Aubrey Graham [email protected] Assessment …...Aubrey Graham Interviewer: [email protected] Assessment Start: 2/26/2019 4:52 PM Assessment End: 2/26/2019 4:52 PM ALCOHOL

Aubrey Graham Interviewer: [email protected]

Assessment Start: 2/26/2019 4:52 PM

Assessment End: 2/26/2019 4:52 PM

Patient: Aubrey GrahamInterviewer: [email protected]

Admission Date: 2/26/2019 4:52 PM Assessment Begun:2/26/2019 4:52 PM Assessment Ended: 2/26/2019 4:52 PM

NOTE: This report contains an automated narrative summary of the patient’s condition,

derived from selected structured interview items. This instrument is not a replacement for

individual provider assessment and sound clinical judgment. ASAM and FEi Systems assume no

direct or indirect liability for improper care or negative outcomes that may ensue from the use of

this instrument. Consider your patient's needs carefully, using this instrument as one of many

clinical tools in your determination of proper care. The Criteria may not encompass all levels and

types of services which may be available in a changing health care field. Therefore, the Criteria

may not be wholly relevant to all levels and modalities of care.

This summary is based on the patient's self-report regarding lifetime and recent Medical,

Employment, Alcohol, Drug, Legal, Family/Social and Psychiatric involvement and/or problems. Included in each of these sections is the interviewer's severity rating, suggesting the client's need for treatment (or additional treatment beyond what the patient is already receiving). This is

based on the information provided by the client and other sources as available at the time.

Class of Assessment: Intake Interview Was Conducted: In person




IDENTIFYING INFORMATION Name: Aubrey Graham Gender: Male

DOB: 10/24/1986 Ethnicity: Undeclared

GENERAL INFORMATION SECTION The following is a clinical summary based on an in-person interview with Aubrey, on 2/26/2019.

Aubrey is a 32 year old male who did not specify a racial category. He states he is Undeclared. He states his

religious preference is Jewish. He has lived at his current address for approximately 5 years. Neither the client

nor his family owns this residence. Aubrey reports spending 30 of the past 30 days in a Jail facility in which his

freedom was restricted and/or prohibited. This could have limited his ability to use alcohol or drugs, as well as

his interactions with family and others.

MEDICAL SECTION Medical History

Aubrey was hospitalized once for medical problems. This hospitalization was in the past month. He does not have any chronic medical problems that require monitoring or dietary restrictions and is not prescribed any medications for physical problems. He does not receive any financial compensation for physical disabilities.

Client Perception of Severity of Medical Problems and Desire for Treatment

Although Aubrey experienced symptoms on 1 of the past 30 days, he is not at all troubled or bothered by them. Nevertheless Aubrey reports that help obtaining treatment for medical problems is of moderate importance to him.

Interviewer Impressions and Recommendations – Medical

It is my impression that Aubrey understood all of the questions, and that he did not deliberately misrepresent

his medical information. Aubrey has a medical problem of substantial concern, and help obtaining appropriate

treatment is necessary at this time.

Interviewer Comments

The interviewer did not have any comments for this section.




EMPLOYMENT SECTION

Employment History

He has worked full time (40 hours per week) for most of the past three years. Aubrey's longest full time job lasted for 10 years.

Current Financial Resources

Aubrey reports working 3 days and making $2.00 income in the past month. He either does not remember or will not discuss whether he has received any income from welfare, unemployment compensation, or pensions/benefits/SSI in the past 30 days. He has received $300.00 cash in the past month from family or friends. Aubrey says that he has not made any money illegally in the past month. Aubrey has no dependents that he supports financially. The majority of Aubrey's support, such as food, housing, etc., is being provided.

Education, Training and Resources

He completed 11 years of traditional schooling but did not attend any technical or vocational training. Aubrey does not have a particular profession or trade that increases his employability. He does not have a valid drivers license or a car available.

