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					                                                                             UNCOPE SCREENING - Electronic Version
                                                                                Permission for use of electronic version granted to ADMH providers by Mark Spurlock                                                                      Fund Code:


  Completed By:                                                                                                                             Provider ID:                                                                ASAIS ID:            0
   Date of Screening:                                                 Date of Entry:                1/0/1900                         Provider:                                                                          CASE No:             0

                  Last Name:                                                                                                     First Name:                                                                          MI:
                         Alias 1:                                                                                                     Alias 2:
What is the most important thing you
want that made you contact us?:
Presenting Problems: (check all that apply)
      -        Abuse Victim                                             -         Dep/Mood Disorder                                           -        Marital                                                    -         Somatic
      -        Alcohol                                                  -         Drug                                                        -        Medical                                                    -         Suicidal
      -        Assault Victim                                           -         Eating Disorder                                             -        Rape Victim                                                -         Thought Disorder
      -        Criminal Justice                                         -         Family                                                      -        Runaway Behavior                                           -         None
      -        Daily Coping                                             -         Interpersonal                                               -        Social                                                     -         Other:

               Date of Birth:                                                                     Age: 0.00                                            SSN#:                                                          Medicaid #:
                      Address:                                                                                                               City:                                                               State:               Zip:
                        County:                                                                             Emerg. Contact:                                                                             Relationship:

    Home Phone No:                                                                                           Cell Phone No:                                                                            Email address:


     Sex:                                            Race:                                                                                                                               Ethnicity:
             Marital Status:                                                                                       If married how long:                              year(s)                          months            Total Number of Marriages:

                          Language Preference:                              If other than English, please specify:

                                   Linguistic Status:                                                                                                                                                   Hearing Status:

Referral Source:

      -        A and/or D Treatment, Inpatient Res.                                                               -         Guardian                                                                     -     Private Psychiatrist
      -        A and/or D Treatment, Not Inpatient                                                                -         ID 310 Program                                                               -     Probation / Parole
      -        Clergy                                                                                             -         ID ARC                                                                       -     Recognized Legal Entity
      -        Court / Correctional Agency                                                                        -         ID Regional Office                                                           -     School System
      -        DHR                                                                                                -         Multi-Service MH Agency                                                      -     Self
      -        Diversionary Program / TASC                                                                        -         OP Psych Ser/Clinic                                                          -     Shelter for the Abused
      -        DUI / DWI                                                                                          -         Nursing Home / Extended Care                                                 -     Shelter for the Homeless
      -        Educational Agency                                                                                 -         Parent                                                                       -     Spouse
      -        Employer / EAP                                                                                     -         Partial Day Organization                                                     -     State / County Psych Hospital
      -        Family                                                                                             -         Personal Care/Boarding Home                                                  -     State / Federal Court
      -        Formal Adjudication Process                                                                        -         Physician                                                                    -     Voc. Rehab Services
      -        Friend                                                                                             -         Police                                                                       -     If Other Specify below:
      -        General / Psychiatric Hospital                                                                     -         Prison

Which is the primary referral source?                                                                                                                                             Secondary?

Reason for referral:

Financial:
I receive my principal source of income from:                                                                                                                               If other specify:
What would you estimate your family's annual income to be?

Health Insurance and Source of Payment:
Insurance Type:                                                                                                                                    Specify the name of company:

Policy Number:                                                                                                                                                      Group. Number:

Source of Payment:                                                                                                                                Special Population:
UNCOPE - Age 18 and Above:
                                                                                                                                                                                                                                                 YES   NO
1. In the past year, have you ever drank or used drugs more than you meant to? 1,2                                                                                                                                                                -     -
2. Have you ever neglected some of your usual responsibilities because of alcohol or drugs? 2                                                                                                                                                     -    -
3. have you felt you wanted or needed to cut down on your drinking or drug use in the last year? 1,2                                                                                                                                              -    -
4. Has anyone obected to your drinking or drug use? 3,1 Or has your family, friend, or anyone else ever told you they objected to
                                                                                                                                                                                                                                                  -    -
alcohol or drug use?
5. Have you ever found yourself preoccupied with wanting to use alcohol or drugs? 2 Or have you found yourself thinking a lot about
                                                                                                                                                                                                                                                  -    -
drinking or using?
6. Have you ever used alcohol or drugs to relieve emotional discomfort, such as sadness, anger or boredom? 2,1                                                                                                                                    -    -
                                                                                                                               UNCOPE Score:                                                                                                     0
1. Brown, R. L., Leonard, T., Saunders, L. A., & Papasouliotis, O. (1977). A two-item screening test for alcohol and other drug problems. Journal of FamilyPractice, 44, (2), 151-160.
2. Hoffman, N. G. & Harrison, P. A. (1995). SUDDS-IV: Substance Use Disorders Diagnostic Schedule, Smithfield, RI: Evince Assessments.
3. Hoffman, N. G. ((1995). TAAD: Triage Assessment for Addictive Disorders, Smithfield, RI: Evince Clinical Assessments.
      ASAIS ID:      0      Last Name:                0                     First Name:              0                      MI:   0
                  University of Rhode Island Change Assessment (URICA): Alcohol and Drug Use Scale

