Substance Use Disorder Assessment

Staff Evaluations: Substance Use Disorder Assessment

Client Name(Required)

First Last

Client Date of Birth(Required)

Case/MDOC Number(Required)

Date of Evaluation(Required)

Referral Source(Required)

Referrer(Required)

First Last

Recommendations(Required)

Alcohol / Drug Education (Level I)

Alcohol / Drug Intervention (Level II)

Outpatient Treatment (Level III)

Intensive Outpatient (IOP)

Inpatient Treatment

Residential Treatment

Community Resources / Self-Help

MAST Score(Required)

DAST Score(Required)

BAC(Required)

Relevant Personal History(Required)

Prior Arrests / Criminal History(Required)

Current Arrest Information(Required)

Alcohol / Substance Use and Mental-Medical Health Background(Required)

Interviewer's Impression and Recommendation(Required)

Evaluator Name(Required)

First Last

Evaluator Title / Credential(Required)

Evaluator License #(Required)

By checking this box, I certify under penalty of perjury under the laws of the State of Michigan that my typed name and submission of this form constitute my true and authorized electronic signature.(Required)

I certify

Evaluator Signature (please type your name)(Required)

Date(Required)