67:16:41:04.01.  Diagnostic assessment components. A diagnostic assessment must include:

    (1)  A face-to-face or telehealth interview with the recipient;

    (2)  Identification of the strengths of the recipient and the recipient's family, if appropriate; previous periods of success and the strengths that contributed to that success; and potential resources within the family, if applicable;

    (3)  Presenting problems or issues that indicate a need for mental health services;

    (4)  Identification of readiness for change for problem areas, including motivation and supports for making such changes;

    (5)  Relevant family history, including family relationship dynamics and family psychiatric and substance abuse history;

    (6)  Behavioral observations and an examination of the recipient's mental status, including a description of anomalies in the recipient's appearance, general behavior, motor activity, speech, alertness, mood, cognitive functioning, and attitude toward the symptoms;

    (7)  Current substance use and relevant treatment history, including 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;

    (8)  A review of the records that pertain to the recipient's medical and social background and history, if available;

    (9)  Contact with the recipient's relatives and significant others to the extent necessary to complete an accurate psychological evaluation for the purpose of writing the assessment report and developing the treatment plan;

    (10)  Formulation of a diagnosis that is consistent with the findings of the evaluation of the recipient's condition, including documentation of co-occurring medical, developmental disability, mental health, substance use disorder or gambling issues, or a combination of these based on the diagnostic evaluation;

    (11)  Educational history and needs, if applicable;

    (12)  Legal issues, if applicable;

    (13)  Living environment or housing, if applicable;

    (14)  Safety needs and risks with regard to physical acting-out, health conditions, acute intoxication, or risk of withdrawal, if applicable;

    (15)  Past or current indications of trauma, domestic violence, or both, if applicable; and

    (16) Vocational and financial history and needs, if applicable.

    Source: 48 SDR 39, effective October 3, 2021.

    General Authority: SDCL 28-6-1(1)(2).

    Law Implemented: SDCL 28-6-1.

    Cross-Reference: Clinic record requirements, § 67:16:41:08.