Section 325.14803. Admissions.

Rule 803. (1) All of the following information shall  be  collected  and recorded for all applicants before, or at the time of, admission:

(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 services were 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.

(2) There shall be an assessment of a client's social and psychological needs made as soon after admission as possible. This history shall be sufficient to make a written assessment of the type of treatment needed and the appropriate referrals to be made upon discharge.

History: 1981 AACS.