Client Perception of Severity of Employment Problems and Desire for Treatment

Overall, he reports having 30 days of employment related problems in the past 30, and is extremely troubled by employment related issues. Aubrey does not want to receive counseling or treatment for his difficulties related to employment issues.

Interviewer Impression and Recommendations-Employment

It is my impression that Aubrey understood all of the questions, and that he did not deliberately misrepresent this information. Aubrey has significant employment problems, and help obtaining treatment in this area is absolutely necessary and should be prioritized.






ALCOHOL & DRUG SECTION

Lifetime and Recent Alcohol Use

In his lifetime, Aubrey drank regularly and heavily (generally defined as 5 or more drinks in one day) for a

period of approximately 10 years. In the past 30 days, he drank 11 days, and has drank heavily, having more

than five drinks per day, on each of those days. He reports having spent $60.00 on alcohol in the past 30 days.

He has never experienced alcohol delirium tremens.

Lifetime and Recent Drug Use

Aubrey used heroin regularly (three or more days per week) for a period of approximately 8 years, he has no

history of ongoing methadone use. Aubrey appears to have no lifelong problems with other opiates,

additionally he reports no periods of ongoing barbiturate use. He has no history of regular or ongoing use of

sedatives, hypnotics, or tranquilizers. Aubrey has never regularly used cocaine or amphetamines. Aubrey has

approximately a 6 year history of ongoing, regular cannabis use, he has no history of ongoing use of

hallucinogens. He has no history of regular or ongoing use of inhalants. Aubrey has no apparent history of

poly-drug use, including alcohol, for any time period of 6 months or more in his life. He has overdosed on

drugs once in his life. Aubrey has used heroin 30 days in the past 30, he has not used any methadone. Aubrey

either will not discuss or cannot remember if he has used any barbiturates in the past month, however, he

denies any other opiates or sedative use during this time. Aubrey has not used any cocaine or amphetamines

in the past 30 days. Aubrey has used cannabis 20 days in the past 30, he has not used any hallucinogens during

this time. He has not used any inhalants in the past month. In the past 30 days, Aubrey has not used any two

drugs, including alcohol, on the same day this month. In the past 30 days, Aubrey reports that he spent

$60.00 on alcohol and $500.00 on other drugs.

Alcohol and Drug Treatment History

Aubrey has never been treated for alcohol use disorder. Aubrey engaged in treatment 4 times for drug

dependence or drug related problems, 2 of these were withdrawal management treatment only. Aubrey's last

period of continuous abstinence from heroin lasted for 6 months, ending approximately 24 months ago. He

has not received any outpatient treatment, including attendance at AA, NA, or CA, for any drug or alcohol

problems in the past 30 days.

Client Perception of Severity of Alcohol and Drug Problems and Desire for Treatment

Aubrey does not report any alcohol problems in the past 30 days, and is not interested in treatment for

alcohol related problems. He either cannot or will not discuss how important alcohol treatment is at this time.

Aubrey experienced drug problems on 30 of the past 30 days, and is bothered profoundly by these problems.

Obtaining drug treatment is of profound importance to Aubrey.




Interviewer Impressions and Recommendations - Alcohol and Drugs

It is my impression that Aubrey was not able to understand the questions clearly enough to provide adequate

information in this section. It is my belief that heroin is his most significant substance use problem. He appears

to have moderate levels of alcohol related problems, treatment is probably needed. Aubrey has a profound

drug problem, and help obtaining appropriate treatment is absolutely necessary and should be prioritized.



LEGAL SECTION

History of Charges and Arrests

Aubrey's participation in this substance use evaluation was not prompted by the criminal justice system.

Aubrey was charged with drug crimes twice, he has never been arrested and charged with driving while

intoxicated. He was never charged with a weapons offense, he has never been arrested and charged with

assault. Aubrey reports being arrested and charged 4 times with probation/parole violations and twice for

shoplifting or vandalism. He was charged with robbery on two occasions, he has never been charged with

burglary, larceny, or breaking & entering. He has never been charged with attempted homicide, homicide or

manslaughter, however, he either cannot remember or will not discuss if he has ever been charged with rape

or attempted rape. He has never been arrested and charged with forgery, however, he either cannot

remember or will not discuss if he has ever been charged with arson. He either cannot remember or will not

discuss if he has ever been arrested and charged with prostitution. He either will not discuss or does not know

if he has been arrested and charged with any other crime. He was convicted on at least 2 of these charges.

