University of Washington

UNIVERSITY OF WASHINGTON

Olympic Counseling Services’ Six‐Domain Adolescent Substance Use Assessment 
Name of Client (Last) School Attending (First) Grade (M.I.) Sex Male Female Age Date of Birth Date

Acute Intoxication/Withdrawal Potential/ASAM DOMAIN 1
PST CODES 1=Primary 2=Secondary 3=Tertiary Type PST ADMINISTRATION CODES O=Oral J=Injection S=Smoking N=Intra nasal H=Inhaling T=Other IM=Intra muscular Age of Age First Use Regular Use Started Administration Frequency Periodicity PERIODICITY CODES C=Continuous E=Episodic/Binge R=Remission U=Unknown Age and Date of Last Use Age Date FREQUENCY OF USE 1=No use in last month 4=3 to 6 times per week 2=1 to 3 times in last month 5=Daily 3=1 to 2 times per week 6=Unknown Initial Use and Major Experiences

Pattern of Last 3 Years Drug Usage (ONLY PRIMARY AND SECONDARY DRUG OF CHOICE) Grade and Summer Average Amount

Frequency

ALCOHOL

Grade Summer

ALCOHOL

Grade Summer

ALCOHOL

Grade Summer

CANNABIS Marijuana Hashish

Grade Summer

CANNABIS Marijuana Hashish

Grade Summer

CANNABIS Marijuana Hashish

Grade Summer

HALLUCINOGENS LSD Mushrooms Mescaline

Grade Summer Grade Summer Grade Summer Grade Summer

HALLUCINOGENS LSD Mushrooms Mescaline

HALLUCINOGENS LSD Mushrooms Mescaline COCAINE Crack

COCAINE Crack

Grade Summer

COCAINE Crack

Grade Summer

David Moore, Ph.D.; University of Washington Center for the Study and Teaching of At-Risk Students

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Acute Intoxication/Withdrawal Potential/ASAM DOMAIN 1 (Continued)
PST CODES 1=Primary 2=Secondary 3=Tertiary Type PST ADMINISTRATION CODES O=Oral J=Injection S=Smoking N=Intra nasal H=Inhaling T=Other IM=Intra muscular Age of Age First Use Regular Use Started Administration Frequency Periodicity PERIODICITY CODES C=Continuous E=Episodic/Binge R=Remission U=Unknown Age and Date of Last Use Age Date FREQUENCY OF USE 1=No use in last month 4=3 to 6 times per week 2=1 to 3 times in last month 5=Daily 3=1 to 2 times per week 6=Unknown Initial Use and Major Experiences

Pattern of Last 3 Years Drug Usage (ONLY PRIMARY AND SECONDARY DRUG OF CHOICE) Grade and Summer Average Amount

Frequency

NICOTINE

Grade Summer

NICOTINE

Grade Summer

NICOTINE

Grade Summer

STIMULANTS Amphetamines Methamphetamines Crank Ritalin STIMULANTS Amphetamines Methamphetamines Crank Ritalin STIMULANTS Amphetamines Methamphetamines Crank Ritalin INHALANTS Gas Butyl-Nitrate Glue

Grade Summer Grade Summer Grade Summer Grade Summer Grade Summer Grade Summer Grade Summer Grade Summer Grade Summer

INHALANTS Gas Butyl-Nitrate Glue INHALANTS Gas Butyl-Nitrate Glue

SEDATIVES/ BARBITURATES Dalmane Quaaludes Phenobarbital SEDATIVES/ BARBITURATES Dalmane Quaaludes Phenobarbital SEDATIVES/ BARBITURATES Dalmane Quaaludes Phenobarbital

David Moore, Ph.D.; University of Washington Center for the Study and Teaching of At-Risk Students

