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Rule 25 Form – Fill Out and Use This PDF

The Rule 25 Assessment Form, designated as DHS-5204-ENG, stands as an essential tool in the sphere of alcohol and drug abuse. It facilitates a structured evaluation aimed at identifying the specific treatment needs of individuals grappling with substance abuse issues. Created to be user-friendly, it allows for electronic completion and saving, provided the user has compatible Adobe software. Take the step towards recovery and support by filling out the form available through the button below.

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Rule 25 Form PDF Details

The Rule 25 Assessment form, released under the Alcohol and Drug Abuse Division, delineates a structured approach for assessing individuals struggling with substance abuse issues, necessitating Adobe Reader 9.1 or higher for electronic completion and submission. This document, equipped with fillable fields, underscores a multifaceted evaluation encompassing the severity of substance abuse, withdrawal potential, and any co-occurring medical or emotional conditions that may complicate treatment. Confidentiality is paramount, with a comprehensive adherence to federal and state laws including Federal Confidentiality 42 CFR Chapter 1, Part 2, Minnesota Data Practices Act, Chapter 13, and HIPAA 45 CFR parts 160 and 164, ensuring the protection of personal health information. Moreover, the form contemplates immediate health concerns that could require urgent care, thus prioritizing the safety and well-being of the individual undergoing assessment. Not only does it facilitate a detailed inquiry into the individual’s substance use pattern and history, but it also seeks to understand the broader context of their health and social environment. By providing a holistic overview of a person's condition, the Rule 25 Assessment serves as a pivotal step towards customized, effective treatment planning for those at the crossroads of substance abuse and recovery.

Question	Answer
Form Name	Rule 25 Form
Form Length	18 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	4 min 30 sec
Other names	what is rule 25 in minnesota, rule 25, virtual rule 25 assessment, rule 25 mn

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DHS-5204-ENG 12-13

Alcohol and Drug Abuse Division

Rule 25 Assessment

Instructions

This form has been designed with ﬁllable form ﬁelds and the capability to save

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features willversionnot beofavailablethis formandisyouavailablwill be promptedto alcoholtoanddownloaddrug abusecurrent version

of Adobe Readprofessionals. .

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email a request to DHS.CCDTF@state.mn.us.

Files such as Microsoft Word, Excel, etc. can be electronically attached to this PDF. To do this in Acrobat 7, go to Tools  Commenting  Attach a File as a Comment. In Acrobat 8, go to Tools  Comment & Markup  Attach a File as a Comment. In Acrobat 9 or higher, go to Comment  Attach File. When you save this PDF, all attached ﬁles will be saved with it.

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Conﬁdential Data: Information contained in this document may be subject

to Federal Conﬁdentiality 42 CFR Chapter 1, Part 2, Minnesota Data

Practices Act, Chapter 13 and HIPPA 45 CFR parts 160 and 164

Please note: At the earliest opportunity during the assessment interview, the assessor shall determine if the

client is: a) in severe withdrawal and is likely to be a danger to self or others; b) has severe medical problems that require immediate attention; or c) has severe emotional or behavioral symptoms that place the client or others at risk of harm. If one of these conditions is present, the assessor will end the interview and help the client obtain appropriate services. The assessment may resume when the conditions in item a, b, or c are resolved.

This interview was not completed.

Reason: Actions taken:

PMI # or insurance number

DHS Rule 25 Assessment – 1 of 18

*DHS-5204-ENG*

DHS-5204-ENG

12-13

Alcohol and Drug Abuse Division

Rule 25 Assessment

Background Information

1. DATE OF ASSESSMENT REQUEST			2. DATE OF ASSESSMENT		3. DATE SERVICE AUTHORIZED

4.	ASSESSOR	5. ASSESSOR PHONE NUMBER		6. REFERENT			7. ASSESSMENT SITE

8.	CLIENT NAME			9. DATE OF BIRTH AGE	10. GENDER		11. PMI/INSURANCE NUMBER
					M	F

12.CLIENT’S PRIMARY LANGUAGE 13. Do you require special accommodations, such as an interpreter or assistance with written material?

YES NO

14. CURRENT ADDRESS	CITY	STATE	ZIP CODE

15. CLIENT PHONE NUMBER	16. ALTERNATE (CELL) PHONE NUMBER

17.TELL ME WHAT HAS HAPPENED TO BRING YOU HERE TODAY?

