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.