N.H. Admin. Code § He-M 408.06

Current through Register No. 50, December 12, 2024
Section He-M 408.06 - Intake Assessment
(a) The CMHP shall complete and document an intake assessment for each individual.
(b) The intake assessment shall:
(1) Include medical, psychiatric, and social information;
(2) Include historical and current information and assessments; and
(3) Serve as a basis for ISP development.
(c) The components of an intake assessment shall include, at a minimum;
(1) Medical information including:
a. A statement of the individual's general physical health status;
b. Medical history, including current weight, height, blood pressure, pulse, and smoking status;
c. When applicable, medical diagnoses, and the results of any medical or neurological screenings, examinations, or tests; and
d. The name and contact information for the individual's primary care physician;
(2) Psychiatric information including:
a. History of mental illness or serious emotional disturbance, including onset and severity;
b. Previous services and treatments, including medications and hospitalizations;
c. Individual's strengths;
d. Illness self-management skills;
e. Precipitating events for current psychiatric symptoms, as applicable;
f. Documentation of the medical necessity for services;
g. Current diagnosis;
h. Medication orders;
i. Current medications;
j. Results of formalized psychiatric and/or psychological tests, if applicable;
k. Mental status examination results; and
l. Diagnostic formulation by a psychiatrist or other licensed practitioner of the healing arts under the auspices of a psychiatrist licensed to practice in the state of New Hampshire; and
(3) Social information including:
a. Developmental history;
b. Educational history and current status, if applicable;
c. Family history and current family status;
d. History of childhood abuse and neglect;
e. History of trauma, including domestic violence;
f. Results of a substance use screening tool;
g. Employment history including work skills and types, and lengths of employment;
h. Military history and veterans status, if applicable;
i. Current living situation including type of environment and nature of relationship with any room/house mates or family;
j. Social and leisure time activities and skills;
k. Ability to develop and maintain friendships;
l. Involvement with or history of involvement with other social service agencies or the criminal justice system;
m. Guardianship, if applicable; and
n. Other legal documents.
(d) Intake assessments that are completed to function as the initial ISP shall include the initial services to be provided and a physician's signature.
(e) The intake assessment and updates shall be signed and dated by the person completing the assessment.

N.H. Admin. Code § He-M 408.06

#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.