Asam Suplement Forms

The Department of Children and Families
Substance Abuse Program
Florida Supplement
To the
American Society of Addiction Medicine Patient Placement Criteria
For the
Treatment of Substance-Related Disorders
Second Edition
(ASAM PPC-2)
Revision Effective: July 10, 2006
Table of Contents
Acknowledgments
Introduction
Supplement Forms
Instructions for Using Supplement Forms
Addictions Receiving Facilities (ARFs)
Example: Decision-Making Process for Client Placement
Adult Patient Placement Criteria

Crosswalk of ASAM PPC-2R Levels of Care and
65D-30, FAC Levels of Care
5-6
8
9
Opioid Maintenance Forms
10-15
Level 0.5 Intervention Forms
16-19
Level I Outpatient Forms
20-24
Level II.1 Intensive Outpatient Forms
25-29
Level II.5 Partial Hospitalization Forms
30-34
Level III.I Clinically Managed Low-Intensity Residential Treatment Forms
35-41
Level III.3 Clinically Managed Medium-Intensity Residential Treatment Forms
42-48
Level III.5 Clinically Managed Medium/High-Intensity Residential Treatment Forms
49-56
Level III.7 Medically Monitored Intensive Inpatient Treatment Forms
57-62
Level I-D Ambulatory Detoxification without Extended On-Site Monitoring Forms
63-65
Level III.2-D Clinically-Managed Residential Detoxification Forms
66-68
Level III.7-D Medically-Monitored Inpatient Detoxification Forms
69-71
Adolescent Patient Placement Criteria

Crosswalk of ASAM PPC-2R Levels of Care and
65D-30, FAC Levels of Care
72
73
Level 0.5 Intervention Forms
74-76
Level I Outpatient Forms
77-81
Level II.1 Intensive Outpatient Forms
82-87
Level II.5 Partial Hospitalization Forms
88-93
Level III.5 Clinically Managed Medium-Intensity Residential Treatment Forms
94-99
Level III.2-D Clinically-Managed Residential/Juvenile Addiction Receiving Facility Form
100-102
Level III.7-D Medically-Monitored Inpatient Detoxification Forms
103-106
Acknowledgments
The implementation of a system of managed behavioral healthcare, along with a uniform system of patient placement, is a significant change
in the way substance abuse and related services are provided. Certainly, the implementation of such a system is to be considered a
monumental undertaking since it affects individuals at all levels of the substance abuse services continuum. This is particularly true of
front line clinicians who make critical decisions on behalf of their clients.
In an effort to make this change to a uniform system of patient placement as easy as possible for Floridas substance abuse providers, the
Department of Children and Family Services Substance Abuse Program Office consulted with a number of individuals and organizations
who have made major contributions to the development and implementation of patient placement criteria. The Substance Abuse Program
Office wishes to thank the following for their contributions to the development and implementation of the Florida Supplement to the
American Society of Addiction Medicine Patient Placement Criteria for the Treatment of Substance-Related Disorders, Second Edition (ASAM
PPC-2):
Jane Alm, The Department of Human Resources, Office of Alcohol and Drug Abuse Programs - Salem, Oregon
James F. Callahan, D.P.A., Executive vice-president and CEO, the American Society of Addiction Medicine
David Mee-Lee, MD
Gerald D. Shulman, M.A., FACATA
Janet Zwick, The Department of Public Health, Division of Substance Abuse and Health Promotion - Des Moines, Iowa
The Florida Alcohol and Drug Abuse Association
The Florida Council for Community Mental Health
Spectrum Programs - Miami, Florida
Gateway Community Services - Jacksonville, Florida
The Agency for Community Treatment Services, Inc. - Tampa, Florida
Center for Substance Abuse Treatment
The Florida Department of Children and Family Services District Administrators and Substance Abuse and Mental Health Program
Supervisors
The Florida Department of Juvenile Justice
The Florida Agency for Health Care Administration
Introduction
As part of the State of Floridas movement toward a comprehensive system of managed behavioral health care, the Department of
Children and Family Services Substance Abuse Program Office implemented the American Society of Addiction Medicine Patient
Placement Criteria for the Treatment of Substance-Related Disorders, Second Edition (ASAM PPC-2) and the Florida Supplement, on
July 1, 1997. All contracted State of Florida substance abuse providers are required to use the ASAM PPC-2R, Florida Supplement,
and its accompanying forms.
The primary purpose of the Florida Supplement, as an extension of the ASAM PPC-2R, is to provide clinicians with an abbreviated
reference document to assist them in documenting their placement decisions in accordance with Floridas system of licensable
services. The Supplement and its accompanying forms include information that is contained in the ASAM PPC-2R without
compromising the latter documents integrity.
Supplement Forms
The Supplement forms contained in this manual were designed to allow substance abuse providers to begin using them immediately
upon implementation of the ASAM PPC-2R. Forms are to be completed by service providers when admission of a client to a specific
level of care is being considered, at interim points during the clients stay or involvement in a particular level of care, and upon
transfer or discharge of a client from that level of care. Every service provider will use the Supplement form that is most appropriate
for the level of care being considered or reviewed for a client.
Note: The Supplement forms are not intended to be used as assessment instruments or to replace any existing
assessment instruments being used by service providers.
Each form is identified for use for adult or adolescent clients and includes the dimensional criteria for a specific level of care within
the ASAM PPC-2R. Each form is labeled at the heading with the Client Name, Client ID Number, Date, the applicable state
licensable component per Chapter 65D-30, and the corresponding ASAM Level of care.
There is sufficient information contained within each Supplement form for clinicians to make placement decisions on most
individuals. However, information contained in each Supplement form should not be relied upon solely by the clinician if there are
questions regarding any aspect of the placement of an individual. Clinicians are advised to read the complete ASAM manual and to
consult the manual, if necessary, when making decisions on placement.
6
It should also be noted that the Supplement forms, and the information contained therein, are intended to assist clinicians in making
thorough and appropriate placement decisions regarding individual clients, and should not be used as a method for generalizing
among all service recipients.
Instructions for Using Supplement Forms

Once an assessment of a client has been completed, the clinician will choose the Florida Supplement form that corresponds to the
ASAM level of care (e.g., Level II.1) and 65D-30 component service (e.g., intensive outpatient), that is being considered for the
client. Begin by completing the ADMISSION form by circling all individual criteria (e.g., circle a., b., c., etc.) in each dimension that
applies to the client. This is followed by placing a check in the appropriate box, which validates a clients placement in that level of
care. This process of decision making will continue and will be completed on separate Supplement forms to determine
CONTINUED STAY in that level of care, and to determine TRANSFER or readiness for DISCHARGE from that level of care.
(Note: Clients must meet a specified minimum of criteria in each dimension at each level of care being considered. In some cases
they must meet all of the criteria.). On the following page is an example of the decision-making process that should be followed at
ADMISSION to determine appropriate placement.
Special Instructions for Addictions Receiving Facilities (ARFs)

Completion of the Florida Supplement form that is contained in this manual will be required for Addictions Receiving Facilities
(ARFs) for documentation and monitoring purposes. As will be indicated on a later page in this Supplement, ARFs correspond in level
of care to the ASAM PPC-2R Level III.2-D, Clinically Managed Residential Detoxification. It must be noted, however, that the
requirements for Level III.2-D have been modified somewhat to correspond to the addictions receiving facility requirements found in
65D-30. Also, implementation of these placement criteria shall not supersede the decision to place an adolescent in an addiction
receiving facility under the involuntary provisions of Chapter 397, Florida Statutes.
Dual Diagnosis Programs
Dual Diagnosis Capable programs primarily focus on the treatment of substance abuse disorders and are also capable of treating
clients who have stable diagnostic or sub-diagnostic co-occurring mental health problems related to the criteria of Dimension 3.
Dual Diagnosis Enhanced programs are designed to treat clients who are unstable or disabled by their co-occurring mental health
disorders in addition to the substance-related disorders.
The Florida Supplement includes the criteria of Dual Diagnosis Enhanced Programs for clients who have a diagnosis of mental
health problems and are not stable enough to be treated solely for substance abuse. Clients who have a dual diagnosis and are stable
and exhibiting symptoms in any Dimension 3 criteria can be placed in a Dual Diagnosis Capable program based upon meeting
Dimension 3 criteria.
Example:
Example: Decision-Making
Decision-MakingProcess
Processfor
for
Client
Placement
at
Admission
Client Placement at Admission
Complete
CompleteClient
Client
Assessment
Assessment
Client
Clientmeets
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Minimum
Minimum
Criteria
Criteriafor
for
Outpatient
OutpatientTX
TX
Outpatient
OutpatientTX
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Recommended
Recommended
Yes
Client
ClientPlaced
Placedinin
Outpatient
OutpatientTX
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Complete
Complete
ASAM
ASAMOutpatient
Outpatient
Admission
AdmissionForm
Form
Place
PlaceForm
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Client
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Consider
ConsiderAnother
Another
Level
LevelofofCare
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Note: Client must meet criteria in

Note: Client must meet criteria in
all six dimensions for admission to
all six dimensions for admission to
this level of care.
this level of care.
Chart 1
ADULT CLIENT PLACEMENT CRITERIA

Levels of Care
Each of the following represents the licensable components as provided for in
Chapter 65D-30, Florida Administrative Code, and corresponds to a specific
level of care in the ASAM PPC-2R.
Medication and Methadone Maintenance Treatment
Intervention
Outpatient Treatment
Intensive Outpatient Treatment
Day or Night Treatment (Inclusive of Host Homes and Community Housing)
Residential IV Treatment
Residential III Treatment
Residential II Treatment
Residential I Treatment
Intensive Inpatient Treatment
Addictions Receiving Facility
Detoxification
The next page contains a comparison of these licensable components and the
corresponding adult ASAM PPC-2R levels of care.
ASAM PPC-2R Levels of Care and 65D-30, FAC Levels of Care (Adult)
Crosswalk
ASAM PPC-2R
Levels of Care
65D-30, FAC
Levels of Care
Opioid Maintenance Therapy
Level 0.5
Early Intervention
Intervention
Level I
Level II.1
Intensive Outpatient
Level II.5
Partial Hospitalization
Day or Night Treatment
Level III.I
Clinically Managed Low Intensity Residential
Treatment
Level IV
Residential Treatment
Level III.3
Clinically Managed Medium Intensity Residential
Treatment
Level III.5
Clinically Managed High Intensity Residential
Treatment
Level III.7
Medically Monitored Intensive Inpatient Treatment
Level III
Level I-D
Ambulatory Detoxification without Extended On-Site
Monitoring
Levels I and II
Intensive Inpatient Treatment
Detoxification
10
Print Client Name:
DIMENSIONS
ASAM Requirements
Dimension 1:
Acute Intoxication
and/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Client Identification Number:
Date:
Adult
65D-30 Medication Treatment
ASAM Opioid Maintenance Therapy
Circle all items in each dimension that apply to the client.

a check in the appropriate box that indicates
[1] ADMISSION CRITERIA Place
validation or lack of validation for the placement into this
level of care.
Client meets the criteria in dimensions one through six.
In this dimension, the client must meet (a) and (b), or one of (c), (d), or (e):
a. A Physician determines that the client is physiologically dependent upon an opiate drug and
became physiologically dependent at least one year before admission to methadone maintenance.
This means that the client was addicted continuously or episodically for most of the year
immediately before admission (FDA 42 CFR Part 8); and
b. Criteria for determining the clients current physiological dependence (in addition to a
history of addiction) include but are not limited to vital signs, early physical signs of
narcotic withdrawal, a urine screen that is positive for opiates, the presence of old or fresh
needle marks, and documented reports from medical professionals, the client or family,
treatment history, or (if necessary) a positive reaction to a naloxone test; or
c. Clients admitted from penal or chronic care settings, if admitted within 14 days of release,
or up to six months after release without documented physiological dependence if the client
was eligible for admission prior to incarceration (FDA 42 CFR Part 8); or
d. Pregnant women who have a documented history of opiate dependence without physiological
dependence, if the program physician certifies that the woman is pregnant and finds that
treatment is medically justified (FDA 42 CFR Part 8); or
e. Previously treated clients who are voluntarily detoxified from methadone within 2 years of
discharge, in the absence of current physiological dependence, if the program can document
prior methadone treatment of 6 months or more duration and, in the judgment of the program
physician, readmission to OMT is medically indicated (FDA 42 CFR Part 8).
The clients status in this dimension is characterized by one of the following:
a. The client meets the biomedical criteria for opiate dependence, with or without the
complications of opiate addiction, requiring medical monitoring and skilled care; or
b. The client has a concurrent biomedical illness or pregnancy, which can be treated on an
outpatient basis with minimal daily medical monitoring; or
c. The client has biomedical conditions that can be managed on an outpatient basis, such as: (1)
liver disease or problems with potential hepatic decompensation, (2) pancreatitis, (3)
gastrointestinal problems, (4) cardiovascular disorders, (5) HIV and AIDS, (6) sexually
transmitted diseases, (7) concurrent psychiatric illness requiring medications, and (8)
tuberculosis.
a. The clients emotional, behavioral or cognitive conditions, if present, are manageable in an
outpatient structured environment; or
b. The clients addiction-related abuse/neglect of the clients spouse, children or significant
others require intensive outpatient treatment to reduce risk of further deterioration; or
c. The client has diagnosed and stable emotional, behavioral or cognitive conditions or thought
disorders (e.g., stable borderline personality or obsessive-compulsive disorder) that require
monitoring, management, and/or medication because of the risks that these conditions will
distract the client from a focus on treatment; or
YES
NO
11
d. The client demonstrates a mild risk of posing harm to self or others, with or without a
history of severe depression, suicidal and/or homicidal behavior, and can be managed safely in
a structured outpatient environment; or
e. The client demonstrates emotional/behavioral stability but requires continued pharmacology to
prevent relapse to opiate use.
Dimension 4:
a. The client requires structured therapy, pharmacotherapy and programmatic milieu to promote
Readiness to
treatment progress and recovery; or
Change
b. The client attributes problems to persons or external events rather than to the clients
addictive disorder. This inhibits the clients ability to make behavior changes in the
absence of clinically directed and repeated structured motivational interventions. However,
the clients resistance is not so high as to render treatment ineffective.
Dimension 5:
a. The client requires structured therapy, pharmacotherapy and programmatic milieu to promote
Relapse/Continued
treatment progress because the client attributes continued relapse to physiologic craving/need
Use Potential
for opiates; or
b. Despite active participation in other treatment interventions without provision for OMT, the
client is experiencing an intensification of addiction symptoms (e.g., difficulty postponing
immediate gratification and related drug-seeking behavior) or continued high-risk behaviors
(e.g., shared needle use), and the individuals level of functioning is deteriorating, despite
revision of the treatment plan; or
c. The client is at high risk of relapse to opiate use without OMT, and is in need of close
outpatient monitoring and structured support, as indicated by lack of awareness of relapse
triggers, difficulty in postponing immediate gratification and/or ambivalence toward or
resistance to treatment.
Dimension 6:
a. A sufficiently supportive psychosocial environment makes OMT feasible (e.g., significant
Recovery
others are supportive of recovery efforts, the clients workplace is supportive, the client is
Environment
subject to legal coercion, the client has adequate transportation to the program, etc.); or
b. Family/significant others are supportive but require professional intervention to improve the
clients likelihood of treatment success (e.g., assistance with limit-setting, communication
skills, avoiding rescuing behaviors, education about methadone treatment and HIV risk
avoidance, etc.); or
c. The client does not have a positive social support system to assist with immediate recovery
efforts, but he or she has demonstrated motivation to obtain such a support system or to
pursue (with assistance) an appropriate alternative living environment; or
d. The client has experienced traumatic events in his or her recovery environment (such as
physical, emotional, sexual or domestic abuse) or has manifested the effects of
emotional/behavioral problems in the environment (such as criminal activity), but these are
manageable on an outpatient basis.
Recommendations/Notes:
Print Counselor Name:
Counselor Signature/Credential:
Date:
12
Print Client Name:
DIMENSIONS
ASAM Requirements
Dimension 1:
Acute Intoxication
and/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to
Change
Date:
Adult
Circle all items in each dimension that apply to

the client. Place a check in the appropriate box
[2] CONTINUED STAY CRITERIA
that indicates validation or lack of validation
for continued stay in this level of care.
Continued service requires the client meet the criteria of dimensions one through six.
a. The client requires continued opioid maintenance therapy to prevent his or her return to
illicit opiate use; or
b. The client evidences current use (or increased risk of use) of drugs other than opiates; or
c. The client has a history of inability to abstain from opiate use, despite multiple attempts at
detoxification.
a. Biomedical conditions, if any, continue to be sufficiently stable to permit the clients
continued participation in outpatient treatment; or
b. The client evidences, or is at risk of a serious or chronic biomedical condition (such as
HIV/AIDS, tuberculosis, etc.) that may be exacerbated by a return to illicit opiate use.
a. The client has achieved stable emotional, behavioral or emotional functioning, which may be
jeopardized by discontinuation of opioid maintenance treatment; or
b. The client demonstrates the potential for making use of OMT (by participating in the program,
attending counseling sessions, decreasing illicit activity, etc.) but has not yet made
necessary life changes; or
c. An emotional, behavioral or cognitive disorder, which is being concurrently managed,
continues to distract the client from focusing on treatment goals; however, the client is
responding to treatment and, with further intervention, is expected to achieve treatment
objectives; or
d. The client continues to manifest behaviors that pose a risk to self or others (e.g., periodic
needle-sharing, unprotected sexual contact, outside drug use, etc.), but the condition is
improving; or
e. Emotional, behavioral or cognitive complications of addiction are still present and are
manageable in a structured outpatient environment but require continued therapeutic
interventions. These behaviors may include illicit drug use/criminal activity, involvement
in domestic violence as a victim or perpetrator, or inability to keep a job or maintain a
stable household (e.g., provide for food, consistent shelter, supervision of children, and
health care).
a. The client recognizes the severity of his or her drug problem but demonstrates minimal
understanding of the self-defeating nature of his/her substance abuse, however, the client is
progressing in treatment; or
b. The client recognizes the severity of his or her drug problem and demonstrates an
understanding of the self-defeating nature of such drug involvement; however, the client does
not demonstrate behaviors that indicate the level of responsibility necessary to cope with
the problem; or
c. The client is beginning to accept responsibility for addressing his or her drug problem but
YES
NO
13
still requires this level of intensity of motivational strategies to sustain progress in
treatment; or
d. The client has accepted responsibility for his or her drug problems and has determined that
ongoing treatment with OMT is the most effective means of preventing relapse.
Dimension 5:
a. The client continues to require structured therapy, pharmacotherapy and programmatic milieu
Relapse/Continued
to promote treatment progress because the client attributes continued relapse to physiologic
Use Potential
craving/need for opiates; or
b. The client recognizes relapse triggers but has not developed sufficient coping skills to
interrupt or postpone gratification or to change inadequate impulse control behaviors; or
c. The clients addiction symptoms, while stabilized, have not been reduced sufficiently to
support functioning outside a structured milieu; or
d. Pharmacotherapy has been a part of an effective treatment process that has alleviated
addiction symptoms and prevented relapse, and the withdrawal of methadone or other medication
is likely to lead to a recurrence of addiction symptoms.
Dimension 6:
a. The client has not yet developed sufficient coping skills to withstand stressors in the work
Recovery
environment so as to prevent return to illicit opiate use and has not developed vocational
Environment
alternatives; or
b. The client has not yet developed sufficient coping skills to deal with non-supportive
family/social environment to prevent return to illicit opiate use and has not developed
alternative support systems; or
c. The client has not yet integrated the socialization skills necessary to establish a
supportive social network; or
d. Problem aspects of the clients social and interpersonal life are responding to treatment,
but are not sufficiently supportive of recovery to allow transfer to a less intensive level
of care; or
e. The clients social and interpersonal life has not improved or has deteriorated and the
client needs additional treatment to learn to cope with the current situation or to take
steps to secure an alternative environment; or
f. The clients social and interpersonal life has stabilized while he/she has been in treatment
and indicates the need for continued OMT.
Date:
14
Print Client Name:
DIMENSIONS
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to
Change
Dimension 5:
Relapse/
Continued Use
Potential
Adult

