| CHEMICAL
DEPENDENCY ASSESSMENT SUMMARY |
Date: |
| Patient's
Name: |
Date of Birth |
Patient’s
Address:
|
Patient’s
Telephone # |
| Court: |
Case # |
BAC Level
Analysis:
|
Refused: |
BAC
Level ___ |
BAC Analysis ______ _
_ |
| History of CD Related Arrests or
Reduced Charges: |
Criminal
history was not provided by court |
|
Driving
record was not provided by client |
| Prior CD
Evaluation? |
Yes |
If
yes, date
/ / |
None Reported |
| Prior ADIS? |
Yes |
If
yes, date
/ / |
None Reported |
| Prior Deferred
Prosecution? |
Yes |
If
yes, date
/ / |
None Reported |
| Prior CD
Treatment? |
Yes |
If
yes, date
/ / |
None Reported |
| Comment:
|
| Diagnostic Assessment:
|
| Treatment
Recommendation:
|
ASAM
Level & Estimated Duration:
(Recommendations for appropriate level of
care and length of stay in accordance with ASAM PPC will be made periodically to the court
and the patient based on ongoing assessment of the patient’s progress in treatment
and individual treatment needs.) |
| Factors Considered in Recommendation:
|
| This assessment
includes collateral information from: |
|
Attorney
|
Court |
Treatment Agency |
Physician |
Family |
Law Enforcement |
| Child Protective Services |
Other: |
| This assessment, and the treatment
recommendations attached, are voided if the patient has failed to fully and honestly
disclose information requested of him/her throughout the assessment process. |
Assessing
CD Counselor / Assessment Officer
|
Agency: |
Phone
#: |
