Table of Contents

ASSESSMENTs FOR SUBSTANCE USE DISORDER INTERVENTION AND TREATMENT SERVICES. 2

How to Document in a Substance Use Disorder Assessment 2

Initial Substance Use Treatment Assessment 5

GENERAL Tab. 5

EDUCATION & EMPLOYMENT Tab. 14

LEGAL Tab. 23

PHYSICAL HEALTH Tab. 26

MENTAL HEALTH Tab. 32

FAMILY & SOCIAL Tab. 40

SUBSTANCE USE Tab. 52

DIAGNOSIS Tab. 55

RECOMMENDATIONS Tab. 59

Update, Service End, Discharge, and Discharge Follow-up Assessments 79

ASSESSMENTs FOR SUBSTANCE USE DISORDER INTERVENTION AND TREATMENT SERVICES

How to Document in a Substance Use Disorder Assessment

To successfully document in a Substance Use Disorder Assessments, complete all the required data fields under each tab of the assessment and save the document in Closed Complete status. Closed Incomplete status is intended for use only when the client is no longer in services. The Ready for Review and Draft Status are not completed Assessments.

The business rules for each assessment are the same. Required data fields are indicated in each screen with a red asterisk *. Some required fields will prepopulate in the Update, Service End and Discharge Assessments and these fields can be edited. Other required fields must be filled in with each iteration of an assessment because they contain information used by the state to comply with federal reporting requirements. Many of the required fields are part of the four calculations available in the Substance Use (SU) Assessment for treatment. The calculations are used in the Initial Assessment only. The Severity Score calculation results in the display of Mild, Moderate, or Severe for the diagnosis. The Priority Population calculation result is displayed on the Recommendation tab. The American Society of Addiction Medicine (ASAM) Recommended Course of Treatment and Modifications to Treatment calculations are displayed on the Recommendation tab. All of these are explained in the instructions on the Diagnosis tab and the Recommendation tab. Many of the optional fields, in addition to required fields, are used to identify areas that need to be addressed in the Treatment/Service Plans.

The items in the assessment are designed to be answered for all adults and youth. There are items added to the employment section and Family Social tab of the assessment when the client profile indicates the person is 18 years old or older. All other items will display for all ages.

There are eleven assessment types for Substance Use Disorder Services.

· The Initial and Update SU Assessment are available for treatment services, and can be found under the left side Assessment menu.

· Service End SU Assessments can be accessed within the Service End screen.

· Discharge SU assessments is accessed within the Discharge screen.

· The SU Discharge Follow-up can be found on the left menu under the heading of Discharge. This document may only be accessed after the client has been discharged from services for a minimum of thirty days.

· The Initial Detoxification Assessment is available for detoxification services and can be found under the left side Assessment menu. This Assessment is only available if there is a Service Begin for a Detoxification level of care.

· Service End Detoxification Assessment and Discharge Detoxification Assessment can be accessed only within the Service End screen and the Discharge screen.

· The Detoxification Assessment Follow-up is under the heading of Discharge on the left menu after the client is discharged from services for a minimum of ten days.

· The Initial and Update Case Management Assessments are available for Substance Use Intervention services, and can be found under the left side Assessment menu, when an Open Case is in Closed Complete status. There is not a discharge or service end assessment for Case Management services.

The SU Assessment questions are displayed in a tab format. The questions are guides for the users or interviewers who may present the questions in whatever form necessary for the client. We encourage counselors use rapport building skills during the initial assessment to develop a treatment plan that assists the client in obtaining their treatment goals.

There are navigation buttons at the top right and bottom right corners, as well as the bottom center of the page.

Title: Tab - Description: Print screen of tab structure in SU Assessments.

Title: Navigation - Description: Print screen of navigation buttons in SU Assessments.

Each assessment type will have a section in the instructions. The instructions for documenting in each assessment type will have some duplication. The items in the Initial Substance Use (SU) Assessment represent the total set of questions for all the assessments. The Detoxification Assessment has a subset of questions from the SU Assessment and there are specific questions to address withdrawal symptoms for people withdrawing from alcohol or opioids. The Case Management Assessment has a subset of questions from the SU Assessment. There are unique items displayed only in the follow-up assessments.

The Update SU Assessment, Service End SU Assessment, Discharge SU Assessment, and the SU Discharge Follow-up all have items from the Initial Assessment. The items will:

· Display in blank and required status

· Display in edit status

· Display in view only status

· Display in a slightly modified version of the item

· Not display in that version of the assessment.

The same process was used for both the Detoxification and Case Management assessment types.

Initial Substance Use Treatment Assessment

GENERAL Tab

The General section has prompts and questions to gather information about the reasons the client is presenting for services; processes that the clinician uses during the assessment; when and where the Assessment took place; referral source and the client’s other provider services. The data fields and questions under the General tab are the same for all clients receiving all service types and of any age.

ASSESSMENT INFORMATION

Assessment Number (Generated by the CMBHS System)

Each assessment completed for a client and documented in CMBHS has a unique assessment number generated by the system. It is view only and cannot be changed by the User.

Assessment Date

The user records the date that the client was assessed. The system will default to the current day’s date.

If the assessment occurred on some other date before the current date, the user can change this field to the correct date. A future date cannot be entered.

If the assessment interview occurred on more than one day, enter the first date that the assessment interview began.

The system requires a full date using either of the following two formats: mmddyyyy or mm/dd/yyyy. When you enter the date using the mmddyyyy format (eight numbers with no slashes), the system automatically reformats and displays the date as mm/dd/yyyy.
CLICK IN the text box and TYPE IN the information.

Assessment Type

The system will auto-fill the Assessment Type (Initial, Update, Service End or Discharge). This is a view-only field and cannot be changed by users.

Contact Type

The user documents the contact type that best describes of how the Assessment interview was conducted with the client. CLICK ON one of the options available:

· Face to Face

· Telehealth

· Telephone

Assessment Site

The user documents the setting where the Assessment interview took place with the client. Information may have been obtained from the client or collaterals in several settings. Answer this question indicating where most of the contact with the client occurred.

· Select the assessment setting that best describes where the interview(s) took place.

· CLICK ON one of the items in the dropdown box:

Ambulance, Land	Boarding Home
Community IMD	Community setting (Community Mental Health Center)
Correctional Facility	Custodial Care Facility
Emergency Room	General medical hospital
Group Home	Home
Hospice	Hospital
Independent Laboratory	Inpatient Hospital
Inpatient Psychiatric Facility	Jail
Mobile	Mobile/Extended/Outreach
Not Applicable	Nursing facility
Office/Clinic	Other
Outpatient Hospital	Psychiatric Facility Partial Hospitalization
Psychiatric Residential Treatment Center	Residential Substance Abuse Treatment Facility
School	Service facility
State Mental Health Facility	State Mental Retardation Facility
State funded community hospital	State or Local Public Health Clinic

Referral Source. This field contains a required element from the Treatment Episodes Data Set Minimum Data Set. The user documents who referred the client to the provider for services.

CLICK ON one of the referral source options:

Community Health Service	Community Mental Health Services
Court Services/DWI/DUI	Department of Family Protective Services (Adult or Child Protective Services)
Drug Court	Family/Friend
Hospital (Community)	Hospital (State)
Insurance/Employee Assistance Program	Outreach, Screening, Assessment, and Referral (OSAR)
Peer Support/Recovery Support	Probation/Parole
School	Self (Client)
Substance Use Disorder Prevention/Intervention/ Treatment	Work/Employer
Community Service Provider (local, state, federal )

Comments

The user may enter comments in this box that relate to the Assessment Information fields. Only include information that relates to these fields.

· Comments will be entered into the client’s health record and will be seen by those that have the authority to view this part of the record.

· Under some circumstances, this may include the client. Always consider the consequences of entering sensitive information such as HIV status.

· This comments text box is optional.

· CLICK IN the text box and TYPE IN the information.

In the past 30 days

Presenting Problem

Document reason the client presented for services clearly and concisely in the client’s own words.

Substance Table

Primary, Secondary and Tertiary

This field contains a required element from the Treatment Episodes Data Set Minimum Data Set.

· If the client uses one drug, select answers in the row labeled Primary. If the client does not use one drug select None and the remainder of the items will not be required fields.

· If the client uses two drugs, fill in the fields on the Primary and Secondary rows.

· If the client uses three drugs, fill in the fields on the Primary, Secondary and Tertiary rows.

· If the client uses four or more drugs, fill in the fields on the Primary, Secondary and Tertiary rows and put information about the other drugs used by the client in the Comment text box.

Primary

What substances have you been using? - Answer the following question about the primary drug that the client uses in the first cell of the table.

· Select the Primary Substance Used by the client from the dropdown list.

· You may select a specific drug or a group of drugs, based on how much information is available and whichever best describes the drug the client uses.

· For substance abuse services, the client must have a “primary” drug used documented.

Route of Administration. This field contains a required element from the Treatment Episodes Data Set Minimum Data Set.

· Select the answer choice that represents how the client gets the substance into his/her body.

· The answer choices are:

§ Oral

§ Inhalation

§ Injection

§ Smoking

§ Other

· CLICK ON the blue arrow to the right of the dropdown box and CLICK ON your answer and move to the next cell.

· If the client uses more than one route of administration, select the usual route of admission.

· If you select Other, document the Other route of administration used by the client in the comments text box.

Frequency of Use. This field contains a required element from the Treatment Episodes Data Set Minimum Data Set. Document how frequently the client uses this drug by selecting one of the answer choices from the dropdown list.

· CLICK ON the blue arrow to display the answer choices. The answer choices for this question are:

§ No use in past month

§ 1-3 times in the past month

§ 1-2 times in the past week

§ 3-6 times in the last week

§ Daily

Age at First Use

What was the client’s age when they first used this drug? CLICK ON one of the options available:

Select from the following choices:

§ <8

§ 8

§ 9

§ 10

§ 11

§ 12

§ 13

§ 14

§ 15

§ 16

§ 17

§ 18

§ 19+

For drugs other than alcohol, these fields identify the age at which the client first used the respective substance. For alcohol, these fields record the age of first intoxication.

