Section 9 Assessment and Service Planning


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Arizona Department of Health Services

Division of Behavioral Health Services

PROVIDER MANUAL


Section 3.9 Assessment and Service Planning





Section 3.9 Assessment and Service Planning

3.9.1 Introduction

3.9.2 Terms

3.9.3 Procedures

3.9.3-A. Assessments

[RBHA, insert additional information and/or links to RBHA forms here.]

3.9.3-B. Service Planning

[RBHA, insert additional information and/or links to RBHA forms here.]

3.9.3-C. Updates to the Assessment and Service Plan

3.9.4 References

3.9.3 Scope

3.9.4 Did you know…?

PM Attachment 3.9.1



3.9.1 Introduction


The Arizona Department of Health Services/Division of Behavioral Health Services (ADHS/DBHS) supports a model for assessment, service planning, and service delivery that is strength-based, person-centered, family friendly, culturally culturally and linguistically appropriatesensitive, and clinically sound and supervised. The model is based on four equally important components:


  • Input from the person regarding his/her individual needs, strengths, and preferences;

  • Input from other persons individuals involved in the person’s care who have integral relationships with the person;

  • Development of a therapeutic alliance between the person and behavioral health provider that fosters an ongoing partnership built on mutual respect and equality; and

  • Clinical expertise.


The model incorporates the concept of a “team”, established for each person receiving behavioral health services. For children, this team is the Child and Family Team (CFT) and for adults, this team is the Adult Recovery Team (ART).
At a minimum, the functions of the Child and Family Team and Adult Recovery Team include:

  • Ongoing engagement of the person, family and others who are significant in meeting the behavioral health needs of the person, including their active participation in the decision-making process and involvement in treatment;




  • An assessment process performed to: (a) elicit information on the strengths, needs and goals of the individual person and his/her family, (b) identify the need for further or specialty evaluations, and (c) support the development and updating of a service plan which effectively meets the person’s/family’s needs and results in improved health outcomes;




  • Continuous evaluation of the effectiveness of treatment through the Child and Family Team and Adult Recovery Team process, the ongoing assessment of the person, and input from the person and his/her team resulting in modification to the service plan, if necessary;







  • Ongoing collaboration, including the communication of appropriate clinical information, with other individuals and/or entities with whom delivery and coordination of services is important to achieving positive outcomes (e.g., primary care providers, school, child welfare, juvenile or adult probation, other involved service providers);




  • Oversight to ensure continuity of care by taking the necessary steps (e.g., clinical oversight, development of facility discharge plans, or after-care plans, transfer of relevant documents) to assist persons who are transitioning to a different treatment program, (e.g., inpatient to outpatient setting), changing behavioral health providers and/or transferring to another service delivery system (e.g., out-of-area, out-of-state or to an Arizona Long Term Care System (ALTCS) Contractor); and




  • Development and implementation of transition plans prior to discontinuation or modification of behavioral health services.


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