Aubrey was charged with disorderly conduct, vagrancy, or public intoxication on one occasion, he has never

been charged with contempt of court. He either cannot remember or will not discuss if he has ever been

arrested and charged with any type of major driving violation. Aubrey has a one month history of

incarceration. His last incarceration lasted about one month and was for robbery.

Current Legal Involvement

In the past 30 days, Aubrey has not engaged in any illegal activities for profit, nor has he been detained or

incarcerated. He is not awaiting any type of charges, trial, or sentencing. He is currently on probation or

parole.

Client Perception of Severity of Legal Problems and Desire for Treatment

Aubrey feels his present legal problems are of moderate importance, he nevertheless feels that counseling for

his legal problems is not important.




Interviewer Impressions and Recommendations - Legal

It is my impression that Aubrey intentionally misrepresented information in this section. Aubrey has a

profound legal problem, and help obtaining appropriate legal counsel or referral is absolutely necessary and

should be prioritized.






FAMILY/SOCIAL SECTION

Marital and Living Situation for Majority of the Past Three Years

Aubrey is currently single, and is generally satisfied with this situation. Aubrey has never been married. Aubrey

has lived with sexual partner alone for most of the past three years, and has generally been satisfied with this

situation. Aubrey has recently been in this living arrangement for about 12 years.

Recovery Environment and Social Contacts

Aubrey states that his current living arrangement will discourage or hinder treatment and recovery. Aubrey

currently spends most of his free time with friends, and is generally satisfied with this situation. He reports

having 2 close friends on whom he can rely.

Relationship Problems Lifetime

Aubrey reports that he has had close, long lasting relationships with his mother, his father, his brothers/sisters

and his sexual partner/spouse. In his lifetime, he has had significant problems getting along with his partner,

but not his children. In his lifetime, he has had serious problems getting along with both his mother and

father. He has not had or reported serious problems getting along with other significant family members in his

lifetime (or this relationship is not applicable). He has had significant problems getting along with siblings, but

not with close friends. He has not had or reported any serious problems getting along with either neighbors or

co-workers (or this relationship is not applicable).

Relationship Problems Past Thirty Days

In the past 30 days, he has had significant problems getting along with his partner, but not with his children. In

the past 30 days, he has had serious problems getting along with both his mother and father. He has had

significant problems getting along with his siblings, but not his close friends. He has not had or reported

serious problems getting along with other significant family members (or this relationship is not applicable).

He has not had or reported serious problems getting along with either neighbors or co-workers recently (or

this relationship is not applicable). Aubrey expressed that he has been abused emotionally in the past 30 days.

Client Perception of Severity of Family and Social Problems and Desire for Treatment

Overall, he reports having 15 days of family related problems in the past 30 days, and is extremely troubled by

these problems. Obtaining treatment for family difficulties is extremely important to Aubrey. He reports

experiencing no problems with others, however, he does report that social issues are moderately troublesome

for him. Nonetheless, help obtaining treatment for social difficulties is moderately important to him.

Interviewer Impressions and Recommendations - Family and Social




It is my impression that Aubrey understood all of the questions, and that he did not deliberately misrepresent

this information. Aubrey has severe family or social problems, and help obtaining treatment in this area is

absolutely necessary and should be prioritized.






PSYCHIATRIC SECTION

Serious Emotional and Psychological Problems - Lifetime

Aubrey has a past history of psychiatric symptoms in his lifetime, including serious problems with depression

and anxiety. Aubrey denies having serious thoughts about suicide and does not have a history of attempting

suicide in his lifetime. Aubrey has a past history of difficulty understanding or concentrating, he does not

acknowledge a history of violent behavior. He does not have a history of being prescribed psychotropic

medications. He does not have a history of treatment for psychological or emotional problems. He does not

receive any financial compensation for a psychiatric disability.

