Name: DOB: Insurance ID: Record #:


Upward Change Health Services
Substance and Alcohol Use Assessment / Today’s Date:
Location of Assessment:
Referred by:
Name: / Sex: ☐Female ☐Male
Address: / Race:
Age:
Best way to contact: / Individuals participating in assessment:
  1. In their own words:

Current problems and stressors related to substance/alcohol use:

Goals for substance alcohol use (ie: cutting back, stopping, etc):

Personal strengths, skills, and supports that are needed to reach goals:

  1. Clinical Observations (presenting concerns, stressors, risk factors, current patterns, frequency, and amount of use, symptoms, etc.):
  1. Co-occurring Medical or Mental Health Problems Contributing to Use of Alcohol or other Substances (underlying mental health or medical issue, prescribed medication, misuse of prescribed medication):

Primary care doctor: ☐None ☐Yes (name and address):

Current medications / Dosage / How often / Compliance / Side effects
  1. Substance Abuse Treatment History (any prior substance abuse treatment):

☐None reported

☐Outpatient therapy (why,where, when, helpful/not helpful):

☐Psychiatric medication (why,where, when, helpful/not helpful):

☐Enhanced Services (why,where, when, helpful/not helpful):

☐Inpatient detox (why,where, when, helpful/not helpful):

☐Inpatient psychiatric (why,where, when, helpful/not helpful):

☐Residential treatment (why,where, when, helpful/not helpful):

☐Other (why,where, when, helpful/not helpful):

  1. Substance Abuse History:☐None reported

Substance / Form / Method / First use / Last use / Average amount used / Frequency of recent use
Alcohol
Tobacco
Marijuana
Cocaine/other amphetamines
Methamphetamines
Hallucinogens
Heroin/Opiates
Benzodiazepines/
Other sedatives
Ecstasy/other Club Drugs
Other/Not listed

Readiness to change/stop problem use: ☐Low ☐Moderate ☐high

Willingnessto change/stop problem use☐Low☐Moderate ☐high

Motivation to change/stop problem use: ☐Low ☐Moderate ☐high

Explain:

ASAM ASSESSMENT☐NO SUD/AUD PRESENT

Dimension / Risk/Explanation
1: Intoxication and withdrawal potential
Recent patterns of use, history of withdrawal symptoms, recent increase/decrease in use, etc. / ☐HIGH:
☐MEDIUM:
☐LOW:
2: Biomedical Conditions
Chronic medical conditions or health issues, pregnancy, prescribed medications, etc. / ☐HIGH:
☐MEDIUM:
☐LOW:
3: Emotional/Behavioral/Cognitive
Current or historical MH symptoms, symptoms worsen during use/withdrawal or impairs functioning, etc. / ☐HIGH:
☐MEDIUM:
☐LOW:
4: Readiness to Change
Stage of change, awareness of problem, internally or externally motivated, voluntary or involuntary admission, etc. / ☐HIGH:
☐MEDIUM:
☐LOW:
5: Relapse and Continued Use
Stress levels and triggers, coping skills, previous successes in abstinence, current cravings, etc. / ☐HIGH:
☐MEDIUM:
☐LOW:
6. Recovery Environment
Supports present, active users in environment, external motivators, environmental factors, access to resources, etc. / ☐HIGH:
☐MEDIUM:
☐LOW:

ASAM Level of Care Recommendation: ☐N/A

  1. Problems caused by Substance/Alcohol Use

☐None reported

☐Legal Involvement (dates and charges, sentencing):

☐Social/Family relationships(explain):

☐Work/Vocational (explain):

☐Medical/Health problems (explain):

☐Mental Health problems (explain):

☐Daily functioning problems (explain):

☐Other (explain):

  1. Risk and Safety Concerns related to substance/alcohol use:

Withdrawl risk: ☐None ☐Historical risks ☐Current Risks

Explanation of identified risks:

Safety Planning:

Overdose risk: ☐None ☐Historical risks ☐Current Risks

Explanation of identified risks:

Safety Planning:

Other identified risks/Explanation: ☐None identified

☐Other:

  1. Summary of Symptoms and Presenting Concerns (To support clinical diagnosis and recommendations):

Substance/Alcohol Use Disorder (2+) symptoms, within 12 months (Specify Substances ______)

☐The substance is often taken in larger amounts or over a longer period than was intended

☐There is a persistent desire or unsuccessful efforts to cut down or control substance use

☐A great deal of time is spent in activities necessary to obtain the substance

☐Recurrent substance use resulting in a failure to fulfill major role obligations at work, school or home

☐Recurrent substance use in situations in which it is physically hazardous

☐Craving or a strong desire to use

☐Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by

the effects of the substance
☐Important social, occupational or recreational activities are given up or reduced because of the substance use

☐The substance was continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by substance use

☐ Tolerance
☐ Withdrawal

Summary:

CLINICAL DIAGNOSIS
  1. Treatment Recommendations(include justification and eligibility for recommended service):

☐Outpatient Therapy☐Psychiatric med eval☐Psychological eval

☐12 step/recovery group☐Family therapy ☐Parenting group

☐Intensive In Home☐Multisystemic Therapy☐Residential treatment

☐Hospitalization☐Inpatient detox☐Substance abuse outpatient

☐Peer support☐Psychosocial rehabilitation ☐Community Support

☐Other:______

  1. Barriers to Treatment: ☐None identified

☐Transportation☐Childcare

☐Insurance eligibility ☐Frequent changes in living environment

☐No phone ☐Anxiety/Agoraphobia/Paranoia

☐Ambivalence ☐Lack of motivation/follow through

☐Distrustful of providers ☐Lack of services in area where client lives

☐Domestic violence ☐Other:

Plan/Recommendations for overcoming barriers:

  1. Informed Consent, Reviewed the following with consumer:

☐Clinical diagnosis

☐Treatment recommendations

☐Consumer choice, reviewed list of provider options

☐Information on how to change providers

☐Information on how to file a grievance

☐Information on crisis response numbers

______

Clinician printed name/title Clinician signed name/credentials Date

______

Supervisor printed name/title Supervisor signed name/credentials Date