Person-centered and family-centered treatment planning

1. The certified clinic directly shall provide person-centered and family-centered treatment planning, including risk assessment and crisis planning. 2. The certified clinic shall develop an individualized treatment plan based on information obtained through the comprehensive evaluation and the individual's goals and preferences. The individualized treatment plan must: a. Address the individual's prevention, medical, and behavioral health needs; b. Be comprehensive, addressing all services required, including recovery supports, with provision for monitoring of progress toward goals; c. Be developed in collaboration with and be endorsed by the adult individual and legal representative, if applicable, and the adult individual's family or other supports to the extent the adult individual so wishes or if the individual is a child, the family or legal representative if permitted by federal laws and regulations; d. Be coordinated with staff or programs necessary to carry out the plan; e. Support care in the least restrictive setting possible; and f. Include needs, strengths, abilities, preferences, and goals, expressed in a manner capturing the words or ideas of the adult individual and legal representative, if applicable, and the adult individual's family or other supports or if the individual is a child, the family or legal representative. 3. The certified clinic shall use the initial evaluation, comprehensive evaluation, and ongoing screening and assessment of the individual to inform the treatment plan and services provided. 4. The certified clinic's treatment planning must include needs, strengths, abilities, preferences, and goals, expressed in a manner capturing the words or ideas of the individual and legal representative, if applicable, and the adult individual's family or other supports or if the individual is a child, the family or legal representative. 5. The certified clinic's treatment plan must be built upon a shared decisionmaking approach and must be comprehensive, addressing all services required, including recovery supports, with provision for monitoring of progress toward goals. 6. The certified clinic shall, where appropriate, seek consultation during treatment planning. 7. The certified clinic shall document any health care directives related to treatment and crisis planning in the individual's health record. If the individual does not wish to share the individual's preferences with the certified clinic, the certified clinic shall document the individual's decision in the individual's health record.