the client. Place a check in the appropriate
box that indicates validation or lack of
for discharge or transfer from this
Enter Level ____ validation
level of care.
Discharge requires that the client meet the criteria in at least one of the six dimensions.
a. The client no longer requires OMT to prevent his or her return to illicit use of opiates or
other drugs; or
b. The client exhibits symptoms of severe intoxication and/or withdrawal, which cannot be safely
managed at this level of care.
a. The clients biomedical conditions, if any, and opiate dependence problem have stabilized and
can be managed without continuing OMT, and the client does not meet any of the continued
service criteria that indicate the need for further treatment; or
b. The clients biomedical condition has deteriorated, and the client requires continued
treatment in a different treatment setting.
a. The clients emotional, behavioral or cognitive problems have diminished or stabilized to the
extent that they can be managed through outpatient counseling or self-help fellowship without
continued OMT, and the client does not meet any of the continued service criteria that
indicate the need for further treatment; or
b. A psychiatric or emotional, behavioral or cognitive problem exists that is interfering with
addiction treatment in an outpatient treatment setting, so that (1) continued participation
in an OMT presents a serious psychiatric risk, as determined by the programs medical
director, and (2) continued treatment is required at a more intensive level of care.
a. The clients awareness and acceptance of his or her addiction and commitment to recovery is
sufficient to expect maintenance of recovery through outpatient counseling or a self-directed
recovery plan, as evidence by (1) the clients recognition of the severity of his/her drug
problem, (2) the clients demonstration of an understanding of the self-defeating nature of
his/her drug use, (3) the clients application of the essential skills necessary to maintain
a stable recovery program without pharmacological supports at this time, and (4) the client
does not meet any of the continued service criteria that indicate the need for further
treatment; or
b. The client consistently has failed to achieve essential treatment objectives, despite
revisions to the treatment plan, to the degree that the client needs placement at another
level of care.
a. The client recognizes relapse triggers and has developed sufficient coping skills to
interrupt or postpone gratification and impulse control behaviors without continued OMT, and
the client does not meet any of the continued service criteria that indicate the need for
further treatment; or
b. The client is experiencing a continuation or exacerbation of drug-seeking behaviors or
[3] DISCHARGE
ASAM Requirements
Dimension 1:
Acute
Intoxication and/
or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Date:
TRANSFER ____
YES
NO
15
craving that is not responding to OMT and which has been determined to require a more
intensive level of care.
Dimension 6:
a. The clients social system and significant others are supportive of recovery to the extent
Recovery
that the client can adhere to a self-directed recovery plan without substantial risk or
Environment
relapse on discontinuation of OMT, and the client does not meet any of the continued service
criteria that indicate the need for further treatment; or
b. The clients social system remains non-supportive or has deteriorated. The client is having
difficulty coping with this environment and is at substantial risk of relapse. The client is
unable to achieve essential treatment objectives within his/her current social environment.
Date:
16
Print Client Name:
DIMENSIONS
ASAM Requirements
Dimension 1:
Acute Intoxication
and/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to
Change
Dimension 5:
Relapse/Continued
Use Potential
Date:
Adult
65D-30 Intervention
ASAM Level .05
Circle all items in each dimension that apply

to the client. Place a check in the
appropriate box that indicates validation or
lack of validation for placement into this
level of care.
Must meet one of the Dimensions of 4, 5, or 6 and any identifiable problems in Dimensions 1, 2
or 3 that are stable or being addressed through appropriate outpatient medical or mental health
services.
a. Client is free from intoxication or withdrawal symptoms/risks; or
b. The clients intoxication or withdrawal symptoms/risks can be managed at this level of care.
[1]
ADMISSION CRITERIA
None or very stable Any biomedical conditions are stable or are being actively addressed and
will not interfere with interventions at this level of care.
None or very stable - Any emotional, behavioral or cognitive conditions or complications are
being addressed through appropriate mental health services and will not interfere with
interventions at this level of service.
Willing to understand how current use may affect personal goals The client expresses a
willingness to gain an understanding of how his/her current use of alcohol and/or other drugs
may interfere with meeting responsibilities and achieving personal goals.
Needs understanding of, or skills to change current use patterns. The situation is
characterized by one of the following:
a. The client does not understand the need to alter the current pattern of use of substances to
prevent further harm related to such use; or
b. The client needs to acquire the specific skills needed to change his/her current pattern of
use.
Social support system or significant others increase risk for personal conflict about
Dimension 6:
alcohol/drug use. The clients living environment is characterized by one of the following:
Recovery
a. The social support system is composed primarily of individuals whose substance use patterns
Environment
prevent them from meeting social, work, school or family obligations; or
b. Family members currently are abusing substances, increasing the clients risk for substance
related disorder; or
c. Significant others express values concerning alcohol or other drug use that create
significant conflict for the client; or
d. Significant others condone or encourage inappropriate use of alcohol or other drugs.
Date:
YES
NO
17
Print Client Name:
DIMENSIONS
Date:
Adult
65D-30 Intervention
ASAM Level .05

validation for continued stay in this level of
care.
The client remains stable in Dimensions 1, 2, and 3, and meets the criteria in at least one of
Dimensions 4, 5, or 6.
Client is free from intoxication or withdrawal symptoms/risks.

ASAM Requirements
Dimension 1:
Acute Intoxication
and/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to
Change
Dimension 5:
Relapse/Continued
Use Potential
Dimension 6:
Recovery
Environment
stable or are being actively addressed and will not interfere with interventions at this level of
service.
Willing to understand how current use may affect personal goals The client continues to express
a willingness to gain an understanding of how his/her current use of alcohol and/or other drugs
The client demonstrates an understanding of the detrimental aspects of his/her alcohol and/or
drug use pattern but does not yet demonstrate the skills necessary to change those patterns.
The clients living environment is characterized by one of the following:

a. Problem aspects of the environment remain, but the client is acquiring the skills needed to
cope with them; or
b. Significant others who have documented problems with alcohol or other drug use are receiving
help for their problems, which have not yet stabilized.
Date:
YES
NO
18
Print Client Name:
DIMENSIONS
Dimension 1:
Acute Intoxication
and/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to
Change
Dimension 5:
Relapse/Continued
Use Potential
Adult
65D-30 Intervention
ASAM Level .05

Enter Level_____ validation
level of care.
Discharge from this level of service requires that the client meet the criteria in one of the
six dimensions.
a. The client is free from intoxication or withdrawal symptoms/risks; or
b. The client exhibits severe intoxication and/or withdrawal, which cannot be safely managed at
this level of care.
a. The clients biomedical conditions, if any, have diminished or stabilized and the client does
not meet any of the continued stay criteria in this or another dimension that indicates the
need for transfer to another level of care; or
b. The clients condition precludes continued participation in this level of care and requires
transfer to another level of care.
a. The clients emotional, behavioral or cognitive conditions, if any, have diminished or
stabilized and the client does not meet any of the continued stay criteria in this or another
dimension that indicates the need for transfer to another level of care; or
b. The clients mental health conditions (e.g., anxiety, guilt, or thought disorders) are stable
and related to substance use or to a co-occurring emotional, behavioral or cognitive
condition. Mental health monitoring is needed to maintain this stability (e.g., fluctuations
in mood recently stabilized with medication, substance induced depression reduced and still
significant or a client with schizophrenic disorder released recently from the hospital); or
c. The clients condition precludes continued participation in this level of care and requires
transfer to another level of care; or
d. The client is assessed as not posing a risk of harm to self or others and is not vulnerable
to victimization by others.
a. The client has remained stable in Dimension 4 and does not meet any other criteria that
indicates the need for continued service at this level of care; or
b. The client no longer is willing to examine personal substance use patterns, despite program
efforts, and a recommendation is being made for further assessment and follow-up.
a. The client has demonstrated the personal skills necessary to make responsible choices about
alcohol/other drug use, and does not meet any other criteria indicating the need for
continued service at this level of care; or
b. The client has not integrated the skills necessary to avoid harmful or inappropriate
substance use, despite professional interventions, and a recommendation is being made for
further assessment and follow-up.
[3] DISCHARGE
ASAM Requirements
Date:
TRANSFER ____
YES
NO
19

a. The client has resolved problems in his/her living environment or demonstrates the needed
coping skills necessary to achieve personal goals and does not meet any other criteria
indicating a need for continued service at this level of care; or
b. The client is no longer willing to examine problems in his/her living environment, despite
program efforts. Since these problems persist, a recommendation is being made for
appropriate living and support services.
Dimension 6:
Recovery
Environment
Date:
20
Print Client Name:
DIMENSIONS
[1] ADMISSION CRITERIA

ASAM Requirements
Dimension 1:
Acute Intoxication
and/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Date:

validation for placement into this level of
care.
Meets criteria in all six dimensions.

None or very stable - The clients biomedical conditions, if any, are stable enough to
participate in outpatient treatment.
None or very stable The situation is characterized by all of the following:

a. The clients anxiety, guilt and/or depression, if present, appear to be related to substancerelated problems rather than to a coexisting psychiatric/emotional/behavioral or cognitive
condition. If they are related to such a condition, appropriate care is being provided
concurrent with ASAM Level I; and
b. The clients mental status does not preclude his/her ability to understand the materials
presented or to participate in the treatment process; and
c. The client is assessed as not posing a risk of harm to self or others.
Dual Diagnosed Enhanced Programs
Dimension 4:
Readiness to
Change
In addition to the foregoing criteria, either (a) or (b) and (c) and (d) characterize the
clients status in Dimension 3.
a. The client has a severe and persistent mental illness that impairs his or her ability to
follow through consistently with mental health appointments and psychotropic medication. The
client maintains the ability to access services such as assertive community treatment and
intensive case management or supportive living designed to help the client remain engaged in
treatment; or
b. The client has a severe and persistent mental disorder or other emotional, behavioral or
cognitive problems, or substance-induced disorder; and
c. The clients mental health functioning is such that he or she has impaired ability to: [1]
understand the information presented, and [2] participate in treatment planning and the
treatment process. Mental health management is required to stabilize mood, cognition and
behavior; and
d. The client is assessed as not posing a risk of harm to self or others and is not vulnerable
to victimization by another.
The situation is characterized by (a) and (b) or (c) or (d):
a. The client wants to adhere to the treatment plan and attend all scheduled activities; and
b. The client admits to a substance abuse and/or a mental health problem but requires monitoring
and motivating strategies. A structured residential program is not required; or
c. The client is ambivalent about or does not recognize that he or she has a substance-related
and/or mental health problem; or
Adult
65D-30 Outpatient
ASAM Level I
YES
NO
21
Dimension 5:
Relapse/Continued
Use Potential
The client may not recognize that they have a substance-related and/or mental health problem.
They may require monitoring and motivating strategies to engage in treatment and to progress
through the stages of change.
Able to maintain abstinence and pursue recovery goals with minimal support The client is
assessed as being able to achieve or maintain abstinence and recovery goals only with support
and scheduled counseling to assist in dealing with issues that include mental preoccupation with
alcohol or other drugs, craving, peer pressure, lifestyle, attitude changes and other treatment
plans issues.
Dimension 6:
Recovery
Environment
In addition to the criteria listed above, the client is assessed as able to achieve or maintain
mental health functioning and related goals only with support and scheduled therapeutic contact
to assist him or her in dealing with issues that include (but are not limited to) impulses to
harm self or others and difficulty in coping with his or her affects, impulses or cognition.
The situation is characterized by one of the following:
a. A sufficiently supportive psychosocial environment makes outpatient treatment feasible; or
b. Although the client does not have an ideal primary or social support system to assist with
sobriety, he or she has demonstrated motivation and willingness to obtain such a support
system; or
c. Family and significant others are supportive but require professional interventions to
improve the clients chance of treatment success and recovery.

In addition to the criteria listed above, (a) or (b) or (c) characterizes the clients status in
Dimension 6.
a. The client does not have an adequate primary or social support system and has mild impairment
in his or her ability to obtain a support system; or
b. The family guardian or significant others require active family therapy or systems
interventions to improve the clients chances of treatment success and recovery; or
c. The clients status in Dimension 6 is characterized by all of the following: (1) the client
has a severe and persistent mental disorder or emotional, behavioral or cognitive problem,
and (2) the client does not have an adequate family or social support system, and (3) the
client is chronically impaired, however, not in imminent danger, and limited ability to
establish a supportive recovery environment. (The client however, does not have access to
intensive outreach and case management services that can provide structure and allow him or
her to work toward stabilizing both the substance and mental health related disorders). The
client does however, have access to intensive outreach and case management services that can
provide structure and allow them to work toward stabilizing both the substance related and
mental disorders.
Date:
22
Print Client Name:
DIMENSIONS
Date:
Adult
65D-30 Outpatient
ASAM Level I

care.
Meets criteria in Dimensions 1 and 2 and one of Dimensions 3, 4, 5 or 6.

ASAM Requirements
Dimension 1:
Acute Intoxication
and/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
None or very stable - The clients status in this dimension is characterized by one of the
following:
a. The clients biomedical conditions are stable enough to continue to participate in outpatient
treatment; or
b. An intervening problem interrupted treatment but is now stable enough for the client to
progress in treatment
Dimension 3:
following:
Emotional,
a. The client is making progress to reduce anxiety, guilt or depression, if present, but these
Behavioral or
symptoms have not been sufficiently resolved to permit discharge from treatment; or
Cognitive
b. An intervening emotional, behavioral or cognitive condition interrupted treatment but is now
Conditions and
stable enough for the client to progress in treatment.
Complications
Willing to cooperate but needs motivating and monitoring strategies - The client continues to
Dimension 4:
work on treatment goals and objectives, but does not yet understand or accept his/her addiction
Readiness to
sufficiently to maintain a self-directed recovery plan.
Change
Able to maintain abstinence and pursue recovery goals with minimal support as characterized by
Dimension 5:
one of the following:
Relapse/Continued
a. Client is not using alcohol or other drugs but remains mentally preoccupied with such use to
Use Potential
the extent he/she is unable to address primary relationships, social or work tasks; however,
there are indications that with continued treatment, the client will effectively address
these issues; or
b. Client is not using alcohol or drugs and demonstrates minimal cravings but requires continued
work on the development of an alternative lifestyle, thinking patterns and emotional
responses; however, the client is making progress toward these goals.
Supportive recovery environment and/or client has skills to cope The social environment
Dimension 6:
remains non-supportive or has deteriorated, but the client is making sufficient progress in
Recovery
learning social and related coping skills to function in the environment without using
Environment
substances.
Date:
YES
NO
23
Print Client Name:
DIMENSIONS

box that indicates validation of lack of
Enter Level____ validation
level of care.
Meets criteria in one of the six dimensions unless discharged for lack of diagnostic criteria.
b. The client exhibits symptoms of severe intoxication and/or withdrawal, which cannot be
safely managed at this level of care.
a. The clients biomedical conditions, if any, have diminished or stabilized to the extent they
can be managed through outpatient appointments at the clients discretion, and the client
does not meet any of the continued stay criteria in this or another dimension that indicates
the need for further treatment in ASAM Level I; or
b. The client has a biomedical condition that is interfering with addiction treatment and that
requires treatment in another setting.
stabilized to the extent they can be managed through outpatient appointments at the clients
discretion, and the client does not meet any of the continued stay criteria in this or
another dimension that indicates the need for further treatment in ASAM Level I; or
b. The client has an emotional, behavioral or cognitive condition that is interfering with
treatment and that requires additional treatment in another setting.
a. The clients awareness and acceptance of his/her addiction problem and commitment to recovery
is sufficient to expect maintenance of a self-directed recovery plan, based on the following
evidence: 1) the client recognizes the severity of the substance abuse problem; 2) the
client has an understanding of the self-defeating relationship with substances; 3) the
client is applying the skills necessary to maintain sobriety in a mutual self-help group
and/or with post-treatment support care; and 4) the client does not meet any of the
continued stay criteria in this or another dimension that indicates the need for further
treatment in ASAM Level I; or
b. The client consistently has failed to achieve essential treatment objectives despite
revisions to the treatment plan, to an extent that no further progress is likely to occur.
a. The clients therapeutic gains in addressing craving and relapse issues have been
internalized and integrated so the client does not meet any of the ASAM Level I continued
stay criteria in this or another dimension that indicates the need for further treatment in
ASAM Level I; or
b. The client is experiencing a worsening of drug-seeking behaviors or craving, requiring
treatment in a more intensive level of care.
[3] DISCHARGE
ASAM Requirements
Dimension 1:
Acute Intoxication
and/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to
Change
Dimension 5:
Relapse/Continued
Use Potential
Date:
TRANSFER ____
Adult
65D-30 Outpatient
ASAM Level I
YES
NO
24
a. The clients social system and significant others are supportive of recovery to an extent
that the client can follow a self-directed treatment plan without substantial risk of
relapse/continued use and the client does not meet any of the continued service criteria in
this or another dimension that indicates the need for further treatment at ASAM Level I; or
b. The client is functioning adequately in assessed life task areas of work, social functioning
or primary relationships and does not meet any of the continued service criteria in this or
another dimension that indicates the need for further treatment at ASAM Level I; or
c. The clients social system remains non-supportive or has deteriorated. The client is having
difficulty coping with this environment and is at substantial risk of relapse and requires
placement in a more intensive level of care.
Dimension 6:
Recovery
Environment
Date:
25
Print Client Name:
DIMENSIONS
Date:
Adult
65D-30 Intensive Outpatient
ASAM Level II.1

level of care.
Must meet Dimensions 1, 2, or 3 and one of Dimensions 4, 5, or 6.
Transfer criteria: Clients may be transferred to this level of care when they have met
essential treatment objectives in a more intensive level and require this intensity of
service provided at this level of care in at least one dimension. A client may transfer from
ASAM Level I when services at that level have been insufficient to address the clients needs
or when ASAM Level I has consisted of motivational interventions to prepare the client for
participation in a more intensive level of care for which admission criteria are met.
The clients situation in this dimension is characterized by one of the following:
b. The clients intoxication or withdrawal symptoms/risks can be managed at this level of
care.
None or not a distraction from treatment and manageable in ASAM Level II.1. The clients
biomedical conditions, if any, are stable or are being concurrently addressed and will not
interfere with treatment at this level of care.

ASAM Requirements
Dimension 1:
Acute Intoxication
and/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Problems in Dimension 3 are not necessary for admission to a Level II.1 program. However, if
any of the Dimension 3 conditions are present, the client must be admitted to either a Dual
Diagnosis Capable or Dual Diagnosis Enhanced program, depending on the clients level of
functioning, stability and degree of impairment in this dimension.
Dual Diagnosed Capable Programs

The clients status in Dimension 3 is characterized by (a) or (b):
a. The client engages in abuse of family members or significant others, and requires
intensive outpatient treatment to reduce the risk of further deterioration; or
b. The client has a diagnosed emotional, behavioral or cognitive disorder that requires
intensive outpatient monitoring to minimize distractions from their treatment or recovery.
Dimension 4:
Readiness to
Change
The clients status in Dimension 3 is characterized by (a) or (b) or (c):

a. The client has a diagnosed emotional, behavioral or cognitive disorder that requires
management because the clients history suggests a high potential for distracting him or
her from treatment; such a disorder requires stabilization concurrent with addiction
treatment; or
b. The client is assessed as at mild risk of behaviors endangering self, others or property;
or
c. The client is at significant risk of victimization by another. However, the risk is not
severe enough to require 24-hour supervision.
Resistance high enough to require a structured program but not so high as to render
outpatient treatment ineffective. The clients status in this dimension is characterized by
one of the following:
a. The client requires structured therapy and a programmatic milieu to promote treatment
YES
NO
26
progress and recovery because of failure at different levels of care. Such interventions
are not likely to succeed at ASAM Level I service; or
b. The clients perspective inhibits his/her ability to make behavior changes without
clinically-directed and repeated structured motivational interventions. Such interventions
are not feasible or not likely to succeed at ASAM Level I service. The clients
resistance, however, is not so high to render the treatment ineffective.
Dimension 5:
Relapse/Continued
Use Potential
The client status in Dimension 4 is characterized by (a) or (b) or (c):

a. The client is reluctant to agree to treatment and is ambivalent about his or her
commitment to change a co-occurring mental health problem; or
b. The clients follow through in treatment is so poor or inconsistent that Level I services
are not succeeding or are not feasible; or
c. The client is assessed as requiring intensive services to improve his or her awareness of
the need to change. The client has such limited awareness of or commitment to change that
he or she cannot maintain an adequate level of functioning with out Level II.1 services.
Despite active participation at a less intensive level of care, the client is experiencing
intensification of addiction symptoms (cravings/drug seeking related behavior) and is
deteriorating in his/her level of functioning despite revisions in the treatment plan.
Dimension 6:
Recovery
Environment
The clients status in Dimension 5 is characterized by psychiatric symptoms that pose a

moderate risk of relapse to the alcohol, drug or psychiatric disorder. The client has
impaired recognition or understanding of and difficulty in managing relapse issues and
requires Level II.1 Dual Diagnosis Enhanced Program services to maintain and adequate level
of functioning.
Environment not supportive, but with structure and support the client can cope. The situation
is characterized by one of the following:
a. Continued exposure to current job, school or living environment will make recovery
unlikely, and the client has insufficient or severely limited resources or skills needed
to maintain an adequate level of functioning without this level of service; or
b. The client lacks social contacts, or has inappropriate social contacts that jeopardize
recovery, or has few friends or peers who do not use alcohol/drugs. The client also has
insufficient or severely limited resources or skills to maintain an adequate level of
functioning without this level of service.

