67 : 61 : 07 : 05 . Integrated assessment. An addiction counselor or addiction counselor trainee shall meet with the client and , if appropriate, the client's family, to complete an integrated assessment, within thirty days of the first day the intake process begins . The integrated assessment must include both functional and diagnostic components. The assessment must establish the historical development and dysfunctional nature of the client's alcohol and drug abuse or dependence , and must assess the client's treatment needs. The assessment must be recorded in the client's case record and must contain :

1. (1) Strengths of the client and the client's family, if appropriate, as well as previous periods of success, the strengths that contributed to that success, and the identification of potential resources within the family, if applicable;
2. (2) Presenting problems or issues that indicate a need for services;
3. (3) Identification of readiness for change for problem areas, including motivation and supports for making such changes;
4. (4) Current substance use and relevant treatment history of any previous mental health and substance use disorder or gambling treatment, and periods of success, psychiatric hospital admissions, psychotropic and other medications, relapse history or potential for relapse, physical illness, and hospitalization;
5. (5) Relevant family history, including family relationship dynamics and family psychiatric and substance abuse history;
6. (6) Family and relationship issues, along with social needs;
7. (7) Educational history and needs;
8. (8) Legal issues;
9. (9) Living environment or housing;
10. (10) Safety needs and risks with regard to physical acting out, health conditions, acute intoxication, or withdrawal;
11. (11) Past or current indications of trauma or domestic violence;
12. (12) Vocational and financial history and needs;
13. (13) Behavioral observations or mental status;
14. (14) Formulation of a diagnosis, including documentation of co-occurring medical, developmental disability, mental health, substance use disorder, or gambling issues or a combination of these based on integrated screening;
15. (15) Eligibility determination, including level of care determination for substance use services, or serious mental illness or serious emotional disturbance for mental health services, or both;
16. (16) Clinician's signature, credentials, and date; and

17. (17) Clinical supervisor's signature, credentials, and date, to verify review of the assessment and if there is agreement with:

    1. (a) The initial diagnosis; or

    2. (b) The formulation of the initial diagnosis, if the staff does not have the education or training to make a diagnosis.

       Any information related to the integrated assessment must be verified through collateral contact, if possible, and recorded in the client's case record.

Source: 43 SDR 80 , effective December 5, 2016; 50 SDR 63, effective November 27, 2023 .

General Authority: SDCL 1-36-25 , 34-20A-27 .

Law Implemented: SDCL 34-20A-27 .

Prior versions effective: 2016-12-05.