ࡱ>  {bjbj A0J 8SlK#*[M(MMMPjEi AtKMMMMMM0M~PP@~~MMMb~MMK~K6Mpw4_k7x0d8yd%{#||yyyMMwjyyy~~~~yyyyyyyyy :   {AGENCY NAME} SAMPLE ADULT CHEMICAL DEPENDENCY ASSESSMENT Patient Name: __________________________________________________________ Date____________________________ I voluntarily consent to assessment of my involvement with alcohol or other drugs. I affirm that the information I give is truthful and complete. Patient Signature: _______________________________________________________________________________DIMENSION 1: ACUTE INTOXICATION AND/OR WITHDRAWAL POTENTIALA. Current Signs and Symptoms of Withdrawal (DSM-IV TR) FORMCHECKBOX  Alcohol Withdrawal Must meet all 4 Criteria to be considered withdrawal  FORMCHECKBOX  Cessation of (or reduction in) alcohol use that has been heavy and prolonged.  FORMCHECKBOX  Two (or more) of the following, developing within a several hours to a few days after Criteria A (above) check at least two if present:  FORMCHECKBOX  (1) Autonomic hyperactivity (e.g. sweating or pulse rate greater than 100),  FORMCHECKBOX  (2) increased hand tremor,  FORMCHECKBOX  (3) insomnia,  FORMCHECKBOX  (4) nausea or vomiting,  FORMCHECKBOX  (5) transient visual, tactile, or auditory hallucinations or illusions,  FORMCHECKBOX  (6) psychomotor agitation,  FORMCHECKBOX  (7) anxiety,  FORMCHECKBOX  (8) grand mal seizures  FORMCHECKBOX  Symptoms in Criteria B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.  FORMCHECKBOX  The symptoms are not due to a general medical condition and are not better accounted for by another medical disorder. FORMCHECKBOX  Amphetamine Withdrawal Must meet all 4 Criteria to be considered withdrawal  FORMCHECKBOX  Cessation of (or reduction in) amphetamine (or a related substance) use that has been heavy and prolonged.  FORMCHECKBOX  Dysphoric mood and two (or more) of the following physiological changes, developing within a few hours to several days after Criteria A  FORMCHECKBOX  (1) fatigue,  FORMCHECKBOX  (2) vivid, unpleasant dreams,  FORMCHECKBOX  (3) insomnia or hypersomnia,  FORMCHECKBOX  (4) increased appetite,  FORMCHECKBOX  (5) psychomotor retardation or agitation  FORMCHECKBOX  Symptoms in Criteria B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.  FORMCHECKBOX  The symptoms are not due to a general medical condition and are not better accounted for by another medical disorder. FORMCHECKBOX  Cocaine Withdrawal Must meet all 4 Criteria to be considered withdrawal  FORMCHECKBOX  Cessation of (or reduction in) cocaine use that has been heavy and prolonged.  FORMCHECKBOX  Dysphoric mood and two (or more) of the following physiological changes, developing within a few hours to several days after Criteria A  FORMCHECKBOX  (1) fatigue,  FORMCHECKBOX  (2) vivid, unpleasant dreams,  FORMCHECKBOX  (3) insomnia or hypersomnia,  FORMCHECKBOX  (4) increased appetite,  FORMCHECKBOX  (5) psychomotor retardation or agitation  FORMCHECKBOX  Symptoms in Criteria B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.  FORMCHECKBOX  The symptoms are not due to a general medical condition and are not better accounted for by another medical disorder. FORMCHECKBOX  Nicotine Withdrawal Must meet all 4 Criteria to be considered withdrawal  FORMCHECKBOX  Daily use of nicotine for at least several weeks.  FORMCHECKBOX  Abrupt cessation of nicotine use, or reduction in the amount of nicotine used, followed within 24 hours by four (or more) of the following signs:  FORMCHECKBOX  (1) dysphoric or depressed mood,  FORMCHECKBOX  (2) insomnia,  FORMCHECKBOX  (3) irritability, frustration, or anger,  FORMCHECKBOX  (4) anxiety,  FORMCHECKBOX  (5) difficulty concentrating,  FORMCHECKBOX  (6) restlessness,  FORMCHECKBOX  (7) decreased heart rate,  FORMCHECKBOX  (8) increased appetite or weight gain  FORMCHECKBOX  Symptoms in Criteria B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.  FORMCHECKBOX  The symptoms are not due to a general medical condition and are not better accounted for by another medical disorder.  FORMCHECKBOX  Opioid Withdrawal Must meet all 4 Criteria to be considered withdrawal  FORMCHECKBOX  Either one of the following:  FORMCHECKBOX  (1) cessation of (or reduction in) opioid use that has been heavy and prolonged (several weeks or longer)  FORMCHECKBOX  (2) administration of an opioid antagonist after a period of opioid use  FORMCHECKBOX  Three (or more) of the following, developing within minutes to several days after Criteria A (above):  FORMCHECKBOX  (1) dysphoric mood,  FORMCHECKBOX  (2) nausea or vomiting,  FORMCHECKBOX  (3) muscle aches,  FORMCHECKBOX  (4) lacrimation or rhinorrhea (runny nose),  FORMCHECKBOX  (5) pupillary dilation, piloerection (skin hair standing on end), or sweating,  FORMCHECKBOX  (6) diarrhea,  FORMCHECKBOX  (7) yawning,  FORMCHECKBOX  (8) fever,  FORMCHECKBOX  (9) insomnia  FORMCHECKBOX  Symptoms in Criteria B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.  FORMCHECKBOX  The symptoms are not due to a general medical condition and are not better accounted for by another medical disorder. FORMCHECKBOX  Sedative, Hypnotic or Anxiolytic Withdrawal Must meet all 4 Criteria to be considered withdrawal  FORMCHECKBOX  Cessation of (or reduction in) sedative, hypnotic or anxiolytic use that has been heavy and prolonged.  FORMCHECKBOX  Two (or more) of the following, developing within several hours to a few days after Criteria A  FORMCHECKBOX  (1) Autonomic hyperactivity (e.g. sweating or pulse rate greater than 100),  FORMCHECKBOX  (2) increased hand tremor,  FORMCHECKBOX  (3) insomnia,  FORMCHECKBOX  (4) nausea or vomiting,  FORMCHECKBOX  (5) transient visual, tactile, or auditory hallucinations or illusions,  FORMCHECKBOX  (6) psychomotor agitation,  FORMCHECKBOX  (7) anxiety,  FORMCHECKBOX  (8) grand mal seizures  FORMCHECKBOX  Symptoms in Criteria B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.  FORMCHECKBOX  The symptoms are not due to a general medical condition and are not better accounted for by another medical disorder.B. Withdrawal/Tolerance HistoryHave you ever been admitted to a Detoxification Facility for withdrawal from alcohol or other drugs?  FORMCHECKBOX  FORMCHECKBOX No  FORMCHECKBOX  Yes Detox Date(s)___________________________ Where? __________________________ Drug? ____________________________ Detox Date(s)___________________________ Where? __________________________ Drug? ____________________________ Detox Date(s)___________________________ Where? __________________________ Drug? ____________________________ If No, Where did the withdrawals occur?  FORMCHECKBOX  FORMCHECKBOX  Home  FORMCHECKBOX  Jail  FORMCHECKBOX  FORMCHECKBOX  Hospital ___________________  FORMCHECKBOX  Other____________________ Have you ever used a substance to relieve or avoid withdrawals?  FORMCHECKBOX No  FORMCHECKBOX  Yes if so, which substance? _________________________ Have you noticed it takes more of a given substance to get the same results as before?  FORMCHECKBOX  No  FORMCHECKBOX  Yes _________________________ Have you noticed less of an effect from a given substance than you used to get before?  FORMCHECKBOX  No  FORMCHECKBOX  Yes _________________________ Dimension 1 - Risk Rating (from PPC-2R - Appendix A): 4  FORMCHECKBOX  Incapacitated with severe signs and symptoms of withdrawal.  FORMCHECKBOX  FORMCHECKBOX  Severe withdrawal presents danger (e.g. seizures).  FORMCHECKBOX  Continued use poses an imminent threat to life. 3  FORMCHECKBOX  FORMCHECKBOX  Demonstrates poor ability to tolerate and cope with withdrawal discomfort.  