Secondary

· If the client uses a secondary substance, select the Secondary Substance used by the client from the dropdown list. If you select a substance on the row in the table labeled Secondary, then all the fields in that row will be required fields. See the above instructions for Route of Administration, Frequency of Use, and Age at First Use.

· If the client does not use a secondary substance, you may leave all the fields blank.

Tertiary

· If the client uses a third substance, select the Tertiary substance used by the client from the dropdown list. If you select a substance on the row in the table labeled Tertiary, then all the fields in that row will be required fields. See the above instructions for Route of Administration, Frequency of Use, and Age at First Use.

· If the client does not use a third substance, you may leave all the fields blank.

What substances do you seek? This field displays only if there are drugs listed in the table. It is a mandatory field. Use this text field to document the drugs the client seeks whether it is one of the drugs listed or another drug. The user documents substances that the client sought, if the preferred substance was not been available or accessible to the client. CLICK IN the text box and TYPE IN the information.

How many days have you used? How many days have you not used? Answer both items. The sum of the answers cannot exceed 30. This text field refers to the days of use within the past 30 days of any misused medication, or misused legal or illegal mind-altering substances. CLICK IN the text box and TYPE IN a number.

Comments Add additional information about the client’s substance use in the available text box. This comments text box is optional. CLICK IN the text box and TYPE IN the information.

Literacy, language or auditory barriers? The user documents language, literacy, or auditory barriers and issues that the client may have. CLICK IN the Yes or No radio button to answer.

Comments Add additional information about the client’s need for accommodation in the treatment setting in the available text box. This comments text box is optional.

OTHER SERVICE PROVIDERS The interviewer identifies who provides the client with support, services, treatment or guidance for their physical, mental, emotional, or spiritual health that impacts the client’s recovery. The user documents information about other current service providers delivering services to the client while the client is in treatment. Adding Current Service Providers is not required. However, if you click on the New Service Provider button, the fields in the detail screen will display required fields.

To enter Other Service Providers CLICK ON the New Service Provider button to access the detail screen. CLICK ON the arrow to the right of the Provider Type box that displays “None Selected”. CLICK ON the provider type that most closely describes the provider’s services. Click IN the Provider Name field and type the name. Click IN the Phone field and type the phone number. CLICK ON the add button to add the information. The user may add as many service providers as needed.

CAUTION:
If information is needed from these service providers, you may need to obtain the client’s consent to contact them for either written or verbal information.

Provider Type

The answer choices for this question are:

Provider Type	Provider Type Description
MH	A traditional provider of Mental Health Services to include a Psychologist, Social Worker, or Marriage & Family Therapist. May be a publicly or privately employed individual or group practice.
SA	Traditional provider of Substance Use Services. May be a publicly or privately employed individual or group practice.
Medical	A traditional Medical practitioner to include a physician or nurse, or home health agency. May be a publicly or privately employed individual or group practice.
Dental	A dentist, orthodontist, or dental surgeon. May be a publicly or privately employed individual or group practice.
Alternative	A “non-traditional” service provider that may not be part of the mainstream culture but may represent the beliefs of an ethnic or cultural minority or sub-group.
Spiritual	Qualified representative, clergy or lay, who spiritually supports, counsels and guides the client. Includes but is not limited to priests, rabbis, ministers, and imams.
Psychiatry	A medical doctor practicing as a psychiatrist.
Legal	An attorney or other person licensed to provide legal services.
Other	Person providing services to the client that does not fit into any of these categories.

· If you select Other as an answer, document what type of service is provided in the Comments text box below the table.

· CLICK IN the text box and TYPE IN the information.

Provider Name Document the Provider’s name, and credentials if available. This text field is required. CLICK IN the text box and TYPE IN the information.

Phone This text field is optional CLICK IN the text box and TYPE IN the information.

Comments Add comments about the client’s support system in the available text field. This comments text box is optional.

STAFF INFO (Information)

Interviewer

The name of the user who first created and started documenting the Assessment will display in this field as the default.

· If the name that displays is not that of the person who actually interviewed the client, the name must be changed.

· CLICK ON the dropdown menu to search for the name of the person who interviewed the client.

· Select the name by highlighting it and CLICK ON the name.

Primary Counselor

The system will display the name of the assigned primary counselor. If the client has not been assigned a primary counselor, no name will display.

Comments Add comments in the available text box related to staff information. This comments text box is optional.

EDUCATION & EMPLOYMENT Tab

Users document information about the client’s education and employment in this section.

EDUCATION Section

What is the highest grade in school you completed? This field contains a required element from the Treatment Episodes Data Set Minimum Data Set. This question is a Life History Screening question. Answers to life history screening questions result in the display of options for modification to treatment on the Recommendation tab. See the full description of modification to treatment on the Recommendation tab.

CLICK ON one of the options available that best represents the client’s answer.

· <6

· 6

· 7

· 8

· 9

· 10

· 11

· 12

· Bachelor

· Master

· Certification

· Other

If you didn’t finish school, why did you leave? This question is a Life History Screening question and displays for adult clients only. Answers to life history screening questions result in the display of options for modification to treatment on the Recommendation tab. See the full description of modification to treatment on the Recommendation tab. CLICK IN the text box and TYPE IN the information. Type In the available text box a summary of the client’s response

In what grade OR at what age did you start using alcohol or drugs? This question is a Life History Screening question. Answers to life history screening questions result in the display of options for modification to treatment on the Recommendation tab. See the full description of modification to treatment on the Recommendation tab. Answers to life history screening questions result in the display of options for modification to treatment on the Recommendation tab. See the full description of modification to treatment on the Recommendation tab. The field contains the highest school grade completed by the client. Select the dropdown list most appropriate to the client’s answer. Then CLICK ON the number that best represents the client’s answer.

Grade:

· None

· 2nd

· 3rd

· 4th

· 5th

· 6th

· 7th

· 8th

· 9th

· 10th

· 11th

· 12th

· College

· Other

Age

· <8

· 8

· 9

· 10

· 11

· 12

· 13

· 14

· 15

· 16

· 17

· 18

· 19+

Did you start using alcohol or drugs after problems in school began? This question is a Life History Screening question. Answers to life history screening questions result in the display of options for modification to treatment on the Recommendation tab. See the full description of modification to treatment on the Recommendation tab. Answers to life history screening questions result in the display of options for modification to treatment on the Recommendation tab. See the full description of modification to treatment on the Recommendation tab. CLICK IN the Yes or No radio button.

Did you ever need extra help in school? This question is a Life History Screening question. Answers to life history screening questions result in the display of options for modification to treatment on the Recommendation tab. See the full description of modification to treatment on the Recommendation tab. Answers to life history screening questions result in the display of options for modification to treatment on the Recommendation tab. See the full description of modification to treatment on the Recommendation tab. CLICK IN the Yes or No radio button.

If Yes, select: CLICK ON the answer that best describes the client’s response.

· English as a Second Language

· Special Education

· Speech Therapy

· Mobility Aid

· Behavioral Health Services

· Alternative School

What area of school caused you the most problems? This question is a Life History Screening question. Answers to life history screening questions result in the display of options for modification to treatment on the Recommendation tab. See the full description of modification to treatment is in the section on the Recommendation tab. This question is a required question. CLICK ON the answer that best describes the client’s response.

· Math

· Language

· Arts

· Physical Education

Have you gotten so high or sick from alcohol or drugs that it kept you from fulfilling work or school obligations? The answer is used in the Severity Score calculation. Please see full description of the severity score calculation in the Diagnosis tab section. The answer is used in the Dimension Calculator for the ASAM Recommended Course of Treatment. Please see full description of the Dimension calculation in the Recommendation tab section. CLICK IN the Yes or No radio button.

Have you spent less time at work or school so that you could drink or use drugs? The answer is used in the Severity Score calculation. Please see full description of the severity score calculation in the Diagnosis tab section. The answer is used in the Dimension Calculator for the ASAM Recommended Course of Treatment. Please see full description of the Dimension calculation in the Recommendation tab section. CLICK IN the Yes or No radio button.

In the last 12 months have you been bullied? CLICK IN the Yes or No radio button.

Are you currently in school? CLICK IN the Yes, No, or N/A radio button.

Would you like assistance with your educational status? CLICK IN the Yes or No radio button.

Would you like assistance with obtaining a GED? CLICK IN the Yes or No radio button.

Comments Add comments in the available text box related to staff information. This comments text box is optional. CLICK IN the text box and TYPE IN the information.

EMPLOYMENT Section (Education & Employment tab)

Are you currently employed?

· CLICK IN the Yes, No, or N/A radio button.

What is your employment status? This field contains a required element from the Treatment Episodes Data Set Minimum Data Set. The user documents the client’s employment status at the time of admission. CLICK ON one of the items in the dropdown list. The options in the dropdown list are:

Full time	36-40 hours per week including active duty members of the uniformed services
Part time	1-35 hours a week
Unemployed	0 hours a week; Looking for work during the past 30 days or on layoff from employment
Not in Labor Force	Not looking for work during the past 30 days or a student, homemaker, disabled, retired or an inmate of an institution.
Unknown	Client doesn’t know how to answer this item

Reason for Not In Labor Force? This field contains a required element from the Treatment Episodes Data Set Minimum Data Set. This item only displays if the answer is “Not in Labor Force” to the question “What is your employment status?” CLICK ON one of the items in the dropdown list. The options in the dropdown list are:

Disabled	Client has a formal status as “Disabled” established by declarations from doctors and documented as such with Social Security or the Office of Veteran Affairs.
Homemaker	Client is the primary person taking care of the dwelling and the occupants of the dwelling.
Inmate	Client was in a legally secured facility that keeps a person, otherwise able, from entering the labor force.
Retired	Client worked and formally retired from the labor force.
Student	Client attends school in any form.
Seasonal Worker	Client only works during specific times of the year.
Other	The client’s reason for not being in the labor force does not meet any of the criteria described in the list.
Not Applicable

What is the longest time you have held a full-time job? This question is a Life History Screening question. Answers to life history screening questions result in the display of options for modification to treatment on the Recommendation tab. See the full description of modification to treatment section on the Recommendation tab. CLICK ON one of the items in the dropdown list. The options in the dropdown list are:

· N/A

· 30 days

· 180 days

· 1 year

· 2-4 years

· 5+ years

Would you like assistance with your employment status? CLICK IN the Yes or No radio button.