A living, working, social and/or community environment that is not supportive of good mental
functioning characterizes the client status in Dimension 6. The client has insufficient
resources and skills to deal with this situation.
Date:
27
Print Client Name:
DIMENSIONS
Date:
Adult
ASAM Level II.1

lack of validation for continued stay in this
level of care.
The client is sufficiently stable in Dimensions 2 and 3 to allow participation in this level of
care, and the client meets the criteria in one of Dimensions 4, 5, or 6.
YES

ASAM
Requirements
Dimension 1:
Acute
Intoxication and
/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension
Readiness
Change
Dimension
Relapse/
Continued
Potential
4:
to
5:
Use
The clients biomedical conditions, if any, are stable or are being concurrently addressed and
will not interfere with treatment at this level of care.

a. The clients risk of addiction related abuse/neglect of spouse, children or significant
others is diminishing in response to treatment but is not fully resolved; or
b. The clients emotional, behavioral or cognitive condition continues to distract the client
from treatment, but the client is responding to treatment and staff anticipates that, with
further interventions, the client will be able to achieve treatment objectives; or
c. The client continues to manifest mild risk behaviors endangering self, others or property,
but these conditions are improving.
The client is beginning to recognize and understand that he/she is responsible for addressing
his/her illness, but still requires ASAM Level II.1 services and motivational strategies to
sustain personal responsibility and progress in treatment.
a. The client recognizes and understands relapse triggers, but has not developed sufficient
coping skills to interrupt or postpone gratification, or to change related to inadequate
impulse-control behaviors; or
b. The clients addiction symptoms, while stabilized, have not been reduced sufficiently to
support functioning outside the structured treatment provided at this level of care.
The client has not integrated the socialization skills necessary to establish a supportive
social network without the support of ASAM Level II.1 structured treatment.
Dimension 6:
Recovery
Environment
Date:
NO
28
Print Client Name:
DIMENSIONS
Dimension 1:
Acute
Intoxication and
/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to
Change
Dimension 5:
Relapse/
Continued Use
Potential
Adult
ASAM Level II.1

discharge or transfer from this level of
Enter Level ____ for
care.
Meets diagnostic criteria in one of Dimensions 2, 3, 4, 5, or 6 unless discharged for lack of
diagnostic criteria.
[3] DISCHARGE
ASAM Requirements
Date:
TRANSFER ____

can be managed through outpatient appointments at the clients discretion at a less intensive
level of care, and the client does not meet any of the continued stay criteria in this or
another dimension that indicates the need for further treatment; or
a. The client no longer requires ASAM Level II.1 clinically directed interventions, as evidenced
by: 1) an assessment that the client no longer is likely to continue addiction-related
abuse/neglect of spouse, children or significant others; and 2) evidence that the clients
emotional, behavioral or cognitive condition has diminished in severity to such an extent that
regular monitoring of the behavior is no longer necessary, and the client does not meet any of
the continued stay criteria indicating the need for further treatment; or
b. Client has a psychiatric, emotional, behavioral or cognitive condition that is interfering with
addiction treatment and that should be addressed in another setting.
a. The client no longer requires ASAM Level II.1 intensive clinically directed-motivational
interventions, as evidenced by the following: 1) The client recognizes the severity of
his/her substance abuse problem; 2) the client has an understanding of his/her self defeating
relationship with substances; and 3) the client is applying skills necessary to maintain
recovery by accessing appropriate community supports or by continuing treatment in a less
intensive level of care, and the client does not meet any of the continued stay criteria
indicating the need for further treatment; or
b. The client consistently has failed to achieve essential treatment objectives despite revisions
to the treatment plan and advice concerning the consequences of continued alcohol/drug use; to
such an extent that further progress is not likely to occur.
significantly integrated in the clients daily behavior to support an ongoing care program at
a less intensive level of care, and the client does not meet continued stay criteria
YES
NO
29
b. The client is experiencing a worsening of drug-seeking behaviors such as craving or return to
regular use of psychoactive substances despite continued interventions, to such an extent that
he/she requires treatment in a more intensive level of care.
by one of the following: 1) problem aspects of the clients social and interpersonal
environment are responding to treatment and the environment is sufficiently supportive of
recovery to allow discharge or transfer to a less intensive level of care; or 2) the clients
social or interpersonal environment has not changed or has deteriorated, but the client has
learned skills adequate to cope with the current situation or has secured an alternative
environment, and the client does not meet any of the continued stay criteria that indicated
the need for further treatment at this or another level of care; or
b. The clients social support system remains non-supportive or has deteriorated and the client
is having difficulty coping with the environment and is at substantial risk of reactivating
his/her addiction. An alternative environment is not feasible. The client requires this
Dimension 6:
Recovery
Environment
Date:
30
Print Client Name:
DIMENSIONS
ASAM Requirements
Dimension 1:
Acute Intoxication
and/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Date:

Place a check in the appropriate box that indicates
[1] ADMISSION CRITERIA validation or lack of validation for placement into this
level of care.
Must meet Dimensions 1, 2, or 3 and one of Dimensions 4, 5, or 6.
Transfer criteria: Clients may be transferred to this level of care when they have met
essential treatment objectives in a more intensive level and require this intensity of service
provided at this level of care in at least one dimension. A client may transfer from ASAM
Level I or Level II.1 when services at that level have been insufficient to address the
clients needs or when ASAM Level II.1 has consisted of motivational interventions to prepare
the client for participation in a more intensive level of care for which admission criteria
are met.
b. The clients intoxication or withdrawal symptoms/risks can be managed at this level of
care.
The clients biomedical conditions and problems are not sufficient to interfere with treatment
and may be managed in ASAM Level II.5, but are severe enough to detract from recovery efforts.
The existence of problems may require medical monitoring or medical management.
Problems in Dimension 3 are not necessary for admission to a Level II.5 program. However, if
any of the Dimension 3 conditions are present, the client must be admitted to either a Dual
Diagnosis Capable or Dual Diagnosis Enhanced program, depending on the clients level of
function, stability and degree of impairment in this dimension.
Dual Diagnosed Capable Programs

The clients status in Dimension 3 is characterized by a history of mild to moderate
psychiatric decompensation or discontinuation of the drug of abuse.
Dimension 4:
Readiness to Change
Adult
65D-30 Day or Night
ASAM Level II.5
The clients status in Dimension 3 is characterized by (a), (b), or (c):

a. The client evidences current inability to maintain behavioral stability over a 48-hour
period;
b. The patient has a history of moderate psychiatric decompensation on discontinuation of the
drug of abuse; or
c. The client is at mild to moderate risk of behaviors endangering self, others, or property,
and is at imminent risk of relapse with dangerous emotional, behavioral, or cognitive
consequences.
Resistance high enough to require a structured program but not so high as to render day or
night treatment ineffective. The clients status in this dimension is characterized by (a)
or (b):
a. The client requires structured therapy and a programmatic milieu to promote treatment
progress and recovery because of failure at different levels of care. Such interventions
are not likely to succeed at ASAM Level II.1 service; or
YES
NO
31
b. The clients perspective inhibits his/her ability to make behavior changes without
clinically-directed and repeated structured motivational interventions. Such interventions
are not feasible or not likely to succeed at ASAM Level II.1 service. The clients
resistance, however, is not so high to render the treatment ineffective.
Dimension 5:
Relapse/Continued
Use Potential
The client status in Dimension 4 is characterized by (a) or (b) or (c):

a. The client has little awareness of his or her co-occurring mental health problem; or
b. The clients follow through in treatment is so poor or inconsistent that Level II.1
services are not succeeding or are not feasible; or
c. The client is assessed as requiring intensive engagement, community or case management
services than are available at Level II.1 in order to maintain an adequate level of
functioning.
The clients status in Dimension 5 is characterized by (a) or (b).
a. The client is experiencing an intensification of symptoms of the substance-related disorder
and his or her level of functioning is deteriorating despite modification of the treatment
plan; or
b. There is a high likelihood that the client will continue to use or relapse to use of
alcohol or other drugs without close outpatient monitoring and structured therapeutic
services, as indicated by his or her lack of awareness of relapse triggers, difficulty in
coping or in postponing immediate gratification or ambivalence toward treatment.
Dimension 6:
Recovery Environment
The clients status in Dimension 5 is characterized by psychiatric symptoms that pose a

moderate risk of relapse to the alcohol, drug or psychiatric disorder. The client has impaired
recognition or understanding of relapse issues and poor skills in coping with and interrupting
mental disorders and/or avoiding or limiting relapse which requires Level II.5 Dual Diagnosis
Enhanced Program services to maintain and adequate level of functioning.
a. Continued exposure to current job, school or living environment will make recovery
unlikely, and the client lacks the resources or skills needed to maintain an adequate level
of functioning without this level of service; or
b. Family members and/or significant others who live with the client are not supportive of his
or her recovery goals, or are passively opposed to his or her treatment. The client
requires the intermittent structure of Level II.5 treatment services in order to remain
focused on recovery.

The clients status in Dimension 6 is characterized by a living, working, social and/or
community environment that is not supportive of good mental functioning. The client has
insufficient resources and skills to deal with this situation.
Date:
32
Print Client Name:
DIMENSIONS
Date:
Adult
65D-30 Day or Night
ASAM Level II.5

level of care.

ASAM Requirements
Dimension 1:
Acute
Intoxication and
/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension
Readiness
Change
Dimension
Relapse/
Continued
Potential
4:
to
5:
Use
The clients biomedical conditions, if any, are stable or are being concurrently addressed and
will not interfere with treatment at this level of care.

a. The clients risk of addiction related abuse/neglect of spouse, children or significant
others is diminishing in response to treatment but is not fully resolved; or
b. The clients emotional, behavioral or cognitive condition continues to distract the client
from treatment, but the client is responding to treatment and staff anticipates that, with
further interventions, the client will be able to achieve treatment objectives; or
c. The client continues to manifest mild risk behaviors endangering self, others or property,
but these conditions are improving.
b. The clients addiction symptoms, while stabilized, have not been reduced sufficiently to
support functioning outside the structured treatment provided at this level of care.
The client has not integrated the socialization skills necessary to establish a supportive
social network without the support of ASAM Level II.5 structured treatment.
Dimension 6:
Recovery
Environment
Date:
YES
NO
33
Print Client Name:
DIMENSIONS
Dimension 1:
Acute
Intoxication and
/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to
Change
Dimension 5:
Relapse/
Continued Use
Potential
Adult
65D-30 Day or Night
ASAM Level II.5

Enter Level ____ for
care.
Meets diagnostic criteria in one of Dimensions 2, 3, 4, 5, or 6 unless discharged for lack of
diagnostic criteria.
[3]DISCHARGE
ASAM Requirements
Date:
TRANSFER ____

can be managed through outpatient appointments at the clients discretion at a less intensive
level of care, and the client does not meet any of the continued stay criteria in this or
another dimension that indicates the need for further treatment; or
by: 1) an assessment that the client no longer is likely to continue addiction-related
abuse/neglect of spouse, children or significant others; and 2) evidence that the clients
emotional, behavioral or cognitive condition has diminished in severity to such an extent that
regular monitoring of the behavior is no longer necessary, and the client does not meet any of
the continued stay criteria indicating the need for further treatment; or
b. Client has a psychiatric, emotional, behavioral or cognitive condition that is interfering
with addiction treatment and that should be addressed in another setting
a. The client no longer requires ASAM Level II.5 intensive clinically directed-motivational
interventions, as evidenced by the following: 1) The client recognizes the severity of
his/her substance abuse problem; 2) the client has an understanding of his/her self defeating
relationship with substances; and 3) the client is applying skills necessary to maintain
recovery by accessing appropriate community supports or by continuing treatment in a less
intensive level of care, and the client does not meet any of the continued stay criteria
to the treatment plan and advice concerning the consequences of continued alcohol/drug use; to
such an extent that further progress is not likely to occur.
significantly integrated in the clients daily behavior to support an ongoing care program at
a less intensive level of care, and the client does not meet continued stay criteria
YES
NO
34
b. The client is experiencing a worsening of drug-seeking behaviors such as craving or return to
regular use of psychoactive substances despite continued interventions, to such an extent that
he/she requires treatment in a more intensive level of care.
Dimension 6:
Recovery
by one of the following: 1) problem aspects of the clients social and interpersonal
Environment
environment are responding to treatment and the environment is sufficiently supportive of
recovery to allow discharge or transfer to a less intensive level of care; or 2) the clients
social or interpersonal environment has not changed or has deteriorated, but the client has
learned skills adequate to cope with the current situation or has secured an alternative
environment, and the client does not meet any of the continued stay criteria that indicated
the need for further treatment at this or another level of care; or
b. The clients social support system remains non-supportive or has deteriorated and the client
is having difficulty coping with the environment and is at substantial risk of reactivating
his/her addiction. An alternative environment is not feasible. The client requires placement
in a more intensive level of care.
Date:
Formatted: Bullets and Numbering
35
Print Client Name:
Date:
Adult
65D-30 Residential Level IV
ASAM Level III.1

care.
DIMENSIONS
[1]
ASAM Requirements
Dimension 1:
Acute Intoxication
and/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Client meets criteria in all six dimensions.

a. Client is free from intoxication or withdrawal symptoms/risks.
ADMISSION CRITERIA

a. Biomedical conditions, if any, are stable and do not require availability of medical or
nursing monitoring, and the client is capable of self-administering any prescribed
medications; or
b. Biomedical conditions are not severe enough to warrant inpatient treatment but are sufficient
to distract from recovery efforts. Such conditions require medical monitoring, which can be
provided by the program or through a concurrent agreement with another provider.
Biomedical Enhanced Services
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
The client who has a biomedical problem that requires a degree of staff attention (such as
monitoring of medications or assistance with mobility) that is not available in other Level III.1.
programs, is in need of Biomedical Enhanced Services.
The client may not have any significant problems in this dimension. However, if any of the
Dimension 3 conditions are present, the resident must be admitted to a Dual Diagnosis Capable or
Dual Diagnosis Enhanced program (depending on his or her level of function, stability and degree
of impairment).
Dual Diagnosis Capable Programs

The client status in Dimension 3 is characterized by (a) or (b) or (c) or (d):
a. The clients psychiatric condition is stable, and he or she is assessed as having minimal
problems in this area, as evidenced by both of the following: [1] the clients thought
disorder, anxiety, guilt and/or depression may be related to substance use problems or to a
stable co-occurring emotional, behavioral or cognitive condition, with dangerous consequences
outside of a structured environment; and [2] the client is assessed as not posing a risk to
self or others; or
b. The clients symptoms and functional deficits, when considered in the context of his or home
environment, are sufficiently severe that he or she is assessed as not likely to maintain
mental stability and/or abstinence if treatment is provided in a non-residential setting.
Functional deficits may include but are not limited to: residual psychiatric symptoms, chronic
addictive disorder, history of criminality, marginal intellectual ability, limited educational
achievement, poor vocational skills, inadequate anger management skills, and the sequelae of
physical, sexual or emotional trauma. These deficits may be complicated by problems in
Dimensions 2 through 6; or
YES
NO
36
c. The client demonstrates (through distractibility, negative emotions, or generalized anxiety)
an inability to maintain stable behavior over a 24 hour period without the structure and
support of a 24 hour setting; or
d. The clients co-occurring psychiatric, emotional, behavioral or cognitive conditions are being
addressed concurrently through appropriate psychiatric services; or
e. The clients mental status (including emotional stability and cognitive functioning) is
assessed as sufficiently stable to allow the client to participate in the therapeutic
interventions provided at this level of care and to benefit from treatment.
Dual Diagnosis Enhanced Programs
Dimension 4:
Readiness to
Change
The clients status in Dimension 3 is characterized by (a) or (b) and (c):

a. The client has a diagnosed emotional, behavioral or cognitive disorder that requires
monitoring of medications or assessment of psychiatric symptoms or behavioral management
techniques, because the clients history suggest that these disorders are likely to distract
him or her from treatment efforts; or
b. The client needs monitoring of psychiatric symptoms concurrent with addictions treatment (as
may occur in a client with borderline or compulsive personality disorder, anxiety or mood
disorder, or persistent schizophrenic disorder in addition to a stabilizing Substance
Dependence or Substance-Induced Disorder); and
c. The client is assessed as able to safely access the community for work, education and other
community resources.
The client meets one of the following:
a. The client recognizes and verbalizes specific relapse triggers and dysfunctional behaviors and
their role in relapse, and is sufficiently cooperative to respond to treatment at this level
of care; or
b. The client is assessed as appropriately placed at ASAM Level I (Outpatient) or ASAM Level II.1
(Intensive Outpatient) and is receiving ASAM Level III.1 services concurrently; or
c. The client requires a 24 hour structured milieu to promote treatment progress and recovery,
because motivating interventions have failed in the past and are assessed as not likely to
succeed in the future in an outpatient setting; or
d. The clients perspective impairs his or her ability to make behavior changes without the
support of a structured environment. For example, the client attributes his or her alcohol,
drug or mental health problem to other persons or external events, rather than to a substance
dependence or mental disorder. Interventions are assessed as not likely to succeed in an
outpatient setting.

The clients status in Dimension 4 is characterized by ambivalence in his or her commitment to
change a co-occurring mental health problem. Similarly, the client who is not consistently able to
follow through with treatment, or who demonstrates minimal awareness of a problem, or who is
unaware of the need to change requires active interventions with family, significant others and
other external systems to create leverage and align incentives so as to promote engagement in
treatment, is appropriately placed in a Level III.1 Dual Diagnosis Enhanced program.
Dimension 5:
37
Relapse/Continued
Use Potential
a. The client understands his or her addiction problems but is at risk of relapse in a less
structured level of care because of inability to apply recovery skills; or
b. The client is at high risk of substance use without close 24-hour monitoring and structured
support (as evidenced, for example, by lack of awareness of relapse triggers, difficulty
postponing immediate gratification or ambivalence/resistance to treatment), and these issues
are being addressed concurrently in ASAM Level II and II.1 programs; or
c. The client needs staff support to maintain engagement in his or her recovery program while
transitioning to life in the community; or
d. The client is at high risk of substance use or deteriorated mental functioning with dangerous
emotional, behavioral or cognitive consequences, in the absence of close 24 hour structured
support (as evidenced, by lack of awareness of relapse triggers, difficulty in postponing
immediate gratification or ambivalence toward or resistance to treatment,) and these issues
are being addressed concurrently in a Level II or II.1 program.

