SUD Level-of-Care Assessment & Placement Recommendation Note

(Omit sections where information was not obtained or not applicable, except: the Safety & Risk Assessment must always appear—document "not assessed" with reason if elements cannot be evaluated; the Multidimensional Assessment table must include all six dimensions; and the Level of Care Recommendation must always include a concrete recommendation or specify what additional information is needed with a timeline to obtain it.)

Date: [Encounter date]

Clinician: [Name and credentials]

Patient: [Name], [DOB], [MRN]

Encounter Type: [in-person / telehealth video / telehealth audio-only / chart review / combination]

Setting: [ED / inpatient consult / outpatient clinic / residential intake / correctional / outreach / other]

Assessment Type: [initial placement / step-up / step-down / continued stay review / return after disengagement / court-mandated evaluation]

Time: [Start time], [Stop time], [Total time] (Include only if required by payer or local policy.)

Referral Question & Patient Goals

[Referral source and reason for assessment]

[Patient's stated goals and treatment preferences, including factors affecting placement: location, family/work obligations, language or cultural needs, modality preference, scheduling constraints]

Clinical Synopsis

[Integrated summary of primary substances and current use pattern; main risks including withdrawal severity, overdose, suicidality, medical or psychiatric instability; relevant social determinants and barriers; prior treatment exposure and response; key drivers of the placement question] (4–8 sentences in narrative format.)

Safety & Risk Assessment

(This section is required. If any element cannot be evaluated, document "not assessed" with reason.)

Suicidal/Homicidal Ideation

• Suicidal ideation: [none / passive / active]; Intent: [yes / no]; Plan: [yes / no]; Recent behavior: [description] (If positive, document immediate safety measures taken.)
• Homicidal ideation/violence risk: [description] (Include access to weapons and protective actions if relevant.)

Overdose Risk

• [Recent overdose history and context]
• [Use alone vs. supervised use]
• [Fentanyl exposure, unknown potency, or counterfeit pills]
• [Polysubstance use with respiratory depressants]
• [Loss of tolerance due to recent abstinence, incarceration, or hospitalization]
• Naloxone: [education provided: yes / no]; [dispensed/prescribed: yes / no]

Withdrawal Status

• Alcohol: [Time since last use]; [Typical daily amount]; [Prior complicated withdrawal: seizures / delirium tremens / none]; [CIWA-Ar score and interpretation if obtained]
• Benzodiazepines: [Time since last use]; [Typical daily amount]; [Prior complicated withdrawal]; [Severity score if obtained]
• Opioids: [Time since last use]; [Typical daily amount]; [Prior complicated withdrawal]; [COWS score and interpretation if obtained]
• Withdrawal management indicated: [yes / no]; [Recommended intensity/setting]; [Brief rationale]

Acute Mental Status

• [Intoxication severity and substances suspected]
• [Psychosis, mania, agitation, or delirium and effect on capacity]
• [Immediate interventions required or need for higher-acuity evaluation]

Substance Use & Treatment History

(Repeat the following for each clinically relevant substance.)

[Substance name]

• Route/Frequency/Quantity/Duration: [Details]
• Last use: [Date/time]
• Tolerance/Withdrawal history: [Description]
• High-risk practices: [Injection, equipment sharing, unsafe sources]
• Consequences: [Medical, legal, social, occupational]
• Overdose history: [Number, dates, naloxone use, medical care required]

Treatment History

• Prior SUD treatment: [Levels of care with approximate dates; completion vs. early discontinuation]
• Response and barriers: [Factors contributing to relapse or disengagement]
• MOUD history: [Buprenorphine / methadone / naltrexone]; [Response]; [Adherence]; [Reasons for discontinuation if applicable]
• Recovery supports: [Mutual-help programs, peer specialist, recovery housing]

Medical, Psychiatric & Social Factors

Medical

• [Conditions affecting withdrawal risk or medical stability]
• [Current medications relevant to placement]
• [Contraindications to withdrawal medications or MOUD]

Psychiatric

• [Current symptoms and diagnoses affecting safety or program fit]
• [Current psychiatric medications and adherence]

Social/Environmental

• [Housing status and safety]
• [Substance use exposure in the home or social network]
• [Legal status and court mandates]
• [Employment, school, or caregiving responsibilities]
• [Available supports and recovery capital]

Data Sources & Objective Findings

Sources Reviewed

• [Patient interview, chart review, PDMP, prior records, collateral contacts]
• Patient reliability: [good / fair / limited] (If limited, specify reason.)

Vitals/Exam

[Vital signs and focused physical/mental status exam findings] (If not obtained, briefly state reason.)

Toxicology & Labs

• Toxicology: [Presumptive / confirmatory]; [Date]; [Results]; [Interpretive caveats]
• Relevant labs: [LFTs, pregnancy, infectious disease screening with placement implications]

Multidimensional Assessment

(Rate each dimension using organizational standard. If a dimension could not be fully assessed, note the reason in Key Findings.)

Dimension	Severity	Key Findings	Service Needs
1. Intoxication/Withdrawal Potential	[low / moderate / high]	[Key findings]	[Service intensity needed]
2. Biomedical Conditions	[low / moderate / high]	[Key findings]	[Service intensity needed]
3. Emotional/Behavioral/Cognitive	[low / moderate / high]	[Key findings]	[Service intensity needed]
4. Relapse/Continued Use Potential	[low / moderate / high]	[Key findings]	[Service intensity needed]
5. Recovery Environment	[low / moderate / high]	[Key findings]	[Service intensity needed]
6. Person-Centered Considerations	[low / moderate / high]	[Key findings]	[Service intensity needed]

[Narrative support for dimensions rated moderate or higher that drive placement recommendation] (Low-severity dimensions need only a single confirmatory sentence.)

Diagnoses

• [SUD diagnosis] [mild / moderate / severe] [early remission / sustained remission / on maintenance therapy] (Use "provisional" with explanation if diagnosis cannot be finalized.)
• [Additional SUD diagnoses with severity and specifiers]
• [Co-occurring mental health diagnoses affecting placement] (Include only if relevant to LOC decision.)

Level of Care Recommendation

Recommended LOC: [ASAM level of care]

Withdrawal Management: [WM level / not indicated]

Timing: [immediate / within 24 hours / scheduled]

Rationale:

• [Dimensional driver with supporting clinical facts]
• [Dimensional driver with supporting clinical facts]
• [Dimensional driver with supporting clinical facts]
• [Why lower LOC is inadequate, citing specific facts]
• [Why higher LOC is not required] (Include if relevant.)

Alternatives Considered:

• [Lower LOC considered and reason rejected]
• [Higher LOC not indicated and reason]

If Patient Declines Recommended LOC

(Include this subsection only if patient declines recommended placement.)

• [Refusal documented and patient's stated reasons]
• [Capacity assessment findings]
• [Risk/benefit discussion held]
• [Best feasible alternative plan with follow-up and return precautions]

Placement Plan & Coordination

• Referrals: [Programs contacted, date/time, acceptance/waitlist status, next steps]
• Barrier Mitigation: [Transportation, childcare, peer support, scheduling accommodations, language assistance]

Interim Plan

(Include if placement is delayed.)

• [Harm reduction steps]
• [Medication bridging]
• [Follow-up cadence]
• [Contingency if symptoms worsen]

Safety Plan

(Include if suicide, overdose, or other acute risk is present.)

• [Crisis resources provided]
• [ED return precautions]
• [Overdose prevention instructions]
• [Safe medication storage]

Disclosure Authorization

Consent for external disclosure: [yes / no / pending]

[Date obtained and authorized scope] (If consent not obtained, state that external disclosure is not currently authorized.)