Funding Application For Out Of Province Mental Health And Or Addictions Page 4

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AsAM level oF cAre MAtrix For pAtients WitH suBstAnce ABuse

dimension

treatment level

1. Acute Intoxication / Withdrawal Potential

2. Biomedical Conditions and Complications

3. Emotional / Behavioural or Cognitive Conditions

4. Readiness to Change

5. Relapse, Continued Use or Continued Problem Potential

6. Recovery Living Environment

The personal information on this form is collected under the Freedom of Information and Protection of Privacy Act, Section 26 (c), and will be used to

assess the application for funding of out-of-province treatment. If you have any questions about the collection and use of this information, please contact

Out of Province Claims by mail at 2-1, 1515 Blanshard Street, Victoria, BC, V8W 3C8 or by phone at (250) 952-1334.

HLTH 2809 2010/08/12

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