FORMCHECKBOX  Severe signs and symptoms of intoxication indicate patient may pose an imminent danger to self and others.  FORMCHECKBOX  FORMCHECKBOX  Severe signs and symptoms or risk of severe but manageable withdrawal, or withdrawal is worsening despite detoxification at a less intensive level of care. 2  FORMCHECKBOX  Some difficulty tolerating and coping with withdrawal discomfort.  FORMCHECKBOX  Intoxication may be severe but responds to treatment so patient does not pose imminent danger to self or others.  FORMCHECKBOX  Moderate signs and symptoms, with moderate risk of severe withdrawal. 1  FORMCHECKBOX  FORMCHECKBOX  Demonstrates adequate ability to tolerate and cope with withdrawal discomfort.  FORMCHECKBOX  Mild to moderate intoxication or withdrawal signs and symptoms interfere with daily functioning, but do not pose imminent danger to self or others.  FORMCHECKBOX  FORMCHECKBOX  Minimal risk of severe withdrawal. 0  FORMCHECKBOX  FORMCHECKBOX  Fully functioning. Demonstrates good ability to tolerate and cope with withdrawal discomfort.  FORMCHECKBOX  No signs or symptoms of intoxication or withdrawal are present, or signs/symptoms, if present, are resolving. Recommended ASAM Level of Care for Dimension 1 Acute Intoxication/Withdrawal Potential:  FORMCHECKBOX  FORMCHECKBOX  No Detoxification services indicated  FORMCHECKBOX  Level III.2D Clinically Managed Residential Detoxification (Sub-acute)  FORMCHECKBOX  FORMCHECKBOX  Level III.7D Medically Managed Residential Detoxification (Acute)CDP Summary Interpreting Dimension 1 Data: DO NOT LEAVE BLANK  DIMENSION 2: BIOMEDICAL CONDITIONS AND COMPLICATIONS1. Which of the following medical conditions do you currently have, or have had in the past? TREATED UNTREATED  FORMCHECKBOX  Anemia or blood disorder  FORMCHECKBOX  FORMCHECKBOX ............. FORMCHECKBOX   FORMCHECKBOX  FORMCHECKBOX  Rheumatic or scarlet fever  FORMCHECKBOX ............. FORMCHECKBOX  FORMCHECKBOX   FORMCHECKBOX  Chest pains  FORMCHECKBOX  FORMCHECKBOX ............. FORMCHECKBOX   FORMCHECKBOX  FORMCHECKBOX  Fainting spells  FORMCHECKBOX ............. FORMCHECKBOX  FORMCHECKBOX   FORMCHECKBOX  Kidney disease or bladder infection  FORMCHECKBOX  FORMCHECKBOX ............. FORMCHECKBOX   FORMCHECKBOX  FORMCHECKBOX  Liver disease-hepatitis or jaundice  FORMCHECKBOX ............. FORMCHECKBOX  FORMCHECKBOX   FORMCHECKBOX  Cancer-Type ___________________  FORMCHECKBOX  FORMCHECKBOX ............. FORMCHECKBOX   FORMCHECKBOX  FORMCHECKBOX  Diabetes  FORMCHECKBOX ............. FORMCHECKBOX   FORMCHECKBOX  High or low blood sugar  FORMCHECKBOX  FORMCHECKBOX ............. FORMCHECKBOX   FORMCHECKBOX  FORMCHECKBOX  Tuberculosis ............................................... FORMCHECKBOX ............. FORMCHECKBOX  Last Test Date ___________ Test results: ___________  FORMCHECKBOX  Ulcers or pains in the stomach  FORMCHECKBOX  FORMCHECKBOX ............. FORMCHECKBOX   FORMCHECKBOX  FORMCHECKBOX  Epilepsy  FORMCHECKBOX ............. FORMCHECKBOX   FORMCHECKBOX  Heart trouble  FORMCHECKBOX  FORMCHECKBOX ............. FORMCHECKBOX   FORMCHECKBOX  FORMCHECKBOX  Shortness of breath  FORMCHECKBOX ............. FORMCHECKBOX  FORMCHECKBOX  TREATED UNTREATED  FORMCHECKBOX  High or low blood pressure  FORMCHECKBOX  FORMCHECKBOX .............. FORMCHECKBOX   FORMCHECKBOX  FORMCHECKBOX  Chronic Pain  FORMCHECKBOX  . FORMCHECKBOX  FORMCHECKBOX   FORMCHECKBOX  Glaucoma  FORMCHECKBOX  FORMCHECKBOX .............. FORMCHECKBOX   FORMCHECKBOX  FORMCHECKBOX  Allergies (food or drug)  FORMCHECKBOX .............. FORMCHECKBOX  If yes, to what: _____________________  FORMCHECKBOX  Physical injury  FORMCHECKBOX  FORMCHECKBOX .............. FORMCHECKBOX  If yes, what: ___________________________________  FORMCHECKBOX  FORMCHECKBOX  Venereal disease  FORMCHECKBOX  . FORMCHECKBOX  FORMCHECKBOX   FORMCHECKBOX  Other:  FORMCHECKBOX  FORMCHECKBOX  .............. FORMCHECKBOX  FOR FEMALES:  FORMCHECKBOX  FORMCHECKBOX  Menopause or menopausal  FORMCHECKBOX .............. FORMCHECKBOX   FORMCHECKBOX  Pre Menstrual Syndrome  FORMCHECKBOX  FORMCHECKBOX .............. FORMCHECKBOX   FORMCHECKBOX  FORMCHECKBOX  Pregnancy:  FORMCHECKBOX  Suspected  FORMCHECKBOX   FORMCHECKBOX  Confirmed Number of months: _______________ Referred to First Steps?  FORMCHECKBOX  No  FORMCHECKBOX   FORMCHECKBOX  Yes2. Have these, or any other medical conditions been impacted by your use of alcohol or other drugs?  FORMCHECKBOX  No  FORMCHECKBOX  FORMCHECKBOX  Yes Have you continued to use a substance despite knowing it has caused or worsened a medical condition?  FORMCHECKBOX  No  FORMCHECKBOX  Yes If Yes, what condition and in what manner? ______________________________________________________________________3. Have you ever had any surgeries or been hospitalized?  FORMCHECKBOX  No  FORMCHECKBOX   FORMCHECKBOX Yes If yes, Why? ____________________________ Where? ______________________________ When?_________________________ Why? ____________________________ Where? ______________________________ When?_________________________ Why? ____________________________ Where? ______________________________ When?_________________________ Were any of these related to your use of alcohol or other drugs?  FORMCHECKBOX  No  FORMCHECKBOX  FORMCHECKBOX  Yes, if so, how? _____________________________4. Do you have access to medical care?  FORMCHECKBOX  No  FORMCHECKBOX  FORMCHECKBOX  Yes Provider Name _____________________________________________ Physicians name:_____________________________________ City:_______________________________ State:________5. Do you routinely access medical care?  FORMCHECKBOX  No  FORMCHECKBOX  FORMCHECKBOX  Yes Last saw a doctor for: ___________________________ Date: ______________ Outcome: ___________________________6. Are you currently taking any prescription medications?  FORMCHECKBOX  No  FORMCHECKBOX  FORMCHECKBOX Yes If Yes: Name of Medication:_______________________ Dose ______________________ Prescribed by:________________________ Name of Medication:_______________________ Dose ______________________ Prescribed by:________________________ Name of Medication:_______________________ Dose ______________________ Prescribed by:________________________7. Current physical illnesses, other than withdrawal, that need to be addressed or which may complicate treatment (from checklist): _______________________________________________________________________________________________________8. How would you describe your physical health?  FORMCHECKBOX  Poor  FORMCHECKBOX  FORMCHECKBOX  Average  FORMCHECKBOX  Good  FORMCHECKBOX  FORMCHECKBOX  Excellent9. Counselors observation of patients physical health:  FORMCHECKBOX  Poor  FORMCHECKBOX  FORMCHECKBOX  Average  FORMCHECKBOX  Good  FORMCHECKBOX  FORMCHECKBOX  ExcellentRisk Rating for Dimension 2 (from PPC-2R - Appendix A): 4  FORMCHECKBOX  Incapacitated, with severe medical problems. 3  FORMCHECKBOX  Demonstrates poor ability to tolerate and cope with physical problems and/or general health is poor.  FORMCHECKBOX  FORMCHECKBOX  Has a serious medical problem he/she neglects during outpatient or intensive outpatient treatment.  FORMCHECKBOX  Severe medical problems are present but stable. 2  FORMCHECKBOX  FORMCHECKBOX  Some difficulty tolerating and coping with physical problems and/or has other biomedical problems.  FORMCHECKBOX  Has a biomedical problem, which may interfere with recovery treatment.  FORMCHECKBOX  FORMCHECKBOX  Neglects to care for serious biomedical problems.  FORMCHECKBOX  Acute, non-life threatening medical signs and symptoms are present. 