What is your primary source of income? This field contains a required element from the Treatment Episodes Data Set Minimum Data Set. The user documents the client’s principal source of financial support. For children under 18, the user documents the parents’ primary source of income or financial support. CLICK ON one of the items in the dropdown list. The options in the dropdown list are:

· Disability

· Public Assistance

· Retirement/pension

· Wages/Salary

· Other

· None

Have you ever received income from SSI? This question is a Life History Screening question. Answers to life history screening questions result in the display of options for modification to treatment on the Recommendation tab. See the full description of modification to treatment section on the Recommendation tab. CLICK IN the Yes, No, N/A radio button.

When you work, what type of work do you do? This question is optional. CLICK IN the text box and TYPE IN the information.

Have you ever engaged in illegal activities for profit? This question is optional. CLICK IN the Yes or No radio button.

If yes, please explain. This question is optional. CLICK IN the text box and TYPE IN the information.

TYPE IN the available text box.

Are you currently active duty in the United States military? This question displays for adults only. CLICK IN the Yes or No radio button.

Have you ever served in the military? This question displays for adults only. This field contains a required element from the Treatment Episodes Data Set Minimum Data Set. CLICK IN the Yes, No, N/A radio button.

Did you serve in the National Guard, Reserves, Coast Guard or in any of the Active Duty Services? This is a question that displays for adult client only. This item is optional CLICK IN the Yes or No radio button.

If you served in the military what was the discharge status on your Defense Department Form 214? This question displays for adults only. This item will display only if the answer is yes to “Have you ever served in the military?” CLICK ON one of the items in the dropdown list. The options in the dropdown list are:

· Medical

· Honorable

· Other than Honorable

· Unknown

Would you like assistance with your Veterans Affairs Services? This field displays for adults only. CLICK IN the Yes or No radio button.

Comments Add text to document additional information the client shared about education or employment that is relevant to requested services. This comments text box is optional. CLICK IN the text box and TYPE IN the information.

LEGAL Tab

The user documents the client’s past legal history and current legal status.

Historical Legal Information

When you were growing up, did any of your household members go to prison? The ACE Questionnaire contains Adverse Childhood Experiences (ACEs) which are potentially traumatic events that can have negative, lasting effects on health and well-being. This question is from the ACE Questionnaire. CLICK IN the Yes or No radio button

If Yes, whom: CLICK ON one of the items in the dropdown list. The options in the dropdown list are:

· Mother

· Father

· Stepparent

· Sibling

· Grandparent

· In Home Relative

· Non-Relative In Home

· Foster Parent

Were you ever in trouble with the law? This question is a Life History Screening question. Answers to life history screening questions result in the display of options for modification to treatment on the Recommendation tab. See the full description of modification to treatment section on the Recommendation tab. CLICK IN the Yes or No radio button.

Were you ever arrested? This question is a Life History Screening question. Answers to life history screening questions result in the display of options for modification to treatment on the Recommendation tab. See the full description of modification to treatment section on the Recommendation tab. CLICK IN the Yes or No radio button.

Past legal status? CLICK ON one of the items in the dropdown list. The options in the dropdown list are:

· Past Probation

· Past Parole

· Past Incarceration

· N/A

Comments Add text to document additional information the client shared about legal experiences that are relevant to requested services. This comments text box is optional. CLICK IN the text box and TYPE IN the information.

Current Legal Information

What is your current legal status? CLICK ON one of the items in the dropdown list. The options in the dropdown list are:

· Jail or Prison

· Probation

· Parole

· Diversion Program

· Awaiting Trial

· Awaiting Sentencing

· NA

In the past 30 days, how many times have you been arrested? This field contains a required element from the Treatment Episodes Data Set Minimum Data Set. This question is a Life History Screening question. Answers to life history screening questions result in the display of options for modification to treatment on the Recommendation tab. See the full description of modification to treatment section on the Recommendation tab. TYPE a number in the available text box. Maximum characters are two. If the client had more than 96 arrests in the last 30 days, TYPE 96 in the text box and provide additional information in the Comments text box.

Would you like assistance with your legal status? CLICK IN the Yes or No radio button.

Who is your point of contact for Legal issues? TYPE the name of the person with whom the client is working to resolve the legal issues. There is only enough space for a name. Additional contact information may be documented in the Comments text box below or on the General tab in the Current Service Provider section. CLICK IN the text box and TYPE IN the information.

Comments Enter any additional information about the client’s legal issues that are relevant to requested services. This comments text box is optional. CLICK IN the text box and TYPE IN the information.

PHYSICAL HEALTH Tab

The user documents answers to medical questions specifically related to Substance Use Disorder symptoms and potential co-occurring medical conditions that may increase the severity of the consequences of substance use.

GENERAL/HISTORICAL Health

Please answer the following questions. In the past 12 months:

Do you have a history of medical conditions or medical problems? This question is optional. CLICK IN the Yes or No radio button.

Have you used larger amounts of alcohol or drugs or used them for a longer time than you planned? This answer is used in the Severity Score calculation. Please see full description of the severity score calculation in the Diagnosis tab section. This answer is used in the Dimension Calculator for the ASAM Recommended Course of Treatment. Please see full description of the Dimension calculation in the Recommendation tab section. CLICK IN the Yes or No radio button.

Have you tried to cut down on alcohol and drugs and were unable to do it? This answer is used in the Severity Score calculation. Please see full description of the severity score calculation in the Diagnosis tab section. This answer is used in the Dimension Calculator for the ASAM Recommended Course of Treatment. Please see full description of the Dimension calculation in the Recommendation tab section. CLICK IN the Yes or No radio button.

Have you gotten so high or sick from alcohol or drugs that it caused an accident or became a danger to you or others? This answer is used in the Severity Score calculation. Please see full description of the severity score calculation in the Diagnosis tab section. This answer is used in the Dimension Calculator for the ASAM Recommended Course of Treatment. Please see full description of the Dimension calculation in the Recommendation tab section. CLICK IN the Yes or No radio button.

Have you gotten so high or sick from alcohol or drugs that it caused physical health or medical problems? This answer is used in the Severity Score calculation. Please see full description of the severity score calculation in the Diagnosis tab section. This answer is used in the Dimension Calculator for the ASAM Recommended Course of Treatment. Please see full description of the Dimension calculation in the Recommendation tab section. CLICK IN the Yes or No radio button.

Have you increased the amount of alcohol or drugs you were taking so that you could get the same effects as before? This answer is used in the Severity Score calculation. Please see full description of the severity score calculation in the Diagnosis tab section. This answer is used in the Dimension Calculator for the ASAM Recommended Course of Treatment. Please see full description of the Dimension calculation in the Recommendation tab section. CLICK IN the Yes or No radio button.

Have you gotten sick or had withdrawals when you quit drinking or missed taking a drug? This answer is used in the Severity Score calculation. Please see full description of the severity score calculation in the Diagnosis tab section. This answer is used in the Dimension Calculator for the ASAM Recommended Course of Treatment. Please see full description of the Dimension calculation in the Recommendation tab section. CLICK IN the Yes or No radio button.

Have you continued to drink or take drugs to avoid withdrawals or to keep from getting sick? This answer is used in the Severity Score calculation. Please see full description of the severity score calculation in the Diagnosis tab section. This answer is used in the Dimension Calculator for the ASAM Recommended Course of Treatment. Please see full description of the Dimension calculation in the Recommendation tab section. CLICK IN the Yes or No radio button.

Has your physical health been so bad that it resulted in hospitalization? CLICK IN the Yes or No radio button.

Comments Type in the available text box any additional information obtained during the interview with the client that relates to physical health issues relevant to the delivery of services. This comments text box is optional. CLICK IN the text box and TYPE IN the information.

CURRENT Health

Do you currently have a chronic medical condition? CLICK IN the Yes or No radio button.

If yes, explain. The system displays this question when the answer is yes to “Do you currently have a chronic medical condition?” Type in the available text box clear and concise information about the client’s chronic health issues that impact the client’s services.

Are you currently taking any prescribed medications for medical reasons? CLICK IN the Yes or No radio button.

If yes, what are they? The system displays this question when the answer is yes to “Are you currently taking any prescribed medications for medical reasons?” TYPE IN the available text box clear and concise information about the client’s medications.

Are you enrolled in Medication Assisted Treatment? This field contains a required element from the Treatment Episodes Data Set Minimum Data Set. The answer “Yes” to this item will result in this field displaying on the client’s treatment plan. CLICK IN the Yes or No radio button.

Are you prescribed any of the following? This field will only display if the answer to “Are you enrolled in Medication Assisted Treatment?” is “Yes”. CLICK ON one of the items in the dropdown list. The options in the dropdown list are:

· Naloxone

· Suboxone

· Methadone

· Subutex

· Buprenorphine

· Vivitrol

Have you recently stopped prescription use of Vivitrol (naltrexone), methadone, or buprenorphine (Suboxone, Subutex)? Yes or No. CLICK IN the Yes or No radio button. The answer to this item is used in the Priority Population calculation.

Have you experienced a non-fatal overdose? Yes or No. CLICK IN the Yes or No radio button. The answer to this item is used in the Priority Population calculation.

