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. 0000044190 00000 n 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. Have you ever tried to cut down or control your use but been unsuccessful. __________________________________ How impaired did you feel at the time of arrest? 0000002526 00000 n FORMCHECKBOX Moderate signs and symptoms, with moderate risk of severe withdrawal. Persistent attempts or one or more unsuccessful efforts made to cut down or control substance use. 0000007283 00000 n FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 7. FORMCHECKBOX FORMCHECKBOX Severe withdrawal presents danger (e.g. 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. At this moment, how confident are you that you will change your current drinking/drug use? FORMCHECKBOX FORMCHECKBOX No FORMCHECKBOX Yes, if yes, explain: 2. No FORMCHECKBOX Yes FORMCHECKBOX If yes, what led you to resume use? 0 3 FORMCHECKBOX Severe emotional condition/complication requires residential intervention, with symptoms that significantly interfere with addiction treatment as evidenced by ______________________________________________________________________. 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 yes, in what ways?___________________________ _______________________________________________________________________________________________________4. FORMCHECKBOX No FORMCHECKBOX FORMCHECKBOX Yes If yes, Why? ASAM's criteria are required in over 30 states. he “assessment” phase of treatment represents the early information-gathering phase, in which patient and physician work together to determine what signs and symptoms are present, and what they point to. FORMCHECKBOX None FORMCHECKBOX Low FORMCHECKBOX Moderate FORMCHECKBOX High 4. FORMCHECKBOX Willing to explore the need for treatment and strategies to reduce or stop substance use. 0000007651 00000 n 0000020682 00000 n FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 5. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. óèÚÌÚÀ³¦œ¦ó�ó…óxójYóKjó h4] h;_ CJ \�^J aJ h4] h;_ CJ OJ QJ ^J aJ h4] h;_ 5�CJ ^J aJ h4] hCˆ CJ ^J aJ hCˆ CJ ^J aJ h4] h4] CJ ^J aJ hCˆ B* aJ ph ÿh4] h;_ B* aJ ph ÿh4] h4] B* aJ ph ÿhCˆ h;_ 5�^J aJ hCˆ h;_ 5�\�^J aJ hCˆ hCˆ 5�\�^J aJ hCˆ 5�\�^J aJ h4] h;_ CJ ^J aJ = § Ÿ í í Ô Ô » � ƒ Æ f¤( ¤( $„üÿ„Õ&P#$/„´ If gd;_ Æ ü ÂŞèf¤( ¤( $„üÿ„Õ&P#$/„´ If gd;_ $ Æ f$„üÿ„Õ&P#$/„´ If a$gd;_ $ Æ ğ$„üÿ„Õ&P#$/„´ If a$gd;_ $„üÿ„Õ&P#$/„´ If gd;_ Ÿ   ­ Ü ~ e Q ¤. 0000070072 00000 n Is there any history of suicide in your family? Recurrent substance-related legal problems. FORMCHECKBOX No FORMCHECKBOX FORMCHECKBOX Yes2. Evaluation of patient’s ability to perform daily living skills? FORMCHECKBOX Intoxication may be severe but responds to treatment so patient does not pose imminent danger to self or others. FORMCHECKBOX FORMCHECKBOX Has a serious medical problem he/she neglects during outpatient or intensive outpatient treatment. 0000027264 00000 n 0000016091 00000 n No FORMCHECKBOX Yes FORMCHECKBOX , if yes, FORMCHECKBOX Past FORMCHECKBOX Current Which one? (C) FORMCHECKBOX Most important thing in my life now (PR) 3. 0000031836 00000 n ____________________________11. 0000009242 00000 n __________________________ Drug? 0000035704 00000 n Have you ever attempted to discontinue your use of alcohol? Do you identify yourself with any particular cultural, ethnic background or community? Have you ever been physically abused? 0000030911 00000 n 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. No FORMCHECKBOX Yes FORMCHECKBOX if yes Does the patient need help accessing or selecting childcare? FORMCHECKBOX No FORMCHECKBOX Yes, if yes, what kind of help? FORMCHECKBOX Yes FORMCHECKBOX No If no, why not? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. CDP assessment of patient’s ability to attain and maintain abstinence: Unknown FORMCHECKBOX Good FORMCHECKBOX Moderate FORMCHECKBOX Poor FORMCHECKBOX As evidenced by _________________________________________________________________________________________6. Do you ever have homicidal thoughts? One or more of the following criteria met within the previous 12-month period indicates abuse. 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. high tolerance/consumption, compare to self-report of use. 1 FORMCHECKBOX Minimum relapse potential with some vulnerability. Have you ever been arrested or charged with any crime? Have you ever done anything while under the influence of alcohol or other drugs that you later regretted?

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