» UR Number:
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Given name:
Date of birth:
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AOD
COMPREHENSIVE
ASSESSMENT
»
FOR STAFF ONLY
PURPOSE OF AOD
COMPREHENSIVE
ASSESSMENT
To ensure that the clients
comprehensive treatment
needs are adequately
assessed so they can
access the services most
suitable to their needs.
Clinician name: Agency: Catchment:
Referral source: Date referral received:
Signature: Date:
Version No. 2
UR Number:
AOD COMPREHENSIVE
ASSESSMENT
INSTRUCTIONS
• Use the intake tool as a starting point so that you can refer back instead of repeating questions that the client may have already answered
• Complete the core part of the assessment
• Complete any Optional Modules as appropriate or if desired
• Complete final case summary sheet and your agency’s care plan, and review regularly
THE OPTIONAL MODULES
OPTIONAL MODULE 1: Physical Examination
OPTIONAL MODULE 2: ABI referral tool
OPTIONAL MODULE 3: Mental Health (Modified MINI Screen)
OPTIONAL MODULE 4: PsyCheck
OPTIONAL MODULE 5: Quality of Life (WHOQOL-BREF)
OPTIONAL MODULE 6: Gambling (Problem Gambling Severity Index)
OPTIONAL MODULE 7: Goals
OPTIONAL MODULE 8: Assessment of recovery capital
OPTIONAL MODULE 9: Strengths
OPTIONAL MODULE 10: Family violence (DHS Identifying family violence recording template)
OPTIONAL MODULE 11: Impact of AOD use on family member (Significant Other Survey)
OPTIONAL MODULE 12: Forensic
UR Number:
1. ALCOHOL AND OTHER DRUGS (AOD)
1A) CURRENT LEVELS OF AOD USE
(check intake tool for additional information. If client was in hospital/prison/rehab in the previous month, record their substance use in the four weeks before that)
SUBSTANCE AGE AGE OF ROUTE AVERAGE DAILY DAYS DAYS DAYS DATE SEEKING
USE AT REGULAR OF USE USE USED USED INJECTED OF HELP
FIRST USE (ingests, (Quantity per day in IN IN PAST IN PAST LAST FOR
(Detail name of specific smokes, past four weeks, cost,
substances used)
USE injects, sniffs no. of injections, binge
PAST FOUR FOUR USE THIS
powder, inhales use etc) WEEK WEEKS WEEKS DRUG
vapour etc.)
Tobacco products
Smoking cessation support
desired?
Yes No
Quitline number (13 7848)
Alcoholic beverages
Cannabis
(marijuana, pot, grass, hash,
synthetic cannabis etc)
Cocaine
Methamphetamine
(ice, speed, base)
Other amphetamine
type stimulants
(MDMA /ecstasy, diet pills,
synthetic ATS etc)
FOR STAFF ONLY
Clinician name: Position: Signature: Date:
1
UR Number:
SUBSTANCE AGE AGE OF ROUTE AVERAGE DAILY DAYS DAYS DAYS DATE SEEKING
USE AT REGULAR OF USE USE USED USED INJECTED OF HELP
FIRST USE (ingests, (Quantity per day in IN IN PAST IN PAST LAST FOR
(Detail name of specific smokes, past four weeks, cost,
substances used)
USE injects, sniffs no. of injections, binge
PAST FOUR FOUR USE THIS
powder, inhales use etc) WEEK WEEKS WEEKS DRUG
vapour etc.)
Inhalants
(nitrous, glue, petrol, paint
thinner, Amyl etc)
Non-prescribed
sedatives or sleeping
pills (benzodiazepines,
xanax, valium, serapax,
rohypnol, stilnox etc)
Prescribed sedatives
or sleeping pills
Hallucinogens
(LSD, acid, mushrooms, PCP,
ketamine, synthetic
hallucinogens etc)
Non-prescribed opioids
(heroin, codeine, methadone,
oxycodone, morphine etc)
GHB
Prescribed opioids
Other
(steroids, caffeine/energy
drinks, Phenergan, new and
emerging drugs etc)
..............................................................................................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................................................................................
