Footprints Consulting Services, LLC
ASAM CRITERIA
ADMISSION
Client Name:Kathleen
Presenting Problems: ______
______
DIMENSION I: Acute Intoxication and/or Withdrawal Potential
Evidence of Withdrawal (include vitals): none: ___ yes: ______
______
History of Withdrawal: none: ___ yes: ______
Quantity of Alcohol, Barbiturates, Benzodiazapines alone or in combination in the last 30 days: ______
______Last use/amount: ______
______
Current use of: Cocaine ___ Opiates ___ Hallucinogens ___ Marijuana ___ Stimulants ___ Methadone ___ Inhalants ___ Last use/amount: ______
______
Comments: ______
______
Severity Rating: None ___ Low ___ Moderate ___ High ___ Critical ___
DIMENSION II: Biomedical Condition/Complications
Acute or chronic unresolved medical conditions: none: ___ yes______
______
Alcohol/Drug related Emergency Room visits: none: ___ yes: ______
______
Medical medication:
NameDosagePurposeDate of last dosage
______
Physical Disability: none: ___ yes: ______
Comments: ______
______
Severity Rating: None ___ Low ___ Moderate ___ High ___ Critical ___
DIMENSION III: Emotional/Behavioral/Cognitive Conditions and Complications
Current emotional/behavioral stressors: none: ___ yes: ______
______
Behavioral risk to self or others: none: ___ yes: ______
Previous Mental Health Treatment: none: ___ yes: ______
______
History of Violent Behavior: none: ___ yes: ______
Serious Suicidal Thoughts/Behaviors: Past: none: ____ yes ______
Summary Page 2
Current: none:____ yes: ______
Does client have plan and means? No ___ yes ______
______
Who does the client go to for support? ______
Evidence of poor impulse control? No ___ Yes ______
Psychiatric Medications: (Current or Past)
NameDosagePurposeDate of last dosage
______
Comments: ______
______
Severity Rating: None ___ Low ___ Moderate ___ High ___ Critical ___
DIMENSION IV: Treatment Resistance/Acceptance/Readiness to Change
Acknowledges a need for alcohol treatment: yes:___ no: ___ drug treatment: yes: ___ no: ___
Ambivalent towards treatment: No: ___ Yes: ______
Acknowledges importance of treatment for all substances of abuse: yes: ___ not for: ______
Crisis events influencing motivation, i.e. legal, employment, family, etc.: ______
Prior attempts at recovery (with or without help): none: ___ yes: ______
Comments: ______
______
Severity Rating: None ___ Low ___ Moderate ___ High ___ Critical a ___ b ___
(High rating indicates resistance)
DIMENSION V: Relapse/Continued Problem or Use Potential
Potential for continued use: low: ___ moderate: ____ high: ______
Current relapse stressors: ______
______
Consequences if use continues (according to client): ______
Recognizes using triggers: yes: ___ no: ___
Rationalizations surrounding chemical use: ______
Relapse prevention strategies used (present/past): ______
______
Comments: ______
______
Severity Rating: None ___ Low ___ Moderate ___ High ___ Critical a ___ b ___
DIMENSION VI: Recovery Environment (Dangers posing a threat to treatment engagement)
Current family stressors/support: ______
______
Current chemical use by others in the home: none: ____ yes: ______
Stable living environment: yes: ___ no: ______
Social support; i.e.: AA, Church, Vocational, etc.: ______
______
Appropriate available transportation to treatment: yes: ___ no: ______
Comments: ______
______
Severity Rating: None ___ Low ___ Moderate ___ High ___ Critical a ___ b ___
Summary Page 3
Diagnosis: ______
Identified Problems: ______
______
______
______
______
Recommendations: ASAM Placement Level:
Level I ____ Outpatient Level III.5 ____ High Intensity Residential
Level II.1 ____ Intensive OutpatientLevel III.7 ____ Medically Monitored Residential
Level II.5 ____ Partial HospitalizationLevel III.2D____ Inpatient/Social Detoxification
Level III.1 ____ Halfway HouseLevel III.7D____ Medical Managed Detoxification
Level III.3 ____ Medium Intensity ResidentialLevel IV-D ____ Detoxification–Hospital Based
Wrap Around Services:______
______
______
Recommendations:______
______
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