Full Asam Assessment - Adult

Full Asam Assessment - Adult

Demographic Information
Name: Date: Phone Number:
Amy X
Address: 123 Main At
DOB: xx/xx/1994 Age: 27 Gender: Female
Race/Ethnicity: Preferred Language: English
Pay Source(s) ☐Self ☐Medicare (Plan) ☒Medi-Cal (Plan) ☐Private Ins (Plan) ☐County ☐ Other ______
Any Medi-Cal or Insurance Plan ID# (identify):
Living Arrangement: ☐Undomiciled ☐ Independent Living ☒Other (specify) Lives with Mother
Referred by:Referral from MAT program

Explanation of why client is currently seeking treatment:

Amy has a 5 yr history of opioid use, beginning with prescription opioids and progressing to mixed prescription and heroin use. She has attempted multiple programs to try and manage her use and despite these attempts and escalating harmful consequences (loss of employment and independent housing), she continues to use. She entered a MAT program several weeks ago and is currently stabilized on 8 mg Buprenorphine. She was referred to services to address the behavioral aspects of her drug use.
  1. Substance Use History

Alcohol or Other Drug / Used past 6 months? / Prior use?
(lifetime) / Route of
Administration / Frequency
(past 6 mo.) / Duration
(of use) / Time since last use
Alcohol / ☒ / ☐ / Oral / 1-2x’s mo. / 6 yrs. / 2 wks.
Amphetamines / ☐ / ☐
Cocaine / ☐ / ☐
Heroin / ☒ / ☐ / Inject/Smoke / 3-4x’s week / 4 yrs. / 14 days
Other Opioids: list / ☒ / ☐ / Oxycodone / Daily / 5 yrs. / 14 days
Marijuana / ☐ / ☒ / Smoke / None / 4.5yrs.
Sedatives: list / ☐ / ☐
Hallucinogens / ☐ / ☐
Inhalants / ☐ / ☐
Over the Counter Med’s- list / ☒ / ☐ / NSAD’s / Daily / 5 yrs. / 2 days
Nicotine / ☒ / ☐ / Smoke / Daily / 8 yrs. / today
Other: / ☐ / ☐

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Dimension 4: Readiness to Change
  1. Is your alcohol and/or other drug use affecting any of the following?

☒Work☐ Mental Health☐ Physical Heath☒Finances

☐ School☒Relationships ☐Sexual activity☐ Legal Matters

☒Self-Esteem☐ Hygiene☐Recreation☐handling everyday tasks

  1. Do you continue to use alcohol and/or other drugs despite having it affect the area(s) above?

Describe:Yes, I’ve lost everything behind oxy and I still want it (to use the drug)
  1. Have you received help for alcohol and/or drug problems in the past? ☒Yes ☐No

Provider’s Name / When / Modality/Outcome
XYZ outpatient / 4 years ago; again 2 years ago / OP- stayed 2 months first time; 1 week second time
ABC Residential / 3 yrs. ago / Residential- stayed 5 days
We work / 1 yrs. ago / Residential- stayed 3 days
New Life Detox / Two weeks ago / Completed 8 days detox
Suburban Clinic / Present time / On MAT
  1. On a scale of 1-10 (10 being very important; 1 not important at all) how important is it for you to get support for your recovery?

Describe:I can’t do it alone. I really need help. It’s about an 8 or so
  1. What would help to support your recovery? What are your concerns about recovery?

Describe:Getting back to work and my own place to live.
  1. What are potential barriers to your recovery (e.g., financial, transportation, relationships, etc.)?

Describe:I don’t have any money or a car. I don’t know where to start. Mostly I just get frustrated and give up.
Severity Rating Dimension 4
1
Mild
Rationale: Amy demonstrates motivation by repeated attempts to address her SU, present engagement in MAT, and insight into many of the harmful consequences of her use. She is clear, however, that unless her pain can be managed she won’t stay in treatment. She has a history of engaging in treatment but not staying. Her longest time in treatment and with any recovery was when she was also using MAT with OP therapy.
PROBLEM STATEMENTS / Indicator(s)
Dimension 5: Relapse, Continuing Use or Continued Problem Potential
  1. In the last 30 days, how often have you experienced cravings, withdrawal symptoms, or disturbing effects of your use?

Alcohol: ☒None ☐Occasionally ☐Frequently ☐Constantly

Drug(s): ☐None ☐Occasionally ☐Frequently ☒Constantly

Describe:I can go a couple of hours then I start to get sick and really have to have get something. The buprenorphine is helping that, I’m not craving so bad. It worked for me before too.
  1. Do you find yourself spending time searching for alcohol and/or drugs, or trying to recover from its effects? ☒Yes ☐No

If Yes, describe:That’s my life.
  1. Do you feel you will continue to either relapse or continue to use without treatment or additional support? ☒Yes ☐No

If Yes, describe:I think I can do good on the buprenorphine but I was on it before and started thinking I could do it on my own. I’ve got to watch out and not do that again. I’ve tried those meeting (A.A.) but they just talk about alcohol and that didn’t help me and my craving—the N.A. meetings just triggered me.
  1. Are you aware of your triggers to use alcohol and/or drugs? ☒Yes ☐No ☐Somewhat