________________________________________________________________________________________________________________________________________________________

18. Have you had other rule 25 assessments? YES NO

IF YES, WHEN, WHERE AND WHAT CIRCUMSTANCES?

________________________________________________________________________________________________________________________________________________________

PMI # or insurance number

DHS Rule 25 Assessment – 2 of 18

DIMENSION I – Acute Intoxication/Withdrawal Potential

1.Chemical use most recent 12 months outside a facility and other signiﬁcant use history (client self-report)

	Age of	Most Recent Pattern of Use and Duration	Date of last	Withdrawal	Method of use
	First	Need enough information to show pattern (both frequency	use and time,	Potential?	Method of use
	First	Need enough information to show pattern (both frequency	use and time,	Potential?	(oral, smoked, snort,
X = Primary Drug Used	Use	and amounts) and to show tolerance for each chemical listed	if needed	Needs special care? (DSM)	IV, etc)
ALCOHOL

MARIJUANA/HASHISH

COCAINE/CRACK

METH/AMPHETAMINES

HEROIN

OTHER OPIATES/
SYNTHETICS

INHALANTS

BENZODIAZEPINES

HALLUCINOGENS

BARBITURATES/
SEDATIVES/HYPNOTICS

OVER-THE-COUNTER
DRUGS

OTHER

NICOTINE

PMI # or insurance number

DHS Rule 25 Assessment – 3 of 18

4. Withdrawal symptoms: Have you had any of the following withdrawal symptoms? YES NO

Symptom	Past 12 months	Recent (past 30 days)	Symptom	Past 12 months	Recent (past 30 days)

SWEATING (RAPID PULSE)			NAUSEA/VOMITING

SHAKY/JITTERY/TREMORS			DIZZINESS

UNABLE TO SLEEP			SEIZURES

AGITATION			DIARRHEA

HEADACHE			DIMINISHED APPETITE

FATIGUE/EXTREMELY TIRED			HALLUCINATIONS

SAD/DEPRESSED FEELING			FEVER

MUSCLE ACHES			UNABLE TO EAT

VIVID/UNPLEASANT DREAMS			PSYCHOSIS

IRRITABILITY			CONFUSED/DISRUPTED SPEECH

SENSITIVITY TO NOISE			ANXIETY/WORRIED

HIGH BLOOD PRESSURE

NOTES:

________________________________________________________________________________________________________________________________________________________

5. ASSESSOR’S VISUAL OBSERVATIONS AND SYMPTOMS	Based on the above information, is withdrawal likely to require
	attention as part of treatment participation?	YES	NO

Dimension I Ratings

Acute intoxication/Withdrawal potential – The placing authority must use the criteria in Dimension I to determine a client’s acute intoxication and withdrawal potential.

RISK DESCRIPTIONS – Severity rating:

0 Client displays full functioning with good ability to tolerate and cope with withdrawal discomfort. No signs or symptoms of intoxication or withdrawal or resolving signs or symptoms.

1 Client can tolerate and cope with withdrawal discomfort. The client displays mild to moderate intoxication or signs and symptoms interfering with daily functioning but does not immediately endanger self or others. Client poses minimal risk of severe withdrawal.

2 Client has some difﬁculty tolerating and coping with withdrawal discomfort. Client’s intoxication may be severe, but responds to support and treatment such that the client does not immediately endanger self or others. Client displays moderate signs and symptoms with moderate risk of severe withdrawal.

3 Client tolerates and copes with withdrawal discomfort poorly. Client has severe intoxication, such that the client endangers self or others, or intoxication has not abated with less intensive levels of services. Client displays severe signs and symptoms; or risk of severe, but manageable withdrawal; or withdrawal worsening despite detox at less intensive level.

4 Client is incapacitated with severe signs and symptoms. Client displays severe withdrawal and is a danger to self or others.