If “yes” then, have you ever been administered naloxone or Narcan? This question displays when the answer is yes to “Have you experienced a non-fatal overdose?” CLICK IN the Yes or No radio button. The answer to this item is used in the Priority Population calculation.

In the past 30 days, how many days have you been hospitalized? Type a number in the available text box. Maximum characters are two. If the client had more than 96 hospitalizations in the last 30 days, Type 96 in the text box and provide additional information in the Comments text box.

Have you given birth in the past 18 months? Yes or No. CLICK IN the Yes or No radio button. This question and the next question display only when the client profile choices are “Female”.

If “yes” then, have you used opioids in the past 3 years? This question displays when the answer is yes to “Have you given birth in the past 18 months?” CLICK IN the Yes or No radio button. The answer to this item is used in the Priority Population calculation.

Are you currently pregnant? This field contains a required element from the Treatment Episodes Data Set Minimum Data Set. This field specifies whether the client was pregnant at the time of admission. This question and the next question display only when the client profile choices are “Female”. CLICK IN the Yes or No radio button.

Do you think you could be pregnant? This item only displays if the answer is no to “Are you currently pregnant?” CLICK IN the Yes, No, or Unknown radio button.

Are you using tobacco? CLICK IN the Yes or No radio button.

Would you like assistance to cut back or quit? This question is only displayed, and is required, if you answered YES to “Are you using tobacco?” This field generates a tobacco cessation referral. CLICK IN the Yes or No radio button.

Do you have any allergies? CLICK IN the Yes or No radio button.

If yes, what are they? This question is only displayed, and is required, if you answered YES to “Do you have any allergies?” CLICK IN the text box and TYPE IN the information. TYPE IN the available text box clear and concise information about the client’s allergies that impact the client’s services.

Would you like assistance with: CLICK IN the box next to each item representing a service for which the client would like to receive assistance. These are things that can be entered into the Referral screens to assist the client’s course of treatment or discharge support.

· Physical health

· Dental health

· Vision care

· Medical Insurance

· Medical Prescription

· HIV Medical Care

· STD/STI Services

· HCV Services

· Prenatal Care

· Reproductive/Sexual Health

Comments TYPE IN the available text box any additional information obtained during the interview with the client that relates to physical health issues relevant to the delivery of services.

MENTAL HEALTH Tab

Clinicians document information about the client’s mental health when not under the influence of mind-altering substances. During the interview, Clinicians need to ensure the client understands that the symptoms describe on this tab represent things that happen when the client is not under the influence of mind altering substances. The information gathered is historical and current information.

Historical Information

Did you receive childhood mental health services? This question is a Life History Screening question. Answers to life history screening questions result in the display of options for modification to treatment on the Recommendation tab. See the full description of modification to treatment section on the Recommendation tab. CLICK IN the Yes, No, or Unknown radio button

Other than a problem with substance use, have you been told you have mental health difficulties or disorders? This question is a Life History Screening question. Answers to life history screening questions result in the display of options for modification to treatment on the Recommendation tab. See the full description of modification to treatment section on the Recommendation tab. CLICK IN the Yes or No radio button.

If yes, what were you told: This field displays when the answer is yes to “Other than a problem with substance use, have you been told you have mental health difficulties or disorders? “CLICK IN the text box and TYPE IN the information. (text box 250 characters)

Was a household member depressed or mentally ill? This question is optional. CLICK IN the Yes or No radio button.

Did a household member attempt suicide? This question comes from the ACE Questionnaire. This question screens for suicide risk factors. CLICK IN the Yes or No radio button.

Have you experienced changes in sleep, eating or your weight? This question screens for suicide risk factors. This question is optional. CLICK IN the Yes or No radio button

Have you ever:

Heard voices no one else could hear or seen objects or things which others could not see? This question is optional. CLICK IN the Yes or No radio button

Felt that people had something against you, without them necessarily saying so, or that someone or some group may be trying to influence your thoughts or behavior? This question is optional. CLICK IN the Yes or No radio button

Had a period of time table

When you were so full of energy and your ideas came very rapidly? This question is optional. CLICK IN the Yes or No radio button

When you talked nearly non-stop? This question is optional. CLICK IN the Yes or No radio button

When you needed little sleep? This question is optional. CLICK IN the Yes or No radio button

Experienced feelings of sadness that were unbearable? This question is optional. CLICK IN the Yes or No radio button

Lost pleasure in all or almost all activities? This question is optional. CLICK IN the Yes or No radio button

Felt worthless or have excessive or inappropriate guilt? This question is optional. CLICK IN the Yes or No radio button

Been unable to make decisions, concentrate, or think? This question is optional. CLICK IN the Yes or No radio button

Getting along with others without arguing or fighting? This question is optional. CLICK IN the Yes or No radio button

Had difficulty managing anger? This question is optional. CLICK IN the Yes or No radio button

Experienced excessive anxiety and worry? This question is optional. CLICK IN the Yes or No radio button

Believed you could do almost anything? This question is optional. CLICK IN the Yes or No radio button

Engaged in self-injurious behavior? This question is optional. CLICK IN the Yes or No radio button

Tried to hurt or kill an animal? This question is optional. CLICK IN the Yes or No radio button

Tried to hurt or kill a person? This question is optional. CLICK IN the Yes or No radio button

Intentionally damaged property that was not yours? This question is optional. CLICK IN the Yes or No radio button

How many times have you been treated for psychological problems in a hospital/residential treatment setting? CLICK ON one of the options available that best matches the client’s answer.

· 0

· 1

· 2

· 3

· 4

· 5

· 6+

Has your use of alcohol or drugs caused emotional or psychological problems? The answer is used in the Severity Score calculation. Please see full description of the severity score calculation in the Diagnosis tab section. The answer is used in the Dimension Calculator for the ASAM Recommended Course of Treatment. Please see full description of the Dimension calculation in the Recommendation tab section. CLICK IN the Yes or No radio button.

Do you frequently have difficulties with any of the following: The items associated with this statement are included in the Life History Screening questions. Answers to life history screening questions result in the display of options for modification to treatment on the Recommendation tab. See the full description of modification to treatment section on the Recommendation tab.

Concentrating and paying attention? CLICK IN the Yes or No radio button

Understanding what adults were telling you? CLICK IN the Yes or No radio button

Remembering things? CLICK IN the Yes or No radio button

Following rules and instructions? CLICK IN the Yes or No radio button

Getting along with others without arguing or fighting? CLICK IN the Yes or No radio button

Being on time? CLICK IN the Yes or No radio button

Keeping enough money to last you throughout the month? CLICK IN the Yes or No radio button

Doing things that later you wish you hadn’t done? CLICK IN the Yes or No radio button

Getting really upset at little things or what people have told you are little? CLICK IN the Yes or No radio button

Concentrating and paying attention? CLICK IN the Yes or No radio button

Understanding what adults were telling you? CLICK IN the Yes or No radio button

Remembering things? CLICK IN the Yes or No radio button

Following rules and instructions? CLICK IN the Yes or No radio button

Getting along with others without arguing or fighting? CLICK IN the Yes or No radio button

Being on time? CLICK IN the Yes or No radio button

Keeping enough money to last you throughout the month? CLICK IN the Yes or No radio button

Doing things that later you wish you hadn’t done? CLICK IN the Yes or No radio button

Getting really upset at little things or what people have told you are little? CLICK IN the Yes or No radio button

Forgetting or missing appointments? CLICK IN the Yes or No radio button

Being surprised when you are in trouble? CLICK IN the Yes or No radio button

Have you wished you were dead or wished you could go to sleep and not wake up? CLICK IN the Yes or No radio button

Have you ever tried to commit suicide? This question screens for suicide risk factors. This question is a Life History Screening question. This question is a Life History Screening question. Answers to life history screening questions result in the display of options for modification to treatment on the Recommendation tab. See the full description of modification to treatment section on the Recommendation tab. Answers to life history screening questions result in the display of options for modification to treatment on the Recommendation tab. See the full description of modification to treatment section on the Recommendation tab. CLICK IN the Yes or No radio button

Comments. This text field is for additional mental health comments. This comments text box is optional. CLICK IN the text box and TYPE IN the information.

Current Information

Are you currently seeing a Licensed Professional of the Healing Arts for any mental health condition or problem? This text field is optional. CLICK IN the Yes or No radio button. This field contains whether the client has a psychiatric problem in additional to his or her alcohol or drug use problem.

Conditional If yes, what are you being treated for? This text field is optional. CLICK IN the text box and TYPE IN the information.

Conditional If yes, are you taking any prescription medications? This text field is optional. CLICK IN the text box and TYPE IN the information.

Conditional If yes, what are they? This text field is optional. CLICK IN the text box and TYPE IN the information.

Are you currently having thoughts of killing yourself? This question screens for suicide risk factors. This question is optional. CLICK IN the Yes or No radio button

Would you like assistance with your mental health? This question is optional. CLICK IN the Yes or No radio button

Comments. This text field is for additional mental health comments. This comments text box is optional. CLICK IN the text box and TYPE IN the information.

FAMILY & SOCIAL Tab

Users document information about the client’s family, social and living environment in this section.

Family History

Were you raised by someone other than your biological/birth parents? This question is a Life History Screening question. Answers to life history screening questions result in the display of options for modification to treatment on the Recommendation tab. See the full description of modification to treatment section on the Recommendation tab. CLICK IN the Yes or No radio button.

How many living situations (different primary caregiver) did you have while you were growing up? This question is a Life History Screening question. Answers to life history screening questions result in the display of options for modification to treatment on the Recommendation tab. See the full description of modification to treatment section on the Recommendation tab. CLICK IN the text box and TYPE IN the information.

Did you live with anyone who was a problem drinker or alcoholic or who used street drugs? This question comes from the ACE Questionnaire. CLICK IN the Yes or No radio button.

Did a parent or other adult in the household often: This section has question that come from the ACE Questionnaire.

Swear at you, insult you, put you down or humiliate you? OR

Act in a way that made you afraid that you might by physically hurt? CLICK IN the Yes or No radio button.

