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LOS ANGELES COUNTY ASSESSMENT TOOL- ADULTS (PAPER VERSION) (County of Los Angeles / Internal Services Department)

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LOS ANGELES COUNTY
ASSESSMENT TOOL- ADULTS (PAPER VERSION)
Ba
sed on the ASAM Criteria [3
rd
Edition] Multidimensional Assessment
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.
Client Name: _______________________________ Medi-Cal ID:______________________
Treatment Agency: __________________________________________________________
Revised: 07/31/17 1
Demographic information
Name: Date:
Phone Number:
Okay to leave voicemail? ☐ Yes ☐ No
Address:
Date of Birth:
Age:
Gender:
Race/Ethnicity:
Preferred Language:
Medi-Cal ID #:
Other ID# (Plan):
Insurance Type:
☐
None
☐
MyHealthLA
☐
Medicare
☐
Medi-Cal
☐
Private
☐
Other
(Plan): (Plan):
(Plan):
(Plan):
Living Arrangement: ☐
Homeless
☐
Independent living
☐
Other (specify):
Referred by (specify):
Explanation of why patient is currently seeking treatment: Current symptoms, functional impairment, severity, duration of
symptoms (e.g., unable to work/school, relationship/housing problems):
Dimension 1: Substance Use, Acute Intoxication and/or Withdrawal Potential
1. Substance use history:
Alcohol and/or Drug Types
(Past 6 Months)
Prior Use?
(Lifetime)
Route
Frequency
Duration
Date of Last
Use
(Inject, Smoke, Snort)
(Daily, Weekly, Monthly)
(Length of Use)
Amphetamines
(Meth, Ice, Crank)
Alcohol
Cocaine/Crack
Heroin
Marijuana
Opioid Pain Medications
Misuse or without prescription
Sedatives
(Benzos, Sleeping Pills)
Misuse or without prescription
Hallucinogens
Inhalants
Over-the-Counter
Medications
(Cough Syrup, Diet Aids)
Nicotine
Other:
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.
Client Name: _______________________________ Medi-Cal ID:______________________
Treatment Agency: __________________________________________________________
Revised: 07/31/17 2
2. Do you find y
ourself 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 current
ly experiencing withdrawal symptoms, such as tremors, excessive sweating, rapid heart rate,
blackouts, anxiety, vomiting, etc.? ☐ Yes ☐ No
Please describe specific symptoms and consider immediate referral for medical evaluation:
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/ decreased, changed route of use)? ☐ Yes ☐ No
Please describe:
8. Please describe family history of alcohol and/or drug use:
Additional 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.
Client Name: _______________________________ Medi-Cal ID:______________________
Treatment Agency: __________________________________________________________
Revised: 07/31/17 3
Please circle one of the following levels of severity
Severity Rating- Dimension 1 (Substance Use, Acute Intoxication and/or Withdrawal Potential)
0
1 2 3 4
None
Mild
Moderate
Severe
Very Severe
No signs of
withdrawal/intoxication
present
Mild/moderate intoxication,
interferers 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.
Additional Comments:
Dimension 2: Biomedical Conditions and Complications
9. Please list known medical provider(s)
Physician Name
Specialty
Contact Information
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 type[s]):____________________________ ☐ Infection(s): __________________________________
☐ Allergies: ________________________________________
☐ Other: ______________________________________
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.
Client Name: _______________________________ Medi-Cal ID:______________________
Treatment Agency: __________________________________________________________
Revised: 07/31/17 4
11. Do any of these conditions significantly interfere with your life? ☐ Yes ☐ No
Pl
ease describe:
12. Provide addi
tional comments on medical conditions, prior hospitalizations (include dates and reasons):
13. Question to b
e answered by interviewer
: Does the patient report medical symptoms that would be considered life-
threatening or require immediate medical attention? ☐ Yes ☐ No
* If yes, consider immediate referral to emergency room or call 911
14. List all current medication(s) for medical condition(s):
Medication
Dose/Frequency
Reason
Effectiveness/Side Effects
Please circle one of the following levels of severity
Severity Rating- Dimension 2 (Biomedical Conditions 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 or intensive
outpatient treatment. Severe medical
problems present but stable. Poor
ability to cope with physical problems.
Incapacitated with
severe medical
problems.
Additional Comments:
Dimension 3: Emotional, Behavioral, or Cognitive Conditions and Complications
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.
