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CAFAC

CENTER FOR ADDICTION & FAMILY COUNSELING, INC.               

Alcohol & Drugs - Mental Health Outpatient Level I Treatment 

MULTIPLE DUI Offender Clinical Evaluation

 

Clients Full Name (Print): _________________________________________________________________ FIRST MIDDLE LAST

Current Mailing Address : __________________________________________________________________

Street Address (NO PO BOX NUMBERS) City State Zip-code
Day Telephone Number : (______) _______________________ Date of Birth : ______ / ______ / ______ Drivers License #: ___________________________ Social Security # ____________________________ RRP Completion Date: _____ / ______ / ______ Risk Reduction Completion # : _____________________ Evaluator Name: ______________________________________ Number: C________________________

Offender Personal Identifying Information Narrative

(Include following information: Precipitating event and related circumstances; Age; Gender, Race / Ethnicity; Marital status; Education history; Referral source and referral's relationship to offender)

Date Evaluation Started

Date Evaluation Completed

Revised June 2009, Page 1 of 1

Employment History Narrative - provide employment history over 5 years prior to evaluation (Include Employer name; Length of employment; Status - full or part time; Occupation; Reason for unemployment if applicable; Reason left previous employer if applicable)

Legal / Criminal History Narrative - provide legal history over past 5 years prior to evaluation (Include following information: DUI dates and BAC levels; Other traffic charges; Legal history current and past; pending charges; Probation / Parole status. (Also obtain 7-year Motor Vehicle Report as collateral verification )

Revised June 2009, Page 2 of 2

ASAM DIMENSION 1 - Alcohol or Substance Use Intoxication / Withdrawal Potential

The goal for Dimension 1 is to determine if the offender is in need of immediate stabilization or detoxification services.

(Include Substance use history; Pattern - frequency, dose, quantity; Tolerance, blackouts, tremens; Noted withdrawal signs / symptoms; Current use pattern; Age of first use; Date last used; Longest time of sobriety; If sober, sobriety date)

Assessment considerations include:

  • What level is risk is associated with offender's current pattern of use?

  • Are there current signs of intoxication or withdrawal?

  • What supports does offender have to assist in detoxification or treatment if recommended?

Current ASAM Severity rating for Dimension 1 (circle) Low Moderate High

Revised June 2009, Page 3 of 3

ASAM DIMENSION 2 - Biomedical Conditions and Complications.

The goal of Dimension 2 is to determine the presence of any medical or chronic conditions, including medications regiment that may require a referral, or that may affect a treatment recommendation.

(Include Medical History, Current / chronic conditions needing attention; Current medication use / dose / frequency / diagnosis or condition if known. Clinical Evaluator may want to conduct a phone consultation / collateral interview with prescribing physician to confirm)

Assessment considerations include

  • Are there current physical illnesses, other than withdrawal, that needs to be addressed because they create

    risk or may complicate treatment?

  • What chronic conditions are present that might affect treatment or might be exacerbated by withdrawal

    (e.g., diabetes, hypertension)?

  • Are medications that might affect treatment? What medication management process is in place to

    determine if offender is taking medications as prescribed?

Current ASAM Severity rating for Dimension 2 (circle) Low Moderate High

Revised June 2009, Page 4 of 4

ASAM DIMENSION 3 - Emotional, Behavioral, or Cognitive Conditions and Complications

The goal of Dimension 3 is to determine the presence of any mental health, psychiatric or other cognitive conditions that may require referral or affect a treatment recommendation.

(Mental Status Examination. Include Mental Health / Psychiatric History, Homicidal / Suicidal ideation or intent; Domestic Violence History, Impulse control pattern; Changes in mental status)

Assessment considerations include:

  • Are there current psychiatric illness or psychological, behavioral, emotional or cognitive problems that

    need to be addressed?

  • Are there chronic conditions that may complicate treatment?

  • Is the offender on any psychotropic medications that might complicate treatment?

  • Do emotional, behavioral or cognitive problems appear to be part of addictive disorder?

  • If yes to previous question, is a referral for a mental health examination or treatment warranted?

Current ASAM Severity rating for Dimension 3 (circle) Low Moderate High

Revised June 2009, Page 5 of 5

DIMENSION 4 - Readiness to Change

The goal of Dimension 4 is to determine the offender's emotional and cognitive awareness of the need to change. The offender's level of commitment to, and readiness for, change indicates his or her degree of cooperation with treatment. In addition, readiness to change indicates the offender's awareness of the relationship of substance use to negative consequences. The degree of readiness to change helps to determine the setting and intensity of treatment rather than the offender's eligibility for treatment itself.

Assessment considerations include

  • Does offender feel coerced into treatment or actively objecting to receiving treatment?

  • What is the degree of willingness to change?

  • If willing to accept treatment, how strongly does offender agree with other's perceptions that s/he has an

    addiction problem or understands the complications that substance use has created?

  • Is the offender compliant solely to avoid negative consequences (externally versus internally motivated)

  • Is the offender internally distressed in a self-motivated way about his/her substance-related problems?

