a. Substance Use History;

b. Current detoxification level determination;

c. Past psychiatric treatment;

d. Past chemical dependency treatment;

e. Significant medical history;

f. Current health status;

g. Current medications;

h. Known food allergies;

i. Known drug allergies; and

j. Current emotional state and behavioral functioning.

a. Confirmation of identity;

b. Name, address (street and number, town, county, state, zip), phone, current housing arrangements, guardianship (if applicable), photograph of client, social security number;

c. Client's date of birth, sex, race or and ethnicity;

d. Name of referral source. Document if treatment was mandated by the referral source;

d. [FN1] If treatment was mandated, the complete address and telephone number of the referral source. Documented conditions of referral and/or information needs of the referral source;

f. Types of problems experienced by the client that are in need of resolution;

g. Substance abuse history to include most recent use patterns (amount per type, route of administration) ages of first use per substance and age of regular and/or addictive patterns. Document any injection use;

h. Document the client's family history to include current marital status, effect of substance use on current and past relationships, history of family members' use, any family members “in recovery”, names and ages of dependents and who has custody of dependents while the client is in treatment;

i. Client's highest grade completed, major (if applicable), effect of substance use on the client's educational process. The client's reading and writing levels must be evaluated when appropriate;

j. Current/most recent vocations, any trained skills, effects of substance use on employment, adequacy of current employment;

k. Legal history, which includes the dates and type of charges, arrests, convictions and sentences;

l. Medical and health history to include chronic medical problems, significant medical/physical events, problems that could influence treatment, medical conditions that could prompt a crisis, special diet needs, current medications (does client have sufficient supply during treatment), purpose of current medications, history of alcohol or other drug related conditions (i.e. blackouts, DT's, etc.), “at-risk” behaviors (multiple sex partners, unprotected sex), pregnancy status, allergies. (allergies and/or other serious conditions are “flagged” on the outside of the record);

m. Medication records for both prescriptions and over the counter medications. Drug type, dosage strength, how many, time/date of dispersion, which dispensed/witnessed dosing;

n. Psychological/psychiatric treatment history to include dates of any treatment, type of problem(s), who provided treatment, outcome of treatment, any current psychotropic medications;

o. Other relevant information to include military service (branch of service, dates of service, discharge status, highest rank, classifications, and any combat experience), copies of court or parole orders, and other information that will aid in assessing the client;

p. A completed Addiction Severity Index (ASI). When applicable, results of other tests or standardized assessment tools;

q. Re-admissions and transfers to another environment are clearly delineated;

r. Summary of client problems and corresponding needs, as based on client information;

s. Summary of the client's strengths and weaknesses, as based on the client information; and,

t. Based upon the assessment each client will be assigned a Diagnostic and Statistical Manual for Mental Disorders (DSM), substance abuse disorder diagnosis and code.

u. Only staff authorized to approve comprehensive treatment plans as specified in this manual will assign the diagnosis code.

v. Counseling personnel registered as Counselors in Training with the Arkansas Substance Abuse Certification Board may assign the diagnosis provided the diagnosis is approved, in writing, by personnel authorized to sign comprehensive treatment plans. The diagnosis and code will meet the current substance abuse disorder criteria as per Diagnostic and Statistical Manual of the American Psychological Psychiatric Association.