The client status in Dimension 5 is characterized by psychiatric symptoms that pose a moderate
risk of relapse to a substance dependence or mental disorder. Such a resident demonstrates limited
ability to apply relapse prevention skills, as well as deteriorating psychiatric functioning,
which increases his or her risk of serious consequences and requires the types of service and 24
hour structure of a Level III.1 Dual Diagnosis Enhanced program in order to maintain an adequate
level of functioning.
Dimension 6:
Recovery
Environment
The client who is receiving concurrent Level II and Level III.1 services requires case management
to coordinate the services across levels of care may be necessary in managing anti-craving,
psychotropic or opioid maintenance medications. Case management and collaboration across levels of
care may be needed to manage anti-craving, psychotropic or opioid maintenance medications.
Preparation for transfer of the resident to a less intensive level of care and/or reentry into the
community requires case management and staff exploration of supportive living environments,
separately from their therapeutic work with the resident.
a. The client has been living in an environment in which there is a high risk of initiation or
repetition of physical, sexual or emotional abuse, or in which substance use is so endemic
that the client is assessed as being unable to achieve or maintain recovery; or
b. The clients social network involves living with an individual who is a regular user/abuser of
alcohol/other drugs, or the clients living environment is so highly invested in drug use that
recovery goals are assessed as unachievable; or
c. The clients social/interpersonal network is characterized by significant social isolation or
withdrawal, such that recovery goals are assessed as unachievable in a level of care less
intensive than ASAM Level III.1; or
d. Continued exposure to the clients school, work or living environment makes recovery unlikely,
and the resident has insufficient resources and skills to maintain an adequate level of
functioning outside of a 24 hour supportive environment; or
e. The client is in danger of victimization by another and thus requires 24 hour supervision; or
f. The client is able to cope, for limited period of time, outside the 24-hour structure of a
Level III.1 program in order to pursue clinical, vocational, educational, and community
activities.
38
The clients status in Dimension 6 is characterized by severe and persistent mental illness. He or
she may be too ill to benefit from skills training to learn to cope with problems in the recovery
environment. Such a client requires planning for assertive community treatment, intensive case
management or other community outreach and support services. The clients living working, social
and/or community environment is not supportive of good mental health functioning. He or she has
insufficient resources and skills to deal with this situation. Such a client needs the support and
structure of a Level III.1 Dual Diagnosis Enhanced program to achieve stabilization and prevent
further deterioration.
Date:
39
Print Client Name:
DIMENSIONS
Date:
Adult
ASAM Level III.1

Client meets criteria in at least one of six dimensions.
YES

ASAM Requirements
Dimension 1:
Acute Intoxication
and/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral and
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to
Change
The clients status in this dimension is characterized by the following:

Biomedical conditions if any continue but are stable and do not require medical monitoring and
the client is capable of self-administration of prescription medications.

a. The client is making progress toward the resolution of emotional, behavioral or cognitive
conditions but has not made sufficient progress to allow discharge or transfer to a less
intensive level of care; or
b. The clients mental status continues to be sufficiently stable to permit participation at
this level of care.
a. The client accepts responsibility for addressing his or her substance-related problems but
continues to require professional interventions to sustain motivation in treatment; these are
being provided concurrently in an ASAM Level I or II program; or
b. The client continues to be sufficiently cooperative to participate in treatment at this level
of care.
The clients status in this dimension is characterized by the following:
Dimension 5:
The client recognizes relapse triggers, but cannot yet reliably apply sufficient coping skills to
Relapse/Continued
interrupt or postpone gratification, control impulsive behavior or avoid relapse-prone
Use Potential
situations.
Dimension 6:
a. The clients social network/recovery environment continues to manifest the non-supportive
Recovery
features present at admission and, despite active efforts of the client and professional
Environment
staff, adequate recovery environment alternatives have not yet been secured; or
b. The clients interpersonal and social environment has remained the same or deteriorated, and
continued care at ASAM Level III.1 is indicated to assist the client with the development of
coping skills to deal with the current situation or to secure an alternative environment; or
c. There are logistical impediments in the recovery environment (distance/transportation
problems) which precludes this level of treatment in a non-residential setting.
Date:
NO
40
Print Client Name:
DIMENSIONS
[3]DISCHARGE
TRANSFER ____
Enter Level_____
ASAM Requirements
Dimension 1:
Acute
Intoxication and/
or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to
Change
Date:
Adult
ASAM Level III.1

for discharge or transfer from this level of care.
The client meets criteria in at least one of the six dimensions.

a. Biomedical conditions, if any, can be managed through outpatient care, and the client does not
meet any of the continued service criteria in this or another dimension that indicates the need
for further treatment at ASAM Level III.1; or
b. The clients biomedical condition has deteriorated sufficiently to meet the criteria for
admission to a more intensive level of care.
a. Emotional, behavioral or cognitive conditions, if any, have diminished to a degree that daily
availability of 24-hour monitoring is no longer necessary, and the client does not meet any
criteria in this or another dimension that indicates the need for continued treatment at ASAM
Level III.1; or
b. The client has experienced a worsening of Dimension 3 problems, which are interfering with
treatment at ASAM Level III.1, and meets criteria for a more intensive level of care; or
c. The client has not responded to treatment in this dimension, and has achieved maximum benefit
from attempts to evoke behavior change.
The client meets (a) and (b) or (c):
a. The client no longer requires clinically directed interventions in this dimension, as evidenced
by: 1) recognition of the severity of the substance related problem, an understanding of the
self-defeating relationship with substances and of the triggers and dysfunctional behaviors
related to continued to use; 2) application of the skills necessary to meet the objectives of
the treatment plan; and 3) acceptance of the concept of continued care and participation in the
development of an ongoing recovery plan; and
b. The client does not meet criteria for continued treatment at ASAM Level III.1; or
c. The client has consistently failed to meet treatment objectives and further progress is not
likely to occur, despite persistent therapeutic efforts and treatment plan revisions. Thus, the
client is being referred to a more appropriate level of care.
YES
NO
41
Dimension 5:
Relapse/
Continued Use
Potential

a. The risk of relapse is assessed as low as evidenced by: 1) the clients ability to
follow/complete a specific continuing care plan; 2) demonstration of sufficient recovery skills
to allow successful participation in a less intensive recovery environment; and 3) the client
does not meet the criteria in this or another dimension indicating the need for continued
service at ASAM Level III.1; or
b. The client is not committed to continuing care and has achieved maximum benefits from all
attempts to help him/her accept the need for continuing care and relapse prevention.

a. The client is functioning adequately in life task areas of work, social and primary
relationships, and does not meet criteria in this or another dimension for continued care at
ASAM Level III.1; and
b. The client is prepared to live independently in the community or in a less structured
environment, as evidenced by one of the following: 1) the clients social and interpersonal
environment is sufficiently supportive to permit adherence to a self-directed recovery plan
without substantial risk of relapse; 2) the clients usual environment is not supportive of
recovery; but the resident has acquired the necessary coping skills to maintain recovery in that
environment; or 3) the client has secured an alternative environment that is supportive of
recovery; or
c. Problems related to the clients social and interpersonal environment continue or have
intensified. The client has not learned the coping skills necessary to deal with the situation;
and the client meets the criteria for referral to a more appropriate level of care.
Dimension 6:
Recovery
Environment
Date:
42
Print Client Name:
Date:
Adult
65D-30 Residential Level III
ASAM Level III.3

care.
DIMENSIONS
[1]
ASAM Requirements
Dimension 1:
Acute Intoxication
and/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Client meets criteria in all six dimensions.

a. Client is free from intoxication or withdrawal symptoms/risks.
ADMISSION CRITERIA

a. Biomedical conditions, if any, are stable and do not require availability of medical/nursing
monitoring, and the client is capable of self-administering any prescribed medications; or

Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
The client, who has a biomedical problem that requires a degree of staff attention that is not
available in other Level III.3 programs, is in need of Biomedical Enhanced Services.
If any of the Dimension 3 conditions are present, the client must be admitted to a Dual Diagnosis
Capable or Dual Diagnosis Enhanced program (depending on his or her level of functioning,
stability and degree of impairment).

The clients status in Dimension 3 is characterized by (a) or (b) or (c) or (d):
a. The clients psychiatric condition is stabilizing, but he or she is assessed as in need of a
24 hour structured environment, as evidenced by one of the following; [1] depression or other
emotional, behavioral or cognitive conditions significantly interfere with activities of daily
living and recovery; or [2] the client exhibits violent or disruptive behavior when
intoxicated and is assessed as posing a danger to self or others; or [3] the client exhibits
stress behaviors related to recent or threatened losses in work, family or social arenas, such
that activities of daily living are significantly impaired and the resident requires a secure
environment to focus on the substance dependence or mental health problem; or [4] concomitant
personality disorders are of such severity that the accompanying dysfunctional behaviors
require continuing structured interventions; or
b. The clients symptoms and functioning deficits, when considered in the context of his or her
home environment are assessed as sufficiently severe that the client is not likely to maintain
mental stability and/or abstinence if treatment is provided in a non-residential setting.
Functional deficits may include, but are not limited to, cognitive impairment, developmental
disability, manifest chronicity and intensity of the primary addictive disease process,
residual psychiatric symptoms, cognitive deficits resulting from traumatic brain injury,
limited educational achievement, poor vocational skills, inadequate anger management skills,
YES
NO
43
and other equivalent indications that services need to be presented at a pace that is slower
and/or more repetitive and concrete than is found at other levels of care. These deficits may
be complicated by problems in Dimensions 2 through 6; or
c. The client is at mild risk of behaviors endangering self, others or property, and is in
imminent danger of relapse without the 24 hour support and structure of a Level III.3 program;
and
d. The clients mental status is assessed as sufficiently stable to permit the client to
participate in the therapeutic interventions provided at this level of care and to benefit
from treatment.
Dimension 4:
Readiness to
Change

a. The client has a diagnosed emotional, behavioral or cognitive disorder that requires active
management. Such disorders complicate treatment of the clients Substance Dependence or
Substance-Induced disorder and require a differential diagnosis. The client thus is in need of
stabilization of psychiatric symptoms concurrent with addiction treatment. Because cognitive
deficits are commonly seen in clients treated at Level III.3, such clients may require
treatment that is delivered at a slower pace or in a more concrete or repetitive fashion; or
b. The client is assessed as at mild to moderate risk of behaviors endangering self, others or
property. During the stabilization period, expectations for the clients involvement in
group, community and activities therapy are limited. A more highly individualized regimen of
individual, group and activities involvement may be required.
a. Despite experiencing serious consequences or effects of the addiction, the client has marked
difficulty in understanding the relationship between his/her substance use, addiction or life
problems, and impaired coping skills and level of functioning; or
b. The client is in danger of harm to self or others through continued substance use,
demonstrates no awareness of the need to address the severity of the addiction problem or does
not recognize the need for treatment. However, assessment indicates that treatment
interventions available at ASAM Level III.3 may increase the clients level of motivation for
change.
Dimension 5:
Relapse/Continued
Use Potential
The clients status in Dimension 4 is characterized by ambivalence in his or her commitment to

change and reluctance to engage in activities necessary to address a co-occurring mental health
problem. Similarly, the client who is not consistently able to follow through with treatment, or
who demonstrates minimal awareness of a problem, or who is unaware of the need to change, requires
active interventions with family, significant others and other external systems to create leverage
and align incentives so as to promote engagement in treatment is appropriately placed in a Level
III.3 Dual Diagnosis Enhanced program.
a. The client does not recognize relapse triggers, and has little awareness of the need for
continuing care. Because of the chronicity and intensity of the addiction or the clients
cognitive limitations, the client is at high risk of continued substance use with imminent
dangerous consequences in the absence of 24-hour monitoring and structured support; or
b. Despite previous active and recent participation in a less intensive level of care, the client
has continued to use substances, with imminent serious consequences, and is at high risk of
44
substance use without close 24-hour monitoring and structured treatment.

The client status in Dimension 5 is characterized by psychiatric symptoms that pose a moderate
risk of relapse to a substance dependence or mental disorder. Such a client demonstrates limited
ability to apply relapse prevention skills, as well as poor skills in coping with mental disorders
and/or avoiding or limiting relapse, with imminent serious consequences. The presence of these
relapse issues requires the types of services and 24 hour structure of a Level III.3 Dual
Diagnosis Enhanced program.
Dimension 6:
Recovery
Environment
Case management and collaboration across levels of care may be needed to manage anti-craving,
psychotropic or opioid maintenance medications. Preparation for transfer of the client to a less
intensive level of care, a different type of service in the community, and/or reentry into the
separately from their therapeutic work with the client.
b. The clients social network involves living with an individual who is a regular user/abuser of
alcohol/other drugs, or the clients living environment is so highly invested in drug use that
recovery goals are assessed as unachievable; or
withdrawal, such that recovery goals are assessed as unachievable in a non-residential
treatment setting.

The clients status in Dimension 6 is characterized by severe and persistent mental illness. He or
environment. This client requires planning for assertive community treatment, intensive case
management or other community outreach and support services.
The clients living, working, social and/or community environment is not supportive of good mental
health functioning. He or she has insufficient resources and skills to deal with this situation.
This client needs the support and structure of a Level III.3 Dual Diagnosis Enhanced program to
achieve stabilization and prevent further deterioration.
Date:
45
Print Client Name:
DIMENSIONS
Date:
Adult
ASAM Level III.3

that indicates validation or lack of validation for
continued stay in this level of care.
Client meets criteria in at least one of six dimensions.

ASAM Requirements
Dimension 1:
Acute Intoxication
and/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to
Change
Dimension 5:
Relapse/Continued
Use Potential

a. Biomedical conditions, if any, continue but are stable and do not require medical monitoring
and the client is capable of self-administration of prescription medications; or
b. The client is assessed as continuing to be appropriately placed at ASAM Level I or II and is
receiving ASAM Level III.3 services concurrently.
a. The client is making progress toward the resolution of emotional, behavioral or cognitive
conditions but has not made sufficient progress to allow discharge or transfer to a less
b. The clients mental status continues to be sufficiently stable to permit participation at
this level of care; or
c. The slower pace of treatment at this level of care continues to be necessary because of the
clients cognitive impairments.
a. The potential for danger to self or others continues due to the clients lack of recognition
of the severity of the substance-related problem or the need for treatment; or
b. The client recognizes the severity of the substance related problem but demonstrates minimal
understanding of his/her self-defeating pattern of use; or
c. The client recognizes the severity of the substance related problem and understands the
nature of its relationship with psychoactive substances but does not apply learned skills,
indicating that he/she has not yet been able to develop the skills necessary to cope with the
problem.
a. The client continues to exhibit intensive addiction symptoms, as evidenced by persistent
alcohol/drug cravings; or
b. The client is progressing in treatment, as evidenced by recognition of specific relapse
triggers or dysfunctional behaviors but the client demonstrates minimal understanding of his
or her role in relapse; or
c. The client is assessed as being at medium or high risk for relapse at a less intensive level
of care.
YES
NO
46
problems) which preclude this level of treatment in a non-residential setting.
Dimension 6:
Recovery
Environment
Date:
47
Print Client Name:
DIMENSIONS
[3]DISCHARGE
TRANSFER ____
Enter Level_____
ASAM Requirements
Dimension 1:
Acute
Intoxication and/
or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to
Change
Date:
Adult
ASAM Level III.3


The clients status in this dimension is characteristic of one of the following:
a. Biomedical conditions, if any, can be managed through outpatient care, and the client does not
meet any of the continued service criteria in this or another dimension that indicates the need
for further treatment at ASAM Level III.3; or
a. Emotional, behavioral or cognitive conditions, if any, have diminished to a degree that daily
availability of 24-hour monitoring is no longer necessary, and the client does not meet any
Level III.3; or
from attempts to evoke behavior change.
a. The client no longer requires clinically directed interventions in this dimension, as evidenced
by: 1) recognition of the severity of the substance related problem, an understanding of the
self-defeating relationship with substances and of the triggers and dysfunctional behaviors
related to continued to use; 2) application of the skills necessary to meet the objectives of
the treatment plan; and 3) acceptance of the concept of continued care and participation in the
development of an ongoing recovery plan; and
likely to occur, despite persistent therapeutic efforts and treatment plan revisions. Thus, the
client is being referred to a more appropriate level of care.
YES
NO
48
Dimension 5:
Relapse/
Continued Use
Potential

a. The risk of relapse is assessed as low as evidenced by: 1) the clients ability to
follow/complete a specific continuing care plan; 2) demonstration of sufficient recovery skills
to allow successful participation in a less intensive recovery environment; and 3) the client
does not meet the criteria in this or another dimension indicating the need for continued
service at ASAM Level III.3; or

recovery; but the resident has acquired the necessary coping skills to maintain recovery in that
environment; or 3) the client has secured an alternative environment that is supportive of
recovery; or
intensified. The client has not learned the coping skills necessary to deal with the situation;
and the client meets the criteria for referral to a more appropriate level of care.
Dimension 6:
Recovery
Environment
Date:
49
Print Client Name:
DIMENSIONS
ASAM Requirements
Dimension 1:
Acute Intoxication
and/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Date:
Adult
65D-30 Residential Levels I & II
ASAM Level III.5

validation for placement into this level or
care.
Client meets criteria in each of the six dimensions.

a. Biomedical conditions, if any, are stable and do not require availability of medical/nursing
monitoring, and the client is capable of self-administering any prescribed medications; or

Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
If any of the Dimension 3 conditions are present, the client must be admitted to a Dual Diagnosis
Capable or Dual Diagnosis Enhanced program (depending on his or her level of functioning,
stability and degree of impairment).

The clients status in Dimension 3 is characterized by (a) or (b) or (c) or (d) or (e) and (f):
a. The clients psychiatric condition is stabilizing. However, despite his or her best efforts,
the resident is unable to control his or her use of alcohol or other drugs and/or antisocial
behaviors, with attendant probability of harm to self or others. The resulting level of
dysfunction is so severe that it precludes the residents participation in a less structured
and intensive level of care; or
b. The client demonstrates repeated inability to control his or her impulses to use alcohol or
other drugs and/or to engage in antisocial behavior, and is in imminent danger of relapse,
with attendant likelihood of harm to self, others or property. The resulting level of
dysfunction is of such severity that it precludes participation in the absence of the 24-hour
support and structure of a Level III.5 program; or
c. The client demonstrates antisocial behavior patterns (as evidenced by criminal activity) that
have led or could lead to significant criminal justice problems, lack of concern for others
and extreme lack of regard for authority (expressed through distrust, conflict or
opposition), and which precludes participation in a less structured and intensive level of
care; or
d. The client has significant functional deficits, which are likely to respond to staff
interventions. These symptoms and deficits, when considered in the context of his or her home
environment are sufficiently severe that the resident is not likely to maintain mental
YES
NO
50
stability and/or abstinence if treatment is provided in a non-residential setting. The
functional deficits are of a pervasive nature, requiring treatment that is primarily
habilitative in focus; they do not require medical monitoring or management. The may include,
but are not limited to, residual psychiatric symptoms, chronic addictive disorder, history of
criminality, marginal intellectual ability, limited educational achievement, poor vocational
skills, inadequate anger management skills, poor impulse control, and the sequel of physical,
sexual or emotional trauma. These deficits may be complicated by problems in Dimensions 2
through 6; or
e. The clients concomitant personality disorders are of such severity that the accompanying
dysfunctional behaviors require continuous boundary setting interventions; and
f. The clients mental status is assessed as sufficiently stable to permit the client to
participate in the therapeutic interventions provided at this level of care and to benefit
from treatment.
Dimension 4:
Readiness to
Change
A range of psychiatric symptoms that require active monitoring, such as poor anger management
characterizes the clients status in Dimension 3. These are assessed as posing a risk of harm to
self or others if the resident is not contained in a 24-hour structured environment. Although
clients do not require specialized psychiatric nursing and close observation, they do need
monitoring and interventions by mental health staff to limit and de-escalate their behaviors. A
24-hour milieu is sufficient to contain such impulses in most cases, but enhanced staff and
therapeutic interventions are required to manage unpredictable losses of impulse control. The
treatment regimen should avoid highly confrontational strategies that are intended to induce
submissive behavior or strong affect.
a. Because of the intensity and chronicity of the addictive disorder or the clients mental
health problems, he or she has little awareness of the need for continuing care or the
existence of his or her substance use or mental health problem and need for treatment, and
thus has limited readiness to change; or
b. Despite experiencing serious consequences or effects of the addictive disorder or mental
health problem, the client has marked difficulty in understanding the relationship between
his or her substance use, addiction, mental health or life problems and his or her impaired
coping skills and level of functioning, often blaming others for his or her substance
dependence problems; or
c. The client demonstrates passive or active opposition to addressing the severity of his or her
mental or addiction problem, or does not recognize the need for treatment. Such continued
substance use or inability to follow through with mental health treatment poses a danger of
harm to self or others. However, assessment indicates that treatment interventions available
at Level III.5 may increase the clients degree of readiness to change; or
d. The client requires structured therapy and a 24-hour programmatic milieu to promote treatment
progress and recovery, because motivational interventions have failed at less intensive
levels of care and are assessed as not likely to succeed in the future at a less intensive
level of care; or
e. The clients perspective impairs his or her ability to make behavior changes without
repeated, structured, clinically directed motivational interventions, delivered in a 24-hour
milieu. Interventions are judged as not feasible or likely to succeed at a less intensive
level of care.
51
Dimension 5:
Relapse/Continued
Use Potential
The clients status in Dimension 4 is characterized by a lack of commitment to change and

reluctance to engage in activities necessary to address a co-occurring mental health problem.
Similarly the client who is not consistently able to follow through with treatment, or who
demonstrates minimal awareness of a problem, or who is unaware of the need to change, requires
active interventions with family, significant others and other external systems to create
leverage and align incentives so as to promote engagement in treatment is appropriately placed in
Level III.5 Dual Diagnosed Enhanced program.
a. The client does not recognize relapse triggers, is not committed to continuing care, and
continued substance use poses an imminent danger to self or others, in the absence of 24-hour
monitoring and structured support; or
b. Despite previous active and recent participation in a less intensive level of care, the
client has continued to use substances, with imminent serious consequences, and is at high
risk of substance use without close 24-hour monitoring and structured treatment; or
c. The client is experiencing addiction symptoms such as drug craving, difficulty postponing
immediate gratification and other drug-seeking behaviors, with imminent serious consequences,
in absence of close 24-hour monitoring and structured support; or
d. The client is in imminent danger of relapse, with dangerous emotional, behavioral or
cognitive consequences, because of a crisis situation; or
e. Despite recent, active participation in treatment at a less intensive level of care, the
client continues to use alcohol or other drugs or to deteriorate psychiatrically, with
imminent serious consequences, is at high risk of continued substance use or mental
deterioration in the absence of close 24-hour monitoring and structured treatment.

