SOP 508.44-att-1: Addiction Severity Index Summary Assessment

Division:
Unknown
Effective Date:
October 19, 2023
Topic Area:
508 Policy-MH Evaluations/Screenings/Treatment
PowerDMS:
View on PowerDMS
Length:
212 words

Summary

This is a standardized assessment form used to document an inmate's addiction severity and related health and social factors. The form captures information about the inmate's medical history, employment, alcohol and drug use, legal status, family history, psychiatric status, and identifies significant problems across multiple domains. The completed assessment is retained in the inmate's mental health record for 10 years or until the end of mental health services.

Key Topics

  • addiction severity index
  • ASI assessment
  • substance abuse screening
  • drug and alcohol evaluation
  • mental health evaluation
  • inmate assessment form
  • psychiatric screening
  • addiction assessment
  • co-occurring disorders
  • substance use history

Full Text

508.44
Attachment 1

10/19/2023

Georgia Department of Corrections

Addiction Severity Index Summary Assessment

Facility:____________________________ Date of Assessment:__________________

Name:_____________________________ GDC#:_____________________________

DOB:_____________________________ Race:______________________________

General Information:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Medical History:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Employment Support:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Alcohol and Drug Usage:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Retention: Attachment 1, shall be placed in the offender’s mental health record, section four (4). At the end of the offender’s need for
mental health services and/or sentence, the mental health record will be placed within the offender’s health record and retained for 10
years.

508.44
Attachment 1

10/19/2023

Legal Status:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Family History:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Family and Social Relations:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Psychiatric Status:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Retention: Attachment 1, shall be placed in the offender’s mental health record, section four (4). At the end of the offender’s need for
mental health services and/or sentence, the mental health record will be placed within the offender’s health record and retained for 10
years.

508.44
Attachment 1

10/19/2023

Significant Problems (based on previous 2 pages)

Mental health/psychiatric: _______________________________________________________________

_____________________________________________________________________________________

Alcohol/drug usage: ____________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Medical: _____________________________________________________________________________

____________________________________________________________________________________

Employment support: __________________________________________________________________

____________________________________________________________________________________

Family/Social support: _________________________________________________________________

____________________________________________________________________________________

Housing/Residence planning: ____________________________________________________________

_____________________________________________________________________________________

Legal: _______________________________________________________________________________

_____________________________________________________________________________________

Other: ______________________________________________________________________________

____________________________________________________________________________________

Staff Name: ____________________________ Title: ________________________________

Staff Signature: ________________________________

___________________________________________________________________________________

Reviewed by: ____________________________ _____________________________________
(Name) (Title)

Signature: ______________________________ Date: _________________________________

Retention: Attachment 1, shall be placed in the offender’s mental health record, section four (4). At the end of the offender’s need for
mental health services and/or sentence, the mental health record will be placed within the offender’s health record and retained for 10
years.

Attachments (3)

  1. Addiction Severity Index Summary Assessment (212 words)
  2. Integrated Treatment Programs 4 Quadrant Assignment (Attachment 2) (299 words)
  3. Summary of Monthly Progress in the ITF (Attachment 3) (138 words)
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