ASAM Form

MP_SNHU_withQuill_Horizstack

COU 640 ASAM Form

ASAM DIMENSIONAL SEVERITY PROFILE
ASAM Dimension	(0) No Problem	(1) Mild	(2) Moderate	(3) Substantial	(4) Severe
Dimension One: Acute intoxication and/or withdrawal potential
Dimension Two: Biomedical conditions and complications
Dimension Three: Emotional, behavioral, and cognitive conditions and complications
Dimension Four: Readiness to change
Dimension Five: Relapse, continued use, or continued problem potential
Dimension Six: Recovery/living environment

Notes/Reasons:

Dimension One: Acute intoxication and/or withdrawal potential

Dimension Two: Biomedical conditions and complications

Dimension Three: Emotional, behavioral, and cognitive conditions and complications

Dimension Four: Readiness to change

Dimension Five: Relapse, continued use, or continued problem potential

Dimension Six: Recovery/living environment

Reflection: