RIVER CITY ASAM ASSESSMENT ADULT SUBSTANCE ABUSE OUTPATIENT PLACEMENT

RIVER CITY ASAM ASSESSMENT ADULT SUBSTANCE ABUSE OUTPATIENT PLACEMENT
(Required for Direct Outpatient, Alcohol and Drug Treatment Program, and IOP Admissions)

This ASAM-based placement tool is to be used as a guide to determine whether or not a consumer is appropriate for the ambulatory (outpatient/ADTP/IOP) level of treatment. It is required to be placed in all River City funded ambulatory treatment substance abuse records, but may be used for substance abuse treatment funded by other sources.
Client Name:
Date of Birth:

Month Day Year
Date
DIMENSION 1 - WITHDRAWAL/DETOXIFICATION POTENTIAL:
Intoxicated/high during assessment?

No Yes
Current withdrawal signs?

No Yes
If yes, specify:
History of severe withdrawals?

No Yes
If yes, specify:
History of medical problems, such as seizures, stroke, hypertension, etc., that would complicate outpatient detoxification?

No Yes
If yes, specify:
Is client appropriate for ambulatory level of treatment?

No Yes
DIMENSION 2 - BIOMEDICAL CONDITIONS AND COMPLICATIONS (not related to withdrawal):
Current and/or chronic physical/medical illnesses that may complicate Tx?

No Yes
If yes, specify:
Current prescribed medications that may interfere with abstinence?

No Yes
If yes, describe:
Is client appropriate for ambulatory level of treatment?

No Yes
DIMENSION 3 - EMOTIONAL/BEHAVIORAL/COGNITIVE CONDITIONS AND COMPLICATIONS:
Current and/or chronic co-occurring mood and/or thought disorder(s) or symptom(s) that needs to be addressed immediately or will interfere with treatment?

No Yes
If yes, specify:
Does consumer meet criteria for Serious and/or Persistent Mental Condition with co-occurring substance use disorder?

No Yes
Current psychiatric medication use?

No Yes
If yes, specify type/date of last use:
Is client appropriate for ambulatory level of treatment?

No Yes
*If answering "No", not appropriate for ambulatory treatment, to any of ASAM Dimensions 1, 2, or 3, consider a referral to an alternate level of treatment. Individuals with acute Medical and/or Psychiatric problems should be directly referred to Medical or Psychiatric emergency/urgent services for stabilization prior to referral and/or admission to treatment.
DIMENSION 4 - READINESS TO CHANGE:
Lacks internal motivation for treatment?

No Yes
Refuses to accept other's perceptions that s/he has a substance use problem?

No Yes
Impulse control is poor, does not respond to negative consequences?

No Yes
Is client appropriate for ambulatory level of treatment?

No Yes
DIMENSION 5 - RELAPSE/CONTINUED USE POTENTIAL
Potential for continued or increased use is high?

No Yes
Lacks recovery skills to cope with addiction and avoid relapse?

No Yes
Lacks awareness of relapse triggers, urge management techniques?

No Yes
If abstinent, risk for using (including needle use) or imminent crisis is high?

No Yes N/A
Is client appropriate for ambulatory level of treatment?

No Yes
DIMENSION 6 - RECOVERY ENVIRONMENT
Family/living circumstances pose a threat to engaging or succeeding in Tx?

No Yes
Lacks sufficient drug free social outlets or friendships to support abstinence/recovery?

No Yes
Family/living environment limits access to substances and/or other using individuals?

No Yes
Is client appropriate for ambulatory level of treatment?

No Yes
***If answering “No”, not appropriate for ambulatory treatment, to two or more of ASAM Dimensions 4, 5 or 6, consider a referral to an alternate level of treatment.

Consumer is appropriate for the following level of care (check THE most acute problem area that applies):
Level 0.5 - Early Intervention Level 1 - OTP - Opioid Treatment Program Level 1 - Outpatient Services Level 2.1 - Intensive Outpatient Services Level 2.5 - Partial Hospitalization Services Level 3.1 - Clinically Managed Low-Intensity Residential Services Level 3.3 - Clinically Managed Population-Specific High-Intensity Residential Services Level 3.5 - Clinically Managed High-Intensity Residential Services Level 3.7 - Medically Monitored Intensive Inpatient Services Level 4.0 - Medically Managed Intensive Inpatient Services
ASSESSOR'S NAME:
DATE:

Month Day Year
Date
Should be Empty:

RIVER CITY ASAM ASSESSMENT ADULT SUBSTANCE ABUSE OUTPATIENT PLACEMENT

DIMENSION 1 - WITHDRAWAL/DETOXIFICATION POTENTIAL:

DIMENSION 2 - BIOMEDICAL CONDITIONS AND COMPLICATIONS (not related to withdrawal):

DIMENSION 3 - EMOTIONAL/BEHAVIORAL/COGNITIVE CONDITIONS AND COMPLICATIONS:

DIMENSION 4 - READINESS TO CHANGE:

DIMENSION 5 - RELAPSE/CONTINUED USE POTENTIAL

DIMENSION 6 - RECOVERY ENVIRONMENT