1. (a) There shall be an initial one-on-one intake interview between the client and a LADC, or a phase II program staff member under LADC supervision.
2. (b) The intake interview shall take place prior to, and separate from, course sessions.

3. (c) The intake interview shall include the following steps:

   1. (1) The client shall provide the phase II program with the documents required pursuant to He-A 904.04;
   2. (2) The client shall complete the diagnostic instruments;

   3. (3) The LADC shall complete Form IDIP-011, client profile, by including the following printed or typewritten information:

      1. a. The facility code;
      2. b. The section where the client is assigned;
      3. c. The last four digits of the client’s Social Security number;
      4. d. The client’s name;
      5. e. The client’s initials;
      6. f. The program type;
      7. g. The client’s address;
      8. h. The client’s date of birth;
      9. i. The date of the client’s intake interview;
      10. j. The client’s gender;
      11. k. Whether the client is restarting a program;
      12. l. The court of the client’s conviction;
      13. m. The date of the client’s arrest;
      14. n. The client’s blood alcohol test results, or an indication of the client’s refusal of consent;
      15. o. All of the client’s DWI convictions, including the current one, and drug impaired driving convictions, unless otherwise protected by law;
      16. p. All DWI courses previously attended by the client;
      17. q. The client’s marital status;
      18. r. The client’s education level;
      19. s. The client’s occupation;
      20. t. The client’s current income;
      21. u. Whether the program fee was reduced due to financial hardship;
      22. v. The client’s history of treatment for any other alcohol or other substance abuse problem;
      23. w. The frequency of alcohol consumption in the past;
      24. x. The signature of the LADC completing the top of the form, which shall not be printed or typewritten;
   4. (4) The client shall provide to the LADC completing Form IDIP-011, client profile, the information required in (3)c., o. through t., v., and w.;

   5. (5) The client shall complete Form IDIP-019, consent for the release of confidential information, specifically for the department, the convicting court, and the department of safety, by including:

      1. a. The client’s name;
      2. b. The name and address of the convicting court; and
      3. c. The client’s dated signature;
   6. (6) The provider staff member shall sign and date Form IDIP-019, consent for the release of confidential information;

   7. (7) The client shall read and complete Form IDIP-016, phase II client agreement, by including:

      1. a. The client’s name; and
      2. b. The client’s dated signature, indicating that he or she has read the form and agrees to attend the identified sessions; and

   8. (8) The provider staff member shall complete Form IDIP-016, phase II client agreement, by including:

      1. a. The class location of the phase II program, including the street address, city or town, and telephone number;
      2. b. All scheduled session days, dates, times, and instructors; and
      3. c. The dated signature of the phase II staff member.
4. (d) The client shall complete, read and sign any other department-approved forms and materials which are provided by each agency to cover the agency’s individual program policies, procedures, or other information.

Source. #7058, eff 7-21-99; ss by #8902, INTERIM, eff 7-13-07, EXPIRED: 1-9-08 New. #9082, eff 1-30-08 (from He-A 907.10)