Current through Register Vol. 30, No. 38, September 20, 2024
A. The following
individuals may participate in and contribute to the assessment of a client:
1. The client;
2. The qualified clinician in
R9-21-303(B);
3. The client's case
manager;
4. Each individual on the
client's clinical team, including:
a.
Behavioral health professionals,
b.
Professionals other than behavioral health professionals,
c. Behavioral health technicians,
d. Family members,
e. Paraprofessionals, and
f. Any individual whom the qualified
clinician and the client deem appropriate and necessary to ensure that the
assessment is comprehensive and meets the needs of the client.
B. The individuals
contributing to the assessment of a client shall not consider the availability
of services, but shall consider the client's circumstances and evaluate all
available information including.
1. The
information obtained during the initial meeting with the client by a qualified
clinician according to R9-21-303(B);
2. Written information such as the client's
clinical history, records, tests, and other evaluations;
3. Information from family, friends, and
other individuals.
C. An
assessment shall include:
1. An evaluation of
the client's:
a. Presenting
concerns;
b. Behavioral health
treatment;
c. Medical conditions
and treatment;
d. Sexual behavior
and, if applicable, sexual abuse;
e. Substance abuse, if applicable;
f. Living environment;
g. Educational and vocational
training;
h. Employment;
i. Interpersonal, social, and cultural
skills;
j. Developmental
history;
k. Criminal justice
history;
l. Public and private
resources;
m. Legal status and
apparent capacity;
n. Need for
special assistance; and
o. Language
and communication capabilities;
2. A risk assessment of the client;
3. A mental status examination of the
client;
4. A summary, impressions,
and observations;
5.
Recommendations for next steps;
6.
Diagnostic impressions of the qualified clinician; and
7. Other information determined to be
relevant.
D. Within 45
days of a request or referral for an SMI eligibility determination, a qualified
clinician shall prepare an assessment report based on the information obtained
according to R9-21-303 and this Section, including:
1. The development of a long-term view by the
client with assistance from the clinical team that establishes a method of
integration for living, employment and social conditions that the client wishes
to achieve over the next three years;
2. A summary of the information gathered
during the eligibility and assessment processes;
3. An identification of the client's legal
status, resources, and assessed strengths and actual needs, regardless of the
availability of services to meet that need, in each area of assessment
identified in subsection (C) above;
4. An analysis of the major findings of the
mental health assessment, including a description of the nature and severity of
any illness and a diagnosis in terms set forth in the DSM;
5. The client's preferences regarding
services to be provided;
6. A
description of any additional interim services which are required and plans for
the referral of the client to additional interim services or the continuation
of interim services already provided;
7. An identification of further evaluations
which the clinical team deem necessary to determine the services appropriate to
the client's needs;
8. An
identification of information that could not be obtained due to the client's
circumstances or unavailability; and
9. A functional assessment of the client's
current status in terms of independent living, employment (or retirement), and
social integration and analysis of the support or skills, if any, necessary to
achieve the client's long-term view.
E. The qualified clinician shall arrange for
any further evaluations recommended by the clinical team. If the client needs
assessment in an area beyond the ability or expertise of the clinical team,
such assessment shall be conducted by professionals with appropriate
credentials, with the client's consent. The need for further evaluations shall
not unreasonably delay the preparation of the ISP.
F. If a qualified clinician determines that
the client is a client who needs special assistance, the case manager shall:
1. Notify the regional authority, the Office
of Human Rights, and the appropriate human rights committees of the client's
need so that the client can be provided special assistance from the human
rights advocate or special review by the human rights committee; and
2. If the client does not have a guardian,
identify a friend, relative or other person who is willing to serve as a
designated representative of the client.
G. Upon completion of the assessment report,
copies shall be sent to the client, the designated representative, if any, the
guardian, and all service providers who have been identified by the case
manager or regional authority to serve the client.