Push, grab, slap, or throw something at you? OR

Ever hit you so hard that you had marks or were injured? CLICK IN the Yes or No radio button.

Did an adult or person at least 5 years older than you ever:

Touch or fondle you or have you touch their body in a sexual way? OR

Attempt or actually have oral, anal or vaginal intercourse with you? CLICK IN the Yes or No radio button.

Did you often feel that: This section has question that come from the ACE Questionnaire.

No one in your family loved you or thought you were important or special? OR

Your family didn’t look out for each other, feel close to each other, or support each other? CLICK IN the Yes or No radio button.

You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? OR

Your parents were too drunk or high to take care of you or take you to the doctor if you needed it? CLICK IN the Yes or No radio button.

Were your parents ever separated or divorced? CLICK IN the Yes or No radio button.

Was your mother or stepmother: This section has question that come from the ACE Questionnaire.

Often pushed, grabbed, slapped, or had something thrown at her? OR

Sometimes, often kicked, bitten, hit with a fist, or hit with something hard? OR

Ever repeatedly hit at least a few minutes or threatened with a gun or knife? CLICK IN the Yes or No radio button.

Comments This text field is for additional family history comments. This comments text box is optional. CLICK IN the text box and TYPE IN the information.

Maternal Alcohol Use

To your knowledge, did your mother ever drink alcohol that caused problems for her or others around her? This question is a Life History Screening question. Answers to life history screening questions result in the display of options for modification to treatment on the Recommendation tab. See the full description of modification to treatment section on the Recommendation tab. CLICK IN the Yes or No radio button

Did your mother drink alcohol when you were young? This question is a Life History Screening question. Answers to life history screening questions result in the display of options for modification to treatment on the Recommendation tab. See the full description of modification to treatment section on the Recommendation tab. CLICK IN the Yes or No radio button

Did your mother drink alcohol while she was pregnant with you? This question is a Life History Screening question. Answers to life history screening questions result in the display of options for modification to treatment on the Recommendation tab. See the full description of modification to treatment section on the Recommendation tab. CLICK IN the Yes or No radio button

Has anyone ever said anything to you about your mother’s drinking during her pregnancy with you? This question is a Life History Screening question. Answers to life history screening questions result in the display of options for modification to treatment on the Recommendation tab. See the full description of modification to treatment section on the Recommendation tab. CLICK IN the Yes or No radio button

Comments This text field is for additional maternal alcohol use comments. This comments text box is optional. CLICK IN the text box and TYPE IN the information.

Living Situation

As an adult, have you ever lived on your own? This question is a Life History Screening question. Answers to life history screening questions result in the display of options for modification to treatment on the Recommendation tab. See the full description of modification to treatment section on the Recommendation tab. CLICK IN the Yes or No radio button

How long have you lived on your own at any one time? This question displays for adult clients only. CLICK ON one of the options available:

· NA

· 3 months

· 6 months

· 1 year

· 2 years

· 3 years

· 5 years

· Over 5 years

Have you ever:

Been homeless? This question is optional. CLICK IN the Yes or No radio button

Been without any family, friends, or caretakers? This question is optional. CLICK IN the Yes or No radio button

Had state protective services involved with your family? This question is optional. CLICK IN the Yes or No radio button

As a child? This question is optional. CLICK IN the Yes or No radio button

Since being an adult? This question displays for adult clients only. This question is optional. CLICK IN the Yes or No radio button

Had a history of Intimate Partner Violence? This question is optional. CLICK IN the Yes or No radio button

Been bullied at home? This question screens for suicide risk factors. This question is optional. CLICK IN the Yes or No radio button

Comments This text field is for additional trauma-related comments. This comments text box is optional. CLICK IN the text box and TYPE IN the information.

Current Trauma

Do you currently feel safe where you live? This question displays for adult clients only. CLICK IN the Yes or No radio button

Do you currently feel safe with the people in your life? This question displays for adult clients only. CLICK IN the Yes or No radio button

Trauma Comments. This text field is for additional trauma-related comments. This comments text box is optional. CLICK IN the text box and TYPE IN the information.

Current Social Status

What is your living situation? This field contains a required element from the Treatment Episodes Data Set Minimum Data Set. This field contains the client’s living status including homeless, living with parents, in a supervised setting or living on his or her own. This question is a Life History Screening question. Answers to life history screening questions result in the display of options for modification to treatment on the Recommendation tab. See the full description of modification to treatment section on the Recommendation tab.

CLICK ON one of the options available:

Term	Treatment Episodes Data Set Minimum Data Set definition
Dependent	Clients living in a supervised setting such as a residential institution, halfway house, or group home, and children under the age of 18 living with parents, relatives, or guardians or in foster care
Independent	Clients living alone or with others without supervision
Homeless	Clients with no fixed address; includes shelters

In the last 30 days have you been released from a secured environment such as residential substance use disorder treatment program, jail, or prison? Yes or No. CLICK IN the Yes or No radio button.

If “yes”, in the year before you entered the controlled environment did you use opioids? This question displays when the answer is anything other than yes to the question “In the last 30 days have you been released from a secured environment such as residential substance use disorder treatment program, jail, or prison?” CLICK IN in the Yes or No radio button. The answer to this item is used in the Priority Population calculation.

Marital status:

This field contains a required element from the Treatment Episodes Data Set Minimum Data Set.

This field contains client’s marital status.

Divorced
Never Married	Includes clients whose only marriage was annulled
Now Married	Includes those living together as married
Separated	Includes those separated legally or otherwise absent from spouse because of marital discord
Widowed

How many children do you have under the age of 18? CLICK IN the text box and TYPE IN the information.

List your Children Table (conditional—displays only if the answer is more than 0 to How many children do you have under the age of 18?)

Child Name: CLICK IN the text box and TYPE IN the information.

Age: CLICK IN the text box and TYPE IN the information.

Gender: CLICK ON one of the options available:

· Male

· Female

· Transgender

Legal Custody CLICK ON one of the options available:

· Self

· Other Biological Parent

· Joint

· DFPS TIA, Foster

· TDCJ TIA, Detention

· Paternal Family

· Maternal Family

· Adoption Family

Are you currently working on Reunification? CLICK IN the Yes or No radio button

Would you like assistance with Reunification? CLICK IN the Yes or No radio button

Have you gotten so high or sick from alcohol or drugs that it kept you from fulfilling your family obligations? The answer is used in the Severity Score calculation. Please see full description of the severity score calculation in the Diagnosis tab section. The answer is used in the Dimension Calculator for the ASAM Recommended Course of Treatment. Please see full description of the Dimension calculation in the Recommendation tab section. CLICK IN the Yes or No radio button.

Have you spent less time with your support system so that you could drink or use drugs?

The answer is used in the Severity Score calculation. Please see full description of the severity score calculation in the Diagnosis tab section. The answer is used in the Dimension Calculator for the ASAM Recommended Course of Treatment. Please see full description of the Dimension calculation in the Recommendation tab section. CLICK IN the Yes or No radio button.

Have you spent a lot of time getting alcohol or drugs, using them or recovering from their use?

Has your use of alcohol or drugs caused problems with your support system?

In the past 30 days, how many times have you attended self-help groups? (e. g. AA, NA, etc.)

This field contains a required element from the Treatment Episodes Data Set Minimum Set. This field contains the number of times the client has attended a self-help group in the past 30 days preceding the date of admission to treatment services. CLICK ON one of the options available:

· No attendance in the past month

· 1-3 times in the past month

· 4-7 times in the past month

· 8-15 times in the past month

· 16-30 times in the past month

· Some attendance in the past month, but frequency unknown

In the past 30 days, how many times have you attended a community support group? This field contains the number of times the client has attended a community support group in the past 30 days non-affiliated with substance use services. CLICK ON one of the options available:

· No attendance in the past month

· 1-3 times in the past month

· 4-7 times in the past month

· 8-15 times in the past month

· 16-30 times in the past month

· Some attendance in the past month, but frequency unknown

Do you do anything for fun? This question is optional. CLICK IN the Yes or No radio button

Conditional If yes, please explain. This text field is optional. CLICK IN the text box and TYPE IN the information.

Conditional if No to “Do you do anything for fun?” Does anything stop you from doing the above? This question is optional. CLICK ON one of the options available:

· Physical Limitations

· Transportation

· Education/Employment

· Family

· Finances

· Substance Use

Do you have any spiritual practices? This question is optional. CLICK IN the Yes or No radio button

If yes, please explain. This text field is optional. CLICK IN the text box and TYPE IN the information.

How many people do you trust? This question is optional. CLICK ON one of the options available:

· 0-2

· 3-5

· 5+

How many people do you rely upon? This question is optional. CLICK ON one of the options available:

· 0-2

· 3-5

· 5+

Do any of your close friends or family use alcohol or other drugs? This question is optional. CLICK IN the Yes or No

Do you and/or your friends/family have access to naloxone or Narcan to reverse an overdose? CLICK IN the Yes or No radio button.

In the last twelve months have you: CLICK ON one of the options available:

· Changed your friends

· Changed the type of clothing (gang colors, gang symbols, gang type clothing)

· Experienced school problems (truancy, lost interest, suspended, detention)

· Distanced yourself from your support system

· Been involved in criminal justice system

· Do you need any help with the following?

Comments. This text field is for additional living situation and family dynamic comments. This comments text box is optional. CLICK IN the text box and TYPE IN the information.

SUBSTANCE USE Tab

Users document information about the client’s substance use in this section.

High Risk Behaviors

Users document information about the client’s high-risk behaviors in this section.