REASONS SEVERITY WAS ASSIGNED (What about the amount of the person’s use and date of most recent use and history of withdrawal problems suggests the potential of withdrawal symptoms requiring professional assistance? )

________________________________________________________________________________________________________________________________________________________

PMI # or insurance number

DHS Rule 25 Assessment – 4 of 18

DIMENSION II – Biomedical Complications and Conditions

1.Do you have any current health/medical concerns? (Include any infectious diseases, allergies, or chronic or acute pain, history of chronic conditions)

________________________________________________________________________________________________________________________________________________________

2.Do you have a health care provider? When was your most recent appointment? What concerns were identiﬁed?

________________________________________________________________________________________________________________________________________________________

3.If indicated by answers to items 1 or 2: How do you deal with these concerns? Is that working for you? If you are not receiving care for this problem, why not?

________________________________________________________________________________________________________________________________________________________

4A. List current medication(s) including over-the-counter or herbal supplements—including pain management

________________________________________________________________________________________________________________________________________________________

4B. Do you follow current medical recommendations/take medications as prescribed?

YES NO

4C. When did you last take your medication?

5. Has a health care provider/healer ever recommended that you reduce or quit alcohol/drug use? YES NO (DSM)

6A. Are you pregnant?

YES NO N/A

6B. RECEIVING PRENATAL CARE?

YES NO

6C. WHEN IS YOUR BABY DUE?

7.Have you had any injuries, assaults/violence towards you, accidents, health related issues, overdose(s) or hospitalizations related to your use of alcohol or other drugs; EXPLAIN:

________________________________________________________________________________________________________________________________________________________

8.Do you have any speciﬁc physical needs/accommodations?

Dimension II Ratings

Biomedical Conditions and Complications – The placing authority must use the criteria in Dimension II to determine a client’s biomedical conditions and complications.

RISK DESCRIPTIONS – Severity rating:

0 Client displays full functioning with good ability to cope with physical discomfort.

1 Client tolerates and copes with physical discomfort and is able to get the services that the client needs.

2 Client has difﬁculty tolerating and coping with physical problems or has other biomedical problems that interfere with recovery and treatment. Client neglects or does not seek care for serious biomedical problems.

3 Client tolerates and copes poorly with physical problems or has poor general health. Client neglects medical problems without active assistance.

4 Client is unable to participate in CD treatment and has severe medical problems, a condition that requires immediate intervention, or is incapacitated.

REASONS SEVERITY WAS ASSIGNED (What physical/medical problems does this person have that would inhibit his or her ability to participate in treatment? What issues does he or she have that require assistance to address?)

________________________________________________________________________________________________________________________________________________________

PMI # or insurance number

DHS Rule 25 Assessment – 5 of 18

DIMENSION III – Emotional, Behavioral, Cognitive Conditions and Complications

1.(Optional) Tell me what it was like growing up in your family. (substance use, mental health, discipline, abuse, support)

________________________________________________________________________________________________________________________________________________________

2. When was the last time that you had signiﬁcant problems...

Past month

2–12 months ago 1+ years ago

Never

A.with feeling very trapped, lonely, sad, blue, depressed or hopeless about the future?

B.with sleep trouble, such as bad dreams, sleeping restlessly, or falling asleep during the day?

C.with feeling very anxious, nervous, tense, scared, panicked, or like something bad was going to happen?

D.with becoming very distressed and upset when something reminded you of the past?

E.with thinking about ending your life or committing suicide?

3. When was the last time that you did the following things two or more times?	Past month	2–12 months ago	1+ years ago	Never

A. Lied or conned to get things you wanted or to avoid having to do
something?

B. Had a hard time paying attention at school, work, or home?

C. Had a hard time listening to instructions at school, work, or home?

D. Were a bully or threatened other people?

E. Started physical ﬁghts with other people?

Note: These questions are from the Global Appraisal of Individual Needs—Short Screener. Any item marked “past month” or “2 to 12 months ago” will be scored with a severity rating of at least 2. For each item that has occurred in the past month or past year ask follow up questions to determine how often the person has felt this way or has the behavior occurred? How recently? How has it affected their daily living? And, whether they were using or in withdrawal at the time?

________________________________________________________________________________________________________________________________________________________

A. If the person has answered item 2E with “in the past year” or		B. If the person answered item 2E “in the past month” ask about
“the past month”, ask about frequency and history of suicide in		intent, plan, means and access and any other follow-up information
the family or someone close and whether they were under the		to determine imminent risk. Document any actions taken to intervene
inﬂuence		on any identiﬁed imminent risk.

