1. (a)

   1. (1) A preadmission screening shall be used to determine a client’s eligibility and appropriateness.

   2. (2) It is to include:

      1. (A) Substance use history;
      2. (B) Current detoxification level determination;
      3. (C) Past psychiatric treatment;
      4. (D) Past chemical dependency treatment;
      5. (E) Significant medical history;
      6. (F) Current health status;
      7. (G) Current medications;
      8. (H) Known food allergies;
      9. (I) Known drug allergies; and
      10. (J) Current emotional state and behavioral functioning.

2. (b) Documentation of client information and history is to include:

   1. (1) Confirmation of identity;
   2. (2) Name;

   3. (3) Address, including:

      1. (A) Street and number;
      2. (B) Town;
      3. (C) County;
      4. (D) State; and
      5. (E) Zip code;
   4. (4) Phone;
   5. (5) Current housing arrangements;
   6. (6) Guardianship, if applicable;
   7. (7) Photograph of client;
   8. (8) Social security number;

   9. (9) Client's:

      1. (A) Date of birth;
      2. (B) Sex; and
      3. (C) Race ethnicity;

   10. (10)

       1. (A) Name of referral source.
       2. (B)

3. (i) Document if treatment was mandated by the referral source.

   1. (ii) If treatment was mandated, the complete address and telephone number of the referral source;

      1. (C) Documented conditions of referral and/or information needs of the referral source;
   2. (11) Types of problems experienced by the client that are in need of resolution;

   3. (12)

      1. (A) Substance abuse history to include:

         1. (i) Most recent use patterns, such as amount per type, route of administration;
         2. (ii) Ages of first use per substance; and
         3. (iii) Age of regular and/or addictive patterns.
      2. (B) Document any injection use;

   4. (13) Document the client's family history to include:

      1. (A) Current marital status;
      2. (B) Effect of substance use on current and past relationships;
      3. (C) History of family members' use;
      4. (D) Any family members "in recovery";
      5. (E) Names and ages of dependents; and
      6. (F) Who has custody of dependents while the client is in treatment;

   5. (14)

      1. (A) Client's highest grade completed, major if applicable, and effect of substance use on the client's educational process.
      2. (B) The client's reading and writing levels must be evaluated when appropriate;

   6. (15) Current/most recent vocations, including:

      1. (A) Any trained skills;
      2. (B) Effect of substance use on employment; and
      3. (C) Adequacy of current employment;

   7. (16) Legal history, which includes:

      1. (A) The dates and type of charges;
      2. (B) Arrests;
      3. (C) Convictions; and
      4. (D) Sentences;

   8. (17) Medical and health history to include:

      1. (A) Chronic medical problems;
      2. (B) Significant medical/physical events;
      3. (C) Problems that could influence treatment;
      4. (D) Medical conditions that could prompt a crisis;
      5. (E) Special diet needs;
      6. (F) Current medications, including does client have sufficient supply during treatment;
      7. (G) Purpose of current medications;
      8. (H) History of alcohol or other drug-related conditions, i.e. blackouts, delirium tremens, etc.;
      9. (I) “At-risk” behaviors, e.g., multiple sex partners, unprotected sex;
      10. (J) Pregnancy status; and

      11. (K)

          1. (i) Allergies.
          2. (ii) Allergies and/or other serious conditions are flagged on the outside of the record;

   9. (18) Medication records for both prescriptions and over-the-counter medications, including:

      1. (A) Drug type;
      2. (B) Dosage strength;
      3. (C) How many;
      4. (D) Time/date of dispersion; and
      5. (E) Who dispensed/witnessed dosing;

   10. (19) Psychological/psychiatric treatment history to include:

       1. (A) Dates of any treatment;
       2. (B) Type of problem or problems;
       3. (C) Who provided treatment;
       4. (D) Outcome of treatment; and
       5. (E) Any current psychotropic medications;

   11. (20) Other relevant information to include:

       1. (A) Military service, to include:

          1. (i) Branch of service;
          2. (ii) Dates of service;
          3. (iii) Discharge status;
          4. (iv) Highest rank;
          5. (v) Classifications; and
          6. (vi) Any combat experience;
       2. (B) Copies of court or parole orders; and
       3. (C) Other information that will aid in assessing the client;

   12. (21)

       1. (A) A completed Addiction Severity Index.
       2. (B) When applicable, results of other tests or standardized assessment tools;
   13. (22) Readmissions and transfers to another environment are clearly delineated;
   14. (23) Summary of client problems and corresponding needs, as based on client information;
   15. (24) Summary of the client's strengths and weaknesses, as based on the client information; and

   16. (25)

       1. (A) Based upon the assessment, each client will be assigned a Diagnostic and Statistical Manual for Mental Disorders substance abuse disorder diagnosis and code.
       2. (B) Only staff authorized to approve comprehensive treatment plans as specified in this part will assign the diagnosis code.

       3. (C)

          1. (i) Counseling personnel registered as Counselors in Training with the Arkansas Substance Abuse Certification Board may assign the diagnosis, provided the diagnosis is approved in writing by personnel authorized to sign comprehensive treatment plans.
          2. (ii) The diagnosis and code will meet the current substance abuse disorder criteria as per the Diagnostic and Statistical Manual of the American Psychological Psychiatric Association.
          3. (c)
   17. (1) An assessment to determine severity and environment placement to include a completed Addiction Severity Index for adults or an equivalent assessment tool for adolescents is to be completed within seventy-two (72) hours of admission.
   18. (2) When applicable, results of other tests or standardized assessments, including the ASAM patient-placement criteria or other nationally recognized placement tool must also to be included.

Codification Notes: "ASAM" means American Society of Addiction Medicine.