev None Mild Mod Sev None Mild Sev None Mild Mod Sev None Mild Mod Sev
Ambulatory Withdrawal Management
without Extended On-Site Monitoring
1-WM
Ambulatory Withdrawal Management with
Extended On-Site Monitoring
2-WM
Clinically Managed Residential Withdrawal
Management
3.2-WM
Medically Monitored Inpatient Withdrawal
Management
3.7-WM
Medically Managed Intensive Inpatient
Withdrawal Management
4-WM
None Mild Mod Sev Mild Mod Sev None Mild Mod Sev None Mild Sev None Mild Mod Sev None Mild Mod Sev
Early Intervention
0.5
Outpatient Services
1
Intensive Outpatient Services
2.1
Partial Hospitalization Services
2.5
Clinically Managed Low-Intensity
Residential Services
3.1
Clinically Managed Population-Specific
High-Intensity Residential Services
3.3
Clinically Managed High-Intensity
Residential Services
3.5
Medically Monitored Intensive Inpatient
Services
3.7
Medically Managed Intensive Inpatient
Services
4
None Mild Mod Sev Mild Mod Sev None Mild Mod Sev None Mild Sev None Mild Mod Sev None Mild Mod Sev
Opioid Treatment Program
OTP
Client Name: Medi-Cal ID:
Treatment Agency:
ASAM LEVEL OF CARE DETERMINATION TOOL
Instructions: For each dimension, indicate the least intensive level of care that is appropriate based on the client’s severity/functioning and service needs.
ASAM Criteria Level of Care- Other Treatment and Recovery Services
Dimension 2
Biomedical Condition
and Complications
Dimension 3
Emotional, Behavioral,
or Cognitive Condition
and Complications
Dimension 6
Recovery/Living
Environment
Severity / Impairment Rating
ASAM Criteria Level of Care-
Withdrawal Management
ASAM
Level
Dimension 1
Substance Use, Acute
Intoxication and/or
Withdrawal Potential
Dimension 5
Relapse, Continued Use,
or Continued Problem
Potential
Dimension 4
Readiness to Change
Mod
Would the patient with alcohol or opioid use disorders benefit from and be interested in Medication-Assisted Treatment (MAT)? ☐ Yes ☐ No
Severity / Impairment Rating
Consider referral to mental health facility
Severity / Impairment Rating
Mod
Mod
ASAM Criteria Level of Care- Other Treatment and Recovery Services
This confidential information is provided to you in accord with State and Federal laws and regulations including
but not limited to applicable Welfare and Institutions Code, Civil Code and HIPAA Privacy Standards.
Duplication of this information for further disclosure is prohibited without the prior written authorization of the
patient/authorized representative to who it pertains unless otherwise permitted by law.
None
None
None
Please describe: ___________________________________________________________________________________________________________________________________________________
ASAM Full Assessment - Adult Revised 5/24/2016
10
Draft
Level of Care: Enter the ASAM Level of Care (e.g., 3.1, 2.1, 3.2, W.M) number that offers the most appropriate treatment setting given the client’s curren
t
severity and functioning:
Level of Care Provided: If the most appropriate Level of Care is not utilized, then enter the next appropriate Level of Care and check off the reason
for this discrepancy (below):
Reason for Discrepancy:
Not Applicable Service Not Available Provider Judgment Client Preference
Transportation Accessibility Financial Preferred to Wait
Language/ Cultural Considerations Environment Mental Health Physical Health
Other:
Briefly Explain Discrepancy:
Designated Treatment Location and Provider Name:
Counselor/LPHA Name Signature Date
*LPHA Name Signature Date
*Complete this line if individual conducting this assessment is not an LPHA
Client Name: Medi-Cal ID:
Treatment Agency:
FULL ASAM ASSESSMENT - ADULT
Based on the ASAM Criteria [3rd Edition] Multidimensional Assessment
PLACEMENET SUMMARY
LPHA (Licensed Practitioner of the Healing Arts) includes: Physician, 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.
This confidential information is provided to you in accord with State and Federal laws and regulations including but
not limited to applicable Welfare and Institutions Code, Civil Code and HIPAA Privacy Standards. Duplication of
this information for further disclosure is prohibited without the prior written authorization of the patient/authorized
representative to who it pertains unless otherwise permitted by law.
ASAM Full Assessment-Adult Revised 5/24/2016
11
Draft
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