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Levels of care

COMPU-TOOLS TEEN/ADOLESCENT (ASAM) CRITERIA WORKSHEET (11/01/2004)
LEVELS OF
LEVEL III
CRITERIA
OUTPATIENT TX
INTENSIVE OUTPATIENT
MEDICALLY
MEDICALLY
DIMENSIONS
MONITORED
MANAGE INPATIENT
INPATIENT TX
Responses
Responses
Responses
Responses
Withdrawal
No withdrawal risk
No overt symptoms of
Risk of Withdrawal but
Severe Withdrawal risk
Potential
withdrawal risk
manageable
Contract = Can quit on
Contract = Can quit on own
Contract = Needs
Contract = Needs
Assistance to quit
Assistance to quit
Results = Possible or
Results = Definite Problem
Results = Definite
Results = Positive
Probable Problem
Psychological results
Questionnaire =
Questionnaire = Recent
Responses = Limited
Health = Poor
Recent Abstinence
Abstinence
Abstinence
Contract = Agrees to
Contract = Agrees to Abstain
Prescription Meds =
Seizures
Biomedical
None or Stable
None or non-distracting
Require Medical
(2.4) 24 Hour medical care
Conditions
Monitoring
Prescription Meds –
Prescription Meds – Non
Prescription Meds –
Prescription Meds –
Non Chronic Problems
Chronic Problems –may need
Chronic Problems
Chronic Problems
to be monitored
Responses = 0 Serious
Responses = 0 Serious Health
Responses = Late Stage
Prescription Meds -
Health symptoms
symptoms
Symptoms of use
Seizures
Questionnaire =
Responses = Late Stage
Unwilling to stop use
Symptoms of use
Health = Poor
Meds = Antabuse
Emotional or
None or Stable
Mild Severity
Moderate Severity
(3.4) 24 Hour Psychiatric care
Behavioral
Results = 0 Positive
Results = 0 Positive
Results = Positive
Results = Positive
Psychological results
Psychological results
Psychological Test
Psychological Test
Responses = 0 Violent
Results = Positive Anti-
Results = Positive Anti-
Behaviors
Social Test results
Social Test results
Results = Legal History
Results = Life Area -
Legal

Responses = Violent
Responses = Violent
behaviors
behaviors
Questionnaire = History
Responses = Suicidal
of Psychological
Thoughts/Actions
problems
Questionnaire = Suicide
Treatment
Willing to Cooperate/Needs
Needs Structured Outpatient
Needs 24 Hour Structure
Acceptance
Motivation
Qualify for
Contract = Agreed to 12
Contract = Agreed to Outpatient Tx
Contract = Refusal to
Step Program
Participate
Responses = Admits to
Responses = Previous Intervention
Results = Positive IQ Score
Effort(s)
Questionnaire = Prior Tx
Results = Positive Anti-
Social results
Questionnaire = Prior Tx
Able to maintain abstinence
High likelihood of relapse
Unable to abstain in
Potential
outpatient environment
Qualify for
Contract = Agreed to
Contract = Refuses to Participate in
Responses = Previous
Monitoring/Case
Monitoring Program
Intervention Efforts
Management
Recovery
Supportive
Unsupportive
Dangerous
Environment
Qualify for
Contract = Agreed to 12
Responses = Social, Family
Responses = Life Area –
Step Program
Environment Unsupportive
Contract = Agreed to
Responses = Family encourages use
Responses = Social, Family
Monitoring/Case
or uses extensively
Management
Contract = Agreed to “non-
Questionnaire = Victim of Abuse
Responses = Family
compliance” conditions
encourages use
Responses = Family and
Questionnaire = CAST test Positive
Questionnaire = CAST test
Friends not users
positive
Questionnaire = Self Test
Results = Risk Factors 1-3
Results = Risk Factors 4+
Positive
Results = CAST test
Negative
DIRECTIONS FOR COMPUTING ASAM
ORIGIN OF EVALUATION CRITERIA
CRITERIA
Compu-Tools Assessment results include data that will assist a

Contract = Performance Contract Conditions that are developed when an individual agrees to change behaviors in accordance with
Clinician in determining the appropriate ASAM admission criteria.
the Contract. Information on the Contract relates to the individuals’ willingness, or lack thereof, to change behaviors. (See the
Specific information can be used to provide a quantitative analysis of
Performance Contract included with the Assessment results.
criteria and, therefore, minimize subjective conclusions that might
Questionnaire = Assessment information is gathered through the use of a printed, or computerized questionnaire. Some of the
otherwise be necessary. There are approximately 75 symptoms that
questions asked therein relate to ASAM Criteria. (See printed questionnaire)
can be categorized and counted in accordance ASAM criteria and
Results = Compu-Tools provide a broad range of assessment results that relate to several of the ASAM criteria. (See Summary Page
Level of Treatment.
of Assessment results)
Responses = A summary of client responses to questions is presented with Compu-Tools results. Each response that is related to
ASAM criteria is labeled with the appropriate Dimension and Treatment Level. (e.g. 1.1, 2.3, etc…) (Count answers by Category)

Source: http://www.imrsystems.com/resource-library/ASAMTEENGRID.pdf

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