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Acute Intoxication/Withdrawal Potential /ASAM DOMAIN 1 (Continued)
PST CODES 1=Primary 2=Secondary 3=Tertiary Type PST ADMINISTRATION CODES O=Oral J=Injection S=Smoking N=Intra nasal H=Inhaling T=Other IM=Intra muscular Age of Age First Use Regular Use Started Administration Frequency Periodicity PERIODICITY CODES C=Continuous E=Episodic/Binge R=Remission U=Unknown Age and Date of Last Use Age Date FREQUENCY OF USE 1=No use in last month 4=3 to 6 times per week 2=1 to 3 times in last month 5=Daily 3=1 to 2 times per week 6=Unknown Initial Use and Major Experiences

Pattern of Last 3 Years Drug Usage (ONLY PRIMARY AND SECONDARY DRUG OF CHOICE) Grade and Summer Average Amount

Frequency

Opiates Heroin Codeine Percodan Opiates Heroin Codeine Percodan

Grade Summer Grade Summer Grade Summer Grade Summer Grade Summer Grade Summer Grade Summer

Opiates Heroin Codeine Percodan BENZODIAZAPINE Klonopin Valium, Librium Other Tranquilizers

BENZODIAZAPINE Klonopin Valium, Librium Other Tranquilizers

BENZODIAZAPINE Klonopin Valium, Librium Other Tranquilizers PHENCYCLIDINE (PCP)

PHENCYCLIDINE (PCP)

Grade Summer

PHENCYCLIDINE (PCP)

Grade Summer

OTHERS Cough/Cold Over the Counter Diet Aids, Nyquil Benadryl OTHERS Cough/Cold Over the Counter Diet Aids, Nyquil Benadryl OTHERS Cough/Cold Over the Counter Diet Aids, Nyquil Benadryl

Grade Summer Grade Summer Grade Summer

David Moore, Ph.D.; University of Washington Center for the Study and Teaching of At-Risk Students

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AMOUNT USED DURING WEEKPRIOR TO ASSESSMENT (For evaluating detoxification needs prior to treatment) DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 Date Day Substance Amount Substance Amount Substance Amount Current pattern of abuse and counselor’s estimate of Information reliability Preferred setting for alcohol or drug use (alone, with Friends, home, etc.) Describe longest period of abstinence MISUSE LEVEL Relaxation from social stress.
Feels the relaxation form social stress when using substances.

DAY 7

Emotional stress relief.
Receives emotional stress relief when using substances

Physical pre-tolerance. Body adaptation to substances has moved towards substance abuse levels. Increased ingestion rates of substances.
The substance use levels have continued upwards towards chemical dependency.

Intoxication. Levels of substance use have been great enough to cause behavioral and/or thinking impairment. Guilt.
Repeated episodes of intoxication have caused a self-esteem loss.

ABUSE LEVEL Concealment of substance use patterns.
Items noted have been actively concealed from parents, adults, or nonusing peers.

Pre-occupation.
A defines pattern of substance misuse has developed.

Denial.
Defensiveness about substance abuse has caused minimizing, rationalizing, or lying about problems and/or social lifestyle.

Break with peer norms.
The pattern of substance abuse (levels or behaviors) is contrary to a large number of same age adolescents. A substance use self-identity is developing.

Fixation with substance using peers.
Peer associations have strengthened denial and substance abuse patterns.

Personality changes related to substance use.
These features may have been present previously, but they are now aggravated and enmeshed in substance abuse.

Family recognition. Attempts to control.
Family recognition of problems and attempts to control adolescent’s use (e.g. arguments, grounding, fighting, etc.)

Personal recognition. Attempts to control.
Personal recognition of problems and attempts at control (cutting back, stopping, switching types of substances, etc.)

CHEMICAL DEPENDENCY LEVEL
Chemical dependency is present when three of the following seven areas have occurred in the adolescent’s substance abuse. These criteria are from the DSM-IV, American Psychiatric Association. The condition of chemical dependency is considered a chronic and serious risk to the person’s health and social development.

1.

Tolerance.
A need for more of a substance to achieve the same effect over time, or a decreasing effect with the continued use of a substance.

2.

Withdrawal.
Either physical withdrawal symptoms that cause significant functioning problems OR using a substance to relieve/avoid withdrawal symptoms.

3.

