Washington Pact Form – Fill Out and Use This PDF

•Utilize client voice in direct quotes whenever possible to reflect attempts to gather information. Example: “I don’t have mental illness.” This helps ensure accuracy of assessment within the first 30 days.

Considerations for Assessing Substance Use in Part 3:

•Use assessment principles and practices consistent with Integrated Dual Disorders Treatment and Motivational Interviewing to assess consumers’ use and abuse of substances.

•In particular, remember that the first goal of substance abuse assessment within a PACT team is to facilitate an environment in which the consumer feels it is safe to talk openly with the team about substance use. Toward this end, Motivational Interviewing methods are especially helpful (e.g., using open-ended questions, using empathic and reflective statements, conveying a neutral and nonjudgmental stance).

•Specific substance abuse assessment forms, such as the Functional Analysis form and the Payoff Matrix, can be completed collaboratively with the consumer or completed initially by staff.

We hope that you find this updated template more purposeful and engaging for new PACT consumers admitted to the program.

For further questions and/or consultation on completion of the WA-PACT Comprehensive Assessment or this template, please contact Maria Monroe-DeVita, Ph.D. (206-604-5669 or mmdv@u.washington.edu) or Shannon Blajeski, MSW (206-685-0331 or blajes@u.washington.edu).

Mental Status Summary:

C. DSM IV

Axis I ______________________________________________________________

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Axis II ______________________________________________________________

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Axis III _____________________________________________________________

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Strengths/Resources

Comprehensive Time Line

Consumer Name

DOB

Marital Status

Education

Records Reviewed

Records Needed

Comprehensive Time Line

WA-PACT Comprehensive Assessment

Part 2: Physical Health

Do you have any specific medical problems or concerns about your health? Are you getting enough rest and exercise? If you smoke, are you interested in trying to quit?

If you want to make changes, what are they? What are your goals for staying healthy?

What are the barriers keeping you from being as healthy as possible? How could the PACT team help you with this area?

Name: __________________________________

3.Serious Illnesses and Disorders:

5.Previous Medical Hospitalizations

Current Medications (non-psychiatric only)

6.List the medications taken NOW, dosage, frequency, reason for taking, when started, last date taken and prescribing physician.

13.Children (number, names, and dates of birth/ages)

20. Mental Illness

21. Substance Abuse

22. Other

Bowel Medication:

40.If yes, how many days do they last?

41.How many days between periods?

44.Do you presently have any noticeable vaginal discharge or discomfort?

45.Have you ever been treated for a yeast infection?

Sexual

46.Do you have any sexual concerns?

47.Which is most true?

52.Did you plan on using any birth control in the future?

53.Are you aware of signs and symptoms of sexually transmitted diseases?

54.Have you ever suspected you have, had, or have you been treated for:

Do you know and/or use measures (e.g., condoms) to prevent sexually transmitted diseases?

55.Have you ever been sexually assaulted or abused?

56.Have you ever been treated for injuries connected with the above?

Summary of Significant Physical Conditions

Recommendations for Immediate Care & Diagnostic Treatment

Strengths/Resources

Name: __________________________________

WA-PACT Comprehensive Assessment

Part 3: Use of Drugs or Alcohol

Do drugs and/or alcohol influence your life right now? If so, how? (if person alludes to possible substance abuse or dependence, utilize assessment questions on page 2)

If you want to make changes, what are they? What are your goals for reducing or eliminating your use of drugs and alcohol and/or decreasing the harmful effect they have on your life?

What are the barriers to reaching these goals? (e.g. all my friends use, there are a lot of drugs in my building) How could the PACT team help you with your goals?)

Name: __________________________________

ASSESSMENT QUESTIONS

1.People use alcohol and street drugs for different reasons. What would you say are the reasons that you drink? That you use street drugs?

2.When you first started drinking/using, how much did you have to drink/use to feel drunk/high?

3.How much does it take for you to feel drunk/high now?

4.Do you find that using alcohol or drugs relieves tremors, shakes, sweating, anxiety, sleep problems, or hallucinations? Which ones?

5.Have you ever drank or used more than you originally planned?

6.Have you ever tried to cut down or quit drinking or using and found that you were unable to do

7.How much of your day do you think about drinking/using/coming down from using?

8.What is the longest you have been able to stay clean and sober?

9.How did you do it? What was helpful to you?

10.Have you ever been in treatment for alcohol or drug use?

11.What are the situations or times in which you DON’T use?

12.What do you think about continuing to use (assess his/her motivations or intentions concerning usage):

13.Describe the client's “islands of health” (those dreams, goals, values, strengths, aspects of the persons life that might be discrepant with drinking or drugging or be used as levers for change)

Name: __________________________________

CLINICIAN RATING SCALES:

SUBSTANCE ABUSE TREATMENT SCALE (SATS)

Client ID:____________________ Rating Date:___________

Instructions: Circle the most appropriate number. This scale is for assessing a person’s stage of substance abuse treatment, not for determining diagnosis. The reporting interval is the last six months. If the person is in an institution, the reporting interval is the time period prior to institutionalization.

1.Pre-engagement The person does not have contact with a case manager, mental health counselor, or substance abuse counselor, and meets criteria for substance abuse or dependence.

