DHS 75.24(11)(d)4.4. Documentation about the current mental and physical health status of the patient. DHS 75.24(11)(d)5.5. Psychosocial history information shall include all of the following areas that relate to the patient’s presenting problem: DHS 75.24(11)(d)5.i.i. Other factors that appear to have a relationship to the patient’s substance use and physical and mental health. DHS 75.24(11)(d)6.6. The clinical assessment shall include any collateral information gathered during the clinical assessment. Collateral information may include one of more of the following: 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)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.