The document outlines the 10 dimensions that should be addressed in a substance use assessment. It notes that the goal of assessment is to gather historical information and uncover how different elements relate to each other, going beyond just behaviors. The assessment process should include an overview to the client, be conducted over a defined time frame, and go at the client's pace. Documentation is also important. Each dimension explores different areas of a client's history and current situation.

1. Chapter 8
Assessment

2. Assessment
Goal
Address historical information
Uncover richer elements & how they relate to each
other
More than just behavior
Assessment process
Time frame
Overview to client
Go with client flow
Documentation

3. Assessment
Goal
Address historical information
Uncover richer elements & how they relate to each
other
More than just behavior
Assessment process
Time frame
Overview to client
Go with client flow
Documentation

4. Assessment
Dimension 1:
Presenting Issue/s
What brings the person?
 Self/family
 Referral
Understanding their
perspective
View on issue
 Problem?
 Priorities
 Initial motivation

Dimension 2:
Treatment history
Background information on
presenting issue
Prior history and
experience
Current reflections
What helped/didn’t help

5. Assessment
Dimension 3: Substance use history
Now & in the past; build on screening
Substance
Frequency
First Last
 Amount
Use Use
 Age at first use
 Last used
 Administration
 Overdose, etc
 Patterns (now & in the past)
 Periods of abstinence
 Family history

Pattern
Rout
e of
admi
n

6. Assessment
Dimension 4: Medical history
Known conditions
Exams/providers/hospitalizations
Unmet medical needs/risks
Medication
Family history
Dimension 5: Basic needs
Being met?
ADLs
Referrals

7. Assessment
Dimension 6: Psychological functioning
Known MH conditions
Trauma
Hospitalizations
History, pattern with/without SA
Risks
SI/attempts
 History
Family history


8. Assessment
Dimension 7: Family history & structure
“Who is family”/basic stats
Family relationships/dynamics/estrangements
View on family
Dimension 8: Social/cultural contexts
Environment/living situation
Community resources/outlets
Stressors
Financial
 Housing


9. Assessment
Dimension 8: Sub-dimensions
Cultural/spiritual values, beliefs & strengths
SES
Vocational history
Educational history
Social-relational
Legal history
Arrests
 Incarcerations
 Current status


10. Assessment
Dimension 9: Motivation
 Values & strengths
 Hopes & dreams
 Client readiness/stage of change
Dimension 10: Diagnosis
 Diagnoses (SUD; MH; Medical)
 Psychosocial/environmental stressors
 MSE & clinical impressions
 Recommendations/plan
 Assessment procedures
Attend to cultural factors throughout entire
assessment process