INSTRUCTIONS: This questionnaire is to help us improve services. Each statement describes how a person
might feel when starting therapy or approaching problems in their lives. Please indicate the extent to which you
tend to agree or disagree with each statement. In each case, make your choice in terms of how you feel right now,
not what you have felt in the past or would like to feel. For all the statements that refer to your "problem", answer
in terms of problems related to your alcohol use and then for your drug use. The words "here" and “this place”
refer to treatment or the program. Please read the following statements carefully. For each statement, the number
in the box that best describes how much you agree or disagree with each statement.
  Alcohol                None                              Drugs                 None
                   Key: SD = No Strongly Disagree D = No Disagree U = Undecided or Unsure A = Yes Agree SA = Yes Strongly Agree
     Problem:                    In regards to my alcohol and drug use…                              SD        D      U     A    SA   Total
   As far as I'm concerned, I don't have any                                       Alcohol Use:        -         -      -     -   -     0
 1
   problems that need changing.                                                       Drug Use:        -         -      -     -   -     0
 2 I think I might be ready for some self-improvement.
                                                                                   Alcohol Use:        -         -      -     -   -     0
                                                                                      Drug Use:        -                -     -   -     0
   I am doing something about the problems that                                    Alcohol Use:        -         -      -     -   -     0
 3
   have been bothering me.                                                            Drug Use:        -         -      -     -   -     0
 4 It might be worthwhile to work on my problem.
                                                                                   Alcohol Use:        -         -      -     -   -     0
                                                                                      Drug Use:        -         -      -     -   -     0
   I'm not the problem one. It doesn't make much                                   Alcohol Use:        -         -      -     -   -     0
 5
   sense for me to be here.                                                           Drug Use:        -         -      -     -   -     0
   It worries me that I might slip back on a problem I                             Alcohol Use:        -         -      -     -   -     0
 6
   have already changed, so I am here to seek help.                                   Drug Use:        -         -      -     -   -     0
 7 I am finally doing some work on my problem.
                                                                                   Alcohol Use:        -         -      -     -   -     0
                                                                                      Drug Use:        -         -      -     -   -     0
   I've been thinking that I might want to change                                  Alcohol Use:        -         -      -     -   -     0
 8
   something about myself.                                                            Drug Use:        -         -      -     -   -     0
   I have been successful in working on my problem                                 Alcohol Use:        -         -      -     -   -     0
 9
   but not sure I can keep up the effort on my own.                                   Drug Use:        -         -      -     -   -     0
10 At times my prob. is difficult, but I'm working on it.
                                                                                   Alcohol Use:        -         -      -     -   -     0
                                                                                      Drug Use:        -         -      -     -   -     0
   Being here is pretty much a waste of time for me                                Alcohol Use:        -         -      -     -   -     0
11
   because the problem doesn't have to do with me.                                    Drug Use:        -         -      -     -   -     0
   I'm hoping this place will help me to better                                    Alcohol Use:        -         -      -     -   -     0
12
   understand myself.                                                                 Drug Use:        -         -      -     -   -     0
   I guess I have faults, but there's nothing that I                               Alcohol Use:        -         -      -     -   -     0
13
   really need to change.                                                             Drug Use:        -         -      -     -   -     0
14 I am really working hard to change.
                                                                                   Alcohol Use:        -         -      -     -   -     0
                                                                                      Drug Use:        -         -      -     -   -     0
15 I have a prob. and I really think I should work at it.
                                                                                   Alcohol Use:        -         -      -     -   -     0
                                                                                      Drug Use:        -         -      -     -   -     0
     I'm not following through with what I had already
16   changed as well as I had hoped, and I'm here to
                                                                                   Alcohol Use:        -         -      -     -   -     0
     prevent a relapse of the problem.                                                Drug Use:        -         -      -     -   -     0
     Even though I'm not always successful in                                      Alcohol Use:        -         -      -     -   -     0
17
     changing, I am at least working on my problem.                                   Drug Use:        -         -      -     -   -     0
     I thought once I had resolved my problem I would
18   be free of it, but sometimes I still find myself
                                                                                   Alcohol Use:        -         -      -     -   -     0
     struggling with it.                                                              Drug Use:        -         -      -     -   -     0
     I wish I had more ideas on how to solve the                                   Alcohol Use:        -         -      -     -   -     0
19
     problem.                                                                         Drug Use:        -         -      -     -   -     0

                                                                Page 1 of 2
       ASAIS ID:      0         Last Name:              0                       First Name:               0                        MI:       0
                   Key: SD = No Strongly Disagree D = No Disagree U = Undecided or Unsure A = Yes Agree SA = Yes Strongly Agree
      I have started working on my problems but I                                      Alcohol Use:         -         -       -      -        -       0
20
      would like help.                                                                    Drug Use:         -         -       -      -        -       0
21 Maybe this place will be able to help me.
                                                                                       Alcohol Use:         -         -       -      -        -       0
                                                                                          Drug Use:         -         -       -      -        -       0
   I may need a boost right now to help me maintain                                    Alcohol Use:         -         -       -      -        -       0
22
   the changes I've already made.                                                         Drug Use:         -         -       -      -        -       0
   I may be part of the problem, but I don't really                                    Alcohol Use:         -         -       -      -        -       0
23
   think I am.                                                                            Drug Use:         -         -       -      -        -       0
   I hope that someone here will have some good                                        Alcohol Use:         -         -       -      -        -       0
24
   advice for me.                                                                         Drug Use:         -         -       -      -        -       0
   Anyone can talk about changing; I'm actually                                        Alcohol Use:         -         -       -      -        -       0
25
   doing something about it.                                                              Drug Use:         -         -       -      -        -       0
   All this talk about psychology is boring. Why can't                                 Alcohol Use:         -         -       -      -        -       0
26
   people just forget about their problems?                                               Drug Use:         -         -       -      -        -       0
   I'm here to prevent myself from having a relapse                                    Alcohol Use:         -         -       -      -        -       0
27
   of my problem.                                                                         Drug Use:         -         -       -      -        -       0
   It is frustrating, but I feel I might be having a                                   Alcohol Use:         -         -       -      -        -       0
28
   recurrence of a problem I thought I had resolved.                                      Drug Use:         -         -       -      -        -       0
   I have worries but so does the next guy. Why                                        Alcohol Use:         -         -       -      -        -       0
29
   spend time thinking about them?                                                        Drug Use:         -         -       -      -        -       0
30 I am actively working on my problem.
                                                                                       Alcohol Use:         -         -       -      -        -       0
                                                                                          Drug Use:         -         -       -      -        -       0
   I would rather cope with my faults than try to                                      Alcohol Use:         -         -       -      -        -       0
31
   change them.                                                                           Drug Use:         -         -       -      -        -       0
   After all I had done to try to change my problem,                                   Alcohol Use:         -         -       -      -        -       0
32
   every now and again it comes back to haunt me.                              Drug Use:                    -         -       -      -        -       0
                                                             FOR OFFICE USE ONLY