1  FORMCHECKBOX  Demonstrates adequate ability to tolerate and cope with physical discomfort.  FORMCHECKBOX  FORMCHECKBOX  Mild to moderate signs or symptoms interfere with daily functioning.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 0  FORMCHECKBOX  Fully functioning and demonstrates adequate ability to tolerate or cope with physical discomfort.  FORMCHECKBOX  FORMCHECKBOX  No biomedical signs or symptoms are present, or biomedical problems are stable.  FORMCHECKBOX  No biomedical conditions that will interfere with treatmentRecommended ASAM Level of Care for Dimension 2 Biomedical Conditions/Complications  FORMCHECKBOX  No immediate biomedical services are needed. Does not affect the placement decision.  FORMCHECKBOX  Level I.0 Outpatient referral to medical primary care  FORMCHECKBOX  FORMCHECKBOX  Level II.1 Intensive Outpatient referral to medical primary care  FORMCHECKBOX  Level II.5 Partial Hospitalization/Day Tx referral to medical primary care  FORMCHECKBOX  FORMCHECKBOX  Level III.1 Recovery House - Clinically Managed Low-Intensity Residential Tx referral to medical primary care  FORMCHECKBOX  Level III.3 Long Term Care - Clinically Managed Medium-Intensity Residential Tx referral to medical primary care  FORMCHECKBOX  FORMCHECKBOX  Level III.5 Intensive Inpatient - Clinically Managed High-Intensity Residential Tx referral to medical primary care  FORMCHECKBOX  Level III.7 Intensive Inpatient Medically Monitored Intensive Residential Tx medical primary care  FORMCHECKBOX  FORMCHECKBOX  Level IV Medically Managed Intensive Inpatient Treatment medical primary careCDP Summary Interpreting Dimension 2 Data (include strengths/needs): DO NOT LEAVE BLANK  DIMENSION 3: EMOTIONAL/BEHAVIORAL/COGNITIVE CONDITIONS AND COMPLICATIONS A. Emotional Conditions/Complications1. Have you ever been physically abused?  FORMCHECKBOX  No  FORMCHECKBOX  FORMCHECKBOX  Yes; if yes, when and by whom: ___________________________________ Have you received or participated in counseling for this issue  FORMCHECKBOX  No  FORMCHECKBOX  FORMCHECKBOX  Yes, When and what was the outcome?________ ___________________________________________________________________________________________________2. Have you ever been sexually abused?  FORMCHECKBOX  No  FORMCHECKBOX  FORMCHECKBOX  Yes; if yes, when and by whom:___________________________________ Have you received or participated in counseling for this issue?  FORMCHECKBOX  No  FORMCHECKBOX   FORMCHECKBOX Yes, When and what was the outcome? ___________________________________________________________________________________________________3. Have you ever been emotionally/verbally abused?  FORMCHECKBOX  No  FORMCHECKBOX  FORMCHECKBOX  Yes, if yes, when and by whom: _____________________ Have you received or participated in counseling for this issue  FORMCHECKBOX  No  FORMCHECKBOX  FORMCHECKBOX  Yes, When and what was the outcome?_______ ___________________________________________________________________________________________________4. Are there any other significant life events (losses, deaths, hardships, loss of custody of children, etc.)?  FORMCHECKBOX  No  FORMCHECKBOX  FORMCHECKBOX  Yes If yes, describe: ______________________________________________________________________________________5. Are you currently experiencing any of the following:  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Feeling hopeless  FORMCHECKBOX   FORMCHECKBOX Moodiness  FORMCHECKBOX  FORMCHECKBOX  Sleeplessness  FORMCHECKBOX   FORMCHECKBOX Self destructive  FORMCHECKBOX   FORMCHECKBOX Decreased energy  FORMCHECKBOX   FORMCHECKBOX Preoccupation with death  FORMCHECKBOX  FORMCHECKBOX   FORMCHECKBOX Feeling Withdrawn  FORMCHECKBOX  FORMCHECKBOX   FORMCHECKBOX  Taking unnecessary risks  FORMCHECKBOX  FORMCHECKBOX   FORMCHECKBOX Giving away valued possessions6. Is there any history of suicide in your family?  FORMCHECKBOX  No  FORMCHECKBOX   FORMCHECKBOX  Yes, If yes, explain: 7. Have you ever attempted suicide?  FORMCHECKBOX  No  FORMCHECKBOX   FORMCHECKBOX  Yes, If yes, when and how? 8. Do you currently have any suicidal thoughts?  FORMCHECKBOX  No  FORMCHECKBOX  FORMCHECKBOX  Yes, If yes, how recently? 9. Do you currently have a plan to harm yourself?  FORMCHECKBOX  No  FORMCHECKBOX   FORMCHECKBOX  Yes, If yes, describe your plan: 10. Suicide risk assessment: (lowest risk to highest risk)  FORMCHECKBOX  None  FORMCHECKBOX  FORMCHECKBOX  Low  FORMCHECKBOX  Moderate  FORMCHECKBOX  FORMCHECKBOX  High  FORMCHECKBOX  Imminent Danger As evidenced by: _____________________________________________________________________________________ If imminent danger describe immediate intervention: ______________________________________________________B. Behavioral Conditions/Complications1. Do you ever have homicidal thoughts?  FORMCHECKBOX  FORMCHECKBOX  No  FORMCHECKBOX  Yes, if yes, explain: 2. Do you have any history of combative and/or assault behavior?  FORMCHECKBOX   FORMCHECKBOX  No  FORMCHECKBOX  Yes; if yes, explain: 3. Have you ever driven a motor vehicle after consuming alcohol or any other mind/mood altering substance?  FORMCHECKBOX  FORMCHECKBOX  No  FORMCHECKBOX  Yes, if yes: How many times have you done it? __________ How often do you do it? ____________ Does it concern you?  FORMCHECKBOX  FORMCHECKBOX  No  FORMCHECKBOX Yes Did it ever result in arrest/charges for DUI?  FORMCHECKBOX  FORMCHECKBOX  No  FORMCHECKBOX  Yes, if yes: How many times? __________ What was the BAL/BAC at the time of arrest(s)? _______________________________________ How much did you consume before driving? _______________ Over how much time? __________________________________ How impaired did you feel at the time of arrest? _________________________________________________________________ What were the circumstances? ______________________________________________________________________________4. Have you ever done anything while under the influence of alcohol or other drugs that you later regretted?  FORMCHECKBOX  No  FORMCHECKBOX Yes, if yes: Describe:5. How much time do you spend, on average, in a typical week, in activities necessary to obtain, use or recover from the effects of using alcohol or other drugs? (spending time at bars/crack houses, seeking out dealers, recovering from hangovers, etc.) Describe: 6. Have you ever given up or reduced important social, occupational or recreational activities because of using alcohol or other drugs? e.g. lost a job or marriage/relationship/friend, quit attending social events.  FORMCHECKBOX  No  FORMCHECKBOX  Yes, if yes explain: 7. Describe any negative impact the use of alcohol or other drugs has had on your life. (e.g. problems with legal system, school, work, at home, relationships, health, etc.): C. Cognitive Conditions/Complications1. Have you continued to use alcohol or other drugs despite having identified problems that were caused or made worse because of that use?  FORMCHECKBOX  No  FORMCHECKBOX  Yes2. Have you ever been diagnosed with any cognitive disorder?  FORMCHECKBOX  No  FORMCHECKBOX  Yes, if yes, when, by whom, and what was it? 3. Do you have any problems with understanding written materials?  FORMCHECKBOX  No  FORMCHECKBOX  Yes, if yes, what is the problem? __________________ Have you ever received any help with this problem?  FORMCHECKBOX  No  FORMCHECKBOX  Yes, if yes, what kind of help? ____________________4. Do you need any help to understand written or verbal information?  