Community Services Programs
Office of Substance Abuse - Chapter 2 Driver Education and Evaluation Programs Procedure Manual - Section E - The clinical substance abuse evaluation provided by a community-based service provider
The clinical substance abuse evaluation is to determine if evidence of a substance abuse problem exists and if the individual is a risk to recidivate by using various tests and interview techniques, and to refer the client who has displayed evidence of abuse to an approved community-based service provider for treatment.
The second opinion evaluation for the purpose of appeal is to determine if the client has an alcohol or other drug problem that requires treatment, or if the client has, as a result of receiving treatment, met the criteria for completion of treatment.
The status update evaluation is to determine if the client meets the criteria for completion of treatment as defined in Section A.
1. All clinical substance abuse evaluations, second opinions, and status updates provided by approved community-based service providers shall be conducted as follows:
- All clinical substance abuse evaluations, second opinions, and status update evaluations shall consist of a minimum of two (2) and a maximum of four (4) clinical hour sessions, with a minimum of five working days between the first and second session, provided that if, after the first session, the evaluator and the client both agree upon a positive finding, the evaluator may waive any subsequent sessions. Clinical substance abuse evaluations, second opinions, or status update evaluations shall not exceed four (4) clinical hour sessions.
- No group evaluations will be performed in either the first or second sessions, except as provided in 1(c) below.
- The community-based service provider conducting the clinical substance abuse evaluation, second opinion, or status update evaluation shall require the presence of a significant other at one of the evaluation sessions, provided that if the first session results in a positive finding, the evaluator may waive the need for a significant other. If, after being requested to do so, a client refuses to bring a significant other to an evaluation session, the refusal shall, by itself, result in an unsatisfactory completion of the evaluation. When, in the judgment of the evaluator, exceptional circumstances prevent the client from bringing a significant other to the evaluation, these reasons shall be documented in the client's case file and this failure shall not, by itself, result in an unsatisfactory completion of the evaluation.
- Clinical substance abuse evaluations, second opinions, and status update evaluations shall be documented. The documentation shall include, but not be limited to, the following:
(1) A statement explaining the reason for the evaluation, including the referral source.
(2) A mental status assessment.
(3) A psychosocial history, including family background, employment, education, legal and medical history.
(4) A detailed history of alcohol and other drug use, including age of first use, evidence of tolerance or withdrawal, memory loss, consumption, list of all drugs used (past and present, patterns of use, and family history of alcohol/drug problems).
(5) The history of previous treatment for a substance abuse disorder, if any, including past participation in self-help, and any significant period of abstinence or recovery.
(6) Diagnostic assessment test instrument scores and their clinical interpretation.
(7) The content of the interview with at least one significant other.
(8) A description of the client's current alcohol and/or other drug use status.
(9) A clinical summary, including the DSM IV diagnosis and the stage of chemical dependency in accordance with the Completion of Treatment Guidelines, any recommendations for further service, and the client's current risk for repeating an alcohol or other-drug related offense.
- Status update evaluations shall include documentation of previous treatment, including a copy of the discharge summary and aftercare plan.
- The community-based service provider shall require abstinence from alcohol and/or other non-prescribed drugs during the course of the evaluation.
2. Upon completion of the last scheduled session, the client will be informed of the results of the evaluation. The result shall be a) an incomplete evaluation, b) a negative finding, c) a positive finding, or d) a positive finding-in remission.
- Incomplete Evaluation. If the client fails to attend all the required evaluation sessions, fails to bring a significant other, fails to complete the evaluation or fails to comply with any other reasonable requirement that is a customary part of the evaluation, the client will be informed that he or she has not satisfactorily completed the evaluation.
Any time an evaluation is not completed within six (6) months, the client will be required to undergo another complete evaluation. However, if the first evaluation has resulted in a positive finding, any subsequent evaluation will be conducted as a second opinion evaluation.
- Negative Finding. When the evaluation determines that there is no clinical evidence that a client has an alcohol or other drug problem requiring treatment, the client will be informed that the evaluation, in the opinion of the community-based service provider, has resulted in a negative finding. The evaluation result will be communicated to DEEP by the evaluator within five (5) working days on forms supplied by the DEEP.
- Positive Finding. When the evaluation determines that a client has an alcohol or other drug problem requiring treatment, the client will be informed that, in the opinion of the community-based service provider, the evaluation has resulted in a positive finding that will require either outpatient, non residential or residential treatment. The consequences of a client's failure to comply with the treatment requirements will be explained to the client. The result of the evaluation will be communicated to DEEP by the community-based service provider within five (5) working days on forms provided by DEEP.
- Positive Finding - in Remission. When the evaluation determines that the client has had an alcohol or other drug problem for which the client has demonstrated clinical evidence of remission sufficient to comply with the Satisfactory Completion of Treatment as defined in Section A, the client will be informed that, in the opinion of the community-based service provider, the evaluation has resulted in a positive-in remission finding. The result will be communicated to DEEP by the community-based service provider within five (5) working days on forms provided by DEEP.
3. When an evaluation results in a positive finding, the community-based service provider will prescribe a type of treatment that is, in the evaluator's judgment, appropriate and likely to be beneficial. The community-based service provider will give the client the names and addresses of at least three (3) different private providers and/or programs that are licensed or approved to provide the type of treatment services prescribed. The client may then choose an approved community-based service provider of the prescribed treatment services. The community-based service provider will communicate the results of the evaluation to DEEP within five (5) working days on forms provided by DEEP.
The Director will review the forms and other submitted documentation and will decide and be responsible for determining the evaluation result. The Director at his/her discretion, may request additional documentation that has resulted in the recommendation.
The Director will notify, verbally, when possible, and in writing, the community-based service provider and the client, when the Director disagrees with the evaluation result.
When treatment is required as a result of the Director's decision, DEEP will provide the client with the names of at least three approved community-based service providers.
When treatment is not required as a result of the Director's decision, DEEP will forward forms to the Secretary of State, Bureau of Motor Vehicle, Division of Driver Licensing Services.
Anytime the client disagrees with a positive finding resulting from the first evaluation, he/she may request a second opinion evaluation.
4. In prescribing a treatment regimen consisting of residential treatment, the evaluator shall consider but not be limited to the following factors:
- Prior and ongoing treatment in a non-residential or outpatient setting;
- Physical addiction to alcohol and/or other drugs;
- Prior residential care;
- Ongoing involvement with the criminal justice system due to substance abuse;
- Ongoing involvement with the social service system due to substance abuse; and
- Prior OUI offenses.
5. In prescribing a treatment regimen consisting of nonresidential rehabilitation, the evaluator shall consider, in addition to all of the factors listed above, the following factors:
- Extent of family, or significant other, support system
- Availability of a substance free home and work environment conducive to intensive outpatient treatment, and
- Ability to commute on a daily basis to and from nonresidential rehabilitation site.
6. When prescribing a treatment regimen, outpatient, nonresidential rehabilitation, or residential rehabilitation, the evaluator will document the reasons and maintain the documentation within the client's record.
