New Hampshire Code of Administrative Rules
Alc - Board of Licensing for Alcohol and Other Drug Use Professionals
Chapter Alc 300 - INITIAL CERTIFICATIONS AND LICENSES
Part Alc 308 - WRITTEN CASE STUDY
Section Alc 308.04 - Required Information and Headings for Information

Universal Citation: NH Admin Rules Alc 308.04

Current through Register No. 12, March 21, 2024

The required information and the headings under which it should be organized shall be:

(a) Under the heading substance use history of the client, the following information about the client:

(1) A list of the substances used;

(2) The frequency of substance use;

(3) The progression in the use of substances;

(4) The severity of substance use or the amount of each substance used;

(5) The approximate date or age when substance use began;

(6) The primary substance used;

(7) The method of substance administration; and

(8) The effect(s) on the client of substance use stated in terms of one or more of the following:
a. Blackouts;

b. Tremors;

c. Tolerance;

d. Seizures;

e. Medical complications; and

f. Other described effects;

(b) Under the heading psychological functioning, the following information:

(1) The client's past mental status stated in terms of one or more of the following:
a. Oriented;

b. Hallucinating;

c. Having delusions;

d. Suicidal;

e. Homicidal; and

f. Mental status of other specific description;

(2) The client's mental status at the time of treatment, stated in the terms listed in (1) above;

(3) The quality of the client's judgment; and

(4) The quality of the client's insight into the client's problems;

(c) Under the heading educational, vocational and financial history, the following information:

(1) The client's educational level and history;

(2) The client's work history;

(3) Any disciplinary action taken against the client at school;

(4) Any disciplinary action taken against the client at work;

(5) Reasons for the client's termination of education, if the client terminated education;

(6) Reasons for the client's termination of work, if the client terminated work;

(7) The client's financial status, as indicated by:
a. The client's living arrangements;

b. The way the client supports herself or himself financially; and

c. Other indicators of financial standing specific to the client; and

(8) The financial status of the client's family of origin, as indicated by:
a. The living arrangements of the family;

b. The way the family supported itself financially in the past and currently supports itself financially; and

c. Other indicators of financial standing specific to the family;

(d) Under the heading legal history, any of the following experiences reported by the client or appearing in records made available to the applicant, whether or not associated with substance use:

(1) Past charges and those pending at the time of treatment;

(2) Arrests;

(3) Findings of juvenile delinquency; and

(4) Criminal convictions;

(e) Under the heading social history, the following information:

(1) The influence on the client of his or her parents;

(2) The number, gender and rank order of the client's siblings;

(3) The influence on the client of his or her siblings;

(4) The influence on the client of his or her children;

(5) The psychological health of the client's family with respect to any mental health, psychiatric or emotional problems;

(6) A description of any substance use by members of the client's family;

(7) The history of the client's level(s) of mental health and actual behavior, both adaptive and maladaptive, in social settings; and

(8) The client's history of relationships, including the number, type and relative level of normality, within family, intimate and other social relationships;

(f) Under the heading physical history, the following information:

(1) The client's past major medical problems and major medical problems at time of treatment, whether related to or not related to substance use;

(2) The client's past disabilities and disabilities at time of treatment, whether related to or not related to substance use;

(3) The client's past pregnancies and pregnancies at time of treatment;

(g) Under the heading treatment history, a summary of:

(1) The client's history of treatment, if any, for:
a. Psychological conditions; and

b. Substance use disorders; and

(2) The client's participation in self-help group(s);

(h) Under the heading assessment:

(1) Identification and evaluation of:
a. The client's personal strengths; and

b. The client's personal limitations; and

(2) Formulation of diagnosis using the most current version of the Diagnostic and Statistical Manual of Psychiatric Disorders (DSM);

(i) Under the heading treatment plan, the following components of the plan:

(1) Identification and ranking, according to severity, of the problems requiring resolution;

(2) The immediate goals and the long-term goals agreed to by the client; and

(3) An identification of each goal's corresponding objectives, including:
a. The frequency of the treatment;

b. The duration of the treatment;

c. The objectives of the treatment;

d. The interventions utilized; and

e. Any required adjunct support, such as self-help, community resources, family members and significant others;

(j) Under the heading course of treatment, the following information about the work of the applicant for licensure:

(1) The counseling theory or theories used with the client;

(2) The applicant's rationale for using such theory or theories; and

(3) Any revisions in the counseling theory or theories made by the applicant in response to the client's specific problems and responses to treatment; and

(k) Under the heading discharge summary:

(1) A concise description of the client's overall response to treatment, including the client's substance use status at the end of the applicant's treatment of the client; and

(2) A continuing care plan.

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