ASAM Multidimensional Level-of-Care Assessment

Encounter Type: [initial LOC assessment / continued service review / transition review / discharge LOC review]

Date/Time: [Date] [Time] — [in-person / telehealth] at [Location]

Assessor: [Name, credentials, role]

Patient: [Name, ID, DOB per local policy]

Referral Source: [Referring person or agency] — [Specific placement decision requested]

ASAM Criteria Version: [Edition used by program/payer]

(Use person-first, non-stigmatizing language throughout. Time-anchor objective findings with dates/times, vital signs, and validated scale scores. If an element was not assessed, write "Not assessed" with the reason and follow-up plan—do not infer absence of risk from missing data.)

Consent and Information Sources

Consent and Capacity: [Consent obtained / not obtained] — [Capacity intact / impaired with findings and plan]

Information Sources: [Sources used: patient report, collateral contacts, PDMP, prior records, labs/toxicology with dates] (Note reliability concerns if relevant: intoxication, inconsistencies, memory gaps.)

Unavailable Key Records: [Records pending or unavailable] — [Impact on LOC decision] — [Plan to obtain]

Confidentiality Constraints: [42 CFR Part 2 protections; consent-to-release status; authorized recipients]

Presenting Concerns and Goals

Chief concern (patient words): "[Direct quote]"

Reason for current presentation: [Trigger: return to use / overdose / withdrawal / legal mandate / medical complication / other] [Date/time if tied to specific event]

• Patient recovery goals: [Patient-stated goals and preferences]
• Practical constraints: [Work / childcare / housing / transportation / finances / other]
• Willingness today: [What patient is willing to do] — Not willing today: [Interventions declined with stated reasons]

Safety Triage

(This section must stand alone for rapid review of acute risks. If assessed and denied, write "patient denies" with clinical impression. If not assessed, write "Not assessed" with reason and follow-up plan.)

Intoxication/Withdrawal

• Current status: [Signs/symptoms with time anchors]
• Objective severity: [Scale name] score [score] at [date/time]
• History of complicated withdrawal: [Seizures / delirium tremens / severe withdrawal with dates]
• Immediate actions: [Stabilization provided with time stamps]

Suicide/Violence Risk

• Suicidal thoughts/intent/plan: [Current status with details]
• Recent attempts or preparatory behaviors: [Details with dates]
• Violence toward others: [Ideation/intent/plan or behaviors]
• Protective factors: [Supports, reasons for living, engagement]
• Lethal means access: [Access status; means safety actions taken]
• Safety actions taken: [Monitoring, safety planning, referrals, contacts notified]

Overdose Risk

• Overdose history: [Number, dates, circumstances, reversals]
• High-risk patterns: [Using alone / polysubstance / sedatives / high-potency / injection / variable supply]
• Naloxone access: [Has naloxone / provided today / declined]

Acute Medical Instability

• Red-flag vitals/symptoms: [Vital signs with date/time; concerning symptoms]
• Actions: [ED transfer / medical clearance / urgent consults with times]

Substance Use Summary

(Include only information relevant to dimensional assessment and placement.)

• Substances used: [Each substance: route, frequency, typical amount, last use date/time]
• Withdrawal history: [Prior severity, complications, treatments]
• Prior treatment: [Levels of care, dates, what helped, barriers]
• Addiction medications: [Current/prior MOUD: medication, response, adherence]
• Toxicology and PDMP: [Results with dates and interpretation]

Dimensional Assessment

(For each dimension: summarize key findings with time anchors; assign risk rating using program scale with explicit justification; list strengths; specify service needs.)

Dimension 1 — Intoxication, Withdrawal, and Addiction Medications

Findings: [Current intoxication/withdrawal state; severity scores with dates; history of complicated withdrawal; current/prior addiction medications and response; ability to manage safely in less intensive setting]

• Risk rating: [Rating] — Justification: [Link to findings]
• Strengths: [Supports, monitoring availability, follow-up reliability]
• Service needs: [Withdrawal management intensity, medication needs, monitoring frequency]

Dimension 2 — Biomedical Conditions

Findings: [Active medical problems impacting LOC; infections; pregnancy; pain and analgesics; labs/clearance needs; proposed setting's capacity]

• Risk rating: [Rating] — Justification: [Link to findings]
• Strengths: [Established care, stable conditions, self-management]
• Service needs: [Medical consults, monitoring, treatment capability]

