This form is not for claiming, service must be documented in a progress note in order to be claimed
Information
Client:
InSyst #	Last Name	First Name
Location:	Episode Opening Date:
Agency:	RU:
Services were provided in:	by ☐ interpreter or ☐ clinician
ALOC Re-Assessment Continuum of Care Form
Directions: The Brief ASAM-Level of Care (A-LOC) engagement questions are designed to ensure placement into the appropriate A-LOC. If or when it is determined a different level of care may be needed the client should receive a more through A-LOC Re-Assessment.
Current Relevant Information
Re-engaged with Family?	Yes ☐ No ☐	Plans to Enroll in School?	Yes ☐ No ☐
Somewhere safe to reside?	Yes ☐ No ☐	Did you put work on hold to enroll in SUD TX?	Yes ☐ No ☐
Plans to return to work?	Yes ☐ No ☐	Identified relapse triggers	Yes ☐ No ☐
Receiving services for mental illness?	Yes ☐ No ☐	Medical insurance?	Yes ☐ No ☐
Outside support system in place?	Yes ☐ No ☐	Yes ☐ No ☐
Stage of Change
☐ Pre- contemplation ☐ Contemplation ☐ Preparation ☐ Action Maintenance ☐ Relapse Comment:
Desire to Change
☐ No desire (4) ☐ Little desire (3) ☐ Ambivalent desire (2) ☐ Desires to change, with some reservations (1) ☐ Active desire to change (0) Comment:
Relapse Prevention
☐ Actively objects to a relapse prevention plan (4) ☐ Unwilling to develop a relapse or continued use prevention plan (3) ☐ Ambivalent about a relapse or cont. use prevention plan (2) ☐ Willing to do a relapse or cont. use prevention plan (1) ☐ Working actively on a prevention or continued use prevention plan (0) Comment:
Interpersonal/ Social Functioning
☐ Actively toxic relationships (4) ☐ Not supportive relationships (3) ☐ Marginally supportive (2) ☐ Moderately supportive (1) ☐ Very supportive (0) Comment:
Self-Care
☐ No self-care deficits noted (0) ☐ Does not seek appropriate treatment/supportive services without assistance or requires significant assistance to do so; needs services to prevent relapse (1) ☐ Requires assistance in basic life and survival skills (i.e. locating food, finding shelter) (2) ☐ Requires assistance in basic hygiene, grooming and care of personal environment (3) ☐ Engages in impulsive, illegal or reckless behavior (4) Comment:
Additional Information:
ASAM DIMENSIONS
DIMENSION 1: Acute Intoxication and/or Withdrawal Potential (a) Past hx of serious withdrawal, life-threatening symptoms or seizures during withdrawal? e.g., need for IV therapy; hospital for seizure control; psychosis with DT’s; medication management with close nurse monitoring & medical management? ☐ Yes ☐ No (b) Currently is having severe, life-threatening and/or similar withdrawal symptoms? ☐ Yes ☐ No
DIMENSION 2: Biomedical Conditions/Complications (a) Does the client have any current severe physical health problems? e.g., bleeding from mouth/rectum in past 24 hours; recent, unstable hypertension; severe pain in chest, abdomen, head; significant problems in balance, gait, sensory/motor abilities not related to intoxication. ☐ Yes ☐ No (b) Does or has the client had a history or recent episode of seizures/convulsions; diagnosed with TB, emphysema, hepatitis C, heart condition? ☐ Yes ☐ No
DIMENSION 3: Emotional/Behavioral/Cognitive Conditions/Complications (a) Imminent danger of harming self or someone else? e.g., SI+ with intent, plan, means to succeed; HI+ or violent ideation, impulses, uncertainty about ability to control impulses, with means to act. ☐ Yes ☐ No (b) Unable to function in ADL’s, care for self with imminent, dangerous consequences? e.g., unable to bathe, feed, care for self-due to psychosis, organicity or uncontrolled intoxication with threat of imminent DTS/O as regards death or severe injury. ☐ Yes ☐ No (c) Client will benefit from a co-occurring capable program as opposed to a co-occurring enhanced program? ☐ Yes ☐ No
DIMENSION 4: Readiness to Change (a) Does the client appear to need SUD treatment/recovery and/or mental health treatment, but is ambivalent or feels it’s unnecessary? e.g., severe addiction, but client feels controlled use is still OK; psychotic, but blames a conspiracy. ☐ Yes ☐ No (b) Client has been coerced or mandated to have assessment and/or treatment by Mental Health Court or CJ system, health or social services, work/school, or family/significant other? ☐ Yes ☐ No (c) Client desires and is ready to change their current SUD behavior? ☐ Yes ☐ No
DIMENSION 5: Relapse/Continued Use/Continued Problem Potential (a) Does the client understand relapse but needs structure to maintain therapeutic gains? ☐ Yes ☐ No (b) Client is unwilling and/or ambivalent to create a continued use prevention plan? ☐ Yes ☐ No (c) Is the client likely to continue to use or have active, acute symptoms in an imminently dangerous manner, without immediate containment? ☐ Yes ☐ No
DIMENSION 6: Recovery Environment (a) Are there any dangerous family, significant others, living/work/school situations threatening the client’s safety, immediate well-being, and/or sobriety? e.g., living with a drug dealer; someone with a Substance Use Disorder or using drugs or alcohol; client is experiencing abuse by a partner or significant other; homeless in freezing temperatures? ☐ Yes ☐ No (b) Does the client have the life skills and/or support necessary to participate in day to day functions? ☐ Yes ☐ No
Select one: ☐ No Risk/Stable (0) Mild (1) ☐Moderate (2) ☐Significant (3) ☐Severe (4)
ASAM Clinical Placement Scoring Summary
ASAM Dimensions
1 - Acute Intoxication and/or Withdrawal Potential	4 – Readiness to Change (including Desire to Change)
2 – Biomedical Conditions and Complications	5 – Relapse/Continued Use/Continued Problem Potential
3 –Emotional/Behavioral/Cognitive Conditions and Complications	6 – Recovery Environment
Risk Ratings	Intensity of Service Need	Dimensions
1	2	3	4	5	6
(0) No Risk or Stable – Current risk absent. Any acute or chronic problem mostly stabilized.	No immediate services needed	☐	☐	☐	☐	☐	☐
(1) Mild – Minimal, current difficulty or impairment. Minimal or mild signs and symptoms. Any acute or chronic problems soon able to be stabilized and functioning restored with minimal difficulty.	Low intensity of services needed for this dimension. Treatment strategies usually able to be delivered tin outpatient settings.	☐	☐	☐	☐	☐	☐
(2) Moderate Moderate difficulty or impairment. Moderate signs and symptoms. Some difficulty coping or understanding, but able to function with clinical and other support services and assistance.	Moderate intensity of services, skills training or supports needed for this level of risk. Treatment strategies may require intensive levels of outpatient care.	☐	☐	☐	☐	☐	☐
(3) Significant – Serious difficulties or impairment. Substantial difficulty coping or understanding and being able to function even with clinical support.	Moderately high intensity of services, skills training, or supports needed. May be in danger or near imminent danger.	☐	☐	☐	☐	☐	☐
(4) Severe – Severe difficulty or impairment. Serious, gross or persistent signs and symptoms. Very poor ability to tolerate and cope with problems. Is in imminent danger.	High intensity of services, skills training, or supports needed. More immediate, urgent services may require inpatient or residential settings; or closely monitored case management services and a frequency greater than daily.	☐	☐	☐	☐	☐	☐
Key Findings Supporting Placement Decision:
☐ Remain in the same Level of Care and Program	☐ Transfer level of care within program
Indicated ASAM LOC/WM:
Additional Indicated ASAM LOC/WM:
Additional Indicated ASAM LOC/WM
Actual ASAM Level of Care to which referred	Program to which referred
For Portals: Select the program by Level of Care and Program Name For Residential Programs: Refer client to your own program or to the SUD Helpline Call Center for ALOC reassessment and referral 1-844-682-7215 For All Other Programs: Refer to SUD Helpline Call Center for ALOC assessment and referral 1-844-682-7215
ASAM Level Referred:
Choose Program:
Intake Appointment Date:	Contact Person:
First Offered Appointment:	Time:
ASAM Level Referred:
Choose Program:
Intake Appointment Date:	Contact Person:
First Offered Appointment:	Time:
Non-ASAM Level of Care to which referred	Program to which referred
ASAM Level Referred:
Choose Program:
Intake Appointment Date:	Contact Person:
First Offered Appointment:	Time:
ASAM Level Referred:
Choose Program:
Intake Appointment Date:	Contact Person:
First Offered Appointment:	Time:
Reason for ASAM LOC Difference
If Actual LOC/WM to which referred differed from the indicated ASAM LOC, indicated the reason for the difference:
Reason:
Reason for ASAM LOC Difference
If referral is being made but admission is expected to be DELAYED, indicated the reason:
Reason:
Notes (optional):
LPHA/SUD Counselor Signature	Printed Name/Credentials	Date