Form DHS-2794-ENG "Rule 25 Assessment and Placement Summary" - Minnesota

What Is Form DHS-2794-ENG?

This is a legal form that was released by the Minnesota Department of Human Services - a government authority operating within Minnesota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2013;
  • The latest edition provided by the Minnesota Department of Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DHS-2794-ENG by clicking the link below or browse more documents and templates provided by the Minnesota Department of Human Services.

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Download Form DHS-2794-ENG "Rule 25 Assessment and Placement Summary" - Minnesota

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Clear Form
*DHS-2794-ENG*
DHS-2794-ENG
12-13
Rule 25 Assessment and Placement Summary
CLIENT NAME
PMI
ASSESSOR
ASSESSMENT DATE
General Guideline
Original
Update
Clients should be offered the least restrictive referral consistent with sound clinical judgment. All items must be clearly
documented in the Assessment Tool. This form must remain in the client file. Check the severity rating for each dimension and
document the provider(s) who will meet the identified needs.
Dimension
Severity Rating
Provider Name and Contact Information
0
I
1
2
Intoxication/
3
Withdrawal
4 = Crisis
0
1
II
2
Biomedical
3
4 = Crisis
0
III
1
Emotional/
2
Behavioral/
3 = SC + R&B
Cognitive
4 = Crisis
0
IV
1
2
Readiness for
3 = SC
Change
4 = SC + R&B
0
V
1
2
Relapse and
3 = SC
Continued Use
4 = SC + R&B
0
VI
1
2
Recovery
3 = SC
Environment
4 = SC + R&B
Service Coordination
(if required above)
Room & Board, if not paid for
through the CCDTF
(if required above)
Page 1 of 2
Clear Form
*DHS-2794-ENG*
DHS-2794-ENG
12-13
Rule 25 Assessment and Placement Summary
CLIENT NAME
PMI
ASSESSOR
ASSESSMENT DATE
General Guideline
Original
Update
Clients should be offered the least restrictive referral consistent with sound clinical judgment. All items must be clearly
documented in the Assessment Tool. This form must remain in the client file. Check the severity rating for each dimension and
document the provider(s) who will meet the identified needs.
Dimension
Severity Rating
Provider Name and Contact Information
0
I
1
2
Intoxication/
3
Withdrawal
4 = Crisis
0
1
II
2
Biomedical
3
4 = Crisis
0
III
1
Emotional/
2
Behavioral/
3 = SC + R&B
Cognitive
4 = Crisis
0
IV
1
2
Readiness for
3 = SC
Change
4 = SC + R&B
0
V
1
2
Relapse and
3 = SC
Continued Use
4 = SC + R&B
0
VI
1
2
Recovery
3 = SC
Environment
4 = SC + R&B
Service Coordination
(if required above)
Room & Board, if not paid for
through the CCDTF
(if required above)
Page 1 of 2
Assessment Summary Rule 25 Chemical Use Assessment
CLIENT NAME
PMI
ASSESSOR
ASSESSMENT DATE
General Guideline
This page should record a summary of the information gained from the client and collateral sources that lead to the severity
rating. It should be essentially the same as the information given in the “reasons” section after each dimension in the Rule 25
Assessment Tool. This form must be completed. The “reasons” sections do not need to be completed if this form accompanies
each completed assessment tool. Each severity rating must be clearly documented in the client file. This form should remain in the
client file.
Dimension
Risk Rating
Rationale
0
I
1
2
Intoxication/
3
Withdrawal
4
0
1
II
2
Biomedical
3
4
0
III
1
Emotional/
2
Behavioral/
3
Cognitive
4
0
IV
1
2
Readiness for
Change
3
4
0
V
1
2
Relapse and
3
Continued Use
4
0
VI
1
2
Recovery
3
Environment
4
Page 2 of 2
DHS-2794-ENG 12-13
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