FORMCHECKBOX  No  FORMCHECKBOX Yes, if yes, what kind of help do you need? D. Mental Health Conditions/Complications1. Have you had a significant period (that was not a direct result of drug/alcohol use) in which you experienced any of the following:  FORMCHECKBOX  FORMCHECKBOX   FORMCHECKBOX  Anxiety/nervousness  FORMCHECKBOX  FORMCHECKBOX  Grief/loss issues  FORMCHECKBOX  Sleep disturbances  FORMCHECKBOX  FORMCHECKBOX  Hostility/violence  FORMCHECKBOX   FORMCHECKBOX  Inability to comprehend  FORMCHECKBOX  FORMCHECKBOX  Depression  FORMCHECKBOX  FORMCHECKBOX  Phobias/paranoia/delusions  FORMCHECKBOX  FORMCHECKBOX  Loss of appetite  FORMCHECKBOX   FORMCHECKBOX  Eating disorders; if checked:  FORMCHECKBOX  FORMCHECKBOX  Anorexia  FORMCHECKBOX  FORMCHECKBOX  Bulimia  FORMCHECKBOX  FORMCHECKBOX  Other _________________________________________  FORMCHECKBOX   FORMCHECKBOX  Hallucinations; if checked:  FORMCHECKBOX  FORMCHECKBOX  Auditory  FORMCHECKBOX  FORMCHECKBOX  Visual When did you experience them and what did you do about it?_______________________________________________________2. Is there a history of mental illness in your family?  FORMCHECKBOX No  FORMCHECKBOX  FORMCHECKBOX   FORMCHECKBOX  FORMCHECKBOX Yes, If yes, who and what is the illness? Relative _______________________________ Illness _________________________ Status _____________________________ Relative _______________________________ Illness _________________________ Status _____________________________ Relative _______________________________ Illness _________________________ Status _____________________________3. Have you ever been diagnosed with a mental health condition?  FORMCHECKBOX  No  FORMCHECKBOX  Yes, if yes what was the diagnosis?_____________ Who diagnosed it? ________________________ Where? _________________________ When? _________________________4. Are you currently a patient at a mental health center or seeing a private practitioner? FORMCHECKBOX   FORMCHECKBOX  No  FORMCHECKBOX   FORMCHECKBOX  Yes, if yes, where/who? ________________________________________________________________________________________________________5. Have you ever received counseling or psychiatric treatment?  FORMCHECKBOX   FORMCHECKBOX No  FORMCHECKBOX  FORMCHECKBOX  Yes, If yes, where, when, and for what? ________________________________________________________________________________________________________6. Are you currently using prescribed medications for mental health purposes?  FORMCHECKBOX  No  FORMCHECKBOX  Yes, If yes: Name of Medication: ___________________________Dose ______________________Prescribed by: ________________________ Name of Medication: ___________________________Dose ______________________Prescribed by: ________________________ Name of Medication: ___________________________Dose ______________________Prescribed by: ________________________7. Are you currently using non-prescribed drugs for mental health purposes?  FORMCHECKBOX  No  FORMCHECKBOX  Yes, If yes: Name of Drug: __________________ Dose: _________________ Frequency: _________________ Duration: __________________ Name of Drug: __________________ Dose: _________________ Frequency: _________________ Duration: __________________ Name of Drug: __________________ Dose: _________________ Frequency: _________________ Duration: __________________8. How would you describe your current mental health:  FORMCHECKBOX Poor  FORMCHECKBOX  FORMCHECKBOX  Average  FORMCHECKBOX  FORMCHECKBOX  Good  FORMCHECKBOX  FORMCHECKBOX  Excellent9. Evaluation of patients mental health: FORMCHECKBOX   FORMCHECKBOX Poor  FORMCHECKBOX  Average  FORMCHECKBOX  Good  FORMCHECKBOX  Excellent10. Evaluation of patients ability to perform daily living skills?  FORMCHECKBOX Poor  FORMCHECKBOX  FORMCHECKBOX  Average  FORMCHECKBOX  FORMCHECKBOX  Good  FORMCHECKBOX  FORMCHECKBOX  Excellent For DUI Assessment - Imminent Danger Potential1. CDP evaluation of BAL/BAC (Describe the clinical significance of the results, e.g. high tolerance/consumption, compare to self-report of use.):__________________________________________________________________________________________________________________________________________________________________________________________________________________ 2. CDP evaluation of the self-reported driving record and abstract of the legal driving record: ____________________________________ __________________________________________________________________________________________________________ 3. What is the likelihood of repeat offense?  FORMCHECKBOX None  FORMCHECKBOX  Low  FORMCHECKBOX Moderate  FORMCHECKBOX High 4. What is the likelihood of significant risk to self or others if repeat offense occurs?  FORMCHECKBOX None  FORMCHECKBOX  Low  FORMCHECKBOX Moderate  FORMCHECKBOX High 5. What is the likelihood of repeat offense in the immediate future?  FORMCHECKBOX None  FORMCHECKBOX  Low  FORMCHECKBOX Moderate  FORMCHECKBOX High As evidenced by __________________________________________________________________________________________ ________________________________________________________________________________________________________Risk Rating for Dimension 3 (from PPC-2R - Appendix A): NOTE: A risk rating of 4 in this dimension requires an immediate intervention. 4  FORMCHECKBOX  Severe emotional condition/complication, with acute risk/potential for imminent danger to self or others as evidenced by ____________________________________________________ requires intensive/residential/involuntary addiction treatment.  FORMCHECKBOX  Severe behavioral condition/complication, with acute risk/potential for imminent danger to self or others as evidenced by ____________________________________________________ requires intensive/ residential/involuntary addiction treatment.  FORMCHECKBOX  Severe cognitive condition/complication, with acute risk/potential for imminent danger to self or others as evidenced by ____________________________________________________ requires intensive/ residential/involuntary addiction treatment.  FORMCHECKBOX  Severe mental health condition/complication, with acute risk/potential for imminent danger to self or others as evidenced by ____________________________________________ requires intensive/residential/involuntary addiction treatment. 3  FORMCHECKBOX  Severe emotional condition/complication requires residential intervention, with symptoms that significantly interfere with addiction treatment as evidenced by ______________________________________________________________________.  FORMCHECKBOX  Severe behavioral condition/complication requires residential intervention, with symptoms that significantly interfere with addiction treatment as evidenced by _____________________________________________________________________.  FORMCHECKBOX  Severe cognitive condition/complication requires residential intervention, with symptoms that significantly interfere with addiction treatment as evidenced by _____________________________________________________________________.  FORMCHECKBOX  Severe mental health condition/complication requires residential intervention, with symptoms that significantly interfere with addiction treatment as evidenced by _____________________________________________________________________.  FORMCHECKBOX 2  FORMCHECKBOX  An acute or persistent emotional condition/complication requires intervention, with symptoms that significantly interfere with addiction treatment, as evidenced by ______________________________________________________________________.  FORMCHECKBOX  An acute/persistent behavioral condition/complication requires intervention, with symptoms that significantly interfere with addiction treatment, as evidenced by ______________________________________________________________________.  FORMCHECKBOX  An acute/persistent cognitive condition/complication requires intervention, with symptoms that significantly interfere with addiction treatment, as evidenced by ______________________________________________________________________.  FORMCHECKBOX  An acute/persistent mental health condition/complication requires intervention, with symptoms that significantly interfere with addiction treatment, as evidenced by ______________________________________________________________________.  FORMCHECKBOX 1  FORMCHECKBOX  An emotional condition/complication requires intervention, but does not significantly interfere with addiction treatment.  FORMCHECKBOX  A behavioral condition/complication requires intervention, but does not significantly interfere with addiction treatment.  FORMCHECKBOX  A cognitive condition/complication requires intervention, but does not significantly interfere with addiction treatment.  FORMCHECKBOX 0  FORMCHECKBOX  No emotional, behavioral or cognitive conditions that require treatment.Recommended ASAM Level of Care for Dimension 3 Emotional/Behavioral/Cognitive Conditions  FORMCHECKBOX  No Treatment Services Recommended  FORMCHECKBOX  Level 0.5 Early Intervention/Education Alcohol and Other Drug Information School  FORMCHECKBOX  Level I.0 Outpatient  FORMCHECKBOX  Level II.1 Intensive Outpatient  FORMCHECKBOX  Level II.5 Partial Hospitalization/Day Treatment  FORMCHECKBOX  Level III.1 Recovery House - Clinically Managed Low-Intensity Residential Treatment  FORMCHECKBOX  Level III.3 Long Term Care - Clinically Managed Medium-Intensity Residential Treatment  FORMCHECKBOX  Level III.5 Intensive Inpatient - Clinically Managed High-Intensity Residential Treatment  FORMCHECKBOX  Level III.7 Intensive Inpatient Medically Monitored Intensive Residential Treatment  FORMCHECKBOX  Level IV Medically Managed Intensive Inpatient TreatmentCDP Summary Interpreting Dimension 3 Data (include strengths/needs): DO NOT LEAVE BLANK DIMENSION 4 READINESS TO CHANGE:A. Chemical Dependency Treatment HistoryProgram Name and LocationDates of TreatmentTreatment Completed?Length of Abstinence FORMCHECKBOX  No FORMCHECKBOX   FORMCHECKBOX  FORMCHECKBOX  Yes FORMCHECKBOX  FORMCHECKBOX  No FORMCHECKBOX   FORMCHECKBOX  Yes FORMCHECKBOX  FORMCHECKBOX  No  FORMCHECKBOX  Yes FORMCHECKBOX  No  FORMCHECKBOX  Yes FORMCHECKBOX  No  FORMCHECKBOX  Yes1. What was the reason you scheduled this appointment?  FORMCHECKBOX  Family pressure  FORMCHECKBOX  Employer intervention FORMCHECKBOX   FORMCHECKBOX  Physician intervention  FORMCHECKBOX  Legal pressure  FORMCHECKBOX  Child custody  FORMCHECKBOX  Reinstate driving privileges  FORMCHECKBOX  DUI? If so, date and BAC/BAL ___________________  FORMCHECKBOX Driving Abstract available for review  FORMCHECKBOX  No  FORMCHECKBOX Yes  FORMCHECKBOX  Self motivated, reason(s): _______________________  FORMCHECKBOX  Other reason(s): ______________________________2. Do you believe you currently have a problem with the use of alcohol/drugs?  FORMCHECKBOX  No  FORMCHECKBOX  Yes, If yes, which? ____________________ Do you believe you have had a problem with the use of alcohol/drugs in the past?  FORMCHECKBOX  No  FORMCHECKBOX  Yes, if yes, which?3. Have you ever felt you should cut down or control your substance use?  FORMCHECKBOX  No  FORMCHECKBOX  Yes, if so, why?4. Have you ever tried to cut down or control your use but been unsuccessful.  FORMCHECKBOX  No  FORMCHECKBOX  Yes, if so, how many times?5. How would you assess your overall use of alcohol/drugs?B. Legal Issues1. Is this assessment prompted or suggested by anyone connected to the legal system?  FORMCHECKBOX  No  FORMCHECKBOX  Yes, If yes, who?______________  FORMCHECKBOX  Your Attorney-Name _________________  FORMCHECKBOX  Judge/Court-Name___________________  FORMCHECKBOX  Other __________________2. Have you ever been arrested or charged with any crime?  FORMCHECKBOX  No  FORMCHECKBOX Yes3. Arrest history:CHARGESALCOHOL/DRUG RELATEDDATEWHEREDISPOSITION FORMCHECKBOX  No  FORMCHECKBOX  Yes FORMCHECKBOX  No  FORMCHECKBOX  Yes FORMCHECKBOX  No  FORMCHECKBOX  Yes FORMCHECKBOX  No  FORMCHECKBOX  Yes FORMCHECKBOX  No  FORMCHECKBOX  Yes4. Have you ever been in jail and/or prison?  FORMCHECKBOX  No  FORMCHECKBOX  Yes, if yes, how many times? If yes, where: 5. Are you currently on probation?  FORMCHECKBOX  No  FORMCHECKBOX Yes If yes, your probation officers name: ______________________________ Court _____________________________ Release of Information (ROI) signed?  FORMCHECKBOX  No  FORMCHECKBOX  Yes6. Have you been court ordered to participate in treatment for a Substance Related Disorder or Mental Health Disorder?  FORMCHECKBOX  No  FORMCHECKBOX  Yes If yes, what court issued the order?________________________________________ Judge ______________________________7. Are you currently under the supervision of the Department of Corrections?  FORMCHECKBOX  No  FORMCHECKBOX  Yes If yes, who is the person assigned to supervise your case? ________________________________________ Will you sign a release of information to allow contact with that person?  FORMCHECKBOX  No  FORMCHECKBOX  Yes ROI signed on ____________________________ (date)8. Are you a Drug Court patient?  FORMCHECKBOX  No  FORMCHECKBOX  Yes, if yes where? __________________________________________________________9. If yes, are you currently in Drug Court treatment?  FORMCHECKBOX  No  FORMCHECKBOX  Yes, if yes, where? _______________________________________10. Any current charges pending:  FORMCHECKBOX  No  FORMCHECKBOX  Yes If yes, describe: When ___________________________ Charge _________________________ Which Court? ____________________________ When ___________________________ Charge _________________________ Which Court? ____________________________ When ___________________________ Charge _________________________ Which Court? ____________________________11. Have your parental rights been terminated?  FORMCHECKBOX  No  FORMCHECKBOX  Yes, if yes: When?__________________ Why? ___________________________ By Whom? _______________________________C. Readiness to Change:1. Would you like to reduce or quit drinking/drug use if you could do so easily?  FORMCHECKBOX  No (PC)  FORMCHECKBOX  Yes (C) 2. At this moment, how important is it that you change your current drinking/drug use?  FORMCHECKBOX  Not important at all. (PC)  FORMCHECKBOX  About as important as most of the other things I would like to achieve now. (C)  FORMCHECKBOX  Most important thing in my life now (PR) 3. At this moment, how confident are you that you will change your current drinking/drug use?  FORMCHECKBOX  I do not think I will change my drinking/drug use. (PC)  FORMCHECKBOX  I have a 50 percent chance of changing my drinking/drug use (C)  FORMCHECKBOX  I think I will definitely change my drinking/drug use. (PR) 4. How seriously would you like to reduce or quit drinking/drug use altogether?  FORMCHECKBOX  Not at all (PC)  FORMCHECKBOX  Probably yes (C)  FORMCHECKBOX  Definitely yes (PR) 5. Do you intend to reduce or quit drinking/using drugs in the next 2 weeks?  FORMCHECKBOX  Definitely not (PC)  FORMCHECKBOX  Probably will (C)  FORMCHECKBOX  Definitely will (PR) 6. What is the possibility that 12 months from now you will have a problem with alcohol or other drugs?  FORMCHECKBOX  Definitely not (PC)  FORMCHECKBOX  Probably will (C)  FORMCHECKBOX  Definitely will (PR) The patient appears to be in the following stage of change:  FORMCHECKBOX  Precontemplation (PC)  FORMCHECKBOX  Contemplation (C)  FORMCHECKBOX  Preparation (PR)  FORMCHECKBOX  Action (A)  FORMCHECKBOX  Maintenance (M)Risk Rating for Dimension 4 (from PPC-2R - Appendix A): 4b  FORMCHECKBOX  Unable to follow through with treatment recommendations resulting in imminent danger to self or others, immediate intervention required.  FORMCHECKBOX  Unable to function independently and to engage in self-care 4a  FORMCHECKBOX  Unable to follow through, has little or no awareness of substance use problems and associated negative consequences.  FORMCHECKBOX  Knows very little about addiction and sees no connection between personal suffering and substance use  FORMCHECKBOX  Not willing to explore change in substance use, as evidenced by _________________________________________________.  FORMCHECKBOX  Is in denial regarding substance use disorder and its implications, blames others for problems, rejects treatment.  FORMCHECKBOX  Is not in imminent danger and is able to care for self 3  FORMCHECKBOX  Exhibits inconsistent follow-through, shows minimal awareness of substance use disorder and need for treatment.  FORMCHECKBOX  Appears unaware of need to change, unwilling or only partially able to follow through with treatment recommendations.  FORMCHECKBOX 2  FORMCHECKBOX  Reluctant to agree to treatment for substance use problems, as evidenced by _______________________________________.  FORMCHECKBOX  Able to articulate negative consequences of substance use, but has low commitment to change use of substances  FORMCHECKBOX  Low readiness to change, passively involved in treatment as evidenced by _________________________________________.  FORMCHECKBOX  Variably compliant with attendance at outpatient treatment sessions or mutual self-help support groups/meetings.  FORMCHECKBOX 1  FORMCHECKBOX  Willing to enter treatment and explore strategies for changing substance use, but ambivalent about need to change.  FORMCHECKBOX  Willing to explore the need for treatment and strategies to reduce or stop substance use.  FORMCHECKBOX  Willing to change substance use, but believes it will not be difficult, or does not accept a full recovery treatment plan 0  FORMCHECKBOX  Willing to engage in treatment/education as proactive, responsible participant, committed to changing alcohol/drug use. FORMCHECKBOX Recommended ASAM Level of Care for Dimension 4 Readiness to Change  FORMCHECKBOX  No Treatment Services Recommended  FORMCHECKBOX  Level 0.5 Early Intervention/Education Alcohol and Other Drug Information School  FORMCHECKBOX  Level I.0 Outpatient  FORMCHECKBOX  Level II.1 Intensive Outpatient  FORMCHECKBOX  Level II.5 Partial Hospitalization/Day Treatment  FORMCHECKBOX  Level III.1 Recovery House - Clinically Managed Low-Intensity Residential Treatment  FORMCHECKBOX  Level III.3 Long Term Care - Clinically Managed Medium-Intensity Residential Treatment  FORMCHECKBOX  Level III.5 Intensive Inpatient - Clinically Managed High-Intensity Residential Treatment  FORMCHECKBOX  Level III.7 Intensive Inpatient Medically Monitored Intensive Residential Treatment  FORMCHECKBOX  Level IV Medically Managed Intensive Inpatient TreatmentCDP Summary Interpreting Dimension 4 Data (include strengths/needs): DO NOT LEAVE BLANK  DIMENSION 5: RELAPSE/CONTINUED USE POTENTIALINSERT DRUG/ALCOHOL HISTORY DATA COLLECTION HERE. COMPLETE A COMPREHENSIVE FACE-TO-FACE DIAGNOSTIC INTERVIEW TO OBTAIN, REVIEW, EVALUATE, AND DOCUMENT A HISTORY OF THE PATIENTS INVOLVEMENT WITH ALCOHOL AND OTHER DRUGS, INCLUDING TYPE OF SUBSTANCE, ROUTE OF ADMINISTRATION, AMOUNT, FREQUENCY, AND DURATION OF USE. Relapse History1. Have you ever attempted to discontinue your use of alcohol? No  FORMCHECKBOX  Yes  FORMCHECKBOX  If yes, how many times? ________________ What is the longest time you have abstained? _________ What motivated you to abstain? ______________________________2. Have you ever attempted to discontinue your use of drugs? No  FORMCHECKBOX  Yes  FORMCHECKBOX  If yes, how many times? ________________ What is the longest time you have abstained? _________ What motivated you to abstain? ______________________________3. Did you resume using? No  FORMCHECKBOX  Yes  FORMCHECKBOX  If yes, what led you to resume use? ___________________________________________ How it make you feel to resume using? _______________________________________________________________________4. Have you ever experienced cravings to use alcohol or drugs? No  FORMCHECKBOX  Yes  FORMCHECKBOX  Which?______________________________ If yes, what are the thoughts or events that evoke cravings? _______________________________________________________5. CDP assessment of patients ability to attain and maintain abstinence: Unknown  FORMCHECKBOX  Good  FORMCHECKBOX  Moderate  FORMCHECKBOX  Poor  FORMCHECKBOX  As evidenced by _________________________________________________________________________________________6. CDP assessment of patients risk for relapse: Unknown  FORMCHECKBOX  High  FORMCHECKBOX  Moderate  FORMCHECKBOX  Low  FORMCHECKBOX  As evidenced by _________________________________________________________________________________________7. CDP assessment of patients potential for continued use: Unknown  FORMCHECKBOX  High  FORMCHECKBOX  Moderate  FORMCHECKBOX  Low  FORMCHECKBOX  As evidenced by _________________________________________________________________________________________Risk Rating for Dimension 5 (from PPC-2R - Appendix A): 4b  FORMCHECKBOX  No skills to arrest the addictive disorder or prevent relapse to substance use. Continued uncontrolled substance use.  FORMCHECKBOX  Continued addictive behavior places the patient and/or others in imminent danger. Immediate intervention required 4a  FORMCHECKBOX  Repeated treatment episodes have had little positive effect on the patients functioning as evidenced by _________________.  FORMCHECKBOX  No skills to cope with and interrupt addiction problems or to prevent or limit relapse or continued use but is not in imminent danger and is able to care for self. 3  FORMCHECKBOX  Little recognition and understanding of substance use relapse issues and has poor skills to cope with and interrupt addiction problems or to avoid or limit relapse or continued use as evidenced by __________________________________________. 2  FORMCHECKBOX  Impaired recognition and understanding of substance use relapse issues but is able to manage with prompting. 1  FORMCHECKBOX  Minimum relapse potential with some vulnerability. Fair self-management and relapse prevention skills.  FORMCHECKBOX 0  FORMCHECKBOX  No potential for further substance use problems.  FORMCHECKBOX  Low relapse or continued use potential and good coping skills.Recommended ASAM Level of Care for Dimension 5 Relapse/Continued Use Potential  FORMCHECKBOX  No Treatment Services Recommended  FORMCHECKBOX  Level 0.5 Early Intervention/Education Alcohol and Other Drug Information School  FORMCHECKBOX  Level I.0 Outpatient  FORMCHECKBOX  Level II.1 Intensive Outpatient  FORMCHECKBOX  Level II.5 Partial Hospitalization/Day Treatment  FORMCHECKBOX  Level III.1 Recovery House - Clinically Managed Low-Intensity Residential Treatment  FORMCHECKBOX  Level III.3 Long Term Care - Clinically Managed Medium-Intensity Residential Treatment  FORMCHECKBOX  Level III.5 Intensive Inpatient - Clinically Managed High-Intensity Residential Treatment  FORMCHECKBOX  Level III.7 Intensive Inpatient Medically Monitored Intensive Residential Treatment  FORMCHECKBOX  Level IV Medically Managed Intensive Inpatient TreatmentCDP Summary Interpreting Dimension 5 Data (include strengths/needs): DO NOT LEAVE BLANK  DIMENSION 6: RECOVERY ENVIRONMENT1. What jobs have you held in the last six months? ________________________________________________________________ Primary occupation:_______________________________________________________________________________________ Last full time employment:__________________________________________________________________________________2. Which of the following employment problems have you ever experienced due to Alcohol/Drug use? Late for work  FORMCHECKBOX  Diminished productivity  FORMCHECKBOX  Absenteeism  FORMCHECKBOX  Quit  FORMCHECKBOX  Fired  FORMCHECKBOX  Used at work  FORMCHECKBOX  None  FORMCHECKBOX 3. Do you currently identify with any organized religion?  