MN DHS DHS-5204-ENG 2009 free printable template
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Clear Form Data FILLABLE FORM DHS-5204-ENG Rule 25 Assessment Alcohol and Drug Abuse Division Instructions This form has been designed with fillable form fields and the capability to save completed forms on your computer. The assessment may resume when the conditions in item a b or c are resolved. l This interview was not completed. Reason Actions taken PMI or insurance number DHS Rule 25 Assessment 1 of 18 8-09 Background Information 1. CURRENT ADDRESS CITY 15. CLIENT PHONE NUMBER 16....
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How to fill out rule 25 assessment form
How to fill out rule 25 assessment form:
01
Gather all required information and documents, such as personal identification, income records, and medical records.
02
Start by providing your personal information, including your name, address, contact details, and any other requested demographic information.
03
Answer all the questions regarding your medical history and current health conditions. Be honest and provide as much detail as possible to ensure an accurate assessment.
04
Provide detailed information about your household and living situation, including the number of people in your household, their ages, and any special circumstances that may impact your eligibility for assistance.
05
Submit any supporting documentation, such as income statements, tax returns, or medical reports, as required by the form.
06
Review the completed form for any errors or omissions before submitting it.
07
Submit the form to the appropriate agency or organization responsible for conducting the rule 25 assessment.
Who needs rule 25 assessment form:
01
Individuals who require assistance for chemical dependency or mental health treatment.
02
Individuals seeking financial assistance or insurance coverage for substance abuse or mental health services.
03
Individuals who are referred to a rule 25 assessment by a healthcare provider, social worker, or legal representative.
Instructions and Help about rule 25 assessment form
Abuse of alcohol and drugs is one of the most serious national public health problems it is prevalent among rich and poor in all regions of the country and all ethnic and social groups stopping alcohol or drug use is the first step to recovery and most people need help to stop often a person with alcohol or drug dependence will need intervention and treatment provided by professionals just as with other diseases at canvas health are chemical health services include assessment consultation education family programming and outpatient treatment several environmental biological and psychological factors influence substance abuse it's also influenced by personal relationships and community dynamics many of our substance abuse clients at canvas health come in using substances to self-medicate past issues hurts traumas and losses when I was still drinking I drank every day which turned into a very isolated lifestyle I didn't have any friends I cut off a lot of contact with my family, and I was big sense of failure I had no self-esteem I got to a point where I had never ever thought that I would get sober I had decided that I was going to just continue to drink until I just didn't wake up one day, and I was perfectly okay with that substance abuse in America has been increasing an estimated twenty-two point five million Americans aged 12 or older which is eight point seven percent of the population had used an illicit drug or abused a psychotherapeutic medication such as a pain reliever stimulant or tranquilizer what makes campus health truly unique is we can offer our clients internal referrals to psychiatry mental health services domestic abuse groups crisis services all these things within one caring compassionate environment the second time I came to cam as hell was at the lowest point in my life where I had completely given up, and I went back to treatment and my counselor that I had through this whole time he helped me get into a long-term outpatient program, and they extended it especially for me if we really incorporate that whole person into the treatment process they're part of it all the way they get to control their recovery they have input into designing their goals and the actions to get them where they want to be this is their treatment program the biggest thing is that I have myself back I didn't know who I was, and now I do I Know Who I am and why I'm here and where I'm going, and it's absolutely wonderful at canvas health we listen and strive to understand the client's behavior we assess recognize issues beyond the clients chemical abuse including mental health disorders or other addictions at canvas health we're dedicated to hope dedicated to healing and dedicated to recovery we would love for you to become a part of our picture you
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What is rule 25 assessment form?
Rule 25 assessment form refers to a standardized assessment tool used in the United States to determine an individual's need for substance abuse treatment services. It is typically used by social workers, counselors, and other professionals in the field of addiction to evaluate the severity of substance abuse and guide appropriate treatment recommendations. The assessment includes questions about substance use patterns, symptoms, consequences, and the individual's readiness for change. The results obtained through the Rule 25 assessment help in determining eligibility for publicly funded treatment programs or insurance coverage for substance abuse treatment services. This form is commonly used in Minnesota, but other states may have similar assessment procedures in place.