2.Engagement The person has had only irregular contact with case manager or counselor, and meets criteria for substance abuse or dependence.

3.Early Persuasion The person has regular contacts with a case manager or counselor, continues to use the same amount of substances or has reduced substance use for less than 2 weeks, and meets criteria for substance abuse or dependence.

4.Late Persuasion The person has regular contacts with a case manager or counselor, shows evidence of reduction in use for the past 2-4 weeks (few substances, smaller quantities, or both), but still meets criteria for substance abuse or dependence.

5.Early Active Treatment The person is engaged in treatment and has reduced substance use for more than the past month, but still meets criteria for substance abuse or dependence during this period of reduction.

6.Late Active Treatment The person is engaged in treatment and has not met criteria for substance abuse or dependence for the past 1-5 months.

7.Relapse Prevention The person is engaged in treatment and has not met criteria for substance abuse or dependence for the past 6-12 months.

8.In Remission or Recovery The person has not met criteria for substance abuse or dependence for more than the past year.

9.Not Applicable No substance use disorder

Comments: ____________________________________________________________

Name: __________________________________

CLINICAN’S RATING SCALES:

Alcohol Use Scale (AUS)

Initial rating will be based on self-report, records, and any other information gathered regarding client’s use over the previous six months. All other rating will be done on a quarterly basis.

Client ID:____________________ Rating Date:____________

1.Abstinent: no use of alcohol during this time period.

2.Use without impairment: use of alcohol during this time period but no evidence of persistent or recurrent problems related to use or dangerous use.

3.Abuse: use of alcohol and evidence of persistent or recurrent problems related to use or recurrent dangerous use.

4.Dependence: meets at least three of the following: greater amounts or intervals of use than intended, much of time used obtaining or using substance, frequent intoxication or withdrawal interferes with other activities, important activities given up because of alcohol use, continued use despite knowledge of alcohol or substance-related problems, marked tolerance, characteristic withdrawal symptoms.

5.Dependence with Institutionalization: Problems related to dependence are so severe that they make non-institutional living difficult.

CLINICIAN ALCOHOL USE RATING:

Name: __________________________________

CLINICAN’S RATING SCALES:

Drug Use Scale (DUS)

Initial rating will be based on client self-report, records, and any other information gathered regarding client’s use over the previous six months. All other rating will be done on a quarterly basis.

Client ID:____________________ Rating Date:____________

1.Abstinent: no use of drugs during this time period.

2.Use without impairment: use of drugs during this time period but no evidence of persistent or recurrent problems related to use or dangerous use.

3.Abuse: use of drugs and evidence of persistent or recurrent problems related to use or recurrent dangerous use.

4.Dependence: meets at least three of the following: greater amounts or intervals of use than intended, much of time used obtaining or using substance, frequent intoxication or withdrawal interferes with other activities, important activities given up because of drug use, continued use despite knowledge of alcohol or substance-related problems, marked tolerance, characteristic withdrawal symptoms.

5.Dependence with Institutionalization: Problems related to dependence are so severe that they make non-institutional living difficult.

CLINICIAN DRUG USE RATING: ___________

Identify drugs used:___________________________________

Name: __________________________________

MY RELAPSE PREVENTION PLAN:

1.Relapse Risk Factors:

2.Lifestyle factors (e.g., high stress):

3.My external triggers: ( people, places, things, times, dates, events):

4.Actions and decisions I make that set me up for relapse ( e.g., hanging out with people who use, going to drinking parties, telling myself that drinking a little won’t hurt):

5.Slips/lapse contingencies:

6.The likely short-term, negative consequences of continuing my drinking are:

7.The likely long-term, negative consequences of continuing my drinking are:

8.Health lifestyle/wellness: What I can do to prevent relapse (daily meditation or prayer, regular exercise):

9.Ways I can prevent or avoid experiencing these triggers:

10.Skills I can use to cope with these triggers if I do experience them, i.e. what I can think, actions I can take:

11.Alternative choices and decisions I can make:

12.People I can ask for support:

13.Other supports I think I need:

14.Resources I can use (for instance, AA):

15.If I do slip or lapse, what do I need to think and do?

Strengths/Resources:

Name: __________________________________

PAYOFF MATRIX

Advantages

Disadvantages

WA-PACT Comprehensive Assessment

Part 4: Money, Employment & Education

A.Money/Finances

What are your sources of income? What do you usually spend your money on? Do you have enough money to do the things you would like to do?

How do you mange your money? Do you have a budget?

If you want to make changes, what are they? In terms of money, what would your ideal situation be (if different from what it is now)?

What are the barriers keeping you from being in the financial situation you want to be in? How could the PACT team help you?

Name: ______________________________________

C.Military History

Have you ever been in the military? If so, what branch?

D.Education

Are you satisfied with your education? Do you feel you have the training you need to do the kind of work you want to do? Are there things you would just like to learn more about?

If you want to make changes, what are they? What are your goals for education/training?

What are the barriers keeping you from getting the education/training you want? How could the PACT team help you with this?

Name: ______________________________________

Please check the things you would like to do during the next six months or at some time in the future.

Strengths/Resources:

Name: ______________________________________

List all names of the members of the family of origin (i.e., parents and siblings) and of spouse or partner:

List the names of Children:

Strengths/Resources: