Section 22. Client Assessments
Effective August 31, 2021
(a) A program must have written policies and procedures for scheduling and conducting client substance abuse assessments that require that:
(1) Assessment staff must document the information described in subsection (b). The completed assessment must be maintained in the client’s record.
(2) The assessment must result in a recommendation that is supported by the evidence obtained during a personal interview with the client in addition to evidence collected from other sources.
(3) Portions of the assessment may be completed by the client at the discretion of the program director.
(4) The procedure specifies the period, not to exceed six weeks, that may pass between the date the judge orders the person to participate in the program and the date the program conducts the assessment.
(5) The procedure specifies the length of time that the program regularly sets aside for a client assessment appointment.
(b) The substance abuse assessment must include information about the following:
(1) statement of the presenting problem, including the client’s version and other relevant information which may include a probable cause affidavit, police report, or other source if available;
(2) social and peer group;
(3) military service history;
(4) financial status;
(5) alcohol and drug use of family members;
(6) occupational and educational status;
(7) legal history and current legal status;
(8) history of medical problems;
(9) history of mental health problems;
(10) current thoughts of suicide or homicide;
(11) family history and environmental setting from which the client comes; and
(12) an alcohol and drug use history of the client, which includes:
(A) substances used, including prescription and over-the-counter drugs;
(B) year of first use of each substance;
(C) substances used within the last 48 hours;
(D) substances of preference;
(E) frequency of use of each substance;
(F) previous occurrences of overdose, withdrawal, or adverse drug reaction;
(G) method of administration of each substance; and
(H) history of previous substance abuse treatment received.
(c) A program must have a written policy and procedure for conducting a risk and needs assessment using the Indiana Risk Assessment System (IRAS). If the program policy indicates the program professional staff members will be conducting the IRAS, the procedure and practice shall meet each of the following criteria:
(1) The IRAS shall be conducted by an individual certified by the Indiana Office of Court Services in accordance with the IRAS user certification policy adopted by the Judicial Conference of Indiana Board of Directors.
(2) Reassessments shall be conducted in accordance with the IRAS policy as adopted by the Judicial Conference of Indiana Board of Directors.
(3) A copy of the summary page of the initial assessment and any reassessments conducted shall be maintained in the client’s case management file.
(4) The confidentiality of client risk assessment information shall be maintained in accordance with the policy adopted by the Judicial Conference of Indiana Board of Directors.
(d) A program must have and observe written policies and procedures for determining client referrals to treatment or substance abuse education courses. The policies and procedures must include recommendation standards and require that when recommendations deviate from these standards, documentation in the client file specifies why an alternate recommendation or no recommendation was made.
(e) Except as provided in subsection (g), the program must develop for each client a written individual service contract (“ISC”) that identifies and responds to the evidence and recommendations determined during the substance abuse assessment. The procedure for developing the ISC must meet the following requirements:
(1) The ISC is developed by an assessment staff member.
(2) The ISC must state:
(A) the recommendations supported by the evidence;
(B) the requirements and expectations for satisfactory completion of the contract by the client; and
(C) the consequences for failure to complete the contract satisfactorily.
(3) The ISC must be signed by the client and by an assessment staff member acknowledging that the client has participated in its development and has received a copy.
(4) The individual service contract is maintained in the client's record.
(f) Changes to an individual service contract may be made by a professional staff member of a program and must be documented in the client’s record.
(g) A program is not required to develop a new individual service contract if:
(1) the program is only implementing or monitoring the implementation of an individual service contract on behalf of another court program; and
(2) the individual service contract is available to the implementing court program.