University of Washington 

UNIVERSITY OF WASHINGTON
Olympic Counseling Services’ Six‐Domain Adolescent Substance Use Assessment 
Name of Client (Last) (First) (M.I.) Age Date

School Attending Grade Sex Date of Birth

Male
Female
Acute Intoxication/Withdrawal Potential/ASAM DOMAIN 1
PST CODES ADMINISTRATION CODES PERIODICITY CODES FREQUENCY OF USE
1=Primary O=Oral J=Injection C=Continuous 1=No use in last month 4=3 to 6 times per week
2=Secondary S=Smoking N=Intra nasal E=Episodic/Binge 2=1 to 3 times in last month 5=Daily
3=Tertiary H=Inhaling T=Other R=Remission 3=1 to 2 times per week 6=Unknown
IM=Intra muscular U=Unknown
Type Age of Age Age and Date Pattern of Last 3 Years Drug Usage Initial Use and
First Use Regular of Last Use (ONLY PRIMARY AND SECONDARY DRUG OF CHOICE) Major
Administration

Frequency
Periodicity

Use Experiences
Started
PST

Age Date Grade and Average

Summer Frequency Amount

ALCOHOL Grade

Summer

ALCOHOL Grade

Summer

ALCOHOL Grade

Summer

CANNABIS Grade
Marijuana
Hashish
Summer

CANNABIS Grade
Marijuana
Hashish
Summer

CANNABIS Grade
Marijuana
Hashish
Summer

HALLUCINOGENS Grade
LSD
Mushrooms
Mescaline Summer

HALLUCINOGENS Grade
LSD
Mushrooms
Mescaline Summer

HALLUCINOGENS Grade
LSD
Mushrooms
Mescaline Summer

COCAINE Grade
Crack

Summer

COCAINE Grade
Crack

Summer

COCAINE Grade
Crack

Summer

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Acute Intoxication/Withdrawal Potential/ASAM DOMAIN 1 (Continued)

PST CODES ADMINISTRATION CODES PERIODICITY CODES FREQUENCY OF USE
1=Primary O=Oral J=Injection C=Continuous 1=No use in last month 4=3 to 6 times per week
2=Secondary S=Smoking N=Intra nasal E=Episodic/Binge 2=1 to 3 times in last month 5=Daily
3=Tertiary H=Inhaling T=Other R=Remission 3=1 to 2 times per week 6=Unknown
IM=Intra muscular U=Unknown
Type Age of Age Age and Date Pattern of Last 3 Years Drug Usage Initial Use and
First Use Regular of Last Use (ONLY PRIMARY AND SECONDARY DRUG OF CHOICE) Major
Administration

Frequency
Periodicity
Use Experiences
Started
PST

Age Date Grade and Average

Summer Frequency Amount

NICOTINE Grade

Summer

NICOTINE Grade

Summer

NICOTINE Grade

Summer

STIMULANTS Grade
Amphetamines
Methamphetamines
Crank Summer
Ritalin

STIMULANTS Grade
Amphetamines
Methamphetamines
Crank Summer
Ritalin

STIMULANTS Grade
Amphetamines
Methamphetamines
Crank Summer
Ritalin

INHALANTS Grade
Gas
Butyl-Nitrate
Glue Summer

INHALANTS Grade
Gas
Butyl-Nitrate
Glue Summer

INHALANTS Grade
Gas
Butyl-Nitrate
Glue Summer

SEDATIVES/ Grade
BARBITURATES
Dalmane
Quaaludes Summer
Phenobarbital

SEDATIVES/ Grade
BARBITURATES
Dalmane
Quaaludes Summer
Phenobarbital

SEDATIVES/ Grade
BARBITURATES
Dalmane
Quaaludes Summer
Phenobarbital

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Acute Intoxication/Withdrawal Potential /ASAM DOMAIN 1 (Continued)

