MILWAUKEE COUNTY BEHAVIORAL HEALTH DIVISION
|Section 3. Service Authorization Request for CONTINUATION OF LEVEL OF CARE |
| | | |
|Client Name |Client ID No. |Current Level of Care |
• Review the client’s existing or new problems in each of the six ASAM Dimensions.
• For each ASAM Dimension: (1) Indicate which of the Continued Stay Criteria apply, and (2) Provide a specific update on client progress or status.
• In the final section, identify treatment recommendations and plan.
|DIMENSION 1: |ASAM CONTINUED STAY CRITERIA |Check |
| | | |
|Acute Intoxication and/or| | |
|Withdrawal Potential | | |
| |1. The client is making progress but has not yet achieved the goals articulated in the individualized | |
| |treatment plan. Continued treatment at the present level of care is assessed as necessary to permit | |
| |the client to continue to work toward his or her treatment goals; OR | |
| |2. The client is not yet making progress, but has the capacity to resolve his or her problems. He or | |
| |she is actively working toward the goals articulated in the individualized treatment plan. Continued | |
| |treatment at the present level of care is assessed as necessary to permit the client to continue to | |
| |work toward his or her treatment goals; AND/OR | |
| |3. New problems have been identified that are appropriately treated at the present level of care. This| |
| |level is the least intensive at which the client’s new problems can be addressed effectively. | |
| |4. Not Applicable: No problem or stable | |
Comment on client progress or status and the plan (be specific):
|DIMENSION 2: |ASAM CONTINUED STAY CRITERIA |Check |
| | | |
|Biomedical Conditions and| | |
|Complications | | |
| | | |
| |1. The client is making progress but has not yet achieved the goals articulated in the individualized| |
| |treatment plan. Continued treatment at the present level of care is assessed as necessary to permit | |
| |the client to continue to work toward his or her treatment goals; OR | |
| |2. The client is not yet making progress, but has the capacity to resolve his or her problems. He or| |
| |she is actively working toward the goals articulated in the individualized treatment plan. Continued| |
| |treatment at the present level of care is assessed as necessary to permit the client to continue to | |
| |work toward his or her treatment goals; AND/OR | |
| |3. New problems have been identified that are appropriately treated at the present level of care. | |
| |This level is the least intensive at which the client’s new problems can be addressed effectively. | |
| |4. Not Applicable: No problem or stable | |
Comment on client progress or status and the plan (be specific):
|DIMENSION 3: |ASAM CONTINUED STAY CRITERIA |Check |
| | | |
|Emotional, Behavioral or | | |
|Cognitive Conditions and | | |
|Complications | | |
| |1. The client is making progress but has not yet achieved the goals articulated in the individualized| |
| |treatment plan. Continued treatment at the present level of care is assessed as necessary to permit | |
| |the client to continue to work toward his or her treatment goals; OR | |
| |2. The client is not yet making progress, but has the capacity to resolve his or her problems. He or| |
| |she is actively working toward the goals articulated in the individualized treatment plan. Continued| |
| |treatment at the present level of care is assessed as necessary to permit the client to continue to | |
| |work toward his or her treatment goals; AND/OR | |
| |3. New problems have been identified that are appropriately treated at the present level of care. | |
| |This level is the least intensive at which the client’s new problems can be addressed effectively. | |
| |4. Not Applicable: No problem or stable | |
Comment on client progress or status and the plan (be specific):
|DIMENSION 4: |ASAM CONTINUED STAY CRITERIA |Check |
| | | |
|Readiness To Change | | |
| |1. The client is making progress but has not yet achieved the goals articulated in the individualized| |
| |treatment plan. Continued treatment at the present level of care is assessed as necessary to permit | |
| |the client to continue to work toward his or her treatment goals; OR | |
| |2. The client is not yet making progress, but has the capacity to resolve his or her problems. He or| |
| |she is actively working toward the goals articulated in the individualized treatment plan. Continued| |
| |treatment at the present level of care is assessed as necessary to permit the client to continue to | |
| |work toward his or her treatment goals; AND/OR | |
| |3. New problems have been identified that are appropriately treated at the present level of care. | |
| |This level is the least intensive at which the client’s new problems can be addressed effectively. | |
| |4. Not Applicable: No problem or stable | |
Comment on client progress or status and the plan (be specific):
|DIMENSION 5: |ASAM CONTINUED STAY CRITERIA |Check |
| | | |
|Relapse, Continued Use or| | |
|Continued Problem | | |
|Potential | | |
| |1. The client is making progress but has not yet achieved the goals articulated in the individualized| |
| |treatment plan. Continued treatment at the present level of care is assessed as necessary to permit | |
| |the client to continue to work toward his or her treatment goals; OR | |
| |2. The client is not yet making progress, but has the capacity to resolve his or her problems. He or| |
| |she is actively working toward the goals articulated in the individualized treatment plan. Continued| |
| |treatment at the present level of care is assessed as necessary to permit the client to continue to | |
| |work toward his or her treatment goals; AND/OR | |
| |3. New problems have been identified that are appropriately treated at the present level of care. | |
| |This level is the least intensive at which the client’s new problems can be addressed effectively. | |
| |4. Not Applicable: No problem or stable | |
Comment on client progress or status and the plan (be specific):
|DIMENSION 6: |ASAM CONTINUED STAY CRITERIA |Check |
| | | |
|Recovery Environment | | |
| | | |
| | | |
| |1. The client is making progress but has not yet achieved the goals articulated in the individualized| |
| |treatment plan. Continued treatment at the present level of care is assessed as necessary to permit | |
| |the client to continue to work toward his or her treatment goals; OR | |
| |2. The client is not yet making progress, but has the capacity to resolve his or her problems. He or| |
| |she is actively working toward the goals articulated in the individualized treatment plan. Continued| |
| |treatment at the present level of care is assessed as necessary to permit the client to continue to | |
| |work toward his or her treatment goals; AND/OR | |
| |3. New problems have been identified that are appropriately treated at the present level of care. | |
| |This level is the least intensive at which the client’s new problems can be addressed effectively. | |
| |4. Not Applicable: No problem or stable | |
Comment on client progress or status and the plan (be specific):
| |
|Treatment Recommendations and Plan: Identify goals to be addressed and how the treatment plan will help the client progress during the |
|continuation period and transition to a less intensive level of care. Be specific. |
| |
|Alternate Plan: If the Request for CONTINUATION is not granted, identify clinical or ancillary services needed to support client’s transition|
|to a less intensive level of care. |
| |
| | | |
|Counselor |Treatment Agency |Phone No. |
Clinical Supervisor (Signature) Date / /
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