Any history of suicide in your family? Or someone close to you?		COMMENTS
YES	NO	__________________________________________________________________________

EXPLAIN
		__________________________________________________________________________

_____________________________________________________________________		__________________________________________________________________________

_____________________________________________________________________		__________________________________________________________________________

_____________________________________________________________________		__________________________________________________________________________

_____________________________________________________________________		__________________________________________________________________________

_____________________________________________________________________		__________________________________________________________________________

_____________________________________________________________________		__________________________________________________________________________

PMI # or insurance number

DHS Rule 25 Assessment – 6 of 18

A. Have you ever been diagnosed with a mental health problem?

YES

B. Are you receiving care for any mental health issues? If yes, what is the focus of that care or treatment? Are you satisﬁed with the service? Most recent appointment? How has it been helpful?

__________________________________________________________________________________________________________________________________________________

A. Have you been prescribed medications for emotional/psychological problems?

YES

B. Current mental health medication(s) If these medications are listed for Dimension II, reference item II-5.

__________________________________________________________________________________________________________________________________________________

C. Are you taking your medications as instructed?

YES

A. Does your MH provider know about your use? YES NO

B. What does he or she have to say about it? (DSM)

__________________________________________________________________________________________________________________________________________________

A. Have you ever been verbally, emotionally, physically or sexually abused?

YES

Follow up questions to learn current risk, continuing emotional impact.

__________________________________________________________________________________________________________________________________________________

B. Have you received counseling for abuse? YES NO

__________________________________________________________________________________________________________________________________________________

A. Have you ever experienced or been part of a group that experienced community violence, historical trauma, rape or assault?

YES NO

B. How has that affected you?

__________________________________________________________________________________________________________________________________________________

C. Have you received counseling for that?

YES

10.

A.VETERAN

YES NO

B. EXPOSURE TO COMBAT

YES NO

11.

Do you have problems with any of the following things in your daily life?

Headaches	Dizziness	Problem solving	Concentrating	Performing your job/schoolwork	Remembering
In relationships with others		Reading, writing, calculating		Fights, being ﬁred, arrests

Note: If the person has any of the above problems, how do they deal with them, have they developed coping mechanisms? Have they received treatment? Follow up with items 12, 13, and 14. If none of the issues in item 11 are a problem for the person, skip to item 15.

________________________________________________________________________________________________________________________________________________________

12.

Have you been diagnosed with traumatic brain injury or Alzheimer’s?

YES

PMI # or insurance number

DHS Rule 25 Assessment – 7 of 18

13.If the answer to #12 is no, ask the following questions:

Have you ever hit your head or been hit on the head?	YES	NO

Were you ever seen in the Emergency room, hospital, or by a doctor because of an injury to your head?			YES	NO

Have you had any signiﬁcant illness that affected your brain (brain tumor, meningitis, West Nile Virus, stroke or seizure, heart attack, near

drowning or near suffocation)?

YES

14. If the answer to #12 is yes, ask if any of the problems identiﬁed in #11 occurred since the head injury or loss of oxygen. YES NO

15.

A. HIGHEST GRADE OF SCHOOL COMPLETED

B. Do you have a learning			C. Did you ever have tutoring in Math or			D. Have you ever been diagnosed with Fetal Alcohol
disability?	YES	NO	English?	YES	NO	Effects or Fetal Alcohol Syndrome?	YES	NO

EXPLAIN

_________________________________________________________________________________________________________________________________________________

16.If yes to item 15 B, C, or D: How has this affected your use or been affected by your use?

________________________________________________________________________________________________________________________________________________________

Dimension III Ratings

Emotional/Behavioral/Cognitive – The placing authority must use the criteria in Dimension III to determine a client’s emotional, behavioral, and cognitive conditions and complications.

RISK DESCRIPTIONS – Severity rating:

0 Client has good impulse control and coping skills and presents no risk of harm to self or others. Client functions in all life areas and displays no emotional, behavioral, or cognitive problems or the problems are stable.

1 Client has impulse control and coping skills. Client presents a mild to moderate risk of harm to self or others or displays symptoms of emotional, behavioral or cognitive problems. Client has a mental health diagnosis and is stable. Client functions adequately in signiﬁcant life areas.