PST CODES ADMINISTRATION CODES PERIODICITY CODES FREQUENCY OF USE
1=Primary O=Oral J=Injection C=Continuous 1=No use in last month 4=3 to 6 times per week
2=Secondary S=Smoking N=Intra nasal E=Episodic/Binge 2=1 to 3 times in last month 5=Daily
3=Tertiary H=Inhaling T=Other R=Remission 3=1 to 2 times per week 6=Unknown
IM=Intra muscular U=Unknown
Type Age of Age Age and Date Pattern of Last 3 Years Drug Usage Initial Use and
First Use Regular of Last Use (ONLY PRIMARY AND SECONDARY DRUG OF CHOICE) Major

Administration

Frequency
Periodicity
Use Experiences
Started
PST
Age Date Grade and Average
Summer Frequency Amount

Opiates Grade
Heroin
Codeine
Percodan Summer

Opiates Grade
Heroin
Codeine
Percodan Summer

Opiates Grade
Heroin
Codeine
Percodan Summer

BENZODIAZAPINE Grade
Klonopin
Valium, Librium
Other Tranquilizers Summer

BENZODIAZAPINE Grade
Klonopin
Valium, Librium
Other Tranquilizers Summer

BENZODIAZAPINE Grade
Klonopin
Valium, Librium
Other Tranquilizers Summer

PHENCYCLIDINE (PCP) Grade

Summer

PHENCYCLIDINE (PCP) Grade

Summer

PHENCYCLIDINE (PCP) Grade

Summer

OTHERS Grade
Cough/Cold
Over the Counter
Diet Aids, Nyquil Summer
Benadryl

OTHERS Grade
Cough/Cold
Over the Counter
Diet Aids, Nyquil Summer
Benadryl

OTHERS Grade
Cough/Cold
Over the Counter
Diet Aids, Nyquil Summer
Benadryl

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AMOUNT USED DURING WEEKPRIOR TO ASSESSMENT (For evaluating detoxification needs prior to treatment)
DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 DAY 7
Date

Day

Substance

Amount

Substance

Amount

Substance

Amount

Current pattern of abuse and counselor’s estimate of

Information reliability
Preferred setting for alcohol or drug use (alone, with
Friends, home, etc.)
Describe longest period of abstinence

MISUSE LEVEL
Relaxation from social Emotional stress relief. Physical pre-tolerance. Intoxication.
stress. Receives emotional stress relief when Body adaptation to substances has Levels of substance use have been great
Feels the relaxation form social stress using substances moved towards substance abuse levels. enough to cause behavioral and/or
when using substances. thinking impairment.
ABUSE LEVEL
Concealment of substance Pre-occupation. Increased ingestion rates of Guilt.
use patterns. A defines pattern of substance misuse substances. Repeated episodes of intoxication have
Items noted have been actively has developed. The substance use levels have caused a self-esteem loss.
concealed from parents, adults, or non- continued upwards towards chemical
using peers. dependency.

Denial. Break with peer norms. Fixation with substance Personality changes related
Defensiveness about substance abuse The pattern of substance abuse (levels or using peers. to substance use.
has caused minimizing, rationalizing, or behaviors) is contrary to a large number Peer associations have strengthened These features may have been present
lying about problems and/or social of same age adolescents. A substance denial and substance abuse patterns. previously, but they are now aggravated
lifestyle. use self-identity is developing. and enmeshed in substance abuse.
Family recognition. Personal recognition.
Attempts to control. Attempts to control.
Family recognition of problems and Personal recognition of problems and
attempts to control adolescent’s use (e.g. attempts at control (cutting back,
arguments, grounding, fighting, etc.) stopping, switching types of substances,
etc.)
CHEMICAL DEPENDENCY LEVEL
Chemical dependency is present when three of the following seven areas have occurred in the adolescent’s substance abuse. These criteria are from the DSM-IV,
American Psychiatric Association. The condition of chemical dependency is considered a chronic and serious risk to the person’s health and social development.

1. Tolerance. 2. Withdrawal. 3. Control loss 4. Persistent desire or

A need for more of a substance to Either physical withdrawal symptoms (unpredictability of use). unsuccessful efforts to
achieve the same effect over time, or a that cause significant functioning The substance is taken in larger
decreasing effect with the continued use problems OR using a substance to cut down OR control
amounts OR over a longer period of
of a substance. relieve/avoid withdrawal symptoms. time than intended. NOTE: This can substance use.
include blackouts and other substantial Has this persisted over six months?
intoxication that the substance user Have efforts been unsuccessful over any
would be expected to attempt to avoid. amount of time?
Repeated loss of control over behavior
when intoxicated is evidence of control
loss.
5. Spending a great deal of time (one or more of the following):
Under the influence (e.g. 12+ hours of intoxication) Seeking the substance (e.g. financial problems, giving up
responsibilities to become intoxicated)
6. Changing lifestyle because of substance use by giving up/reducing important activities in the following areas (Choose one or
more):
Social. Recreational. Occupational.
Includes family and peer relationships. Weekend activities, sports, other organized activities or School work or academic involvement included.
planned family activities.
7. Substance use continues despite the youth’s knowledge that it is related to (choose one or more):
Medical condition (includes exacerbating Psychological condition (includes
a pre-existing condition) exacerbating a pre-existing condition)
Check headaches, stomach problems, diabetes or other Particularly aggression, depression.
issues.

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BIOMEDICAL CONDITIONS/COMPLICATIONS NEEDING MEDICAL MONITORING OR MANAGEMENT/ASAM DOMAIN 2

Hallucinations Liver problems High blood pressure Other ____________________
Convulsions Muscle cramps Diabetes
Nausea/vomiting/upset DT’s Headaches Other ____________________
stomach
Withdrawal or overdose history

Assessment of current medical

Condition and likelihood of
Pregnancy
EMOTIONAL/BEHAVIORAL OR COGNITIVE CONDITIONS AND COMPLICATIONS/ASAM DOMAIN 3
History (including past therapy)

Current (including current therapy)

Adolescent Developmental Level/Development problems associated with chemical use

SUICIDE
Suicide Ideation Yes If yes, please explain
No
Plan? Yes If yes, please explain
No
Verbal client Yes If yes, please explain
contract to not No
harm self?
Parent/Guardian Yes If yes, please explain
Notified? No
ABUSE AND/OR NEGLECT
Abuse (current and history, current risk). SEXUAL ABUSE, PHYSICAL ABUSE, PSYCHOLOGICAL ABUSE

CHILD PROTECTIVE SERVICES/DFYS

Meets DFYS mandatory DFYS contact report made? Time and Date of call: Name of DFYS Caseworker:
reporting?
Yes No Yes No
RUNNING AWAY/OUT OF HOME PLACEMENT/INSTITUTIONAL CARE
Counselor’s assessment of client’s
history of running away, out of
home placements, institutional
care or custody.
GRIEF/LOSS
Grief and loss issues:

AREAS OF CONCERN

Possible Depressive Conditions: (Depression)

Sadness Erratic sleep Lack of appetite Negative self statements Thoughts of harming self Plans to harm self

Withdrawal and isolation from
others. (Dependency or
avoidant disorders)
Comments
Feelings of hostility or Possible obsessive, ruminating, Fear of others. (Avoidant or
aggressive behavior. (Conduct or anxiety producing thought paranoid disorders)
disorder) patterns. (Anxiety or obsessive-
compulsive disorders

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READINESS TO CHANGE/ASAM DOMAIN 4
Precipitating Factor Explanation

Yes Acknowledges problem Yes Recognizes role of secondary Yes Evidences blame or projection
No No substances No

Yes Recognizes treatment need Yes Evidences minimization Yes Evidences rationalization
No No No
DENIAL SUMMARY
Open, cooperative, adequate self-disclosure Cooperative, inadequate self-disclosure of Guarded, resistant to assessment process.
of significant problems. personal problems.
Comments

NON-COMPLIANCE CHECKLIST
Prior treatment Previously left Complaining about Shaking, tremulous, Talking about outside
completed treatment AMA intake or past diaphoretic (sweating) issues
treatment
Denying level of Denies Expresses desire to Other________________________________
substance use problem needing/belonging in leave treatment
treatment
EXTERNAL MOTIVATION
Legal Status:(Courts, Deferred Prosecution, Diversion, Pending Charges)
Number of Arrests: Probation Officer Attorney

School Status: (Suspensions, expulsion, school staff involvement with referral)

