Comments: SECTION XIX: DEGREE OF SEVERITY FOR THE SEVEN DIMENSIONS/ADMISSION CRITERIA Admission Criteria - Adult Protocol Level of Care (Must meet 4 out of 6 dimensions in each level of care. Check all boxes that apply in all dimensions) I-A: Non-Intensive Outpatient Treatment Level I-B: Intensive Outpatient Treatment Level I-C: Day Treatment Level II-A: Non-Medical Community Residential Level II-B: Medical Community Residential Level III-A: Ambulatory Detoxification Level III-B: 23 Hour Observation Bed Level III-C: Sub-Acute Care IV: Acute Hospital Detoxification Dimension 4 Treatment Acceptance Resistance Aware of problem, willing to engage in treatment Resistant but can be motivated to engage in treatment Resistance requires structured treatment Intensive clinical treatment needed to motivate client for treatment Denial/ Resistance requires intense structured treatment Client motivated for treatment Motivated to receive structured treatment 24 hours per day Moderate resistance to tx. requires motivation 24 hours per day Motivated to receive structured treatment 24 hours per day Moderate resistance to tx. requires motivation 24 hours per day History of at a less intensive level of care Minimal awareness of addiction, treatment referral after detoxification is required Potential to be motivated for treatment if additional interventions are provided Resistant to treatment, requires medical treatment for acute addiction symptoms Acceptance, resistance requires additional evaluation and medical supervision Minimal awareness of addiction, tx. referral after detox. Required Some awareness of addiction, yet requires intensive inpatient intervention Acute crisis, referral after detox required Resisted tx. at level of care Some awareness of addiction, but intensive intervention needed Comments: Dimension 5 Relapse Potential Moderate to high relapse risk without treatment Low relapse potential Moderate to high relapse risk without treatment monitoring needed to prevent relapse Moderate to high relapse risk without day tx. Client has history of relapse in a less structured setting Moderate to high relapse risk without 24 hour treatment Client has history of relapse in a less intensive level of care Moderate to high relapse risk without 24 hour supervision Client has history of relapse in a less intensive level of care addiction crisis, no immediate recovery potential without treatment referral after detoxification History of repeated complicated detoxifications Symptoms require immediate medical management in a structured setting Relapse potential requires medical evaluation and management Acute addiction crisis, needs treatment to prevent relapse Has a history of relapse Acute addiction crisis requires immediate treatment History of relapse at a lower level of care Comments:
Dimension 6 Recovery Environment (Environ.) Supportive environment Has access to social and peer support Tx. will help client cope with environment Environment does not interfere with treatment at this level Environment supportive Needs regular reinforcement to cope with environment not supportive, treatment can increase coping skills Environment interfering with tx. progress, needs structured tx. Environment unstable, ongoing reinforcement needed. Environment does not support recovery Environment has deteriorated 24 hour per day residential treatment is required immediately Environment does not support recovery Environment has deteriorated and 24 hour per day stabilization is necessary No means of developing a support system Environment stable, supportive, can follow detoxification regimen on outpatient Environment poor for recovery, yet is able to cope at this level of care Environment not supportive of recovery, needs stabilization elsewhere Diagnostic evaluation indicates a need to remove client from environment ENVIRONMENT NOT A FACTOR IN ADMISSION ENVIRONMENT NOT A FACTOR IN ADMISSION Comments: Level of care recommended: Level of care placed: If not placed in of care recommended, check reasons below: ____Waiting list ____ Level of care offered, client not able to attend ____Level of care not available ____Client refuses level of care DSM IV Diagnostic Code and Written Description: Axis I: ___________________________________ Axis II: __________________________________ Axis III: __________________________________