Section 325.14603. Client records.

Rule   603.   The   following   information   shall   be   collected    and     recorded     on   all individuals assessed for referral:

(a)   Name, address, and telephone number, when applicable.

(b)   Date of birth and sex.

(c)   Family and social history.

(d)  Educational history.

(e)   Occupation.

(f)  Legal and court-related history.

(g)   Present substance abuse problem.

(h)   Date the information was gathered.

(i)   Signature of the staff member gathering the information.

(j)   Name of referring agency, when appropriate.

(k)   Address, telephone number, and name of nearest relative  to   contact in case of emergency.

(l)   History of current and past substance abuse or other counseling services received. The agency, type of service, and the date the service was received shall be indicated.

(m)   Name, address, and telephone number of the  most   recent    family     or private physician.

(n)   A substance abuse history, including    information   about   prescribed drugs and alcohol, which indicates, at a minimum,  all   of   the   following information:

(i)   Substances used in the past, including prescribed drugs

(ii)   Substances used recently especially those used within the last 48 hours.

(iii)   Substances of preference.

(iv)   Frequency with which each substance is used.

(v)    Previous occurrences of overdose, withdrawal, or    adverse    drug    or alcohol reactions.

(vi)   History of previous substance abuse treatment received.

(vii)   Year of first use of each substance.

(o)    Results of an assessment for referral shall be entered in the client record and shall include a  summary  of  presenting   problems,  a needs assessment, and any referral resources  deemed appropriate  to  meet   the individual's needs.

(p)   Outcome of the referral shall be documented in the client record.

History: 1981 AACS.