      Precontemplation                       Contemplation (C)                                  Action (A)                         Maintenance (M)
            (PC)
      Alcohol Drug                           Alcohol         Drug                             Alcohol    Drug                      Alcohol          Drug
  1     0                   0           2      0              0                          3      0          0                   6      0              0
  5     0                   0           4     Omit           Omit                        7      0          0                   9     Omit           Omit
 11     0                   0           8      0              0                         10      0          0                  16      0              0
 13     0                   0          12      0              0                         14      0          0                  18      0              0
 23     0                   0          15      0              0                         17      0          0                  22      0              0
 26     0                   0          19      0              0                         20     Omit       Omit                27      0              0
 29     0                   0          21      0              0                         25      0          0                  28      0              0
 31    OMIT         OMIT               24      0              0                         30      0          0                  32      0              0
        0            0                         0              0                                 0          0                          0              0
       Total        Total                     Total          Total                             Total      Total                      Total          Total


         0            0                         0              0                                 0          0                            0            0
        Mean        Mean                      Mean           Mean                              Mean       Mean                       Mean           Mean

                                                        Stage                                                       Stage                    Group Average

      Alcohol:        0                Pre-contemplation                                                    Pre-contemplation                 8 or lower
                                                                                                                Contemplation                     9-11
                                                        Stage                                                    Preparation                      12-14
        Drug :        0                Pre-contemplation                                                         Maintenance                 15 and above

The Readiness to Change score is calculated by taking the sum of each subscale divide by 7 to get the mean for each
subscale. The sum of the means score from Contemplation, Action, and Maintenance subscales are combined and the
Precontemplation mean is subtracted (C + A + M) - PC = Readiness.
      Source: University of Maryland, Health and Addictive Behaviors lab, http://www.umbc.edu/psyc/habits/content/ttm_measures/urica/readiness.html


                                                                     Page 2 of 2
                                                         ADULT ASAM INTEGRATED PLACEMENT ASSESSMENT - Electronic Version
                                                                             Permission for use of the Adult-ASAT granted to ADMH providers by Mark Spurlock


                     ASAIS ID:                0                       Last Name:                                 0                                         First Name:                0                      MI:       0

            DIMENSION 1. ACUTE INTOXICATION AND / OR WITHDRAWAL POTENTIAL:
            Do you have a history of withdrawal symptoms when you haven't been able to obtain alcohol and or other drugs, cut down on your use, or stopped using?                                -
            If "No" go to next question
                -      Agitated (fidget, pace, etc.)            -      Fever                                                      -      Move and talk slower than usual                  -   Seizures
                -      Anxiety                                  -      Hand Tremors                                               -      Muscle aches                                     -   Sweating or heart racing
                -      Diarrhea                                 -      Increased appetite                                         -      Nausea / Vomiting                                -   Vivid, unpleasant dreams
                -      Fatigue                                  -      Insomnia or Hypersomnia                                    -      Runny nose / watery eyes                         -   Yawning
                -      Feeling sad/tense/angry                  -      Memory Loss                                                -      See/feel/hear things that aren't there

            Are you currently experiencing any of the above?                 -                 If "No" go to next question




                                                                                                                       -              If "No" go to next
            Have any of these symptoms kept you from doing social, family, job or other activities?
                                                                                                                                          question
            Have you used AOD to stop or avoid having these symptoms?                    -            If "No" go to next question

            Are the symptoms due to a medical condition or some other problem?                          -                  If "No" go to next question

                                                               Substance Use Background (Please use the following codes on the tables below)
                                                  Route of Administration:                                                                                      Frequency of Use:
            1 - Oral                               4 - Injection/IV                                                  1 - No use in the past month                        4 - 3 to 6 times in the past week
            2 - Smoking                            5 - Injection/Intramuscular                                       2 - 1 to 3 times in past month                      5 - Daily
            3 - Inhalation                         6 - Other (Specify)                                               3 - 1 to 2 times in the past week                   8 - Other
                                                                                                                     Age of                 Date Last      How Long Frequency Age of            Periods of
                    Class of Substances                Specific Substances               Route of Admin.                                                                      Regular                              Rank Order
                                                                                                                       1st Use                Used           Used     of Use                    Abstinence
                                                                                                                                                                                      Use
               A                  None                           NA                              NA                        NA                    NA           NA            NA        NA             NA               NA

               B                  Alcohol

               C               Marijuana

               D             Cocaine/Crack

               E                  Heroin

                          Non-Prescription
               F
                             Methadone
                          Other Opiates and
               G
                              Synthetics

               H                   PCP

                I        Other Hallucinogens

               J          Methamphetamine

               K        Other Amphetamines

               L           Other Stimulants

               M          Benzodiazepines

                             Other Non-
               N
                          benzodiazepines
                            tranquilizers
               O            Barbiturates

                        Other Non-barbiturate
               P
                        sedatives or hypnotics

               Q               Inhalants

               R           Over the counter

               Y                  Other

               U               Unknown



 Notes or
Comments:



                                                                                                                                                                                                      Page 1 of 8

                       ASIS ID:               0                       Last Name:                                 0                                         First Name:                0                      MI:       0
            DIMENSION 2. BIOMEDICAL CONDITIONS AND COMPLICATIONS:
            Do you have / have you had any medical problems, including infectious communicable diseases?                              -        If "No" go to next question



            Do you have any known allergies?             -         If "No" go to next question

            Does your chemical use affect your medical conditions in any way?                             No                   If "No" go to next question

            List and medications you currently take, have taken, or should take:
                             Medication                                                    Prescribed For                                        Dosage                          Frequency                     Taking as Prescribed