Counselor’s assessment of patient’s motivation for recovery

List of local offenses

RELAPSE /CONTINUED USE/CONTINUED PROBLEM POTENTIAL/ASAM DOMAIN 5

Dates Agency Outcome Dates Agency Outcome

SCHOOL SUPPORT
School support Yes Type of support:
group involvement No

Dates___________________

SELF-HELP GROUP INVLOVEMENT

th
Has client attended a 12- No Alanon AA Has client done a 5 Does client have a Does client have a
step study group? CA Alateen NA Step? home group? sponsor?
Yes No Yes No Yes No
Date first attended Frequency of attendance: Has client ever completed formal treatment (inpatient or outpatient)or Yes
(month/year) Become involved in a self-help group followed by 3 months sobriety? No
If yes, when

MEDICATIONS/TRIGGERS/CRAVINGS
Stashed at home? Yes No Is client unable to manage “triggers” in Does client have significant preoccupations or
environment (patterns, moods, occasions, cravings?
etc.)? Yes No
Yes No
COUNSELOR’S ASSESSMENT
Counselor’s assessment of client’s ability to attain and maintain abstinence:

Counselor’s assessment of client’s risk of relapse

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RECOVERY ENVIRONMENT/ASAM DOMAIN 6

Family Involvement Yes
No
Marital Status Single Currently Both parents Grandparents Foster Care Does Yes If Yes, specify
Married living with Mother Other family Other (specify) client No ages of children
Divorced Father Friends have
children?
Job/School Status

Learning Disabilities/Special Education and Needs

Reading Level/Learning Ability

COUNSELOR’S ASSESSMENT
Counselor’s assessment of client’s
strengths/abilities/preferences/needs.

Counselor’s assessment of client’s needs. (Include

current and future safety needs and risk factors).

Counselor’s assessment of client’s

current and historical custodial status.

FAMILY HISTORY OF CHEMICAL DEPENDENCY

Circle appropriate code letter below
P= Problem (no treatment) T=Treated UK=Unknown N=No Problem C=Current Use
Relationship Living with Alcoholism/ Psychiatric Relationship Living with Alcoholism/ Psychiatric
client Substance Problem client Substance Problem
Abuse Abuse
Maternal Yes No P T UK N C P T UK N C Brother (age) Yes No P T UK N C P T UK N C
Grandmother
Maternal Yes No P T UK N C P T UK N C Sister (age) Yes No P T UK N C P T UK N C
Grandfather
Paternal Yes No P T UK N C P T UK N C Sister (age) Yes No P T UK N C P T UK N C
Grandmother
Paternal Yes No P T UK N C P T UK N C Sister (age) Yes No P T UK N C P T UK N C
Grandfather
Mother Yes No P T UK N C P T UK N C Sister (age) Yes No P T UK N C P T UK N C

Father Yes No P T UK N C P T UK N C Sister (age) Yes No P T UK N C P T UK N C

Step Mother Yes No P T UK N C P T UK N C Significant Yes No P T UK N C P T UK N C

Other
Step Father Yes No P T UK N C P T UK N C Best Friend Yes No P T UK N C P T UK N C

Brother (age) Yes No P T UK N C P T UK N C Other (specify) Yes No P T UK N C P T UK N C

Brother (age) Yes No P T UK N C P T UK N C Other (specify) Yes No P T UK N C P T UK N C

Brother (age) Yes No P T UK N C P T UK N C Other (specify) Yes No P T UK N C P T UK N C

FAMILY INVOLVEMENT
Family involvement in the evaluation or treatment process

GANG INVOLVEMENT

AXIS I: DAIGNOSTIC SUMMARY OF SUBSTANCE USE

Since drug/alcohol problems are seen as healthcare problems, the evaluation uses the American Medical Association’s health care codes and
evaluation standards, the minimum level of problem is:
th
AMA Codes: (Each number used as the 5 digit indicates) 1=Continuous 2=Episodic/Binges 3=Disease in Remission
No identifiable substance problem

Substance Misuse (intoxication and impairment)

Alcohol:303.0___ Glue (Inhalants): Marijuana/Hashish: 292.89___ Cocain:292.89___

292.89___
Barbiturates: 292.89___ Hallucinogens: 292.89___ Opiates: 292.89___ Other (specify):292.89_______

