Rule 25 assessment form pdf

Call to schedule an appointment through your county from this list of referral contacts. The form contains, at minimum, the following information. If the applicant lacks one or two requirements, then that may not necessarily rule him or her out. Chemical dependency nicollet county, mn official website. An individual can access these funds by contacting nicollet county human services intake worker and requesting a rule 25 chemical use assessment. Unless the court directs otherwise, parties must apply for the courts permission as mentioned in section 1, 3 or 5 of the 2014 act or rule 25. Your request must be in writing or on a form approved by the. The rule 25 assessment will determine an individuals level of chemical dependency and recommend an appropriate level of care. Understanding rule 25 rule 25 refers to the administrative rule that addresses chemical use assessment, administrative requirements, and appeal and fair hearing rights of the client.

Heres what is involved in a minnesota rule 25 assessment, along with how club recovery, a minnesota substance abuse treatment program, can help. A fillable and savable version of this form is available to. If you have any further questions about this application or the rule 25 program, please call 7633241270. File menu, choose save as, and save it with a file name that you recognize. When you save this pdf, all attached files will be saved with it. Yes no if yes, date place who referred you for a rule 25. State laws and federal rules protect your placement and treatment. Whereas a chemical health assessment is a broader term and are conducted around the united states. Rule 25 is the common name for chemical use assessment rule 25 by a qualified assessor to determine appropriate treatment planning decisions, a service offered by anoka county chemical health services.

Rule 25 assessment providers list washington county, mn. Prior authorization form substance use disorder treatment. The form summarizes the results of each rule 25 assessment which results in a placement for chemical dependency treatment services, and records the authorized service provider\ s. Release of information consent form chemical health services form is not valid unless completed in full i, birthdate, authorize dakota county social. If you are eligible, the state of minnesota will pay for you to have a chemical dependency evaluation and assessor recommended treatment.

Placement summary dhs handout 4a3 circle severity ratings, do not add any narrative in the boxes send to dakota county social services. Check the severity rating for each dimension and document. A rule 25 also known as a rule 25 assessment is a clinical tool used to screen for what the medical community refers to as substance use disorders sometimes referred to as either alcoholism, addiction, substance abuse, or chemical dependency. Chemical health assessment rule 25 application anoka county. Rule 25 contracted provider brochure dakota county. I, confirm that on this date i do not have a source of financial income trough employment or other sources. Rule 25 pdf mhcp enrolled providers rule 25 assessment and placement summary pdf client placement authorization form pdf. Refer a person to the rule 25 assessment number or the social service agency dhs5685 pdf in the persons county or tribe of residence. Revised total coliform rule level 1 assessment form us epa. Traditional zip files of the rai manual and the change tables that crosswalk the changes made to this years manual. Walk in rule 25 assessments are available, call 612 2493656 for directions. Mhcp provider manual substance use disorder services sud. For more information about substance use, please visit the department of human services alcohol and drug abuse website.

Real hope, real life, real recovery rule 25 assessments. Rule 25 also refers to a set of state rules shakopee assessors must follow. Mhcp provider manual rule 25 process minnesota department of. Before filling out this form, save this pdf to your computer. Agency completes the rule 25 packet our forms and agencys rois during the. Dakota county chemical health rule 25 assessor check list. You may need a pdf reader to view some of the files on this page. Chemical health rule 25 wright county, mn official website. The counselor gets to know you better and your situation through a structured interview.

A rule 25 is a chemical health evaluation conducted by a licensed medical professional. Alcohol, drug and other addictions minnesota department of. Dhs2794eng dhs2794eng 12 page 1 of 2 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. A rule 25 chemical health assessment is often recommended by courts, attorneys, or employers, to help people with issues concerning drug and alcohol use. Chemical health rule 25 wright county, mn official. It is a lengthy interview that inquires on a lot of information about your past alcohol and drug use, physical health, mental health, your interest in moderating or quitting.

Section 9, applicant should sign and then date on the. Agency must submit each rule 25 assessment and all relevant documentation to the county within seven business days of the date of the assessment date. Documents filed electronically must be filed in portable document format pdf. The minnesota rule 25 assessment is a standardized process that includes a one to one session with a licensed clinician. To access services through rule 25 a person must have a rule 25 assessment and meet clinical and financial eligibility requirements. The evaluation itself requires a facetoface interview between the medical professional and the person in need of a chemical dependency evaluation.

The courts rules of practice and procedure are available for download 626kb. Rule 25a is not limited to the situation involving. The past three 3 years personal and business federal and state income tax returns and. Clear form dhs5204eng 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. The motion for substitution may be made by any party or by the representative of the deceased party and, together with the notice of hearing, shall be served on the parties as provided in rule 5 and upon persons not parties in the manner provided in rule 4 for the. One signed original and four conformed copies of this form and amendments thereto must be completed and. For more information or to access this service, please call 7636827400 and request to speak with a rule 25 assessment social worker. An application for rule 25 assessment and tennessen must be completed. All items must be clearly documented in the assessment tool. In order to hasten download time, each title of the rules of practice and procedure below has been stored as a separate acrobat. Rule 25 eligibility and assessment process page 3 of 4. Minnesota chemical health assessments hennepin county. Mar 18, 2020 rule 25 chemical use assessments services delivered before the completion of a rule 25 or comprehensive assessment roomandboard services not clinically or medically necessary services delivered to people with mhcp managed by an enrolled in an mco, with the exception of roomandboard services detoxification services.