 Notes or
Comments:


            Have you ever been hospitalized?                      -               If "No" go to next question
                    Date                                                   Facility                                                       Length of Stay                                      Treated For




 Notes or
Comments:

            Are you pregnant?            -               If "NA" go to next question         -                   If "NA" go to next question                         -                 If "NA" go to next question

 Notes or
Comments:

            Is childcare available for these children?            -        Describe:

            Are you required to pay child support?                -                      If yes are you current with child support payments?                         -

            Do you feel you have adequate parenting skills?                   -             Would you be interested in receiving more skills?                        -

            Pain Assessment
            Do you have pain now?                        -        If "NA" go to next question                                                                       If "NA" go to next question

            Are you under a doctor's care for this pain?          -               If "No" go to next question

            On a scale of 1 to 10 how would you rate the pain pain you are experiencing?                                                         Is this pain related to withdrawal?              -     If "No" go to next question




            What makes the pain feel better or worse?                                                                   Do you take medication of any kind to relieve the pain?                   -     If "No" go to next question



            Have you had this same pain in the recent past?                   -         If "No" go to next question
 Notes or
Comments:

            Have you had TB or tested positive for TB in the past?                           -         If "No" skip to next question



            For more than two weeks do you…. (consider possible withdrawal symptoms)

             1. Have sputum-producing cough?                      -                                                     4. Have night sweats?                        -
             2. Cough up blood?                                   -                                                     5. Have a fever?                             -
             3. Have loss of appetite?                            -                                                     6. Receive a TB medication?                  -
 Notes or
Comments:

            DIMENSION 3. EMOTIONAL/BEHAVIORAL/COGNITIVE CONDITIONS AND COMPLICATIONS
            As a child, were there any serious physical injuries or mental illnesses causing trauma?                       -                    If "No" skip to next question


                                                                                                                                   If "No" go to next
            Have you ever been diagnosed with a mental/emotional disorder?                                  -                               question:
                                                                                                                                   If "No" go to next
            Have you ever had any treatment for mental/emotional problems?                                  -                               question:
               When (Date)                               Where                                          Level of Care                         Length of TX                                    Treated For




 Notes or
Comments:
                                                                                                                                                                                                               Page 2 of 8
                     ASAIS ID:               0                           Last Name:                                0                                            First Name:                   0                      MI:      0


            Have you ever been the victim of abuse?                           -             If "No" go to next question:
                -      Physical                          -      Domestic Violence                           -           Neglect                  -         Sexual                 -         Emotional
            When & by whom?                                                                                 Has this been reported?             -            If yes to whom:
            Did you receive intervention?                 -         Is further assessment needed?             -
 Notes or
Comments:

            Have you ever been the perpetrator of abuse?                          -            If "No" go to next question:

                -      Physical                            -        Domestic Violence                         -             Neglect               -           Sexual                       -          Emotional
            When & to whom?                                                                                   Has this been reported?             -                If yes to whom:
            Did you receive intervention?                 -         Is further assessment needed?             -

 Notes or
Comments:


            In the last year have you felt like hurting or killing yourself (suicidal Ideation)?                                  -                    If "No" skip to next question




            In the last year have you felt like hurting or killing someone else (homicidal Ideation)?                             -                    If "No" skip to next question




            In the last year, have you experienced hallucinations or difficulty telling what is real from that which is not? (auditory, visual, olfactory, tactile)                        -                   If "No" skip to next question




            In the last year, have you had trouble remembering, concentrating or following simple instructions?                                                                            -                   If "No" skip to next question




 Notes or
Comments:



            Mental Status Examination:
                                              While prompts are provided below, the assessor should make sure to describe his/her observations and impressions of the person for each grouping below.
            ORIENTATION:
               -   Normal                 -                    Deficits           -                        Person                      -              Place                -                   Time                  -            Situation
 Notes or
Comments:

            GENERAL APPEARANCE:
            DRESS:             -                          Appropriate             -           Meticulous                      -       Eccentric                -          Seductive                        -               Disheveled
            GROOMING:          -                          Appropriate             -           Meticulous                      -       Dirty                    -          Poor                             -                 Bizarre
            FACIAL EXP.:       -                          Appropriate             -           Flat                            -       Sad                      -      Angry                                -                 Fearful

 Notes or
Comments:

            MOOD/AFFECT:
            MOOD:                         -               Appropriate             -                 Depressed                 -            Euphoric            -        Anxious            -      Irritable          -            Euthymic
            AFFECT:                       -               Appropriate             -                  Hostile                  -            Blunted             -       Restricted          -       Labile            -              Flat

 Notes or
Comments:

            SELF-CONCEPT:
            SELF-CONCEPT:                 -                        Self-assured                 -               Realistic              -              Low self-esteem                      -                      Inflated self-esteem

 Notes or
Comments:

            SPEECH:
            SPEECH:                       -                    Normal             -                 Pressured                 -       Stammering               -                 Mute                      -                   Loud
                                          -                     Soft              -                 Rambling                  -         Slurred                -               Echolalia

 Notes or
Comments:


                                                                                                                                                                                                                           Page 3 of 8
                     ASAIS ID:                  0                             Last Name:                               0                                              First Name:                      0                        MI:       0
            MEMORY:
            IMMEDIATE:                    -             Intact            -                Mildly Impaired                    -               Moderately Impaired                          -                       Severely Impaired
            RECENT:                       -             Intact            -                Mildly Impaired                    -               Moderately Impaired                          -                       Severely Impaired
            REMOTE:                       -             Intact            -                Mildly Impaired                    -               Moderately Impaired                          -                       Severely Impaired

 Notes or
Comments:

            THOUGHT PROCESS:
            THOUGHT                      -          Logical                  -        Relevant                                  -      Coherent             -            Illogical         -        Goal Directed
            PROCESS:                     -          Incoherent               -        Circumstantial                            -      Rambling             -            Blocking          -        Flight of Ideas
                                         -          Neologisms               -        Loose Associations                        -      Tangential           -            Perplexed         -        Confabulating
                                         -          Clanging                 -        Confused                                  -      Grossly Disorganized
 Notes or
Comments:

