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Adult Asam Assessment E Form

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ADULT ASAM
Based on the American Society of Addiction Medicine (ASAM)
Criteria Multidimensional Assessment; 3
rd
Edition
1
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,
HIPAA
Privacy
Standards,
and
42
CFR
part
2.
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.
Consumer Name:
Consumer ID:
Date:
Start time:
Stop time:
Total time:
Initial Screening and Placement Update Transitional Placement
Demographic Information
Name:
Address:
DOB:
Age:
Race:
Occupation:
Preferred Language:
Self Identified Gender: Male Female Transgender Male/Trans Man Transgender Female/Trans Woman
Gender Queer/Gender non-conforming Another Gender identity Unknown/Prefer not to answer
Insurance Type: ☐None ☐Drug Medi-Cal ☐Medicare ☐Medi-Cal ☐Private ☐Other (specify):
Referred by (specify):
Brief explanation of why consumer is seeking services including a history of how substance use has affected their life in the last 12 months:
Dimension 1: Substance Use, Acute Intoxication, Withdrawal Potential
1. In the past 30 days, have you used:
Alcohol:
☐ Yes ☐ No
Amount last used?
Time from last use?
Route of administration?
Marijuana:
☐ Yes ☐ No
Amount last used?
Time from last use?
Route of administration?
Cocaine/Crack:
☐ Yes ☐ No
Amount last used?
Time from last use?
Route of administration?
Heroin:
☐ Yes ☐ No
Amount last used?
Time from last use?
Route of administration?
*If consumer is using heroin, consider referral to Opioid Treatment Program or provider of Medication-Assisted Treatment
Methamphetamine:
☐ Yes ☐ No
Amount last used?
Time from last use?
Route of administration?
Other:
☐ Yes ☐ No
If yes, specify name:
Amount last used?
Time from last use?
Route of administration?
Other:
☐ Yes ☐ No
If yes, specify name:
Amount last used?
Time from last use?
Route of administration?
Other:
☐ Yes ☐ No
If yes, specify name:
Amount last used?
Time from last use?
Route of administration?
Developed by Riverside County
2
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,
HIPAA
Privacy
Standards,
and
42
CFR
part
2.
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.
Consumer Name:
Consumer ID:
2. In the past 30 days, have you used or misused any prescription medication? (with or without prescription): ☐ Yes ☐ No
Specify type:
☐ Opioid Pain Medication Specify name:
Amount last used?
Time from last use?
Route of administration?
☐Benzodiazepines/Sleeping/Anxiety Medication Specify name:
Amount last used?
Time from last use?
Route of administration?
☐Stimulants Specify name:
Amount last used?
Time from last use?
Route of administration?
☐ Other Specify name:
Amount last used?
Time from last use?
Route of administration?
☐ Other Specify name:
Amount last used?
Time from last use?
Route of administration?
☐ Other Specify name:
Amount last used?
Time from last use?
Route of administration?
*If consumer is misusing opioid medications, consider referral to Opioid Treatment Program or provider of Medication-Assisted Treatment
3. Is there evidence or suspicion of intoxication (withdrawal potential) or current withdrawal? ☐ Yes ☐ No
If yes, answer the following:
a. When you have been in withdrawal from alcohol or any of the drugs listed above, what happened for you?
b. Are you currently experiencing any withdrawal signs such as: tremors, tingling, excessive sweating, heart racing, numbness, anxiety,
vomiting, or diarrhea? ☐ Yes ☐ No
c. Have you ever had life threatening symptoms or been hospitalized during withdrawal? ☐ Yes ☐ No
d. Are you currently having similar withdrawal symptoms? ☐ Yes ☐ No
e. Do you have a history of seizures? ☐ Yes ☐ No
f. Have you had head injury? ☐ Yes ☐ No If yes, when:
Did you lose consciousness? ☐ Yes ☐ No
4. Have you ever been to treatment for your alcohol/drug problems before, including DUI, and PC1000? ☐ Yes ☐ No
Please circle one of the following levels of severity
Severity Rating- Dimension 1 (Substance Use, Acute Intoxication, Withdrawal Potential)
0
1
2
3
4
None
Mild
Moderate
Severe
Very Severe
No signs of
withdrawal/
intoxication present
Mild/moderate intoxication,
interferes with daily
functioning. Minimal risk of
severe withdrawal. No danger
to self/others.
May have severe intoxication but
responds to support. Moderate
risk of severe withdrawal. No
danger to self/others.
Severe intoxication with
imminent risk of danger to
self/others. Risk of severe
manageable withdrawal.
Incapacitated. Severe signs and
symptoms. Presents danger, i.e.
seizures. Continued substance use poses
an imminent threat to life.
3
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,
HIPAA
Privacy
Standards,
and
42
CFR
part
2.
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.
Consumer Name:
Consumer ID:
Comments:
Dimension 2: Biomedical Condition and Complications
5. Do you have any active medical problems or disabilities that you are aware of? ☐ Yes ☐ No
If yes, do any of the medical problems require immediate attention? ☐ Yes ☐ No
Briefly explain:
If yes, are you currently using any medications for a physical health issue? ☐ Yes ☐ No ☐ Unsure
Briefly explain:
6. Are any of these issues directly related to alcohol and/or drug use? ☐ Yes ☐ No ☐ N/A
Briefly Explain:
7. If female: Are you pregnant? ☐ Yes ☐ No ☐ N/A If yes, how many weeks?
8. In the past 30 days, have you been to an urgent care, emergency room, or hospitalized for any medical concerns? ☐ Yes ☐ No
If yes, briefly explain what you were treated for:
9. (Question to be answered by interviewer): Does the consumer report any medical symptoms that would be considered life-threatening or
require immediate attention/treatment?
☐ Yes ☐ No *If yes, consider immediate referral to emergency room and/or call 911
Please circle one of the following levels of severity
Severity Rating- Dimension 2 (Biomedical Condition and Complications)
0
1
2
3
4
None
Mild
Moderate
Severe
Very Severe
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 problems. Acute,
nonlife threatening problems
present, or serious biomedical
problems are neglected.
Serious medical problems neglected
during outpatient treatment. Severe
medical problems present but stable.
Poor ability to cope with physical
problems.
Incapacitated with severe
medical problems.
Comments:
4
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,
HIPAA
Privacy
Standards,
and
42
CFR
part
2.
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.
Consumer Name:
Consumer ID:
Dimension 3: Emotional, Behavioral, or Cognitive Condition and Complications
10. Are you currently receiving supportive therapy for mental health needs? ☐ Yes ☐ No
If yes, briefly explain:
11. In the past 30 days, have you received outpatient mental health services or been hospitalized for psychological or emotional reasons?
☐ Yes ☐ No
If yes, briefly explain:
12. Do you have a history of memory loss and/or head trauma such as concussion? ☐ Yes ☐ No
If yes, briefly explain:
*If consumer has cognitive or mental health condition that requires a slower pace of treatment and a residential level of care, consider referral to
ASAM level 3.3 residential care.
13. In the last 30 days have you acted physically aggressive towards people or property? ☐ Yes ☐ No
If yes, briefly explain:
14. In the past 30 days, have you had thoughts about wanting to hurt yourself and/or someone else or wanting to die? ☐ Yes ☐ No
If yes, do you currently have any thoughts of hurting yourself? (if yes, follow protocol for ambulance transport to ETS) ☐ Yes ☐ No
* Have you acted on these feelings to hurt yourself? ☐ Yes ☐ No
Please describe:
15. In the past 30 days, have you taken prescribed medication for mental health needs? ☐ Yes ☐ No
If yes, which ones and who is prescribing them:
Prescribed by:
Specify name(s) and dosage:
16. Has your mental health condition interfered with:
☐ Social functioning ☐ Ability for self care ☐ Addiction recovery efforts ☐ Ability to work ☐ N/A
17. Has the course of your mental health condition been (check as many as applicable):
☐ Stable w/ meds ☐ Stable w/out meds ☐ Unstable ☐ N/A
5
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,
HIPAA
Privacy
Standards,
and
42
CFR
part
2.
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.
Consumer Name:
Consumer ID:
18. Is there reason to believe that any current emotional, behavioral, and/or cognitive problems are related directly to your use of alcohol and/or
drugs? (no pre-morbid history) ☐ Yes ☐ No
Please circle one of the following levels of severity
Severity Rating- Dimension 3 (Emotional, Behavioral, or Cognitive Condition and Complications [EBC])
0
1
2
3
4
None
Mild
Moderate
Severe
Very Severe
No impulsive behaviors,
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).
*If consumer scores a 3 or 4 in severity, consider referral to Behavioral Health Clinic
Comments:
Dimension 4: Readiness to Change
19. Do you ever feel uncomfortable or guilty about your alcohol or other drug use? ☐ Yes ☐ No
20. Have you continued to use alcohol or drugs despite experiencing problems at work or with your relationships? ☐ Yes ☐ No
21. Can you get through the week without using drugs and/or alcohol? ☐ Yes ☐ No
22. Have you been mandated to have an assessment and/or treatment? ☐ Yes ☐ No
23. How important is it to you now to get help for:
Alcohol concerns:
Not at all Slightly Moderately Considerably Extremely N/A
Drug concerns:
Not at all Slightly Moderately Considerably Extremely N/A
Mental Health issues:
Not at all Slightly Moderately Considerably Extremely N/A
24. On a scale of 1 (low) to 5 (very) how interested are you in stopping alcohol and/or drug use? 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐
Please circle one of the following levels of severity
Severity Rating- Dimension 4 (Readiness to Change)
0
1
2
3
4
None
Mild
Moderate
Severe
Very Severe
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.
6
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,
HIPAA
Privacy
Standards,
and
42
CFR
part
2.
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.
Consumer Name:
Consumer ID:
Comments:
Dimension 5: Relapse, Continued Use, or Continued Problem Potential
25. What high risk situations are created by your use of alcohol and/or drugs (driving under the influence, caring for minor children, working with
machinery, heavy equipment, etc.)?
List:
26. On a scale of 1 to 5 what degree of cravings or urges to use alcohol and/or drugs in the last 30 days have you had?
1 (None) 2 (Slight urge) 3 (Moderate urge) 4 (Considerate urge) 5 (Extreme urge)
27. In the past 30 days, how frequent are these cravings or urges to use alcohol and/or drugs?
hourly daily weekly none
28. Do you have any coping skills that have helped to prevent continual use of alcohol and/or drugs? ☐ Yes ☐ No
29. Are you likely to continue to use or relapse without immediate care? ☐ Yes ☐ No
30. In the last 30 days, how many days of continuous abstinence have you had from drugs and/or alcohol?
31. Is Consumer requesting NTP services? ☐ Yes ☐ No ☐ N/A
If yes,
a. Have you been to NTP before?
☐ Yes ☐ No
b. Does Consumer have two year history of addiction to Opioid?
☐ Yes ☐ No
c. Does Consumer have two treatment failures for Opioid use?
☐ Yes ☐ No
d. Does Consumer have one year of episodic or continual use prior admission?
☐ Yes ☐ No
32. Are you interested in medications used in conjunction with treatment for alcohol or opioids? ☐ Yes ☐ No
Please circle one of the following levels of severity
Severity Rating- Dimension 5 (Relapse, Continued Use, or Continued Problem Potential)
0
1
2
3
4
None
Mild
Moderate
Severe
Very Severe
Low/no potential for
relapse. Good coping &
relapse prevention skills.
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/others in
danger.
Comments:
7
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,
HIPAA
Privacy
Standards,
and
42
CFR
part
2.
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.
Consumer Name:
Consumer ID:
Dimension 6: Recovery/Living Environment
33. What are your current living arrangements? Homeless No stable arrangements Stable housing
34. Are your current relational/environmental resources supportive of your recovery efforts? ☐ Yes ☐ No
Explain:
35. Do you currently live with others that use alcohol and/or drugs? ☐ Yes ☐ No
If yes, how do you cope with that situation?
36. Do you have children or others that you are responsible for providing care on a daily basis? ☐ Yes ☐ No
37. Are you currently employed, enrolled in school, or a job training program? ☐ Yes ☐ No ☐ Decline to state
38. Do you currently have transportation? ☐ Yes ☐ No
39. Are you currently involved with the legal system (on probation, parole, or awaiting trial/sentencing)? ☐ Yes ☐ No
If yes, specify: ☐Parole ☐Probation ☐Awaiting trial/sentence ☐DPSS/CPS ☐Court Mandated Treatment
☐Other:
40. Have you been convicted of a felony? ☐ Yes ☐ No
If yes, do any of these charges include homicide, manslaughter, a sex crime, or arson? ☐ Yes ☐ No
Specify:
Please circle one of the following levels of severity
Severity Rating- Dimension 6 (Recovery/Living Environment)
0
1
2
3
4
None
Mild
Moderate
Severe
Very Severe
Environment supportive
of recovery process.
