1-2-1 – LMAS

Immediate Concerns (Select all that apply):

Crisis or Distress

Withdrawal Symptoms

Housing Instability

Additional Details:

Emotional State (Select all that apply):

Anxiety

Depression

Risk Level for Self-Harm/Suicidal Thoughts:

Substance Use & Related Behaviors (Select all that apply):

Alcohol Use

Opioid Use

Recent Patterns of Use:

Client Presentation (Select all that apply):

Disheveled Appearance

Agitated or Restless

Session Takeaways & Client Reflection:

One-to-One Contact Form