FOR STAFF ONLY
Clinician name: Position: Signature: Date:
2
UR Number:
1B) CURRENT DRUG USE STATE (signs of intoxication, withdrawal, BAC)
1C) AOD USE HISTORY AND BEHAVIOURS
TICK AS MANY BOXES AS RELEVANT TO
NOTES
INDICATE WHEN EXPERIENCED
Periods of abstinence
Current (within the last four weeks) Past Never
Treatment / interventions
Current (within the last four weeks) Past Never
Hospitalisations/ED presentations related to AOD use
Current (within the last four weeks) Past Never
Drug overdose
Current (within the last four weeks) Past Never
Aware of naloxone? No Yes
Withdrawal and related complications (seizures,
delirium, hallucinations etc)
Current (within the last four weeks) Past Never
Risky injecting practices (shares equipment etc)
Current (within the last four weeks) Past Never
Uses alone
Current (within the last four weeks) Past Never
Drives while intoxicated (or under the influence of
other drugs)
Current (within the last four weeks) Past Never
Notes/actions/patterns of use:
FOR STAFF ONLY
Clinician name: Position: Signature: Date:
3
UR Number:
2. PSYCHOSOCIAL
(check INTAKE TOOL. OPTIONAL MODULE 5: QUALITY OF LIFE; OPTIONAL MODULE 6: GAMBLING; OPTIONAL MODULE 7: GOALS also available)
2A) RESOURCES AND SUPPORTS (OPTIONAL MODULE 8: ASSESSMENT OF RECOVERY CAPITAL & OPTIONAL MODULE 9: STRENGTHS available)
Informal:
Formal:
Other services involved:
2B) GENOGRAM / ECOMAP / SOCIOGRAM
FOR STAFF ONLY
Clinician name: Position: Signature: Date:
4
UR Number:
2C) FAMILY, CHILDREN, DEPENDANTS AND SOCIAL RELATIONSHIPS (include responsibilities for children/dependants, the impact of substance use on
these, whether they are vulnerable, have child protection involvement and responsibility for pets)
Are children /dependants safe? Yes No
Details:
2D) HOUSING
Are you supported around housing?
FOR STAFF ONLY
Clinician name: Position: Signature: Date:
55
UR Number:
2E) FINANCES, EMPLOYMENT AND TRAINING (consider main income source such as benefits or employment and need for financial counselling)
2F) CURRENT LEGAL STATUS (OPTIONAL MODULE 12: FORENSIC available}
No criminal justice involvement Parole Youth justice Imprisonment
Drug treatment order (e.g., drug court) Bond Charged Police custody
Community correction order (CCO) Post-sentence supervision order Bail Non-parole
Compulsory treatment order (severe substance dependence Act 2011)
Drug diversion (e.g., courts, police, etc.) Please Specify: ....................................................................................................................................................................................
Other (e.g., family violence intervention or child protection order, etc.) Please Specify: ..........................................................................................................................
Charges pending, offences and legal history brackets (e.g. next court date, previous convictions, involvement with sheriff, etc.):
Correction officer / CISP Manager details:
Name:
Justice Office Location:
Phone:
FOR STAFF ONLY
Clinician name: Position: Signature: Date:
6
UR Number:
3. MEDICAL HISTORY
(OPTIONAL MODULE 1: PHYSICAL EXAMINATION available)
3A) PROBLEM/CONDITION/EXPERIENCE
CONDITIONS History of conditions, hospital admissions, past and needed investigations,
(tick as many as relevant) actions, or treatments where appropriate
Allergies
Dietary requirements
Cardiac or respiratory problems
(e.g. asthma, emphysema, high blood
pressure, heart attack/angina)
Gastrointestinal/hepatic problems
(e.g. liver disease, pancreatitis,
gastric ulcer, reflux)
Skeletal injuries or problems
(e.g. back injury, limb fracture or injury)
Endocrine problems
(e.g. diabetes)
Neurological problems
(e.g. fits, seizures, epilepsy, migraines)
FOR STAFF ONLY
Clinician name: Position: Signature: Date:
7
UR Number:
CONDITIONS History of conditions, hospital admissions, past and needed investigations,
(tick as many as relevant) actions, or treatments where appropriate
Head injuries or ABI
(Optional Module 2: ABI Referral Tool available)
Dental problems
Chronic pain condition
Pregnancy
Skin conditions
STIs (e.g., Chlamydia, gonorrhea,
herpes etc.)
Would the client like to be tested?
Yes No
Blood borne viruses
Has the client been tested for blood borne
viruses? Yes No
Would the client like to be tested for blood borne
viruses? Yes No
Would the client like info about current treatments
(e.g. Prep, Hep C)? Yes No
Other
FOR STAFF ONLY
Clinician name: Position: Signature: Date:
8
UR Number:
4. MENTAL HEALTH
4A) CURRENT DIAGNOSED CONDITIONS (consider administering OPTIONAL MODULE 3: MODIFIED MINI SCREEN or OPTIONAL MODULE 4: PSYCHECK if possible
undiagnosed mental health issues suspected or indicated by K10)
CURRENT DIAGNOSED CONDITIONS History of conditions, who diagnosed it and when, investigations, and treatments
(tick as many as relevant) where appropriate
Mood [affective] disorders
Depressive disorder
Bipolar affective Disorder
Mood Disorder (Unspecified)
Other
Anxiety disorders
Generalised Anxiety Disorder
Post-Traumatic Stress Disorder
Social phobia
Panic disorder
Specific phobias
OCD
Other
Psychotic disorders
Schizophrenia /schizoaffective disorder
Psychosis
Drug-induced psychosis
Other
Personality disorders
Borderline Personality Disorder
Anti-social Personality Disorder
Personality Disorder (other)
FOR STAFF ONLY
Clinician name: Position: Signature: Date:
9
UR Number:
CURRENT DIAGNOSED CONDITIONS History of conditions, who diagnosed it and when, investigations, and treatments
(tick as many as relevant) where appropriate
Behavioral Addictions
Pathological Gambling
Other
Eating disorders
Bulimia Nervosa
Anorexia Nervosa
Other
Other disorders
Intellectual Disability
Dementia
Attention Deficit Hyperactive Disorder
(ADHD)
Autism
Other. Please Specify: ......................................
Client has a mental health case manager or other mental health worker? No Yes
If Yes, worker name and contact details
Client has a MH care plan from GP No Yes
If Yes details
Current undiagnosed mental health concerns No Yes
If Yes, details
FOR STAFF ONLY
Clinician name: Position: Signature: Date:
10
UR Number:
4B) MENTAL STATE
Appearance/Behaviour
Grooming, hygiene, eye contact, motor activity, abnormal movements
Speech
Rate, volume (loud, quiet, whispered), quantity (poverty of speech,
monotonous, mutism), fluency (stuttering, slurring, normal)
Mood/Affect
Client (Self) rated mood on a scale of 1-10. Staff observed affect;
Anxious, elevated, blunted, labile (uncontrollably/excessively sad,
happy, angry), incongruent, range and intensity
Thoughts: Form
Amount and speed of thought, poverty of ideas. Flight of ideas,
perseveration, loosening of associations, continuity of ideas,
disturbances in language (incoherence)
Thoughts: Content
Delusions, suicidal thought, obsession and phobias
Perceptions
Hallucinations (auditory, visual taste, touch, smell), depersonalisation,
derealisation, illusions, distortion of senses, misinterpretation of
true sensation
Cognition
Level of consciousness & alertness, memory (recent and past),
orientation, concentration
Insight/Judgement
Client’s knowledge of problem and need for treatment. Reasoned,
poor or impaired judgement
FOR STAFF ONLY
Clinician name: Position: Signature: Date:
11
UR Number:
5. CURRENT PRESCRIBED MEDICATIONS
(including methadone, psychotropic medication, over-the-counter-drugs, and complementary medicines)
MEDICATION PRESCRIBED DOSE REASON FOR TAKEN AS PRESCRIBER/
AND DURATION PRESCRIPTION/USE PRESCRIBED. PHARMACY & PICK-
OF TREATMENT If no, reason? UP ARRANGEMENTS
& CONTACT DETAILS
Notes and actions:
FOR STAFF ONLY
Clinician name: Position: Signature: Date:
12
UR Number:
6. RISK
Complete your agency’s risk assessment form. The below table is just a guide, and not a replacement for your current risk assessment.
