N.H. Admin. Code § He-M 408.05

Current through Register No. 50, December 12, 2024

Section He-M 408.05 - Application and Demographic Data

(a) Pursuant to He-M 401, an application for services shall be completed and signed by the individual or guardian at or before the intake interview.

(b) The following demographic data shall be collected and documented:

(1) Name, address, and telephone number of the individual or applicant;

(2) Date of application for services;

(3) Date of birth of the individual or applicant;

(4) Name, address, and telephone number of guardian, if applicable;

(5) Financial information including:

a. Insurance;

b. Private resources; and

c. Eligibility determinations for financial assistance from programs such as Supplemental Security Income, Aid to the Permanently and Totally Disabled, Medicare, Medicaid, and food stamps;

(6) Emergency contact information;

(7) Educational history;

(8) Marital or civil union status;

(9) Living situation;

(10) Employment status and history;

(11) Race, ethnicity, and primary language;

(12) Gender;

(13) Gender identification; and

(14) Current legal involvement, such as:

a. Probation or parole;

b. Conditional discharge;

c. Guardianship; and

d. Any other court ordered involvement.

(c) Data collected in (b) above shall be reviewed and a hard copy signed by the individual at least annually and updated as needed.

N.H. Admin. Code § He-M 408.05

#2039, eff 7-1-82; ss by #2423, eff 7-13-83; rpld by #2468, eff 9-6-83

New. #3051, eff 7-8-85, EXPIRED: 7-8-91

New. #7281, eff 5-23-00, EXPIRED: 5-23-08

New. #9512, eff 7-9-09

Amended by Volume XXXVII Number 45, Filed November 09, 2017, Proposed by #12409, Effective 10/24/2017, Expires 10/24/2027.