Current ASAM Severity rating for Dimension 4 (circle) Low Moderate High

Revised June 2009, Page 6 of 6

DIMENSION 5 - Relapse, Continued Use or Continued Problem Potential

The goal of Dimesion 5 is to determine the risk of continued substance use, awareness of triggers and coping strategies to maintain and support recovery beyond harm reduction and abstinence. The assignment of a level of care should be made on the basis of both history and an assessment of current problems, and not merely history alone

Also include history of substance use / abuse or emotional / psychiatric / mental health issues within immediate family.

Assessment considerations include:

  • Is offender in immediate danger of continued substance use or mental health distress?

  • How aware is offender of understanding or using coping skills to reduce use or risk behavior, and enhance

    sobriety beyond mere abstinence?

  • How severe are continued use problems or further distress if the offender is not successfully engaged in

    treatment at this time?

  • How aware is offender of relapse triggers, ways to cope with craving to use, and skills to control impulses

    to use or engage in harmful behaviors?

  • What is the offender's ability to remain abstinent based upon supportive evidence and collateral

    interviews?

  • What is the offender's current level of craving?

  • How successfully can the offender resist using?

Current ASAM Severity rating for Dimension 5(circle) Low Moderate High

Revised June 2009, Page 7 of 7

DIMENSION 6 - Recovery / Living Environment

The goal of Dimension 6 is to determine the stability of the offender's living environment and offender supports to improve the likelihood of recovery.

Assessment considerations include:

  • Are there any dangerous family or significant others, living or working situations threatening treatment

    engagement and success?

  • Does the offender have supportive friendship, financial, or vocational resources to improve the likelihood

    of successful treatment?

  • Are there barriers to access treatment?

  • Are there legal, vocational, social service agency, or criminal justice mandates that may enhance

    motivation for engagement into treatment?

  • Are there transportation, childcare, housing, or employment issues that need to be clarified and addressed?

Current ASAM Severity rating for Dimension 6 (circle) Low Moderate High

Revised June 2009, Page 8 of 8

RISK ASSESSMENT

What is offender consider his/her phase adjusted low risk guidelines (from Risk Reduction program)? ________________________________________________________________________________________ ________________________________________________________________________________________ How has attending Risk Reduction Program made a difference in offender's life? ________________________________________________________________________________________ ________________________________________________________________________________________ What is offender's plan to maintain abstinence / low risk patterns for the future? What supports are in place? ________________________________________________________________________________________ ________________________________________________________________________________________ History of Domestic Violence? Yes No

Issues should be explored thoroughly to determine if they are a factor in the offender's substance use history

Comments:

Revised June 2009, Page 9 of 9

SUBSTANCE ABUSE TREATMENT HISTORY

Has offender participated in substance abuse treatment since last DUI? Yes No
Name of treatment program / facility: __________________________________________________________ Dates of treatment: From _______ / _______ / _______ To _______ / _______ / _______

Reason for termination of treatment:

  • (  ) Completed Attach Discharge Summary from facility

  • (  ) Referral to another level of care or another facility or

  • (  ) Early discharge.

    Explain nature of circumstances of premature discharge or transfer : _________________________________________________________________________________________ _________________________________________________________________________________________ Discharge Recommendations. (Has offender followed discharge recommendations - please explain) _ ________________________________________________________________________________________ _________________________________________________________________________________________

    TEST RESULTS and SUMMARY

    (Include copy of NEEDS Assessment if submitting to DBHDD for release from treatment recommendation. NEEDS Assessment can be transferred with Clinical Evaluation to Treatment Provider ONLY when offender has signed authorization to release evaluation packet).

    NEEDS Assessment Score: __________ NEEDS Assessment ASAM Level Recommendation : _______________ Other relevant NEEDS Assessment Information : __________________________________________________ ________________________________________________________________________________________ Additional Testing Instruments Narrative

    (Include name of instrument, date administered, results, and impressions / recommendations)

Revised June 2009, Page 10 of 10

CLINICAL IMPRESSIONS and RECOMMENDATIONS

Clinical Impressions should be provided in the form of an Interpretive Summary.
Clinical observations and insights include information about the following, but may not be limited to
:

  1. Behavior and Appearance

  2. Affect

  3. Intellectual Functioning

  4. Interpersonal Relationships

  5. Self-concept

  6. Character structure

Revised June 2009, Page 11 of 11

ASAM LEVEL OF CARE RECOMMENDED:

Level I Level II.1 Level II.5 Level III.1 Level III.5 Level III.7 Level IV
No further treatment recommended

CLINICAL EVALUATOR'S PROFESSIONAL AFFIRMATION

I affirm the included information and attachments are an accurate presentation of the clinical evaluation I
have conducted on the identified offender on the stated date. I understand that the records can be requested for
review by the Department of
Behavioral Health & Developmental Disabilities, Division of Addictive Diseases, Public S

_________________________________________________________________________________________ Clinical Evaluator Signature Credentials Date

______________________________________________________________________CE# _______________ Printed Name of Clinical Evaluator

_________________________________________________________________________________________ Address City State Zip

Day Telephone Number: (_____) _________________ Fax Number: (_____) _________________

Revised June 2009, Page 12 of 12

TREATMENT RECOMMENDATION INSTRUCTIONS:

When making a treatment recommendation, the Clinical Evaluator will send the following to the Treatment Provider:

  • Page 1 – demographic information

  • Page 11 – Clinical Impressions

  • Page 12 – Levels of Care recommendation and signature page

  • SALCE Assessment from Risk Reduction Program

    OR

    REQUEST TO RELEASE THE OFFENDER FROM THE OBLIGATION OF TREATMENT (REQUIREMENT MET PROCESS) INSTRUCTIONS,

    ADDITIONAL DOCUMENTATION
    MUST BE TO INCLUDED
    IN THE PACKET SUBMITTED TO THE DIVISION

  1. Entire Clinical Evaluation Format

  2. 7 - year Motor Vehicle Report
    Can be obtained from local Georgia State Patrol or licensing office. There is a small fee to obtain the 7-year MVR

  3. SALCE Assessment from Risk Reduction Program

  4. Relapse prevention plan or risk reduction plan.
    The offender needs to submit a written plan in his / her words about how things are different now compared to when s/he incurred the DUI's. What
    he/she learned from Risk Reduction Program that he/she is applying in his/her life today? Triggers; Low risk phase adjusted guidelines; Reducing risk; Plan to maintain sobriety
    and reduce the probability of another DUI offense.

  5. Discharge summary from treatment program / facility (if engaged in treatment prior to evaluation)

  6. Letters of Verification.

Revised June 2009, Page 13 of 13

GEORGIA MULTIPLE DUI OFFENDER PROGRAM GUIDELINES FOR VERIFICATION OF INFORMATION

You must obtain documentation of sobriety or low risk choices in the form of notarized affidavits from people in your community who have frequent contact with you and may know something about your drinking and/or use of controlled substances. This would include:

1. Probation/Parole Officer, Local Police 2. Relatives/Including Spouse.
3. Friends
4. Pastors, Ministers

5. Recognized Support Group Members / Sponsor: AA/NA/CA/COA
6. Treatment Provider, Therapist, Physician, Social Worker, Aftercare coordinator

If any of the requested information is received from anyone listed above in a face to face interview or telephone conversation with the clinical evaluator, the documentation of the interview is not required to be notarized.

A treatment provider's discharge summary or a therapist's or physician's testimony must be in writing and on official letterhead and does not have to be notarized.

All letters of testimony above should be signed, dated, and notarized. All letters and interviews recorded by the clinical evaluator should contain at least the following information:

  • <  How often do you see the offender?

  • <  What is your relationship with the offender?

  • <  How long have you known the offender?

  • <  How often do you see or did you see the offender drink or use drugs?

  • <  How much do/did you see the offender drink or consume at the time?

  • <  When was the last time you saw the offender use alcohol or other drugs?

  • <  In what activities does the offender participate involving alcohol?

  • <  What is you knowledge of the offender's involvement in treatment or support groups?

  • <  Include other information you believe is important for us to consider in our review of this offender's

    eligibility for driver's license reinstatement.

    If there is a request for release from the obligation to participate in substance abuse treatment, failure to comply with the verification guidelines may lead to a delay in the review of the request or possible denial of the recommendation.

    You may use the attached form for verification.
    All letters of verification, other than the attached format, must be on formal stationary and notarized.

Revised June 2009, Page 14 of 14

GEORGIA MULTIPLE DUI OFFENDER PROGRAM GUIDELINES FOR VERIFICATION OF INFORMATION

You must obtain documentation of sobriety or low risk choices in the form of notarized affidavits from people in your community who have frequent contact with you and may know something about your drinking and/or use of controlled substances.
All letters of verification other than this form should be on formal stationary, signed, dated, and notarized.

OFFENDER'S NAME: _____________________________________ DATE:_________________________

  • <  How often do you see the offender?

  • <  What is your relationship with the offender?

  • <  How long have you known the offender?

  • <  How often do you see or did you see the offender drink or use drugs?

  • <  How much do/did you see the offender drink or consume at the time?

  • <  When was the last time you saw the offender use alcohol or other drugs?

  • <  In what activities does the offender participate involving alcohol?

  • <  What is you knowledge of the offenders involvement in treatment or support groups?

  • <  Include other information you believe is important for us to consider in our review of this offenders eligibility for drivers license reinstatement.

    ________________________________________________________________________________________ Verifying Person's Signature Printed Name

    ________________________________________________________________________________________ Verifying persons street address, city, state, zipcode and phone number

    _________________________________________________________________________________________ 

Notary Date Commission Expiration

Revised June 2009, Page 15 of 15

 

Notes or additional comments:

Revised June 2009, Page 16 of 16