Have you ever:

Injected drugs? CLICK IN the Yes or No radio button

Shared injecting equipment? CLICK IN the Yes or No radio button

Shared equipment for snorting drugs? CLICK IN the Yes or No radio button

Had unprotected sex without condoms or latex barriers? CLICK IN the Yes or No radio button

Had unprotected sex with someone who injects drugs? CLICK IN the Yes or No radio button

Do you have tattoos or piercings? CLICK IN the Yes or No radio button

Have you had a persistent cough (longer than three months) and not visited a doctor? CLICK IN the Yes or No radio button

Have you been tested (screened for TB) within the past year? CLICK IN the Yes or No radio button

Comments This text field is for additional high risk behavior comments. This comments text box is optional. CLICK IN the text box and TYPE IN the information.

Substance Use

Age at first use of any substances? CLICK ON one of the options available:

· <6

· 6

· 7

· 8

· 9

· 10

· 11

· 12

· 13

· 14

· 15

· 16

· 17

· 18

· 18+

Have you ever sought Substance Use Treatment before today? CLICK IN the Yes or No radio button

Treatment Services Received Table:

Number of Episodes

CLICK ON to select client Treatment Received

· Residential Detoxification Services (ASAM Level 3.7 Withdrawal Management)

· Ambulatory Detoxification Services (ASAM Level 2 Withdrawal Management)

· Intensive Residential Services (ASAM Level 3.5 Clinically Managed - Intensity Residential Services)

· Supportive Residential Services (ASAM Level 3.1 Clinically Managed – Low Intensity Residential Services)

· Outpatient Services (ASAM Level 1 Outpatient Services)

· Outpatient Services (ASAM Level 2.1 Intensive Outpatient Services)

· Medically Assisted Treatment for substance use

Sum of number of prior treatment episodes. This field contains a required element from the Treatment Episodes Data Set Minimum Data Set.

In the past when you stopped using, have you had any of the following: CLICK IN the box next to each item the client disclosed:

· Shakes/Tremors

· Blackouts

· Memory Lapses

· Cravings

· Vomiting

· Nausea

· Profuse sweating

· Seizures

· Delirium Tremors (DT)

· Anxiety

· Hallucinations (Visual, Tactile, Auditory)

· Headaches

Comments This text field is for additional historical detoxification comments. This comments text box is optional. CLICK IN the text box and TYPE IN the information.

DIAGNOSIS Tab

Strengths and Limitations

Texas Administrative Code 25, Part 1, Chapter 448, Subchapter H Rule 448.803 Assessment requires a description of client’s strengths and weaknesses as well as a comprehensive list of client’s problems, needs and strengths for each assessment.

Client's Strengths CLICK IN the text box and TYPE IN the information.

Client's Limitations CLICK IN the text box and TYPE IN the information.

CLICK ON the Calculate button to calculate the Severity Score. The result of the calculation will display Mild, Moderate, Severe after the words Severity Score. The table below shows the calculation and the source of the scores.

Severity	Scores used in the Calculator
Mild	2-4 symptoms/questions answered yes;
Moderate	5-7 symptoms/questions answered yes;
Severe	8+/questions answered yes
Tab	Questions	Answers
Education Tab:	Have you gotten so high or sick from alcohol or drugs that it kept you from fulfilling work or school obligations?	Answer: Yes = 1; No = 0
	Have you spent less time at work or school so that you could drink or use drugs?	Answer: Yes = 1; No = 0
Physical Tab	Have you used larger amounts of alcohol or drugs or used them for a longer time than you planned?	Answer: Yes = 1; No = 0
	Have you tried to cut down on alcohol and drugs and were unable to do it?	Answer: Yes = 1; No = 0
	Have you gotten so high or sick from alcohol or drugs that it caused an accident or became a danger to you or others?	Answer: Yes = 1; No = 0
	Have you gotten so high or sick from alcohol or drugs that it caused physical health or medical problems?	Answer: Yes = 1; No = 0
	Have you increased the amount of alcohol or drugs you were taking so that you could get the same effects as before?	Answer: Yes = 1; No = 0
	Have you gotten sick or had withdrawals if you quit drinking or missed taking a drug?	Answer: Yes = 1; No = 0
	Have you continued to drink or take drugs to avoid withdrawals or to keep from getting sick?	Answer: Yes = 1; No = 0
Mental Health Tab	Has your use of alcohol or drugs caused emotional or psychological problems?	Answer: Yes = 1; No = 0
Family and Social Tab:	Have you gotten so high or sick from alcohol or drugs that it kept you from fulfilling your family obligations?	Answer: Yes = 1; No = 0
	Have you spent less time with your support system so that you could drink or use drugs?	Answer: Yes = 1; No = 0
	Have you spent a lot of time getting alcohol or drugs, using them or recovering from their use?	Answer: Yes = 1; No = 0
	Has your use of alcohol or drugs caused problems with your support system?	Answer: Yes = 1; No = 0

The selection of diagnoses is done in the rows displayed. The clinician may enter up to 18 diagnoses. The clinician needs to ensure the diagnosis associated with the number one (1) is the diagnosis being treated. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM), the diagnosis being treated is referred to as the Principal Diagnosis. The clinician may arrange the numbers next to each line in the order of treatment services. The calculated severity will be display only based on the diagnostic-related questions throughout the assessment. The diagnostic-related questions can be found on the physical health, mental health, family and social, and substance use tabs. The system will rearrange the diagnosis so they are displayed in the order the clinician selected when the clinician adds the diagnoses. To add the diagnosis or diagnoses, the clinician needs to CLICK ON the Add button.

Order of Treatment Services table

The search method allows the clinician to type in three characters associated with the code or five characters associated with the diagnosis description. The system will display all the codes related to the information typed in the row. The clinician needs to CLICK ON the code the represents the diagnosis supported by the symptoms discovered during the assessment which match the criteria in the DSM.

Justification CLICK ON the option that describes the reason the diagnosis code was selected.

· By client report

· By clinician observation

· By collateral report

· By history

· By impression

· By physician report

Comments This text field is for additional diagnostic comments. This comments text box is optional. CLICK IN the text box and TYPE IN the information.

RECOMMENDATIONS Tab

The content of this tab shows the results of three calculations and a list of things for which the client may need assistance.

Priority Population Status

View Only (Explain calculation and show formula with questions associated)

· Pregnant Injecting Drug User

· Pregnant Substance User

· Injecting Drug User

· High Risk for Overdose

· Referred by DFPS

· Priority Population Designation Not Met

The table below shows the items used to calculate the status of Priority Population.

	Priority Population Label and Items in the SU Initial Assessment	Scores used in the Calculator
	Pregnant and Injecting
Tab	Questions	Answers
General tab	Route of administration? The answer to this item is used in the Priority Population calculation.	Answer: Injection =1
General/Historical Health:	Are you currently pregnant? The answer to this item is used in the Priority Population calculation.	Answer: Yes = 1; No = 0
	Do you think you could be pregnant? The answer to this item is used in the Priority Population calculation.	Answer: Yes = 1; No = 0
	Pregnant	Answer: Yes = 1; No = 0
Tab	Question	Answers
General/Historical Health	Are you currently pregnant? The answer to this item is used in the Priority Population calculation.	Answer: Yes = 1; No = 0
	Injecting
Tab	Question	Answers
General tab	Route of administration? The answer to this item is used in the Priority Population calculation.	Answer: Injection =1
	High Risk for Overdose	Answer: Yes = 1; No = 0
Tab	Questions	Answers
Current Health	Have you recently stopped prescription use of Vivitrol (naltrexone), methadone, or buprenorphine (Suboxone, Subutex)?	Answer: Yes = 1; No = 0
	Have you experience a non-fatal overdose?	Answer: Yes = 1; No = 0
	If “yes” then, have you ever been administered naloxone or Narcan? This question displays when the answer is yes to “Have you experienced a non-fatal overdose?”	Answer: Yes=1 ; No = 0
	Have you given birth in the past 18 months?	Answer: Yes=1; No=0
	If “yes” then, have you used opioids in the past 3 years? This question displays when the answer is yes to “Have you given birth in the past 18 months?”	Answer: Yes = 1; No = 0
	DFPS
Tab	Question	Answers
General tab	Referral Source	Answer: DFPS =1

ASAM Recommended Course of Treatment

The ASAM Recommended Course of Treatment is a View Only field. The array of services displayed are a result of several factors obtained from questions in the assessment. The possible services listed in the order of treatment services are:

· Residential Detoxification

· Ambulatory Detoxification

· Residential

· Outpatient Services

· Medication Assisted Treatment

· Recovery Support Services

The reference to Residential services included both intensive and support residential services shown in the service array offered by SU contractors.

Levels of Care in the HHSC service array are:

· Residential Detoxification

· Intensive Residential

· Supportive Residential

· Outpatient Services

· Medication Assisted Treatment

· Ambulatory Detoxification

· Recovery Support Services

The table shows the recommended course of treatment for each Substance Use Disorder. The method of determining the course of treatment includes the following elements in the calculation: Diagnosis + Severity + Dimension Score + Medication Assisted Treatment = Recommended Course of Treatment. The Severity component is a calculated field also based upon responses to items in the SU assessment. (See the table in the section for the Diagnosis Tab.) The Dimension component is a sum of the answers to questions that are grouped in the ASAM Dimensions. The assumption for establishing values for the answers to the dimension questions was based upon the risk of the client leaving services—the lower the number the less likely the person would leave services. The higher the number the more likely stay in services. The sum of those scores indicates the volume of symptoms containd in the assessment resulting in a higher need for services. A person with an Opioid Disorder not receiving Medication Assisted Treatment (MAT) is considered higher risk when the volume of symptoms is between 50 and 63.