Client Name: _______________________________ Medi-Cal ID:______________________
Treatment Agency: __________________________________________________________
Revised: 07/31/17 5
15. Do you consider any of the following behaviors or symptoms to be problematic?
Mood
☐
Depression/sadness
☐
Loss of Pleasure/Interest
☐
Hopelessness
☐
Irritability/Anger
☐
Impulsivity
☐
Pressured Speech
☐
Grandiosity
☐
Racing Thoughts
Anxiety
☐
Anxiety/Excessive Worry
☐
Obsessive Thoughts
☐
Compulsive Behaviors
☐
Flashbacks
Psychosis
☐
Paranoia
☐
Delusions: ______________________
☐
Hallucinations: ____________________
Other
☐
Sleep Problems
☐
Memory/Concentration
☐
Gambling
☐
Risky Sex Behaviors
☐
Suicidal Thoughts: please describe
☐
Thoughts of Harming Others: please describe
☐
Abuse (physical, emotional, sexual): please describe
☐
Traumatic Event(s): please describe
☐
Other:
16. Have you eve
r 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:
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.
Client Name: _______________________________ Medi-Cal ID:______________________
Treatment Agency: __________________________________________________________
Revised: 07/31/17 6
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 cu
rrent medication(s) for psychiatric condition(s):
Medication
Dose
Reason
Effectiveness/Side Effects
21. Please list m
ental health provider(s):
Provider Name
Contact Information
Please circle one of the following levels of severity
Severity Rating- Dimension 3 (Emotional, Behavioral, or Cognitive Conditions and Complications)
0
1 2 3 4
None
Mild
Moderate
Severe
Very Severe
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).
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.
Client Name: _______________________________ Medi-Cal ID:______________________
Treatment Agency: __________________________________________________________
Revised: 07/31/17 7
Additional Comments:
Dimension 4: Readiness to Change
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 recei
ved help for alcohol and/or drug problems in the past? ☐ Yes ☐ No
P
lease list treatment provider(s)
Provider Name
Contact Information
25. What would help to support your recovery?
26. What are pot
ential barriers to your recovery (e.g., financial, transportation, relationships, etc.)?
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.
Client Name: _______________________________ Medi-Cal ID:______________________
Treatment Agency: __________________________________________________________
Revised: 07/31/17 8
Alcohol Problems:
☐ Not at all
☐ Slightly ☐ Moderately ☐ Considerably ☐ Extremely
Drug P
roblems:
☐
Not at all
☐
Slightly
☐
Moderately
☐
Considerably
☐
Extremely
Please describe:
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.
Additional Comments:
Dimension 5: Relapse, Continued Use, or Continued Problem Potential
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
Please Describe:
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
☐
Environment
☐
Unemployment
☐
Chronic Pain
☐
Peer Pressure
☐
Other: __________________________________________
27. How important is it for you to receive treatment for:
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.
Client Name: _______________________________ Medi-Cal ID:______________________
Treatment Agency: __________________________________________________________
Revised: 07/31/17 9
32. What do you do if you are triggered?
33. Can you pl
ease describe any attempts you have made to either control or cut down on your alcohol and/or drug use?
34. What is th
e longest period of time that you have gone without using alcohol and/or drugs?
35. What helped
and didn’t help?
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
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.
Additional Comments:
Dimension 6: Recovery/Living Environment
36. Do you have any relationships that are supportive of your recovery? (e.g., family, friends)
37. What is yo
ur current living situation (e.g., homeless, living with family/alone)?
38. Do you curre
ntly live in an environment where others are using drugs? ☐ Yes ☐ No
Please describe:
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.
Client Name: _______________________________ Medi-Cal ID:______________________
Treatment Agency: __________________________________________________________
Revised: 07/31/17 10
40. Are you curre
ntly involved in relationships or situations that would negatively impact your recovery? ☐ Yes ☐ No
Please describe:
41. Are you curre
ntly employed or enrolled in school? ☐ Yes ☐ No
Please describe (e.g., where employed, duration of employment, name and type of school):
42. Are you current
ly involved with social services or the legal system (e.g., DCFS, court mandated, probation, parole)?
Please describe: ☐ Yes ☐ No
If on parol
e/probation:
Name of Probation/Parole Officer
Contact Information
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
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.
Addition
al Comments:
39. ☐ Yes ☐ NoAre you currently involved in relationships or situations that pose a threat to your safety?
Please describe:
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.
Client Name: _______________________________ Medi-Cal ID:______________________
Treatment Agency: __________________________________________________________
Revised: 07/31/17 11
Dimension
Severity Rating (Based on Ratings Above)
Rationale
Dimension 1
Substance Use, Acute
Intoxication and/or
Withdrawal Potential
☐
0
☐
1
☐
2
☐
3-4
None
Mild
Moderate
Severe
Dimension 2
Biomedical Condition
and Complications
☐
0
☐
1
☐
2
☐
3-4
None
Mild
Moderate
Severe
Dimension 3
Emotional,
Behavioral, or
Cognitive Condition
and Complications
☐
0
☐
1
☐
2
☐
3-4
None
Mild
Moderate
Severe
Dimension 4
Readiness to Change
☐
0
☐
1
☐
2
☐
3-4
None
Mild
Moderate
Severe
Dimension 5
Relapse, Continued
Use, or Continued
Problem Potential
☐
0
☐
1
☐
2
☐
3-4
None
Mild
Moderate
Severe
Dimension 6
Recovery/Living
Environment
☐
0
☐
1
☐
2
☐
3-4
None
Mild
Moderate
Severe
Summary of Multidimensional Assessment
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.
