/ State of Oregon
OREGON YOUTH AUTHORITY
ASSESSMENT FOR
DRUG AND ALCOHOL SERVICES
(Attach to Initial Assessment for General Therapy Services YA 6010 A)
Provider Name: / Youth Name:
JPPO Name: / Youth’s JJIS #:

Substance Abuse History

Primary drug of choice:
Second drug of choice:
Age at Onset / Method of Administration / Use / Level / ATOD
Non use
Experimental
Habitual
Abusive
Chemically Dependent / Nicotine (cigarettes, pipe & chewing tobacco, cigars, etc.)
Non use
Experimental
Habitual
Abusive
Chemically Dependent / Alcohol
Non use
Experimental
Habitual
Abusive
Chemically Dependent / Marijuana / Hashish
Non use
Experimental
Habitual
Abusive
Chemically Dependent / Hallucinogens / Psychedelics (Mushrooms, LSD, Ecstasy, PCP, Ketamine)
Non use
Experimental
Habitual
Abusive
Chemically Dependent / Inhalants
Non use
Experimental
Habitual
Abusive
Chemically Dependent / Crack / Freebase
Non use
Experimental
Habitual
Abusive
Chemically Dependent / Heroin and Cocaine (Speedball)
Non use
Experimental
Habitual
Abusive
Chemically Dependent / Cocaine
Non use
Experimental
Habitual
Abusive
Chemically Dependent / Heroin
Non use
Experimental
Habitual
Abusive
Chemically Dependent / Opiates & Opiods (Opium, Morphine, Methadone, Codeine, Demerol, hydrocodone, oxycodone, Dilaudid, Fentanyl)
Non use
Experimental
Habitual
Abusive
Chemically Dependent / Methamphetamines
Non use
Experimental
Habitual
Abusive
Chemically Dependent / Amphetamines
(Adderall, Ritalin, diet pills, ephedra, etc.)
Non use
Experimental
Habitual
Abusive
Chemically Dependent / Sedative-Hypnotics
(GHB, Rohypnol, Barbiturates, Benzodiazepines, etc.)
Non use
Experimental
Habitual
Abusive
Chemically Dependent / OTC drugs
(Cough syrup, etc.)
Non use
Experimental
Habitual
Abusive
Chemically Dependent / Other (specify):

Has youth been involved in treatment for drug/alcohol problems? Yes No

Where did the treatment occur? What type of treatment was it?

DISTRIBUTION: ORIGINAL – Provider (for their records in accordance with contract standards for retention)
COPY TO – OYA JPPO/Juvenile Court Worker (whichever is appropriate) and OYA Contract Administrator
Restricted Information / Page 3
YA 6010 B REV 8/10
DISTRIBUTION: ORIGINAL – Provider (for their records in accordance with contract standards for retention)
COPY TO – OYA JPPO/Juvenile Court Worker (whichever is appropriate) and OYA Contract Administrator
Restricted Information / Page 3
YA 6010 B REV 8/10

Did youth complete the treatment? What was the outcome?
(Get youth’s signature for release of information, if relevant)

DISTRIBUTION: ORIGINAL – Provider (for their records in accordance with contract standards for retention)
COPY TO – OYA JPPO/Juvenile Court Worker (whichever is appropriate) and OYA Contract Administrator
Restricted Information / Page 3
YA 6010 B REV 8/10
DISTRIBUTION: ORIGINAL – Provider (for their records in accordance with contract standards for retention)
COPY TO – OYA JPPO/Juvenile Court Worker (whichever is appropriate) and OYA Contract Administrator
Restricted Information / Page 3
YA 6010 B REV 8/10

Summary and Clinical formulation: (Use ASAM standards and criteria for this formulation.)

DISTRIBUTION: ORIGINAL – Provider (for their records in accordance with contract standards for retention)
COPY TO – OYA JPPO/Juvenile Court Worker (whichever is appropriate) and OYA Contract Administrator
Restricted Information / Page 3
YA 6010 B REV 8/10
DISTRIBUTION: ORIGINAL – Provider (for their records in accordance with contract standards for retention)
COPY TO – OYA JPPO/Juvenile Court Worker (whichever is appropriate) and OYA Contract Administrator
Restricted Information / Page 3
YA 6010 B REV 8/10

Recommendation for services:

DISTRIBUTION: ORIGINAL – Provider (for their records in accordance with contract standards for retention)
COPY TO – OYA JPPO/Juvenile Court Worker (whichever is appropriate) and OYA Contract Administrator
Restricted Information / Page 3
YA 6010 B REV 8/10
DISTRIBUTION: ORIGINAL – Provider (for their records in accordance with contract standards for retention)
COPY TO – OYA JPPO/Juvenile Court Worker (whichever is appropriate) and OYA Contract Administrator
Restricted Information / Page 3
YA 6010 B REV 8/10
Provider Signature: / Date:
Date document discussed with youth:
Date document provide to JPPO:
Via: Fax Email Postal Service Other:
DISTRIBUTION: ORIGINAL – Provider (for their records in accordance with contract standards for retention)
COPY TO – OYA JPPO/Juvenile Court Worker (whichever is appropriate) and OYA Contract Administrator
Restricted Information / Page 3
YA 6010 B REV 8/10