2 Client has difﬁculty with impulse control and lacks coping skills. Client has thoughts of suicide or harm to others without means; however, the thoughts may interfere with participation in some treatment activities. Client has difﬁculty functioning in signiﬁcant life areas. Client has moderate symptoms of emotional, behavioral, or cognitive problems. Client is able to participate in most treatment activities.

3 Client has a severe lack of impulse control and coping skills. Client has frequent thoughts of suicide or harm to others including a plan and the means to carry out the plan. In addition, the client is severely impaired in signiﬁcant life areas and has severe symptoms of emotional, behavioral, or cognitive problems that interfere with the client’s ability to participate in treatment activities.

4 Client has severe emotional or behavioral symptoms that place the client or others at acute risk of harm. Client also has intrusive thoughts of harming self or others. Client is unable to participate in treatment activities.

REASONS SEVERITY WAS ASSIGNED – What current issues might with thinking, feelings or behavior pose barriers to participation in a treatment program? What coping skills or other assets does the person have to offset those issues? Are these problems that can be initially accommodated by a treatment provider? If not, what specialized skills or attributes must a provider have?

________________________________________________________________________________________________________________________________________________________

PMI # or insurance number

DHS Rule 25 Assessment – 8 of 18

DIMENSION IV – Readiness for Change

1.You’ve told me what brought you here today. (ﬁrst page) What do you think the problem really is?

________________________________________________________________________________________________________________________________________________________

2.Tell me how things are going. Ask enough questions to determine whether the person has use related problems or assets that can be built upon in the following areas: Family/friends/relationships; Legal; Financial; Emotional; Educational; Recreational/leisure; Vocational/ employment; Living arrangements (DSM)

________________________________________________________________________________________________________________________________________________________

3.What activities have you engaged in when using alcohol/other drugs that could be hazardous to you or others (i.e. driving a car/ motorcycle/boat, operating machinery, unsafe sex, sharing needles for drugs or tattoos, etc.)? (DSM)

________________________________________________________________________________________________________________________________________________________

4.How much time do you spend getting, using or getting over using alcohol or drugs? (DSM)

________________________________________________________________________________________________________________________________________________________

Reasons for drinking/drug use (Use the space below to record answers. It may not be necessary to ask each item.)

Like the feeling

Trying to forget problems

To cope with stress

To relieve physical pain

To cope with anxiety

To cope with depression

To relax or unwind

Makes it easier to talk with people

Partner encourages use

Most friends drink or use

To cope with family problems

Afraid of withdrawal symptoms/to feel better

Other (specify)

A. What concerns other people about your alcohol or drug use/Has anyone told you that you use too much? What did they say? (DSM)

__________________________________________________________________________________________________________________________________________________

B. What did you think about that/ do you think you have a problem with alcohol or drug use?

__________________________________________________________________________________________________________________________________________________

PMI # or insurance number

DHS Rule 25 Assessment – 9 of 18

6.What changes are you willing to make? What substance are you willing to stop using? How are you going to do that? Have you tried that before? What interfered with your success with that goal?

________________________________________________________________________________________________________________________________________________________

7.What would be helpful to you in making this change?

________________________________________________________________________________________________________________________________________________________

Dimension IV Ratings

Readiness for Change – The placing authority must use the criteria in Dimension IV to determine a client’s readiness for change.

RISK DESCRIPTIONS – Severity rating:

0 Client is cooperative, motivated, ready to change, admits problems, committed to change, and engaged in treatment as a responsible participant.

1 Client is motivated with active reinforcement, to explore treatment and strategies for change, but ambivalent about illness or need for change.

2 Client displays verbal compliance, but lacks consistent behaviors; has low motivation for change; and is passively involved in treatment.

3 Client displays inconsistent compliance, minimal awareness of either the client’s addiction or mental disorder, and is minimally cooperative.

4 The client is: (A) non-compliant with treatment and has no awareness of addiction or mental disorder and does not want or is unwilling to explore change or is in total denial of the illness and its implications, or (B) dangerously oppositional to the extent that the client is a threat of imminent harm to self and others.

REASONS SEVERITY WAS ASSIGNED (What information did the person provide that supports your assessment of his or her readiness to change? How aware is the person of problems caused by continued use? How willing is she or he to make changes? What does the person feel would be helpful? What has the person been able to do without help?)