--Please check of any of the following which you know are triggers for you:

☒Strong Cravings☐Work/School Pressure☐Mental Health☒Relationship problems

☒Difficulty with feelings☒Financial Stress☐Physical Health ☒My environment

☒Unemployment☒Chronic Pain☐Peer Pressure

☐Other:

  1. What do you typically do if you are triggered?

Describe:Usually I find a way to get some dope and go use—if I can’t get anything then I feel really sick and just try and sleep it off. That really doesn’t work so I just jones.
  1. Have you ever tried to control your use (stop or “cut down”)? ☒Yes ☐No

If Yes, describe:I’ve been trying this for almost 5 years
  1. What is the longest period of time that you have gone without using alcohol and/or other drugs:

Describe (include what substance, dates, and duration):I stopped for a week or so on my own; I do that once in a while. I stopped for a couple of months when I was in that program last year. I was on the buprenorphine then too.
  1. If you have had times when you were able to go without using alcohol and/or other drugs, what helped you to do this? What things didn’t help?

Describe:I had a good friend trying to stop with me but mostly it was having the other medication, the buprenorphine.
Severity Rating Dimension 5
3
Severe
Rationale: Amy has some insight and understanding of her use/relapse issues but describes a very limited ability to manage either her exposure or response to triggers to use. She knows some recovery skills but does not seem to have functional use of them and shows a poor ability to cope with both the compulsion to use and the harmful consequences that follow. She reports spending a lot of time using or recovering from use; also, trying to cut down or control use without success.
PROBLEM STATEMENTS / Indicator(s)
Dimension 6: Recovery/Living Environment
  1. Do you have any relationships that are supportive of your recovery? (e.g., family, friends)

Describe:My sister is really supportive. I think I want to do this more for her than myself. My mom tries to help but mostly she get either mad or frustrated and depressed. It hurts me that I disappoint and hurt her so much.
  1. What is your current living situation? (e.g., homeless, living with family)

Describe:I live in a little place with my mom and my sister. I have to either sleep on the couch or in the little bed with my sister. We have other family that just comes in and stays there sometimes too. It’s pretty crazy.
  1. Do you currently live where others drink alcohol and/or use drugs? ☒Yes ☐No

Describe:My mom or sis don’t drink, but I’ve got uncles who come over and get pretty lit up. They don’t use though so that’s not too bad.
  1. Are you currently involved in relationships or situations that pose a threat to your safety?

☐Yes ☒No

If yes, describe: I was but I cut it off and haven’t seen him for a couple of weeks. It’s all good now, I’m better off without him.
  1. Are you currently involved in relationships or situations that could negatively affect your recovery?

☐Yes ☒No

If yes, describe:
  1. How do you spend your free time? (e.g., interests; activities; recreation)

Describe:I don’t have money for anything so I don’t do anything. We’ve got a TV, but no cable so even that’s pretty boring. I go out and walk around, see some old work friends when I can.
  1. What was your family’s religious or spiritual practice when you were growing up?

☒Catholic ☐Protestant ☐Christian ______☐Jewish ☐Muslim ☐None☐Other: ______

Is this still your preference: ☒Yes ☐No

Comments:I don’t really want to talk about the “God thing” and recovery, thanks!
  1. What are your family or cultural belief’s about alcoholism or addiction?

Describe:It would be okay if I was a guy. My mom thinks I’ve shamed the family forever.
  1. When you think about what you have accomplished with your education or training you are:

☐Satisfied ☐Dissatisfied ☒Neither

Describe:I’m happy I got my B.A. but I haven’t done anything with it so it’s not been a big deal
  1. When you think about what you have accomplished with your work/employment, you are:

☐Satisfied ☐Dissatisfied ☒Neither

Describe:I’d be more dissatisfied if I didn’t know I have some skills and I can work—it’s the pain and the drugs that knocked me out of work. I’d like to go back but I’ve got to get straight and I’ve got to be able to be able to work 8 hours without being in agony.
  1. Are you currently involved with social services or the legal system? (court mandated, probation, etc.)

☐Yes ☒No

If yes, describe:No history of involvement with social services or other than minor legal issues (parking tickets, etc.)

If you are on parole/probation:No

Name of Probation/Parole Officer / Contact Information
Severity Rating Dimension 3
1
Mild
Rationale: Amy has housing, albeit with some conflict (space and relationships), but also with some support—some active, most passive. There is concern about the recent relationship which she says is “over” but may linger as a recovery issue. She has a good education and job skills but feels she can’t or doesn’t know how to use them while in her present state of chronic pain and needing SU recovery. She lacks a clear recovery environment (social and community) and uses isolation as a primary coping skill. She does not have any current or historical legal problems. She relies on public transportation to get around. She clearly embraces her culture and it is very important to her but she does not see how her culture can embrace and support her as a recovering woman.

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PROBLEM STATEMENTS / Indicator(s)

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Representative to which it pertains unless otherwise permitted

By law.Client Name:

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