Client Perception of Severity of Emotional and Psychological Problem and Desire for Treatment

Aubrey has had problems with depression in the past 30 days, and he was clearly depressed at the time of the

interview. Aubrey has had serious problems with anxiety in the past 30 days, and he was clearly anxious at the

time of the interview. Aubrey has not experienced suicidal ideation in the past 30 days and did not appear to

be having suicidal thoughts at the time of the interview. Aubrey has not attempted suicide in the past 30 days.

Aubrey has had trouble understanding or concentrating in the past 30 days, he was clearly having trouble with

memory/comprehension at the time of the interview. Aubrey denies experiencing any trouble controlling

violent behavior in the past 30 days, however, he was clearly hostile at the time of the interview. Aubrey has

not experienced hallucinations in the past 30 days and did not appear to be experiencing symptoms of a

thought disorder at the time of the interview. Aubrey has not been prescribed psychotropic medications in the

past 30 days. Aubrey experienced symptoms on 12 of the past 30 days, and is moderately bothered by them.

Obtaining psychological or emotional treatment is of moderate importance to him.

Interviewer Impressions and Recommendations - Psychiatric

It is unclear whether or not Aubrey can understand the questions in this section. He appears to have some

psychological or emotional problems or concerns, but treatment does not look as though it is necessary.






PATIENT PERCEPTION The following is a graph showing the patient's perception of his problems, column A, and his desire for

treatment, column B.

Medical 2 Employ 0 Alcohol 0 Drug 4 Legal 0 Family 4 Social 2 Psych 2

Medical 0 Employ 4 Alcohol 0 Drug 4 Legal 2 Family 4 Social 2 Psych 2

0

1

2

3

4

Medical Employ Alcohol Drug Legal Family Social Psych

Pat

ien

t's

Rat

ing

Problem Area

Patient Perception of Problem and Need for Treatment

Patient's Rating of ProblemPatient's Rating of Desire for Treatment

Rating Scale

0-Not at All, 1-Slightly, 2-Moderately, 3-Considerably, 4-Extremely




ADDICTION SEVERITY INDEX COMPOSITE SCORES The ASI Composite scores rate severity in seven areas of the patient's life. Analysis of his ASI responses revealed the following composite scores: (NOTE: The same score in different ASI Composite Subscales does not necessarily denote a similar extent of severity.)

ASI Composite Scores

Category Value

Medical 0.178

Employment 0.967

Alcohol 0.163

Drug 0.359

Legal 0.100

Family and Social 0.500

Psychiatric 0.400

0

0.2

0.4

0.6

0.8

1

ASI Composite Scores




PROBLEM LIST ASAM DIMENSION 1 - ACUTE INTOXICATION AND/OR WITHDRAWAL POTENTIALItem ID Item Statement ASId1-13b Substance(s) used within the past 3 days:

Alcohol, Heroin, Cannabis, Nicotine.ASIm6a Is the patient currently showing symptoms or signs of intoxication?

Not sure or possiblyASId99 Is the patient experiencing significant withdrawal, or is there evidence that withdrawal is

imminent? Consider substance intake, age, gender, previous withdrawal history, symptoms, physical, emotional, behavioral and cognitive conditions.Withdrawal (WD) OR evid. of imminent WD AND mod. risk of severe WD outside a program, but free of severe phys. & psych. complications AND would safely respond to several hours of meds & treatment

ASAM DIMENSION 2 - BIOMEDICAL CONDITIONS AND COMPLICATIONSItem ID Item Statement ASIm6 Medical problems in past 30 days?