The client status in Dimension 5 is characterized by psychiatric symptoms that pose a moderate to
high risk of relapse to a substance dependence or mental disorder. The client demonstrates
limited ability to apply relapse prevention skills, as well as poor skills in coping with mental
disorders and/or avoiding or limiting relapse, with imminent serious consequences. The presence
of relapse issues requires the intensity and types of services and 24-hour structure of a Level
III.5 Dual Diagnosis Enhanced program.
Dimension 6:
Recovery
Environment
Case management and collaboration across levels of care may be needed to manage anti-craving,
psychotropic or opioid maintenance medications. Preparation for transfer of the client to a less
intensive level of care, a different type of service in the community, and/or reentry into the
separately from their therapeutic work with the client.
b. The clients social network involves living with an individual who is a regular user/abuser
of alcohol/other drugs, or the clients living environment is so highly invested in drug use
that recovery goals are assessed as unachievable; or
withdrawal, such that recovery goals are assessed as unachievable in a non-residential
52
treatment setting; or
d. Criminal behavior, victimization, and other antisocial norms and values characterize the
clients living environment; or
e. The client is unable to cope, for even limited periods of time, outside of 24-hour care. He
or she needs staff monitoring to learn to cope with Dimension 6 problems before being
transferred safely to a less intensive setting.

The client status in Dimension 6 is characterized by severe and persistent mental illness. He or
environment. The client requires planning for assertive community treatment, intensive case
management or other community outreach and support services. The clients living, working,
social and/or community environment is not supportive of good mental health functioning. He or
she has insufficient resources and skills to deal with this situation. This client needs the
support and structure of a Level III.5 Dual Diagnosis Enhanced program to achieve stabilization
and prevent further deterioration.
Date:
53
Print Client Name:
DIMENSIONS
Date:
Adult
ASAM Level III.5
Circle all items in each dimension that apply to the

client. Place a check in the appropriate box that
indicates validation or lack of validation for
Client meets criteria in Dimension 1 and at least one of the Dimensions 2, 3, 4, 5 or 6.
ASAM Requirements
Dimension 1:
Acute Intoxication
and/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to
Change
Dimension 5:
Relapse/Continued
Use Potential

a. Biomedical conditions, if any, continue but are stable and do not require medical monitoring
and the client is capable of self-administration of prescription medications; or
b. Biomedical conditions continue but are not so severe as to warrant inpatient treatment;
however, they are sufficient to distract from recovery efforts. Such conditions may require
medical monitoring which can be provided by the program or through a concurrent arrangement
with another treatment provider.
a. The client recognizes his/her repeated inability to control impulses to use alcohol or other
drugs and to prevent harm to self of others. However, the client is gaining skills to control
such impulses and behaviors. A 24-hour structure remains necessary to maintain and reinforce
treatment progress; or
b. The client has begun to understand his/her anti-social behavior as self-defeating but
continues to require intensive daily program interventions to recognize these behaviors when
they occur; or
c. The client has begun to understand the concept and purpose of boundaries but continues to
require boundary setting from an external source; or
d. The clients understanding of his/her self-defeating behaviors has not yet been converted to
behavior change.
The client is progressing in treatment, as evidenced by recognition of the severity of the
substance-related problem; however, he/she still requires the intensity of motivating strategies
found only at ASAM Level III.5 to sustain personal responsibility in treatment.
a. Addiction symptoms while stabilized have not been sufficiently reduced to allow functioning
outside of a structured treatment program; or
b. The client may or may not recognize relapse triggers, but he/she has not yet developed coping
skills sufficient to interrupt or postpone gratification or to control related impulsive
behavior outside of a highly structured and controlled residential setting.
YES
NO
54
problems) which preclude this level of treatment in a non-residential setting.
Dimension 6:
Recovery
Environment
Date:
55
Print Client Name:
DIMENSIONS
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to
Change
Adult
ASAM Level III.5

Enter Level______ for
care.
The clients status in this dimension is characterized by one or the following:
a. Biomedical conditions, if any, can be managed through outpatient care, and the client does
not meet any of the continued service criteria in this or another dimension that indicates
the need for continued treatment at ASAM Level III.5; or
a. Emotional, behavioral or cognitive problems, if any, have diminished to a degree that daily
availability of 24-hour monitoring is no longer necessary, and the client does not meet
Level III.5; or
from attempts for positive behavior change.
a. The client no longer requires clinically directed interventions in this dimension, as
evidenced by: 1) recognition of the severity of the substance related problem, an
understanding of the self-defeating relationship with substances and of the triggers and
dysfunctional behaviors related to continued to use; 2) application of the skills necessary
to meet the treatment objectives of the treatment plan; and 3) acceptance of the concept of
continued care and participation in the development of an ongoing recovery plan; and
likely to occur, despite persistent therapeutic efforts and treatment plan revisions. Thus,
the client is being referred to a more appropriate level of care.
[3] DISCHARGE TRANSFER ____
ASAM Requirements
Dimension 1:
Acute Intoxication
and/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Date:
YES
NO
56
Dimension 5:
Relapse/Continued
Use Potential

a. The risk of relapse is assessed as low as evidenced by 1) the clients ability to
follow/complete a specific continuing care plan; 2) demonstration of sufficient recovery
skills to allow successful participation in a less intensive recovery environment; and 3) the
client does not meet the criteria in this or another dimension indicating the need for
continued service at ASAM Level III.5; or
The clients status meets (a) and (b) or (c):

recovery, but the client has acquired the necessary coping skills to maintain recovery in
that environment; or 3) the client has secured an alternative environment that is supportive
of recovery; or
intensified; the client has not learned the coping skills necessary to deal with the
situation and the client meets the criteria for referral to a more appropriate level of care.
Dimension 6:
Recovery
Environment
Date:
57
Print Client Name:
DIMENSIONS
Date:
Adult
65D-30 Intensive Inpatient Treatment
ASAM Level III.7

indicates validation or lack of validation for placement
into this level of care.
Client meets criteria of at least two of the six dimensions, at least one of which is in dimension
1, 2 or 3.
The clients status in this dimension is characterized by (a) or (b):
a. The client is experiencing signs and symptoms of severe withdrawal, or there is evidence that a
severe withdrawal syndrome is imminent and is assessed as manageable at this level of service;
or
b. There is a strong likelihood that the client will not complete detoxification at another level
of care and enter into continuing treatment or self-help recovery.
Client requires medical monitoring but not intensive care - The clients status in this dimension
a. Without placement in this level of care, continued substance use places the client in imminent
danger of serious damage to physical health or concomitant biomedical conditions; or
b. A concurrent biomedical illness requires monitoring available in this level of care.
[1]ADMISSION CRITERIA
ASAM Requirements
Dimension 1:
Acute
Intoxication and
/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications

Dimension 3:
Emotional,
Behavioral and
Cognitive
Conditions and
Complications
Problems in Dimension 3 are not necessary for admission. However, if any of the Dimension 3
conditions are present the resident must be admitted to a Dual Diagnosis Capable or Dual Diagnosis
Enhanced program.

The clients status in Dimension 3 is characterized by one of the following:
a. The clients psychiatric condition is unstable. Depression and/or other emotional, behavioral
or cognitive symptoms are interfering with abstinence, recovery and stability to such a degree
that the client needs a structured 24 hour medically monitored environment to address recovery
efforts; or
b. The client exhibits stress dependence behaviors associated with recent or threatened losses in
work, family or social domains, to a degree that his or her ability to manage the activities of
daily living are significantly impaired. The client thus requires a secure, medically monitored
environment in which to address self-care problems and to focus on his or her substance abuse
or mental health problems; or
c. The client has significant functional deficits that require active psychiatric monitoring. They
may include, but are not limited to, problems with activities of daily living, problems with
self-care, lethality or dangerousness, and problems with social functioning. These deficits may
be complicated by problems in Dimensions 2 through 6; or
d. The client is at moderate risk of behaviors endangering self, others or property, and is in
YES
NO
58
imminent danger of relapse without the 24 hour support and structure of a Level III.7 program;
or
e. The client is actively intoxicated, with resulting violent or disruptive behavior that poses
imminent danger to self or others; or
f. The client has a thought disorder or cognitive limitations that require stabilization but not
medical management.
Dimension 4:
Treatment
Acceptance/Resist
ance

a. The client has a moderate psychiatric de-compensation on discontinuation of drugs of abuse, and
is currently present; or
b. The client is assessed as at moderate to high risk of behaviors endangering self, others or
property, and is in imminent danger of relapse without 24 hour structure and support and
medically monitored treatment; or
c. The client is severely depressed, with suicidal impulses and a plan. However, he or she is able
to contract to reach out for help as needed and does not require a one-on-one suicide watch; or
d. The client has a co-occurring psychiatric disorder that is interfering with his or her
addictions treatment and thus requires stabilization with psychotropic medications; or
e. The client has a co-occurring psychiatric disorder of moderate to high severity that is
marginally and tenuously stable and which requires care to prevent exacerbation. The client
thus requires the type of close management available only in an addiction treatment program
with integrated mental health services, or in a mental health program with integrated addiction
treatment services.
Resistance is high and impulse control is poor despite negative consequences; client needs
motivating strategies found in 24-hour structured setting - The clients status in this dimension
a. Despite serious consequences of the effects of the addiction the client does not relate the
addiction to the severity of the problems; or
b. The client is in need of intensive motivating strategies, activities, and processes available
found in a 24-hour structured setting; or
c. The client needs psychiatric monitoring to assure follow-through with the treatment regimen and
psychiatric medications; or
d. The client requires structured therapy and a 24 hour programmatic milieu because motivational
interventions have failed at less intensive levels of care and are assessed as not likely to
succeed in the future at a less intensive level of care; or
e. The clients perspective impairs his or her ability to make behavior changes without repeated,
structured, clinically directed motivational interventions delivered in a 24 hour milieu.

The clients status in Dimension 4 is characterized by a lack of commitment to change and refusal
to engage in activities necessary to address a co-occurring mental health problem. Similarly, the
client who cannot consistently follow through with treatment, or demonstrates minimal awareness of
a problem, or is unaware of the need to change, requires active interventions with family,
significant others and other external systems to create leverage and align incentives so as to
promote engagement in treatment, is appropriately placed in a Level III.7 Dual Diagnosed Enhanced
program.
59
Dimension 5:
Relapse/
Continued Use
Potential
Unable to control use with dangerous consequences despite active participation in less intensive
care. The clients status in this dimension is characterized by one of the following:
a. Despite active participation in less intensive care, the client is experiencing an acute crisis
with intensification of addiction symptoms and is in imminent danger of substance use with
attendant severe consequences and is in need of 24-hour short term professionally directed
clinical interventions; or
b. The client recognizes that the substance use is excessive and has attempted to reduce or
control it but has been unable to do so as long as alcohol/other drugs are present in the
environment; or
c. The client requires this level of care.
Dimension 6:
Recovery
Environment
The clients status in Dimension 5 is characterized by psychiatric symptoms that pose a moderate
to high risk of relapse to a substance dependence or mental disorder. This client may demonstrate
limited ability to apply relapse prevention skills, as well as poor skills in coping with mental
disorders and/or avoiding or limiting relapse, with imminent serious consequences. The clients
follow through in treatment is poor or inconsistent, and his or her relapse problems are
escalating to such a degree that treatment at a lower level of care is not succeeding or not
feasible.
Environment dangerous for recovery; client lacks skills to cope outside of a highly structured 24hour setting - The clients status in this dimension is characterized by one of the following:
a. The client lives in an environment in which treatment is unlikely to succeed such as family
conflict, substance abusing family members; or
b. Distance from treatment facility would impede clients access to treatment, or treatment at a
lesser level of care is not possible because of a lack of transportation or loss of drivers
license; or
c. There is a danger of physical, sexual and/or severe emotional abuse or victimization in the
clients current living environment which makes recovery unlikely; or
d. The client is engaged in an occupation in which continued drug/alcohol use poses an imminent
risk to public or personal safety.

The client status in Dimension 6 is characterized by severe and persistent mental illness. He or
environment. This client may require planning for assertive community treatment, intensive case
management or other community outreach and support services. This clients living, working; social
and/or community environment is not supportive of good mental health functioning. He or she has
insufficient resources and skills to deal with this situation. Such a resident needs the support
and structure of this program to achieve stabilization and prevent further deterioration.
Date:
60
Print Client Name:
DIMENSIONS
ASAM Requirements
Dimension 1:
Acute Intoxication
and/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Date:
Adult
ASAM Level III.7

care.
Meets criteria in at least one of the six dimensions.
YES

a. Biomedical conditions require medical monitoring, or a concurrent biomedical illness needs
medical monitoring but not intensive care; or
b. Without placement in this level of care, continued alcohol/other drug use places the client
in imminent danger of serious damage to physical health or concomitant biomedical conditions.
Dimension 3:
a. The client is making progress toward resolution of concomitant emotional, behavioral or
Emotional,
cognitive problems but has not sufficiently resolved the problem to allow transfer to a less
Behavioral or
Cognitive
b. The client is being monitored pending transfer (within 72 hours) to a more intensive level of
Conditions and
care.
Complications
Dimension 4:
a. The client recognizes the severity of the substance related problem but demonstrates minimal
Readiness to
understanding or his/her self-defeating use of alcohol/drugs, yet the client is progressing
Change
in treatment; or
b. The client recognizes the severity of his/her substance-related problems and manifests
understanding of his/her personal relationship with substances, yet does not demonstrate
behaviors indicating that he or she has developed the skills needed to cope with the problem.
Dimension 5:
a. The client continues to exhibit intensive addiction symptomatology (persistent drug or
Relapse/Continued
alcohol craving); or
Use Potential
b. The client recognizes specific relapse triggers or dysfunctional behaviors that previously
undermined sobriety. While the client demonstrates minimal understanding of their role in
relapse, he/she is progressing in treatment; or
c. The client recognizes the severity of his/her relapse triggers and dysfunctional behaviors
that undermine sobriety, and manifests an understanding of these dysfunctional behaviors, yet
does not demonstrate skills necessary to interrupt these behaviors and to apply alternative
coping skills necessary to maintain ongoing abstinence.
Dimension 6:
a. Problem aspects of the clients social and interpersonal life are responding to treatment but
Recovery
are not sufficiently supportive of recovery to allow discharge or transfer to a less
Environment
b. The social and interpersonal life of the client has not changed or has deteriorated, and the
client needs additional treatment to learn to cope with the current situation or take steps
to secure alternative placement.
Date:
NO
61
Print Client Name:
Date:
DIMENSIONS
[3]DISCHARGE
TRANSFER ____
Enter Level_____
ASAM Requirements
Dimension 1:
Acute
Intoxication and/
or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to
Change
Dimension 5:
Relapse/
Continued Use
Potential
Adult
ASAM Level III.7
indicates validation or lack of validation for the
discharge or transfer from this level of care.

a. Biomedical conditions, if any, have diminished or stabilized to a degree that daily availability of
24-hour medical and/or nursing care is no longer necessary, and the client does not meet criteria in
this or another dimension that indicates the need for continued treatment at ASAM Level III.7; or
b. A biomedical condition is interfering with addiction treatment and requires treatment at another
level of care.
a. Emotional, behavioral or cognitive conditions, if any, have diminished or stabilized to a degree
that daily availability of 24-hour medical, psychosocial and/or nursing care is no longer
necessary, and the client does not meet criteria in this or another dimension that indicates the
need for continued treatment at ASAM Level III.7; or
b. A psychiatric, emotional, behavioral or cognitive condition is interfering with treatment
sufficiently that the client requires treatment at another level of care.
a. The clients awareness and acceptance of his/her addiction problem and commitment to definitive
treatment is sufficient to expect treatment compliance in a less intensive level of care, as
evidenced by: 1) ability to recognize the severity of the substance abuse problem; 2)
understanding of the self-defeating relationship with substances and of the triggers and
dysfunctional behaviors that lead to use; and 3) acceptance of the concept of continuing care and
participation in the development of a post-treatment recovery plan; or
c. The client has consistently failed to meet treatment objectives and further progress is not likely
to occur, despite persistent therapeutic efforts and treatment plan revisions. Thus, the client is
being referred to a more appropriate level of care.
a. The client is capable of following and completing a specific continuing care recovery plan. The
clients integration of therapeutic gains is sufficient that the client does not appear to be at
risk of imminent relapse, and the client does not meet criteria in this or another dimension
indicating the need for continued treatment at ASAM Level III.7; or
b. The client is not committed to continuing care and has achieved maximum benefit from all attempts to
help him/her accept the need for continuing care and relapse prevention.
YES
NO
62
a. Problem aspects of the clients social and interpersonal life are responding to treatment and the
environment is now sufficiently supportive of recovery to allow discharge or transfer to a less
intensive level of care and the client does not meet criteria in this or another dimension for
continued care at ASAM Level III.7; or
b. The social and interpersonal life of the client has not changed or has deteriorated, but the client
has acquired skills to cope with the current situation or has secured an alternative environment,
and the client does not meet criteria in this or another dimension for continued care ASAM Level
III.7; or
c. The social and interpersonal life of the client has deteriorated and the client has not learned the
skills necessary to cope with the current situation. An extended care alternative environment has
been found, but the client is unwilling to be transferred, and the client does not meet the criteria
in this or another dimension for continued treatment in ASAM Level III.7.
Dimension 6:
Recovery
Environment
Date:
63
Print Client Name:
DIMENSIONS
ASAM
Requirements
Dimension 1:
Acute
Intoxication
and/or
Withdrawal
Potential
Date:
Adult
65D-30 Detoxification
ASAM Level I-D Outpatient
Circle all items in Dimension 1 that apply to the client.

Place a check in the appropriate box that indicates
validation or lack of validation for placement into this
level of care.
Admission to this level of care requires that the client meet the criteria in Dimension 1.
YES

a. The client is experiencing at least mild signs and symptoms of withdrawal, or there is evidence
that withdrawal is imminent. The client is assessed as being at minimal risk for severe
withdrawal syndrome and can be safely managed at this level; or
b. The client has withdrawal symptoms but is at minimal risk of severe withdrawal syndrome and is
assessed as likely to complete needed detoxification and enter into continued treatment or
self-help recovery, as evidenced by meeting [1] or [2], or [3]:
[1] The client has an adequate understanding of and expressed commitment to enter
ambulatory detoxification services; or
[2] The client has adequate support services to ensure commitment to completion of
detoxification and entry into ongoing treatment or recovery; or
[3] The client is willing to accept recommendations for treatment (e.g., to begin
disulfiram, naltrexone or other medication once withdrawal has been managed, and attends
outpatient sessions or self-help groups).
c. For clients whose withdrawal symptoms are no more severe than those in section (a), the client
has, and responds to, emotional support and comfort.
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to
Change
Dimension 5:
Relapse/
Continued Use
Potential
Dimension 6:
Recovery
Environment
Date:
NO
64
Print Client Name:
DIMENSIONS
Date:
Adult
Circle the item in Dimension 1 that applies to

YES
Meets criteria in Dimension 1.

ASAM
Requirements
Dimension 1:
a. Continues in ASAM Level I-D until withdrawal signs and symptoms are sufficiently resolved that
Acute
the client can participate in self-directed recovery or ongoing treatment without the need for
Intoxication
further medication or nursing detoxification monitoring; or
and/ or
b. Signs and symptoms of withdrawal have failed to respond to treatment and have intensified,
Withdrawal
such that transfer to a more intensive level of detoxification service is indicated.
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to
Change
Dimension 5:
Relapse/
Continued Use
Potential
Dimension 6:
Recovery
Environment
Date:
NO
65
Print Client Name:
DIMENSIONS
ASAM
Requirements
Dimension 1:
Acute
Intoxication
and/or
Withdrawal
Potential
Date:
Adult
Circle the items in Dimension 1 that apply to

client. Place a check in the appropriate
[3]DISCHARGE
TRANSFER ____ the
for discharge or transfer from
Enter Level ____ validation
this level of care.
The client meets criteria in Dimension 1 for discharge or transfer.
YES

a. Clients withdrawal signs and symptoms are sufficiently resolved that the client can
participate in self-directed recovery or ongoing treatment without the need for further
medical or nursing detoxification monitoring; or
such that transfer to a more intensive level of detoxification service is indicated; or
c. The client has been unable to complete ASAM Level I-D, despite an adequate trial. The
client is experiencing intense craving and demonstrates insufficient coping skills to
prevent continued alcohol/other drug use concurrent with the detoxification medication,
such that more intensive service is indicated.
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional/
Behavioral
Conditions and
Complications
Dimension 4:
Readiness to
Change
Dimension 5:
Relapse/
Continued Use
Potential
Dimension 6:
Recovery
Environment
Date:
NO
66
Print Client Name:
DIMENSIONS
Date:
Adult
65D-30 Addictions Receiving Facility
ASAM Level III.2-D
Circle all items in Dimension 1 that apply to

care.
YES

ASAM
Requirements
Dimension 1:
Acute
Intoxication
and/or
Withdrawal
Potential

a. The client is experiencing signs and symptoms of withdrawal, or there is evidence that
withdrawal is evident. The patient is assessed as not being at risk for severe withdrawal,
and moderate withdrawal syndrome is safely manageable at this level of care; or
b. The client is assessed as not requiring medication, but requires this level of service to
complete detoxification and enter into continued treatment or self-help recovery because of
inadequate home supervision or support structure.
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to
Change
Dimension 5:
Relapse/
Continued Use
Potential
Dimension 6:
Recovery
Environment
Date:
NO
67
Print Client Name:
DIMENSIONS
Date:
Adult
ASAM Level III.2-D

validation for continued stay at this level of
care.
YES
Client meets criteria in Dimension 1.

ASAM
Requirements
Dimension 1:
a. The client continues in ASAM Level III.2-D until withdrawal signs and symptoms are
Acute
sufficiently resolved that the client can safely be managed at a less intensive level of
Intoxication
care; or
and/or
Withdrawal
such that transfer to a more intensive level of detoxification service is indicated.
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to
Change
Dimension 5:
Relapse/
Continued Use
Potential
Dimension 6:
Recovery
Environment
Date:
NO
68
Print Client Name:
DIMENSIONS
ASAM Requirements
Dimension 1:
Acute
Intoxication and/
or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Date:
Adult
ASAM Level III.2-D

the clients situation. Place a check in the
[3]DISCHARGE
TRANSFER ____
appropriate box that indicates validation or lack
validation for discharge or transfer from this
Enter Level_____ of
level of care.
The client meets criteria in Dimensions 1, 2, and 3 for discharge or transfer.
a. Clients withdrawal signs and symptoms are sufficiently resolved that the client can be safely
managed at a less intensive level of care; or
b. Signs or symptoms of withdrawal have failed to respond to treatment and have intensified, such
that a transfer to a more intensive level is indicated.
a. Biomedical conditions, if any, have diminished or stabilized, and the client does not meet
criteria that indicates the need for continued service at Level III.7-D level of care; or
b. A biomedical condition is complicating the detoxification process, such that a transfer to a
more intensive level of detoxification is indicated.
a. Emotional, behavioral or cognitive conditions, if any, have diminished or stabilized, and the
client does not meet criteria in this dimension that indicates the need for continued service
at Level III.7-D; or
b. A psychiatric, emotional, behavioral or cognitive condition is complicating the detoxification
process, such that a transfer to a more intensive level is indicated.
YES
NO
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to
Change
Dimension 5:
Relapse/
Continued Use
Potential
Dimension 6:
Recovery
Environment

Print Client Name:
Date:
Date:
Adult
69
ASAM Level III.7-D
DIMENSIONS
ASAM Requirements
Dimension 1:
Acute Intoxication
and/or Withdrawal
Potential

a check in the appropriate box that indicates
validation or lack of validation for placement into this
level of care.
Client meets criteria of at least one of the three dimensions.
Severe withdrawal but manageable in this level of care requires the client meet a or b:
a. The client is experiencing signs and symptoms of severe withdrawal, or there is evidence that
severe withdrawal symptoms are imminent. The severe withdrawal syndrome is assessed as
manageable at this level of care; or
b. There is a strong likelihood that the client, who requires medication, will not complete
detoxification at another level of service and enter into continued treatment or self-help
recovery.
[1] The client requires medication and has a recent history of detoxification at a
less intensive level of care, marked by past and current inability to complete
detoxification and enter into continuing addiction treatment. The client continues to
have insufficient skills or supports to complete detoxification; or
[2] The client has a recent history of detoxification at less intensive levels of
service that is marked by the inability to complete detoxification or to enter into
continuing addiction treatment, and the client continues to have insufficient skills to
complete detoxification; or
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to Change
[3] The client has a co-morbid physical, emotional, behavioral or cognitive condition
that is manageable in a level III.7-D setting but which increases the clinical severity
of the withdrawal and complicates detoxification.
The clients co-morbid physical condition, if any, is manageable in an ASAM Level III.7-D setting
but increases the clinical severity of the withdrawal and complicates detoxification.
The clients co-morbid emotional, behavioral or cognitive condition, if any, is manageable in an

ASAM Level III.7-D setting but increases the clinical severity of the withdrawal and complicates
detoxification.
Dimension 5:
Relapse/Continued
Use Potential
Dimension 6:
Recovery
Environment
Date:
YES
NO
70
Print Client Name:
DIMENSIONS
Date:
Adult
ASAM Level III.7-D

YES

ASAM
Requirements
The clients status in this dimension is characterized by one of the following::
Dimension 1:
a. Continues in this level of care until withdrawal signs and symptoms are sufficiently resolved
Acute
that the client can be safely managed at a less intensive level of care; or
Intoxication
and/or
such that transfer to a more intensive level of service is indicated.
Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to
Change
Dimension 5:
Relapse/
Continued Use
Potential
Dimension 6:
Recovery
Environment
Date:
NO
71
Print Client Name:
DIMENSIONS
Adult
ASAM Level III.7-D

Enter Level_____ for
care.
a. Clients withdrawal signs and symptoms are sufficiently resolved that the client can be safely
managed at a less intensive level of care; or
b. Signs or symptoms of withdrawal have failed to respond to treatment and have intensified, such
that a transfer to a more intensive level of care is indicated.
a. Biomedical conditions, if any, have diminished or stabilized, and the client does not meet
criteria that indicates the need for continued service at ASAM Level III.7-D level of care; or
b. A biomedical condition is complicating the detoxification process, such that a transfer to a
more intensive level of care is indicated.
a. Emotional, behavioral or cognitive conditions, if any, have diminished or stabilized, and the
client does not meet criteria in this dimension that indicates the need for continued service
at ASAM Level III.7-D; or
b. A psychiatric, emotional, behavioral or cognitive condition is complicating the detoxification
process, such that a transfer to a more intensive level of care is indicated.
[3] DISCHARGE
ASAM Requirements
Dimension 1:
Acute
Intoxication and/
or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Date:
YES
TRANSFER ____
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to
Change
Dimension 5:
Relapse/
Continued Use
Potential
Dimension 6:
Recovery
Environment
Date:
NO
72
ADOLESCENT PATIENT PLACEMENT CRITERIA

Levels of Care
Each of the following represents the licensable components as provided for in
Chapter 65D-30, Florida Administrative Code, and corresponds to a specific
level of care in the ASAM PPC-2R.
Intervention
Residential II Treatment
Residential I Treatment
Addictions Receiving Facility
Detoxification
The next page contains a comparison of these licensable components and the
corresponding adolescent ASAM PPC-2R levels of care.
73
ASAM PPC-2R Levels of Care and 65D-30, FAC Levels of Care (Adolescent)
Crosswalk
ASAM PPC-2R
Levels of Care
65D-30, FAC
Levels of Care
Level 0.5
Early Intervention
Intervention
Level I
Level II.1
Level II.5
Partial Hospitalization
Level III.5
Clinically Managed High-Intensity
Levels I and II Residential Treatment
Level III.2-D
Clinically-Managed Residential
Detoxification
Addictions Receiving Facilities
Level III.7-D
Medically-Monitored Inpatient
Detoxification
Detoxification
74
Print Client Name:
DIMENSIONS
Date:
Adolescent
65D-30 Intervention
ASAM Level .05

for placement into this level of care.
Must meet one of Dimensions of 4, 5, or 6 and Dimensions 1, 2, and 3 are stable or being
addressed through appropriate outpatient medical or mental health services.
YES

ASAM Requirements
Dimension 1:
Acute Intoxication
and/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to
Change
Dimension 5:
Relapse/Continued
Use Potential
being addressed through appropriate mental health services and will not interfere with
interventions at this level of service.
Willing to understand how current use may affect personal goals The client expresses
willingness to gain an understanding of how his/her current use of alcohol and/or other drugs
Needs understanding of, or skills to change current use patterns. The situation is characterized
by one of the following:
a. The client does not understand the need to alter the current pattern of use of substances to
prevent further harm related to such use; or
b. The client needs to acquire the specific skills needed to change his/her current pattern of
use.
Social support system or significant others increase risk for personal conflict about
Dimension 6:
alcohol/drug use. The clients living environment is characterized by one of the following:
Recovery
Environment
a. The social support system is composed primarily of individuals whose substance use patterns
prevent them from meeting social, work, school or family obligations ; or
b. Family members currently are abusing substances, increasing the clients risk for substance
related disorder; or
c. Significant others express values concerning alcohol or other drug use that create
significant conflict for the client; or
d. Significant others condone or encourage inappropriate use of alcohol or other drugs.
Date:
NO
75
Print Client Name:
DIMENSIONS
Date:
Adolescent
65D-30 Intervention
ASAM Level .05

level of care.
The client remains stable in Dimensions 1, 2, and 3, and meets the criteria in at least one of
Dimensions 4, 5, or 6.
YES

ASAM Requirements
Dimension 1:
Acute Intoxication
and/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to Change
Dimension 5:
Relapse/Continued
Use Potential
Dimension 6:
Recovery
Environment
None or very stable - Any emotional, behavioral or emotional conditions or complications are
stable or are being actively addressed and will not interfere with interventions at this level
of care.
Willing to understand how current use may affect personal goals The client continues to
express a willingness to gain an understanding of how his/her current use of alcohol and/or
other drugs may interfere with meeting responsibilities and achieving personal goals.
The client demonstrates an understanding of the detrimental aspects of his/her alcohol and/or
drug use pattern but does not yet demonstrate the skills necessary to change those patterns.
The clients living environment is characterized by one of the following:

a. Problem aspects of the environment remain, but the client is acquiring the skills needed to
cope with them; or
b. Significant others who have documented problems with alcohol or other drug use are receiving
help for their problems, which have not yet stabilized.
Date:
NO
76
Print Client Name:
DIMENSIONS
[3] DISCHARGE
TRANSFER ____
Enter Level_____
ASAM Requirements
Dimension 1:
Acute
Intoxication and/
or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to
Change
Date:
Adolescent
65D-30 Intervention
ASAM Level .05

Discharge from this level of care requires that the client meet the criteria in one of the six
dimensions.
a. The client has a condition in Dimension 2 that precludes continued participation in this level
of care and requires transfer to another level; or
b. The client has no biomedical conditions or they are stable.
a. The client has a condition in Dimension 3 that precludes continued participation in this level
of care and requires transfer to another level; or
b. The client has no emotional, behavioral or cognitive conditions or they are stable and are being
actively addressed.

a. The client has remained stable in Dimension 4 and does not meet any other criteria that
indicates the need for continued service at this level of care; or
b. The client is no longer willing to examine personal substance use patterns, despite program
efforts, and a recommendation is being made for further assessment and follow-up.
Dimension 5:
a. The client has demonstrated the personal skills necessary to make responsible choices about
Relapse/
alcohol/other drug use, and does not meet criteria indicating the need for continued service at
Continued Use
Potential
this level of care; or
b. The client has not integrated the skills necessary to avoid harmful or inappropriate substance
use, despite professional interventions, and a recommendation is being made for further
assessment and follow-up.
Dimension 6:
a. The client has resolved problems in his/her living environment or demonstrates the needed coping
Recovery
skills necessary to achieve personal goals and does not meet criteria indicating a need for
Environment
continued service at this level of care; or
b. The client no longer is willing to examine problems in his/her living environment, despite
program efforts.
Since these problems persist, a recommendation is being made for appropriate
living and support services.
Date:
YES
NO
77
Print Client Name:
DIMENSIONS

ASAM Requirements
Dimension 1:
Acute Intoxication
and/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to
Change
Date:

level of care.
Meets criteria in all six dimensions.

b. The clients intoxication or withdrawal risks symptoms/risks can be managed at this level of
care.
None or very stable - The clients biomedical conditions, if any, are stable enough to
participate in outpatient treatment.
The clients status in Dimension 3 is characterized by all of the following:

a. Dangerousness/Lethality: The client is assessed as not posing a risk of harm to self or
others. He or she has adequate impulse control to deal with any thoughts of harm or self or
others;
b. Interference with Addiction Recovery Efforts: The clients emotional concerns relate to
negative consequences and effects of addiction, and he or she is able to view them as part of
addiction and recovery. Emotional, behavioral or cognitive symptoms, if present, appear to be
related to substance-related problems rather than to a co-occurring psychiatric, emotional or
behavioral condition. If they are related to such a condition, appropriate additional
psychiatric services are provided concurrent with the Level I treatment. The clients mental
status does not preclude his or her ability to: [1] understand the materials presented; [2]
participate in the treatment process;
c. Social Functioning: The clients relationships or spheres of social functioning are impaired
but not endangered by substance use. The client is able to meet personal responsibilities and
to maintain stable, meaningful relationships despite the mild symptoms experienced;
d. Ability for Self-Care: The client has adequate resources and skills to cope with emotional,
behavioral or cognitive problems, with some assistance. He or she has the support of a stable
environment and is able to manage the activities of daily living;
e. Course of Illness: The client has only mild signs and symptoms. Any acute problems have been
well stabilized, and chronic problems are not serious enough to pose a high risk of
vulnerability.
Willing to cooperate but needs motivating and monitoring The situation is characterized by one
of the following:
a. The client expresses willingness to cooperate with the treatment plan and attend all
scheduled activities; or
b. The client admits to having a substance abuse problem but requires monitoring and motivating
strategies. However, a structured residential program is not required; or
c. The client who has a co-occurring mental and substance-related disorder is able to
acknowledge one of the diagnoses but is resistant to the other; or
d. The client is responsive to minimal external motivation (e.g., requests by parents and/or
requirements of the school system).
Adolescent
65D-30 Outpatient
ASAM Level I
YES
NO
78
Able to maintain abstinence and pursue treatment goals with minimal support The client is
willing to consider maintaining abstinence and recovery goals with support and scheduled
therapeutic contact.
The situation is characterized by one of the following:
a. A sufficiently supportive psychosocial environment makes outpatient treatment feasible; or
b. Although the client does not have an ideal primary or social support system to assist with
immediate sobriety, he/she has demonstrated motivation and willingness to obtain such a
support system; or
c. Family and significant others are supportive but require professional interventions to
improve the clients chance of treatment success and recovery. This may involve assistance
in limit setting, communication skills, a reduction in rescuing behaviors, etc.
Dimension 5:
Relapse/Continued
Use Potential
Dimension 6:
Recovery
Environment
Date:
79
Print Client Name:
DIMENSIONS
Date:
Adolescent
65D-30 Outpatient
ASAM Level I

care.
Continued service at this level of care requires meeting criteria in Dimensions 1 and 2, and one
of Dimensions 3, 4, 5 or 6

ASAM Requirements
Dimension 1:
Acute Intoxication
and/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
following:
a. The clients biomedical conditions are stable enough to continue to participate in
outpatient treatment; or
b. An intervening problem interrupted treatment but has been resolved enough for the client to
progress in treatment.
Dimension 3:
following:
Emotional,
a. The client is making progress to reduce anxiety, guilt, and/or depression, if present, but
Behavioral or
these symptoms have not been sufficiently resolved to permit discharge from treatment; or
Cognitive
b. An intervening emotional, behavioral or cognitive condition interrupted treatment but, with
Conditions and
stabilization, the client again is progressing in treatment.
Complications
Willing to cooperate but needs motivating and monitoring - The client continues to work on
Dimension 4:
treatment goals and objectives, but does not understand or accept his/her addiction sufficiently
Readiness to
to maintain a self-directed treatment plan.
Change
Able to maintain abstinence and pursue treatment goals with minimal support. The client, while
Dimension 5:
not using alcohol and/or drugs remains mentally preoccupied with such use to the extent he/she
Relapse/ Continued
is unable to address primary relationships, social matters or school tasks; however, there are
Use Potential
indications with continued treatment, and the client will effectively address these issues.
Supportive recovery environment and/or client has skills to cope The social environment
Dimension 6:
remains non-supportive or has deteriorated, but the client is making sufficient progress in
Recovery
learning social and related coping skills to function in the environment without using
Environment
substances.
Date:
YES
NO
80
Print Client Name:
DIMENSIONS
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to
Change
Dimension 5:
Relapse/Continued
Use Potential
Adolescent
65D-30 Outpatient
ASAM Level I

Enter Level_____ for
care.
Meets criteria in one of the six dimensions unless discharged for lack of diagnostic criteria.
can be managed through outpatient appointments at the clients discretion, and the client does
not meet any of the continued stay criteria in this or another dimension that indicates the
need for further treatment in ASAM Level I; or
b. The client has a biomedical condition that is interfering with treatment and that requires
treatment in another setting.
stabilized to the extent they can be managed through outpatient appointments at the clients
discretion, and the client does not meet any of the continued stay criteria in this or another
dimension that indicates the need for further treatment in ASAM Level I; or
b. The client has a psychiatric or emotional, behavioral or cognitive condition that is
interfering with addiction treatment and that requires treatment in another setting.
a. The clients awareness and acceptance of his/her addiction problem and commitment to recovery
is sufficient to expect maintenance of a self-directed aftercare plan, based on the following
evidence: 1) the client recognizes the severity of the substance abuse problem; 2) the
client has an understanding of the self-defeating relationship with substances; 3) the client
is applying the skills necessary to maintain sobriety in a mutual self-help group and/or with
post-treatment support care; and 4) the client does not meet any of the continued stay
criteria in this or another dimension that indicates the need for further treatment in ASAM
Level I; or
b. The client is experiencing escalation in drug seeking behaviors or craving that necessitates
a. The clients therapeutic gains in addressing craving and relapse issues have been internalized
and integrated so the client does not meet any of the ASAM Level I continued stay criteria in
this or another dimension that indicates the need for further treatment in ASAM Level I; or
b. The client is experiencing a worsening of drug-seeking behaviors or craving, requiring
[3]DISCHARGE
ASAM Requirements
Dimension 1:
Acute Intoxication
and/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Date:
TRANSFER ____
YES
NO
81
a. The clients social system and significant others are supportive of recovery to an extent that
the client can adhere to a self-directed treatment plan without substantial risk of
relapse/continued use and the client does not meet any of the continued stay criteria in this
or another dimension that indicates the need for further treatment at ASAM Level I; or
b. The client is functioning adequately in assessed areas of deficiency in life tasks including
school, work, social functioning or primary relationships and the client does not meet any of
the continued stay criteria in this or another dimension that indicates the need for further
treatment at ASAM Level I; or
c. The clients social system remains non-supportive or has deteriorated. The client is having
difficulty in coping with this environment and is at substantial risk of relapse and requires
Dimension 6:
Recovery
Environment
Date:
82
Print Client Name:
DIMENSIONS
Date:
Adolescent
ASAM Level II.1

placement into this level of care.
Must meet Dimension 1 and 2, and at least one of Dimensions 3, 4, 5, or 6.
Transfer criteria: Clients may be transferred to this level of care when they have met essential
treatment objectives in a more intensive level and require this intensity of service provided at
this level of care in at least one dimension. A client may transfer from ASAM Level I when services
at that level have been insufficient to address the clients needs or when ASAM Level I has
consisted of motivational interventions to prepare the client for participation in a more intensive
level of care for which admission criteria are met.

ASAM Requirements
Dimension 1:
Acute Intoxication
and/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
The clients status in this dimension is characterized in one of the following:

c. The client has made a commitment to sustain treatment and to follow treatment recommendations or
has external supports that promote engagement in treatment.
None or not a distraction from treatment and manageable in ASAM Level II. The clients status in
this dimension is characterized by one of the following:
a. The clients biomedical conditions, if any, are stable or are being concurrently addressed and
will not interfere with treatment at this level of care; or
b. The clients biomedical conditions are not severe enough to warrant inpatient treatment but are
sufficient to distract from recovery efforts. Such conditions require medical monitoring and/or
medical management, which can be provided by the intensive outpatient program or through a
concurrent arrangement with another treatment provider.
The clients status in Dimension 3 is characterize by at least one of the following:
a. Dangerous Lethality: The client is at mild risk of behaviors endangering self, others or property
and requires frequent monitoring to assure that there is a reasonable likelihood of safety
between IOP sessions. However, his or her condition is not so severe as to require daily
supervision;
b. Interference with Addiction Recovery Efforts: The clients recovery efforts are negatively
affected by an emotional, behavioral or cognitive problem, which causes mild interference with
and requires increased intensity to support treatment participation and/or compliance;
c. Social Functioning: The client symptoms are causing mild to moderate difficulty in social
functioning, but not to such a degree that he or she is unable to manage the activities of daily
living or to fulfill responsibilities at home, school, work or community;
d. Ability for Self-Care: The client is experiencing mild to moderate impairment in ability to
manage the activities of daily living, and thus requires frequent monitoring and treatment
interventions. Problems may involve poor hygiene secondary to exacerbation of a chronic mental
illness. Poor self-care or lack of independent living skills in an older client who is
transitioning to adulthood, or in a younger adolescent who lacks adequate family supports;
e. Course of Illness: The clients history and present situation suggest that an emotional,
behavioral or cognitive condition would become unstable without frequent monitoring and
maintenance.
YES
NO
83
Dimension 4:
Readiness to
Change

a. The client requires structured therapy and a programmatic milieu to promote progress through the
stages of change, as evidenced by behaviors such as the following: [1] the adolescent is verbally
compliant, but does not demonstrate consistent behaviors; [2] the client is only passively
involved in treatment; or [3] the client demonstrates variable compliance with attendance at
outpatient sessions or self- or mutual-help meetings or support groups. Such interventions are
not feasible or are not likely to succeed in a level I services; or
b. The clients perspective inhibits his or her ability to make progress through the stages of
change. The client thus requires structured therapy and a programmatic milieu. Such interventions
are not feasible or are not likely to succeed in a Level II.1 service.
Dimension 5:
Relapse/Continued
Use Potential

a. There is a high likelihood of alcohol or drug use without close outpatient monitoring and
structured support, as indicated by the clients lack of awareness of relapse triggers,
difficulty in postponing immediate gratification, and/or ambivalence/resistance to treatment; or
b. The client is assessed as being unable to interrupt his or her impulsive and self-defeating
behaviors, which threaten abstinence in the absence of ongoing clinical support; or
c. Despite active participation in treatment, the client is experiencing an intensification of
addiction symptoms (such as craving and drug seeking behavior) with associated moderate risk of
relapse.

a. Continued exposure to current job, school or living environment will make recovery unlikely, and
the client has insufficient or severely limited resources or skills needed to maintain an
adequate level of functioning without this level of service; or
b. The client lacks social contacts, or has inappropriate social contacts that jeopardize recovery,
or has few friends or peers who do not use alcohol or other drugs. He or she also has
insufficient resources or skills necessary to maintain an adequate level of functioning without
the services of a level II.1 program, but is capable of maintaining an adequate level of
functioning between sessions; or
c. The client family is supportive of recovery but family conflicts and related family dysfunction
impedes the clients ability to learn the skills necessary to achieve and maintain abstinence.
Dimension 6:
Recovery
Environment
Date:
84
Print Client Name:
DIMENSIONS
Date:
Adolescent
ASAM Level II.1

care.

ASAM Requirements
Dimension 1:
Acute Intoxication
and/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to
Change
Dimension 5:
Relapse/Continued
Use Potential

a. The clients biomedical conditions or problems, if any, are stable or are being currently
addressed and do not interfere with treatment; or
b. The client is responding to treatment. Biomedical conditions are not severe enough to
warrant inpatient treatment, yet they distract from recovery efforts. Such problems require
medical monitoring and/or medical management, which can be provided by the intensive
outpatient program or through a concurrent arrangement with another treatment provider.
a. The client continues to demonstrate recurrent impulsive behavior and/or current inability to
maintain behavioral stability for more than a 72-hour period; however, the behavioral
stability problem is being actively addressed in treatment, and there are indications that
the client is responding to treatment interventions; or
b. The clients emotional, behavioral or cognitive disorder, which is being concurrently
managed, continues to distract the client from treatment; however, the client is responding
to treatment, and it is anticipated that, with further interventions, he/she will be able to
achieve treatment objectives.
b. The clients alcohol/drug seeking behaviors, while diminishing, have not been reduced
sufficiently to support functioning outside the structured milieu provided at this level of
care; or
c. The client, despite active participation in treatment, is experiencing an intensification of
addiction symptoms (such as craving and a return to drug seeking behaviors) and has begun to
deteriorate in his/her level of functioning. However, the treatment interventions, guided by
the treatment plan, have been revised to address this problem and the client is beginning to
respond.
YES
NO
85
a. Continuing family conflicts inhibit the development of family problem solving skills
necessary to support ongoing abstinence, yet the family engaged in active treatment; or
b. The client, while actively engaged in treatment, remains minimally engaged in school or other
academic/vocational endeavors; or
c. The client is involved in some non-alcoholic/other drug-centered peer activities but still
remains involved in chemically abusing peer-support system; or
d. The client had not yet integrated the socialization skills necessary to establish a
supportive social network.
Dimension 6:
Recovery
Environment
Date:
86
Print Client Name:
Date:
Adolescent
ASAM Level II.1

DIMENSIONS
[3]DISCHARGE
TRANSFER ____
Enter Level ____
ASAM Requirements
Dimension 1:
Acute
Intoxication and/
or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to
Change
Dimension 5:
Relapse/
Continued Use
Potential

that indicts validation or lack of validation for
Meets diagnostic criteria in one of the six dimensions unless discharged for lack of diagnostic
criteria.
a. The clients biomedical conditions, if any, have diminished or have been stabilized to the
extent they can be managed through outpatient appointments at a less intensive level of care,
and the client does not meet any of the continued stay criteria indicating the need for
further treatment in this or another dimension; or
b. The client has a biomedical condition that is interfering with treatment that requires
a. The clients emotional, behavioral or cognitive conditions have diminished in severity to such
an extent that regular monitoring of the behavior is no longer necessary, and the client does
not meet any of the continued stay criteria for further treatment at ASAM Level II.1; or
b. The client has a psychiatric, emotional or behavioral condition that is interfering with
addiction treatment and that should be addressed in another setting; or
c. The client has been unable to benefit from treatment due to the inability to function at least
at the 11-year old age level.
a. The clients no longer requires ASAM Level II.1 intensive clinically directed motivational
interventions, as evidenced by the following: 1) the client recognizes the severity of
his/her substance abuse problem; and 2) the client has an understanding of his/her selfdefeating relationship with substances; 3) the client is beginning to apply skills necessary
to maintain recovery by accessing appropriate community supports or by continuing treatment in
a less intensive level of care; and 4) the client does not meet any of the continued stay
criteria for ASAM Level II.1 indicating the need for further treatment; or
to the treatment plan and advice concerning the consequences of continued alcohol/other drug
use; to such an extent that further progress is not likely to occur.
a. The clients therapeutic gains in addressing craving and relapse issues have been integrated
into the clients daily behavior to support an ongoing care program at a less intensive level
of care, and the client does not meet continued stay criteria indicating the need for further
treatment at ASAM Level II.1; or
b. The client is experiencing an intensification of drug-seeking behaviors such as craving or
YES
NO
87
regular use of substances despite continued interventions, to such an extent that he/she
requires treatment in a more intensive level of care.
a. Problem aspects of the clients social and interpersonal environment are responding to
treatment and the environment is sufficiently supportive of recovery to allow discharge or
transfer to a less intensive level of care, and the client does not meet any of the continued
stay criteria that indicate the need for further treatment at this level of care; or
b. The clients social or interpersonal environment has not changed or has deteriorated, but the
client has learned skills adequate to cope with the current situation or has secured an
alternative environment, and the client does not meet continued stay criteria that indicated
the need for further treatment at this level of care; or
c. The clients support system remains non-supportive or has deteriorated and the client is
having difficulty coping with this environment and is at substantial risk of reactivating
his/her addiction. An alternative environment is not feasible. The client requires placement
in a more intensive level of care or an alternative supportive environment.
Dimension 6:
Recovery
Environment
Date:
88
Print Client Name:
DIMENSIONS
Date:
Adolescent
65D-30 Day or Night
ASAM Level II.5

Must meet Dimension 1 and 2, and at least one of Dimensions 3, 4, 5, or 6.
Transfer criteria: Adolescents may be transferred to this level of care when they have met essential
treatment objectives in a more intensive level and require this intensity of service provided at
this level of care in at least one dimension. An adolescent may transfer from ASAM Level II.1 when
services at that level have been insufficient to address the adolescents needs or when ASAM Level
II.1 has consisted of motivational interventions to prepare the adolescent for participation in a
more intensive level of care for which admission criteria are met.

ASAM Requirements
Dimension 1:
Acute
Intoxication
and/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
The adolescents status in this dimension is characterized by the following:

a. The adolescent is able to tolerate mild withdrawal symptoms.
b. He or she has made a commitment to sustain treatment and to follow treatment recommendations.
c. The adolescent has external supports that promote treatment engagement.
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
The adolescents status in Dimension 3 is characterize by at least one of the following:

a. Dangerous Lethality: The adolescent is at mild risk of behaviors endangering self, others or
property and requires frequent monitoring to assure that there is a reasonable likelihood of
safety between day treatment sessions. However, his or her condition is not so severe as to
require daily supervision;
b. Interference with Addiction Recovery Efforts: The adolescents recovery efforts are negatively
affected by an emotional, behavioral or cognitive problem, which causes moderate interference
with and requires increased intensity to support treatment participation and/or compliance;
c. Social Functioning: The adolescents symptoms are causing mild to moderate difficulty in social
functioning, but not to such a degree that he or she is unable to manage the activities of daily
living or to fulfill responsibilities at home, school, work or community;
d. Ability for Self-Care: The adolescent is experiencing moderate impairment in ability to manage
the activities of daily living, and thus requires near-daily monitoring and treatment
interventions. Problems may involve disorganization and inability to manage the demands of daily
self-scheduling, a progressive pattern of promiscuous or unprotected sexual contacts, or poor
vocational or prevocational skills that require habilitation and training in the program;
e. Course of Illness: The adolescents history and present situation suggest that an emotional,
behavioral or cognitive condition would become unstable without daily or near-daily monitoring
and maintenance.
The clients status in this dimension is characterized by at least one of the following:
a. The adolescents biomedical conditions, if any, are stable or are being concurrently addressed
and will not interfere with treatment at this level of care; or
b. The adolescents biomedical conditions and problems are severe enough to detract form recovery
and treatment at a lower level of care but will not interfere with recovery at Level II.5. The
biomedical conditions and problems are being addressed concurrently by a medical treatment
provider.
YES
NO
89
Dimension 4:
Readiness to
Change
The adolescents status in Dimension 4 is characterized by (a) or (b):

a. The adolescent requires structured therapy and a programmatic milieu to promote progress through
the stages of change, as evidenced by behaviors such as the following: [1] the adolescent
demonstrates verbal or behavioral opposition to treatment; [2] the adolescent is only minimally
involved in treatment; [3] the adolescent demonstrates poor compliance with attendance at day or
night sessions; or (4) the adolescents alcohol or drug use is escalating, contributing to school
failure, truancy or behaviors leading to suspension from school; or
b. The adolescents perspective and lack of impulse control inhibits his or her ability to make
progress through the stages of change. The adolescent thus requires structured therapy and a
programmatic milieu.
Dimension 5:
Relapse/
Continued Use
Potential
The adolescents status in this dimension is characterized by (a) or (b):

a. The adolescent is at high risk of relapse or continued use without almost daily outpatient
monitoring and structured therapeutic services. Also, treatment at a less intensive level of
care is given serious consideration and been judged insufficient to stabilize the adolescents
condition; or
b. The adolescent demonstrates impaired recognition of relapse issues. He or she has poor skills in
coping with and interrupting substance use problems, and avoiding or eliminating relapse, that
the near-daily structure afforded by a Level II.5 program is needed to prevent or arrest
significant deterioration in function.
The adolescents status in this dimension is characterized by (a), (b), or (c):

a. Continued exposure to the adolescents current school, work, or will render recovery unlikely.
He or she lacks the resources and skills necessary to maintain an adequate level of functioning
without the services of a Level II.5 program, but is capable of maintaining an adequate level of
b. The adolescent lacks social contacts, or has inappropriate social contacts that jeopardize
recovery, or has few friends or peers who do not use alcohol or other drugs. He or she also has
insufficient resources or skills necessary to maintain an adequate level of functioning without
the services of a level II.5 program, but is capable of maintaining an adequate level of
c. Family members and/or significant others living with the adolescent are not supportive of his or
her recovery goals and/or are passively opposed to treatment. The adolescent requires structured
treatment services and relief from the home environment in order to remain focused on recovery,
but he or she may live at home because there is no active opposition to, or sabotaging of, the
recovery effort.
Dimension 6:
Recovery
Environment
Date:
90
Print Client Name:
DIMENSIONS
ASAM Requirements
Dimension 1:
Acute Intoxication
and/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to Change
Dimension 5:
Relapse/Continued
Use Potential
Date:
Adolescent
65D-30 Day or Night
ASAM Level II.5

care.
The adolescent is sufficiently stable in Dimensions 2 and 3 to allow participation in this level
of care, and the client meets the criteria in one of Dimensions 4, 5, or 6.
The adolescent is free from intoxication or withdrawal symptoms/risks.
The adolescents status in this dimension is characterized by one of the following:

a. The adolescents biomedical conditions or problems, if any, are stable or are being currently
addressed and do not interfere with treatment; or
b. The adolescent is responding to treatment. Biomedical conditions are not severe enough to
warrant inpatient treatment, yet they distract from recovery efforts. Such problems require
medical monitoring and/or medical management, which can be provided by the day treatment
program or through a concurrent arrangement with another treatment provider.
a. The adolescent continues to demonstrate recurrent impulsive behavior and/or current inability
to maintain behavioral stability for more than a 72-hour period; however, the behavioral
stability problem is being actively addressed in treatment, and there are indications that
the adolescent is responding to treatment interventions; or
b. The adolescents emotional, behavioral or cognitive disorder, which is being concurrently
managed, continues to distract the adolescent from treatment; however, the client is
responding to treatment, and it is anticipated that, with further interventions, he/she will
be able to achieve treatment objectives.
The adolescent is beginning to recognize and understand that he/she is responsible for
addressing his/her illness, but still requires ASAM Level II.5 services and motivational
strategies to sustain personal responsibility and progress in treatment.
a. The adolescent recognizes and understands relapse triggers, but has not developed sufficient
b. The adolescents alcohol/drug seeking behaviors, while diminishing, have not been reduced
sufficiently to support functioning outside the structured milieu provided at this level of
care; or
c. The adolescent, despite active participation in treatment, is experiencing an intensification
of addiction symptoms (such as craving and a return to drug seeking behaviors) and has begun
YES
NO
91
to deteriorate in his/her level of functioning. However, the treatment interventions, guided
by the treatment plan, have been revised to address this problem and the adolescent is
beginning to respond.
a. Continuing family conflicts inhibit the development of family problem solving skills
necessary to support ongoing abstinence, yet the family engaged in active treatment; or
b. The adolescent, while actively engaged in treatment, remains minimally engaged in school or
other academic/vocational endeavors; or
c. The adolescent is involved in some non-alcoholic/other drug-centered peer activities but
still remains involved in chemically abusing peer-support system; or
d. The adolescent had not yet integrated the socialization skills necessary to establish a
supportive social network.
Dimension 6:
Recovery
Environment
Date:
92
Print Client Name:
DIMENSIONS
[3]DISCHARGE
TRANSFER ____
Enter Level_____
ASAM Requirements
Dimension 1:
Acute Intoxication
and/ or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to
Change
Date:
Adolescent
65D-30 Day or Night
ASAM Level II.5

that indicts validation or lack of validation for
Meets diagnostic criteria in one of the six dimensions unless discharged for lack of diagnostic
criteria.
a. The adolescent is free from intoxication or withdrawal symptoms/risks; or
b. The adolescent exhibits symptoms of severe intoxication and/or withdrawal, which cannot be
safely managed at this level of care.
a. The adolescents biomedical conditions, if any, have diminished or have been stabilized to the
extent they can be managed through outpatient appointments at a less intensive level of care,
and the adolescent does not meet any of the continued stay criteria indicating the need for
further treatment in this or another dimension; or
b. The adolescent has a biomedical condition that is interfering with treatment that requires
a. The adolescents emotional, behavioral or cognitive conditions have diminished in severity to
such an extent that regular monitoring of the behavior is no longer necessary, and the
adolescent does not meet any of the continued stay criteria for further treatment at ASAM
Level II.5 ; or
b. The adolescent has a psychiatric, emotional or behavioral condition that is interfering with
addiction treatment and that should be addressed in another setting; or
c. The adolescent has been unable to benefit from treatment due to the inability to function at
least at the 11-year old age level.
a. The adolescents no longer requires ASAM Level II.5 intensive clinically directed motivational
interventions, as evidenced by the following: 1) the adolescent recognizes the severity of
his/her substance abuse problem; and 2) the adolescent has an understanding of his/her selfdefeating relationship with substances; 3) the adolescent is beginning to apply skills
necessary to maintain recovery by accessing appropriate community supports or by continuing
treatment in a less intensive level of care; and 4) the adolescent does not meet any of the
continued stay criteria for ASAM Level II.5 indicating the need for further treatment; or
b. The adolescent consistently has failed to achieve essential treatment objectives despite
revisions to the treatment plan and advice concerning the consequences of continued
alcohol/other drug use, to such an extent that further progress is not likely to occur.
YES
NO
93
Dimension 5:
Relapse/Continued
Use Potential

a. The adolescents therapeutic gains in addressing craving and relapse issues have been
integrated into the clients daily behavior to support an ongoing care program at a less
intensive level of care, and the adolescent does not meet continued stay criteria indicating
the need for further treatment at ASAM Level II.5; or
b. The adolescent is experiencing an intensification of drug-seeking behaviors such as craving or
regular use of substances despite continued interventions, to such an extent that he/she
requires treatment in a more intensive level of care.