Amphetamines/Speed: 292.89___ ___________________________

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Substance Abuse (Intoxication and impairment)

Alcohol:305.0___ Glue (Inhalants): 305.9___ Marijuana/Hashish: 305.2___ Cocain:305.6___

Barbiturates: 305.4___ Hallucinogens: 305.3___ Opiates: 305.5___ Other (specify):305.9________

Amphetamines/Speed: 305.7___ ___________________________

Chemical Dependency

Alcohol:303.9___ Glue (Inhalants): 304.5___ Marijuana/Hashish: 304.3___ Cocain:304.2___

Barbiturates: 304.1___ Hallucinogens: 304.5___ Opiates: 304.0___ Other (specify):304.9________

Amphetamines/Speed: 304.4___ Poly Substance Dependence 304.8___ ___________________________

Significant Defensiveness due to potential client resistance

The recommended education or therapy is designed to complete the diagnosis and keep the client substance-free.
AXIS I: DIAGNOSTIC SUMMARY (Additions to Any Substance Use Disorder)

Mental Health Screening Referral: 799.9___

RULE OUT/ EVALUATE:

AXIS II: PERSONALITY DEVELOPMENT

Diagnosis deferred (may need further testing): 799.9___

AXIS III: PHYSICAL DISORDERS/CONDITIONS

Indicate concerns that are potentially relevant to case management and noted on a physician’s H & P

AXIS IV: SEVERITY OF PSYCHOSOCIAL STRESSORS FOR THE PAST YEAR

Problems with primary support group: (specify)

Problems related to social environment: (specify)

Educational problems: (specify)

Occupational problems: (specify)

Housing problems: (specify)

Economic problems: (specify)

Problems related to interaction with the legal system/crime: (specify)

Other psychological and environmental problems: (specify)

AXIS V: GLOBAL ASSESSMENT OF FUNCTIONING

Indicate client’s relative location on the continuum scale below. Consider psychological, social and educational functioning on a hypothetical
continuum of mental-health illness. Do not include impairment in functioning due to physical (or environmental) limitations.

INSTRUCTIONS: Circle an appropriate set of numbers in each column.

CURRENT
Superior functioning in a wide range of
activities, life’s problems never seem to
get out of hand, is sought out by others 91-100
because of his or her many positive
qualities. No symptoms.
Absent or minimal symptoms (e.g. mild
anxiety before exam), good functioning
in all areas, interested and involved in a 81-90
wide range of activities, socially
effective, generally satisfied with life, no
more than everyday problems or
concerns (e.g. an occasional argument
with family members)
If symptoms are present, they are
transient and expectable reactions to
psychosocial stressors (e.g. difficulty
concentrating after family argument) no 71-80
more than slight impairment in social,
occupational or school functioning (e.g.
occasional truancy or theft within the
household) but generally functioning
pretty well, has some meaningful
interpersonal relationships.
PAST YEAR CURRENT PAST YEAR
Serious symptoms (e.g. suicidal ideation,
severe obsessional rituals, frequent
91-100 shoplifting) or any serious impairment in 41-50 41-50
social, occupational or school functioning
(e.g. no friends, unable to keep a job).
Some impariemnt in reality testing or
communication (e.g. speech is at times
81-90 illogical, obscure or irrelevant) or major 31-40 31-40
impairment in several areas such as work or
school, family relations, judgement, thinking
or mood (e.g. avoids friends, neglects
family, frequently beats up younger
children, defiant at home, failing at school).
Behavior is considerably influenced by
delusions or hallucinations or serious
impairment in communication or judgement
71-80 (e.g. sometimes incoherent, acts grossly 21-30 21-30
inappropriately, suicidal preoccupation) or
inability to function in almost all areas (e.g.
stays in bed all day, no job, home or
friends).

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CURRENT PAST YEAR CURRENT PAST YEAR
Some mild symptoms (e.g. depressed Some danger of hurting self or others (e.g.
mood and mild insomnia) or some suicide attempts without clear expectation
difficulty in social, occupational, or of death, frequently violent, manic
school functioning (e.g. occasional 61-70 61-70 excitement) or occasionally fails to maintain 11-20 11-20
truancy or theft within the household) minimal personal hygiene (e.g. smears
but generally functioning pretty well, has feces) or gross impairment in
some meaningful interpersonal communication (e.g. largely incoherent or
relationships. mute)
Moderate symptoms (e.g. flat affect and Persistent danger of severely hurting self or
circumstantial speech, occasional panic others (e.g. recurrent violence) or persistent
attacks) or moderate difficulty in social, 51-60 51-60 inability to maintain minimal personal 1-10 1-10
occupational or school functioning (e.g. hygiene or serious acts with clear
no friends, conflicts with coworkers). expectation of death.
Inadequate information 0 0

ADDITIONAL INFORMATION ON CONFIDENTIALITY AND REFERRAL SPECIFIC TO RIVERSIDE COUNTY OFFICE

OF EDUCATION CAN BE PLACED HERE IN MEDICAL RECORDS FORM

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Assessment Summary Sheet
Client was referred by the following:
Probation Officer name:________________ School District
Counselor or Physician name:________________ Parent Self

Review of American Society of Addiction Medicine Domains and Level Decisions

Low Medium High
I. Intoxication and withdrawal, including Post Acute Withdrawal
II. Biomedical conditions and complications
III. Emotional, behavioral and cognitive conditions and complications
Consider the following: a) dangerousness/lethality, b) interference with recovery efforts, c) social
functioning, d) ability for self-care, and e) course of illness.
IV. Readiness to change, includes treatment resistance and motivation
V. Relapse prevention skills, continued use or problem potential
VI. Recovery environment, including family and peer systems

Summary Placement Decision Based on ASAM Criteria

Select One Care Level Description
Level .5* Motivational Psychoeducation and Evaluation
Level 1.0* Outpatient Treatment (1-8 hours weekly)
Level 2.0** Intensive outpatient Treatment (9-12 hours weekly)
Level 2.5*** Day Treatment
Level 3.5 Residential Treatment in a Recovery House Setting
Level 3.7 Residential Treatment in a Medically Managed
Setting
Level 4.0 Hospital-Based Care in a Medically Managed
Setting
Patient Elects Services at the following level: __________
Level .5 through 2.5 services available at T-4 Learning Center
* If client was recommended to level .5 or 1.0 please indicated desired groups.
** If client was recommended to level 2.0 all groups are indicated.
*** If client was recommended to level 2.5 all groups plus Community Health Class

Please indicated desired groups/class:

Community Health Class [daily therapy curriculum]
Primary men’s/women’s process group (1 hour weekly)
12-Step Study Group (1 hour weekly)
Intensive Education Group (2 hours weekly)
Multi-Family Group (1 hour weekly)
Relapse Prevention Group (2 hours weekly)
Individual Counseling
Monitored Urinalysis

Residential Programs Level 3.0 through Level 4.0

Level 3.5 [ADD Program Option]
Level 3.5 [ADD Program Option]
Level 3.7 [ADD Program Option]
Level 3.7 [ADD Program Option]
Level 3.7 Sundown M Ranch (WA) (800) 327-7444
Level 4.0 [ADD Program Option]
Level 4.0 [ADD Program Option]
Level 4.0 [ADD Program Option]

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AIDS/HIV BRIEF RISK ASSESSMENT AND TB SCREEN

AIDS/HIV brief risk intervention was conducted in accordance with public health recommendations, and if appropriate, a referral was made to related
services.

Signature of counselor: Date

CLIENT ACKNOWLEDGEMENT OF ASSESSMENT OUTCOME

Yes, client was informed

No, client was not informed. Explain:_____________________________________________________________________________
_____________________________________________________________________________________________________________

Client has elected to receive services from:___________________________________________________________________________

I have been informed of my assessment results and advised of the right Client was informed of assessment results, and advised of the right to be
to be referred to any appropriate facility offering services consistent with referred to any appropriate facility offering services consistent with the
the results of the assessment. When available, three referral options results of the assessment. When available, three referral options were
were provided. provided.

Signature of
Signature of Client: Date: Counselor: Date:

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