FORMCHECKBOX Recommended ASAM Level of Care for Dimension 4 Readiness to Change FORMCHECKBOX No Treatment Services Recommended FORMCHECKBOX Level 0.5 Early Intervention/Education Alcohol and Other Drug Information School FORMCHECKBOX Level I.0 Outpatient FORMCHECKBOX Level II.1 Intensive Outpatient FORMCHECKBOX Level II.5 Partial Hospitalization/Day Treatment FORMCHECKBOX Level III.1 Recovery House - Clinically Managed Low-Intensity Residential Treatment FORMCHECKBOX Level III.3 Long Term Care - Clinically Managed Medium-Intensity Residential Treatment FORMCHECKBOX Level III.5 Intensive Inpatient - Clinically Managed High-Intensity Residential Treatment FORMCHECKBOX Level III.7 Intensive Inpatient Medically Monitored Intensive Residential Treatment FORMCHECKBOX Level IV Medically Managed Intensive Inpatient TreatmentCDP Summary Interpreting Dimension 4 Data (include strengths/needs): DO NOT LEAVE BLANK DIMENSION 5: RELAPSE/CONTINUED USE POTENTIALINSERT DRUG/ALCOHOL HISTORY DATA COLLECTION HERE. ASAM Criteria Intake Assessment Guide Have you ever attempted to discontinue your use of alcohol? _________________________ When? No FORMCHECKBOX Yes FORMCHECKBOX , if yes, which one?_____________________7. PDF Overview of Substance Use Disorder Care Clinical Guidelines - Medicaid It is a useful tool for mental health professionals to gather relevant information about a person's mental and emotional health, as well as their background and current situation. ASAM's Definition of Addiction is incorporated in the new edition as follows: (a) It provides guidelines to have all addiction services be provided by addiction physicians. lost a job or marriage/relationship/friend, quit attending social events. _______________________________________ How much did you consume before driving? These standards describe six dimensions that should be assessed, including: Acute intoxication and/or withdrawal potential Biomedical conditions and complications Evaluation of patients ability to perform daily living skills? 2 Get Fast Answers to Your Questions LOCI-3 (ASAM) with comments addressing patient's clinical SUD and MH symptoms in all six (6) ASAM Dimensions. FORMCHECKBOX No FORMCHECKBOX Yes, if yes, what kind of help do you need? 0000037298 00000 n The ASAM criteria help determine the best level of care for the person's substance use disorder at the time of assessment, accounting for their need for medical oversight and safety. 0000020121 00000 n FORMCHECKBOX Poor FORMCHECKBOX FORMCHECKBOX Average FORMCHECKBOX FORMCHECKBOX Good FORMCHECKBOX FORMCHECKBOX ExcellentFor DUI Assessment - Imminent Danger Potential1. __________________________ Drug? 0000079297 00000 n FORMCHECKBOX Level I.0 Outpatient referral to medical primary care FORMCHECKBOX FORMCHECKBOX Level II.1 Intensive Outpatient referral to medical primary care FORMCHECKBOX Level II.5 Partial Hospitalization/Day Tx referral to medical primary care FORMCHECKBOX FORMCHECKBOX Level III.1 Recovery House - Clinically Managed Low-Intensity Residential Tx referral to medical primary care FORMCHECKBOX Level III.3 Long Term Care - Clinically Managed Medium-Intensity Residential Tx referral to medical primary care FORMCHECKBOX FORMCHECKBOX Level III.5 Intensive Inpatient - Clinically Managed High-Intensity Residential Tx referral to medical primary care FORMCHECKBOX Level III.7 Intensive Inpatient Medically Monitored Intensive Residential Tx medical primary care FORMCHECKBOX FORMCHECKBOX Level IV Medically Managed Intensive Inpatient Treatment medical primary careCDP Summary Interpreting Dimension 2 Data (include strengths/needs): DO NOT LEAVE BLANK DIMENSION 3: EMOTIONAL/BEHAVIORAL/COGNITIVE CONDITIONS AND COMPLICATIONS A. 0000276517 00000 n CDP assessment of patients risk for relapse: Unknown FORMCHECKBOX High FORMCHECKBOX Moderate FORMCHECKBOX Low FORMCHECKBOX As evidenced by _________________________________________________________________________________________7. Have you ever received counseling or psychiatric treatment? SUBSTANCE ABUSE PREVENTION AND CONTROL FULL ASAM ASSESSMENT - ADULT Based on the ASAM Criteria [3rd Edition] Multidimensional Assessment Mail: Substance Abuse Prevention and Control Website: 1000 S. Fremont Ave, Bldg. FORMCHECKBOX Willing to change substance use, but believes it will not be difficult, or does not accept a full recovery treatment plan 0 FORMCHECKBOX Willing to engage in treatment/education as proactive, responsible participant, committed to changing alcohol/drug use. FORMCHECKBOX The symptoms are not due to a general medical condition and are not better accounted for by another medical disorder.B. 0000033441 00000 n ASAM Transition - Department of Drug and Alcohol Programs Chief Architect, CONTINUUM TM - The ASAM Criteria Decision Engine . Adjust your file. In case of ASAM eLearning Center registration inquiries, please consult the FAQ page here or contact 301.656.3920 or education@asam.org. FORMCHECKBOX No FORMCHECKBOX Yes ROI signed on ____________________________ (date)8. Acute intoxication and/or withdrawal potential 2. FORMCHECKBOX No FORMCHECKBOX FORMCHECKBOX Yes If Yes: Name of Medication:_______________________ Dose ______________________ Prescribed by:________________________ Name of Medication:_______________________ Dose ______________________ Prescribed by:________________________ Name of Medication:_______________________ Dose ______________________ Prescribed by:________________________7. FORMCHECKBOX Unable to function independently and to engage in self-care 4a FORMCHECKBOX Unable to follow through, has little or no awareness of substance use problems and associated negative consequences. 0000026645 00000 n ____________________________ Where? DOC SAMPLE ADULT CD ASSESSMENT - Washington State Department of Social and ____________________________ Where? high tolerance/consumption, compare to self-report of use. 3 FORMCHECKBOX Environment is not supportive of addiction recovery, and the patient finds coping difficult, even with clinical structure. (e.g. Adam assessment example Form is usually required for individuals who are seeking therapy or counseling services. 0000010527 00000 n If yes, are you currently in Drug Court treatment? FORMCHECKBOX No FORMCHECKBOX FORMCHECKBOX Yes If yes, Why? FORMCHECKBOX Able to articulate negative consequences of substance use, but has low commitment to change use of substances FORMCHECKBOX Low readiness to change, passively involved in treatment as evidenced by _________________________________________. ): C. Cognitive Conditions/Complications1. Are you currently using prescribed medications for mental health purposes? PDF What is the ASAM Narrative? - MARETweb Project ASAM CONTINUUM is a family of products that allows clinicians and non-clinicians to assess patients with addictive, substance-related and co-occurring conditions through computer-guided, structured interviews. Have you ever been arrested or charged with any crime? FORMCHECKBOX FORMCHECKBOX Minimal risk of severe withdrawal. FORMCHECKBOX Severe medical problems are present but stable. 0000032787 00000 n FORMCHECKBOX Family pressure FORMCHECKBOX Employer intervention FORMCHECKBOX FORMCHECKBOX Physician intervention FORMCHECKBOX Legal pressure FORMCHECKBOX Child custody FORMCHECKBOX Reinstate driving privileges FORMCHECKBOX DUI? FORMCHECKBOX No FORMCHECKBOX Yes, if yes, what is the problem? 0000034109 00000 n Immediate intervention required. CDP evaluation of the self-reported driving record and abstract of the legal driving record: ____________________________________ __________________________________________________________________________________________________________ 3. FORMCHECKBOX No FORMCHECKBOX FORMCHECKBOX Yes, If yes, explain: 7. FORMCHECKBOX FORMCHECKBOX Severe withdrawal presents danger (e.g. 0000237979 00000 n Recurrent substance use in situations in which it is physically hazardous. FORMCHECKBOX FORMCHECKBOX No FORMCHECKBOX Yes, if yes, explain: 2. PDF Documenting Medical Necessity for Asam Residential Level of Care Continued substance use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the use of the substance. FORMCHECKBOX None FORMCHECKBOX Low FORMCHECKBOX Moderate