Code of Maine Rules › 14 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 118 - OFFICE OF SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES (SAMHS) › Chapter 2 - DRIVER EDUCATION AND EVALUATION PROGRAMS PROCEDURE MANUAL › Section 118-2-E - THE CLINICAL SUBSTANCE ABUSE EVALUATION, SECOND OPINION AND STATUS UPDATE EVALUATION

Current through 2024-29, July 17, 2024
1. All clinical
				substance abuse evaluations, second opinions, and status updates provided by
				approved Community-based Service Providers shall be conducted as follows:
a. All clinical substance abuse evaluations,
				second opinions, and status update evaluations shall be provided by a clinician
				licensed and qualified under criteria set forth under Section B.3.or certified
				as a Certified Alcohol and Drug Counselor (CADC) pursuant to the Maine Revised
				Statutes Title 32, Chapter 81. Clinical substance abuse evaluations, second
				opinions and status updates shall not be provided by an Alcohol and Drug
				Counseling Aide (ADCA).
Clinical substance abuse evaluations, second opinions and
				  status update evaluations shall consist of a minimum of two (2) and a maximum
				  of four (4) clinical hour sessions, with a minimum of five working days between
				  the first and second session, provided that if, after the first session, the
				  evaluator and the client both agree upon a positive finding, the evaluator may
				  waive any subsequent sessions. When the client agrees to a positive finding
				  during the first evaluation session, the client may request to enter directly
				  into treatment. Waiving the evaluation will be communicated to DEEP by the
				  Community-based Service Provider within five (5) working days on a form
				  provided by DEEP. A copy of the DEEP form shall be maintained in the client
				  file.
b. No group
				evaluations will be performed.
c.
				The Community-based Service Provider conducting the clinical substance abuse
				evaluation, second opinion, or status update evaluation shall require the
				presence of a significant other or concerned person at one of the evaluation
				sessions, provided that if the first session results in a positive finding, the
				evaluator may waive the need for a significant other or concerned person. If,
				after being requested to do so, a client refuses to bring a significant other
				or concerned person to an evaluation session, the refusal shall, by itself,
				result in an unsatisfactory completion of the evaluation. When, in the judgment
				of the evaluator, exceptional circumstances prevent the client from bringing a
				significant other or concerned person to the evaluation, these reasons shall be
				documented in the client's case file and this failure shall not, by itself,
				result in an unsatisfactory completion of the evaluation.
d. Clinical substance abuse evaluations,
				second opinions, and status update evaluations shall be documented. The
				documentation shall include, but not be limited to, the following:
(1) A mental status assessment.
(2) A psychosocial history, including family
				background, employment, education, legal and medical history.
(3) A detailed history of alcohol and other
				drug use, including age of first use, evidence of tolerance or withdrawal,
				memory loss, consumption, list of all drugs used (past and present, patterns of
				use and family history of alcohol/drug problems).
(4) The history of previous treatment for a
				substance abuse disorder, if any, including past participation in self-help,
				and any significant period of abstinence or recovery.
(5) Diagnostic assessment test instrument
				scores and their clinical interpretation.
(6) The content of the interview with at
				least one significant other.
(7) A
				description of the client's current alcohol and/or other drug use
				status.
(8) A clinical summary,
				including the DSM IV diagnosis and the stage of chemical abuse/dependency in
				accordance with the Completion of Treatment Guidelines, any recommendations for
				further service, and the client's current risk for repeating an alcohol or
				other-drug related offense.
e. Status update evaluations shall include
				documentation of previous treatment,including a copy of the discharge summary
				and aftercare plan.
f. The
				Community-based Service Provider shall require abstinence from alcohol and/or
				other non-prescribed drugs during the course of the evaluation.