FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. ___________________________ By Whom? Have you ever been physically abused? 0000027264 00000 n ____________________________ When ___________________________ Charge _________________________ Which Court? FORMCHECKBOX No FORMCHECKBOX FORMCHECKBOX Yes; if yes, when and by whom:___________________________________ Have you received or participated in counseling for this issue? FORMCHECKBOX Low relapse or continued use potential and good coping skills.Recommended ASAM Level of Care for Dimension 5 – Relapse/Continued Use Potential FORMCHECKBOX No Treatment Services Recommended FORMCHECKBOX Level 0.5 Early Intervention/Education – Alcohol and Other Drug Information School FORMCHECKBOX Level I.0 Outpatient FORMCHECKBOX Level II.1 Intensive Outpatient FORMCHECKBOX Level II.5 Partial Hospitalization/Day Treatment FORMCHECKBOX Level III.1 Recovery House - Clinically Managed Low-Intensity Residential Treatment FORMCHECKBOX Level III.3 Long Term Care - Clinically Managed Medium-Intensity Residential Treatment FORMCHECKBOX Level III.5 Intensive Inpatient - Clinically Managed High-Intensity Residential Treatment FORMCHECKBOX Level III.7 Intensive Inpatient – Medically Monitored Intensive Residential Treatment FORMCHECKBOX Level IV Medically Managed Intensive Inpatient TreatmentCDP Summary Interpreting Dimension 5 Data (include strengths/needs): DO NOT LEAVE BLANK DIMENSION 6: RECOVERY ENVIRONMENT1. Are you currently under the supervision of the Department of Corrections? 3. 0000023802 00000 n FORMCHECKBOX No FORMCHECKBOX FORMCHECKBOX Yes2. Emotional Conditions/Complications1. 0000025834 00000 n FORMCHECKBOX 1 FORMCHECKBOX An emotional condition/complication requires intervention, but does not significantly interfere with addiction treatment. 0000016091 00000 n FORMCHECKBOX No FORMCHECKBOX Yes If yes, your probation officer’s name: ______________________________ Court _____________________________ Release of Information (ROI) signed? FORMCHECKBOX No FORMCHECKBOX Yes, If yes, which? What jobs have you held in the last six months? 0000020682 00000 n (C) FORMCHECKBOX Most important thing in my life now (PR) 3. ______________________________ When?_________________________ Why? At least three of the seven criteria must be met to diagnose Substance Dependence Disorder. 1 FORMCHECKBOX Minimum relapse potential with some vulnerability. ________________ What is the longest time you have abstained? FORMCHECKBOX Two (or more) of the following, developing within a several hours to a few days after Criteria A (above) – check at least two if present: FORMCHECKBOX (1) Autonomic hyperactivity (e.g. _______________________________C. ________________________________________________________________________________________________________5. Are you a Drug Court patient? (PC) FORMCHECKBOX About as important as most of the other things I would like to achieve now. __________________ Have you ever received any help with this problem? ____________________________ If No, Where did the withdrawals occur? 1054 0 obj <> endobj xref 1054 56 0000000016 00000 n Immediate intervention required. FORMCHECKBOX Nicotine Withdrawal – Must meet all 4 Criteria to be considered withdrawal FORMCHECKBOX Daily use of nicotine for at least several weeks. Are you currently using non-prescribed drugs for mental health purposes? 2 FORMCHECKBOX Environment is not supportive of addiction recovery, but with clinical structure, the patient is able to cope most of the time. FORMCHECKBOX No FORMCHECKBOX Yes _________________________ Have you noticed less of an effect from a given substance than you used to get before? FORMCHECKBOX Yes FORMCHECKBOX No If no, why not? _______________________________________________________5. Is there any history of suicide in your family? Do you currently identify with any organized religion? 