SD Depart of Human Services Division of Alcohol and Drug Abuse LEVEL OF FUNCTIONING/SEVERITY: Using assessment protocols that address all six dimensions, assign a severity rating of High, Medium or Low for each dimension that best reflects the client's functioning and severity. Place a check mark in the appropriate box for each dimension. Level of Functioning/Severity Need Intensity of Service 1.Intox/ With 2. 3. 4. 5. 6. Bio- Emot Read Relapse Rec. med i-ness Envir Beha Low Severity - Minimal, current difficulty or impairment. Absent, minimal, or mild signs and symptoms. Acute or chronic problem mostly stabilized; or soon able to be stabilized and functioning restored with minimal difficulty Medium Severity - Moderate difficulty or impairment. Moderate to serious signs and symptoms. Difficulty coping or understanding, but able to function with clinical and other support services and assistance High Severity - Severe difficulty or impairment. Serious, gross or persistent signs and symptoms. Very poor ability to tolerate & cope with problems. L No immediate services or low intensity of services needed for this Dimension. Treatment strategies usually able to be delivered in outpatient settings M Moderate intensity of services, skills training, or supports needed for this Dimension. Treatment strategies may require intensive levels of outpatient care H High intensity of services, skills training, or supports needed. More immediate, urgent services may require inpatient or residential settings; or closely monitored case management services at a frequency greater than daily CLINICAL ASSESSMENT AND PLACEMENT SUMMARY SD Depart of Human Services Division of Alcohol and Drug Abuse Name: Date: Immediate Need Profile: Assessor considers each dimension and with just sufficient data to assess immediate needs, checks "yes" or "no" in the following table: Dimension 1. Acute Intoxication and/or Withdrawal Potential 1. as above 2. Biomedical Conditions/Complications 3. Emotional/Behavioral/Cognitive Conditions/Complications 3. as above Questions 1(a) Past history of serious withdrawal, life- threatening symptoms or seizures during withdrawal? 1(b) Currently having similar withdrawal symptoms? 2 Any current severe physical health problems? 3(a) Imminent danger of harming self or someone else? 3(b) Unable to function and safely care self? Yes No Yes to questions 1a, 1b, 2 and/or 3a, 3b requires that the client immediately be referred for medical and/or mental health evaluation, depending on which dimension(s) involved. Dimension Questions Yes No 4. Readiness to Change 4(a) Does client appear to need alcohol or other drug treatment/recovery, but ambivalent or feels it 4. as above unnecessary? e.g., severe addiction, but client feels controlled use still OK 4(b) Client been coerced, mandated or required to have assessment and/or treatment? Yes to questions 4a and/or to 4b alone, requires staff to begin immediate intervention and motivational strategies appropriate to client's stage of readiness to change. Questions 5. Relapse/Continued Use 5(a) Is client currently under the influence or Dimension Potential 5. as above intoxicated? 5(b) Is client likely to continue use of alcohol and/or other drugs, or to relapse, in an imminently dangerous manner? Yes No Yes to question 5a requires client be considered for withdrawal potential. Yes to question 5a and/or 5b, individual may need to be considered for 24-hour structure or care. Dimension Questions Yes No 6. Recovery Environment 6. Are there any dangerous family, sig, others, living/work/school situations threatening client's safety, immediate well-being, and/or sobriety? Yes to Dimension 6, without any Yes in questions 1, 2 and/or 3, requires that the client be assessed for the need of a safe or supervised environment.