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Department of Human Services (DHS) Division of Addiction Services (DAS) Information Systems ... - page 2 / 21

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Name of the client: _____________________

Date of Evaluation: _____________________

                                       Dependence                              Abuse

Substance

D1

D2

D3

D4

D5

D6

D7

A1

A2

A3

A4

Abuse(A1..A4)

Alcohol

A1=Role Obligations

Marijuana-Hashish

A2=Hazardous Use

Cocaine

A3=Legal Problems

Opioids

A4=Social Problems

Amphetemine(or)

Methamphetamines

Sedatives/Hypnotic/

Anxiolytic

Dependence(D1..D7)

Hallucinogens

D1=Tolerance

PCP

D3=Excessive Use

Inhalants

D4=Desire/Attempts to stop

Poly/Unspecified

D5=Times pent using

Club Drugs

D6=Sacrificing activities to use

Steroids

D7=Physical/Psychological consequences

Tobacco

Other:specify

If the client is not diagnosed and the counselors/Clinicians want to see the client meets any criteria from LOCI, check the box and click on “Continue LOCI” button.

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