PATIENT PLACEMENT CRITERIA GRID

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					CLIENT NAME:                                                                                                                                SSN:

                                               PLACEMENT CRITERIA GRID (based on ASAM PPC-2R)
                                            LEVEL 0.5                               LEVEL I                               LEVEL II                                    LEVEL III
       Levels of Care                       Education                               Outpatient                       Intensive Outpatient                             Residential

      Criteria Dimensions                                                         Meets DSM-IV criteria                    Meets DSM-IV criteria                     Meets DSM-IV criteria
                                                                            for substance abuse or dependence        for substance abuse or dependence         for substance abuse or dependence

           1.                    No significant risk                    None to minimal risk                    Minimal to moderate                       Moderate to high risk but manage-
      WITHDRAWAL                                                                                                withdrawal risk                           able in clinically monitored environ

           2.                    None or very stable                    None or very stable                     Mildly distracting from treatment         Requires 24-hr medical monitoring,
       BIOMEDICAL                                                                                               but manageable in IOP                     but not intensive services

          3.                     None or very stable                    None to mild severity, but very         Mild to moderate severity with            Moderate severity needing a 24-
      EMOTIONAL/                                                        stable                                  potential to distract from recovery       hour structured setting
      BEHAVIORAL/
       COGNITIVE

           4.                    Willing to explore how current         Ready but needs additional              Poor engagement in treatment,             Resistance high & impulse control
      READINESS TO               alcohol/drug use may affect            motivating/monitoring strategies; or    significant ambivalence, or lack of       poor despite negative consequences
        CHANGE                   personal goals                         high severity in this dimension but     awareness of problems, requiring          Needs motivating strategies in a 24-
                                                                        not in other dimensions                 intensive structured program              hour structured setting

           5.                    Needs understanding of, or skills to   Able to maintain abstinence or          High likelihood of relapse or             Unable to control use, with
       RELAPSE/                  change, current alcohol/drug use       control use and pursue recovery or      continued use or continued                imminently dangerous
    CONTINUED USE/               patterns                               motivational goals with minimal         problems without near-daily               consequences needing 24-hr
                                                                        support                                 monitoring and support                    monitoring and structured support
    C0NT. PROBLEM

         6.                      Social support system abuses or        Supportive recovery environment         Unsupportive recovery                     Dangerous recovery environment,
   RECOVERY/LIVING               condones alcohol/drugs and             and/or patient has skills to cope       environment, but with structure and       and lacks skill to cope outside of
    ENVIRONMENT                  increases risk of personal conflict                                            support, the patient can cope             structured 24-hr setting
                                 about alcohol/drug use

          7.                     N/A                                    Command willing to commit to            Command willing to commit to              Command willing to commit to
     OPERATIONAL                                                        treatment requirements                  treatment requirements                    treatment requirements; logistical
     COMMITMENTS                                                                                                                                          impediment to less intensive tx


DIMENSIONAL SPECS: LEVEL 0.5 (meets 1, 2, 3, and at least one of 4, 5, 6)             LEVEL I (meets all six ASAM criteria)          LEVEL II (meets at least one of 4, 5, 6, with 2 and 3 at
Level II or less) LEVEL III (meets two of 1 thru 6, with at least one being 1, 2, 3, or 7-logistical impediment)



                                        DIAGNOSIS:             ***                                                         RECOMMENDED PROGRAM:                              ***

                                        LICENSED INDEPENDENT PRACTIONER:

                                        DATE:

				
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