FORMCHECKBOX High 5. Recurrent substance-related legal problems. Assessment Dimensions The ASAM criteria identify the following problem areas (dimensions) as the most important in formulating an individualized treatment plan and in making subsequent patient placement decisions. No FORMCHECKBOX Yes FORMCHECKBOX (e.g., legal mandates, logistical barriers, lack of available services, etc. FORMCHECKBOX I do not think I will change my drinking/drug use. Any current charges pending: FORMCHECKBOX No FORMCHECKBOX Yes If yes, describe: When ___________________________ Charge _________________________ Which Court? PDF Assessment Using the ASAM Dimensions - Center for Practice Transformation American Society of Addiction Medicine (ASAM) dimensions to guide their clinical rationale and approach toward SUD care, as demonstrated below. 0000026181 00000 n Clinicians use the dimensions to identify problems, goals and treatment plan objectives. 0 FORMCHECKBOX Has a supportive environment, or is able to cope with poor support.Recommended ASAM Level of Care for Dimension 6 Recovery Environment FORMCHECKBOX No Treatment Services Recommended FORMCHECKBOX Level 0.5 Early Intervention/Education Alcohol and Other Drug Information School FORMCHECKBOX Level I.0 Outpatient FORMCHECKBOX Level II.1 Intensive Outpatient FORMCHECKBOX Level II.5 Partial Hospitalization/Day Treatment FORMCHECKBOX Level III.1 Recovery House Clinically Managed Low-Intensity Residential Treatment FORMCHECKBOX Level III.3 Long Term Care Clinically Managed Medium-Intensity Residential Treatment FORMCHECKBOX Level III.5 Intensive Inpatient Clinically Managed High-Intensity Residential Treatment FORMCHECKBOX Level III.7 Intensive Inpatient Medically Monitored Intensive Residential Treatment FORMCHECKBOX Level IV Medically Managed Intensive Inpatient TreatmentCDP Summary Interpreting Dimension 6 Data (include strengths/needs): DO NOT LEAVE BLANK A. ----- Progress Note Sample - SOAP (Subjective, Objective, Assessment, Plan) SUD Goal - In client's words: "I want to stop fighting with my wife and get my job back so I have to stop using." FORMCHECKBOX Definitely not (PC) FORMCHECKBOX Probably will (C) FORMCHECKBOX Definitely will (PR) The patient appears to be in the following stage of change: FORMCHECKBOX Precontemplation (PC) FORMCHECKBOX Contemplation (C) FORMCHECKBOX Preparation (PR) FORMCHECKBOX Action (A) FORMCHECKBOX Maintenance (M)Risk Rating for Dimension 4 (from PPC-2R - Appendix A): 4b FORMCHECKBOX Unable to follow through with treatment recommendations resulting in imminent danger to self or others, immediate intervention required. PDF Substance Abuse Prevention and Control Full Asam Assessment- Adult Which of the following employment problems have you ever experienced due to Alcohol/Drug use? Behavioral HealthChoices Provider ASAM Rates. ASAM CONTINUUM Assessment Overview Practical & Optimal Use Review of Questions Clinical Considerations of SUD Placement Summary Background: ASAM Criteria The ASAM Criteria is a standardizedand organizedway to deliver comprehensive and biopsychosocial substance use disorder (SUD) treatment services through a multidimensional assessment. FORMCHECKBOX No FORMCHECKBOX FORMCHECKBOX Yes, When and what was the outcome? No FORMCHECKBOX Yes FORMCHECKBOX if yes Referral information for child care services: _________________________________________________________________ HIV/AIDS Brief Risk Intervention conducted? ____________ Does it concern you? 0000202757 00000 n Family members should be encouraged to participate in treatment, either individually or with the patient. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition TR Diagnostic Codes FORMCHECKBOX Denied use of alcohol FORMCHECKBOX 305.00 Alcohol abuse FORMCHECKBOX 303.90 Alcohol dependence: FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX Severe FORMCHECKBOX Physiological dependence FORMCHECKBOX Denied use of substance(s) (drugs other than alcohol) FORMCHECKBOX 305.50 Opioid abuse FORMCHECKBOX 304.00 Opioid dependence: FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX Severe FORMCHECKBOX Physiological dependence FORMCHECKBOX 305.60 Cocaine abuse FORMCHECKBOX 304.20 Cocaine dependence: FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX Severe FORMCHECKBOX Physiological dependence FORMCHECKBOX 305.20 Cannabis abuse FORMCHECKBOX 304.30 Cannabis dependence: FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX Severe FORMCHECKBOX Physiological dependence FORMCHECKBOX 305.70 Amphetamine abuse FORMCHECKBOX 304.40 Amphetamine dependence: FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX Severe FORMCHECKBOX Physiological dependence FORMCHECKBOX 305.30 Hallucinogen abuse FORMCHECKBOX 304.50 Hallucinogen dependence: FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX Severe FORMCHECKBOX Physiological dependence FORMCHECKBOX 305.90 Inhalant abuse FORMCHECKBOX 304.60 Inhalant dependence: FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX Severe FORMCHECKBOX Physiological dependence FORMCHECKBOX 305.90 Phencyclidine (PCP) abuse FORMCHECKBOX 304.60 PCP dependence: FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX Severe FORMCHECKBOX Physiological dependence FORMCHECKBOX 305.40 Sedative, hypnotic, anxiolytic abuse FORMCHECKBOX 304.10 Sedative, hypnotic, anxiolytic dependence: FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX Severe FORMCHECKBOX Physiological dependence FORMCHECKBOX 304.80 Poly substance dependence FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX Severe FORMCHECKBOX Physiological dependence FORMCHECKBOX 305.10 Nicotine dependence FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX Severe FORMCHECKBOX Physiological dependence FORMCHECKBOX Screening of substance use revealed insufficient symptoms to indicate abuse or addiction.Treatment Recommendations using ASAM PPC Levels of Care:The patient meets the following level of care admission criteria: Dimension 1: Level _________Dimension 3: Level _________Dimension 5: Level _________ Dimension 2: Level _________Dimension 4: Level _________Dimension 6: Level _________ Overall Level: ________________ Overrides: Are there any circumstances that would override the ASAM PPC clinical recommendations for placement? Behavioral Conditions/Complications1. Are there any other significant life events (losses, deaths, hardships, loss of custody of children, etc.)? FORMCHECKBOX The symptoms are not due to a general medical condition and are not better accounted for by another medical disorder. Have you ever done anything while under the influence of alcohol or other drugs that you later regretted? FORMCHECKBOX FORMCHECKBOX Severe signs and symptoms or risk of severe but manageable withdrawal, or withdrawal is worsening despite detoxification at a less intensive level of care. (ASAM) Criteria to promote consistency in client placement for SUD treatment. 0000027033 00000 n FORMCHECKBOX FORMCHECKBOX Home FORMCHECKBOX Jail FORMCHECKBOX FORMCHECKBOX Hospital ___________________ FORMCHECKBOX Other____________________ Have you ever used a substance to relieve or avoid withdrawals? Have you ever been emotionally/verbally abused? 0000004654 00000 n TREATED UNTREATED FORMCHECKBOX Anemia or blood disorder FORMCHECKBOX FORMCHECKBOX . FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Rheumatic or scarlet fever FORMCHECKBOX . FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Chest pains FORMCHECKBOX FORMCHECKBOX . FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Fainting spells FORMCHECKBOX . FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Kidney disease or bladder infection FORMCHECKBOX FORMCHECKBOX . FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Liver disease-hepatitis or jaundice FORMCHECKBOX . FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Cancer-Type ___________________ FORMCHECKBOX FORMCHECKBOX . FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Diabetes FORMCHECKBOX . FORMCHECKBOX FORMCHECKBOX High or low blood sugar FORMCHECKBOX FORMCHECKBOX . FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Tuberculosis .. FORMCHECKBOX . FORMCHECKBOX Last Test Date ___________ Test results: ___________ FORMCHECKBOX Ulcers or pains in the stomach FORMCHECKBOX FORMCHECKBOX . FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Epilepsy FORMCHECKBOX . FORMCHECKBOX FORMCHECKBOX Heart trouble FORMCHECKBOX FORMCHECKBOX . FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Shortness of breath FORMCHECKBOX . FORMCHECKBOX FORMCHECKBOX TREATED UNTREATED FORMCHECKBOX High or low blood pressure FORMCHECKBOX FORMCHECKBOX .. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Chronic Pain FORMCHECKBOX . A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from effects. This confidential information is provided to you in accord with State and Federal laws and regulations including but not limited to applicable Welfare and Institutions Code, ____________________________ When ___________________________ Charge _________________________ Which Court? FORMCHECKBOX No FORMCHECKBOX Yes, if yes, how many times? 0000013543 00000 n 0000000016 00000 n Are you currently on probation? Continued uncontrolled substance use. ___________________________________________ How it make you feel to resume using? 0000112885 00000 n __________ How often do you do it? NIAAA: PPC-2R Assessment Software - SBIR grant R44 -AA12004 CSAT: Access to Recovery Initiative - grant 270-02-7120 ________________________________________________________________________________________________________5. I affirm that the information I give is truthful and complete. ______________________________ When?_________________________ Were any of these related to your use of alcohol or other drugs? Have you ever attempted to discontinue your use of drugs? FORMCHECKBOX Moderate signs and symptoms, with moderate risk of severe withdrawal. _______________________________________________________5. 0000027518 00000 n 1 FORMCHECKBOX Minimum relapse potential with some vulnerability. 0000023387 00000 n PDF What Using The ASAM Criteria Really Means: Skill-Building and - NAADAC FORMCHECKBOX No FORMCHECKBOX FORMCHECKBOX Yes; if yes, when and by whom: ___________________________________ Have you received or participated in counseling for this issue FORMCHECKBOX No FORMCHECKBOX FORMCHECKBOX Yes, When and what was the outcome?________ ___________________________________________________________________________________________________2. FORMCHECKBOX Knows very little about addiction and sees no connection between personal suffering and substance use FORMCHECKBOX Not willing to explore change in substance use, as evidenced by _________________________________________________. FORMCHECKBOX Severe mental health condition/complication, with acute risk/potential for imminent danger to self or others as evidenced by ____________________________________________ requires intensive/residential/involuntary addiction treatment. Biomedical conditions and complications 0000021341 00000 n FORMCHECKBOX No FORMCHECKBOX Yes6. The six ASAM Dimensions are:1 Dimension #1 - Acute Intoxication/Withdrawal Potential Exploring an individual's past and current substance use and withdrawal. FORMCHECKBOX No FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Yes, If yes, who and what is the illness? PDF 3.5 Service Characteristics - Department of Drug and Alcohol Programs 0000029627 00000 n FORMCHECKBOX No FORMCHECKBOX Yes If yes, who is the person assigned to supervise your case? 0000056218 00000 n 1 FORMCHECKBOX FORMCHECKBOX Demonstrates adequate ability to tolerate and cope with withdrawal discomfort. FORMCHECKBOX Poor FORMCHECKBOX FORMCHECKBOX Average FORMCHECKBOX Good FORMCHECKBOX FORMCHECKBOX Excellent9. Formerly known as the ASAM patient placement criteria, The ASAM Criteria is the result of a collaboration that began in the 1980s to define one national set . PDF What using the ASAM criteria really mean-common misconceptions and The ASAM criteria: Treatment criteria for addictive, substance-related and co-occurring . OR 2) Early Intervention Services ________________________ When?__________________________ Why?