0000003397 00000 n FORMCHECKBOX No FORMCHECKBOX FORMCHECKBOX Yes Have you continued to use a substance despite knowing it has caused or worsened a medical condition? No FORMCHECKBOX Yes FORMCHECKBOX If yes, how many times? 0000066645 00000 n 0000002526 00000 n 0000009242 00000 n CDP evaluation of BAL/BAC (Describe the clinical significance of the results, e.g. ________________________ Where? Have you ever experienced cravings to use alcohol or drugs? 0000002677 00000 n Which of the following medical conditions do you currently have, or have had in the past? How would you assess your overall use of alcohol/drugs?B. FORMCHECKBOX No FORMCHECKBOX Yes ROI signed on ____________________________ (date)8. 3536 0 obj <>/Filter/FlateDecode/ID[]/Index[3513 37]/Info 3512 0 R/Length 106/Prev 166241/Root 3514 0 R/Size 3550/Type/XRef/W[1 2 1]>>stream 0000006344 00000 n FORMCHECKBOX No FORMCHECKBOX Yes, if yes, where? If so, date and BAC/BAL ___________________ FORMCHECKBOX Driving Abstract available for review FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX Self motivated, reason(s): _______________________ FORMCHECKBOX Other reason(s): ______________________________2. FORMCHECKBOX Amphetamine Withdrawal – Must meet all 4 Criteria to be considered withdrawal FORMCHECKBOX Cessation of (or reduction in) amphetamine (or a related substance) use that has been heavy and prolonged. FORMCHECKBOX 1 FORMCHECKBOX Willing to enter treatment and explore strategies for changing substance use, but ambivalent about need to change. FORMCHECKBOX Literacy/Tutoring Program FORMCHECKBOX Self-help support groups FORMCHECKBOX Other______________ Does the patient need part time or around the clock childcare in order to access treatment? h�bbd``b`��@��H0� !��&����D|I��]WH�:�����$*@�+H�N����� !e $D��y=A�10�A���� � �{W Have you ever felt you should cut down or control your substance use? K�-zeӹ)�9�����r3�\bvL)��f\s��r�N�)��d�|��tש_��:�"T�y��庄r�3�`����6�ٮ�j=����R3��yLR�Y���|�|�ĆC�_&2��θ��{����V�ۦ��7�����0���;�;[�>�X��v*�pwFa�K�Y������x���� F�,�kN8�̴C�$"f�E��4��G�e��u߫�����E��d�� ܆��RG�I@-Z���)`.W�sË��~l3�el ���䎖�|�:��F,;52���)�Q��ze˯�^>��:�s�|���RGjT����w@@Z,���U`� 0000027460 00000 n FORMCHECKBOX The symptoms are not due to a general medical condition and are not better accounted for by another medical disorder. Have you ever given up or reduced important social, occupational or recreational activities because of using alcohol or other drugs? Ä Ä ÿÿÿÿ 8 S l ¿ Œ ¨¤ æ K# * [M ( ƒM ƒM ƒM ÛP j Ei ü Have these, or any other medical conditions been impacted by your use of alcohol or other drugs? Do you believe you currently have a problem with the use of alcohol/drugs? FORMCHECKBOX Definitely not (PC) FORMCHECKBOX Probably will (C) FORMCHECKBOX Definitely will (PR) The patient appears to be in the following stage of change: FORMCHECKBOX Precontemplation (PC) FORMCHECKBOX Contemplation (C) FORMCHECKBOX Preparation (PR) FORMCHECKBOX Action (A) FORMCHECKBOX Maintenance (M)Risk Rating for Dimension 4 (from PPC-2R - Appendix A): 4b FORMCHECKBOX Unable to follow through with treatment recommendations resulting in imminent danger to self or others, immediate intervention required. FORMCHECKBOX No FORMCHECKBOX Yes, if yes where? FORMCHECKBOX FORMCHECKBOX No FORMCHECKBOX Yes; if yes, explain: 3. 4a FORMCHECKBOX Environment is not supportive of addiction recovery, and is chronically hostile and toxic to recovery or treatment progress.
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