(b) These standards shall include, but are not limited to, all of the following:

1. (1) For services funded pursuant to subdivision (a) of Section 5892, the county may consult with the stakeholders listed in paragraph (1) of subdivision (a) of Section 5963.03.

2. (2)

   1. (A) Outreach to families with a child or youth with a serious emotional disturbance or a substance use disorder to provide coordination and access to behavioral health services, medications, housing interventions pursuant to Section 5830, and supportive services as defined in subdivision (h) of Section 5887.
   2. (B) Service planning shall include evaluation strategies that shall consider cultural, linguistic, gender, age, and special needs of the target populations.
   3. (C) Provision shall be made for a workforce with the cultural background and linguistic skills necessary to remove barriers to mental health and substance use disorder treatment services due to limited-English-speaking ability and cultural differences.
   4. (D) Recipients of outreach services may include families, the public, primary care physicians, hospitals inclusive of emergency departments, behavioral health urgent care, and others who are likely to come into contact with individuals who may be suffering from either an untreated serious emotional disturbance or substance use disorder, or both, who would likely become homeless or incarcerated if the illness continued to be untreated for a substantial period of time.
3. (3) Provision for services for populations with identified disparities in behavioral health outcomes.
4. (4) Provision for full participation of the family in all aspects of assessment, service planning, and treatment, including, but not limited to, family support and consultation services, parenting support and consultation services, and peer support or self-help group support, where appropriate for the individual.
5. (5) Provision for clients who have been suffering from an untreated serious emotional disturbance or substance use disorder, or both, for less than one year and who do not require the full range of services but are at risk of becoming homeless or justice involved unless a comprehensive individual and family support services plan is implemented. These clients shall be served in a manner that is designed to meet their needs, including housing for clients that is immediate, transitional, permanent, or all of these.
6. (6) Provision for services to be client-directed, to use psychosocial rehabilitation and recovery principles, and to be integrated with other services.
7. (7) Provision for psychiatric and psychological collaboration in overall service planning.
8. (8) Provision for services specifically directed to children and youth experiencing first episode psychosis.
9. (9) Provision for services for frequent users of behavioral health urgent care, crisis stabilization units, and hospitals or emergency departments as the primary resource for mental health and substance use disorder treatment.
10. (10) Provision for services to meet the special needs of clients who are physically disabled, clients who are intellectually or developmentally disabled, or persons of American Indian or Alaska Native descent.

(d) A personal services coordinator shall perform all of the following:

1. (1) Conduct a comprehensive assessment and periodic reassessment of a client’s needs. The assessment shall include the following:

   1. (A) Taking the client’s history.
   2. (B) Identifying the individual’s needs, including reviewing available records and gathering information from other sources, including behavioral health service providers, medical providers, family members, social workers, and others needed to form a complete assessment.
   3. (C) Assessing the client’s living arrangements, employment or education status, and training needs.

2. (2) Plan for services using information collected through the assessment. The planning process shall do all of the following:

   1. (A) Identify the client’s goals and the behavioral health, supportive, medical, educational, social, prevocational, vocational, rehabilitative, housing, or other community services needed to assist the client to reach their goals.
   2. (B) Include active participation of the client and others in the development of the client’s goals.
   3. (C) Identify a course of action to address the client’s needs.
   4. (D) Address the transition of care when a client has achieved their goals.
3. (3) Assist the client in accessing needed behavioral health, supportive, medical, educational, social, prevocational, vocational, rehabilitative, housing, or other community services.
4. (4) Coordinate the services the county furnishes to the client between settings of care, including appropriate discharge planning for short-term hospital and institutional stays.
5. (5) Coordinate the services the county furnishes to the client with the services the client receives from managed care organizations, the Medicaid fee-for-service delivery system, other human services agencies, and community and social support providers, including local educational agencies.
6. (6) Ensure that, in the course of coordinating care, the client’s privacy is protected in accordance with all federal and state privacy laws.

(f) The service planning process shall ensure children and youth receive age-appropriate, gender-appropriate, and culturally appropriate services or appropriate services based on a characteristic listed or defined in Section 11135 of the Government Code, to the extent feasible, that are designed to enable recipients to:

1. (1)

   1. (A) Live in the most independent, least restrictive housing feasible in the local community and to live in a supportive housing environment that strives for family reunification.
   2. (B) Rejoin or return to a home they had previously maintained with a family member or in shared housing environment that is supportive of their recovery and stabilization.
2. (2) Engage in the highest level of educational or productive activity appropriate to their age, abilities, and experience.
3. (3) Create and maintain a support system consisting of friends, family, and participation in community activities.
4. (4) Access necessary physical health care and maintain the best possible physical health.
5. (5) Reduce or eliminate serious antisocial or criminal behavior and thereby reduce or eliminate their contact with the justice system.
6. (6) Reduce or eliminate the distress caused by the symptoms of either mental illness or substance use disorder, or both.
7. (7) Utilize trauma-informed approaches to reduce trauma and avoid retraumatization.

(g)

1. (1)

   1. (A) The client’s clinical record shall describe the service array that meets the requirements of subdivisions (d) and (f) and, to the extent applicable to the individual, the requirements of subdivision (a) and (b).
   2. (B) The State Department of Health Care Services may develop and revise documentation standards for service planning to be consistent with the standards developed pursuant to paragraph (3) of subdivision (h) of Section 14184.402.
2. (2) Documentation of the service planning process in the client’s clinical record pursuant to paragraph (1) may fulfill the documentation requirements for both the Medi-Cal program and this section.