            THOUGHT CONTENT:
            THOUGHT                      -          Normal                   -        Somatic Complaints                        -      Obsessions/Compulsions                -        Poverty of Content
               CONTENT                   -          Guilt                    -        Illogical Thinking                        -      Hopelessness                          -        Suicidal or Homicidal Ideation
                                         -          Suspicious               -        Prejudices/Biases                         -      Depressive                            -        Hypochondriacally
 Notes or
Comments:

            JUDGEMENT AND INSIGHT:
            JUDGEMENT:          -                         Good               -                        Partial                   -                   Limited                  -                              Poor
            INSIGHT:            -                         Good               -                        Partial                   -                   Limited                  -                              Poor
 Notes or
Comments:

            DIMENSION 4. READINESS TO CHANGE:
            Do you have any behaviors that you need to change? (e.g. criminal activity, fighting, cursing or smoking)                        -                 If "No" skip to next question


            Do you think you have a problem with AOD and/or mental/emotional disorders?                                                      -                 If "No" skip to next question


            Has anyone ever complained about your AOD use?                                                                                   -                 If "No" skip to next question


            Have you tried to hide your alcohol or drug use?                 -               If "No" go to next question
            Has your alcohol or drug use caused you to feel any of the following:                          -          If "No" go to next question
                -             Depressed                          -     Decreased sexual desire
                -              Nervous                           -     Diminished interest in normal activities
                -             Suspicious                         -     Other psychological problems

            Have you used AOD to the point that you have neglected important obligations?                                                                                    -                   If "No" skip to next question



            Has your AOD use affected your health by causing numbness, blackouts, shakes, tingling, TB, STD's, or any other health problems?                                 -                   If "No" skip to next question


            Have you continued to use despite the negative consequences (at work, school, or home)?                                                                          -                   If "No" skip to next question


            Have you continued to use despite placing yourself and others in dangerous or unsafe situations?                                                                 -                   If "No" skip to next question



            Have previous efforts to cut down or control AOD use been unsuccessful?                                                                                          -                   If "No" skip to next question


            Have you had problems with the law because of your use?                                                                                                          -                   If "No" skip to next question


            Have you continued using AOD even though your use affected you socially (fights, problem relationships, etc.) ?                                                  -                   If "No" skip to next question


            Do you need more AOD to get the same high?                                                                                                                       -                   If "No" skip to next question


            Do you spend a great deal of time in activities to obtain AOD and / or feeling it's effects?                                                                     -                   If "No" skip to next question


            Has your AOD use caused you to give up or not participate in social, occupational, or recreational activities that you once enjoyed?                             -                   If "No" skip to next question


            Have you continued to use after knowing it caused or contributed to physical and or psychological problems?                                                      -                   If "No" skip to next question


            Have you used larger amounts of AOD than you intended?                                                                                                           -                   If "No" skip to next question


                                                                                                                                                                                                             Page 4 of 8
                     ASAIS ID:               0                         Last Name:                                 0                                       First Name:                  0                           MI:      0

            The URICA score and stage of readiness:                                                   Alcohol Use:     0        Pre-contemplation                        Drug Use:      0                 Pre-contemplation

            DIMENSION 5. RELAPSE, CONTINUED USE OR CONTINUED PROBLEM POTENTIAL
            Have you ever been treated for and AOD problem?                              -                            Are you currently receiving Opioid Replacement Therapy?                          -
               Treated For:                      Where (Facility)                                 When                       Level of Care (including Detox)                                   Type of Discharge
 Notes or
Comments:

            Does anyone in your immediate family have or has had a…
               -     Drug problem?                                If yes, who:
               -     Alcohol problem?                             If yes, who:
               -     Mental/emotional illness?                    If yes, who:
               -     Illness/injury/handicapped?                  If yes, who:
            Is your current living environment drug free?                    -          If "Yes" skip to next question
            Are you participating in any support groups?                     -           If "No" skip to next question
                -        AA     If yes how often do you attend?                                                              Do you have or have had an AA sponsor?                               -
                -        NA     If yes how often do you attend?                                                              Do you have or have had an NA sponsor?                               -
                -        CA     If yes how often do you attend?                                                              Do you have or have had an CA sponsor?                               -
                -        Other Support Group       If yes name?                                                              Do you have or had a Mentor/Big Brother or Sister?                   -
            Have you had any periods of abstinence from AOD?                 -                    If "No" skip to next question
             1. How was abstinence/maintenance achieved?
             2. What would you consider your relapse triggers?
             3. Are you aware of what caused you to relapse?
            In the past year, have you tried to reduce the effect of your AOD/problems?                 -             If "No" skip to next question


            Have you had any periods without mental/emotional problems?                                 -                           If "No" skip to next question
             1. How was maintenance achieved?
             2. What causes the symptoms to get worse?

            DIMENSION 6. RECOVERY / LIVING ENVIRONMENT
            Are you the head of household?             -               Number in Household:
            Check which of the following best describes your current living arrangement:
                -      Ala. Housing Finance Authority Housing                                           -          Independent Living                          -        Other (list below)
                -      Center Operated / Contracted Res. Program                                        -          Jail/Correctional Facility
                -      Center Subsidized Housing                                                        -          Reside with Family
                -      Homeless/Shelter                                                                 -          Other Institutional Setting

            How would you describe the quality of interaction with family?               -

            The level of satisfaction with current support systems in your life?         -
            How many times have you moved in your lifetime either with or without family?

