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Run: ASAM Level of Care Assessment

ASAM Level of Care Assessment template for documenting the six dimensions, supporting placement decisions, and summarizing the rationale for payer authorizat...

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Consent, Privacy, and Submission Notice

Consent to document and share this assessment for treatment planning and authorization (required)

Yes No N/A

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 (required)

Client Identification and Referral Details

Client name (required)

Date of birth

Collect only if needed for record matching or payer requirements.

Medical record number

Referral source (required)

If other, specify referral source

ASAM Dimension 1: Acute Intoxication and/or Withdrawal Potential

Risk rating (required)

Clinical findings (required)

Describe current substance use, last use, withdrawal symptoms, and any monitoring needs.

Withdrawal management needed? (required)

ASAM Dimension 2: Biomedical Conditions and Complications

Risk rating (required)

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 (required)

Clinical findings (required)

Document mood, anxiety, psychosis, cognition, safety concerns, and need for psychiatric support.

Current suicidal or homicidal ideation? (required)

ASAM Dimension 4: Readiness to Change

Risk rating (required)

Clinical findings (required)

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 (required)

Clinical findings (required)

Describe relapse history, cravings, triggers, and prior treatment response.

Recent relapse within the past 30 days? (required)

ASAM Dimension 6: Recovery/Living Environment

Risk rating (required)

Clinical findings (required)

Describe housing stability, exposure to substance use, safety concerns, and recovery supports.

Living environment stability (required)

Recommended Level of Care and Authorization Summary

Recommended level of care (required)

If other, specify recommended level of care

Placement rationale (required)

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.

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