INTAKE AND PSYCHOSOCIAL ASSESSMENT

Date :
PATIENT INFORMATION:
PATIENT NAME:
AGE:
DATE OF BIRTH:
PHONE:
ADDRESS/CITY/STATE/ZIP:
SEX: MALE FEMALE TRANSGENDER OTHER
MARITAL STATUS: SINGLE DIVORCED SEPARATED WIDOWED DOMESTIC PARTNERSHIP
REFERRAL SOURCE:
ACCOMPANIED BY:
RELATIONSHIP TO PATIENT:
DIMENSION 1 ACUTE INTOXICATION OR WITHDRAWAL POTENTIAL:
CURRENT SUBSTANCE USED AGE OF FIRST USE ROUTE AMOUNT/FREQUENCY DURATION OF USE LAST USE/AMOUNT
SUBSTANCE ABUSE WITHDRAWAL (CHECK ALL THAT APPLY):
N/A NO ACTIVE SYMPTOMS
INSOMNIA
SHAKES/TREMORS
IRRITABILITY
DELIRIUM
STOMACH CRAMPS
SWEATS/CHILLS
ANXIETY
FEVER
FLU-LIKE ACHES
GOOSEFLESH
DIARRHEA
CRAVINGS
WEAKNESS
YAWNING
DILATED PUPILS
PREOCCUPATION
AGITATION
HALLUCINATIONS
NAUSEA
LEG CRAMPS
CHANGES IN BP
VOMITING
CONCERNS FOR WITHDRAWALS:
DOES THE PATIENT HAVE A HISTORY OF DELIRIUM TREMORS (DTS), BLACKOUTS, OR SEIZURES? (INCLUDE LAST OCCURRENCE)
HAS THE PATIENT ATTENDED ANY 12 STEP PROGRAMS SUCH AS NA OR AA? Yes No
URRENT OR PAST? SPONSOR? Yes No
SEVERITY RATING: Please circle the intensity and urgency of the patient’s CURRENT needs for services based on the information collected in Dimension 1
0 None 1 Mild 2 Moderate 3 Severe 4 Very Severe
  • No signs of withdrawal/ intoxication present
  • Mild/moderate intoxication
  • Interferes with daily functioning
  • Minimal risk of severe withdrawal
  • No danger to self/others
  • May have severe intoxication but responds to support
  • Moderate risk of severe withdrawal
  • No danger to self/others
  • Severe intoxication with imminent risk of danger to
  • Severe intoxication with imminent risk of danger to self/others
  • Difficulty coping
  • Significant risk of severe withdrawal
  • Incapacitated
  • Severe signs and symptoms
  • Presents danger, i.e.,seizures
  • Continued substance use poses an imminent threat to life
Withdrawal management (WM) follow up for controlled or mild symptoms Prioritize the link to medical WM services Urgent, high risk or severe WM needs, high need of support 24-hours/day Emergency Departmentimminent danger
DIMENSION 2 BIOMEDICAL CONDITIONS
MEDICATIONS:
LIST ANY MEDICAL ISSUES:
LIST ANY KNOWN ALLERGIES:
LIST ANY PHYSICAL LIMITATIONS:
LIST ANY RECENT EXPOSURE TO OR CONTRACTING OF COMMUNICABLE DISEASES:
HOW HAS YOUR ADDICTION IMPACTED YOUR HEALTH:
HAVE YOU OR ARE YOU CURRENTLY TAKING A PRESCRIPTION NOT PRESCRIBED TO YOU? Yes No
IF YES, PLEASE EXPLAIN.