            Current Employment Status:
            What is your current employment status?
            Employment History:
                          Employer                                                     Position                                        Dates Employed                                     Reason for Leaving




            Current Educational Status:

            Are you currently in school, enrolled in a GED program, or vocational program?              -             If "No" skip to next question

            Number of years completed in school?                           Are you interested in pursuing additional education and or training?                -             If "No" skip to next question

 Notes or
Comments:



                                                                                                                                                                                                        Page 5 of 8
                     ASAIS ID:               0                         Last Name:                              0                                        First Name:                   0                     MI:       0

            Detailed Legal Status:

            My legal status is:                                                                                 If Other:

            Do you have a PO or parole officer?        -                If "No" skip to next question                                     -                                                  -
                                                                                                                                         NAME                                             PHONE
            Current Charges:                                                                                                                                  No. of Arrests in 30 days Prior to Admission:           -

                                                                         No. of              Convicted                                                                             No. of          Convicted
                                     Arrest History:                                                                             Arrest History:
                                                                         Arrests:      Yes           No                                                                            Arrests:       Yes      No
                      Assault                                                      -     -              -                   Public Intoxication                                              -     -         -

                      Auto Theft                                                   -     -              -                   Rape                                                             -     -         -

                      Burglary                                                     -     -              -                   Receiving Stolen Property                                        -     -         -

                      Robbery                                                      -     -              -                   Fraudulent use of a credit card                                  -     -         -
                        Criminal Trespass                                                        -       -             -                   Shoplifting                                                      -   -          -

                        Distribution                                                             -       -             -                   Theft of Property                                                -   -          -

                        DUI                                                                      -       -             -                   Violation of Probation                                           -   -          -

                        Harassment                                                               -       -             -                   Domestic Violence                                                -   -          -

                        Minor in Possession                                                      -       -             -                   Child / Elder Abuse                                              -   -          -

                        Possession                                                               -       -             -                   Negotiating a Worthless Instrument                               -   -          -

                        Other                                                                    -       -             -                   Other                                                            -   -          -


            Explanation of the above to include outcome:




            Social & Recreational Status:
            How often do/did you engage in any of the following activities?
                                          Activity                                                    Frequency                                                                    Comments
                -       Partying
                -       Going to clubs, bars, etc.
                -       Participate in sports
                -       Bully
                -       Gang activities

            Are you currently or have you ever been bullied?                               -             If "No" go to next question:
            What type of social activities did you participate in
            prior to your alcohol / drug use?
            List & describe any support groups, org., clubs, that
            will help you in your recovery efforts?
            How often do you participate in these activities?

            Do you have any hobbies or leisure activities you'd like
            to learn?
            What do others consider to be your strengths
            (interests, talents, skills, abilities, knowledge,
            education, religion/spiritual, cultural)?
            Do you have or have you had a boy/girlfriend during                            -                          If "No" go to next question:                            -
            the past 90 days?
            Are you sexually active?                            -        Do you use birth control or protection (condoms) to prevent pregnancy or sexually transmitted disease?                         -       Type:
            Family Background:
            Describe your relationship with your:
            Mother:                                                                                                                       Children:
            Father:                                                                                                               Grandparents:
            Siblings:                                                                                                                      Others:
            Who would you ask to take you to the hospital if you were to suddenly become ill?
            Would you call the same person to tell some really good news? (If not, why & who)

            Do you have reliable transportation?                            -             If yes describe:                                                          Do you have a valid drivers license?        -


 Notes or
Comments:


                                                                                                                                                                                                                        Page 6 of 8
                        ASAIS ID:                    0                               Last Name:                               0                                          First Name:                0                          MI:    0

   ASAM PPC-2R Diagnostic Summary (summarize each dimension as assessed):
   Risk Rating: 0 = Indicates full functioning; no severity,                                                                               Risk Rating: 1-4 = Indicates various levels of functioning and severity
                                                      no risk in this dimension.                                                                                           and the level of risk in the dimension.
                                       (NOTE: A higher score indicates a greater level of severity)     0              1            2         3          4

    D       ACUTE INTOXICATION AND / OR WITHDRAWAL POTENTIAL:                                                                     SA           -
    I
    M
    E
    N
    S                                     FALSE
    I
    O
      O
    N
      N
      E
                         Substance Abuse Risk Rating:                        -
              #REF!        #REF!             #REF!            #REF!       #REF!          FALSE         FALSE         FALSE        FALSE      FALSE
    D       BIOMEDICAL CONDITIONS & COMPLICATIONS:                                                                                SA           -
    I
    M
    E
    N
    S                                     FALSE
    I
        I
        O
          T
        N
          W
          O
                                  Substance Abuse Risk Rating:                -
                             0              0                   0       0         0       FALSE    FALSE       FALSE       FALSE     FALSE               MH Rating Not required if risk rating = 0 or 1
    D                                                                          SA
                  EMOTIONAL / BEHAVIORAL / COGNITIVE CONDITIONS & COMPLICATIONS:                                                       -
    I
    M
    E         T
    N         H                                    FALSE
    S         R
    I         E
    O         E
    N                                               FALSE

                                  Substance Abuse Risk Rating:                -
                             0              0                   0       0         0       FALSE    FALSE       FALSE       FALSE     FALSE

D                 READINESS TO CHANGE:                                                                                     SA          -              MH              -
I
M
E                                                  FALSE
N
S
                  F
I                                 Substance Abuse Risk Rating:                -
                  O
O
                  U
N
                  R
                                                   FALSE



                                                      0
                                            Mental Health Risk Rating:        -
                             0              0                   0       0         0       FALSE    FALSE       FALSE       FALSE     FALSE                   If rated 4 (severe) specify A or B


D                 RELAPSE / CONTINUED USE OR CONTINUED PROBLEMS:                                                           SA          -              MH              -
I
M
E
                                                   FALSE
N
S                                        Substance Abuse Risk Rating:         -
                  F
I
                  I
O
                  V
N
                  E                                FALSE



                                                      0
                                            Mental Health Risk Rating:        -

D                 Recovery Living Environment:                                                                             SA          -              MH              -
I
M
E                                                  FALSE
N
S
I                                        Substance Abuse Risk Rating:         -
O                 S
N                 I
                  X                                FALSE


