Exhibit 15 - Smart TAP Assessment.pdf

Exhibit 15 - SMART TAP Assessment

Client Profile

Client’s First Name: Last Name:

SSN# DOB Gender: Male Female

Zip Code

Race:

Pacific Islander

Ethnicity: panic

Highest Grade Completed For grades 1-11 enter the number 12/High School Diploma/GED st College/Graduate School Degree

H.S. Diploma:

Veterans Status

– In Combat 0-6 months ago

– In Combat 6-12 months ago n – In Combat more than 12 months ago.

INTAKE

County of Residence: Injection Drug User:

Currently Pregnant: Unknown (If Yes enter Due Date / / ) Intake Date / /

Presenting Problem ( In Client’s own words)

Explanation for Veterans Status.

When asking about a client’s veterans status please select from the list documented here on the form only.

DPDS - SUDTS (Pre-Trial) Solicitation #: BPM055260

Source of Referral:

Aids Administration Other Criminal Justice Alcohol and Drug Abuse Admin. Other Health Care Provider Alcohol/Drug Abuse Care Provider Parent/Guardian/Family Defense Attorney Parole Drug Court Poison Control Agency DSS/TCA (Temporary Cash Asst.) Pre-Trial Services Agency DWI/DUI Referral Probation Employer/EAP School Individual/Self Referral State Prison Juvenile Justice Student Assistant Program Local Detention TASC-Other Diversionary programs Other Attorney DHMH (HG-8505) Other Community Referral DHMH (HG-507)

TREATMENT ASSIGNMENT PROTOCOL (TAP) ASSESSMENT

Class: Intake Follow-up How Long at Current Address: Yrs Mos

Is the Residence Owned by You or Family? Yes No

Primary Payment Source

Primary Adult Care (PAC) ADAA (State Funding) DHMH Managed Care/Health Choice Medicaid Other than Health Choice Other Medicare Non-Managed Private Insurance

Interviewed By:

Special Code: N/A, Interview Completed Patient Terminated

Patient Refused Patient Unable to Respond

Religious Preference? Baptist Catholic

Methodist Jewish

Non-denominational Protestant Islamic Other None

Controlled Environment past 30 days No Jail Alcohol/Drug Treatment Medical Treatment Psychiatric Treatment

If in a controlled environment how many days did you spend there?

Days Attended AA/NA/Similar Meetings in Last 30 Days Days on Wait List

Is this TAP for Concerned Person: Yes No Months Since DC From Last Admission

Event Type: Admission Crisis Intervention Placement Screening Event Type Date

DPDS - SUDTS (Pre-Trial) Solicitation # - BPM055260

Muscle Aches, bone pain

Withdrawal

1. What is the longest # of days in a row that you have gone without using alcohol and/or drugs:

a. In the last 30 days? b. In the last 6 months?

2. Is the client reporting or exhibiting any of the following symptoms:

Headaches Increased pulse rate

Depression Runny Nose

Excessive Sleeping Seizures Excessive Yawning Tremors

Watery eyes

3. How many times in your life have you been treated for:

a. Alcohol abuse? b. Drug abuse?

4. How many of these were for:

a. Alcohol detox only? b. Drug detox only?

5. How many days in the last 30 have you been treated for alcohol and/or drugs as an:

a. In-patient? b. Out-patient?

6. How many times in the last 30 days have you used:

a. Alcohol? b. Drugs?

1. 1-2 times per week 5. Daily

2. 1-3 times per month 6. More than 3 times daily

3. 2-3 times daily 7. No use in past month

4. 3-6 times per week 8. Unknown

7. How many days in the last 30 have you experienced:

a. Alcohol problems? b. Drug problems?

8. How many times have you had:

a. Alcohol DTs? b. A drug overdose?

Agitation

DPDS - SUDTS (Pre-Trial)

9. Do you sometimes use prescription, over the counter medication, alcohol, or an illicit drug to No relieve withdrawal symptoms? Yes No

10. Have you noticed the need to increase the amount you use to achieve the same effect or high, Yes or sometimes feel less effect or high, after using your usual amount? Yes No

11. Would you say that you often use more than you initially intended to over a longer period of time?

Yes No

12. Have you ever had blackouts while drinking or using; drank or used enough that you could not No remember what you said or did the next day? Yes No

13. Would you say that you spend a great deal of time obtaining the substance(s) you use, using No them, and/or recovering from their effects? Yes No

14. IV drug use in the past? Yes No

15. Do you currently use tobacco?

No Tobacco Use Cigarettes Cigars and Pipes Smokeless Tobacco Combo/more than 1

16. If yes, indicate daily amount? 1/2 Pack 2 Packs 1-2 Packs ½-1 Pack No tobacco use

17. Would there be adequate support at home for you if you needed help while detoxing? Yes No

18. Do you have significant problems with other possible addictions such as sex, eating disorders, No or gambling? Yes No

Interviewer Rating:

19. How would you rate the client's need for detox treatment?

Critical High Moderate Low Not at all

Notes:

DPDS - SUDTS (Pre-Trial) ansmitted disease

Medical

1. How many times in your life have you been hospitalized for medical treatment?

2. How long ago was your last hospitalization for a physical problem? Yrs Mo

3. Do you have a history of or current diagnosis of any of the following:

(Select all that apply)

4. Do you have chronic medical problems which continue to interfere with your life? Yes No

5. Are you taking any prescribed medication on a regular basis for a physical problem? Yes No

If yes please list:

6. How many days in the last 30 have you experienced medical problems?

(If answer is greater than 0 proceed to #7. If not proceed to #8)

7. How troubled have you been in the last 30 days by these medical problems?

Not at all Slightly Moderately Considerably Extremely

8. How many times in the last 30 days have you visited an ER?

9. Have you ever been diagnosed with TB? Yes No

10. Are you currently using birth control? Yes No

11. What is your weight? lbs.

12. Have you noticed a recent weight loss? Yes No

13. How many times in the last 6 months have you been hospitalized due to a non-Tx drug and/or alcohol related problem?

DPDS - SUDTS (Pre-Trial)

Interview Rating:

14. How would you rate the client's need for detox treatment?

Critical High Moderate Low Not at all

Notes:

DPDS - SUDTS (Pre-Trial)

Co-occurring

1, How many times have you been treated for any psychological or emotional problems in a hospital or in-patient setting?

Questions 2-9 Have you had a significant period, that was not a direct result of alcohol/drug use, in which you have:

(The questions requires a Yes/No response for both columns.) Past 30 Day Lifetime 2 Experienced serious depression, sadness, hopelessness, lack of interest?

3 Experienced serious anxiety, tension, inability to relax, unreasonable worry?

4 Experienced hallucinations or saw/heard things that did not exist?

5 Experienced trouble understanding, concentrating, remembering?

6 Experienced trouble controlling violent behavior including rage or violence?

7 Experienced serious thoughts of suicide?

8 Attempted suicide?

9 Been prescribed meds for psychological or emotional problems?

If #9 is yes for 30 day or lifetime please specify medications:

10. How many days in the last 30 have you experienced psychological or emotional problems?

(If answer is greater than 0 proceed to #11. If not proceed to #12)

11. How troubled have you been in the last 30 days by these emotional problems?

Not at all Slightly Moderately Considerably Extremely

12. Psychiatric problem in addition to alcohol/drug problem? Yes No

Interview Rating:

At the time of the interview was the client:

13. Obviously withdrawn/depressed? Yes No

14. Obviously hostile? Yes No

15. Obviously anxious/nervous? Yes No

16. Having trouble with reality testing, thought disorders, paranoid thinking? Yes No

17. Having trouble comprehending, concentrating, remembering? Yes No

18. Having suicidal thoughts? Yes No

19. How would you rate the client's need for treatment for emotional problems?

Not at all Slightly Moderately Considerably Extremely

Notes:

DPDS - SUDTS (Pre-Trial)

Motivation

1 Is the client motivated to change his/her alcohol/drug use? Yes No

2. Are there any medical conditions which interfere with the client's treatment needs? Yes No

If yes please specify:

3. How important now to the client is treatment for these medical problems?

Not at all Slightly Moderately Considerably Extremely

4. Are there any psychological conditions which interfere with the client's treatment needs? Yes No

5. How important now to the client is treatment for these psychological problems?

6. How would you rate the client's readiness to change?

Action Contemplation Determination Maintenance Pre-contemplation Relapse

Notes:

DPDS - SUDTS (Pre-Trial)

1. Which substance/s is considered the client's Primary, Secondary, Tertiary

2. Was the substance prescribed to the client?

3. What was the age of first use?

4. What is the Severity of use?

5. What is the frequency of use?

6. What are the methods of use?

Alcohol/Drug Usage

For Questions 1-5 complete the Substance Matrix Chart on the following page

7. Have you ever tried to reduce or control your use of this substance?

a. Primary Yes No b. Secondary Yes No c. Tertiary Yes No

8. Has anyone ever asked you to stop using these substances?

a. Primary Yes No b. Secondary Yes No c. Tertiary Yes No

9. What was the date of last use?

a. Primary b. Secondary c. Tertiary

Other Addictions: Eating Disorder Gambling Sex Tobacco

10. Is Methadone Maintenance Planned Yes No

11. Have you ever attended a self-help/support group (AA/NA, R/R, church, etc.)? Yes No

12. Last substance admission environment in the last 10 years

Extended Outpatient Medically managed Detox Intensive Outpatient Medically monitored Detox Medically monitored intensive res Medically managed intensive inpt.

Outpatient Detox Clinically managed high intensity Res.

PMIC Clinically managed medium intensity Res.

No Previous Admission Day Treatment partial Hospitalization Not Applicable Clinically managed low intensity Res.

Continuing Care

13. Number of prior substance abuse admissions during the last 10 years

14. How would you rate the client's potential for continued use?

Critical High Moderate Low Not at all

Substance Matrix Chart to be Used to Indicate Substance Use at Admission and at Discharge Substance Rating 1=substance most used or abused 2=substance two 3=substance three Severity 0=Not a problem (discharge only) 1=Mild Problem 2=Moderate Problem 3=Severe Problem Frequency 0=No use past month 1=1-3 times past month 2=1-2 times past week 3=3-6 times per week 4=Once Daily

5=2-3 times daily 6=More than 3 times daily 7=Unknown (Discharge Only) Route 1= Oral 2=Smoking 3=Inhalation 4=Injection 5=Other Rating Prescribed? Substance Severity Freq. Route Age/Use

Alcohol Amphetamines - Amphetamine Amphetamines - Methamphetamine (Speed) Amphetamines - Methylenedioxymethamphetamine (MDMA,Ecstacy) Amphetamines - Other Barbiturates - Phenobarbital (Solfoton) Barbiturates - Secobarbital (Seconal) Barbiturates - Secobarbital/Amobarbital (Tuinal) Barbiturates - Other Benzodiazepines - Alprazolam (Xanax) Benzodiazepines - Chlordiazepoxide (Librium) Benzodiazepines - Clonazepam (Klonopin, Rivotril) Benzodiazepines - Clorazepate (Tranxene) Benzodiazepines - Diazepam (Valium) Benzodiazepines - Flunitrazepam (Rohypnol) Benzodiazepines - Flurazepam (Dalmane) Benzodiazepines - Lorazepam (Ativan) Benzodiazepines - Triazolam (Halcion) Benzodiazepines - Other Cocaine - Crack Cocaine - Other Diphenylhydantoin/Phenytoin (Dilantin) GHB/GBL (Gamma-Hydroxybutyrate, Gamma-Butyrolactone) Hallucinogens - LSD Hallucinogens - Other Inhalants - Aerosols Inhalants - Nitrites Inhalants - Solvents Inhalants - Other Ketamine (Special K) Marijuana/Hashish Meprobamate (Miltown) Opiates/Synthetics - Codeine Opiates/Synthetics - Heroin Opiates/Synthetics - Hydracodone (Vicodin) Opiates/Synthetics - Hydromorphone (Dilaudid) Opiates/Synthetics - Meperdine (Demoral) Opiates/Synthetics - Non-Prescription Methadone Opiates/Synthetics - Oxycodone (OxyContin, Percocet, Percodan) Opiates/Synthetics - Pentazocine (Talwin) Opiates/Synthetics - Propoxyphene Opiates/Synthetics - Tramadol (Ultram) Opiates/Synthetics - Other Over The Counter - Diphenhydramine (Benadryl) Over The Counter - Other PCP or PCP Combination Sedatives - Ethchlorvynol (Placidyl) Sedatives - Glutethimide (Doriden) Sedatives - Methaqualone (Quaaludes) Sedatives - Other Stimulants - Methylphenidate (Ritalin) Stimulants - Other Tranquilizers Other Drug

DPDS - SUDTS (Pre-Trial)

