Valley: Client Name: Client ID: Dob: Effective Date

Client ID: 158
Page 1 of 3
Valley
ASAM
Client Information
Client Name:
World, cup
Client ID:
158
DOB:
02/11/1983
Effective Date:
02/11/2015
Dimension 1
Dimension 1: Alcohol Intoxication and/or Withdrawal Potential
No treatment recommended
The patient is not at risk of withdrawal (Level 0.5)
The patient is physiologically dependent on opiates and requires Opioid Maintenance Therapy to prevent withdrawal
(Opioid Maintenance Therapy)
The patient is not experiencing significant withdrawal or is at minimal risk of sever withdrawal (Level 1)
The patient is at minimal risk of severe withdrawal (Level 2.1)
The patient is at moderate risk of severe withdrawal manageable at Level 2 (Level 2.5)
The patient is not at risk of withdrawal, or is experiencing minimal or stable withdrawal. The patient is concurrently
receiving Level I-WM (minimal) or Level II-WM (Moderate) services (Level 3.1)
The patient is at minimal risk of severe withdrawal. If withdrawal is present, manageable at Level 3.2 WM (Level 3.5)
General
Level:
Opioid Maintenance Therapy
Documented Risk:
Moderate
Comments:
cscscs
Dimension 2
Dimension 2: Biomedical Conditions and Complications
None or very stable (Level 0.5)
None or manageable with outpatient medical monitoring (Opioid Maintenance Therapy)
None or very stable, or the patient is receiving concurrent medical monitoring (Level 1)
None or not a distraction from treatment. Such problems are manageable at Level 2.1 (Level 2.1)
None or not sufficient to distract from treatment. Such problems are manageable at Level 2.5 (Level 2.5)
None or stable, or the patient is receiving concurrent medical monitoring (Level 3.1)
General
Level:
Level 1.0
Documented Risk:
Low
Comments:
csacsacas
Dimension 3
Dimension 3: Emotional, Behavioral or Cognitive conditions and Complications
None or very stable (Level 0.5)
None or manageable with outpatient medical monitoring (Opioid Maintenance Therapy)
None or very stable, or the patient is receiving concurrent mental health monitoring (Level 1)
Page 1
Printed on: 02/11/2015
Client ID: 158
Page 2 of 3
Mild severity, with the potential to distract from recovery; the patient needs monitoring (Level 2.1)
Mild to moderate severity, with potential to distract from recovery; the patient needs stabilization (Level 2.5)
None or minimal; not distracting to recovery. If stable, a co-occurring capable program is appropriate. If not a cooccurring enhanced program is required (Level 3.1)
Demonstrates repeated inability to control impulses, or unstable and dangerous signs/symptoms require stabilization and
a 24 hour setting to prepare for community Integration and continuing care. A co-occurring enhanced setting is required
for those with servers and chronic mental illness (Level 3.5)
General
Level:
Level 3.5
Documented Risk:
High
Comments:
csacsac
Dimension 4
Dimension 4: Readiness to Change
The patient is willing to explore how current alcohol or drug use may affect personal goals (Level 0.5)
The patient is ready to change the negative effects of opiate use, but not ready for total abstinence (Opioid Maintenance
Therapy)
The patient is ready for recovery, but needs motivating & monitoring strategies to strengthen readiness. Or, has high
severity in this dimension but not other Dimensions. Needs Level 1 motivational enhancement program (Level 1)
The patient has variable engagement in treatment, ambivalence or lack of awareness of the substance use or mental
health problem, and requires a structured program several times a week to promote progress through the stages of
change (Level 2.1)
The patient has poor engagement in treatment, significant ambivalence, or lack of awareness of the substance
use/mental health problem, requiring a near-daily structured program or intensive engagement services to promote
progress through the stages of change (Level 2.5)
The patient is open to recover, but needs a structured environment to maintain therapeutic gains (Level 3.1)
The patient has marked difficulty with, or opposition to, treatment with dangerous consequences. Or there is high
severity in this dimension but not other Dimensions. Therefore, patient requires a Level 1 motivational enhancement
program (3.5)
General
Level:
Level 2.5
Documented Risk:
Moderate
Comments:
csacasc
Dimension 5
Dimension 5: Relapse, Continued Use, Continued Problem Potential
The patient needs an understanding of, or skills to change, his or her current alcohol or drug use pattern (Level 0.5)
The patient is at high risk of relapse or continued use without Opioid Maintenance Therapy and structured therapy to
promote treatment progress (Opioid Maintenance Therapy)
The patient is able to maintain abstinence or control use and/or addictive behaviors and pursue recovery or motivational
goals with minimal support (Level 1)
Intensification of the patients addiction or mental health symptoms indicate a high likelihood of relapse or continued use
or continued problems without close monitoring and support several times a week (Level 2.1)
Intensification of the patients addiction or mental health symptoms, despite active participation in level 1 or level 2.1
program, indicates a high likelihood of relapse or continued use or continued problems without near-daily monitoring and
support (Level 2.5)
The patient understands relapse but needs structure to maintain therapeutic gains (Level 3.1)
Page 2
Client ID: 158
Page 3 of 3
The patient has no recognition of the skills needed to prevent continued use, with imminently dangerous consequences
(Level 3.5)
General
Level:
Level 1.0
Documented Risk:
High
Comments:
cdcdscds
Dimension 6
Dimension 6: Recovery Environment
The patients social support system or significant others increase the risk of personal conflict about alcohol, tobacco or
other drug use (Level 0.5)
The patients recovery environment is supportive and/or the patient has skills to cope (Opioid Maintenance Therapy)
The patients recovery environment is supportive and/or the patient has skills to cope (Level 1)
The patients recovery environment is not supportive, but with structure and support, the patient can cope (Level 2.1)
The patients recovery environment is not supportive, but with structure and support and relief from the home
environment, the patient can cope (Level 2.5)
The patients environment is dangerous, but recovery is achievable if level 3.1 / 24 hour structure is available (Level 3.1)
The patients environment is dangerous and patient lacks skills to cope outside of a highly structured 24-hour setting
(Level 3.5)
General
Level:
Level 2.1
Documented Risk:
Moderate
Comments:
dsfdsfdsfs
Final Determination
Dimension 1 Level Opioid Maintenance
Risk: Moderate
Dimension 2
Level 1.0
Risk: Low
Level 2.5
Risk: Moderate
Level 2.1
Risk: Moderate
Therapy
cscscs
Dimension 3
csacsacas
Level 3.5
Risk: High
csacsac
Dimension 5
Dimension 4
csacasc
Level 1.0
Risk: High
cdcdscds
Dimension 6
dsfdsfdsfs
Final Placement Determination

Indicated/Referred Level:
Low-Intensity Residential
Provided Level:
OPT - Level 1
Comments:
cdscdscdscds
Clinician: Surya s
Signature Date: 02/11/2015
Page 3

Valley: Client Name: Client ID: Dob: Effective Date

Uploaded by

Copyright:

Available Formats

Valley: Client Name: Client ID: Dob: Effective Date

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Valley: Client Name: Client ID: Dob: Effective Date

Uploaded by

Copyright:

Available Formats

Client ID: 158

Opioid Maintenance Therapy

Printed on: 02/11/2015

Client ID: 158

Printed on: 02/11/2015

Client ID: 158

Final Placement Determination

Signature Date: 02/11/2015

Printed on: 02/11/2015

You might also like