_______________________________ How do you feel about your involvement? FORMCHECKBOX An acute/persistent mental health condition/complication requires intervention, with symptoms that significantly interfere with addiction treatment, as evidenced by ______________________________________________________________________. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. 0000010490 00000 n ____________________________ Detox Date(s)___________________________ Where? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Other: FORMCHECKBOX FORMCHECKBOX .. FORMCHECKBOX FOR FEMALES: FORMCHECKBOX FORMCHECKBOX Menopause or menopausal FORMCHECKBOX .. FORMCHECKBOX FORMCHECKBOX Pre Menstrual Syndrome FORMCHECKBOX FORMCHECKBOX .. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Pregnancy: FORMCHECKBOX Suspected FORMCHECKBOX FORMCHECKBOX Confirmed Number of months: _______________ Referred to First Steps? FORMCHECKBOX No FORMCHECKBOX Yes, if yes, when, by whom, and what was it? 0000145603 00000 n Have these, or any other medical conditions been impacted by your use of alcohol or other drugs? FORMCHECKBOX No FORMCHECKBOX Yes, If yes, explain:________________________________________ _______________________________________________________________________________________________________6. ASAM Assessment Questions Example.pdf - Course Hero FORMCHECKBOX No FORMCHECKBOX Yes, if yes where? FORMCHECKBOX No FORMCHECKBOX FORMCHECKBOX Yes2. Do you need any help to understand written or verbal information? 0000021314 00000 n ASAM Assessment Questions Example.pdf - TOOL 1: QUESTIONS BY ASAM DIMENSIONS The following tool highlights specific questions that should be asked of ASAM Assessment Questions Example.pdf - TOOL 1: QUESTIONS. 0000008121 00000 n 0 FORMCHECKBOX FORMCHECKBOX Fully functioning. Diagnostic Criteria for Substance Abuse DisorderA maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one or more of the following criteria occurring within a 12-month period. PDF An Introduction to The ASAM Criteria for Patients and Families - Aetna ______________________________________________________________________________4. Persistent attempts or one or more unsuccessful efforts made to cut down or control substance use. e.g. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. __________________ Have you ever received any help with this problem? No FORMCHECKBOX Yes FORMCHECKBOX if yes Does the patient need help accessing or selecting childcare? FORMCHECKBOX A behavioral condition/complication requires intervention, but does not significantly interfere with addiction treatment. Tools and resources from ASAM online and LIVE CME courses. Six Dimensions of the ASAM Criteria - The Change Companies ASAM Criteria & Levels of Care in Addiction Treatment (spending time at bars/crack houses, seeking out dealers, recovering from hangovers, etc.) Are you a Drug Court patient? 2 FORMCHECKBOX Some difficulty tolerating and coping with withdrawal discomfort. FORMCHECKBOX Nicotine Withdrawal Must meet all 4 Criteria to be considered withdrawal FORMCHECKBOX Daily use of nicotine for at least several weeks. B. Overview of ASAM Assessment Dimensions and Levels of Care 1. 3 FORMCHECKBOX FORMCHECKBOX Demonstrates poor ability to tolerate and cope with withdrawal discomfort. 0000150278 00000 n FORMCHECKBOX No FORMCHECKBOX FORMCHECKBOX Yes; if yes, when and by whom:___________________________________ Have you received or participated in counseling for this issue? 0000187447 00000 n FORMCHECKBOX None FORMCHECKBOX Low FORMCHECKBOX Moderate FORMCHECKBOX High As evidenced by __________________________________________________________________________________________ ________________________________________________________________________________________________________Risk Rating for Dimension 3 (from PPC-2R - Appendix A): NOTE: A risk rating of 4 in this dimension requires an immediate intervention. __________________________ Drug? FORMCHECKBOX No FORMCHECKBOX Yes, if yes, in what ways?___________________________ _______________________________________________________________________________________________________4. Have you ever been in jail and/or prison?
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