Who is required to file rule 25 assessment form?
The Rule 25 assessment form is typically required to be filed by individuals seeking chemical dependency treatment in Minnesota, USA. This form helps determine eligibility for various treatment services and funding options.
How to fill out rule 25 assessment form?
To fill out a Rule 25 assessment form, follow these steps:
1. Obtain the Rule 25 assessment form: You can usually obtain this form from your local county's human services department or alcohol and drug abuse treatment center.
2. Start with personal information: Fill in your name, contact details, and demographic information requested on the form.
3. Provide insurance and financial information: If you have insurance coverage, enter your insurance provider's information. Additionally, provide details about your income, assets, and any expenses related to your healthcare needs.
4. Medical history: Answer questions regarding your past and present medical health, including any physical or mental health conditions you have been diagnosed with.
5. Substance abuse history: Provide information about your substance abuse history, including the types of substances you have used or are currently using, the frequency and duration of use, and any previous attempts at treatment.
6. Treatment history: Record any past treatment services or programs you have participated in related to substance abuse or mental health issues.
7. Legal and criminal history: Answer questions regarding any legal or criminal issues you have faced that are related to substance abuse.
8. Mental health history: Provide details about any mental health conditions you have been diagnosed with or have received treatment for in the past.
9. Medications and allergies: List any medications you are currently taking, including dosage and frequency. Also, mention any allergies or adverse reactions you have experienced to medications or substances.
10. Current situation and needs: Describe your current living situation, employment status, support system, and any challenges you are facing that may affect your ability to address substance abuse.
11. Consent and signatures: Sign and date the form to provide consent for the assessment and acknowledgment that the information provided is accurate and complete.
12. Submitting the form: Return the completed form to the designated agency or treatment center as instructed.
What is the purpose of rule 25 assessment form?
Rule 25 assessment form is a tool used in the field of chemical dependency evaluation and treatment. It is used to assess and determine the severity and appropriate treatment options for individuals who may be struggling with substance abuse issues. The purpose of the form is to gather comprehensive information about the individual's substance use history, treatment needs, and other relevant factors in order to make informed decisions regarding their treatment plan. This assessment is often conducted by trained professionals, such as chemical dependency counselors or social workers, and the information gathered helps guide the development of an effective treatment approach.
What information must be reported on rule 25 assessment form?
The specific information required on a Rule 25 Assessment form may vary slightly depending on the jurisdiction. However, the general information typically included on a Rule 25 Assessment form includes:
1. Personal information: This includes the client's name, contact details, date of birth, and other identifying information.
2. Demographic information: Details about the client's gender, race, ethnicity, and marital status may be included.
3. Substance use history: Comprehensive information regarding the client's substance use history, including the types of substances used, frequency, duration, and recent patterns of use.
4. Treatment history: Any previous attempts at treatment or rehabilitation, including dates and types of treatment received.
5. Legal history: Information pertaining to any legal issues or criminal involvement related to the individual's substance use.
6. Medical and mental health history: A summary of the person's medical and mental health history, including any diagnoses, prescribed medications, and previous or current psychiatric treatment.
7. Social and family history: A review of the person's current living situation, support system, family dynamics, and any significant life events or stressors.
8. Use of other services: Any involvement in other social services such as housing assistance, employment services, or counseling.
9. Risk assessment: An evaluation of the individual's current level of risk related to their substance use, including any history of overdose, suicide attempts, or self-harm.
10. Recommendations for care: Based on the assessment, recommendations for appropriate treatment or support services are provided. These may include specific levels of care like residential treatment, outpatient programs, or referrals to community resources.
It is important to note that while these are common elements, the specifics may differ depending on the local regulations and requirements. Therefore, it is advisable to refer to the specific rules and guidelines set by the relevant jurisdiction when completing a Rule 25 Assessment form.
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