1. (a) The CMHP shall complete and document an intake assessment for each individual.

2. (b) The intake assessment shall:

   1. (1) Include medical, psychiatric, and social information;
   2. (2) Include historical and current information and assessments; and
   3. (3) Serve as a basis for ISP development.

3. (c) The components of an intake assessment shall include, at a minimum;

   1. (1) Medical information including:

      1. a. A statement of the individual’s general physical health status;
      2. b. Medical history, including current weight, height, blood pressure, pulse, and smoking status;
      3. c. When applicable, medical diagnoses, and the results of any medical or neurological screenings, examinations, or tests; and
      4. d. The name and contact information for the individual’s primary care physician;

   2. (2) Psychiatric information including:

      1. a. History of mental illness or serious emotional disturbance, including onset and severity;
      2. b. Previous services and treatments, including medications and hospitalizations;
      3. c. Individual’s strengths;
      4. d. Illness self-management skills;
      5. e. Precipitating events for current psychiatric symptoms, as applicable;
      6. f. Documentation of the medical necessity for services;
      7. g. Current diagnosis;
      8. h. Medication orders;
      9. i. Current medications;
      10. j. Results of formalized psychiatric and/or psychological tests, if applicable;
      11. k. Mental status examination results; and
      12. l. Diagnostic formulation by a psychiatrist or other licensed practitioner of the healing arts under the auspices of a psychiatrist licensed to practice in the state of New Hampshire; and

   3. (3) Social information including:

      1. a. Developmental history;
      2. b. Educational history and current status, if applicable;
      3. c. Family history and current family status;
      4. d. History of childhood abuse and neglect;
      5. e. History of trauma, including domestic violence;
      6. f. Results of a substance use screening tool;
      7. g. Employment history including work skills and types, and lengths of employment;
      8. h. Military history and veterans status, if applicable;
      9. i. Current living situation including type of environment and nature of relationship with any room/house mates or family;
      10. j. Social and leisure time activities and skills;
      11. k. Ability to develop and maintain friendships;
      12. l. Involvement with or history of involvement with other social service agencies or the criminal justice system;
      13. m. Guardianship, if applicable; and
      14. n. Other legal documents.
4. (d) Intake assessments that are completed to function as the initial ISP shall include the initial services to be provided and a physician’s signature.
5. (e) The intake assessment and updates shall be signed and dated by the person completing the assessment.

Source. #7281, eff 5-23-00, EXPIRED: 5-23-08 New. #9512 eff 7-9-09; ss by #12409, eff 10-24-17