Please m ake copi es as needed and pleas e type or print l egibly. The adolescent drug abuse and psychiatric treatment. Reason for t he clients referral in clude deta ils tha t lead to a form. Asimv addiction severity indexmultimedia version is the electronic version of the traditional paper and penciladministered asi.
Substance abuse evaluation form 2 free templates in pdf. A practitioners guide is designed to help health care professionals quickly identify youth at risk for alcoholrelated problems. The addiction severity index asi is a semistructured interview for substance abuse assessment and treatment planning. Substance abuse management system appendix c, page 3. Skilled manual usually having had training baker, barber, brakeperson. He is a licensed professional counselor and a licensed alcohol and drug counselor.
Examples of screening and assessment tools for substance use disorders. The asi gathers information in seven important areas of a patients life. American society of addiction medicine asam home page. Asi manual united nations office on drugs and crime. Identification and intervention a guide for marriage and family therapists source.
Bhimv asimv addiction severity indexmultimedia version. Template for assessing a clients substance use developed by. Chat client placement asam worksheet page 1 of 18 chat client placement asam worksheet this worksheet presents a summary of relevant client selfreported data from chat into each. Supplementary administration manual for the expanded female version of the addiction severity index asi instrument the asif. Workshop 2 handout 1 making required data collection useful he has no history of regular or ongoing use. Patients may fill in the following form themselves but screening personnel should offer to read the questions aloud in a private setting and complete the form.
Teen addiction severity index t asi brief description the tasi is a semistructured interview that was developed to fill the need for a reliable, valid, and standardized instrument for a periodic evaluation of adolescent substance abuse. The bhimv behavioral health indexmultimedia version is an online, client selfadministered. Wellness assessments are available here, on the forms page, at the secured user section, or by mail. Asimv addiction severity indexmultimedia version is the electronic. Chat client placement asam worksheet page 3 of 18 debbie reported that she has used the following substances. Complete this form and use these questions to guide the eap client interview when conducting a formal substance abuse assessment to determine a clients treatment needs. An improved diagnostic evaluation instrument for substance abuse. National institute on alcohol abuse and alcoholism, 83 pages. Before reading this text, you should have an understanding of substance abuse counseling theory, principles, and knowledge.
Asi treatment plan client problem plan family asidens format service codes iindividual ggroup ffamily ccouples ppsychoeducational hhomework rreading mmedia vvideotape aaudiotape rreferral treatment planning m. Substance abuse evaluation form michigan free download. Substance abuse and mental health services administration, 2005. Items with an asterisk are cumulative and should be. A sample of 82 randomly selected patients from substance abuse. It effectively assesses a clients status in several areas, and the composite score measures how a clients need for treatment changes over time. S utilizing the addiction severity index asi to make required data collection useful background and rationale for the course this course seeks to transform required paperwork into clinically useful information.
Developing clinical skills for substance abuse counseling. The addiction severity index asi, used throughout the united states and other countries, is the most widely used assessment tool in the addictions field. The asi provides an overview of problems related to substance, rather than focusing on any single area. Newton, ma rp7 recovery behaviors form from the list of negative treatment behaviors.
Drug and alcohol use alcohol screening and brief intervention for youth. Medical, employmentsupport status, alcohol, drug, legal, familysocial, and psychological. Template for assessing a clients substance use developed by cynthia gliddentracey, ph. Substance abuse and mental health services administration.
The center for adolescent substance abuse research. Introduce and explain the seven potential problem areas. Page 2 of 5 has client been intoxicated, hungover, or in withdrawal at times when heshe is. The asi can be used effectively to explore problems within any adult group of individuals who report substance abuse. The addiction severity index asi is one of the most widely used tools for the assessment of substance userelated problems. This section will address the severity of alcohol andor substance abuse. Iii harmful risk of health problems related to drug use and a possible mild or moderate substance. Workshop 2 handout 1 making required data collection useful he has no history of regular or ongoing use of inhalants. Thomas mclellan, along with collaborators from the. Addiction severity index, 5th edition clinicaltraining version a. Substance abuse refers to the use of substances in ways outside of societal conventions and that have an adverse effect on an individual.
The recommended behavior change is to abstain fro m recreational drug use. John has a history of using multiple module 4 substances, on an ongoing basis, for a period of 15 years. How many times in your life have you been treated for. The addiction severity index lite asi lite adapted from. Recommended by the american academy of pediatrics committee on substance abuse. The asi is most useful as a general intake screening tool. Addiction severity index asi is an assessment tool widely used in the evaluation of substance abuse treatment. The interviewer will ask about each possible substance one by one using the following routing of administration and the frequency of use. Originating office quality improvement and workforce development branch, division of services improvement, center for substance abuse. Aod is an acronym for alcohol and other drugs category of drug. Kentucky drug court asi questionnaire 2001 uk cdar.
Violation of the employers substance abuse policy, example. This tool serves as a guidance instrument in treatment planning. Skilled manual usually having had training baker, barber, brakeperson, chef. The asilite contains 22 fewer questions than the asi, and omits items relating to severity ratings, and a family history grid. Newton, ma rp7 recovery behaviors form from the list of negative treatment behaviors see rp6, list 3 you believe you display. Screening tools despite the high prevalence of mental health and substance use problems, too many americans go without treatment in part because their disorders go undiagnosed. Clinicians all over the world use the asi to get a better. This appendix provides information about and samples of screening and assessment tools for substance use disorders. In the description of each tool, the definition follows the tool acronym. The addiction severity index asi is an instrument that is used in assessing the extent of a substance. This instrument is an interview process that assesses history, frequency, and consequences of alcohol and drug use. Substance days used in past 2 days days used in past 30 days alcohol any use neither day 3 in the past 30 days drank to intoxication alcohol 4 or more drinks in a row female neither day 2 in the past 30 days. Supplementary administration manual for the expanded female version of the addiction. It is a semistructured assessment instrument designed for use with clients for substance abuse treatment.
Wellness assessment forms does not apply to unison membership. Substance abuse services printing facility composite scores there is a composite score for each problem area of the asi that has been derived from sets of items within each of the asi problem areas. Miller 2005 and jarvis, tebbutt, mattick, and shand 2005. Tip 51 substance abuse treatment addressing the specific. Mclellan, at, luborsky, l, woody, ge, obrien cp 1980. In addition, the center for substance abuse treatment csat has approved treatment and. Addiction severity index reference substance abuse management system appendix c, page 1. Asi treatment plan client problem plan family asidens format service codes iindividual ggroup ffamily ccouples ppsychoeducational hhomework rreading mmedia. The same items are used in initial and followup scores. Reproductions supplied by edrs are the best that can be made. It effectively assesses a clients status in several areas, and the composite score measures how a clients need for. Located on the eap billing form to be completed by clinician with client, or clients family member when screening indicates sacd issues. The addiction severity index asi is a standardized interview used to assess problems associated with substance use. Us department of health and human services, substance abuse and mental health services administration, center for substance abuse.
Substance abuse treatment facilities, was scheduled to expire on june 1, 2016. Our products include adult, adolescent, criminal justice and cooccurring assessments. Reason for t he clients referral in clude deta ils tha t lead to a form al eap referral by the em ployer if ap plicable. Apply the asam ppc2r in clinical work to broaden services and better meet the needs of clients, including dual diagnosis clients. Chapter 161b, standards for licensure of outpatient substance abuse treatment. A 6question behavioral health screening tool to screen adolescents for high risk alcohol and other drug use disorders simultaneously. Download the addiction severity index form, which is often used by psychiatrists for the purpose of a more in depth patient evaluation with regard to the level of severity of addiction and addictive behaviors. Other terms associated with substance abuse include chemical dependency, drug addiction, drug abuse, and substance. If requesting tx sb 58 services, fax completed tx utp to 18774506011. This instrument is best suited for secondary assessment because the asi does not provide. For each one, list 3 positive actions you can take to improve it.
Medical, employment support status, alcohol, drug, legal. The asi form is completed for each client admitted or readmitted after one. Substance abuse treatment for persons with cooccurring disorders. Other drug abuse among adults in the criminal justice system treatment improvement protocol tip series 7 james a.
The interviewer will address an abundance of possible uses that may require assistance for the patients treatment plan, if any. Clinical opiate withdrawal scale introduction the clinical opiate withdrawal scale cows is an 11item scale designed to be administered by a clinician. The addiction severity index asi is one of the most widely used tools for the assessment of. Dast10 drug abuse screen test is a 10item, yesno selfreport instrument that has been condensed from the 28item dast and should take less than 8 minutes to complete. Adults adolescents groups for which this instrument might be especially helpful. It is not based on the diagnostic and statistical manual of.
Screening instrument for substance abuse when referring to this screening instrument. Forms and resources samhsa substance abuse and mental. The asi can be used effectively to explore problems within any adult group of individuals who report substance abuse as their major problem. Two works that fit well with this book and provide the necessary knowledge are by g. A sample of 82 randomly selected patients from substance abuse treatment programs were interviewed with the asi 6, the asi 5 and were administered a validity battery of selfquestionnaires that included measures corresponding to each of the asi domains. Alcohol to intoxication does not necessarily mean drunk, use the words to feel. Substance abuse has no universally accepted definition. Department of health and human services public health service substance abuse and mental health services administration center for substance abuse. The characteristics and the validity of the recent status scores rsss, the new summary scores generated by the 6th version of the addiction severity index asi6, are compared to the 5 th version of the asi summary scores, the composite scores css. The dast10 was designed to provide a brief instrument for clinical screening and treatment evaluation and can be used with adults and older youth. Assessment in substance abuse counseling has a different focus.
Addiction severity index lite cf clinicaltraining version thomas mclellan, ph. Drug abuse screening test dast all the dast drug abuse screening test versions screen for problems with the use of drugs only. Addiction severity index an overview sciencedirect topics. Net page 1 template for assessing a clients substance use developed by cynthia gliddentracey, ph.
Associate professor of psychiatry alcohol research center university of connecticut health center school of medicine 263 farmington avenue farmington, ct 060302103. Supplementary administration manual for the expanded female version of the addiction severity index asi instrument the asi f. Asimv is your powerful online solution for behavioral health assessment, treatment planning, and data management. An improved diagnostic evaluation instrument for substance abuse patients. The asi is designed to gather valuable information about areas of a clients life that may contribute to their substanceabuse problems. Brief interventions are typically performed in 3 15 minutes, and should occur in the same session as screening. We feel the composite scores are better indicators of. Other terms associated with substance abuse include chemical dependency, drug addiction, drug abuse, and substance dependence. Template for assessing a clients substance use developed. Substance abuse services printing facility composite scores there is a composite score for each problem area of the asi that has been derived from sets of items within each of the asi. Samhsas mission is to reduce the impact of substance abuse and mental illness on americas communities. The asi form will provide a comprehensive, overall understanding of all aspects of the patients existence in order to properly evaluate any addiction issues the patient experiences as. Screening and assessment for alcohol and other drug abuse. Reliability of the addiction severity index selfreport form asisr.
Screenings should be provided to people of all ages, even the young and the elderly. Fax completed utp forms to 18772359905, unless requesting tx sb 58 services. General symptoms of chemical dependency check all that apply preoccupation daily use guilt or remorse tolerance. Bobby smyth, consultant child and adolescent psychiatrist specialising in substance abuse. More than 1 substance per day including alcohol route of administration 1oral 4noniv injection 2nasal 5iv injection 3smoking d17.
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