Dimension 3 — Psychiatric and Cognitive Conditions

Findings: [Psychiatric symptoms affecting safety/engagement; cognitive impairment or delirium risk; medication adherence; needed psychiatric intensity]

• Risk rating: [Rating] — Justification: [Link to findings]
• Strengths: [Engagement, medication stability, supportive relationships]
• Service needs: [Psychiatry involvement, therapy modality, monitoring level]

Dimension 4 — Substance Use–Related Risks

Findings: [Severity and patterns driving harm; frequency of return to use; inability to maintain stability in less structured settings; overdose risk features; treatment-interfering behaviors]

• Risk rating: [Rating] — Justification: [Link to findings]
• Strengths: [Motivation, skills, harm-reduction practices]
• Service needs: [Structure level, contact frequency, specific interventions]

Dimension 5 — Recovery Environment Interactions

Findings: [Housing stability and substance exposure; family/peer supports vs. destabilizers; violence risk; transportation/communication; legal mandates; work/caregiver responsibilities]

• Risk rating: [Rating] — Justification: [Link to findings]
• Strengths: [Sober supports, stable housing, pro-recovery networks]
• Service needs: [Case management, housing, legal coordination, scheduling flexibility]

Dimension 6 — Person-Centered Considerations

Findings: [Preferences for setting/intensity/modality/medications; cultural, religious, trauma-informed, gender-affirming needs; SDOH barriers; motivation; feasibility of engaging in recommended LOC today]

• Risk rating: [Rating] — Justification: [Link to findings]
• Strengths: [Values, goals, supports, prior successes]
• Service needs: [Accommodations, language access, peer support, care coordination]

(If patient declines recommended LOC: document discussion of risks, benefits, and alternatives; patient's stated reasons; negotiated safety plan with follow-up timeline.)

Dimensional Drivers and Risk Summary

Dimensional Drivers (3–6 findings most strongly determining placement):

• [Dimensional Driver with dimension reference]
• [Dimensional Driver with dimension reference]
• [Dimensional Driver with dimension reference]
• [Additional drivers as needed]

Clinical formulation: [Brief synthesis linking key risks, protective factors, barriers, and rationale for required intensity]

Diagnostic Impression

• Substance use diagnoses: [Diagnoses with severity/specifiers; include intoxication/withdrawal if applicable; mark provisional with data gap if uncertain]
• Co-occurring psychiatric diagnoses: [Diagnoses; note provisional status and clarification plan if needed]
• Biomedical diagnoses affecting LOC: [Relevant medical conditions]

Level-of-Care Recommendation

• Recommended LOC: [ASAM level] [Co-occurring capable / enhanced or biomedical enhanced if applicable] — Withdrawal management: [WM level if needed separately]
• Why this is the least intensive safe option: [Tie directly to Dimensional Drivers]
• Why lower levels are insufficient: [Anticipated harms or unmet needs at lower intensity]
• Why higher levels are not required: [Stabilizing factors making higher intensity unnecessary] (Omit if recommending highest indicated level.)
• Patient participation: [Agreement/disagreement; preferences incorporated; shared decision-making summary]
• Barriers and contingencies: [Bed availability, insurance, logistics; interim safety plan if placement delayed]

Initial Plan (First 24–72 Hours)

• Withdrawal management: [Monitoring frequency; medications with doses]
• Psychiatric stabilization: [Medication and/or therapy actions; safety planning]
• Medical evaluations: [Labs, imaging, consultations with timelines]
• Counseling and case management: [Modality, frequency; coordination tasks]
• Harm reduction: [Naloxone; safer use education; infectious disease screening]
• Recovery supports: [Peer support, family involvement, mutual help]
• Barrier mitigation: [Transportation, housing, benefits, communication access]

Transition Criteria and Reassessment

Reassessment: [Target date/time; responsible clinician]

Step-down criteria: [Stability markers supporting transition to lower intensity]

Step-up criteria: [Instability markers requiring escalation]

Transition plan: [Next setting; warm handoff method; appointments; medication continuity; overdose prevention plan]

Disposition and Referrals

• Current disposition: [Admitted / Transferred / Discharged with plan / Pending placement]
• Referrals placed: [Programs/services with timelines]
• Care coordination: [Parties contacted, dates, summary; Part 2 compliance confirmed]

Signature: [Name, credentials, role] — Date/Time: [Date and time]