LOCUS Crosswalk 2012 by 0PQ2fe6V

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									Client Name                                                                                                Date

                                                             LOCUS Crosswalk:
Directions: Select all ratings that apply by checking the appropriate box/boxes. The highest rating for each dimension represents the score for that
dimension, but any criteria that apply should be noted on this tool. Circle the corresponding criteria that support the rating. Justification for ratings
should be included in the box on the first page.

Provide justification for level of care requested in space below*




* Note: If a person scores a 4 or 5 in the first three domains (Risk of Harm, Functional Status or Medical or Addictive
Co-Morbidity), Level V or VI needs to be considered for Level of Care Placement Criteria.

Composite Score                                                              Level of Care Recommendation
Dimension 1-
                1- Minimal Risk of   2- Low Risk of Harm    3- Moderate Risk of   4- Serious Risk of Harm   5- Extreme Risk of
                Harm                 a.                     Harm                  a.                        Harm
Risk of Harm    a.                   b.                                           b.
                                                            a.                                              a.
                b.                   c.                     b.                    c.                        b.
                                                            c.                    d.                        c.
                                                            d.
                                                            e.


Dimension 2-
                1-Minimal            2-Mild Impairment      3-Moderate            4-Serious Impairment      5-Severe Impairment
                Impairment           a.                     Impairment            a.                        a.
Functional                           b                                            b.                        b.
                a.                                          a.
Status                               c.                     b.                    c.                        c.
                                     d.                     c.                    d.                        d.
                                                            d.                    e.                        e.
                                                            e.
                                                            f.

Dimension 3-
                1- No Co-morbidity   2-Minor Co-morbidity   3-Significant         4- Major-Co-morbidity     5- Severe Co-morbidity
                a.                   a.                     Co-morbidity          a.                        a.
Medical,        b.                   b.                                           b.                        b.
                                                            a.
Addictive and                        c.                     b.                    c.                        c.
Psychiatric                                                 c.                    d.                        d.
                                                            d.                    e.                        e.
Co-Morbidity
                                                            e.
                                                            f.
Dimension 4-
               1- Low Stress         2- Mildly Stressful   3- Moderately         4- Highly Stressful       5- Extremely Stressful
               Environment           Environment           Stressful Environment Environment               Environment
Recovery
               a.                    a.                    a.                    a.                        a.
Environment    b.                    b.                    b.                      b.                      b.
               c.                    c.                    c.                      c.                      c.
A) Level of    d.                    d.                    d.                      d.                      d.
               e.                    e.                    e.                      e.                      e.
Stress         f.                    f.                    f.                      f.                      f.
                                                           g.                      g.


Dimension 4-
               1- Highly Supportive 2- Supportive          3- Limited Support in   4- Minimal Support in   5- No Support in
               Environment          Environment            Environment             Environment             Environment
Recovery                            a.
               a.                                          a.                      a.                      a.
Environment    b.                    b.                    b.                      b.
                                     c                     c.                      c.
B) Level of                                                d.                      d.
                                                           e.
Support

Dimension 5-
               1- Fully Responsive   2- Significant        3- Moderate or          4- Poor Response to     5- Negligible Response
               to Treatment and      Response to           Equivocal Response      Treatment and           to Treatment
Treatment
               Recovery              Treatment and         to Treatment and        Recovery                a.
and Recovery   a.                    Recovery              Recovery                Management              b.
History        b.                    Management            Environment             a.
               c                                                                   b.
                                     a.                    a.
                                     b.                    b.
                                                           c.
                                                           d.
Dimension 6-
               1- Optimal       2- Positive and   3- Limited         4- Minimal       5- Unengaged and
               Engagement and   Engagement and    Engagement and     Engagement and   Stuck
Engagement
               Recovery         Recovery          Recovery           Recovery         a.
and Recovery   a.               a.                a.                 a.               b.
Status         b.               b.                b.                 b.               c.
               c.               c.                c.                 c.               d.
               d.               d.                d.                 d.
                                                  e.                 e.




                                                               Clinician Name

								
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