Client Name: _______________________________ Medi-Cal ID:______________________
Treatment Agency: __________________________________________________________
Revised: 07/31/17 12
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):
Substance Use Disorder Criteria (DSM-5)
Name of Substance(s)
#1:
____________
#2:
____________
#3:
____________
1
Substance often taken in larger amounts or over a longer
period than was intended.
☐ ☐ ☐
2
There is a persistent desire or unsuccessful efforts to cut
down or control substance use.
☐ ☐ ☐
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.
☐
☐
☐
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.
☐ ☐ ☐
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.
☐ ☐ ☐
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.
☐ ☐ ☐
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
*
The presence of at least 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
Diagnosis: Diagnostic Statistical Manual, 5
th
Edition (DSM-5)
Criteria For Substance Use Disorder
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.
Client Name: _______________________________ Medi-Cal ID:______________________
Treatment Agency: __________________________________________________________
Revised: 07/31/17 13
ASAM LEVEL OF CARE DETERMINATION TOOL
Instructions: For each dimension, indicate the least intensive level of care that is appropriate based on the patient’s severity/functioning and service needs.
ASAM Criteria Level of Care-
Withdrawal Management
ASAM
Level
Dimension 1
Substance
Use, Acute Intoxication and/or
Withdrawal Potential
Dimension 2
Biomedical Condition and
Complications
Dimension 3
Emotional, Behavioral, or
Cognitive Condition and
Complications
Dimension 4
Readiness to Change
Dimension 5
Relapse, Continued Use, or
Continued Problem Potential
Dimension 6
Recovery/Living Environment
Severity / Impairment Rating
None
Mild
Mod
Sev
None
Mild
Mod
Sev
None
Mild
Mod
Sev
None
Mild
Mod
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
ASAM Criteria Level of Care- Other Treatment and Recovery Services
Severity / Impairment Rating
None
Mild
Mod
Sev
None
Mild
Mod
Sev
None
Mild
Mod
Sev
None
Mild
Mod
Sev
None
Mild
Mod
Sev
None
Mild
Mod
Sev
Early Intervention
0.5
Consider referral to mental health facility
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
ASAM Criteria Level of Care- Other Treatment and Recovery Services
Severity / Impairment Rating
None
Mild
Mod
Sev
None
Mild
Mod
Sev
None
Mild
Mod
Sev
None
Mild
Mod
Sev
None
Mild
Mod
Sev
None
Mild
Mod
Sev
Opioid Treatment Program
OTP
Would the patient with alcohol or opioid use disorders benefit from and be interested in Medication-Assisted Treatment (MAT)?
☐
Yes
☐
No Please describe:
___________________________________________________________________________________________________________________________________
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.
Client Name: _______________________________ Medi-Cal ID:______________________
Treatment Agency: __________________________________________________________
Revised: 07/31/17 14
L
evel 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 patient’s current severity and functioning:
L
evel 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):
Rea
son for Discrepancy:
☐ Not Applicable ☐ Service Not Available ☐ Provider Judgment ☐ Patient Preference
☐ Transportation ☐ Accessibility ☐ Financial ☐ Preferred to Wait
☐ Language/ Cultural Considerations ☐ Environment ☐ Mental Health ☐ Physical Health
☐ Other: __________________________________________
Briefly Explain Discrepancy:
D
esignated Treatment Location and Provider Name:
__
___________________________________________________________________________________________________
Counselor Name (if applicable) Signature Date
__
___________________________________________________________________________________________________
Licensed-eligible LPHA Name (if applicable) Signature Date
__
___________________________________________________________________________________________________
*Licensed LPHA Name Signature Date
Licensed-eligible LPHA’s are psychological assistants, associate social workers (ASWs), marriage and therapy family interns (MFTI/IMFT),
professional clinical counselor interns (PCCIs).
A Licensed LPHA is required to sign the ASAM assessment. Licensed LPHA (Licensed Practitioner of the Healing Arts) includes: Physicians,
Nurse Practitioners, Physician Assistants, Registered Nurses, Registered Pharmacists, Licensed Clinical Psychologists (LCPs), Licensed
Clinical Social Workers (LCSWs), Licensed Professional Clinical Counselors (LPCCs), and Licensed Marriage and Family Therapists (LMFTs).
Placement Summary
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LOS ANGELES COUNTY ASSESSMENT TOOL- ADULTS (PAPER VERSION) (County of Los Angeles Internal Services Department)

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Completed 31 August 2021

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