FORMCHECKBOX  No  FORMCHECKBOX  Yes, if yes, which:__________________________________ Were you raised in an organized religion?  FORMCHECKBOX  No  FORMCHECKBOX  Yes, if yes, which:__________________________________ Do you consider yourself to be a spiritual person?  FORMCHECKBOX  No  FORMCHECKBOX  Yes, if yes, in what ways?___________________________ _______________________________________________________________________________________________________4. Do you identify yourself with any particular cultural, ethnic background or community? No  FORMCHECKBOX  Yes  FORMCHECKBOX , describe __________ _______________________________________________________________________________________________________ Is there a particular form of support from this community you can use for your recovery?  FORMCHECKBOX  No  FORMCHECKBOX  Yes, describe___________ _______________________________________________________________________________________________________ Cultural considerations/barriers to treatment or recovery _______________________________________________________________________________________________________5. Are there any barriers to accessing treatment?  FORMCHECKBOX  No  FORMCHECKBOX  Yes, If yes, explain:________________________________________ _______________________________________________________________________________________________________6. Have you ever been involved with any self-help support group? No  FORMCHECKBOX  Yes  FORMCHECKBOX , if yes,  FORMCHECKBOX  Past  FORMCHECKBOX  Current Which one? ________________________ When?__________________________ Why?_______________________________ How do you feel about your involvement? _____________________________________________________________________ Are you willing to attend self-help support groups now? No  FORMCHECKBOX  Yes  FORMCHECKBOX , if yes, which one?_____________________7. NO YES COMMENTS Family history of chemical dependency  FORMCHECKBOX   FORMCHECKBOX  _________________________________________________ Family supportive of abstinence  FORMCHECKBOX   FORMCHECKBOX  _________________________________________________ Friends supportive of abstinence  FORMCHECKBOX   FORMCHECKBOX  _________________________________________________ Spouse supportive of abstinence  FORMCHECKBOX   FORMCHECKBOX  _________________________________________________ Living arrangements supportive  FORMCHECKBOX   FORMCHECKBOX  _________________________________________________ Funds for basic needs  FORMCHECKBOX   FORMCHECKBOX  _________________________________________________ Employment opportunities  FORMCHECKBOX   FORMCHECKBOX  _________________________________________________ Safe environment in home/neighborhood  FORMCHECKBOX   FORMCHECKBOX  _________________________________________________Risk Rating for Dimension 6 (from PPC-2R - Appendix A): 4b  FORMCHECKBOX  Environment is not supportive of addiction recovery, and is actively hostile to recovery posing an immediate threat to safety and well-being. Immediate intervention required. 4a  FORMCHECKBOX  Environment is not supportive of addiction recovery, and is chronically hostile and toxic to recovery or treatment progress.  FORMCHECKBOX  Unable to cope with the negative effects of the living environment on recovery efforts as evidenced by ___________________. 3  FORMCHECKBOX  Environment is not supportive of addiction recovery, and the patient finds coping difficult, even with clinical structure. 2  FORMCHECKBOX  Environment is not supportive of addiction recovery, but with clinical structure, the patient is able to cope most of the time. 1  FORMCHECKBOX  Has passive support in environment.  FORMCHECKBOX  Significant others are not are not interested in supporting addiction recovery but patient is not too distracted by this situation and is able to cope with the environment. 0  FORMCHECKBOX  Has a supportive environment, or is able to cope with poor support.Recommended ASAM Level of Care for Dimension 6 Recovery Environment  FORMCHECKBOX  No Treatment Services Recommended  FORMCHECKBOX  Level 0.5 Early Intervention/Education Alcohol and Other Drug Information School  FORMCHECKBOX  Level I.0 Outpatient  FORMCHECKBOX  Level II.1 Intensive Outpatient  FORMCHECKBOX  Level II.5 Partial Hospitalization/Day Treatment  FORMCHECKBOX  Level III.1 Recovery House Clinically Managed Low-Intensity Residential Treatment  FORMCHECKBOX  Level III.3 Long Term Care Clinically Managed Medium-Intensity Residential Treatment  FORMCHECKBOX  Level III.5 Intensive Inpatient Clinically Managed High-Intensity Residential Treatment  FORMCHECKBOX  Level III.7 Intensive Inpatient Medically Monitored Intensive Residential Treatment  FORMCHECKBOX  Level IV Medically Managed Intensive Inpatient TreatmentCDP Summary Interpreting Dimension 6 Data (include strengths/needs): DO NOT LEAVE BLANK A. Diagnostic Criteria for Substance Dependence DisorderA maladaptive pattern of substance use, leading to clinically significant impairment or distress as manifested by three or more of the following criteria occurring at any time in the same 12-month period. At least three of the seven criteria must be met to diagnose Substance Dependence Disorder. P S T (P=Primary, S=Secondary, T=Tertiary)  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  1. Tolerance, as defined by either of the following: a. Markedly increased amounts of the substance in order to achieve intoxication or desired effect; b. Markedly diminished effect with continued use of the same amount.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  2. Withdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome for the substance b. The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  3. Substance is often taken in larger amounts and/or over a longer period than the patient intended.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  4. Persistent attempts or one or more unsuccessful efforts made to cut down or control substance use.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  5. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from effects.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  6. Important social, occupational or recreational activities given up or reduced because of substance abuse.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  7. 