ASAM Level of Care Assessment

Clinical assessment form to document the six ASAM dimensions and recommend an appropriate level of care for placement, supporting payer authorization and treatment matching.

Consent, Privacy, and Submission Notice

• Consent to document and share this assessment for treatment planning and authorization
• Attestation
  I attest that the information provided is accurate to the best of my knowledge and is limited to what is necessary for ASAM placement and authorization.
• Submission method

Client Identification and Referral Details

• Client name
• Date of birth
  Collect only if needed for record matching or payer requirements.
• Medical record number
• Referral source
• If other, specify referral source

ASAM Dimension 1: Acute Intoxication and/or Withdrawal Potential

• Risk rating
• Clinical findings
  Describe current substance use, last use, withdrawal symptoms, and any monitoring needs.
• Withdrawal management needed?

ASAM Dimension 2: Biomedical Conditions and Complications

• Risk rating
• Relevant medical conditions
  List only conditions relevant to placement or treatment safety.
• Current medications impacting care
  Include medications only if they affect withdrawal, safety, or level of care.

ASAM Dimension 3: Emotional, Behavioral, or Cognitive Conditions

• Risk rating
• Clinical findings
  Document mood, anxiety, psychosis, cognition, safety concerns, and need for psychiatric support.
• Current suicidal or homicidal ideation?

ASAM Dimension 4: Readiness to Change

• Risk rating
• Clinical findings
  Describe willingness to engage, stage of change, and any need for motivational support.
• Barriers to engagement

ASAM Dimension 5: Relapse, Continued Use, or Continued Problem Potential

• Risk rating
• Clinical findings
  Describe relapse history, cravings, triggers, and prior treatment response.
• Recent relapse within the past 30 days?

ASAM Dimension 6: Recovery/Living Environment

• Risk rating
• Clinical findings
  Describe housing stability, exposure to substance use, safety concerns, and recovery supports.
• Living environment stability

Recommended Level of Care and Authorization Summary

• Recommended level of care
• If other, specify recommended level of care
• Placement rationale
  Explain how the six dimensions support the recommended level of care and why lower levels would be insufficient or unsafe.
• Authorization supporting points
  Summarize the minimum necessary facts needed for payer authorization.