S.D. Admin. R. 67:62:08:05

Current through Register Vol. 51, page 57, November 12, 2024

Section 67:62:08:05 - Integrated assessment

A mental health staff member shall meet with the client and, if appropriate, the client's family, to complete an integrated assessment, within thirty days of intake. The integrated assessment must include both functional and diagnostic components. For a client under eighteen years old, the mental health staff shall obtain permission from the parent or guardian to meet with the child, and at least one parent or guardian shall participate in the assessment. The assessment must include:

(1) Strengths of the client and the client's family, if appropriate, as well as previous periods of success, the strengths that contributed to that success, and the identification of potential resources within the family, if applicable;

(2) Presenting problems or issues that indicate a need for mental health services;

(3) Identification of readiness for change regarding problem areas, including motivation and supports for making such changes;

(4) Current substance use and relevant treatment history of previous mental health and substance use disorder or gambling treatment, and periods of success, psychiatric hospital admissions, psychotropic and other medications, relapse history or potential for relapse, physical illness, and hospitalization;

(5) Relevant family history, including family relationship dynamics and family psychiatric and substance abuse history;

(6) Family and relationship issues, along with social needs;

(7) Educational history and needs;

(8) Legal issues;

(9) Living environment or housing;

(10) Safety needs and risks with regard to physical acting out, health conditions, acute intoxication, or withdrawal;

(11) Past or current indications of trauma or domestic violence, or both;

(12) Vocational and financial history and needs;

(13) Behavioral observations or mental status;

(14) Formulation of a diagnosis, including documentation of co-occurring medical, developmental disability, mental health, substance use disorder, or gambling issues, or a combination of these based on integrated screening;

(15) Eligibility determination for mental health services based on serious mental illness or serious emotional disturbance, and level of care determination for substance use services, or both;

(16) Clinician's signature, credentials, and date; and

(17) Clinical supervisor's signature, credentials, and date, to verify review of the assessment and agreement with:

(a) The initial diagnosis; or

(b) The formulation of the initial diagnosis if the staff does not have the education or training to make a diagnosis.

S.D. Admin. R. 67:62:08:05

43 SDR 80, effective 12/5/2016; 50 SDR 063, effective 11/27/2023

General Authority: SDCL 1-36-25, 27A-5-1.

Law Implemented: SDCL 1-36-25, 27A-3-1, 27A-5-1(3)(5).