1. (a) Client records for specific services shall conform to the following:

   1. (1) Shelter Program Facility Services:

      1. (A) On a client's entry to the program facility, staff or volunteers shall record the client's name, emergency contact person(s), if applicable, known allergies, and any referrals for medical or emergency services. This information may be a part of the full intake interview if the full intake is done on entering the program facility. Assessing client's safety planning shall also be done at the time of the full intake;
      2. (B) Program clients shall have the full intake interview and screening completed within fourteen (14) days of entry into the program facilities;
      3. (C) Service plans shall be offered within thirty (30) business days of client's entry to the program facilities and at the client's discretion;
      4. (D) The service plan shall be reviewed and updated at least every two (2) weeks;
      5. (E) The client's service plan shall include components which address the needs of each child accompanying the client;
      6. (F) The service plan shall include safety issues for the client and children; and
      7. (G) A daily note.

   2. (2) Crisis Intervention Services:

      1. (A) All face-to-face and virtual contacts with clients are documented and contacts with persons not receiving additional services shall be offered and documented. Documentation shall minimally include the following:

         1. (i) Staff/Volunteer Name and signature;
         2. (ii) Date, time, length, and location of intervention;
         3. (iii) Safety Planning based on risk;
         4. (iv) Client's name, age, race, county of residence, and contact number if given;
         5. (v) Protective order information, if applicable;
         6. (vi) Personnel involved such as police, hospital, etc;
         7. (vii) Summary of contact including visible injuries, treatment and services requested; and
         8. (viii) Follow up services shall be offered to all victims, if victim safety is not compromised; and
         9. (ix) Outcome.

      2. (B) All telephone contacts shall be documented. Documentation shall minimally include the following:

         1. (i) Staff/Volunteer name;
         2. (ii) Date, time and length of call;
         3. (iii) Safety planning based on risk;
         4. (iv) Caller's name and contact number, if given; However, no caller shall be required to give a name, phone number or any other identifying information as a condition to receive information about human trafficking services;
         5. (v) Summary of the call including services needed; and
         6. (vi) Outcome.
      3. (C) Contact information is kept by the program.
      4. (D) Clients to be transported to program facilities shall be screened before the shelter referral is made. If the client is in immediate danger, no safe housing is available, or appropriate screenings are conducted by other parties which the certified program has approved to do screenings, this screening may be initially waived. If the screening is waived, documentation shall reflect the reason(s) and the notification of such to the progam facility.

   3. (3) Counseling, Support and Advocacy Services:

      1. (A) An assessment of the client's needs, including culturally specific needs shall be completed by the third (3rd) counseling or advocacy session;
      2. (B) A service plan shall be completed by the fifth (5th) advocacy or counseling session; and
      3. (C) A service plan review and update shall be completed at a minimum of once every six (6) months.
   4. (4) Transitional Living Services: A service plan including safety issues for the client and dependents shall be developed within five (5) business days of the client moving in.
2. (b) Where required information is not obtained, efforts to comply with the requirements of this subsection shall be documented in the client record.
3. (c) Compliance with this Section shall be determined by a review of client records, policies and procedures, call logs, and/or other supporting documentation.

Added at 28 Ok Reg 1931, eff 7-11-11

Amended at 31 Ok Reg 820, eff 9-12-14

Amended at 33 Ok Reg 1226, eff 9-11-16

Amended at 35 Ok Reg 882, eff 9-14-18

Amended at 41 Ok Reg, Number 21, effective 7-25-24

Amended at 43 Ok Reg, Number 18, effective 6-11-26