                                                      0
                                            Mental Health Risk Rating:        -


                                                                                                                                                                                                                      Page 7 of 8
                                 ASAIS ID:                  0                         Last Name:                       0                                     First Name:                               0                   MI:        0

                       CROSSWALK RESULTS:                                   Substance Abuse Criteria NOT Met                       Dependence Criteria NOT Met                                    With Out Physiological Dependence

                  DSM-IV Diagnostic Impression and/or Diagnosis: See Substance Abuse Background Page 1 for Details
                  Problem                                                                                    Age                                                                    DSM
                                       Class of Substance           Specific Substance          Route                                           Frequency                                                           Specifer
                       Substances:                                                                           1st                                                                     Code
                       Primary
    D                 Secondary
    S
    M                   Tertiary
    -
    I I           Axis I                             Code                         Specifier:                                     Class of Substance
    V m                           Primary:           0.00                            0                                                    0
      p
    D r                      Secondary:              0.00                             0                                                    0
    i e
    a s                           Tertiary:          0.00                             0                                                    0
    g s           Axis II
    n i
    o o
    s n
    t             Axis III
    i
    c             Axis IV            -          None                                                                         -     5. Housing Problems
                                     -          1. Problems with primary support group                                       -     6. Economic Problems
                                     -          2. Problems related to social environment                                    -     7. Problems with access to health care services
                                     -          3. Educational Problems                                                      -     8. Problems related to legal system / crime
                    -        4. Occupational Problems                                                                               -    9. Other psychological and environmental problems

Axis V                                          Current GAF:                                                 Population Code:

                                                                            Assessed Level of Care (Check one unless also receiving OMT):
    -       0.5              Early Intervention Services                                                           -    III.01     Transitional Residential Treatment
    -       1                Outpatient Treatment                                                                  -    III.1      Clinically Managed Low Intensity Residential Treatment
    -       1-D              Ambulatory Detoxification without extended on-site monitoring                         -    III.3      Clinically Managed Medium Intensity Residential Treatment
            1-O              Opiod Maintenance Therapy                                                                  III.5      Clinically Managed High Intensity Residential Treatment
    -       II.1             Intensive Outpatient Treatment                                                        -    III.7      Medically Monitored High Intensity Inpatient Treatment
    -       II.5             Partial Hospitalization                                                               -    III.7-D Medically Monitored Inpatient Detoxification
    -       II-D             Ambulatory Detoxification with extended on-site monitoring                            -
Placed Level of Care:
Reason for Difference:                                                                                             Comment:
Disposition:
    -        1. Admitted to:                                                                                                             for assessed level of care.       Client Start Date:
    -        2. Referred to:                                                                                                             for assessed level of care.
    -        3. Referred for case management services to assisst:
    -        4. Assessed level not available, referred to:                                                                                                             for interim care.
    -        5. No service available, referred to:                                                                                                              &
                                                                                                              and placed on waiting list(s) in ASIS.
    -              5. Refused further services, client discharged.

                                                                                                                                                                                          NOTES OR COMMENTS
    -       Indigent Offender                                                                            -    Special Women's Program
    -       Special Adolescent Program                                                                   -    Pardons and Paroles Program
    -       HIV Early Intervention Program                                                               -    Special COD Program

Was the Co-occurring disorder screen administered?                                                                                                      Note:
Was the Co-occurring disorder assessment administered?                                                                                                  Note:
Is client seeking treatment due to Co-dependent / Collateral?                                            -                         If yes explain:
Explanation of the above to include outcome:




Medical provider review of LOC Assessment:
   -     Agree with diagnostic impression                                                                                                    -       Treatment authorization
   -     Agree with the level of care determination                                                                                          -       Number of days / hours approved
   -     Agree with recommended admission to level of care                                                                                   -       Recommended additional services
   -     Agree with the preliminary treatment plan                                                                                           -       Need additional information

Release of Information:                                           -       An appropriate release for this information is on file for this client.
                                          Typed Signatures:                                                        Date                                                                     Signatures:

           0                                             0                                           0              -                                                    See Client Service Roster
    Client's Last Name                               First Name                           MI                                                                                              Client's Signature

                                                    -                                                               -
                  Assessment Staff Typed Signature and Credentials                    Provider ID:                                                                            Assessment Staff Signature and Credentials

                                                                                                                    -
                                     Staff Signatures and Credentials                                                                                                              Staff Signatures and Credentials

                                                                                                                    -
                                   Physician Signatures and Credentials                                                                                                          Physician Signatures and Credentials

                                                                                                                                                                                                                           Page 8 of 8
                                                                         ASAIS DATA:
ASAIS ID:                                 -         Status*                   -                   Center Case No:                                         -
                                 Client Characteristic Data Summary - Complete information in colored boxes


Provider:                            0
Date of Screen:                          1/0/1900                    Entered By:                    0                            Provider ID:                 0
Date of Assessment:                           -                      Entered By:                    0                            Provider ID:                 0
Client Start Date:                       1/0/1900                 Request Type:                     -
Client Discharge Date:                                            Request Type:                     -
                                                                                            0

                      -       Treatment Completed                                       -       Transfer to Another Program or Facility
                      -       Left Against Professional Advise                          -       Transfer to Another Program or Facility, but did not report
                      -       Terminated by Facility                                    -       A. Patient unable to resolve problem
                      -       Incarcerated                                              -       B. Patient demonstrated lack of capacity to resolve problem(s)
                      -       Death                                                     -       C. Patient demonstrated intensification of problem/developed new problems




Client Name:                                  0                                             0                                   0
                                          LAST NAME                                    FIRST NAME                          MIDDLE INTIAL


DOB:                      1/0/1900                         Social Security No.:       000-00-0000

Street Address:                                               0                                           City:                        0
State:                0                       Zip Code:                   0                             County:                        0
Phone:                       0                    Population Code:                                          0
Gender:                      0                     Race:                          0                 Ethnicity:                             0



                                                                      UNCOP                                                                        YES            NO
1. In the past year, have you ever drank or used drugs more than you meant to?1,2
                                                                                                                                                      -           -
2. Have you ever neglected some of your usual responsibilities because of alcohol or drugs?2
                                                                                                                                                      -           -
3. have you felt you wanted or needed to cut down on your drinking or drug use in the last year?1,2
                                                                                                                                                      -           -
4. Has anyone obected to your drinking or drug use?3,1 Or has your family, friend, or anyone else ever told you
they objected to alcohol or drug use?                                                                                                                 -           -
5. Have you ever found yourself preoccupied with wanting to use alcohol or drugs?2 Or have you found yourself
thinking a lot about drinking or using?                                                                                                               -           -
6. Have you ever used alcohol or drugs to relieve emotional discomfort, such as sadness, anger or boredom?2,1
                                                                                                                                                      -           -

                                                                                                                         UNCOPE Score:               0            0
                                                      ASAIS PROFILE OR DISCHARGE:
                         0                                                                                                                          0
                    ASAIS ID:                                                                                                              CENTER CASE NO:


Client Name:                              0                                                           0                                         0

Review:                           -                    Date of Assessment:                    -                       Fund Code:                0

Entered By:                           -                              Status:               1/0/1900                     Provider:                       0

Referral - Admission Information:

Co-Dependent / Collateral:                        -

Principal Source of Referral:                                       0                                                                  0
                                                                  Primary                                                           Secondary


Specific Substance Abuse Problems:

Axis I - Primary Problem
Primary Substance Problem Type:                                                   0                           0
Primary Substance Detail:                                                         0                           0
                                                                               Specifier
Primary Substance Route:                                                                                      0
Primary Substance Frequency:                                                                                  0
Primary Substance Age of 1st Use:                                                                                 0
Axis I - Secondary
Sec. Substance Problem Type:                                                      0                           0

Sec. Substance Detail:                                                            0                           0
                                                                               Specifier
Sec. Substance Route:                                                                                         0
Sec. Substance Frequency:                                                                                     0
Sec. Substance Age of 1st Use:                                                                                    0
Axis I - Tertiary
Tertiary Substance Problem Type:                                                  0                           0
Tertiary Substance Detail:                                                        0                           0
                                                                               Specifier
Tertiary Substance Route:                                                                                     0
Tertiary Substance Frequency:                                                                                 0
Tertiary Substance Age of 1st Use:                                                                                0

Axis II
Problem Code & Description:                                                       0                           0

Problem Code & Description:                                                       0                           0

Axis III
Description:                  0

Axis IV
    -           None                                                                              -       5. Housing Problems
    -           1. Problems with primary support group                                            -       6. Economic Problems
    -           2. Problems related to social environment                                         -       7. Problems with access to health care
    -           3. Educational Problems                                                           -       8. Prob. related to legal system/crime
    -           4. Occupational Problems                                                          -       9. Psychological & environment

Axis V                Current GAF:            0       Pop Code:                                                            0



                                                                                                                                                             PAGE 1
Client Name:                                         0                                                           0                                                    0
Client Characteristics and Services

Marital Status:                                                                                              0
Employment Status:                                                                                           0
Education:                                                                                                   0
Name of last school attended and City it is located:                                                         0
Highest grade completed:                                                                                     0
Hearing Status:                                                                                              0
Linguistic Status:                                                                                           0
Living Arrangements:

                       -        Ala. Housing Finance Authority Housing                             -          Independent Living
                       -        Center Operated / Contracted Res. Program                          -          Jail/Correctional Facility
                       -        Center Subsidized Housing                                          -          Reside with Family
                       -        Homeless/Shelter                                                   -          Other Institutional Setting

                                     -           Other (list below)                                          0
Pregnant at Time of Admission:                            -         If yes how many weeks?     -           Receiving Prenatal Care?                 -

Veteran:                                                                                                               NA

Co-occurring
Was a Co-occurring Disorder Scrren Administered?                                                                                                         -
Was a Co-occurring Disorder Assessment Administered?                                                                                                     -
Is Client Participating in Opioid Replacement Therapy?                                                                         -
Number of Prior Treatment Episodes?                                                                                            -
Number of Arrest in the 30 days Prior to Admission?                                                                            -
Has client participated in self-help groups or support groups (e.g.
AA, NA, etc.) in the last 30 days?                                                                                             -
Financial

Source of Financial Support                                                                                                                 0
Health Insurance                                                                                                                                    0
Policy Number                                                                                                                               0
Group Number                                                                                                                   0
Medicaid Number                                                                                                                                     0
Source of Payment                                                                                                                                   0
Intake Level of Care Placement Summary

Assessed Level of Care
      -        0.5             Early Intervention Services                          - II-D             Ambulatory Detoxification with extended on-site monitoring
      -        1               Outpatient Treatment                                 - III.01           Transitional Residential Treatment
      -        1-D                                                                  - III.1
                               Ambulatory Detoxification without extended on-site monitoring           Clinically Managed Low Intensity Residential Treatment
      -        1-O             Outpatient Maintenance Therapy                       - III.5            Clinically Managed Medium Intensity Residential Treatment
      -        II.1            Intensive Outpatient Treatment                       - III.7            Medically Monitored High Intensity Inpatient Treatment
      -        II.5            Partial Hospitalization                              - III.7-D          Medically Monitored Inpatient Detoxification

Placed Level of Care                                                                                   0
If placement is different from assessed level what reason?                                                                   0
Disposition

      -           1. Admitted to:                                   0                  for assessed level of care.
      -           2. Referred to:                                   0                  for assessed level of care.
      -           3. Assessed level not available, referred to:                                        0                                        for interim care.
      -           4. No service available, referred to:                                0                                       &                              0

      -           5. Refused further services, client discharged.

                                                                                                                                                                    PAGE 2