Wisconsin Law – DHS 75.03

The assessment is meant to comply with provisions of Wisconsin law under which SUD RECOVERY CENTERS are required to conduct both a psychiatric and a physical health an assessment of each client prior to admission, to wit:

[Note: All text is from the original Code.  Highlighting in yellow has been supplied.]

12. ASSESSMENT.

(a) Staff of a service [i.e., SUD Recovery Centers] shall assess each patient through screening interviews, data obtained during intake, counselor observation and talking with people who know the patient. Information for the assessment shall include all of the following:

        1. The substance abuse counselor’s evaluation of the patient and documentation of psychological, social and physiological signs and symptoms of substance abuse and dependence, mental health disorders and trauma, based on criteria in DSM-IV.
        2. The summarized results of all psychometric, cognitive, vocational and physical examinations taken for, or as a result of, the patient’s enrollment into treatment.

(b) The counselor’s recommendations for treatment shall be included in a written case history that includes a summary of the assessment information leading to the conclusions and outcomes determined from the counselor’s evaluation of the patient’s problems and needs.

(c) If a counselor identifies symptoms of a mental health disorder and trauma in the assessment process, the service shall refer the individual for a mental health assessment conducted by a mental health professional.

(d) If a counselor identifies symptoms of physical health problems in the assessment process, the service shall refer the individual for a physical health assessment conducted by medical personnel.

(e) Initial assessment shall be conducted for treatment planning. The service shall implement an ongoing process of assessment to ensure that the patient’s treatment plan is modified if the need arises as determined through a staffing at least every 30 days.