Section 40.09. Initial assessment.

 

(1)   Multidisciplinary team. The case manager shall within 5 working days assemble a multidisciplinary and multi-agency treatment team to assess the strengths and the needs of a newly admitted client and his or her family and to prepare a written treatment plan for the client under s. DHS 40.10 . The team shall include:

(a) The client's case manager;

(b) The program's clinical coordinator;

(c) An occupational therapist, a clinical social worker or a registered nurse;

(d) An educational professional from the client's school;

(e) The client, to the degree the client is willing and able to participate, to the extent appropriate to his or her age, maturity and clinical condition;

(f) The client's parent or guardian, if available and willing to participate;

(g) Representatives of any other profession or agency necessary in order to adequately and appropriately respond to the treatment needs of the client and family which were identified in the referral materials or the intake screening process; and

(h) If the client has been placed under the supervision of a county department or the department by a juvenile court order, the social worker who has been assigned to the case.

(2)   Elements of the initial assessment. The initial assessment shall be carried out by appropriate professionals identified in s. DHS 40.06 (4) (a) to (h) , and shall include:

(a) Obtaining and reviewing any existing evaluation of the client and his or her family, after having first obtained any necessary consent for their release and use;

(b) Completing any new test or evaluation which the multidisciplinary team finds is necessary for development of an effective treatment plan for the client and his or her family, including early and periodic screening and diagnosis under s. DHS 107.22 ; and

(c) Completing an evaluation of:

1. The client's mental health status by a psychiatrist or a clinical psychologist and the clinical coordinator of the program, resulting in a diagnosis of the client on all 5 axes specified in DSM IV. Principal and secondary diagnoses shall be indicated as described in DSM IV if there are multiple diagnoses within axes I and II. The 5 axes in DSM IV are the following:

a. Axis I: Clinical syndromes and V codes;

b. Axis II: Developmental disorders and personality disorders;

c. Axis III: Physical disorders and conditions;

d. Axis IV: Severity of psychosocial stressors; and

e. Axis V: Global assessment of functioning;

2. The client's use of drugs or alcohol or both drugs and alcohol;

3. The client's level of academic functioning;

4. The client's level of social and behavioral functioning in the home, school and community;

5. For a client over the age of 15, the client's vocational and independent living skills and needs;

6. Screening for suicide risk and dangerous reactions to psychotropic medications. The assessment process shall include procedures for determining the level of risk of suicide presented by clients and any risk of harm resulting from a dangerous reaction to a psychotropic medication, including:

a. Procedures for assessing and monitoring the effects and side effects of psychotropic medications which the person may be taking, for dealing with the results of a possible medication overdose, an error in medication administration, an unanticipated reaction to the medication or the effects of a concurrent medical illness or condition occurring while the person was receiving the medication;

b. Criteria for deciding when the level of risk of suicide or a reaction to a psychotropic medication requires a face to face response, use of mobile services or hospitalization;

c. Procedures for notifying those around the person such as family members or people with whom the person is living that he or she may be at risk of harming him or herself;

d. Procedures for obtaining a more thorough mental status examination or other forms of in-depth assessment when necessary based on the results of the initial emergency assessment;

e. Procedures for gathering as much information as possible, given the nature and circumstances of the emergency, about the person's health, the medications, if any, that the person has been taking, prior incidents of drug reaction or suicidal behavior, and other information which can be used to determine the level of risk and the type of response most likely to help the person;

7. The client's relationship with his or her family, including an assessment of family strengths and weaknesses which might affect treatment; and

8. Any other assets and needs of the client and his or her family which affect the client's ability to participate effectively in relationships and activities in home, community and school environments.

(3)   Written report. The multi-disciplinary team shall prepare a written report on the initial assessment which:

(a) Describes the client's current mental health status and level of functioning both in terms of assets that the client brings to the treatment program and problems which are to be addressed through treatment;

(b) Provides current baseline data regarding the severity, duration or frequency with which mental health symptoms or problem behaviors have been observed or, if these are not currently evident, describes them as being reported as part of the client's history; and

(c) Establishes primary treatment goals and objectives for the client and his or her family, expressed in measurable terms, which identify the conditions or behaviors which the client will be helped to achieve as well as the dates by which it is anticipated that the client will achieve them.

History: Cr. Register, August, 1996, No. 488 , eff. 9-1-96; correction in (2) (b) made under s. 13.93 (2m) (b) 7., Stats., Register January 2004 No. 577 ; correction in (2) (b) made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635 .