Ariz. Admin. Code § 9-21-305

Current through Register Vol. 30, No. 45, November 8, 2024

Section R9-21-305 - Assessments

A. The following individuals may participate in and contribute to the assessment of a client:

1. The client;

2. The qualified clinician in R9-21-303(B);

3. The client's case manager;

4. Each individual on the client's clinical team, including:

a. Behavioral health professionals,

b. Professionals other than behavioral health professionals,

c. Behavioral health technicians,

d. Family members,

e. Paraprofessionals, and

f. Any individual whom the qualified clinician and the client deem appropriate and necessary to ensure that the assessment is comprehensive and meets the needs of the client.

B. The individuals contributing to the assessment of a client shall not consider the availability of services, but shall consider the client's circumstances and evaluate all available information including.

1. The information obtained during the initial meeting with the client by a qualified clinician according to R9-21-303(B);

2. Written information such as the client's clinical history, records, tests, and other evaluations;

3. Information from family, friends, and other individuals.

C. An assessment shall include:

1. An evaluation of the client's:

a. Presenting concerns;

b. Behavioral health treatment;

c. Medical conditions and treatment;

d. Sexual behavior and, if applicable, sexual abuse;

e. Substance abuse, if applicable;

f. Living environment;

g. Educational and vocational training;

h. Employment;

i. Interpersonal, social, and cultural skills;

j. Developmental history;

k. Criminal justice history;

l. Public and private resources;

m. Legal status and apparent capacity;

n. Need for special assistance; and

o. Language and communication capabilities;

2. A risk assessment of the client;

3. A mental status examination of the client;

4. A summary, impressions, and observations;

5. Recommendations for next steps;

6. Diagnostic impressions of the qualified clinician; and

7. Other information determined to be relevant.

D. Within 45 days of a request or referral for an SMI eligibility determination, a qualified clinician shall prepare an assessment report based on the information obtained according to R9-21-303 and this Section, including:

1. The development of a long-term view by the client with assistance from the clinical team that establishes a method of integration for living, employment and social conditions that the client wishes to achieve over the next three years;

2. A summary of the information gathered during the eligibility and assessment processes;

3. An identification of the client's legal status, resources, and assessed strengths and actual needs, regardless of the availability of services to meet that need, in each area of assessment identified in subsection (C) above;

4. An analysis of the major findings of the mental health assessment, including a description of the nature and severity of any illness and a diagnosis in terms set forth in the DSM;

5. The client's preferences regarding services to be provided;

6. A description of any additional interim services which are required and plans for the referral of the client to additional interim services or the continuation of interim services already provided;

7. An identification of further evaluations which the clinical team deem necessary to determine the services appropriate to the client's needs;

8. An identification of information that could not be obtained due to the client's circumstances or unavailability; and

9. A functional assessment of the client's current status in terms of independent living, employment (or retirement), and social integration and analysis of the support or skills, if any, necessary to achieve the client's long-term view.

E. The qualified clinician shall arrange for any further evaluations recommended by the clinical team. If the client needs assessment in an area beyond the ability or expertise of the clinical team, such assessment shall be conducted by professionals with appropriate credentials, with the client's consent. The need for further evaluations shall not unreasonably delay the preparation of the ISP.

F. If a qualified clinician determines that the client is a client who needs special assistance, the case manager shall:

1. Notify the regional authority, the Office of Human Rights, and the appropriate human rights committees of the client's need so that the client can be provided special assistance from the human rights advocate or special review by the human rights committee; and

2. If the client does not have a guardian, identify a friend, relative or other person who is willing to serve as a designated representative of the client.

G. Upon completion of the assessment report, copies shall be sent to the client, the designated representative, if any, the guardian, and all service providers who have been identified by the case manager or regional authority to serve the client.

Ariz. Admin. Code § R9-21-305

Adopted under an exemption from A.R.S. Title 41, Chapter 6 pursuant to Laws 1992, Ch. 301, § 61, effective October 7, 1992; received in the Office of the Secretary of State October 14, 1992 (Supp. 92-4). Amended under an exemption from A.R.S. Title 41, Chapter 6 pursuant to Laws 1992, Ch. 301, § 61, effective September 30, 1993 (Supp. 93-3). Amended by exempt rulemaking at 9 A.A.R. 3296, effective June 30, 2003 (Supp. 03-2).