ASAM Dimensions

Dimension 1: Acute Intoxication and/or Withdrawal Potential

Dimension 2: Biomedical Conditions and Complications

Dimension 3: Emotional, Behavioral, or Cognitive Conditions and Complications

Dimension 4: Readiness to Change

Dimension 5: Relapse, Continued Use, or Continued Problem Potential

Dimension 6: Recovery /Living Environment

Diagnosis	Substances Included (Primary Substance - General Tab)	Severity (Severity Index - Calculate, Diagnosis Tab)	Dimension Calculation Score	Additional (Medication Assisted Treatment) Factor	Recommended Course of Treatment (ASAM Recommended Course of Treatment - Recommendation Tab)
Alcohol Use Disorder	Alcohol	Severe	50-63		Residential Detoxification, Residential Services, Outpatient Services, Recovery Support Services
		Severe	40-49		Residential Services, Outpatient Services, Recovery Support Services
		Moderate	25-39		Residential Services, Outpatient Services, Recovery Support Services
		Moderate	16-24		Outpatient Services, Recovery Support Services
		Mild	11-15		Outpatient Services, Recovery Support Services
		Mild	0-10		Recovery Support Services
Cannabis Use Disorder	Marijuana/Hashish	Severe	21-63		Outpatient Services, Recovery Support Services
		Moderate	21-63		Outpatient Services, Recovery Support Services
		Mild	0-20		Recovery Support Services
Phencyclidine Use Disorder/ Other Hallucinogen Use Disorder	Hallucinogens, DMT, LSD, Mescaline, Other Synthetic Cannabinoids (K2, Spice), Peyote, Psilocybin Mushrooms, STP, Synthetic Hallucinogens (2C drugs)	Severe	50-63		Residential Services, Outpatient Services, Recovery Support Services
		Severe	40-49		Outpatient Services, Recovery Support Services
		Moderate	25-39		Outpatient Services, Recovery Support Services
		Mild	0-24		Recovery Support Services
Inhalant Use Disorder	Inhalants, Aerosols, Anesthetics (Nitrous Oxide, Either, Chloroform), Nitrites, Solvents (Paint Thinner, Gasoline, Glue)	Severe	50-63		Residential Services, Outpatient Services, Recovery Support Services
		Severe	40-49		Outpatient Services, Recovery Support Services
		Moderate	25-39		Outpatient Services, Recovery Support Services
		Mild	0-24		Recovery Support Services
Opioid Use Disorder	'Opiates and Synthetics', Buprenorphine, Codeine, Darvocet/Darvon (D-Propoxyphene), Demerol (Meperidine Hcl), Dilaudid (Hydromorphone), Heroin, Methadone (Non-Prescription), Oxycodone, Pentazocine, Ultram (Tramadol), Vicodin (Hydrocodone)	Severe	50-63	MAT No	Residential Detoxification (Medically Assisted Treatment), Ambulatory Detoxification (Medically Assisted Treatment), Residential Services, Outpatient Services, Recovery Support Services
			50-63	MAT Yes	Ambulatory Detoxification (Medically Assisted Treatment), Residential Services, Outpatient Services, Recovery Support Services
			40-49	MAT No or Yes	Ambulatory Detoxification (Medically Assisted Treatment), Residential Services, Outpatient Services, Recovery Support Services
		Moderate	0-39	MAT No or Yes	Ambulatory Detoxification (Medically Assisted Treatment), Outpatient Services, Recovery Support Services
		Mild	0-39	MAT No or Yes
Sedative, Hypnotic and Anxiolytics Use Disorder	Sedatives Benzodiazepines, Ativan (Lorazepam), Dalmane (Flurazepam), Halcion (Triazolam), Klonopin (Clonazepam), Librium (Chloridiazepoxide), Restoril (Temazepam), Rohypnol (Flunitrazepam), Tranzene (Clorazepate), Valium (Diazepam), Xanax (Alprazolam), Barbiturate Sedatives, Luminal (Phenobarbital), Nembutal (Pentobarbital), Seconal (Secobarbital), Tuinal (Secobarbital/Amobarbital), Other Sedatives, Doriden (Glutethimide), Miltown (Meprobamate), Placidyl (Ethchlorvynol), Quaalude (Methaqualone), Sonata (Zaleplon)	Severe	50-63		Residential Detoxification, Residential Services, Outpatient Services, Recovery Support Services
		Severe	40-49		Ambulatory Detoxification, Residential Services, Outpatient Services, Recovery Support Services
		Moderate	30-39		Ambulatory Detoxification, Residential Services, Outpatient Services, Recovery Support Services
		Moderate	20-29		Ambulatory Detoxification, Outpatient Services, Recovery Support Services
		Mild	0-19		Outpatient Services, Recovery Support Services
Stimulant Use Disorder/Cocaine Use Disorder	Stimulants, Amphetamine, Benzedrine, Cocaine, Crack, Dexedrine, MDMA/Ecstasy, Methamphetamine, Other Synthetic Stimulants (Bath Salts), Preludin, Ritalin (Methylphenidate)	Severe	29-63		Residential Services, Outpatient Services, Recovery Support Services
		Moderate	29-63
		Mild	0-29		Outpatient Services, Recovery Support Services
Other Substance Use Disorder	Other Drugs, Anabolic Steroids, Dilantin (Diphenylhydantoin/Phenytoin), GHB/GBL (Gamma-Hydroxybutyrate, Gamma-Butyrolactone), Special K (Ketamine), 'Over-the-counter' Aspirin Benadryl (Diphenhydramine) Cough Syrup Ephedrine/Pseudoephedrine Sominex	Severe	40-63		Residential Services, Outpatient Services, Recovery Support Services
		Moderate	30-39		Outpatient Services, Recovery Support Services
		Mild	0-29		Recovery Support Services

The Recommended Course of Treatment is calculated only in an Initial SU Assessment. When a client declares there are no substances sought on the General tab, then there will be no ASAM recommended course of treatment will occur.

The four calculations occur only in the Initial SU Assessment and do not occur in any subsequent assessment.

The following table shows the questions associated with the ASAM Dimensions. The sum of the points assigned to the answers are used to in the calculation for the ASAM Recommendation Course of Treatment.

Tab	Question	Answer	Value in Calculation
Dimension 1 Acute Intoxication and/or Withdrawal Potential
Physical Health	Do you have a chronic medical condition?	Yes, No	Yes = 1 No = 0
Substance Use	In the past when you stopped using, have you had any of the following:	Shakes/Tremors Blackouts Memory Lapses Cravings Vomiting Nausea Profuse sweating Seizures Delirium Tremors (DT) Anxiety Hallucinations (Visual, Tactile, Auditory) Headaches	4 or more Selections
Dimension 2 Biomedical Conditions and Complications
Physical Health	Do you have a history of medical conditions or medical problems?	Yes, No	Yes = 1 No = 0
Physical Health	Do you have a chronic medical condition?	Yes, No	Yes = 1 No = 0
Physical Health	Are you currently taking any prescribed medications for medical reasons?	Yes, No	Yes = 1 No = 0
Physical Health	Has your physical health been so bad that it resulted in hospitalization?	Yes, No	Yes = 1 No = 0
Physical Health	Are you currently pregnant?	Yes, No	Yes = 1 No = 1
Physical Health	Do you think you could be pregnant?	Yes, No, Unknown	Yes = 1 No = 2
Dimension 3 Emotional, Behavioral, or Cognitive Conditions and Complications
Physical Health	Are you enrolled in Medication Assisted Treatment?	Yes, No	Yes = 1 No = 0
Mental Health	Historical Information section	Any Question answered 'Yes' ‐ or ‐ ‘Psychological Treatment Setting' field answer not zero
Mental Health	Are you currently seeing a Licensed Professional of the Healing Arts for any mental health condition or problem?	Yes, No	Yes = 1 No = 0
Mental Health	If yes, are you taking any prescription medications?	Yes, No	Yes = 1 No = 0
Mental Health	Are you currently having thoughts of killing yourself?	Yes, No	Yes = 4 No = 0
Mental Health	Would you like assistance with your mental health?	Yes, No	Yes = 3 No = 0
Dimension 4 Readiness to Change
General	What Substances have you been using? (Primary)	None, Not None	None=0 Not None=1
Family Social	In the past 30 days, how many times have you attended self‐help groups? (e. g., AA, NA, etc.)	No attendance in the past month 1‐3 times in the past month 4‐7 times in the past month 8‐15 times in the past month 16‐30 times in the past month Some attendance in the past month, but frequency unknown	No attendance in the past month=0 1‐3 times in the past month=3 4‐7 times in the past month=2 8‐15 times in the past month=0 16‐30 times in the past month=0 Some attendance in the past month, but frequency unknown=0
Substance Use	Have you ever sought Substance Use Treatment before today?	Yes, No	Yes=0 No=2
Dimension 5 Relapse, Continued Use, or Continued Problem Potential
Physical Health	Have you used larger amounts of alcohol or drugs or used them for a longer time than you planned?	Yes, No	Yes = 1 No = 0
Physical Health	Have you tried to cut down on alcohol and drugs and were unable to do it?	Yes, No	Yes = 1 No = 0
Physical Health	Have you gotten so high or sick from alcohol or drugs that it caused an accident or became a danger to you or others?	Yes, No	Yes = 1 No = 0
Physical Health	Have you increased the amount of alcohol or drugs you were taking so that you could get the same effects as before?	Yes, No	Yes = 1 No = 0
Physical Health	Have you gotten sick or had withdrawals when you quit drinking or missed taking a drug?	Yes, No	Yes = 1 No = 0
Physical Health	Have you continued to drink or take drugs to avoid withdrawals or to keep from getting sick?	Yes, No	Yes = 1 No = 0
Family Social	Have you spent a lot of time getting alcohol or drugs, using them or recovering from their use?	Yes, No	Yes = 1 No = 0
Dimension 6 Recovery /Living Environment
General	Referred by	Community Health Service Community Mental Health Services Court Services/DWI/DUI Department of Family Protective Services (Adult or Child Protective Services) Drug Court Family/Friend Hospital (Community) Hospital (State) Insurance/Employee Assistance Program Outreach, Screening, Assessment, and Referral (OSAR) Peer Support/Recovery Support Probation/Parole School Self (Client) Substance Use Disorder Prevention/Intervention/ Treatment Work/Employer Community Service Provider ( local, state, federal )	Self=4, Family/Friend=3, Else=0
Education & Employment	Have you gotten so high or sick from alcohol or drugs that it kept you from fulfilling work or school obligations?	Yes, No	Yes=3 No=0
Education & Employment	Have you spent less time at work or school so that you could drink or use drugs?	Yes, No	Yes=3 No=0
Legal	What is your current legal status?	None Selected Jail or Prison Probation Parole Diversion Program Awaiting Trial Awaiting Sentencing NA	NA=0 Any Value other than NA and None Selected=1
Family Social	What is your living situation?	Dependent Independent Homeless	Dependent=0, Independent=2, Homeless=4
Family Social	Marital status:	Divorced Never Married Now Married Separated Widowed	Divorced or Widowed=4, Never married or Separated=3, Now Married=0
Family Social	Have you gotten so high or sick from alcohol or drugs that it kept you from fulfilling your family obligations?	Yes, No	Yes=3, No=0
Family Social	Has your use of alcohol or drugs caused problems with your support system?	Yes, No	Yes=4, No=0
Family Social	Have you spent a lot of time getting alcohol or drugs, using them or recovering from their use?	Yes, No	Yes=4, No=0
Recommendation	Client Support Needs	Language or Auditory; Veterans Affairs; Education Employment; Legal; Tobacco; Physical Health; Dental Health; Vision Care; Medical Insurance; Medical Prescription; Mental Health; Living Situation; Trauma; Reunification Services; Family Support; Housing Environment; Paying for Housing; Community Support; Financial Assistance Programs; Child Welfare System; Social Welfare Programs; Sober Living Environment; Sober Activity; Recovery Coach; Support Group; Food Assistance; Transportation Assistance; Children’s Services and Needs	Transportation and Child Care are checked = 1

