Substance Abuse Worksheet

Transcription

1 Substance Abuse Worksheet Reliant Behavioral Health, L.L.C EAP Clinical Manager: Fax: Date: Name: Referred by: Length of Employment: Employer: ROI to: Precipitating event: Levels: Positive random Reasonable suspicion Post-accident Relevant History: Motivation: Client s goal? Why is goal important to client? 1

2 DIMENSION 1: Intoxication / Withdrawal Potential: Drug Used Age #1st Use Last Use Past 12mos. Quantity Heaviest Route Alcohol: Cannabis: Marijuana Hash Hallucinogens: LSD Mushrooms Mescaline Peyote Nicotine: Cigarettes Chew Stimulants: Amphet. Meth. Cocaine Ritalin Caffeine Other Inhalants: Glue Gas Butyl Nitrate Other Opiates: Heroin Methadone Codeine Synthetic: Other Others: Club Drugs Steroids Other s Prescription Med. Diet Aids/Nyquil/ Benadryl Alcohol and drug use/abuse, route of ingestion, related physical and/or emotional consequences of use, and past and /or current withdrawal. Use by Self Failed Self-Made Contracts Pass Out Black Out Hangovers Vomiting Skip Meals to Use Tolerance Use Until Supply Runs Out Use Before Going to Party/Social Event Increased Irritability Paranoia Hallucinations Current or Past Withdrawal: Seizures Tremors Anxiety Nausea Restlessness Day Sweats Night Sweats Sleep Disturbance None reported COMMENTS: 2

3 DIMENSION 2: Biomedical Conditions: Past or present medical problems: Past or present dental problems: Has a physician ever told you that you have medical problems? If Yes explain: Abnormal Liver Functioning Heart Dysfunction Abnormal Kidney Function Lung Dysfunction Esophagus Related Problems Diabetes Positive TB Test HIV/AIDS Testing History of Sexually Transmitted Disease History of Skin Infections Hepatitis Other Infectious Diseases Currently Pregnant Allergies: Bruise Easily Head Injuries Knocked Unconscious Chronic Medical Problems? Medications Name Length of time on Medication Basis for Medication Prescribing Physician: Are you on disability or receive a pension? If Yes please explain. Continued use of alcohol, street or RX drugs despite recurrent problems COMMENTS: Hospitalizations or ER Visits: Reasons Length of Stay Your Age 3

4 DIMENSION 3: Emotional, Behavioral or Cognitive Conditions & Complications: Others living in household: Name Relationship Age Substance use Historical or current signs of psychological disorder, abuse history, education, family and/or other interpersonal relationships. Past Suicidal Ideation Past Suicide Attempts Current Suicidal Ideation Recent Suicide Attempt Homicidal Ideation Homicidal Attempts/Gestures/Threats Physical Abuse History Emotional Abuse History Sexual Abuse History Continued use despite knowledge of having a persistent and/or recurrent psychological problem that is likely to be exacerbated by use. COMMENTS: How do alcohol or drugs effect behavior / moods? Aggressive Depression No Personality Change Illegal Acts/Activities Injuries Dangerous Situations Calms / relaxes me More social Energizes / > productive Argues / aggressive (emotional, psychological, physical) Psychiatric History: Mental Health Counseling: when, reason, duration counselor Psychiatric Hospitalization(s): when, where, reason, duration Family Psychiatric History: Diagnosed Mental Illness and/or Mood Disorders (Maternal or Paternal Side) Who Diagnosis How Treated Family and Family History of Substance Abuse: Names, ages, health, residence (state); Alcohol and/or drug use/abuse history). Mother Father Brother Step Mother Step Father Sister Maternal Grandparents Paternal Grandparents Other relatives Family History of Criminal Behavior (drug related, violence, weapons) 4

5 Work Consequences of A&D Use: Has an employer requested a substance abuse assessment? Have you ever been terminated due to substance use/abuse? Have you ever been placed on Last Chance Agreement Ever not apply for a job because agency did a pre-employment drug screen? Work related driving offenses in past ten (10) years and consequences. Work related accidents in past ten (10) years, minor and major (consequences)? Problems with coworker conflict? Reassignments/transfers? History of job instability or recent job change due to use? Work history since high school Where Employed Length of Employment Reason for Leaving Legal Driving Offenses Selling and/or Fencing Arrests Military: Branch of service Discharge status Reductions in rank Financial Cost per week to use: $ Compulsive spending Gambling Disregard for personal responsibilities due to use Wages garnished Filed bankruptcy Social Loss of friends due to use Percentage of friends who use % Recreational activities consist of using Recreational accidents due to use (i.e. snow mobiling, skiing, boating) Intimate/Family Relationships Partner/Spouse knows about this situation History of having Partners/Spouses that use Use has caused problems with family Use has interfered with parenting and family activities SCF has been involved in your life due to use Divorce, separation due to use 5

6 DIMENSION 4: Readiness to Change: Understands how current use may affect personal goals. Lacks skills to maintain abstinence. Drug test does or does not match self-report? External Mandate: Partner/Spouse Employer Legal Other Self-motivated Approach to Treatment: Resists Accepts Gamy Minimizes Externalizes Pre-contemplative: "What problem? Contemplative: "We'll maybe I have a problem." Preparation: "I have a problem. What do I do?" Action: "This is what I will do to address the problem." Relapse. Recycling: "I'm doing what I need to do to maintain recovery." Client s Goal: (Inquire: Why is it important?) How: Where: When: DIMENSION 5: Relapse, Continued Use and / Continued Problem Potential: History of previous treatment Detox. Inpatient Outpatient Diversion Jail/Prison 12 STEP Counseling Rational Recovery Treatment Program Dates? Mandated? Completed? Clean Time?_ Left treatment early, against medical advice Absence of non-using support system Use by others within home Able to maintain abstinence with minimal support Lacks understanding of relapse, requiring structure to be abstinent 6

7 Relapse Triggers Preoccupied with use Cravings Alcohol/drugs in home Alcohol/drugs in work environment Impulsive regarding gratification Ambivalence regarding abstinence lifestyle Other: COMMENTS: DIMENSION 6: Recovery Environment: Housing Recovery based home Home Environment Unstable Stable / Safe Homeless External support systems % of friends who do not use alcohol or drugs: % Education High School: year GED: Other Special Training or Education Identified having learning disabilities? Explain Literate Desire for further training, education, etc. Marketable skills Spiritual and/or Religious affiliation: Cultural Identification : Recreation, Hobbies & Interests (time spent in these activities) Less time spent in recreational activities, hobbies & interests then in past? Work environment supports abstinence. Work environment provides structure. Mental Status: Appearance Behavior Motor Speech Affect Mood Appropriate Cooperative WNL WNL Congruent WNL Meticulous Guarded Retardation Rapid Incongruent Depressed Bizarre Hostile Agitation Loud Blunted Anxious Unkempt Withdrawn Lethargy Soft Flat Angry Body Odor Distractible Tremor Sparse Irritable Irritable Sloppy Complainant Tic Mumbling Labile Fearful Dirty Visitor Rambling Euphoric Apathetic Customer Constricted Restricted 7

8 Thought Content Thought Process Perception WNL WNL WNL Suicidal ideation Flight of ideas Depersonalization Suicidal plan Obsessions Derealization Early suicide, relief thinking Circumstantial Illusions Homicidal ideation Tangential Hallucinations: Homicidal plan Loose Auditory Paranoid ideation Other Olfactory Magical ideation Visual Depressive cognitions Tactile Homicidal Ruminations Phobias Delusions Orientation Memory Insight Judgment Concentration Impulse Control WNL WNL WNL WNL WNL WNL Impaired: Impaired: Impaired: Impaired: Impaired: Impaired: Mild Mild Mild Mild Mild Mild Moderate Moderate Moderate Moderate Moderate Moderate Severe Severe Severe Severe Severe Severe Dangerousness: To Self To Others Not assessed Not assessed None None Ideation Threat to harm others Plan Specific victim Means Has means Recent attempt Hx of assaultive behavior Hx of attempts Hx of self-mutilation Family Violence: Current Past Victim(s) Perpetrator(s) Not assessed Not assessed Denied Denied Physical Physical Sexual Sexual Verbal Verbal Emotional Emotional Safety Plan Referral SUBSTANCE ABUSE ASSESSMENT & RECOMMENDATIONS Releases of Information: Employer MRO Spouse/Partner Other: DMV PCP Treatment Providers Assessment Instruments: Date: DAST Drug Abuse Screening Test (DAST) MAST Michigan Alcoholism Screening Test SASSI Substance Abuse Subtle Screening Inventory OTHER Problem Areas Identified: Employment Relationship Recreational Medical Legal Financial Coping Skills Support Systems Psychological 8

9 ASAM ADULT PLACEMENT CRITERIA LEVEL OF CARE MATRIX Level.5 Meets Criteria in dimension 4, 5, and 6. Dimension 1, 2 and 3 are stable (Early Intervention) Level I Dimension 1, 2, 3, 5 and 6 meet Level 1 Criteria or are stable and manageable at this level. (0-8 hours per week) Dimension 4 may exceed Level I Criteria if all others are with level 1. Level II.1 Meets criteria two of Dimensions 3, 4, 5, and 6. There are no significant problems in Dimension 1 (9-19 hours per week) & / or 2. Level II.5 Two of Dimension 3, 4, 5, and 6 meet criteria. There are no significant problems in Dimensions 1 (20+ hours per week) & / or 2. Level III.1 Meets criteria in Dimensions 3, 4, 5, & 6 dimensions for this level. There are no significant (5+ hours of Treatment and problems in Dimensions 1 & / or 2. supervised living) Level III.3 Meets criteria in Dimensions 3, 4, 5, & 6 dimensions for this level. There are no significant (Medium intensity residential) problems in Dimensions 1 & / or 2. Level III.5 Meets criteria in Dimensions 3, 4, 5, & 6 dimensions for this level. There are no significant (High intensity residential) problems in Dimensions 1 & / or 2. Level III.7 Meets criteria in 2 of 6 dimensions, at least one must be dimensions 1, 2, or 3. (Medically monitored residential) Level IV Meets criteria in at least one of Dimensions 1, 2, or 3. Level IV in dimensions 4, 5, or 6 is (Medically managed inpatient) sufficient. Summary: Treatment Recommendation: Assessor s Signature Date 9