Request for Substance Use Disorder Services Form

Request for Substance Use Disorder Services Form (BH104)

Fax to GHC-SCW Care Management at (608) 831-6099
Member Name*

First NameLast Name
Member Date of Birth*

MonthDayYear
Date
Date of Request*

MonthDayYear
Date
GHC-SCW Member Number:*
ICD10 Code/DSM-5 Diagnosis*
Treating Provider/Agency*
Email of Person Submitting Online Form Request*
example@example.com
Treatment Summary

Please comment on client’s progress toward treatment plan goals, any current psychiatric concerns, and all urine drug screen results since last report. Comment on interventions used, what is working, what adjustments you will be making in your approach, if needed, and the goal for this next period of treatment.
American Society of Addiction Medicine Criteria

Placement Decision: Indicate for each dimension, the least intensive level of care consistent with sound clinical judgment and based on the client’s functioning, severity of condition, and service needs. Select the ASAM level that offers the most appropriate level of care that can provide the service intensity needed to address the client’s current functioning/severity. Please make criteria/symptoms listed objective, measurable, and quantifiable.
Dimension 1 - Alcohol Intoxication and /or Withdrawal Potential
Identify the criteria and symptoms which support the recommended ASAM level or care. (Please list CIWA and COWS scores if appropriate.)*
Dimension 2 - Biomedical Conditions and Complications
Identify the criteria and symptoms which support the recommended ASAM level or care (included any diagnosed medical conditions or disease). *
Dimension 3 - Emotional, Behavioral or Cognitive Conditions and Complications
Identify the criteria and symptoms which support the recommended ASAM level or care.*
Dimension 4 - Readiness to Change
Identify the criteria and symptoms which support the recommended ASAM level or care (include the stage of change client is in). *
Dimension 5 - Relapse, Continued Use or Continued Problem Potential
Identify the criteria and symptoms which support the recommended ASAM level or care. *
Dimension 6 - Recovery Environment
Identify the criteria and symptoms which support the recommended ASAM level or care (include whether or not the client is engaged in community self-help groups like AA, NA, Smart Recovery). *
ASAM Levels at this time.

Select the recommended ASAM Level of Care on all 6 dimensions.
1. Intoxication-Withdrawal*

IIIIIIIVOTP
2. Biomedical*

IIIIIIIVOTP
3. Emotional-Behavioral*

IIIIIIIVOTP
4. Tx Acceptance-Resistance*

IIIIIIIVOTP
5. Relapse Potential*

IIIIIIIVOTP
6. Recovery Environment*

IIIIIIIVOTP
Requested Level of Care*

OutpatientIntensive OutpatientResidentialInpatientPartial HospitalizationOTP (Opioid Treatment Program)
Identify Treatment Plan Goals (attach current treatment plan below) and Include Percentage of Goal Met
Percentage of Goal Met:

25%50%75%100%
Percentage of Goal Met:

25%50%75%100%
Percentage of Goal Met:

25%50%75%100%
Percentage of Goal Met:

25%50%75%100%
Please upload treatment plan here:

Cancelof
Discharge Criteria*
Anticipated Discharge Date*

MonthDayYear
Date
Request for Sessions (list number requested & if the sessions are group or individual)
Should be Empty:

Request for Substance Use Disorder Services Form (BH104)

Treatment Summary

American Society of Addiction Medicine Criteria

Dimension 1 - Alcohol Intoxication and /or Withdrawal Potential

Dimension 2 - Biomedical Conditions and Complications

Dimension 3 - Emotional, Behavioral or Cognitive Conditions and Complications

Dimension 4 - Readiness to Change

Dimension 5 - Relapse, Continued Use or Continued Problem Potential

Dimension 6 - Recovery Environment

ASAM Levels at this time.

Identify Treatment Plan Goals (attach current treatment plan below) and Include Percentage of Goal Met