Control loss (unpredictability of use).
The substance is taken in larger amounts OR over a longer period of time than intended. NOTE: This can include blackouts and other substantial intoxication that the substance user would be expected to attempt to avoid. Repeated loss of control over behavior when intoxicated is evidence of control loss.

4.

Persistent desire or unsuccessful efforts to cut down OR control substance use.
Has this persisted over six months? Have efforts been unsuccessful over any amount of time?

5.

Spending a great deal of time (one or more of the following):
Under the influence (e.g. 12+ hours of intoxication) Seeking the substance (e.g. financial problems, giving up responsibilities to become intoxicated)

6. Changing lifestyle because of substance use by giving up/reducing important activities in the following areas (Choose one or more): Social. Recreational. Occupational.
Includes family and peer relationships. Weekend activities, sports, other organized activities or planned family activities. School work or academic involvement included.

7.

Substance use continues despite the youth’s knowledge that it is related to (choose one or more): Medical condition (includes exacerbating a pre-existing condition)
Check headaches, stomach problems, diabetes or other issues.

Psychological condition (includes exacerbating a pre-existing condition)
Particularly aggression, depression.

David Moore, Ph.D.; University of Washington Center for the Study and Teaching of At-Risk Students

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BIOMEDICAL CONDITIONS/COMPLICATIONS NEEDING MEDICAL MONITORING OR MANAGEMENT/ASAM DOMAIN 2 Hallucinations Liver problems High blood pressure Other ____________________ Convulsions Muscle cramps Diabetes Nausea/vomiting/upset DT’s Headaches Other ____________________ stomach Withdrawal or overdose history Assessment of current medical Condition and likelihood of Pregnancy EMOTIONAL/BEHAVIORAL OR COGNITIVE CONDITIONS AND COMPLICATIONS/ASAM DOMAIN 3 History (including past therapy)

Current (including current therapy)

Adolescent Developmental Level/Development problems associated with chemical use

SUICIDE Suicide Ideation Plan?

Verbal client If yes, please explain contract to not harm self? Parent/Guardian Yes If yes, please explain Notified? No ABUSE AND/OR NEGLECT Abuse (current and history, current risk). SEXUAL ABUSE, PHYSICAL ABUSE, PSYCHOLOGICAL ABUSE

Yes No Yes No Yes No

If yes, please explain If yes, please explain

CHILD PROTECTIVE SERVICES/DFYS DFYS contact report made? Time and Date of call: Meets DFYS mandatory reporting? Yes No Yes No RUNNING AWAY/OUT OF HOME PLACEMENT/INSTITUTIONAL CARE Counselor’s assessment of client’s history of running away, out of home placements, institutional care or custody. GRIEF/LOSS Grief and loss issues:

Name of DFYS Caseworker:

AREAS OF CONCERN Possible Depressive Conditions: (Depression) Sadness Erratic sleep Lack of appetite Negative self statements Thoughts of harming self Plans to harm self

Withdrawal and isolation from others. (Dependency or avoidant disorders) Comments

Feelings of hostility or aggressive behavior. (Conduct disorder)

Possible obsessive, ruminating, or anxiety producing thought patterns. (Anxiety or obsessivecompulsive disorders

Fear of others. (Avoidant or paranoid disorders)

David Moore, Ph.D.; University of Washington Center for the Study and Teaching of At-Risk Students

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READINESS TO CHANGE/ASAM DOMAIN 4 Precipitating Factor

Explanation

Yes Acknowledges problem No Yes Recognizes treatment need No DENIAL SUMMARY Open, cooperative, adequate self-disclosure of significant problems. Comments

Yes No Yes No

Recognizes role of secondary substances Evidences minimization

Yes No Yes No

Evidences blame or projection Evidences rationalization

Cooperative, inadequate self-disclosure of personal problems.

Guarded, resistant to assessment process.

