PURPOSE OF TOOL: The BQuIP tool is a fast and free web-based tool designed to generate recommendations for initial placement for individuals seeking treatment for substance use disorders (SUD). The BQuIP is intended for potential recipients of Adult SUD services.

DISCLAIMER: These are preliminary recommendations based on limited information, and are meant to provide initial placement options for the user's consideration. Ultimately, the initial placement decision must be made according to the clinical judgement of the individual using this tool and the county policy. The BQuIP tool is not a replacement for a full assessment, and the appropriateness of the provisional placement decision made as a result of using this tool must be confirmed via a comprehensive American Society of Addiction Medicine (ASAM) assessment as soon as possible. The BQuIP tool has not been created or endorsed by ASAM.

Use of this software is subject to the following: IN NO EVENT SHALL THE CALIFORNIA DEPARTMENT OF HEALTHCARE SERVICES OR THE UNIVERSITY OF CALIFORNIA OR ANY OF ITS CAMPUSES ("UC") BE LIABLE TO ANY ENTITY OR PERSON FOR DIRECT, INDIRECT, SPECIAL, INCIDENTAL, OR CONSEQUENTIAL DAMAGES, INCLUDING LOST PROFITS, ARISING OUT OF THE USE OF THIS SOFTWARE, EVEN IF UC HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGE. UC SPECIFICALLY DISCLAIMS ANY AND ALL WARRANTIES, EXPRESS AND IMPLIED, INCLUDING, BUT NOT LIMITED TO, ANY IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE. THE SOFTWARE IS PROVIDED "AS IS." EXCEPT TO THE EXTENT UC IS REQUIRED TO PURSUANT TO A SEPARATE CONTRACT, UC HAS NO OBLIGATION TO PROVIDE MAINTENANCE, SUPPORT, UPDATES, ENHANCEMENTS, OR MODIFICATIONS OF THIS SOFTWARE.

Only trained users may use the BQuIP.

For more information about the BQuIP tool go to: http://www.uclaisap.org/dmc-ods-eval/html/bquiptool.html

     The BQuIP tool has not been created or endorsed by ASAM.

A. Please enter initials of staff completing this questionnaire

 
B. Please enter your county
Please enter "TEST" if practicing or training on the BQuIP tool

 
C. Please enter full agency name

 

 

BQuIP USER INSTRUCTIONS: To minimize burden, you may enter responses in the BQuIP based on information you already have gathered. Ask questions if the answer is not known. You may also rephrase questions for clarity and to meet the needs of your potential clients.

1. (OPTIONAL) Which of the following drugs or alcohol have you used in the last 12 months? (Read list and select all that apply)Learn more

Do not include prescription drugs (e.g. pain medication) that are taken as prescribed to the individual by their doctor.

	Learn more Heroin, Fentanyl, Vicodin, Norco, Hydrocodone, Oxy, Morphine, Codeine, Dolophine, Methadone
	Learn more Uppers, Meth, Coke, Crack, Crystal, Adderall, Ritalin, Benzedrine, Dexedrine, Khat
	Learn more Downers, Xanax, Valium, Librium, Ativan, Halcion, GHB, Rohypnol, Roofies
Please specify other drug(s):	Learn more Include hallucinogens and club drugs: e.g, Spice, K2, Bath Salts, Kratom, Peyote, Ecstasy, Mollies, MDMA, Psilocybin Shrooms, Special K, Ayahuasca, Salvia, Inhalants, Dextromethorphan

 

2. Which of the following are your drug(s) of choice that you may want help with? (Read list and select all that apply)

2A. Please specify other drug(s):

 

Instruction/question for the BQuIP user:
Is this individual a candidate for substance use services?

 

Please indicate substance for which potential client may need treatment

Please specify other drug(s):

Interview complete. The BQuIP is only intended for potential recipients of Adult SUD services.

3. Are you currently experiencing SEVERE WITHDRAWAL symptoms (e.g., tremors/shaking, recent seizures, hallucinations, vomiting, diarrhea, racing heartbeat or other significant physical symptoms)? Learn more

Severe withdrawal means symptoms that are life threatening and require immediate medical intervention.

 

ALERT: HIGH POTENTIAL FOR CLINICALLY RISKY WITHDRAWAL. CONSIDER NEED FOR IMMEDIATE INTERVENTION
(e.g., provide immediate medical consult or referral to emergency room/911 or onsite withdrawal management if appropriate/available).

 

4. If you stopped using now would you expect to get sick and experience milder withdrawal symptoms like mild tremors, excessive sweating, anxiety, nausea and/or vomiting, stomach cramps, or muscle aches? Or are you currently experiencing these milder symptoms?
 

5. In your life, have you ever OVERDOSED (e.g., loss of consciousness) or experienced SERIOUS WITHDRAWAL OR LIFE THREATENING SYMPTOMS DURING WITHDRAWAL (e.g., irregular heart rate/arrhythmia, seizures, hallucinations with DTs/delirium tremens, need for IV therapy or inpatient medication management)?
 

6. Have you used any drugs or alcohol within the last 3 days?
 

6A. Have you used any drugs or alcohol within the last 4 hours?
 

7. Do you currently have any serious MEDICAL issues that you are aware of? Learn more

Examples of "serious medical issues" include any medical issues for which the individual should get ongoing treatment, such as diabetes, HIV/AIDS, asthma, hypertension, cancer, broken bones and abscesses, and any other medical issue that meaningfully impacts the individual's daily life.

 

7A. Do these medical problems make it difficult to do your normal daily activities? Learn more

Examples of "daily activities" include going to school or work, socializing, self-care (hygiene), and engaging in hobbies.

 

7B. Do you think these medical issues can improve if you do something more or different than what you are doing?
 

8. In the past 30 days, have you experienced any periods of sadness, hopelessness, loss of interest in activities, hallucinations, or significant anxiety that are NOT resulting from withdrawal or drug use?
 

8A. Do these emotional problems make it difficult to do your normal daily activities? Learn more

Examples of "daily activities" include going to school or work, socializing, self-care (hygiene), and engaging in hobbies.

 

8B. In the past 30 days, have you thought about wanting to kill yourself or wanting to die?
 

8C. Are you currently having thoughts about wanting to kill yourself or wanting to die?
 

ALERT: CONSIDER POTENTIAL IMMINENT DANGER TO SELF. Follow your local county/program policies to assess for immediate intervention
(e.g., provide immediate consult, STOP screen and call 911 if imminent need is identified, provide information to call 911/suicide hotline/go to an emergency room)
 

9. Has a doctor ever given you medications for emotional or mental health issues?
 

10. Which statement best describes your current thinking about your drug and alcohol use?
 

11. Without help, do you think you would continue using?
 

12. Are you currently experiencing homelessness (e.g., couch surfing, living outdoors or in a car, no permanent housing)?
 

13. Do you have a place to stay that is free of alcohol and other drugs?
 

14. Do you currently have someone who you would consider as a social support, or someone you can rely on for support when needed?
 

15. Are you or do you think you could be pregnant?
 

16. Of the drugs we have talked about, have you injected any in the last year?
 

Click here

Record clinical notes here: (Optional)