Chemical health assessment rule 25 application anoka. Rule 25 assessment vrs comprehensive assesssment rule 25 9530. A rule 25 also known as a rule 25 assessment is governed by minnesota statutes. Rule 25a1 treats the situation where the claim for or against the deceased party survives the death.

All 87 minnesota counties, 11 american indian tribes, and 9 state contracted managed care organizations are mandated to provide rule 25 assessments to anyone who. Chemical health assessment rule 25 application rule 25 is state paid chemical dependency treatment funding. Licensed alcohol and drug counselors meet with individuals to assess their use of alcohol or other drugs, and to determine where their use pattern puts them on the continuum of dependency based on clinical evaluation criteria. Provider name clients served hours address city zip code phone createsouth create, inc. This gives a client a referral andor guidance on whether further services are necessary.

The states rule 25 assessment form should be only one of many chemical dependency chemical assessment tools that are used during your assessment process. The assessment can take place inside st paul or anywhere else in the state of minnesota. Rule 25 eligibility and assessment process page 4 of 4. How do can i find contact information for my county to get a rule 25 assessment.

Evaluation locations rule 25 dependency assessment. Oftentimes, chemical health assessors utilize the rule 25 screening tool during the assessment because this screening tool used to be placed into alcohol and. Rule 25 chemical health assessments northern bridges. In minnesota, the process of the assessment and the criteria the decision is based upon are governed by rule 25. A student assessment form may be used by the faculty to filter students who are qualified and worth the educational benefits that the school can provide. The rule 25 assessment is also sometimes referred to as a chemical health evaluation or chemical dependency assessment. Have you had a previous chemical health assessmentrule 25. Ch case aide compiles paperwork, submits case for opening in ssis, and. Rule 25 is the common name for chemical use assessment rule 25 by a qualified assessor to determine appropriate treatment planning decisions, a service.

I, also, do not have health insurance coverage of any kind and am in. Rule 25 assessment and eligibility process dakota county. Unless the clerk requests or the relevant local rule requires, and notwithstanding frap provisions addressing number of copies, a party must not submit a paper copy of a document other than the original. Minnesota chemical health assessments hennepin county rule 25.

Counties, tribes and managed care organizations are required to use this form. This form should be completed when a water system is notified that a level 1 assessment has been triggered, as required under the revised total coliform rule rtcr. If you disagree with treatment planning decision proposed by the assessor, you have the right to a second chemical use assessment. The medical professional follows mn state guidelines, as outlined in state statute rule 25. As resources allow, rule 25 assessments may be conducted by properly trained staff to facilitate access to sud services in the community and to aid in offender release planning. A single pdf file of the entire rai manual for use as an electronic version with bookmarks that you can click on to take you to each section of the manual. One twelve provides affordable chemical health assessments, also known as rule 25 assessments. The assessment can take place inside anoka county or anywhere else in the state of minnesota. To schedule an assessment please call 6514374209 and ask for the rule 25 scheduler in crp between the hours of 8. The rule 25 assessment is also referred to as a chemical health evaluation or chemical dependency assessment, which can take place inside ramsey county or in a nearby area such as minneapolis, hennepin county, anoka county, or dakota county. Information contained in this document may be subject to federal confidentiality 42 cfr chapter 1, part 2, minnesota data practices act, chapter and hippa 45 cfr parts 160 and 164. A fillable and savable version of this form is available to alcohol and drug abuse professionals. A completed rule 25 form is needed for a person to enter residential and nonresidential treatment programs in the state minnesota.

Rule 25 assessment hennepin county chemical evaluation. If the assessment recommends chemical dependency treatment you may. Make sure to save an electronic copy of the completed document. Rule 25 risk descriptions chemical health division mn. We offer rule 25 assessments at our hastings site located at 1294 east 18th street, hastings, mn 55033 on the veterans home campus. For more information on rule 25, visit the minnesota department of human services website. Having a professional, quality, stateapproved assessment will be key in determining what the probation department will recommend the judge order as part of your sentence. During this appointment, you will meet with a licensed alcohol and drug counselor in hennepin county minnesota. Instructions for rule 25 assessment application rule 25 is an assessment process that consists of a chemical dependency evaluation and to determine the need for chemical dependency treatment. Rule 25 assessment, rule 25 summary, or comprehensive assessment dated within 45 days of request for services and discharge summary. Such profiles have an average decreased accuracy of approximately 20 %. 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.

Along with the guidelines all assessors follow, there is also a 16page standardized interview form assessors use. You do not have to answer the questions on this form. Reporters notes 2009 the 2009 amendments reflect changes resulting from the adoption of the massachusetts uniform probate code. The rule 25 assessment in minneapolis minnesota is essentially a therapistpatient meeting where a 16page standardized form the rule 25 is filled out during the meeting. A caseworker, agent, offender, or other source may make a request for a rule 25 chemical use assessment. Rule 25 risk descriptions chemical health division mn dept. Instructions for rule 25 assessment application washington county. The assessment form is very much similar to an interview assessment form, the only difference is the exception of the workjob experience rating. A current financial affidavit in the format required by family division rule 2. Our unbiased and objective evaluation is done through a conversational interview. This version of the rule 25 assessment form cannot be completed and saved electronically. Alcohol, drug and other addictions minnesota department. Your privacy rights tennessen notice information about your rights under the minnesota data practices act. Referral and coordination of care at a chemical health treatment facility.