Environment is supportive.
May require clinical
intervention.
Environment unsupportive to
recovery process but able to
participate with clinical
support.
Environment unsupportive to
recovery process, difficulty in
participating even with clinical
support.
Environment toxic/hostile to
recovery. Unable to participate and
the environment may pose a threat
to safety.
Comments:
8
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,
HIPAA
Privacy
Standards,
and
42
CFR
part
2.
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.
Consumer Name:
Consumer ID:
Summary of Multidimensional Assessment
Dimension
Severity Rating (Based on rating above)
Dimension 1
Substance Use, Acute
Intoxication, Withdrawal Potential
0
None
1
Mild
2
Moderate
3
Severe
4
Very Severe
Dimension 2
Biomedical Condition and
Complications
0
None
1
Mild
2
Moderate
3
Severe
4
Very Severe
Dimension 3
Emotional, Behavioral, or Cognitive
Condition and Complications
0
None
1
Mild
2
Moderate
3
Severe
4
Very Severe
Dimension 4
Readiness to Change
0
None
1
Mild
2
Moderate
3
Severe
4
Very Severe
Dimension 5
Relapse, Continued Use, or
Continued Problem Potential
0
None
1
Mild
2
Moderate
3
Severe
4
Very Severe
Dimension 6
Recovery/Living Environment
0
None
1
Mild
2
Moderate
3
Severe
4
Very Severe
9
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,
HIPAA
Privacy
Standards,
and
42
CFR
part
2.
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.
Consumer Name:
Consumer ID:
PLACEMENT SUMMARY
Level of Care/Service Indicated by ASAM: The following ASAM level of care offers the most appropriate level of care/service
intensity given the consumer’s functioning/severity:
Prevention:
0.5
Outpatient:
OTP (NTP)
1.0
IOT: 2.1
Partial Hosp.
2.5
Residential:
3.1
3.3
3.5
Medical Inpatient:
3.7
4.0
Withdrawal Management:
1-WM
2-WM
3.2-WM
3.7-WM
4-WM
Not Applicable (Referred to Recovery Services)
Level of Care/Service Provided: If the most appropriate level of care/service intensity was not utilized, enter the
most appropriate ASAM level of care that is available then select the reason for this discrepancy (if any):
Prevention:
0.5
Outpatient:
OTP (NTP)
1.0
IOT: 2.1
Partial Hosp.
2.5
Residential:
3.1
3.3
3.5
Medical Inpatient:
3.7
4.0
Withdrawal Management:
1-WM
2-WM
3.2-WM
3.7-WM
4-WM
Not Applicable (Referred to Recovery Services)
Reason for Discrepancy: If there is a difference between the level of care indicated by the ASAM and the level of care actually
provided then select the reason for discrepancy.
Not applicable
Service not available
Family responsibility
Geographic accessibility
Language
Safety sensitive occupation
Transportation
Physical Health
Living environment
Cognitive/Mental Health
condition consideration
Service available, but no
payment source
Consumer on waiting list
for more appropriate level
Consumer preference, explain:
Other (specify):
If special consumer requests or needs were taken into consideration of placement, please indicate below:
Designated Treatment Provider Name and Location:
Staff/Clinician Name:
Signature:
Date:
10
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,
HIPAA
Privacy
Standards,
and
42
CFR
part
2.
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.
Consumer Name:
Consumer ID:
ADULT ASAM TOOL – INSTRUCTIONS
INDICATE TYPE OF ASAM
Initial Screening and Placement is the consumer’s first contact and/or when the consumer is no longer active in
an open episode.
Update is to be completed at a minimum of every 30 days for Residential/Inpatient providers, or at a minimum of
every 90 days for other modalities (including Prevention, Outpatient, Intensive Outpatient, Partial Hospitalization,
and Opioid Treatment Program (OTP).
Transition is when consumer is moving from one level of care to another, or for discharge, one time in the last 14
days of an open episode.
DEMOGRAPHIC INFORMATION
Enter the consumer’s name in the order of last name, first name and middle name.
Enter the date the ASAM screening was performed.
Enter the consumer’s phone number and check yes or no, indicating if it is okay to leave a voicemail.
Enter the consumer’s address.
Enter the consumer’s date of birth.
Enter the consumer’s age.
Enter the consumer’s self identified gender.
Enter the consumer’s race.
Enter the consumer’s occupation.
Enter the consumer’s preferred language.
Enter the consumer’s medical record or ‘P’ number.
Check off or specify the consumer’s insurance type and indicate what type of plan they have.
Enter who and/or which agency referred the consumer for assessment.
Enter explanation for why consumer is currently seeking services and a brief substance use history.
DIMENSION 1: SUBSTANCE USE, ACUTE INTOXICATION AND/OR WITHDRAWAL POTENTIAL
For questions 1-4, the interviewer asks the consumer the following questions, to which the consumer would
respond yes or no. The interviewer is then to ask the consumer to further describe their yes or no response
and document it in the space provided. The intent is to gather as much relevant information on each topic
in order to best determine the consumer’s severity rating for Dimension 1: Substance Use, Acute
Intoxication and/or Withdrawal Potential.
Question 1: Record any alcohol and/or drugs that the consumer has used in the past 30 days. If the
consumer is using opioids or
alcohol, consider a referral to an Opioid Treatment Program or to a provider
who offers Medication-Assisted Treatment, as
appropriate.
Question 2: Record any Opioid pain medication, benzodiazepines, stimulants or other prescription
medication used or misused in the past 30 days. If the consumer is using opioids or
alcohol, consider a
referral to an Opioid Treatment Program or to a provider who offers Medication Assisted Treatment, as
appropriate.
Questions 3: Check yes or no. If yes, continue to answer a – f, indicating when for f as necessary.
Question 4: Check yes or no.
Enter additional comments (if any) relevant to Dimension 1: Substance Use, Acute Intoxication and/or
Withdrawal Potential, in the space provided, that may impact the placement of the consumer.
Choose a severity rating of 0-4 for Dimension 1: Substance Use, Acute Intoxication and/or Withdrawal
Potential, based on the consumer’s current risk level (0 = None; 1 = Mild; 2 = Moderate; 3 = Severe; 4 = Very
Severe). This is done by reading the descriptions
for each severity level and considering the information that
11
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,
HIPAA
Privacy
Standards,
and
42
CFR
part
2.
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.
Consumer Name:
Consumer ID:
was gathered in questions 1-7. The interviewer then chooses the rating that best describes the consumer’s
current level of risk for substance use, acute intoxication, and risks associated with
withdrawal.
DIMENSION 2: BIOMEDICAL CONDITIONS AND COMPLICATIONS
For questions 5-8, the interviewer asks the consumer the following questions, to which the consumer would
respond yes or no. The interviewer is then to ask the consumer to further describe their yes or no response and
document it in the space provided. Question
9 is to be answered by the interviewer. The intent is to gather as
much relevant information on each topic in order to best
determine the consumer’s severity rating for
Dimension 2: Biomedical Conditions and Complications.
Questions 5-8: Check yes or no. Further describe the response in the space provided.
Question 9 to be answered by interviewer: Check yes or no. If yes, consider an immediate referral to the
emergency room or call 911.
Enter additional comments relevant to Dimension 2: Biomedical Conditions and Complications, in the space
provided, that may
impact the placement of the consumer.
Choose a severity rating of 0-4 for Dimension 2: Biomedical Conditions and Complications, based on the
consumer’s current risk level.
(0 = None; 1 = Mild; 2 = Moderate; 3 = Severe; 4 = Very Severe). This is done by
reading the descriptions for each severity level,
and considering the information that was gathered in questions
8-10. The interviewer then chooses the rating that best describes
the consumer’s current level of risk for
physical health problems and how they may impact the consumer’s treatment placement.
DIMENSION 3: EMOTIONAL, BEHAVIORAL, OR COGNITIVE CONDITIONS AND COMPLICATIONS
For questions 10-18, the interviewer asks the consumer the following questions, to which the consumer would
respond yes or no. The interviewer is then to ask the consumer to further describe their yes or no response and
document it in the space provided.
Questions 10-12: Check yes or no. Further describe the response in the space provided.
If the consumer has a cognitive or mental health condition that requires a slower pace of treatment and
residential care, consider a
referral to ASAM level 3.3 residential care.
Question 13: Check yes or no. Further describe the response in the space provided.
Question 14: Check yes or no. If yes, continue to next question.
Check yes or no. If yes, consider transport to emergency room or call 911.
*Check yes or no. Further describe your responses in the space provided.
Question 15: Check yes or no. If yes, describe name and dosage in space provided.
Question 16: Check all that apply or N/A if none.
Question 17: Check one that applies or N/A if none.
Question 18: Check yes or no.
Enter additional comments relevant to Dimension 2: Biomedical Conditions and Complications, in the space
provided, that may
impact the placement of the consumer.
Choose a severity rating of 0-4 for Dimension 3: Emotional, Behavioral, or Cognitive Conditions or
Complications, based on the consumer’s current risk level. (0 = None; 1 = Mild; 2 = Moderate; 3 = Severe; 4 =
Very Severe). This is done by reading the descriptions
for each severity level, and considering the information
that was gathered in questions 10-18. The interviewer then chooses the rating that best describes the
consumer’s current level of risk for mental health problems and how they may impact the consumer’s
treatment
placement. *If a consumer scores a 3 or 4 in severity, consider referral to a Behavioral Health Clinic.
DIMENSION 4: READINESS TO CHANGE
For questions 19-24, the interviewer asks the consumer the following questions. The interviewer is then to
12
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,
HIPAA
Privacy
Standards,
and
42
CFR
part
2.
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.
Consumer Name:
Consumer ID:
ask the consumer to further
describe their response and document it in the space provided. The intent is to
gather as much relevant information on each
topic in order to best determine the consumer’s severity rating
for Dimension 4: Readiness to Change.
Question 19: Check yes or no.
Question 20: Check yes or no.
Question 21: Check yes or no.
Question 22: Check yes or no.
Question 23: Check off only one of the responses given for alcohol, drugs, and mental health issues
separately.
Question 24: Indicate response to scaling question, 1 being low and 5 being high.
Enter additional comments relevant to Dimension 4: Readiness to Change, in the space provided, that may
impact placement of the consumer
Choose a severity rating of 0-4 for Dimension 4: Readiness to Change, based on the consumer’s current risk
level. (0 = None; 1 = Mild;
2 = Moderate; 3 = Severe; 4 = Very Severe). This is done by reading the descriptions
for each severity level, and considering the information that was gathered in questions 19-24. The interviewer
then chooses the rating that best describes the consumer’s
current level of risk for readiness to change and
engage in treatment, and how that may impact the consumer’s treatment placement.
DIMENSION 5: RELAPSE, CONTINUED USE, OR CONTINUED PROBLEM POTENTIAL
For questions 25-32, the interviewer asks the consumer the following questions. The interviewer is then to
ask the consumer to further
describe their response and document it in the space provided. The intent is to
gather as much relevant information on each
topic in order to best determine the consumer’s severity rating
for Dimension 5: Relapse, Continued Use or Continued Problem Potential.
Question 25: Describe the response in the space provided.
Question 26: Indicate response to scaling question, 1 being none and 5 being extreme urge.
Question 27: Check one box.
Question 28: Check yes or no.
Question 29: Check yes or no.
Question 30: Enter number of days in space provided.
Question 31: Check yes, no, or N/A.
If yes, check yes or no to a – b. A yes answer to a alone or b, c, and d indicates consumer is eligible for
Narcotic Treatment Program services. Consider referral to methadone.
Question 32: Check yes or no. If yes, consider referral to Medication Assisted Treatment (MAT).
Choose a severity rating of 0-4 for Dimension 5: Relapse, Continued Use or Continued Problem Potential,
based on the consumer’s
current risk level. (0 = None; 1 = Mild; 2 = Moderate; 3 = Severe; 4 = Very Severe).
This is done by reading the descriptions for
each severity level, and considering the information that was
gathered in questions 20-23. The interviewer then chooses the rating that best describes the consumer’s
current level of risk for relapse, continued use or continued problems and how that may
impact the
consumer’s treatment placement.