Employment

1. Education completed?

2. Training or technical education? Yrs Mo

3. Do you have a profession, trade, or skill? □ Yes □ No

If yes please specify:

4. Do you have a valid driver's license? □ Yes □ No

5. Do you have an automobile available for use? □ Yes □ No

6. Longest full time job? Yrs Mo

7. Usual or last occupation?

□ Farming, Forestry and Fishing occupations

□ Homemaker

□ Management and Professional Specialty

□ Occupation not reported

□ Operators, Fabricators, and Laborers

□ Precision Production Craft and Repair Occupations

□ Refused to answer

□ Service Occupations

□ Technical, Sales and Administrative

8. Does someone contribute to your support in any way? □ Yes □ No (if yes answer #9. If no cont. to #10)

9. If yes, does this constitute the majority of your support? □ Yes □ No

10. Employment Status

□ Employed Full Time (35 hours or more per week) D Self-Employed □ Unemployed

□ Homemaker Full Time

□ Attending School Full Time-Not Working

□ In Skills Development, Training or School full

□ Unemployed, seeking work time

□ Unemployed, note seeking work

□ Employed Part Time in Steady Job

□ Disabled (cannot work)

□ Incarcerated (cannot work)

□ Retired/Permanently Out of Work Force

□ Other, Out of Work Force

□ Unemployed, not seeking work

11. Employer

12. How many days in the last 30 were you paid for work? (Include under the table)

How much money did you receive from the following resources in the last 30 days:

13. Employment (gross)? $

14. Unemployment comp? $

15. Welfare? $

16. Pension, SS, benefits? $

17. Mate, family, friends? $

18. Illegal? $

Current Gross/Taxable Individual monthly income

19. What is your primary source of income?

Disability Self-employment Other Unemployment compensation Public Assistance/TCA Unknown Retirement/pension Wages/Salary

19a Other Income Sources

Disability Self-employment Other Unemployment compensation Public Assistance/TCA Unknown Retirement/pension Wages/Salary

20. How many months have you been employed during the last 6 months?

21. How many days in the last 30 have you experienced employment problems?

22. How many days of work and/or school have you missed in the last 6 months due to substance abuse related problems?

23. Do you have current health insurance?

DHMH Medicaid Managed Care No Health Insurance Medicaid (Other than Health Choice) Non-Managed Private Insurance Medicare Other Public Funds PAC (Primary Adult Care) Private Managed Care (HMO)

24. If yes, does it cover substance abuse treatment? Yes No

25. How would you rate the client's need for employment services?

Family/Social Relationships

1. What is your current relationship status?

□ Common Law/Domestic Partner

□ Divorced

□ Married

□ Never Married

□ Unknown

□ Separated

□ Widowed

2. Are you satisfied with this situation? □ Yes □ No □ Indifferent

If no please specify:

3. What has been your usual living arrangement?

□ Child/Adolescent Foster Care

□ Group Home

□ Halfway House, Transitional Housing

□ Hospital, Nursing Home

□ Independent Living

□ Jail/Prison/Detention Facility

□ Private Residence (apartment, home)

□ Residential Substance Abuse Treatment

□ Shelter

□ Sober Living Facility

□ Street/Outdoors (sidewalk, abandon buildings)

□ Dependent Living

4. How long have you lived in these arrangements? Yrs Mo

5. Are you satisfied with these arrangements? □ Yes □ No □ Indifferent

6. Do you live with anyone who:

a. Has a current alcohol problem? □ Yes □ No

b. Uses non-prescribed drugs? □ Yes □ No

7. With whom do you spend most of your free time? □ Alone □ Family □ Friends

8. Are you satisfied spending your free time this way? □ Yes □ No □ Indifferent

9. How many close friends do you have?

10. Select the people with whom you have had a close, long lasting relationship:

□ Mother □ Father □ Sister/Brother □ Children □ Friends

DPDS - SUDTS (Pre-Trial)

11. Have you had significant periods in the last 30 days or in your lifetime in which you have experienced serious problems getting along with your:

(The questions require a Yes/No response for both columns.)

Past 30 Day Lifetime

Mother?

Father?

Brother/sister?

Sexual partner/spouse?

Children?

Other significant family?

Close friends?

Neighbors?

Co-workers?

12. Have any of these people abused you? If so, how and when?

(The questions require a Yes/No response for all columns.)

Past 30 Days Lifetime Emotionally Physically Sexually Emotionally Physically Sexually Mother Father Brother/sister Sexual Partner/spouse

Children Other Significant Family

Close friend Neighbor Co-worker

13. How many children do you have age 17 or less (birth, adopted, or stepchildren) whether they live with you or not? (If answer is greater than 0 proceed to #14 & 15. If not proceed to #16)

14. How many of these children spent the last 6 months living with you?

15. Are any of your children living with someone else because of a child protection order? Yes No

16. Does your substance use cause problems at home with your partner, kids, or home obligations?

Yes No

17. Do you have a DSS case worker? Yes No

18. How troubled have you been in the last 30 days by:

a. Family problems? Not at all Slightly Moderately Considerably Extremely

b. Social problems? Not at all Slightly Moderately Considerably Extremely

19. Have you given up or reduced your involvement in important social or recreational activities that did NOT include drinking or using? Yes No

20. Is there a family history of substance abuse or dependency? Yes No

22. How would you rate the client's need for family or social counseling?

Notes

Legal

1. Was this admission prompted by the criminal justice system? Yes No

2. Are you on parole or probation? Yes No

How many times have you been arrested and/or charged and/or convicted for the following:

Leave gray areas blank Arrested Charged Convicted

3. Shoplifting/vandalism?

4. Parole/probation violation?

5. Drug charges?

6. Forgery?

7. Weapons offense?

8. Burglary, larceny, B & E?

9. Robbery?

10. Assault?

11. Arson?

12. Rape?

13. Homicide/manslaughter?

14. Prostitution?

15. Contempt of court?

16. Driving While Intoxicated past 12 months?

17. Non-drug or alcohol-related crime while under the influence in the last 12 months?

18. Non-drug or alcohol-related crime while not under the influence in the last 12 months?

19. Drug or alcohol-related crime in the last 12 months?

20. Other?

21. How many times have you been arrested in the past 12 months?

22. How many times have you been arrested in the past 30 days?

23. How many months were you incarcerated in your life? Yrs Mos Days

24. How long was your last incarceration? Yrs Mos Days

25. What was it for?

26. Are you presently awaiting charges, trial, or sentence? Yes No

27. If yes, what for?

28. How many days in the last 30 were you detained or incarcerated?

29. How many days in the last 30 have you engaged in illegal activities for profit?

30. How serious do you feel your current legal problems are?

31. How would you rate the client's need for legal services?

ASAM - PPC2R ( Recommended but not required)

Dimension Level of Risk Level of Care

1. Acute Intoxication and/or Withdrawal Potential

Comments:

2. Biomedical Conditions and Complications

3. Emotional, Behavioral, or Cognitive Conditions and Complications

4. Readiness to Change

5. Relapse, Continued Use, or Continued Problem Potential

Comments:

6. Recovery/Living Environment

Environments

Health

For Level of Risk

0 – Not at all 1 – Slightly 2 – Moderately 3- Considerably 4 - Extremely

For Level of Care enter the corresponding number

0.5 Early Intervention

I Outpatient I .D Outpatient Ambulatory Detox.

I OMT Opiod Maintenance Therapy II.1 Intensive Outpatient Treatment II.D Intensive Outpatient Detox II.5 Partial Hospitalization III. 1 Clinically Managed – Low Intensity III. 3 Clinically Managed – Medium Intensity III. 5 Clinically Managed – High Intensity III. 7 Medically Monitored Intensive Inpatient III.7-D Medically Monitored Intensive Inpatient Detox.

IV Medically Managed Intensive Inpatient IV.D Medically Managed Intensive Inpatient Detox OMT.D Opioid Maintenance Thearpy-Detox

DPDS - SUDTS (Pre-Trial)

Clinical Override: Clinical Judgment Managed Care Refusal

Lack of Insurance N/A Legal Issues Other Level of Care Not Available Patient Opinion

Recommended Level of Care

Recommended Environment

Actual Level of Care

Actual Environment

Summary

Interviewer Confidence Rating:

1. In your opinion, is the information in this assessment significantly distorted due to client's Not at all misrepresentation?

2. In your opinion, is the information in this assessment significantly distorted due to client's Not at all ability to understand?

Comments

Assessment Duration

Interview: Start Date End Date Total Interview Time

DPDS - SUDTS (Pre-Trial)