R03-605 Assessment

A. A licensee shall develop, implement, and comply with policies and procedures that:

1. Ensure a client’s personal history as identified in (C)(1-15) is documented in the assessment, and

2. Address the use of a substance abuse assessment tool to provide additional clinical information and justification for modality of treatment recommended.

Review policy and procedure manual.

 

B. A licensee shall ensure that a client's assessment is completed with the participation of the client and the client’s parent, guardian, designated representative, if available.

Review policy and procedure manual.

 

C. A licensee shall ensure that a client’s assessment include the following client information

1. Presenting issues,

2. Risk of suicidal or homicidal behavior,

3. Previous treatment history of substance use and mental health issues,

4. Health history and current medical conditions, including medications,

5. Alcohol and drug use history to include the following:

a. When usage began,

b. Amount used,

c. Frequency of use,

d. Method of administration,

e. Longest and last period of abstinence,

f. Time and date of most recent use,

g. Behaviors exhibited during use, and

h. Effect on relationships with others,

6. History of abuse (emotional, sexual, and/or physical) to include whether individual was a victim or perpetrator,

7. Current family social history, including family history of substance use,

8. Educational level achieved,

9. Religious/spiritual affiliation,

10. Vocational experience, if applicable,

11. Military experience, if applicable,

12. Five year employment history,

13. Risk factors for infectious disease including HIV, AIDS, HCV, and STI’s,

14. Legal history to include record of conviction and date of incarceration, or pending litigation,

15. Current living situation to include: a. Economic resources, including gross income and the number in the family, and b. Support system,

16. Information from collateral sources when available.

Review policy and procedure manual. Verify in progress notes in client records.

 

D. A licensee shall ensure that a client assessment includes:

1. The date the assessment was conducted, and

2. A summary of the assessment which includes the modality of treatment recommended if applicable with a dated signature of a qualified staff according to R03-30, and

3. A referral to a licensed medical or mental health professional as indicated.

Review client file and verify that an assessment summary has been completed and that it justifies the admission to the recommended level of care. 3. Document as indicated in R03-603 B 4.