ASAM Self Assessment Tool

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Instructions: Please answer the following questions based on the individual’s current situation and needs. For each response, assign the corresponding score. Add up the scores to determine the level of care needed according to the ASAM criteria.

Name *

First

Last

Email *

Phone Number *

Acute Intoxication and/or Withdrawal Potential: Are you currently experiencing acute withdrawal symptoms, or have a recent history of substance use? *

No (0)
Yes (1)

Biomedical Conditions and Complications: Do you have any medical conditions that require management or affect your ability to participate in treatment? *

No (0)
Yes (1)

Emotional, Behavioral, or Cognitive Conditions and Complications: Do you have any mental health, behavioral, or cognitive conditions that require management or affect your ability to participate in treatment? *

No (0)
Yes (1)

Readiness to Change: Are you currently motivated and willing to engage in treatment? *

Yes (0)
Uncertain (1)
No (2)

Relapse, Continued Use or Continued Problem Potential: Do you have have a recent history of relapse, continued substance use, or continued problems related to substance use? *

No (0)
Yes (1)

Recovery Environment: Do you have a supportive and safe recovery environment? *

Yes (0)
Uncertain (1)
No (2)

Add Your Score Together To Determine Level Of Care Needed: *

ASAM Criteria Level of Care Guidelines:

Score of 0-1: Level 1 outpatient treatment
Score of 2-3: Level 2 intensive outpatient or partial hospitalization treatment
Score of 4-5: Level 3 residential or inpatient treatment
Score of 6 or higher: Level 4 medically-managed intensive inpatient treatment detox or rehab

Note: This tool is intended as a guide only, and a comprehensive assessment by a qualified professional is recommended to determine the appropriate level of care needed for each individual. Once submitted one of our team members will reach out to you to discuss further. All calls and inquiries are kept strictly confidential.

Call 800-638-5370

Bundy Recovery

151 Haddon Ave F, West Berlin, NJ 08091

[email protected]
800-638-5370

ASAM Self Assessment Tool

Instructions: Please answer the following questions based on the individual’s current situation and needs. For each response, assign the corresponding score. Add up the scores to determine the level of care needed according to the ASAM criteria.

ASAM Criteria Level of Care Guidelines:

Score of 0-1: Level 1 outpatient treatment

Score of 2-3: Level 2 intensive outpatient or partial hospitalization treatment

Score of 4-5: Level 3 residential or inpatient treatment

Score of 6 or higher: Level 4 medically-managed intensive inpatient treatment detox or rehab

Bundy Recovery