NON-COMPLIANCE CHECKLIST Prior treatment Previously left completed treatment AMA Denying level of substance use problem Denies needing/belonging in treatment

Complaining about intake or past treatment Expresses desire to leave treatment

Shaking, tremulous, diaphoretic (sweating)

Talking about outside issues

Other________________________________

EXTERNAL MOTIVATION Legal Status:(Courts, Deferred Prosecution, Diversion, Pending Charges) Number of Arrests: Probation Officer School Status: (Suspensions, expulsion, school staff involvement with referral)

Attorney

Counselor’s assessment of patient’s motivation for recovery

List of local offenses

RELAPSE /CONTINUED USE/CONTINUED PROBLEM POTENTIAL/ASAM DOMAIN 5 Dates Agency Outcome Dates

Agency

Outcome

SCHOOL SUPPORT School support group involvement

Yes No

Type of support:

Dates___________________ SELF-HELP GROUP INVLOVEMENT Has client attended a 12No CA step study group? Date first attended (month/year) Alanon Alateen Does client have a Does client have a Has client done a 5 home group? sponsor? Step? Yes No Yes No Yes No Has client ever completed formal treatment (inpatient or outpatient)or Yes No Become involved in a self-help group followed by 3 months sobriety? If yes, when AA NA Does client have significant preoccupations or cravings? Yes No
th

Frequency of attendance:

MEDICATIONS/TRIGGERS/CRAVINGS Stashed at home? Yes No

Is client unable to manage “triggers” in environment (patterns, moods, occasions, etc.)? Yes No

COUNSELOR’S ASSESSMENT Counselor’s assessment of client’s ability to attain and maintain abstinence:

Counselor’s assessment of client’s risk of relapse

David Moore, Ph.D.; University of Washington Center for the Study and Teaching of At-Risk Students

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RECOVERY ENVIRONMENT/ASAM DOMAIN 6 Family Involvement Yes No Currently Marital Status Single Both parents living with Married Mother Divorced Father Job/School Status Learning Disabilities/Special Education and Needs Reading Level/Learning Ability COUNSELOR’S ASSESSMENT Counselor’s assessment of client’s strengths/abilities/preferences/needs. Counselor’s assessment of client’s needs. (Include current and future safety needs and risk factors). Counselor’s assessment of client’s current and historical custodial status. FAMILY HISTORY OF CHEMICAL DEPENDENCY Circle appropriate code letter below P= Problem (no treatment) T=Treated Relationship Living with Alcoholism/ client Substance Abuse Maternal Yes No P T UK N C Grandmother Maternal Yes No P T UK N C Grandfather Paternal Yes No P T UK N C Grandmother Paternal Yes No P T UK N C Grandfather Mother Yes No P T UK N C Father Step Mother Step Father Brother Brother Brother
(age) (age) (age)

Grandparents Other family Friends

Foster Care Other (specify)

Does client have children?

Yes No

If Yes, specify ages of children

UK=Unknown N=No Problem C=Current Use Psychiatric Relationship Living with Alcoholism/ Problem client Substance Abuse P T UK N C Brother (age) Yes No P T UK N C P T UK N C P T UK N C P T UK N C P T UK N C P T UK N C P T UK N C P T UK N C P T UK N C P T UK N C P T UK N C Sister Sister Sister Sister Sister
(age) (age) (age) (age) (age)

Psychiatric Problem P T UK N C P T UK N C P T UK N C P T UK N C P T UK N C P T UK N C P T UK N C P T UK N C P T UK N C P T UK N C P T UK N C

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No No No

P T UK N C P T UK N C P T UK N C P T UK N C P T UK N C P T UK N C P T UK N C P T UK N C P T UK N C P T UK N C

Yes Yes Yes Yes Yes Yes

No No No No No No

P T UK N C P T UK N C P T UK N C P T UK N C P T UK N C P T UK N C

Significant Other Best Friend Other (specify) Other (specify) Other (specify)

FAMILY INVOLVEMENT Family involvement in the evaluation or treatment process GANG INVOLVEMENT AXIS I: DAIGNOSTIC SUMMARY OF SUBSTANCE USE Since drug/alcohol problems are seen as healthcare problems, the evaluation uses the American Medical Association’s health care codes and evaluation standards, the minimum level of problem is: th AMA Codes: (Each number used as the 5 digit indicates) 1=Continuous 2=Episodic/Binges 3=Disease in Remission No identifiable substance problem Substance Misuse (intoxication and impairment) Alcohol:303.0___ Barbiturates: 292.89___ Amphetamines/Speed: 292.89___ David Moore, Ph.D.; University of Washington Center for the Study and Teaching of At-Risk Students Glue (Inhalants): 292.89___ Hallucinogens: 292.89___ Marijuana/Hashish: 292.89___ Opiates: 292.89___ Cocain:292.89___ Other (specify):292.89_______ ___________________________

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Substance Abuse (Intoxication and impairment) Alcohol:305.0___ Barbiturates: 305.4___ Amphetamines/Speed: 305.7___ Chemical Dependency Alcohol:303.9___ Barbiturates: 304.1___ Amphetamines/Speed: 304.4___ Glue (Inhalants): 304.5___ Hallucinogens: 304.5___ Marijuana/Hashish: 304.3___ Opiates: 304.0___ Cocain:304.2___ Other (specify):304.9________ ___________________________ Glue (Inhalants): 305.9___ Hallucinogens: 305.3___ Marijuana/Hashish: 305.2___ Opiates: 305.5___ Cocain:305.6___ Other (specify):305.9________ ___________________________

Poly Substance Dependence 304.8___

Significant Defensiveness due to potential client resistance The recommended education or therapy is designed to complete the diagnosis and keep the client substance-free. AXIS I: DIAGNOSTIC SUMMARY (Additions to Any Substance Use Disorder) Mental Health Screening Referral: 799.9___ RULE OUT/ EVALUATE: AXIS II: PERSONALITY DEVELOPMENT Diagnosis deferred (may need further testing): 799.9___ AXIS III: PHYSICAL DISORDERS/CONDITIONS Indicate concerns that are potentially relevant to case management and noted on a physician’s H & P

AXIS IV: SEVERITY OF PSYCHOSOCIAL STRESSORS FOR THE PAST YEAR Problems with primary support group: (specify) Problems related to social environment: (specify) Educational problems: (specify) Occupational problems: (specify) Housing problems: (specify) Economic problems: (specify) Problems related to interaction with the legal system/crime: (specify) Other psychological and environmental problems: (specify) AXIS V: GLOBAL ASSESSMENT OF FUNCTIONING Indicate client’s relative location on the continuum scale below. Consider psychological, social and educational functioning on a hypothetical continuum of mental-health illness. Do not include impairment in functioning due to physical (or environmental) limitations. INSTRUCTIONS: Circle an appropriate set of numbers in each column. CURRENT
Superior functioning in a wide range of activities, life’s problems never seem to get out of hand, is sought out by others because of his or her many positive qualities. No symptoms. Absent or minimal symptoms (e.g. mild anxiety before exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g. an occasional argument with family members) If symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g. difficulty concentrating after family argument) no more than slight impairment in social, occupational or school functioning (e.g. occasional truancy or theft within the household) but generally functioning pretty well, has some meaningful interpersonal relationships.

PAST YEAR 91-100
Serious symptoms (e.g. suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g. no friends, unable to keep a job). Some impariemnt in reality testing or communication (e.g. speech is at times illogical, obscure or irrelevant) or major impairment in several areas such as work or school, family relations, judgement, thinking or mood (e.g. avoids friends, neglects family, frequently beats up younger children, defiant at home, failing at school). Behavior is considerably influenced by delusions or hallucinations or serious impairment in communication or judgement (e.g. sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all areas (e.g. stays in bed all day, no job, home or friends).

CURRENT 41-50

PAST YEAR 41-50

91-100

81-90

81-90

31-40

31-40

71-80

71-80

21-30

21-30

David Moore, Ph.D.; University of Washington Center for the Study and Teaching of At-Risk Students

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CURRENT
Some mild symptoms (e.g. depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g. occasional truancy or theft within the household) but generally functioning pretty well, has some meaningful interpersonal relationships. Moderate symptoms (e.g. flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational or school functioning (e.g. no friends, conflicts with coworkers).