Enter additional comments relevant to Dimension 5: Relapse, Continued Use or Continued Problem Potential,
in the space provided, that may impact placement of the consumer.
DIMENSION 6: RECOVERY/LIVING ENVIRONMENT
For questions 33-40, the interviewer asks the consumer the following questions. The interviewer is then to
ask the consumer to further
describe their response and document it in the space provided. The intent is to
gather as much relevant information on each
topic in order to best determine the consumer’s severity rating
for Dimension 6: Recovery/Living Environment.
13
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,
HIPAA
Privacy
Standards,
and
42
CFR
part
2.
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.
Consumer Name:
Consumer ID:
Question 33: Check off only one of the responses.
Question 34: Check yes or no. Further describe response in space provided.
Question 35: Check yes or no. Further describe response in space provided.
Question 36: Check one box.
Question 37: Check yes, no, or decline to state.
Question 38: Check yes or no.
Question 39: Check yes or no. If yes, check box(es) indicating involvement.
Question 40: Check yes or no. If yes, check yes or no. Further explain yes response in space provided.
Choose the severity rating of 0-4 for Dimension 6: Recovery/Living Environment, based on the consumer’s
current risk level. (0 = None; 1 = Mild; 2 = Moderate; 3 = Severe; 4 = Very Severe). This is done by reading
the descriptions for each severity level, and
considering the information that was gathered in questions 24-27.
The interviewer then chooses the rating that best describes
the consumer’s current level of risk due to their
recovery and living environment and how that may impact the consumer’s treatment
placement.
*Note: homelessness does not automatically mean the consumer is eligible for residential
treatment. The risk of all 6
Dimensions must be fully taken into account when deciding level of
care placement.
Enter additional comments relevant to Dimension 6: Recovery/Living Environment, in the space provided,
that may impact treatment or placement of the consumer.
SUMMARY OF MULTIDIMENSIONAL ASSESSMENT
The intent of the ‘Summary of Multidimensional Assessment’ section of the assessment is to consolidate
the information gathered from all 6 ASAM dimensions onto one page to help the interviewer synthesize
this information to develop an
individualized case formulation and ultimately select the most appropriate
ASAM level of care.
For Dimensions 1-6, check off the severity rating that you chose in the previous section.
PLACEMENT SUMMARY INFORMATION
Enter the Level of Care as indicated by the ASAM. *Use the key below for definition of the numbers and
corresponding description of each level of care.
Enter the Level of Care that is being provided. *Use the key below for definition of the numbers and
corresponding description of each level of care.
There may be exceptions in which the Level of Care chosen for the consumer and Level of Care that the
consumer is placed differ. This
may be due to lack of availability, or consumer preference. If there is a
discrepancy between the Level of Care chosen by the interviewer and the Level of Care that is to be
provided, please check off the appropriate reason for the discrepancy and briefly
explain why.
Describe if any special consumer requests or needs were taken into consideration of placement.
Provide the information and location for the designated treatment provider for the consumer.
Enter the interviewer’s (counselor) name, signature and date of the multidimensional screening.
*ASAM LEVELS OF CARE
0.5: Early Intervention
OTP (NTP): Opioid Treatment Services
1.0: Outpatient Services
2.1: Intensive Outpatient Services
14
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,
HIPAA
Privacy
Standards,
and
42
CFR
part
2.
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.
Consumer Name:
Consumer ID:
2.5: Partial Hospitalization Services
3.1: Clinically Managed Low-Intensity Residential Services
3.3: Clinically Managed High-Intensity Residential Services (Population-Specific)
3.5: Clinically Managed High-Intensity Residential Services (Non-population-Specific)
3.7: Medically Monitored Intensive Inpatient Services
4.0: Medically Managed Intensive Inpatient Services
1-WM: Ambulatory Withdrawal Management (Without extended onsite monitoring)
2-WM: Ambulatory Withdrawal Management (With extended onsite monitoring)
3.2-WM: Residential Withdrawal Management (Clinically Managed)
3.7-WM: Inpatient Withdrawal Management (Clinically Managed)
4-WM: Inpatient Withdrawal Management (Medically Managed and Intensive Services)
N/A: Not Applicable – no Substance Use Prevention or Treatment Services will be provided
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Adult Asam Assessment E Form

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Completed 16 July 2020

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