(1) Every petition or request for a level of mental health services with greater autonomy shall be initially handled with a screening process to determine the nature of the minor’s problem and the need for mental health services. The screening process shall consist of, among others:
(a) Advising the minor and his/her parent with patria potestas, legal guardian or person with provisional custody, of the process to be carried out, the findings and the recommendations.
(b) Making a determination based upon the capacity shown by the minor as information transmitter and receptor.
(c) Conducting an initial social evaluation to identify the areas of conflict and relevant information related to factors and resources that affect the minor’s condition.
(2) If through this screening, it is determined that the nature of the problem requires a kind of care unrelated to mental health services, then the situation shall be referred to the corresponding agency, if necessary, and the parents, legal guardian or legal representative shall be advised of other services. This information shall be documented and shall be included in the clinical record. The screening shall be conducted by a mental health professional so authorized by law. If through the screening it is determined that the minor meets the criteria to receive mental health services, the mental health professional shall be required to initiate the comprehensive evaluation process and refer the minor to another type of mental health service according to minor’s symptoms and signs. The comprehensive evaluation shall determine the diagnosis and level of care the minor needs to receive treatment. Here, the professional shall determine the individual and family nature of recurring or existing problems and the factors that contribute or have contributed to it. He/she shall also identify and evaluate the resources of the minor, his/her family and community for dealing with the problem(s). The comprehensive evaluation shall include, among others:
(a) Substantial information as to, or in relation to, services that have been offered to the minor by other agencies. The consent of the parent with patria potestas or custody, or the legal guardian shall be obtained for this.
(b) Evaluation of the minor in the areas of functioning, among which are.
(c) The minor’s identification.
(d) The minor’s developmental history, including educational and occupational development and social adjustment.
(e) Family medical records, including the presence or absence of mental disorders.
(f) Family profile, as well as physical and economic resources.
(g) Presence or absence of special situations, such as abuse, mistreatment or learning problems.
(h) Substance use and abuse, or dependency.
(i) Laboratory and toxicology tests that help diagnose mental disorders or other medical conditions.
(j) The mental, affective and physical state, and the minor’s behavior at the time of receiving the service.
(k) Any other information that must to be obtained from other sources, such as other professionals, document analysis or previous clinical records.
(l) Conclusions and recommendations made by the mental health professional or the inter- or multidisciplinary team, diagnosis and preliminary individualized treatment, recovery and rehabilitation plan.
The information described above shall be included in the minor’s clinical record. Participation of the minor’s family, custodian or legal representative shall be essential in this comprehensive evaluation process. All appropriate measurements and evaluative instruments shall be used. They shall be valid, reliable, clinically useful and culturally competent for the population being served because they shall be useful when programming the services to be offered.
History —Oct. 2, 2000, No. 408, § 8.05, eff. 90 days after Oct. 2, 2000.