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Download the Addiction Severity Index Form, which is often used by psychiatrists for the purpose of a more in depth patient evaluation with regard to the level of severity of addiction and addictive behaviors. The ASI form will provide a comprehensive, overall understanding of all aspects of the patient’s existence in order to properly evaluate any  addiction issues the patient experiences as well as who or what with the addiction issues may be connected. With this knowledge, a psychiatrist will be able to better implement a more personalized treatment plan. ASI may be used on a clinical as well as a training level.

How To Write

Step 1 – Page 2 – Administrative information to be provided

At the top of page 2, begin by providing the following information:

  • Agency Name
  • Site Name
  • ID Number
  • Date mm/dd/yyyy

Step 2 – Page 2 – Section 1 – General Information –

Begin by providing general information for the record by asking the list of basic information questions about the patient

  • D1. Identification number
  • G4. Date of Admission mm/dd/yyyy
  • G5. Date of Interview mm/dd/yyyy
  • G6. Time Begun – Use  the 24 hour clock code providing hours and minutes
  • G7. Time Ended – Use  the 24 hour clock code providing hours and minutes
  • G8. Class – 1 Intake – 2 Follow-up
  • G9. Contact Code – 1 – In person –  2 – Telephone ( the Intake ASI must be taken in person)
  • G10. Gender –  1 – Male –  2 – Female
  • G99. Treatment Episode Number
  • G11. Interviewer Code Number
  • G12. Special 1 – Patient terminated 2 – Patient refused 3 – Patient unable to respond

Step 2 Cont. – Page 2 – Block 2 – General information

This section will address, living environment, race, religious preferences etc. If patient is responsive ask and answer all of the questions on the page accordingly and provide the appropriate response according to the patient’s answers –

  • Comments- Provide brief comments in the intake comments box

Step 3 – Page 3 – Medical Status – Medical Comments –

  • This section will address medical issues and any chronic illnesses –
  • Speaking with the patient, ask all of the questions in this section. Note the instruction for each question and answer the questions accordingly.
  • After the questions have been asked and answered interviewer must provide a severity rating as well as a confidence rating and comments.
  • The interviewer must enter comments into the comments block provided, with regard to the medical condition of the patient and if the interviewer is of the opinion that the patient will require further medical attention, if medical attention is required.

Step 4 – Page 4 – Employment/Support Status –

  • This section will assess education, training, military experience etc. Interviewer must ask the patient all of the questions, noting any special question instructions in order to evaluate ability for employment, if any.
  • After this section is completed, the interviewer will be required to perform a severity and confidence rating addressing the probability of employment with counseling. As well the confidence the interviewer has in the patient having the ability to understand the interviewer
  • Comments must be entered by the interviewer about their initial findings about employability with this patient.

Step 5 – Page 6 – Alcohol/Drugs-

  • This section will address the severity of alcohol and/or substance abuse. The interviewer will address an abundance of possible uses that may require assistance for the patient’s treatment plan, if any.
  • The interviewer will ask about each possible substance one by one using the following routing of administration and the frequency of use.
  • 1 – Oral 2 – Nasal 3 – Smoking 4 – Non-IV injection 5 – IV- The interviewer will record the information according to the answers provided by the patient.
  • Once the alcohol/drugs evaluation is complete, the interviewer will provide their opinion of the most major abuse issues are, adding any comments especially those that may be crucial to treatment.
  • The interviewer will also provide a severity rating as well as a confidentiality rating, as well as comments, in the comment area, that may provide a better understanding of this patient’s addiction issues, if any.

Step 6 –  Page 8 – Legal Status

  • This section will provide a line of questioning that will assist the interviewer in evaluating the frequency and therefor the severity of involvement with the legal system. The questions will range from whether or not the reason for the admission was a result of the justice system, to all other possible aspects of issues that could ultimately land the patient into a long term legal situation.
  • Once the interviewer has asked the patient all of the questions regarding legal status and answered all of the questions according to the the patient responses, the interviewer will be required to provide a severity and confidence rating  with regard the patient’s need for legal services or counseling, if any or if possible.
  • The interviewer must provide comments with regard to the patient’s answers and any suggestions the interviewer may have with regard to the answers the patient had provided.

Step 7 – Page 10 – Family History –

  • The Family History section will address all relatives that may or may not have experienced some sort of addiction that may or may not have ever been treated. Since the patient is the only person familiar with these individuals, the interview should accept the patient’s opinion and judgement with regard to family members.
  • Once all members of the family have been addressed with regard to addiction and /or psychiatric issues, comments with regard to abuse severity in the family must be recorded in the comments section

Step 8 – Page 11 – Family/Social Relationships –

  • This section will address all aspects of social and family relationships with regard to this patient.
  • The interviewer must pay close attention to the questions and how the patient reacts, as well, closely follow the instructions to each individual question with regard how to properly answer each respective question. Be thorough.
  • Once this section has been asked and answered, a severity rating and confidence rating must be provided by the interviewer.

Step 9 – Page 13 – Psychiatric Status –

  • The “psychiatric status” section will address many of the psychiatric issues that often go hand in hand with addiction or what some patients will consider self medication. This section is directly related to the patient respectively, not in relation to any other family member or relationship.
  • The interviewer must ask every question and must pay specific attention to the instructions that accompany each question and use them accordingly in the answering process.
  • Once the psychiatric evaluation is complete, the interviewer must also provide an opinion in the severity and confidence ratings that will specify the level of need for psychiatric/psychological treatment. This will be an important aspect of the development of the treatment plan, if any.
  • The interviewer must include comments with regard to answers and observations. Place any vital information related to the psychiatric aspect of this evaluation in this comments section.

Step 10 – Page 15 – Severity Profile – (Table)

In this section a complete profile will be created and established with the table used in this area, based on the answers to the questions provided by the patient. All aspects of the evaluation will be rated by the interviewer.

Based upon the completion of evaluation with the patient, a treatment plan could be established and appropriate services will be assigned as needed for the best continued result for the patient as long as the patient continues to make it possible.