ASAM SCALE
Client Name
First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Date completed
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Month
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Day
Year
Date
DIMENSION 1: ACUTE INTOXICATION AND/OR WITHDRAWAL POTENTIAL
Substance Dependence Disorder?
Yes
No
Symptoms (Please choose all that apply)
Nausea and vomiting
Tremors
Sweating
Anxiety
Agitation
Tactile Disturbances
Auditory Disturbances
Visual Disturbances
Headaches
Disorientation
Sleep
Appetite
Weight loss or gain
None
Other
Dimension One Score: (0=none, 1=mild, 2=moderate, 3=severe)
0 (none)
1 (mild) [IOP/Outpatient]
2 (moderate) [BHRF/Residential recommendation]
3 (severe) [Hospital recommendation]
DIMENSION 2: BIOMEDICAL CONDITIONS AND COMPLICATIONS
Can resident self-administer medications?
Yes
No
Are there concerns as to whether the resident can take medications independently and without supervision? YES/NO Explain.
Dimension Two Score: (0=none, 1=mild, 2=moderate, 3=severe)
0 (none)
1 (mild) [IOP/Outpatient]
2 (moderate) [BHRF/residential recommendation]
3 (severe) [Hospital recommendation]
DIMENSION 3: EMOTIONAL, BEHAVIORAL, OR COGNITIVE CONDITIONS AND COMPLICATIONS
Are there cognitive deficits?
Yes
No
Repeated inability to control impulses?
Yes
No
Personality disorder requires high structure to shape behavior?
Yes
No
Co-occurring disorder causes difficulties with mood?
Yes
No
Are there behavioral or cognitive symptoms that are troublesome?
Yes
No
Dimension Three Score: (0=none, 1=mild, 2=moderate, 3=severe)
0 (none)
1 (mild) [IOP/Outpatient]
2 (moderate) [PHP]
3 (severe) [BHRF/residential recommendation]
DIMENSION 4: READINESS TO CHANGE
Opposition to treatment which could have dangerous consequence?
Yes
No
Resident is in need of motivation in what areas?
Dimension Four Score: (0=none, 1=mild, 2=moderate, 3=severe)
0 (none)
1 (mild) [IOP/outpatient]
2 (moderate) [BHRF/Residential recommendation]
3 (severe) [Level 1 hospital care, locked]
DIMENSION 5: RELAPSE, CONTINUED USE OR CONTINUED PROBLEM POTENTIAL
Has no recognition of skills needed to prevent continued use with imminently dangerous consequences
Yes
No
Does not recognize triggers?
Yes
No
Is client unable to control use?
Yes
No
Is in danger of relapse without close 24 hour monitoring and structured treatment?
Yes
No
Dimension Five Score: (0=none, 1=mild, 2=moderate, 3=severe)
0 (none)
1 (mild) [IOP/Outpatient]
2 (moderate) [PHP]
3 (severe) [BHRF/Residential recommendation]
DIMENSION 6: RECOVERY/LIVING ENVIRONMENT
Environment Resident would transition into if discharged today:
Resident's coping skills and assessment of utilization:
Individual is experiencing significant functional impairments in at least one (1) of the following areas: (Choose all that apply)
Activities of daily living
Interpersonal functioning
Psychological functioning
Ability to live without recurrent abuse of chemicals
Support Systems/Case Management needed by Resident (Check all that apply)
Vocational
Legal
Educational
Housing
Transportation
Family
Dimension Six Score: (0=none, 1=mild, 2=moderate, 3=severe)
0 (none)
1 (mild) [IOP/Outpatient]
2 (moderate) [PHP]
3 (severe) [BHRF/Residential recommendation]
Level of Care Recommendation: ASAM corresponding level of care. Please choose ONE option that applies to treatment recommendation.
Early Intervention/DUI Program (Level 0.5): Dimensions 1, 2, 3 and 4 stable. Dimensions 5 and 6 are potentially problematic. Outpatient Treatment
(Level 1.0): Dimensions 1, 2, 3, 5 and 6 only mild problems. Dimension 4 is problematic. Intensive Outpatient Treatment
(Level 2.1): Dimensions 1 and 2 stable. Dimension 3 mild severity. Dimensions 4, 5 and 6 mild to moderate severity. Partial Hospital Program
(Level 2.5): Dimensions 1, 2 and 3 warrant daily monitoring or management. Meet moderate severity in 2 out of 3 of Dimensions 4, 5 or 6. Residential Treatment
(Level 3.1—example: Halfway House): Problems in Dimensions 5 and 6. Residential Treatment
(Level 3.3—example: Extended/Long-Term Care): Mild to moderate severity in Dimension 3 and in 2 out of 3 of Dimensions 4, 5 or 6. Residential Treatment
(Level 3.5): Significant problems in Dimensions 3 and 6; Moderate problems in Dimensions 4 and 5. Residential Treatment
(Level 3.7): Functional deficits in 2 out of 3 of Dimensions 1, 2 or 3; Moderate severity in Dimensions 4, 5 and 6. Inpatient Treatment
(Level 4.0): Severe problems in Dimensions 1, 2 or 3. Problems in the other Dimensions do not qualify for this level of care..
Clinician Completing Form/ credentials
First Name
Last Name
Clinician Signature
TERI
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Month
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Day
Year
Date
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