6A) SUICIDE AND SELF-HARM RISK (based upon SAFE-T approach)
Risk Comments
Sense of hopelessness/worthlessness
Current/past psychiatric diagnoses
Ongoing medical illness
History of abuse/neglect trauma
Intoxication
Stressful or triggering events
Previous attempts of suicide or self-harm
Suicidal inquiry Comments
Ideation (Do you ever think about killing/harming yourself)
Intent (Do you want to kill/harm yourself)
Plan (How would you do it)
Lethality (Is the method likely to be lethal)
Accessibility to means
Suicide/attempted-suicide
of significant other or family member
Protective factors Comments
Internal (coping ability, resilience spirituality, work etc.)
External
(responsibility to children or pets, social support,
therapeutic relationships, meaningful activities)
High risk? If YES, action taken (ie. referral etc)
Yes No
Reason/s:
FOR STAFF ONLY
Clinician name: Position: Signature: Date:
13
UR Number:
6B) HARM TO OR FROM OTHERS (history of violence to or from others including assaults (e.g., sexual), family violence, children present, threats to kill and relationship to AOD use)
(OPTIONAL MODULE 10: FAMILY VIOLENCE available to record family violence as appropriate)
Indication of being a victim of violence (incl. family violence) Yes No
Details:
Indication of being violent (incl. family violence) to others Yes No
Details:
Does the client feel safe? Yes No
Details:
FOR STAFF ONLY
Clinician name: Position: Signature: Date:
14
UR Number:
SAFETY PLAN: when do you need to call someone?
What happens before you reach this point? How to recognise when this is happening
People you can call:
Phone numbers:
Lifeline - Call 13 11 14 for 24 hour crisis support & suicide prevention
DirectLine - Call 1800 888 236 for 24 hour free and confidential advice, counselling and referral for any alcohol or
other drug related issues
Emergency services - 000
1800 Respect - 1800 737 732
Actions for you:
Who has a copy of plan?
Provide a copy of this page to the client
FOR STAFF ONLY
Clinician name: Position: Signature: Date:
15
UR Number:
7. FINAL CASE SUMMARY SHEET
Allergies:
GOALS AND REASONS FOR PRESENTATION (including client demographics e.g. gender, age & presenting issues)
MAIN SUBSTANCES Main substance
OF CONCERN:
1 Other substances
3
0-7 low risk
AUDIT score: 8-15 moderate risk
SUBSTANCE USE AND MENTAL HEALTH 16-19 high risk
>20 dependence likely
Potentially harmful use:
DUDIT score: >1 and the client is
female
>5 and the client is male
0-24 dependence
unlikely
>24 dependence likely
10-19 low psychological
K10 score: distress
20-24 mild
psychological distress
25-29 moderate
psychological distress
30-50 high
psychological distress
1 = Not dependent and
Tier (1-5): no complexity factors
2 = Not dependent and
complexity factors
3 = Dependent and 0-1
complexity factors
4 = Dependent and 2-3
complexity factors
5 = Dependent and 4+
complexity factors
RISK TO SELF, CHILDREN AND OTHERS: (if high risk suspected, document actions to be taken)
Risk to self:
0 None
1 Low
2 Medium
3 High
Risk to others 0 None
1 Low
2 Medium
3 High
Safety plan actions:
FOR STAFF ONLY
Clinician name: Position: Signature: Date:
16
UR Number:
OTHER KEY ISSUES (e.g. Medical, psychosocial etc.)
BRIEF CASE FORMULATION
Predisposing:
Precipitating:
Perpetuating:
Protective:
FOR STAFF ONLY
Clinician name: Position: Signature: Date:
17
UR Number:
TREATMENT TYPE/S DATE
AGREED ACTIONS (note referrals including agency name, contact worker,
REFERRAL
REQUIRED referral reason, & appointment time and date, & if referral letter sent, etc)
MADE
Brief intervention
Bridging support
Standard counselling
Complex counselling
Residential withdrawal
(include general hospital)
Non-residential withdrawal
Residential rehabilitation
Therapeutic day rehabilitation
Care and recovery coordination
Pharmacotherapy
Family support
Youth outreach
Other (please specify)
.............................................................
Date Assessment completed: Number of sessions to complete assessment:
Number of assessment sessions the client did not attend:
Setting where assessment was completed: Residential Non-residential Home Off-site Phone Other
Has the agency ‘consent to share information’ form been completed? No Yes
FOR STAFF ONLY
Clinician name: Position: Signature: Date:
18