PAST YEAR 61-70
Some danger of hurting self or others (e.g. suicide attempts without clear expectation of death, frequently violent, manic excitement) or occasionally fails to maintain minimal personal hygiene (e.g. smears feces) or gross impairment in communication (e.g. largely incoherent or mute) Persistent danger of severely hurting self or others (e.g. recurrent violence) or persistent inability to maintain minimal personal hygiene or serious acts with clear expectation of death.

CURRENT 11-20

PAST YEAR 11-20

61-70

51-60

51-60

1-10 0

1-10 0

Inadequate information

ADDITIONAL INFORMATION ON CONFIDENTIALITY AND REFERRAL SPECIFIC TO RIVERSIDE COUNTY OFFICE OF EDUCATION CAN BE PLACED HERE IN MEDICAL RECORDS FORM

David Moore, Ph.D.; University of Washington Center for the Study and Teaching of At-Risk Students

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Assessment Summary Sheet
Client was referred by the following: Probation Officer name:________________ Counselor or Physician name:________________ School District Parent

Self High

Review of American Society of Addiction Medicine Domains and Level Decisions Low Medium I. Intoxication and withdrawal, including Post Acute Withdrawal II. Biomedical conditions and complications III. Emotional, behavioral and cognitive conditions and complications
Consider the following: a) dangerousness/lethality, b) interference with recovery efforts, c) social functioning, d) ability for self-care, and e) course of illness.

IV. Readiness to change, includes treatment resistance and motivation V. Relapse prevention skills, continued use or problem potential VI. Recovery environment, including family and peer systems Summary Placement Decision Based on ASAM Criteria Select One Care Level Description Level .5* Motivational Psychoeducation and Evaluation Level 1.0* Outpatient Treatment (1-8 hours weekly) Level 2.0** Intensive outpatient Treatment (9-12 hours weekly) Level 2.5*** Day Treatment Level 3.5 Residential Treatment in a Recovery House Setting Level 3.7 Residential Treatment in a Medically Managed Setting Level 4.0 Hospital-Based Care in a Medically Managed Setting Patient Elects Services at the following level: __________ Level .5 through 2.5 services available at T-4 Learning Center * If client was recommended to level .5 or 1.0 please indicated desired groups. ** If client was recommended to level 2.0 all groups are indicated. *** If client was recommended to level 2.5 all groups plus Community Health Class Please indicated desired groups/class: Community Health Class [daily therapy curriculum] Primary men’s/women’s process group (1 hour weekly) 12-Step Study Group (1 hour weekly) Intensive Education Group (2 hours weekly) Multi-Family Group (1 hour weekly) Relapse Prevention Group (2 hours weekly) Individual Counseling Monitored Urinalysis Residential Programs Level 3.0 through Level 4.0 Level 3.5 [ADD Program Option] Level 3.5 [ADD Program Option] Level 3.7 [ADD Program Option] Level 3.7 [ADD Program Option] Level 3.7 Sundown M Ranch (WA) (800) 327-7444 Level 4.0 [ADD Program Option] Level 4.0 [ADD Program Option] Level 4.0 [ADD Program Option]

David Moore, Ph.D.; University of Washington Center for the Study and Teaching of At-Risk Students

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AIDS/HIV BRIEF RISK ASSESSMENT AND TB SCREEN AIDS/HIV brief risk intervention was conducted in accordance with public health recommendations, and if appropriate, a referral was made to related services. Signature of counselor: CLIENT ACKNOWLEDGEMENT OF ASSESSMENT OUTCOME Yes, client was informed No, client was not informed. Explain:_____________________________________________________________________________ _____________________________________________________________________________________________________________ Client has elected to receive services from:___________________________________________________________________________ I have been informed of my assessment results and advised of the right to be referred to any appropriate facility offering services consistent with the results of the assessment. When available, three referral options were provided. Signature of Client: Date: Client was informed of assessment results, and advised of the right to be referred to any appropriate facility offering services consistent with the results of the assessment. When available, three referral options were provided. Signature of Counselor: Date: Date

David Moore, Ph.D.; University of Washington Center for the Study and Teaching of At-Risk Students

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