HISTORY OF PSYCH MEDS:
SEVERITY RATING: Please circle the intensity and urgency of the patient’s CURRENT needs for services based on the information collected in Dimension 2
0 None 1 Mild 2 Moderate 3 Severe 4 Very Severe
  • Fully functional/no significant pain or discomfort
  • Mild symptoms interfering minimally with daily functioning
  • Able to cope with physical discomfort
  • Acute or chronic biomedical problems are non-life threatening but are neglected and need new or different treatment
  • Health issues moderately impacting *ADLs and independent living
  • Sufficient support to manage medical problems at home with medical intervention
  • Poorly controlled medical problems requiring evaluation
  • Poor ability to cope with medical problems
  • Insufficient support to manage medical problems independently
  • Difficulty with ADLs and/or independent living
  • Unstable condition with severe medical prob- lems,** including but not limited to:
  • Emergent chest pain
  • Delirium tremens (DTs)***
  • Unstable pregnancy
  • Vomiting bright red blood
  • Withdrawal seizure in the past 24 hours
  • Recurrent seizures
Regular follow up, low intensity services for controlled conditions Priority follow up and evaluation for new/ uncontrolled conditions Need for evaluation and treatment, including medical monitoring in conjunction with 24-hour nursing to ensure stabilization Need for evaluation and treatment, including medical monitoring in conjunction with 24-hour nursing to ensure stabilization
DIMENSION 3 EMOTIONAL, BEHAVIORAL, COGNITIVE
PREVIOUS PSYCHIATRIC AND/OR SUBSTANCE ABUSE TREATMENT - INPATIENT/OUTPATIENT
FACILITY DATE MD/THERAPIST DIAGNOSIS COMPLETION OF PROGRAM
Yes No
Yes No
PRESENTING PROBLEMS/SOMATIC SYMPTOMS ( SYMPTOMS/CHANGES PRESENT IN THE PAST TWO WEEKS)
Problematic areas Present Describe (frequency, intensity, duration, occurrence)
Depressed or sad mood Yes No
Loss of energy or interest in activities or school refusal Yes No
Deterioration in hygiene and/or Grooming Yes No
Social withdrawal or isolation Yes No
Difficulties with the ability to parent/or be parented Yes No
Difficulties with home, school, or work relationships or responsibilitie Yes No
Sleeping Patterns Present Describe (frequency, intensity, duration, occurrence)
Change in number of hours/night Yes No
Difficulty falling asleep Yes No
Frequent awakening during the night Yes No
Early morning Awakenings Yes No
Nightmares/dreams Yes No
Eating Habits Present Describe (frequency, intensity, duration, occurrence)
Changes in eating habits: overeating/loss of appetite Yes No
Binge eating and/or purging Yes No
Weight Gain/Loss?Amount of change: Yes No
Use of laxatives or excessive exercise Yes No
Panic attacks Yes No
Anxiety Symptoms Present Describe (frequency, intensity, duration, occurrence)
Obsessive/compulsive thoughts Yes No
Obsessive/compulsive behaviors Yes No
Impact on daily living or avoidance of situations/ objects due to level of anxiety Yes No
SEX FEMALE MALE
AGE 1-15 15-24 25-49 50+
MARITAL/PARTNER STATUS MARRIED SINGLE DIVORCED WIDOWED
HISTORY OF SUICIDE NONE IDEATION ONLY GESTURE/NON-LETHAL GESTURE/POTENTIALLY LETHAL
HISTORY OF ATTEMPTS NONE 5+ YEARS 1-5 YEARS IN PAST YEAR
INTENT/AMBIVALENCE (CURRENTLY) NO INTENT TO DIE MINIMAL INTENT MODERATE INTENT CLEAR INTENT
SUPPORT SYSTEM GOOD SUPPORT SOME SUPPORT CONFLICTED SUPPORT NO SUPPORT
LOSS OR TRAUMA NONE MODERATE SERIOUS MULTIPLE
IMPULSIVENESS/AGGRESSION NONE MILD MODERATE SEVERE
SUBSTANCE ABUSE NONE RECREATIONAL ABUSE DEPENDENCE
HOPELESSNESS HOPEFUL SOME HOPE AMBIVALENT HOPELESS
SCORE
TOTAL SCORE
INITIAL THE IDENTIFIED RISK LEVEL
INITIALS    MILD RISK=1-9
INITIALS    MODERATE RISK=10-21
INITIALS    SERIOUS RISK= 22 OR
NOTES RELATED TO SUICIDE RISK ASSESSMENT(PLEASE DESCRIBE ANY PLAN OR CURRENT SUICIDAL IDEATION)
IF HISTORY OF SUICIDE ATTEMPT, PLEASE DESCRIBE:
LOSS OR TRAUMA, PLEASE EXPLAIN:
CURRENT OR PAST ABUSE/TRAUMA HISTORY (EMOTIONAL, SEXUAL, PHYSICAL ABUSE, VICTIM OF CRIME OR NATURAL DISASTER)
EVALUATION OF THE PATIENT'S RISK TO OTHERS
Current Risk to Others
Does the patient, or do others, report the patient having homicidal ideation or making threats to others?