Digestive, stomach, bowel, liver, pancreas, diabetes, Dental, teeth, gums, Urinary, bladder, .ASIm6i Do you have any unsteadiness on your feet, problems with walking or balance, such that you

could easily fall or have trouble getting around or using stairs?Not sure or possibly

ASIm6l Do you have any liver problems or disease (e.g., jaundice) that are so serious and worsening to the point that you might require inpatient treatment?Not sure or possibly

ASIm6o Has the patient suffered a serious impairment of mental status, cardiac or other vital function due to substance overdose in the past 24 hours?Not sure or possibly

ASIm6p Does the patient have more than one serious, active medical problem?Not sure or possibly

ASIm6q Would the patient's continued substance use endanger his/her medical condition?Yes

ASIm6r Does the patient exhibit any symptoms that would be considered life-threatening AND are related to alcohol or drug use?Yes

ASIm6s Is the patient's use of substances likely to cause a severely dangerous exacerbation of a medical condition?Yes




ASAM DIMENSION 2 - BIOMEDICAL CONDITIONS AND COMPLICATIONSItem ID Item Statement ASIm6t Does the patient's medical condition(s) make abstinence vital?

YesASIm6u Are the patient's biomedical problems the complications of alcohol or drug use?

YesASIm8a How much medical or nursing care or physical rehabilitation do you need?

HospitalizationASIm9 How would you rate the patient's need for medical treatment?

Moderate problems require close outpatient follow-up (e.g. diabetes)ASIm8 How important to you now is treatment for these medical problems?

Moderately

ASAM DIMENSION 3 - EMOTIONAL, BEHAVIORAL, OR COGNITIVE CONDITIONS AND COMPLICATIONSItem ID Item Statement ASIp4s Trouble falling asleep, staying asleep, or sleeping too much?

ExtremelyASIp4v Recurring & persisting thoughts, not just excessive worries, that intrude & make you feel bad?

ExtremelyASIp10a Are you currently receiving the psychiatric care and services that you need? (Don't include any

alcohol or drug service needs with this item)No

ASIp12 How much have you been troubled or bothered by the previously discussed psychological or emotional problems in the past 30 days?Moderately

ASIp13 How important to you now is counseling for these psychological problems? Why?Moderately, psychological needs will require specialized psychiatric care

ASIp19h Is the patient able to safely access the commuint? for work, education, and other commuint? resources?No

ASIp20a Does the patient's current behavior seem inconsistent with reliable self-care, safety, or ability to participate in treatment?Yes

ASIp22 Is the above information significantly distorted by the patient's inability to understand?Not sure or possibly




ASAM DIMENSION 4 - READINESS TO CHANGEItem ID Item Statement

In this Dimension, the patient's assessment did not reveal immediate treatment needs.

ASAM DIMENSION 5 - RELAPSE, CONTINUED USE OR CONTINUED PROBLEM POTENTIALItem ID Item Statement ASId14 Which substance is the major problem?

HeroinASId##Qa Interviewer: Has the patient responded to appropriate recent efforts by the prescriber to

maintain dose at therapeutic levels?No

ASId18d How many times in your life have you been treated for drug use problems?4

ASId19d Counting the times in your life you have been treated for drug use problems, how many of these were withdrawal management only?2

ASId19e Have you usually left withdrawal management before you were advised to, in the past?Yes

ASId21c Do you usually find you can't wait for things that you really want badly?Yes

ASId21d Is it hard for you to work at things that will only pay off in the future?Yes

ASIl26 How serious do you feel your present legal problems are (Exclude civil problems)?Moderately

ASIl28 How would you rate the patient's need for legal services or counseling?9

ASIl29 Is the above information significantly distorted by the patient's misrepresentation?Yes

ASId25e Is the patient manifesting any current serious escalation of relapse behaviors?Yes

ASId22e Imagine yourself in the environment in which you previously used drugs and/or alcohol. If you were living in this environment today, what is the likelihood that you would use?Extremely

ASId22f Rate how strong your urges are for a drug and/or alcohol when something in the environment reminds you of it.Extremely

