DHS 75.24(11)(d)6.b.b. Records of the patient’s legal history.
DHS 75.24(11)(d)6.c.c. Information from referral sources.
DHS 75.24(11)(d)6.d.d. Consultation with the patient’s physician or other medical or behavioral health provider.
DHS 75.24(11)(d)6.e.e. Consultation with department of corrections or child protective services when applicable.
DHS 75.24(11)(d)6.f.f. Information from the patient’s family or significant others.
DHS 75.24(11)(d)6.g.g. Results of toxicology testing.
DHS 75.24(11)(d)7.7. Level of care recommendation based on ASAM or other department-approved placement criteria.
DHS 75.24(11)(e)(e) If no collateral information is obtained to inform the assessment, the service shall document the reason for not including collateral information.
DHS 75.24(11)(f)(f) The clinical staff’s recommendations for treatment shall be included in a summary of the assessment that is consistent with diagnosis and level of care placement criteria.
DHS 75.24(11)(g)(g) If an assessing substance abuse counselor identifies symptoms of a mental health disorder during the assessment process, the substance abuse counselor shall refer the individual to an appropriately credentialed provider for a comprehensive mental health assessment, unless the substance abuse counselor is also a licensed mental health professional.
DHS 75.24(11)(h)(h) If the assessing clinical staff identifies symptoms of a physical health problem during the assessment process, the service shall refer the individual for a physical health assessment conducted by medical personnel.
DHS 75.24(11)(i)(i) If the assessing clinical staff identifies that an individual is pregnant at the time of the assessment, the service shall make a referral for prenatal care or ensure that the patient is already receiving prenatal care, and document efforts to coordinate care with prenatal care providers.
DHS 75.24(11)(j)(j) In the event that the assessed level of care is not available, a service shall:
DHS 75.24(11)(j)1.1. Document accurately the level of care indicated by the clinical assessment.
DHS 75.24(11)(j)2.2. Indicate on the treatment plan what alternative level of care is available or agreed upon.
DHS 75.24(11)(j)3.3. Identify on the treatment plan what efforts will be made to access the appropriate level of care, additional services or supports that will be offered to bridge the gap in level of care, and ongoing assessment for clinical needs and level of care review.
DHS 75.24(11)(k)(k) For assessments completed by a substance abuse counselor in-training or a graduate student QTT, the assessment and recommendations shall be reviewed and signed by the clinical supervisor within 7 days of the assessment date.
DHS 75.24(11)(L)(L) For a patient receiving mental health services under s. DHS 75.50 or 75.56 who does not have a co-occurring substance use disorder, the requirement for ASAM or other department-approved level of care placement criteria is not required.
DHS 75.24(12)(12)Referral.
DHS 75.24(12)(a)(a) A service shall have written policies and procedures for referring patients to other service providers and for coordinating care with other providers.
DHS 75.24(12)(b)(b) Policies and procedures shall include a description of follow-up activities to be completed to support that recommended care is received.
DHS 75.24(12)(c)(c) Follow-up shall occur within one week of the referral.
DHS 75.24(13)(13)Treatment plan.
DHS 75.24(13)(a)(a) Clinical staff of a service shall develop a treatment plan for each patient.
DHS 75.24(13)(b)(b) A patient’s treatment plan shall represent an agreement between the service and the patient regarding needs identified in the clinical assessment, the patient’s identified treatment goals, and treatment interventions and resources to be applied.
DHS 75.24(13)(c)(c) When feasible, the treatment plan shall be developed in collaboration and with input from the patient’s family or significant other, or other supportive persons identified by the patient.
DHS 75.24(13)(d)(d) The treatment plan shall be signed by the patient, the primary counselor, and other behavioral health clinical staff, identified in the treatment plan.
DHS 75.24(13)(e)(e) A treatment plan completed by a substance abuse counselor in-training or a graduate student QTT shall be reviewed and signed by the clinical supervisor within 14 days of the development of the plan or the next treatment plan review, whichever is earlier.
DHS 75.24(13)(f)(f) The content of the treatment plan shall describe the identified needs and specify individualized treatment goals that are expressed in behavioral and measurable terms.