provides assessments for all persons served at specific junctures from
Intake/Admission (as required by program specific licensing), throughout
service provision, to discharge. An Initial Assessment is conducted within the
first 14 to 30 days of placement (or as required by program specific
licensing). A Comprehensive Assessment is conducted annually thereafter, from
the date of admission.
are tailored to unique individual needs and service objectives. In each type of
Assessment, Community Care collects only that information as is necessary to
provide the requested service, and as is required.
will include the following information, as required, to provide the requested
information, including name, date of birth, and social security number;
danger or risk of future harm, as appropriate for the service being provided;
assistance eligibility, if applicable.
Basic Assessment (Initial Assessment)
A) The elements in the Intake Assessment listed above;
B) A preliminary evaluation of the request or need for service;
C) Information about the person's past or current use of services from
Community Care or other organizations;
D) A family violence, abuse, or neglect screening;
E) The need for a medical examination;
F) Any dental problems;
G) Medical care currently being provided;
H) An alcohol and substance use screening;
Need for on-going health care needs including
dental and physical;
Unique ethnic and/or cultural background and
the need for any special approaches as a result;
K) Insurance coverage; and
L) Other information necessary to provide service.
A) The elements listed above in the Intake and Basic Assessments
B) The person's and/or family's strengths, resources, and existing formal
and informal support systems;
C) Psychiatric issues;
D) A Mental status exam;
E) Alcohol and substance abuse assessment;
F) Assessment of non-substance addictive behaviors;
G) Educational and vocational information;
H) Family relationships and the legal status of minor persons served;
Social and physical environments;
Housing status and history;
K) Legal status;
L) The client's perception of his or her needs.
M) Developmental status if the person served is a child, and
N) Financial status, including eligibility for public assistance.
O) The family/guardian's input and perception of the client's needs, so long
as such input is appropriate and received with the client's permission.
Additional Information that may be included in Assessments:
A physical health history and current status including identification of
any current used prescription and over the counter medications.
B) Developmental history.
C) Physical and environmental barriers that may impede the client and family's
ability to obtain services.
D) Status of vocational, educational, social, living, leisure/recreational
and medical domains.
E) Potential need for crisis intervention services.
F) Status of the ISP if applicable.
G) A review of the need for referral to a qualified individual for a
H) A review of the need for referral to a qualified individual for a
cognitive functioning assessment.�������
I) A review of the need for referral to a qualified individual for a neurological
assessments, including the Comprehensive Assessment, must be signed by the
individual completing the assessment, and the signature must include their
4) The individual
conducting the assessment must be a qualified, licensed individual possessing
the skills necessary to recognize and assess persons with special needs, and
make appropriate referrals for needed services if special needs exist.
assessments, including the Comprehensive Assessment, must be dated.
assessments must be placed in the client's case record.
7) For programs
where assessments are not part of the services provided by Community Care, a
Basic Assessment will be conducted, as listed above, to ensure that appropriate
services are provided to the client.