Service must be documented in a note to claim, this form is not for claiming
Service #: SUD Brief Engagement Form
Client:
InSyst #	Last Name	First Name
Location:	Episode Opening Date:
Agency:	RU:
Services were provided in:	by ☐ interpreter or ☐ clinician
Brief Engagement & Assessment Review
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. At a minimum, the Brief A-LOC should be administered every 45-50 days and/or if there is concern regarding the placement.
Date of Birth:	Client’s Phone Number:
Program:	Modality:
For the next month, would you find it most helpful to (choose one): ☐ Stay in the same level of treatment intensity ☐ Move to a more intensive level of treatment ☐ Move to a less intense level of treatment
Do you believe you need more time in this treatment program? ☐ Yes ☐ No
If yes, how long?	Why?
Do you have an outside support system in place? ☐ Yes ☐ No
If yes, what?	Where?
Have you identified your relapse triggers? ☐ Yes ☐ No
If yes, what are they?
Do you have an employment opportunity? ☐ Yes ☐ No
If yes, when?	Where?
Do you have a safe place to live? ☐ Yes ☐ No
If yes, where?	With who?
Do you have transportation? ☐ Yes ☐ No
If yes, how?
Does the counselor need to schedule an individual counseling session with the client? ☐ Yes ☐ No
LPHA/Counselor Signature	Printed Name/Credentials	Date