________________________________________________________________________________________________________________________________________________________

PMI # or insurance number

DHS Rule 25 Assessment – 10 of 18

DIMENSION V – Relapse, Continued Use, and Continued Problem Potential

1.In what ways have you tried to control, cut-down or quit your use? If you have had periods of sobriety, how did you accomplish that? What was helpful? What happened to prevent you from continuing your sobriety? (DSM)

________________________________________________________________________________________________________________________________________________________

2.Have you experienced cravings? If yes, ask follow up questions to determine if the person recognizes triggers and if the person has had any success in dealing with them.

________________________________________________________________________________________________________________________________________________________


A. Have you been treated for alcohol/other drug abuse/dependence?		YES	NO

B. NUMBER OF TIMES (LIFETIME) (OVER WHAT PERIOD)	C. NUMBER OF TIMES COMPLETED TREATMENT (LIFETIME)

D. During the past three years have you participated in outpatient and/or residential?				YES	NO

E. WHEN AND WHERE?

__________________________________________________________________________________________________________________________________________________

F. What was helpful? What was not?

__________________________________________________________________________________________________________________________________________________

4.Support group participation: Have you/do you attend support group meetings to reduce/stop your alcohol/drug use? How recently? What was your experience? Are you willing to restart? If the person has not participated, is he or she willing?

________________________________________________________________________________________________________________________________________________________

5.What would assist you in staying sober/straight?

________________________________________________________________________________________________________________________________________________________

PMI # or insurance number

DHS Rule 25 Assessment – 11 of 18

Dimension V Ratings

Relapse/Continued Use/Continued problem potential – The placing authority must use the criteria in Dimension V to determine a client’s relapse, continued use, and continued problem potential.

RISK DESCRIPTIONS – Severity rating:

0 Client recognizes risk well and is able to manage potential problems.

1 Client recognizes relapse issues and prevention strategies, but displays some vulnerability for further substance use or mental health problems.

2 (A) Client has minimal recognition and understanding of relapse and recidivism issues and displays moderate vulnerability for further substance use or mental health problems. (B) Client has some coping skills inconsistently applied.

3 Client has poor recognition and understanding of relapse and recidivism issues and displays moderately high vulnerability for further substance use or mental health problems. Client has few coping skills and rarely applies coping skills.

4 No awareness of the negative impact of mental health problems or substance abuse. No coping skills to arrest mental health or addiction illnesses, or prevent relapse.

REASONS SEVERITY WAS ASSIGNED (What information did the person provide that indicates his or her understanding of relapse issues? What about the person’s experience indicates how prone he or she is to relapse? What coping skills does the person have that decrease relapse potential?)

________________________________________________________________________________________________________________________________________________________

DIMENSION VI – Recovery Environment

1.Are you employed/attending school? Tell me about that.

________________________________________________________________________________________________________________________________________________________

2A. Describe a typical day; evening for you. Work, school, social, leisure, volunteer, spiritual practices. Include time spent obtaining, using, recovering from drugs or alcohol. (DSM)

________________________________________________________________________________________________________________________________________________________

2B. How often do you spend more time than you planned using or use more than you planned? (DSM)

________________________________________________________________________________________________________________________________________________________

3.How important is using to your social connections? Do many of your family or friends use?

________________________________________________________________________________________________________________________________________________________

4A. Are you currently in a signiﬁcant relationship?

YES NO

4B. IF YES, HOW LONG?

4C. SEXUAL ORIENTATION

PMI # or insurance number

DHS Rule 25 Assessment – 12 of 18

5A. Who do you live with?

5B. Tell me about their alcohol/drug use and mental health issues

5C. Are you concerned for your safety there?

YES NO

5D. Are you concerned about the safety of anyone else who lives with you?

YES NO

6A. Do you have children who live with you? If the person lives with children, ask follow-up questions to determine the person’s relationship and responsibility, both legal and care giving; and what arrangements are made for supervision for the children when the person is not available.

________________________________________________________________________________________________________________________________________________________

6B. Do you have children who do not live with you? If yes, ask follow up questions to learn where the children are, who has custody and what the person’s relationship and responsibility is with these children and what hopes the person has for his or her future with these children.

