37.106.1915 MENTAL HEALTH CENTER: CLIENT ASSESSMENTS
(1) Each mental health center shall complete a clinical intake assessment within 12 hours after admission for crisis stabilization program services and within three contacts, or 14 days from the first contact, whichever is later, for other services. Intake assessments must be conducted by a licensed mental health professional trained in clinical assessments and must include the following information in a narrative form to substantiate the client's diagnosis and provide sufficient detail to individualize treatment plan goals and objectives:
(a) presenting problem and history of problem;
(b) mental status;
(c) diagnostic impressions;
(d) initial treatment plan goals;
(e) risk factors to include suicidal or homicidal ideation;
(f) psychiatric history;
(g) substance use/abuse and history;
(h) current medication and medical history;
(i) financial resources and residential arrangements;
(j) education and/or work history; and
(k) legal history relevant to history of illness, including guardianships, civil commitments, criminal mental health commitments, and prior criminal background.
(2) Based on the client's clinical needs, each mental health center shall conduct additional assessments which may include, but are not limited to, physical, psychological, emotional, behavioral, psychosocial, recreational, vocational, psychiatric, and chemical dependency evaluations.
(3) Each mental health center shall maintain a current list of providers who accept referrals for assessments and services not provided by the center.