Screening, assessment, and diagnosis

1. The certified clinic shall directly provide screenings, assessments, and diagnoses, including risk assessments for behavioral health conditions, to individuals. If specialized services outside the expertise of the certified clinic are required for purposes of screening, assessment, or diagnosis of an individual, the certified clinic shall refer the individual to an appropriate provider. The certified clinic, if necessary and appropriate, may provide the screening, assessment, and diagnosis through telehealth, telemedicine, videoconferencing, remote patient monitoring, asynchronous interventions, or other technologies. 2. The certified clinic shall conduct the screening, assessment, and diagnosis in a time frame responsive to the needs and preferences of the individual and shall ensure the screening, assessment, and diagnosis are of sufficient scope to assess the need for all services required to be provided by the certified clinic. 3. The initial evaluation, as required in section 75-03-44-17, provided by the certified clinic, must include at a minimum: a. Preliminary diagnoses; b. The source of referral; c. The reason for seeking care, as stated by the adult individual and legal representative, if applicable, and the adult individual's family or other supports if the adult individual so wishes or if the individual is a child, the family or legal representatives; d. Identification of the immediate clinical care needs related to the diagnosis for mental and substance use disorders of the individual; e. A list of all known current prescriptions and over-the-counter medications, herbal remedies, and dietary supplements used by the individual and the indication for any medications; f. A summary of known previous mental health and substance use disorder treatments with a focus on which treatments were beneficial and which were not; g. The use of alcohol or drugs; h. An assessment of whether the individual is a risk to self or to others, including suicide risk factors; i. An assessment of whether the individual has other concerns for the individual's safety, such as intimate partner violence; j. Assessment of need for medical care, with a referral and followup as required; k. A determination of whether the individual presently is, or ever has been, a member of the United States armed forces; and l. For a child, whether the child has criminal and juvenile justice or child welfare system involvement. 4. A certified clinic shall provide a comprehensive evaluation for all individuals. Subject to applicable federal and state laws and regulations and accreditation standards, certified clinic's clinicians shall use their clinical judgment with respect to the depth of questioning within the comprehensive evaluation so the comprehensive evaluation actively engages the individual around the individual's presenting concern. The certified clinic's comprehensive evaluation must gather the amount of information commensurate with the complexity of the individual's specific needs and prioritize preferences of the individual with respect to the depth of the comprehensive evaluation and the individual's treatment goals. The comprehensive evaluation must include: a. The individual's reasons for seeking services at the certified clinic, including information regarding onset of symptoms, severity of symptoms, and circumstances leading to the presentation to the certified clinic of the individual; b. An overview of the individual's relevant social supports, social determinants of health, health-related social needs such as housing, vocational, and educational status, family or legal representative and social supports legal issues, and insurance status; c. A description of the individual's cultural and environmental factors that may affect the treatment plan of the individual, including the need for linguistic services or supports for individuals with limited English proficiency; d. The individual's pregnancy and parenting status; e. The individual's behavioral health history, including trauma history and previous therapeutic interventions and hospitalizations with a focus on what was beneficial and what was not beneficial in past treatments; f. The individual's relevant medical history and major health conditions that impact the individual's current psychological status; g. A medication list including prescriptions, over-the counter medications, herbal remedies, dietary supplements, and other treatments or medications of the individual. A certified clinic's medication list must include treatments or medications identified in a prescription drug monitoring program that may affect the individual's clinical presentation and pharmacotherapy, as well as information on allergies including medication allergies; h. An examination of the individual which includes current mental status, mental health, and substance use disorders; i. Basic cognitive screening of the individual for cognitive impairment; j. Assessment of imminent risk to the individual, including suicide risk, withdrawal and overdose risk, danger to self or others, urgent or critical medical conditions, and other immediate risks, including threats from another person; k. The strengths, goals, preferences, and other factors to be considered in treatment and recovery planning of the individual; l. Assessment of the need for other services required by this chapter; m. Assessment of any relevant social or human service needs of the individual, with necessary referrals made to social or human services. For children receiving services, assessment of criminal and juvenile justice and child welfare system involvement and referral to child welfare agencies as appropriate; n. An assessment of need for a physical examination or further evaluation by appropriate health care professionals, including the primary care provider, with appropriate referral and followup, of the individual; and o. The preferences of the individual regarding the use of technologies such as telehealth, telemedicine, videoconferencing, remote patient monitoring, asynchronous interventions, or other technologies. 5. A certified clinic shall include data and quality metrics in screening, assessment, and evaluations as identified in sections 75-03-44-37 and 75-03-44-38, and as clinically indicated. 6. The certified clinic shall use standardized, validated, and developmentally appropriate screening and assessment tools appropriate for the individual and, if warranted, brief motivational interviewing techniques to facilitate engagement. If the certified clinic's screening identifies unsafe substance use, including problematic alcohol or other substance use, the certified clinic shall conduct a brief intervention and shall provide a full assessment and treatment for the individual, if appropriate within the level of care of the certified clinic. If the full assessment and treatment for the individual is not appropriate within the level of care provided by the certified clinic, the certified clinic shall refer the individual to a more appropriate level of care. If the certified clinic's screening identifies more immediate threats to the safety of the individual, the certified clinic shall take appropriate action as described in subsection 1 of section 75-03-44-17.