Conditional. Modification to Treatment Recommended. The Life History Screening displays when the client needs modifications to treatment based on unobtrusive or adverse life-course outcomes typically found in Fetal Alcohol Syndrome Disorder. The descriptions of modifications to treatment provide guidance for treatment planning. The Life History Screening includes the following questions:

Childhood History (Key Life Domain)

Were you raised by someone other than your biological parents? Yes results in inclusion to the calculation.

How many living situations (different primary caregivers) did you have while you were growing up (up to the age of 18) [Prompt: Different people raising you]. More than 2 living situations results in inclusion to the calculation.

Maternal Alcohol Use (Key Life Domain)

To your knowledge, did your mother ever drink alcohol that caused problems for her or others around her? Yes results in inclusion to the calculation.

Did she drink alcohol when you were young? Yes results in inclusion to the calculation.

Did your mother drink alcohol while she was pregnant with you? Yes results in inclusion to the calculation. Has anyone ever said anything to you about your mother’s drinking during her pregnancy with you? Yes results in inclusion to the calculation. Education (Other Life History Domain)

Education (Other Life History Domain)

What is the highest grade in school you completed? 10th grade or lower results in inclusion to the calculation.

Did you ever need extra help in school? Yes results in inclusion to the calculation.

What was the subject in school that caused you the most problems? Math generates a result in inclusion to the calculation.

In what grade (or at what age) did you start using alcohol or drugs? Before the age 12 results in inclusion to the calculation.

Did you start using alcohol or drugs after problems in school began? Yes results in inclusion to the calculation.

Criminal History (Other Life History Domain)

Were you ever in trouble with the law? Yes results in inclusion to the calculation.

Were you ever arrested? Yes results in inclusion to the calculation.

Employment and Income (Other Life History Domain)

What is the longest time the client has held a full-time job? When the response is less than one year it results in inclusion to the calculation.

Have you ever received SSI? [Prompt: SSI is a federal income supplemental program designed to help people who have little to no income to meet basic needs for food, clothing and shelter.] Yes results in inclusion to the calculation.

Living Situation (Other Life History Domain)

As an adult, have you ever lived on your own (paying your own rent, etc.)? No results in inclusion to the calculation. For adolescents, the answer should be NA and this will not be counted towards scoring.

How long have you lived on your won at any one time? When the response is less than 1 year it results in inclusion to the calculation.

Mental Health (Other Life History Domain)

Have you ever tried to commit suicide? Yes results in inclusion to the calculation.

Day-to-Day Behaviors (Key Life Domain)

Do you frequently have difficulties with any of the following? There is a list of 11 items, if the client answers yes to 5 or more than it results in inclusion to the calculation.

The calculation first determines if there are answers in the three Key Life History Domains (please see above) to indicate if the client is eligible for modifications to treatment.

If the client has three Key Life History Domains then the Other Life History Domains are counted to determine if the client needs modifications to treatment.

If the client does not have three elements from the Key Life History Domains or the Other Life History Domains, the client does not need modification to treatment.

Life History Screening-Modifications to Treatment

These are the possible modifications. These are suggested modifications to treatment to maximize the client’s potential success in treatment and in recovery. The list is a multi-select list. CLICK ON all items that will improve the client’s experience in treatment.

· Establish, teach, and model structure and consistency

· Remember the person’s functional age and abilities

· Learn person’s unique language patterns and present information strategically

· Frame treatment expectations and requirements within the client’s perspective

· Communicate concretely and repetitively

· Help individual implement/improve effective coping strategies while reducing/eliminating ineffective strategies

· Reduce all distracting stimuli in the environment to the extent possible

Comments This text field is for additional recommendation comments. This comments text box is optional. CLICK IN the text box and TYPE IN the information.

Client Support Needs

The items on display are all the items listed on all the tabs. The interviewer or clinician needs to check the boxes associated with every item for which the client requested assistance. The clinician may edit any item on the original tab.

Tab	Support Need
General	Language or Auditory
Education & Employment	Education, GED, Employment, Veterans Affairs
Legal	Legal
Physical Health	Tobacco, Physical Health, Dental Health, Vision Care, Medical Insurance, Medical Prescription, HIV Medical Care, STD/STI Services, HCV Services, Prenatal Care, Reproductive/Sexual Health
Mental Health	Mental Health
Family Social	Reunification Services, Living Situation, Family Support, Housing Environment, Paying for Housing, Community Support, Financial Assistance Programs, Child Welfare System, Social Welfare Programs, Sober Living Environment, Recovery Coach, Support Group, Food Assistance, Transportation Assistance, Children’s Services and Needs

The Trauma in the list will display results of the Adverse Childhood Experiences (ACEs) calculation and will remain as view only.

Comments This text field is for additional client support needs comments. This comments text box is optional. CLICK IN the text box and TYPE IN the information.

The system will carry forward answers to questions that do not require updated responses. The interviewer may edit any of the responses carried forward to the Update, Service End, or Discharge assessments.

Update, Service End, Discharge, and Discharge Follow-up Assessments

The update, Service End, and Discharge assessments have the same items displayed as the initial assessment. There are many answers carried forward for the user. These items can be edited if the client’s information changes. There are other items that must be answered with new information from the client. The required items are displayed with the red asterisk *. The Discharge Follow-up Assessment has fewer items from the initial assessment than the other assessments. Some items have language that is a little bit different. The required items will be displayed with the red asterisk *.

ASSESSMENT INFORMATION

Substance Table

EDUCATION Section

EMPLOYMENT Section (Education & Employment tab)

Historical Legal Information

Current Legal Information

GENERAL/HISTORICAL Health

Please answer the following questions. In the past 12 months:

CURRENT Health

Historical Information

Have you ever:

Had a period of time table

Current Information

Users document information about the client’s family, social and living environment in this section.

Family History

Did a parent or other adult in the household often: This section has question that come from the ACE Questionnaire.

Did you often feel that: This section has question that come from the ACE Questionnaire.

Was your mother or stepmother: This section has question that come from the ACE Questionnaire.

Maternal Alcohol Use

Living Situation

Have you ever:

Current Trauma

Current Social Status

High Risk Behaviors

Have you ever:

Substance Use

Treatment Services Received Table:

Strengths and Limitations

CLICK ON the Calculate button to calculate the Severity Score. The result of the calculation will display Mild, Moderate, Severe after the words Severity Score. The table below shows the calculation and the source of the scores.

Order of Treatment Services table

Justification CLICK ON the option that describes the reason the diagnosis code was selected.

RECOMMENDATIONS Tab

Priority Population Status

The following table shows the questions associated with the ASAM Dimensions. The sum of the points assigned to the answers are used to in the calculation for the ASAM Recommendation Course of Treatment.

Tab

Question

Answer

Value in Calculation

Dimension 1 Acute Intoxication and/or Withdrawal Potential

Physical Health

Do you have a chronic medical condition?

Yes, No

No = 0

Substance Use

In the past when you stopped using, have you had any of the following:

Shakes/Tremors Blackouts Memory Lapses Cravings Vomiting Nausea Profuse sweating Seizures Delirium Tremors (DT) Anxiety Hallucinations (Visual, Tactile, Auditory) Headaches

4 or more Selections

Dimension 2 Biomedical Conditions and Complications

Physical Health

Do you have a history of medical conditions or medical problems?

Yes, No

No = 0

Physical Health

Do you have a chronic medical condition?

Yes, No

No = 0

Physical Health

Are you currently taking any prescribed medications for medical reasons?

Yes, No

No = 0

Physical Health

Has your physical health been so bad that it resulted in hospitalization?

Yes, No

No = 0

Physical Health

Are you currently pregnant?

Yes, No

No = 1

Physical Health

Do you think you could be pregnant?

Yes, No, Unknown

No = 2

Dimension 3 Emotional, Behavioral, or Cognitive Conditions and Complications

Physical Health

Are you enrolled in Medication Assisted Treatment?

Yes, No

Mental Health

Mental Health

Are you currently seeing a Licensed Professional of the Healing Arts for any mental health condition or problem?

Yes, No

Shakes/Tremors
Blackouts
Memory Lapses
Cravings
Vomiting
Nausea
Profuse sweating
Seizures
Delirium Tremors (DT)
Anxiety
Hallucinations (Visual, Tactile, Auditory)
Headaches