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 use of the substance. Additional indicators of alcoholism or drug addiction (not diagnostic criteria): P S T P S T P S T P S T  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  None  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Compulsion to use  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Decreased tolerance  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Increased tolerance  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Binge use  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Neglected responsibilities  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Severe withdrawal  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Failed control  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Memory problems  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Family/friends concerned  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Seizures  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Family history  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Loss of control  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Protecting/hoarding supply  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Difficulty performing job  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Preoccupation  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Arrested for use  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Gulping/sneaking  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Medical consequences  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Blackouts  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  A.M. use to avoid WD  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Crawling skin/goose fleshComplete the following only if the person does not meet the diagnostic criteria for dependence for the substance (3 or more of #1-7 above).B. Diagnostic Criteria for Substance Abuse DisorderA maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one or more of the following criteria occurring within a 12-month period. One or more of the following criteria met within the previous 12-month period indicates abuse. P S T  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  2. Recurrent substance use in situations in which it is physically hazardous.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  3. Recurrent substance-related legal problems.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  4. Continued substance use despite persistent/recurrent social or interpersonal problems caused/exacerbated by use.C. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition TR Diagnostic Codes FORMCHECKBOX  Denied use of alcohol  FORMCHECKBOX  305.00 Alcohol abuse  FORMCHECKBOX  303.90 Alcohol dependence:  FORMCHECKBOX  Mild  FORMCHECKBOX  Moderate  FORMCHECKBOX  Severe  FORMCHECKBOX  Physiological dependence  FORMCHECKBOX  Denied use of substance(s) (drugs other than alcohol)  FORMCHECKBOX  305.50 Opioid abuse  FORMCHECKBOX  304.00 Opioid dependence:  FORMCHECKBOX  Mild  FORMCHECKBOX  Moderate  FORMCHECKBOX  Severe  FORMCHECKBOX  Physiological dependence  FORMCHECKBOX  305.60 Cocaine abuse  FORMCHECKBOX  304.20 Cocaine dependence:  FORMCHECKBOX  Mild  FORMCHECKBOX  Moderate  FORMCHECKBOX  Severe  FORMCHECKBOX  Physiological dependence  FORMCHECKBOX  305.20 Cannabis abuse  FORMCHECKBOX  304.30 Cannabis dependence:  FORMCHECKBOX  Mild  FORMCHECKBOX  Moderate  FORMCHECKBOX  Severe  FORMCHECKBOX  Physiological dependence  FORMCHECKBOX  305.70 Amphetamine abuse  FORMCHECKBOX  304.40 Amphetamine dependence:  FORMCHECKBOX  Mild  FORMCHECKBOX  Moderate  FORMCHECKBOX  Severe  FORMCHECKBOX  Physiological dependence  FORMCHECKBOX  305.30 Hallucinogen abuse  FORMCHECKBOX  304.50 Hallucinogen dependence:  FORMCHECKBOX  Mild  FORMCHECKBOX  Moderate  FORMCHECKBOX  Severe  FORMCHECKBOX  Physiological dependence  FORMCHECKBOX  305.90 Inhalant abuse  FORMCHECKBOX  304.60 Inhalant dependence:  FORMCHECKBOX  Mild  FORMCHECKBOX  Moderate  FORMCHECKBOX  Severe  FORMCHECKBOX  Physiological dependence  FORMCHECKBOX  305.90 Phencyclidine (PCP) abuse  FORMCHECKBOX  304.60 PCP dependence:  FORMCHECKBOX  Mild  FORMCHECKBOX  Moderate  FORMCHECKBOX  Severe  FORMCHECKBOX  Physiological dependence  FORMCHECKBOX  305.40 Sedative, hypnotic, anxiolytic abuse  FORMCHECKBOX  304.10 Sedative, hypnotic, anxiolytic dependence:  FORMCHECKBOX  Mild  FORMCHECKBOX  Moderate  FORMCHECKBOX  Severe  FORMCHECKBOX  Physiological dependence  FORMCHECKBOX  304.80 Poly substance dependence  FORMCHECKBOX  Mild  FORMCHECKBOX  Moderate  FORMCHECKBOX  Severe  FORMCHECKBOX  Physiological dependence  FORMCHECKBOX  305.10 Nicotine dependence  FORMCHECKBOX  Mild  FORMCHECKBOX  Moderate  FORMCHECKBOX  Severe  FORMCHECKBOX  Physiological dependence  FORMCHECKBOX  Screening of substance use revealed insufficient symptoms to indicate abuse or addiction.Treatment Recommendations using ASAM PPC Levels of Care:The patient meets the following level of care admission criteria: Dimension 1: Level _________Dimension 3: Level _________Dimension 5: Level _________ Dimension 2: Level _________Dimension 4: Level _________Dimension 6: Level _________ Overall Level: ________________ Overrides: Are there any circumstances that would override the ASAM PPC clinical recommendations for placement? No  FORMCHECKBOX  Yes  FORMCHECKBOX  (e.g., legal mandates, logistical barriers, lack of available services, etc. If yes, explain: ___________________________________________________________________________________________ Was the patient informed of the diagnosis and assessment results?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If no, why not? __________________________ Was the patient provided with treatment and referral options?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If no, why not? _________________________________ DASA Certified Agencies providing the recommended treatment services: Name 1. _________________________________________ Phone # __________________ Contact Person ________________ Name 2. _________________________________________ Phone # __________________ Contact Person ________________ Name 3. _________________________________________ Phone # __________________ Contact Person ________________ Also recommended:  FORMCHECKBOX  Domestic Violence Perpetrator Program  FORMCHECKBOX  Anger Mgmt  FORMCHECKBOX  Vocational Rehabilitation  FORMCHECKBOX  GED  FORMCHECKBOX  Mental Health Counseling.  FORMCHECKBOX  Literacy/Tutoring Program  FORMCHECKBOX  Self-help support groups  FORMCHECKBOX  Other______________ Does the patient need part time or around the clock childcare in order to access treatment? No  FORMCHECKBOX  Yes  FORMCHECKBOX  if yes Does the patient need help accessing or selecting childcare? No  FORMCHECKBOX  Yes  FORMCHECKBOX  if yes Referral information for child care services: _________________________________________________________________ HIV/AIDS Brief Risk Intervention conducted?  FORMCHECKBOX  Yes  FORMCHECKBOX  No, if no, explain:_______________________________________________Authentication Information DASA Certified Agency __________________________________________________________ Agency # __________________ Chemical Dependency Professional Name ___________________________________________ CP# ______________________ CDP Signature _________________________________________________________________ Date ______________________      Revised Feb 29, 2008  PAGE 1 OF  NUMPAGES 11  <=Dgu; B    xjYKjh4]h;_CJ\^JaJ h4]h;_CJOJQJ^JaJh4]h;_5CJ^JaJh4]hCCJ^JaJhCCJ^JaJh4]h4]CJ^JaJhCB*aJphh4]h;_B*aJphh4]h4]B*aJphhCh;_5^JaJhCh;_5\^JaJhChC5\^JaJhC5\^JaJh4]h;_CJ^JaJ=  f(($&P#$/Ifgd;_ f(($&P#$/Ifgd;_$ f$&P#$/Ifa$gd;_$  $&P#$/Ifa$gd;_$&P#$/Ifgd;_ ~eQ<$&P#$/Ifgd;_$ $&P#$/Ifa$gd;_kd$$Ifl40,+ 6P0,4 laf4ytC  f$ $&P#$/Ifa$gd;_kd$$Ifl4,,  6P 0,4 laf4p yt;_  t ]C & F 3$&P#$/Ifgd;_! j) 0 ($&P#$/Ifgd;_kd$$Ifl4,,  6P 0,4 laf4p yt;_  & ' ( O W t u < D p q  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