________________________________________________________________________________________________________________________________________________________

7A. Who supports you in making changes in your alcohol or drug use? What are they willing to do to support you? Who is upset or angry about you making changes in your alcohol or drug use? How big a problem is this for you?

________________________________________________________________________________________________________________________________________________________

7B. This table is provided to record information about the person’s relationships and available support It is not necessary to ask each item; only to get a comprehensive picture of their support system.

	Always	Usually	Rarely	Never	Willing to
How often can you count on the following people when you need someone?	supportive	supportive	supportive	supportive	stop using?

Partner/spouse

Parent(s)/Aunt(s)/Uncle(s)/Grandparent(s)

Sibling(s)/Cousin(s)

Child(ren)

Other relative(s)

Friend(s)/neighbor(s)

Child(ren)’s father(s)/mother(s)

Support group member(s)

Community of faith members

Social worker/counselor/therapist/healer

Other (specify)

8A. What is your current living situation?

________________________________________________________________________________________________________________________________________________________

8B. What is your long term plan for where you will be living?

________________________________________________________________________________________________________________________________________________________

8C. Tell me about your living environment/neighborhood? Ask enough follow up questions to determine safety, criminal activity, availability of alcohol and drugs, supportive or antagonistic to the person making changes.

________________________________________________________________________________________________________________________________________________________

PMI # or insurance number

DHS Rule 25 Assessment – 13 of 18

9.Criminal justice history: Gather current/recent history and any signiﬁcant history related to substance use—Arrests? Convictions? Circumstances? Alcohol or drug involvement? Sentences? Still on probation or parole? Expectations of the court? Current court order? Any sex offenses – lifetime? What level? (DSM)

________________________________________________________________________________________________________________________________________________________

10.What obstacles exist to participating in treatment? (Time off work, childcare, funding, transportation, pending jail time, living situation)

________________________________________________________________________________________________________________________________________________________

Dimension VI Ratings

Recovery environment – The placing authority must use the criteria in Dimension VI to determine a client’s recovery environment.

RISK DESCRIPTIONS – Severity rating:

0 Client is engaged in structured, meaningful activity and has a supportive signiﬁcant other, family, and living environment.

1 Client has passive social network support or family and signiﬁcant other are not interested in the client’s recovery. The client is engaged in structured meaningful activity.

2 Client is engaged in structured, meaningful activity, but peers, family, signiﬁcant other, and living environment are unsupportive, or there is criminal justice involvement by the client or among the client’s peers, signiﬁcant others, or in the client’s living environment.

3 Client is not engaged in structured, meaningful activity and the client’s peers, family, signiﬁcant other, and living environment are unsupportive, or there is signiﬁcant criminal justice system involvement .

4 Client has (A) Chronically antagonistic signiﬁcant other, living environment, family, peer group or long-term criminal justice involvement that is harmful to recovery or treatment progress, or (B) Client has an actively antagonistic signiﬁcant other, family, work, or living environment with immediate threat to the client’s safety and well-being.

REASONS SEVERITY WAS ASSIGNED (What support does the person have for making changes? What structure/stability does the person have in his or her daily life that will increase the likelihood that changes can be sustained? What problems exist in the person’s environment that will jeopardize getting/staying clean and sober?)

________________________________________________________________________________________________________________________________________________________

Client Choice/Exceptions

Would you like services speciﬁc to language, age, gender, culture, religious preference, race, ethnicity, sexual orientation or disability?

YES

IF YES, SPECIFY:

What particular treatment choices and options would you like to have?

Do you have a preference for a particular treatment program?

PMI # or insurance number

DHS Rule 25 Assessment – 14 of 18

Criteria for Diagnosis

DSM-V Criteria for Substance Abuse

Instructions

Determine whether the client currently meets the criteria for a Substance Use Disorder using the diagnostic criteria in the DSM-V, pp. 481-589. Current means during the most recent 12 months outside a facility that controls access to substances.

