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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

completed forms on your computer. You must have Adobe Reader 9.1 or higher or Acrobat toThisuse thisversionformof(GettheAdobeRule Reader25 Assessment). If you openFormthiscannotform withbe an older version of completedAdobe R aderandorsavedAcrobat,electronicallydialog box. Awillﬁllableapp arandindicatingsavablethat some

features willversionnot beofavailablethis formandisyouavailablwill be promptedto alcoholtoanddownloaddrug abusecurrent version

of Adobe Readprofessionals. .

Before ﬁlling out this form, save this PDF to your computer. To do this, go to the

If you need a ﬁllable and savable version of this form,

File menu, choose Save As, and save it with a ﬁle name that you recognize.

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.

Make sure to save an electronic copy of the completed document.

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

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1. To start off, when filling out the dhs rule 25, start in the section that contains the subsequent blanks:

2. Now that the previous section is completed, you'll want to include the needed particulars in This interview was not completed, Reason, Actions taken, PMI or insurance number, and DHS Rule Assessment of so you're able to move forward to the next part.

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

4. The fourth paragraph comes next with these particular fields to focus on: Have you had other rule, YES, IF YES WHEN WHERE AND WHAT, PMI or insurance number, and DHS Rule Assessment of.

25 rule completion process shown (step 4)

5. Because you come close to the end of the file, you'll notice a few more points to complete. Specifically, Age of First Use, Need enough information to show, if needed, Withdrawal Potential, Method of use oral smoked snort, Needs special care DSM, IV etc, X Primary Drug Used, ALCOHOL, MARIJUANAHASHISH, COCAINECRACK, METHAMPHETAMINES, HEROIN, OTHER OPIATES, and SYNTHETICS should be done.

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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