Wisconsin Administrative Code › Department of Health Services › DHS 30-100 - Community Services › Chapter DHS 35 - Outpatient Mental Health Clinics › Subchapter IV - Outpatient Mental Health Services › Section DHS 35.17 - Assessment

Current through June 24, 2024
(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.
(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. The consumer's presenting
				  problems.
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. The recipient's symptoms which support the
				  given diagnosis.
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. 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.