ASId22g How strong is your desire to use any drug right now?Extremely




ASAM DIMENSION 5 - RELAPSE, CONTINUED USE OR CONTINUED PROBLEM POTENTIALItem ID Item Statement ASId22i Have your addiction symptoms increased recently? How...? (Ask about any items below not

mentioned by the patient) Have you had more craving, risk behaviors, more frequent use, increased amount of substance or have you used a more rapid route of administration?Increased use or more acute route of administration than before

ASId22k Do you feel you are likely to continue using or, if not using, that you are in danger of relapsing? How soon...? Do you feel at risk, even if you have had some treatment previously?At risk today

ASId25a How would you rate the patient's need for treatment for alcohol use problems?5

ASId23d How troubled or bothered have you been in the past 30 days by these drug problems?Extremely

ASId24d How important at this time is treatment for your drug problem (if any)?Extremely

ASId25d How would you rate the patient's need for treatment for drug use problems?9

ASId27 Is the above information significantly distorted by the patient's inability to understand?Yes

ASAM DIMENSION 6 - RECOVERY/LIVING ENVIRONMENTItem ID Item Statement ASIf6a Tell me about alcohol & drug use in your current living situation... How will these living

arrangements affect your needs for treatment & recovery?Will discourage or hinder treatment/recovery

ASIe19 How many days have you experienced employment problems in the past 30 days?30

ASIe20 How troubled or bothered have you been by these employment problems in the past 30 days?Extremely

ASIe22 How would you rate the patient's need for employment counseling?9

ASIe25 Comments

ASIf8a Tell me about alcohol & drug use in your free time activities... How will your free time affect your treatment & recovery?Will discourage or hinder treatment/recovery

ASIf9a Tell me about alcohol & drug use among your friends... How will your friends affect your treatment and recovery?Will discourage or hinder treatment/recovery




ASAM DIMENSION 6 - RECOVERY/LIVING ENVIRONMENTItem ID Item Statement

How many days in the past 30 have you had serious conflicts:

ASIf10b with your family15In the past month, have you had significant periods, in which you have experienced serious problems with:

ASIf11 MotherYes

ASIf12 FatherYes

ASIf13 Brother(s)/Sister(s)Yes

ASIf14 Sexual parter/SpouseYes

ASIf19a Have you been emotionally abused during the past 30 days?Slightly

ASIf19d Have you recently neglected/abused family members?Not at all

ASIf19e Did your neglect/abuse of family occur during your substance use?Yes

ASIf19f Is it likely that family neglect/abuse will worsen without care at a level greater than Level II?Extremely

ASIf19g Who is the person (or persons) with whom you have had contact during the past 4 months and who has been most important to you?Close friends

ASIf19h How much help will this person (or these persons) need to assist in your treatment and recovery and how likely is it that he/she/they will get involved in your treatment?Needs couples or family counseling or therapy and will participate

ASIf19i What is the likelihood that you could cause harm to or neglect others?Slightly

ASIf19k Is the risk of harm only a problem during alcohol or drug intoxication?Extremely

ASIf19l Are you able to locate & get yourself to community resources safely?NoHow troubled or bothered have you been in the past 30 days by these:




ASAM DIMENSION 6 - RECOVERY/LIVING ENVIRONMENTItem ID Item Statement ASIf20 How troubled or bothered have you been in the past 30 days by family problems?

ExtremelyASIf21 How troubled or bothered have you been in the past 30 days by social problems?

ModeratelyHow important to you now is treatment or counseling for these:

ASIf22 How important to you now is treatment or counseling for family problems?Extremely

ASIf23 How important to you now is treatment or counseling for social problems?Moderately

ASIf24 How would you rate the patient's need for family and/or social counseling?9

ASIf24d If transitioning to life in the community, does the patient need staff support to maintain recovery?Needs contact daily

Documents

Aubrey Graham [email protected] Assessment …...Aubrey Graham Interviewer: [email protected] Assessment Start: 2/26/2019 4:52 PM Assessment End: 2/26/2019 4:52 PM ALCOHOL