Section DHS 40.13 - Assessment(1) INTERDISCIPLINARY TREATMENT TEAM. (a) Within 5 working days following the decision to admit a youth into the program, the care coordinator shall assemble an interdisciplinary treatment team to begin an assessment of the strengths, needs, and current status of the youth.(b) The team shall include all of the following:1. The youth, to the extent appropriate to his or her age, maturity and clinical condition, if available and willing to participate.2. The youth's legal representative.3. The youth's care coordinator.4. The program's clinical coordinator.(c) The youth or legal representative shall be asked to participate in identifying additional members of the interdisciplinary team. With consent of the youth or legal representative, reasonable efforts should be made to include all of the following: 1. An occupational therapist or a registered nurse, based on youth needs identified in the screening summary.2. An educational professional from the youth's school.3. Representatives of any other profession or agency necessary in order to adequately and appropriately respond to the treatment needs of the youth which were identified in the referral materials or the intake screening process.4. Family members who are involved in the life of the youth.5. If the youth has been placed under the supervision of a county department, the social worker who has been assigned to the case.(2) ASSESSMENT. (a) The purpose of the assessment is to identify the individual strengths and needs of the youth to address the level of functioning as well as specific strategies that will be utilized to treat the youth. The clinical coordinator shall prepare a written report describing and evaluating all of the following:1. Biopsychosocial information that is sufficient to identify the goals that the youth or legal representative want to accomplish through their participation in the program, the needs that will have to be addressed to reach those goals, and the strengths of the youth that can form the foundation of the individual treatment plan to meet the identified needs and achieve the chosen goals, through conducting a respectful and thorough series of interviews that engage the youth or legal representative. Biopsychosocial information includes developmental history, significant past events, significant past relationships and prominent influences, behavioral history, financial history, and overall life adjustment.2. The current mental health status of each youth including frequency, severity and duration of the symptoms and behaviors and the manner in which the symptoms and behaviors impact the youth's ability to function, attitude, judgement, memory, speech, thought content, perception, intellectual functioning, general appearance, diagnosis, or medical impression. Note: The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. Washington, DC, American Psychiatric Association, 2013. The Diagnostic and Statistical Manual of Mental Disorders may be ordered through http://www.appi.org/Pages/DSM.aspx or other sources.
3. Completing an evaluation of all of the following: a. Current living arrangements, social relationships, support systems, including the youth's level of social and behavioral functioning in the home, school and community, and the youth's relationship with his or her family members, including an assessment of family member strengths and weaknesses which might affect treatment.b. A youth's trauma history and experiences and how treatment approaches will avoid re-traumatization.c. A youth's ability to work in a group setting.d. The youth's level of academic functioning and educational history, including areas where the youth shows interest, skill and achievement.e. A youth's history of criminal activity, including sexual perpetration, peer-to-peer violence, battery, and safety concerns.f. The youth's health, medical history, and prescribed medications, including a youth's prior history of dangerous reactions to psychotropic medications, including procedures for assessing and monitoring the desired objectives and side effects of medications which the youth is taking, dealing with the results of possible medication interactions, medication overdose, an error in medication administration, an unanticipated reaction to the medication, the effects of a concurrent medical illness or condition occurring while the client is receiving the medication, and monitoring the medication regime to determine if any of the medications, solely or in combination, may mask or mimic psychiatric symptoms or behaviors.g. Suicide risk and self-harm history and risk including criteria for deciding when the level of risk of suicide requires the use of crisis response services or hospitalization.h. For a youth over the age of 15, the youth's vocational and independent living history, skills and needs.i. The youth's current or recent use of drugs or alcohol and the possible presence of any co-occurring disorder that will have to be addressed through the treatment plan.j. Any other assets and needs of the youth which affect the youth's ability to participate effectively in relationships and activities in home, community and school environments.k. Past treatment, including where it occurred, for how long, and by whom.l. Recommendations for completing any new test or evaluation which the interdisciplinary treatment team finds is necessary for development of an effective treatment plan for the youth, including psychological, neuropsychological functional, cognitive, behavioral, developmental or early and periodic screening and diagnosis under s. DHS 107.22.(b) The written assessment shall inform and be completed prior to development of the treatment plan.(c) The written assessment shall be signed by the youth or legal representative and the clinical coordinator.Wis. Admin. Code Department of Health Services § DHS 40.13
Cr. Register, August, 1996, No. 488, eff. 9-1-96; corrections in (1) (m) and (5) made under s. 13.93(2m) (b) 7 Stats., Register January 2004 No. 577; corrections in (1) (m) and (5) made under s. 13.92(4) (b) 7, Stats., Register November 2008 No. 635.Adopted by, CR 19-018: cr. Register June 2020 No. 774, eff. 7/1/2020