Category of substance	Severity	ICD-10 Code/DSM V Code
Alcohol Use Disorder	Mild	(F10.10) (305.00)
	Moderate	(F10.20) (303.90)
	Severe	(F10.20) (303.90)
Cannabis Use Disorder	Mild	(F12.10) (305.20)
	Moderate	(F12.20) (304.30)
	Severe	(F12.20) (304.30)
Hallucinogen Use Disorder	Mild	(F16.10) (305.30)
	Moderate	(F16.20) (304.50)
	Severe	(F16.20) (304.50)
Inhalant Use Disorder	Mild	(F18.10) (305.90)
	Moderate	(F18.20) (304.60)
	Severe	(F18.20) (304.60)
Opioid Use Disorder	Mild	(F11.10) (305.50)
	Moderate	(F11.20) (304.00)
	Severe	(F11.20) (304.00)
Sedative, Hypnotic, or Anxiolytic Use Disorder	Mild	(F13.10) (305.40)
	Moderate	(F13.20) (304.10)
	Severe	(F13.20) (304.10)
Stimulant Related Disorders	Mild	(F15.10) (305.70) Amphetamine type substance
		(F14.10) (305.60) Cocaine
		(F15.10) (305.70) Other or unspeciﬁed stimulant
	Moderate	(F15.20) (304.40) Amphetamine type substance
		(F14.20) (304.20) Cocaine
		(F15.20) (304.40) Other or unspeciﬁed stimulant
	Severe	(F15.20) (304.40) Amphetamine type substance
		(F14.20) (304.20) Cocaine
		(F15.20) (304.40) Other or unspeciﬁed stimulant
Tobacco use Disorder	Mild	(Z72.0) (305.1)
	Moderate	(F17.200) (305.1)
	Severe	(F17.200) (305.1)
Other (or unknown) Substance Use Disorder	Mild	(F19.10) (305.90)
	Moderate	(F19.20) (304.90)
	Severe	(F19.20) (304.90)

PMI # or insurance number

DHS Rule 25 Assessment – 15 of 18

Collateral Contact Summary

NUMBER OF CONTACTS MADE

CONTACT WITH REFERRING PERSON

YES NO

If court related records were reviewed, summarize here:

________________________________________________________________________________________________________________________________________________________

Information from collateral contacts supported/largely agreed with information from the client and associated risk ratings.

Information from collateral contacts was signiﬁcantly different from information from the client and lead to different risk ratings. Summarize new information here:

________________________________________________________________________________________________________________________________________________________

Rule 25 Assessment Summary and Plan

ASSESSOR’S RECOMMENDATION

________________________________________________________________________________________________________________________________________________________

INTERVIEW CONDUCTED BY (SIGNATURE)	DATE

PMI # or insurance number

DHS Rule 25 Assessment – 16 of 18

Collateral Contacts

Please duplicate this page for each contact. If this includes information which is sensitive and not public, separate this page from the rest of the assessment before sharing. Retain the page in the assessment ﬁle.

NAME	RELATIONSHIP	PHONE NUMBER	RELEASES
			YES	NO

INFORMATION PROVIDED

________________________________________________________________________________________________________________________________________________________

PMI # or insurance number

DHS Rule 25 Assessment – 17 of 18

Collateral Contacts

NAME	RELATIONSHIP	PHONE NUMBER	RELEASES
			YES	NO

INFORMATION PROVIDED

________________________________________________________________________________________________________________________________________________________

PMI # or insurance number

DHS Rule 25 Assessment – 18 of 18

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3. Through this step, examine DATE OF ASSESSMENT REQUEST, DATE OF ASSESSMENT, DATE SERVICE AUTHORIZED, ASSESSOR, ASSESSOR PHONE NUMBER, REFERENT, ASSESSMENT SITE, CLIENT NAME, DATE OF BIRTH AGE GENDER, PMIINSURANCE NUMBER, CLIENTS PRIMARY LANGUAGE, Do you require special, YES, CURRENT ADDRESS, and CITY. Each one of these should be filled out with greatest accuracy.

ASSESSOR PHONE NUMBER, DATE SERVICE AUTHORIZED, and ASSESSMENT SITE of 25 rule

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2. Do you use greater amounts of alcohol/other drugs to feel intoxicated or achieve the desired effect?

Or use the same amount and get less of an effect?

3A. Have you ever been to detox?

3B. WHEN WAS THE FIRST TIME?

3C. HOW MANY TIMES SINCE THEN?

3D. DATE OF MOST RECENT DETOX