a. Problem aspects of the adolescents social and interpersonal environment are responding to
treatment and the environment is sufficiently supportive of recovery to allow discharge or
transfer to a less intensive level of care, and the adolescent does not meet any of the
continued stay criteria that indicate the need for further treatment at this level of care;
b. The adolescents social or interpersonal environment has not changed or has deteriorated, but
the adolescent has learned skills adequate to cope with the current situation or has secured
an alternative environment, and the adolescent does not meet continued stay criteria that
indicated the need for further treatment at this level of care; or
c. The adolescents support system remains non-supportive or has deteriorated and the adolescent
is having difficulty coping with this environment and is at substantial risk of reactivating
his/her addiction. An alternative environment is not feasible. The adolescent requires
placement in a more intensive level of care or an alternative supportive environment.
Dimension 6:
Recovery
Environment
Date:
94
Print Client Name:
DIMENSIONS
ASAM
Requirements
Dimension 1:
Acute
Intoxication
and/or
Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Date:
Adolescent
65D-30 Residential Level I and II
ASAM Level III.5

Must meet at least Dimensions 2 and 3, if problems do not exist that exclude placement from this level
of care.
Transfer criteria: Clients may be transferred to this level of care when they have met essential
treatment objectives in a more intensive level and require this intensity of service provided at this
level of care in at least one dimension. A client may transfer from a less intense level of care, when
services at that level have been insufficient to address the clients needs or that level of care has
consisted of motivational interventions to prepare the client for participation in a more intensive
level of care for which admission criteria are met.
b. The risk of withdrawal is present, as evidenced by a history of current alcohol/or other drug use or
a high index of suspicion of such use. However, withdrawal is manageable in this level.

a. The clients continued alcohol/other drug use places the client in imminent danger of serious damage
to his or her physical health, or concomitant biomedical conditions (such as pregnancy); or
b. Biomedical complications require medical monitoring or concurrent biomedical illness requires medical
monitoring but not acute medical care.
Biomedical Enhanced Program

The client has a biomedical problem that requires a degree of staff attention that is provided directly
by the program or by a Level I or Level II service outside of the Level III.5 program.
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications

a. Dangerousness/Lethality: The adolescent is at risk for dangerous consequences because of the lack of
a stable living environment. He or she needs a stable residential setting for protection;
b. Interference with Addiction Recovery Efforts: The adolescent needs a stable living environment to
promote a sustained focus on recovery tasks;
c. Social Functioning: The clients emotional, behavioral or cognitive problem results in moderate
impairment in social functioning. He or she therefore needs limited 24-hour supervision, which can be
provided by program staff or in combination with a Level I or Level II program. This might involve
protection from antisocial peer influences in a motivated client reinforcement of improving behavior
self-management techniques, support of increasingly independent functions and the like.
d. Ability for Self-Care: the client has moderate impairment in his or her ability to manage the
activities of daily living and thus needs limited 24 hour supervision, which can be provided by
program staff or through coordination with a Level I or Level II program. The clients impairments
might require the provision of food and shelter, prompting for self-care, or supervised self
administration of medications;
YES
NO
95
e. Course of Illness: The clients history and present situation suggest that an emotional, behavioral
or cognitive condition would become unstable without 24 hour supervision; or the clients emotional,
behavioral or cognitive conditions suggests the need for low-intensity and/or longer term
reinforcement and practice of recovery skills in a controlled environment.
Dimension 4:
Readiness to
Change
The clients status in Dimension 4 is characterized by both of the following:

a. The client is open to recovery but requires limited 24 hour supervision to promote or sustain
progress through the stages of change; and
b. The client is cooperative and likely to engage in treatment at this level of care.
Dimension 5:
Relapse/
Continued Use
Potential

a. The lack of monitoring or supervision between treatment encounters at a less intensive level of care
has been a major barrier to abstinence and achievement of recovery goals. The clients continued
substance use poses a high risk of serious impairment in the absence of 24-hour monitoring and
structured support; or
b. The clients recovery skills are not sufficient to overcome environmental triggers such as peer
substance use or internal triggers such as craving; or
c. The clients history of chronic substance use, repeated relapse and/or resistance to treatment
predicts continued use or relapse without residential treatment and a structured programmatic milieu;
or
d. The clients likelihood of relapse and/or continued use poses a high risk of serious impairment in
the absence of 24-hour monitoring and structured support. This client might be at a high risk of
relapse/continued use due to ongoing exposure to substances in the context of trafficking,
involvement with a gang or other delinquent or drug involved peers.

a. The clients environment is not conducive to successful treatment at less intensive levels of care;
or
b. The clients parents or legal guardian(s) are unable to provide the consistent participation
necessary to support treatment at less intensive levels or care; or
c. Logistical impediments (e.g. lack of public transportation or parents inability or refusal to provide
transportation) preclude participation in treatment at less intensive levels of care; or
d. There is danger of physical, sexual and/or severe emotional attack or victimization in the clients
current living environment, which make recovery unlikely. Thus, the client must be removed from that
environment.
Dimension 6:
Recovery
Environment
Date:
96
Print Client Name:
DIMENSIONS

ASAM Requirements
Dimension 1:
Acute Intoxication
and/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral and
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to
Change
Dimension 5:
Relapse/Continued
Use Potential
Date:
Adolescent
ASAM Level III.5

Must meet one of Dimensions 1-6.


a. The clients biomedical conditions, if any, are stable or are being currently addressed and do not
interfere with treatment; or
b. The client is responding to treatment for biomedical conditions that are not severe enough to
warrant inpatient treatment, yet distract from recovery efforts. Such conditions require medical
monitoring and/or medical management, which can be provided by the program or through a concurrent
arrangement with another treatment provider.
a. The client is making progress toward resolution of an emotional, behavioral or cognitive condition,
but he or she has not resolved the condition(s) sufficiently to allow discharge or transfer to a
less intensive level of care; or
b. The client continues to display significant depression, with thoughts of self-harm, but is making
progress in achieving treatment objectives; or
c. The client is being monitored pending transfer within 72 hours to an acute psychiatric inpatient
service; or
d. The client manifests continued recurrent impulsive behavior (angry outbursts, withdrawal from
social contacts, violation of program expectations), which is slowing, but is not preventing
progress in treatment; or
e. The client manifests continued risk of severe self-defeating behaviors, such as running away,
return to victimization or a return to illegal drug activities; however, he/she is making progress
in achieving treatment objectives.
The client recognizes that he/she has an alcohol/other drug problem and is responding to treatment but
has not demonstrated behaviors indicative of the problem-solving or social skills necessary to cope
with the problem.
a. The client exhibits moderate intensification of addiction symptoms (such as difficulty postponing
gratification and related drug seeking behaviors) which would jeopardize his or her ability to
respond to treatment in a less intensive level of care;
b. The client recognizes relapse triggers or dysfunctional behaviors that previously have undermined
sobriety but demonstrates minimal understanding of his/her self-defeating responses to such
triggers or use of such dysfunctional behaviors; however, the client is progressing in treatment;
or
c. The client recognizes relapse triggers or dysfunctional behaviors that previously have undermined
sobriety but does not demonstrate the skills necessary to interrupt such behaviors and apply the
alternative coping skills needed to maintain ongoing abstinence.
YES
NO
97
a. Problem aspects of the clients social and interpersonal environment are responding to treatment
but are not sufficiently resolved to support recovery. Thus the client is not ready for discharge
or transfer to a less intensive level of care; or
b. The clients social or interpersonal environment has not changed or has deteriorated, and the
client needs additional treatment to learn to cope with the current situation or to take steps to
secure an alternative environment.
Dimension 6:
Recovery
Environment
Date:
98
Print Client Name:
DIMENSIONS
[3] DISCHARGE
TRANSFER ____
Enter Level_____
ASAM Requirements
Dimension 1:
Acute Intoxication
and/or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to
Change
Dimension 5:
Relapse/Continued
Use Potential
Date:
Adolescent
ASAM Level III.5

Meets diagnostic criteria in one of Dimensions 1-6.

a. The clients biomedical conditions, if any, have diminished or stabilized to the extent they can
be managed through outpatient appointments at a less intensive level of care, and the client does
not meet any of the continued stay criteria in this or another dimension that indicates the need
for further treatment; or
b. The client has a biomedical condition that is interfering with addiction treatment that requires
a. The clients emotional, behavioral or cognitive problems have diminished in severity to such an
extent that regular monitoring of the behavior is no longer necessary, and the client does not
meet any of the continued stay criteria for further treatment at ASAM Level III.5; or
b. The client has a psychiatric, emotional, behavioral or cognitive condition that is interfering
with addiction treatment and that should be addressed in another setting; or
c. The client has been unable to benefit from treatment due to the inability to function at least at
the 11-year old age level.
a. The clients awareness and acceptance of his or her addiction problem and commitment to
definitive treatment is sufficient to expect treatment compliance at a less intensive level of
care, as evidenced by the following: 1) The client recognizes the severity of his/her substance
abuse problem; 2) the client has an understanding of his/her self-defeating relationship with
substances; 3) the client is applying skills necessary to maintain recovery by accessing
appropriate community supports or by continuing treatment in a less intensive level of care; and
4) the client does not meet any of the continued stay criteria for ASAM Level III.5; or
b. The client consistently has failed to achieve essential treatment plan objectives despite
revisions to the treatment plan and advice concerning the consequences of continued alcohol/other
drug use, to such an extent that further progress is not likely to occur.
a. The client is capable of following a specific and complete post-treatment recovery plan. The
clients therapeutic gains in addressing craving and relapse issues have been integrated into the
clients daily behavior to support an ongoing care program at a less intensive level of care, and
the client does not meet continued stay criteria indicating the need for further treatment at
ASAM Level III.5; or
b. The client is not committed to continuing care and has achieved maximum benefit from all attempts
to have him or her accept the need for continuing care and relapse prevention.
YES
NO
99

a. Problem aspects of the clients social and interpersonal environment are responding to treatment
and the environment is sufficiently supportive of recovery to allow discharge or transfer to a
less intensive level of care, and the client does not meet any of the continued stay criteria
that indicate the need for further treatment at this level of care; or
b. The clients social or interpersonal environment has not changed or has deteriorated, but the
client has learned skills adequate to cope with the current situation or has secured an
alternative environment, and the client does not meet any of the ASAM Level III continued stay
criteria that indicates the need for further treatment at this level of care; or
c. The clients social support system remains non-supportive or has deteriorated and the client is
having difficulty coping with the environment and is at substantial risk of reactivating his/her
addiction. An alternative environment is not feasible because the parent(s)/guardian(s) or family
does not accept the recommendation.
Dimension 6:
Recovery
Environment
Date:
100
Print Client Name:
DIMENSIONS
ASAM
Requirements
Dimension 1:
Acute
Intoxication
and/or
Withdrawal
Potential
Date:
Adolescent
ASAM Level III.2-D
Circle all items in Dimension 1 that apply to the client.

a check in the appropriate box that indicates validation
or lack of validation for placement into this level of care.
a. The client is experiencing signs and symptoms of withdrawal, or there is evidence that withdrawal
is evident. The client is assessed as not being at risk for severe withdrawal, and moderate
withdrawal syndrome is safely manageable at this level of care; or
b. The client is assessed as not requiring medication, but requires this level of service to complete
detoxification and enter into continued treatment or self-help recovery because of inadequate home
supervision or support structure, as evidenced by meeting [1], [2], or [3]:
[1] The clients recovery environment is not supportive of detoxification and entry
into treatment, and the client does not have sufficient coping skills to safely deal with
the problems in the recovery environment; or
[2] The client has a recent history of detoxification at less intensive levels of
service that is marked by inability to complete detoxification or to enter into continuing
addiction treatment, and the client continues to have insufficient skills to complete
detoxification; or
[3] The client recently has demonstrated an inability to complete detoxification at a
less intensive level of service, as exhibited by continued use of other-than-prescribed
drugs or other mind-altering substances.
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to
Change
Dimension 5:
Relapse/
Continued Use
Potential
Dimension 6:
Recovery
Environment
Date:
YES
NO
101
Print Client Name:
DIMENSIONS
Date:
Adolescent
ASAM Level III.2-D
Circle the item in Dimension 1 that applies to the

continued stay at this level of care.
Client meets criteria in Dimension 1.

ASAM
Requirements
Dimension 1:
a. The client continues in ASAM Level III.2-D until withdrawal signs and symptoms are sufficiently
Acute
resolved that the client can safely be managed at a less intensive level of care; or
Intoxication
b. Signs and symptoms of withdrawal have failed to respond to treatment and have intensified, such that
and/or
transfer to a more intensive level of detoxification service is indicated.
Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Treatment
Acceptance/Resis
tance
Dimension 5:
Relapse/
Continued Use
Potential
Dimension 6:
Recovery
Environment
Date:
YES
NO
102
Print Client Name:
DIMENSIONS
[3]DISCHARGE
TRANSFER ____
Enter Level______
Date:
Adolescent
ASAM Level III.2-D

Meets diagnostic criteria in Dimension 1.

ASAM
Requirements
Dimension 1:
a. Clients withdrawal signs and symptoms are sufficiently resolved that the client can be managed at a
Acute
Intoxication
b. Signs and symptoms of withdrawal have failed to respond to treatment and have intensified, such that
and/or
a transfer to ASAM Level IV-D is indicated.
Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Treatment
Acceptance/Resis
tance
Dimension 5:
Relapse/
Continued Use
Potential
Dimension 6:
Recovery
Environment
Date:
YES
NO
103
Print Client Name:
DIMENSIONS
Date:
Adolescent
ASAM Level III.7-D

Place a check in the appropriate box that indicates validation or
lack of validation for placement into this level of care.
Client meets criteria of at least one of the three dimensions.

ASAM
Requirements
Dimension 1:
Acute
Intoxication
and/or
Withdrawal
Potential
Severe withdrawal but manageable in this level of care requires the client meet a or b:
a. The client is experiencing signs and symptoms of severe withdrawal, or there is evidence that severe
withdrawal symptoms are imminent. The severe withdrawal syndrome is assessed as manageable at this
level of care; or
b. There is a strong likelihood that the client, who requires medication, will not complete detoxification
at another level of service and enter into continued treatment or self-help recovery.
[1] The client requires medication and has a recent history of detoxification at a less
intensive level of care, marked by past and current inability to complete detoxification and
enter into continuing addiction treatment. The client continues to have insufficient skills or
supports to complete detoxification; or
[2] The client has a recent history of detoxification at less intensive levels of service
that is marked by the inability to complete detoxification or to enter into continuing addiction
treatment, and the client continues to have insufficient skills to complete detoxification; or
[3] The client has a co morbid physical, emotional, behavioral or cognitive condition that
is manageable in a Level III.7-D setting but which increases the clinical severity of the
withdrawal and complicates detoxification.
The clients co-morbid physical condition, if any, is manageable in an ASAM Level III.7-D setting but
increases the clinical severity of the withdrawal and complicates detoxification.
Dimension 2:
Biomedical
Conditions and
Complications
The clients co-morbid emotional, behavioral or cognitive condition, if any, is manageable in an ASAM
Dimension 3:
Level III.7-D setting but increases the clinical severity of the withdrawal and complicates
Emotional,
detoxification.
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Treatment
Acceptance/
Resistance
Dimension 5:
Relapse/
Continued Use
Potential
Dimension 6:
Recovery
Environment
Date:
YES
NO
104
Print Client Name:
DIMENSIONS
[2]CONTINUED STAY CRITERIA

ASAM Requirements
Dimension 1:
Acute Intoxication
and/ or Withdrawal
Potential

The clients status in this dimension is
a. Continues in this level of care until
the client can be safely managed at a
b. Signs and symptoms of withdrawal have
transfer to a more intensive level of
Date:
Adolescent
ASAM Level III.7-D

characterized by one of the following:
withdrawal signs and symptoms are sufficiently resolved that
failed to respond to treatment and have intensified, such that
service is indicated.
Dimension 2:
Biomedical
Conditions and
Complications
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to Change
Dimension 5:
Relapse/ Continued
Use Potential
Dimension 6:
Recovery
Environment
Date:
YES
NO
105
Print Client Name:
DIMENSIONS
[3] DISCHARGE
TRANSFER ____
Enter Level_____
ASAM Requirements
Dimension 1:
Acute
Intoxication and/
or Withdrawal
Potential
Dimension 2:
Biomedical
Conditions and
Complications
Date:
Adolescent
ASAM Level III.7-D

indicates validation or lack of validation for discharge
or transfer from this level of care.

a. Clients withdrawal signs and symptoms are sufficiently resolved that the client can be safely managed
at a less intensive level of care; or
b. Signs or symptoms of withdrawal have failed to respond to treatment and have intensified, such that a
transfer to a more intensive level of care is indicated.
a. Biomedical conditions, if any, have diminished or stabilized, and the client does not meet criteria
that indicates the need for continued service at ASAM Level III.7-D level of care; or
b. A biomedical condition is complicating the detoxification process, such that a transfer to a more
intensive level of service is indicated.
a. Emotional, behavioral or cognitive conditions, if any, have diminished or stabilized, and the client
does not meet criteria in this dimension that indicates the need for continued service at ASAM Level
III.7-D; or
b. A psychiatric, emotional/behavioral condition is complicating the detoxification process, such that a
transfer to more intensive level of service is indicated.
Dimension 3:
Emotional,
Behavioral or
Cognitive
Conditions and
Complications
Dimension 4:
Readiness to
Change
Dimension 5:
Relapse/
Continued Use
Potential
Dimension 6:
Recovery
Environment
Date:
YES
NO

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What levels of care are described in the document?

What levels of care are described in the document?

What are the dimensions used for patient placement?

What are the dimensions used for patient placement?

The Department of Children and Families

Substance Abuse Program

Instructions for Using Supplement Forms

Addictions Receiving Facilities (ARFs)

Example: Decision-Making Process for Client Placement

Adult Patient Placement Criteria

Opioid Maintenance Forms

Level 0.5 Intervention Forms

Level I Outpatient Forms

Level II.1 Intensive Outpatient Forms

Level II.5 Partial Hospitalization Forms

Level III.I Clinically Managed Low-Intensity Residential Treatment Forms

Level III.3 Clinically Managed Medium-Intensity Residential Treatment Forms

Level III.5 Clinically Managed Medium/High-Intensity Residential Treatment Forms

Level III.7 Medically Monitored Intensive Inpatient Treatment Forms

Level I-D Ambulatory Detoxification without Extended On-Site Monitoring Forms

Level III.2-D Clinically-Managed Residential Detoxification Forms

Level III.7-D Medically-Monitored Inpatient Detoxification Forms

Adolescent Patient Placement Criteria

Level 0.5 Intervention Forms

Level I Outpatient Forms

Level II.1 Intensive Outpatient Forms

Level II.5 Partial Hospitalization Forms

Level III.5 Clinically Managed Medium-Intensity Residential Treatment Forms

Level III.2-D Clinically-Managed Residential/Juvenile Addiction Receiving Facility Form

Level III.7-D Medically-Monitored Inpatient Detoxification Forms

Instructions for Using Supplement Forms

Special Instructions for Addictions Receiving Facilities (ARFs)

Note: Client must meet criteria in

ADULT CLIENT PLACEMENT CRITERIA

Medication and Methadone Maintenance Treatment

Intensive Outpatient Treatment

Day or Night Treatment (Inclusive of Host Homes and Community Housing)

Residential III Treatment

Intensive Inpatient Treatment

Addictions Receiving Facility

Opioid Maintenance Therapy

Medication and Methadone Maintenance Treatment

Intensive Outpatient Treatment

Day or Night Treatment

Client Identification Number:

Circle all items in each dimension that apply to the client.

Print Counselor Name:

Client Identification Number:

Circle all items in each dimension that apply to

Print Counselor Name:

Client Identification Number:

Circle all items in each dimension that apply to

Print Counselor Name:

Client Identification Number:

Circle all items in each dimension that apply

Client Identification Number:

Circle all items in each dimension that apply to

[2] CONTINUED STAY CRITERIA

The clients living environment is characterized by one of the following: