1. (1)

   1. (a) A mental health professional, shall complete an initial assessment of a consumer before a second meeting with a staff member. The information collected during the initial assessment shall be sufficient to identify the consumer’s need for outpatient mental health services.

   2. (b) A comprehensive assessment shall be valid, accurately reflect the consumer’s current needs, strengths and functioning, be completed before beginning treatment under the treatment plan established under s. DHS 35.19 (1), and include all of the following:

      1. 1. The consumer’s presenting problems.

      2. 2. A diagnosis, which shall be established from the current Diagnostic and Statistical Manual of Mental Disorders, or for children up to age 4, the current Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood.

         Note: The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. Washington, DC, American Psychiatric Association, 2013. The Diagnostic and Statistical Manual of Mental Disorders may be ordered through http://www.appi.org/Pages/DSM.aspx or other sources. Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood is published by the National Center for Clinical Infant Programs: Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood. Arlington, VA, National Center for Clinical Infant Programs, 1994. The Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood may be ordered https://secure2.convio.net/zttcfn/site/Ecommerce?VIEW_PRODUCT=true&product_id=1681&store_id=1121 or other sources.

      3. 3. The recipient’s symptoms which support the given diagnosis.
      4. 4. Information on the consumer’s strengths, and current and past psychological, social, and physiological data; information related to school or vocational, medical, and cognitive functioning; past and present trauma; and substance abuse.

      5. 5. The consumer’s unique perspective and own words about how the consumer views his or her recovery, experience, challenges, strengths, needs, recovery goals, priorities, preferences, values and lifestyle, areas of functional impairment, and family and community support.

         Note: Nothing in this chapter is intended to interfere with the right of providers under s. 51.61 (6), Stats., to use customary and usual treatment techniques and procedures in a reasonable and appropriate manner in the treatment of patients who are receiving services under the mental health system, for the purpose of ameliorating the conditions for which the patients were admitted to the system.

2. (2) If a consumer is determined to have one or more co-occurring disorders, a licensed treatment professional, mental health practitioner, or a recognized psychotherapy practitioner, shall document the treatments and services concurrently received by the consumer through other providers; whether the clinic can serve the consumer’s needs using qualified staff members or in collaboration with other providers; and any recommendations for additional services, if needed. If a clinic cannot serve a consumer’s needs, independently, or in collaboration with other providers, the clinic shall refer the consumer, with the consumer’s consent, to an appropriate provider.

History

History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09.