Assessment

1. When conducting an assessment, a program shall administer instruments or conduct clinical interviews or both sufficient to gather enough information to substantiate or rule out a client's diagnosis. 2. An assessment must include adequate assessment in at least each of the following areas: withdrawal potential; medical conditions and complications; psychiatric, including emotional, behavioral, and cognitive functioning and the presence of co-occurring mental health problems; employment; alcohol, tobacco, and other drug use; legal; family and social; readiness to change; relapse, continued use, and continued problem potential; and recovery environment. 3. When clinically appropriate, previous diagnostic, medical, treatment, and training reports that impact the development of an individual must be: a. Requested from appropriate current or previous providers and referral sources with signed, informed consent to release of information forms in compliance with applicable laws and regulations; and b. Integrated into the assessment process. 4. A program shall provide requested information within a reasonable time period when the request is accompanied by an appropriate consent to release of information. 5. A program's report from the assessment process must clearly describe the diagnostic impressions based on a five-axis assessment of the DSM and recommendations for treatment based on the ASAM patient placement criteria. 6. Based on the information gathered in the assessment, a program's report should identify and prioritize problems by severity, which should then be addressed in the individual treatment plan with the involvement of the client. 7. A program shall keep progress notes that reflect the client's progress or lack of progress in measurable and behavioral language associated with treatment plan objectives.