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Run: Level of Care Transition Documentation

Document a level-of-care reassessment, ASAM criteria review, and transition decision in one clinical form. Use it to justify continued service, transfer, or ...

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Patient and Encounter Details

Patient Identifier (required)

Use the internal patient ID or medical record number. Do not enter SSN.

Encounter Date (required)

Current Level of Care (required)

Reassessment Type (required)

Clinical Reassessment

Current Clinical Concerns (required)

Summarize the symptoms, risks, or functional concerns relevant to the level of care decision.

Current Risk Level (required)

Substance Use Status

Functional Status

Summary of Clinical Change Since Last Review (required)

Describe what has changed since the last assessment, including improvement, deterioration, or new concerns.

ASAM Criteria Review

ASAM Dimension 1: Acute Intoxication and/or Withdrawal Potential (required)

ASAM Dimension 2: Biomedical Conditions and Complications (required)

ASAM Dimension 3: Emotional, Behavioral, or Cognitive Conditions (required)

ASAM Dimension 4: Readiness to Change (required)

ASAM Dimension 5: Relapse, Continued Use, or Continued Problem Potential (required)

ASAM Dimension 6: Recovery/Living Environment (required)

Are continued service criteria met at the current level of care? (required)

Are transfer criteria met for a different level of care? (required)

Transition Decision and Rationale

Transition Decision (required)

Clinical Rationale (required)

Explain the rationale for the decision, including ASAM criteria, risks, supports, and treatment response.

Barriers or Risks Considered

Planned Receiving Level of Care or Program (required)

Plan, Consent, and Attestation

Next Steps (required)

List referrals, follow-up timing, safety planning, handoff actions, and any required monitoring.

Patient Notified of Transition Plan

Confirm whether the patient was informed of the decision and plan.

Yes No N/A

Consent and Disclosure Notes

Document any consent, privacy disclosures, or information-sharing limitations relevant to the transition.

Clinician Name (required)

Clinician Signature (required)

What happens after I submit

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Email (required)

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