Yes No
Is the ideation repetitive or persistent?
Yes No N/A
Does the patient have a specific plan? (please describe)
Yes No N/A
Does the ideation involve serious/lethal intent?
Yes No N/A
Has the patient demonstrated preparatory behaviors?
Yes No N/A
Does the patient have access to weapons such as firearms, knives, etc.?
Yes No N/A
Does the ideation have delusional or hallucinatory content?
Yes No N/A
Has there been an attempt to assaultive behavior in the past 48 hours?
Yes No N/A
If yes, explain:
History of Homicidal Ideation/Behaviors
Is there a lifetime history of homicidal ideation/assaultive behavior?
Yes No
Is there any evidence or concern that the patient or others may be concealing or denying current or past homicidal/assaultive ideation/behaviors?
Yes No
Collateral Comments:
SEVERITY RATING :Please circle the intensity and urgency of the patient’s CURRENT needs for services based on the information collected in Dimension 3
0 None 1 Mild 2 Moderate 3 Severe 4 Very Severe
  • No dangerous symptoms
  • Good social functioning
  • Good self-care
  • No symptoms interfering with recovery
  • Possible diagnosis of emotional, behavioral,cognitive condition
  • Requires monitoring for stable mental health condition
  • Symptoms do not interfere with recovery
  • Some relationship impairments
  • Symptoms distract from recovery
  • Requires treatment and management of mental health condition
  • No immediate threat to self/others
  • Symptoms do not prevent independent functioning
  • Inability to care for self at home
  • May include dangerous impulse to harm self/others
  • Does require 24-hr support
  • At risk of becoming a 4/Very Severe without treatment
  • Life-threatening symptoms including active suicidal ideation
  • Psychosis
  • Imminent danger to self/others
Further assessment and referral or follow-up with existing mental health (MH) provider Prioritize follow up or new evaluation with MH provider for new/uncontrolled conditions Urgent assessment and treatment for unstable signs and symptoms Emergency Departmentimmediate assessment
DIMENSION 4 READINESS TO CHANGE
HOW MUCH IS SUBSTANCE USE A PROBLEM FOR YOU?
HAVE YOU DONE ANYTHING IN THE PAST TO CHANGE YOUR ALCOHOL OR OTHER DRUG USE?
DO YOU HAVE ANY CONCERNS OR FEARS THAT WOULD MAKE IT HARD FOR YOU TO STAY IN TREATMENT?
WHO ELSE IN YOUR LIFE CARES IF YOU QUIT SUBSTANCE USE?
HOW IMPORTANT IS IT FOR YOU TO MAKE CHANGES IN YOUR LIFE AT THIS TIME?
NOT AT ALL A LITTLE SOMEWHAT VERY EXTREMELY
HOW IMPORTANT IS IT FOR YOU TO QUIT YOUR ALCOHOL OR DRUG USE?
NOT AT ALL A LITTLE SOMEWHAT VERY EXTREMELY
HOW READY ARE YOU TO STOP YOUR ALCOHOL OR DRUG USE?
NOT AT ALL A LITTLE SOMEWHAT VERY EXTREMELY
ARE THERE OTHER THINGS IN YOUR LIFE THAT YOU WOULD LIKE TO BE DIFFERENT THAN HOW THEY ARE NOW?
NOT AT ALL A LITTLE SOMEWHAT VERY EXTREMELY
IF THINGS WERE BETTER THAN THEY ARE NOW, WHAT WOULD THAT LOOK LIKE?
SEVERITY RATING :Please circle the intensity and urgency of the patient's CURRENT needs for services based on the information collected in Dimension 4
0 None 1 Mild 2 Moderate 3 Severe 4 Very Severe
  • Proactive responsible participant in treatment
  • Committed to changing alcohol or other drug (AOD) use
  • Willing to enter treatment
  • Ambivalent to the need to change
  • Reluctant to agree to treatment
  • Low commitment to change AOD use
  • Variable adherence to treatment
  • Unaware of and not interested in the need to change
  • Unwilling/only partially able to follow through with treatment
  • Passively compliant, goes through the motions in treatment
  • Rejecting need to change
  • Engaging in potentially dangerous behavior
  • Unwilling/unable to follow through with treatment recommendations
Requires moderate intensity services for motivational enhancement Requires moderate intensity services for motivational enhancement Requires high intensi- ty engagement and/or motivational enhancement services to prevent decline in functioning/safety Secure placement for acute or imminently dangerous situations and/or close observation required
DIMENSION 5 RELAPSE POTENTIAL
DOES THE PATIENT HAVE ANY PERIOD OF SOBRIETY? WHEN WAS THE PATIENT’S SOBRIETY?
IF YOU RELAPSED IN THE PAST, WHAT KINDS OF THINGS DO YOU THINK LED TO YOUR RELAPSE?
WHICH TRIGGERS OR PROBLEMS HAVE BEEN THE WORST FOR YOU IN THE PAST MONTH OR SO?
GENERALLY, HOW DO YOU HANDLE THESE TRIGGERS OR PROBLEMS?
WHAT ARE YOUR CURRENT STRESSORS?
DO YOU FEEL LIKE YOU HAVE A GOOD PLAN TO DEAL WITH THESE ISSUES OR TRIGGERS?
WHAT DO YOU BELIEVE WILL HAPPEN IF YOU CONTINUE YOUR SUBSTANCE USE?
SEVERITY RATING :
Please circle the intensity and urgency of the patient's CURRENT needs for services based on the information collected in Dimension 5:
0 None 1 Mild 2 Moderate 3 Severe 4 Very Severe
  • Low/no potential for relapse
  • Some minimal risk for use
  • Fair coping and relapse prevention skills
  • Some or inconsistent use of coping skills
  • Able to self-manage with prompting
  • Little recognition of risk for use
  • Poor skills to cope with relapse
  • No coping skills for relapse/addiction problems
  • Substance use/behavior places self/others in imminent danger
Low-intensity relapse prevention services are needed or self-help/peer support group Relapse prevention services and education are needed.
Possible need for:
  • intensive case management
  • medication management
  • assertive community treatment
 Relapse prevention services including:
  • structured coping skills training
  • motivational strategies
  • assertive case management and assertive community treatment
  • possible need for structured living environment
 Likely needs all services listed in "Severe"
  • For acute cases, need for 24-hour clinically managed living environment. OR
  • For chronic cases, not imminently dangerous situations, need 24-hour supportive living environment
DIMENSION 6 RELAPSE POTENTIAL
WHO LIVES WITH YOU AGE RELATIONSHIP DO THEY USE SUBSTANCES?
Yes No
HOUSEHOLD DYSFUNCTION, INCLUDING SEPARATION/DEATH/DIVORCE/INCARCERATION:
CURRENT RELATIONSHIP PROBLEMS:
NUMBER OF PREVIOUS MARRIAGES:
CHILDREN (AGE AND GENDER)
SUPPORT SYSTEMS:
CULTURAL INFLUENCES/ RELIGIOUS BACKGROUND AND CURRENT ACTIVITY:
PATIENT HAS RELIGIOUS AFFILIATION        NAME OF RELIGION:
CURRENT SCHOOL.EMPLOYMENT (PLACE, LENGTH OF EMPLOYMENT, GRADE IN SCHOOL, EXTRACURRICULAR ACTIVITIES, JOB ROLE, PROBLEMS WITH SCHOOL OR JOB)
MILITARY HISTORY:
NONE        WHICH BRANCH TYPE OF DISCHARGE
CURRENT LEGAL ISSUES:
CURRENT FINANCIAL ISSUES:
PATIENT STRENGTHS
PATIENT WEAKNESSES:
SEVERITY RATING :
Please circle the intensity and urgency of the patient’s CURRENT needs for services based on the information collected in Dimension 6:
0 None 1 Mild 2 Moderate 3 Severe 4 Very Severe
  • Able to cope in environment/supportive
  • Passive/disinterested social support, but still able to cope
  • No serious environmental risks
  • Unsupportive environment, but able to cope in the community with clinical structure most of the time
  • Unsupportive environment,difficulty coping even with clinical structure
  • Environment toxic/hostile to recovery
  • Unable to cope and the environment may pose a threat to safety
May need assistance in:
  • finding a supportive environment
  • developing supportsre: skills training
  • childcare
  • transportation
 Needs assistance listed in "Mild," as well as:
  • assertive care management
 Needs more intensive assistance in
  • finding supportive living environment
  • skills training (depending on coping skills and impulse control)
  • assertive care management
  • Patient needs immediate separation from a toxic environment
  • Assertive care management
  • Environmental risks require a change in housing/environment
  • For acute cases with imminent danger: patient needs immediate secure placement
ASAM CONTINUUM OF CARE
.5 EARLY INTERVENTION
1 OUTPATIENT SERVICES
2.0 IOP/PHP
2.1 INTENSIVE OUTPATIENT SERVICES
2.5 PARTIAL HOSPITALIZATION SERVICES
3.0 RESIDENTIAL/INPATIENT
3.1 CLINICALLY MANAGED LOW-INTENSITY-RESIDENTIAL SERVICES
3.3 CLINICALLY MANAGED
3.5 CLINICALLY MANAGED HIGH INTENSITY RESIDENTIAL SERVICES
3.7 MEDICALLY MONITORED INTENSIVE -INPATIENT SERVICES
4 MEDICALLY MANAGED INTENSIVE INPATIENT SERVICES
OVERALL SUMMARY/NOTES:
ALERT (MEDICAL OR CLINICAL):
LEVEL OF CARE DETERMINATION
ACUTE INPATIENT TREATMENT
BEHAVIOR WHICH IS LIFE THREATENING, DESTRUCTIVE, OR DISABLING TO SELF OR OTHERS
SYMPTOMS/BEHAVIORS INDICATIVE OF NEED FOR 24 HOUR MONITORING AND ASSESSMENT OF PATIENT’S CONDITION
FAILURE AT OUTPATIENT, INTENSIVE OUTPATIENT, OR PARTIAL HOSPITALIZATION TREATMENT EVIDENCED BY CLINICAL INSTABILITY OR MD
CONDITION REQUIRES A MEDICALLY MONITORED DETOXIFICATION PROCESS
SEVERE DETERIORATION OF THE LEVEL OF FUNCTIONING
LEVEL OF RISK: HIGH MODERATE LOW
TOWARDS: SELF OTHERS
BELLA NIRVANA CENTER PSYCHOSOCIAL ASSESSMENT
PATIENT/PARENT OR GUARDIAN IF MINOR ACCEPTS OR DECLINES LEVEL OF CARE RECOMMENDATION (PLEASE CIRCLE)
IF DECLINE (PLEASE DESCRIBE WHY)
ASSESSMENT COMPLETED BY NAME ASSESSMENT COMPLETED BY SIGNATURE:
PROGRAM DIRECTOR NAME: PROGRAM DIRECTOR SIGNATURE:
CLINICAL DIRECTOR NAME: CLINICAL DIRECTOR SIGNATURE:
CONSULTING/ATTENDING PHYSICIAN'S NAME: CONSULTING/ATTENDING PHYSICIAN'S SIGNATURE:
THERAPIST NAME: THERAPIST SIGNATURE: