"Individuals' First Choice"

 - In God We Trust -

Coporate Office

219 West Broad Street

St Pauls, North Carolina 28384




Diagnostic Assessment


Service Definition and Required Components


A Diagnostic Assessment is an intensive clinical and functional face to face evaluation of a recipient's mental health, developmental disability, or substance abuse condition that results in the issuance of a Diagnostic/Assessment report with a recommendation regarding whether the recipient meets target population criteria, and includes an order for Enhanced Benefit services that provides the basis for the development of an initial Person Centered Plan. For substance abuse focused Diagnostic/Assessment, the designated Diagnostic Tool specified by DMH (e.g., SUDDS IV, ASI, SASSI) for specific substance abuse target populations (i.e., Work First, DWI, etc.) must be used. In addition, any elements included in this service definition that are not covered by the tool must be completed.

The Assessment must include the following elements:


 A. a chronological general health and behavioral health history (includes both mental health andsubstance abuse) of the recipient's symptoms, treatment, treatment response and attitudes abouttreatment over time, emphasizing factors that have contributed to or inhibited previous recoveryefforts;


B. biological, psychological, familial, social, developmental and environmental dimensions andidentified strengths and weaknesses in each area;


C. a description of the presenting problems, including source of distress, precipitating events, associated problems or symptoms, recent progressions; and current medications


D. a strengths/problem summary which addresses risk of harm, functional status, co-morbidity, recovery environment, and treatment and recovery history;


E. diagnoses on all five axes of DSM-IV;F. evidence of an interdisciplinary team progress note that documents the teams review and discussion of the assessment;


G. a recommendation regarding target population eligibility; andH. evidence of recipient participation including families, or when applicable, guardians or other caregivers This assessment will be signed and dated by the MD, DO, PA, NP, licensed psychologist and will serve as the initial order for services included in the PCP. Upon completion, the PCP will be sent to the LME for administrative review and authorization of services under the purview of the LME. For additional services added after the development of the initial PCP, the order requirement for each service is included in the service definition.