NORTHPOINTE BEHAVIORAL HEALTHCARE SYSTEMS
POLICY TITLE: Bio-Psychosocial Assessment for Children
MANUAL: Clinical
ORIGINAL EFFECTIVE DATE: 10/1/06
REVIEWED/REVISED ON DATE: 7/29/15
REVISIONS TO POLICY STATEMENT:
YES
NO
PAGE: 1 of 3
SECTION: Entry to Care
BOARD APPROVAL DATE: 9/26/13
CURRENT EFFECTIVE DATE: 8/1/15
OTHER REVISIONS:
YES
NO
APPLIES TO:
This policy applies to all children, age 17 and under, requesting or being referred for services.
POLICY:
It is the policy of Northpointe Behavioral Healthcare Systems that all individuals will be assessed by a qualified
mental health professional knowledgeable to assess specific needs of the person served, and trained in the use of
applicable tools. The clinician will be responsible for ensuring that individuals receive the most clinically appropriate
and relevant service, i.e., through internal or external referrals and emergency triage when necessary, using the person
centered planning process. All internal referrals will be based on clinical criteria and in accordance with regulatory
agency’s standards. Individuals will receive a standardized clinical assessment with a face-to-face interview by a
qualified mental health professional. Northpointe Behavioral Healthcare Systems will include as a part of the
psychosocial assessment, an assessment procedure for the early detection of mental health problems that are life
threatening, indicate severe personality disorganization or deterioration, or may seriously affect the treatment or
rehabilitation process, as well as a procedure for assessing the individual's health, medical, nutritional status, and full
range of the individual's functioning. Priority population will be identified and served (SMI, SED, and I/DD
Population). Children with mild to moderate will be served if they have MI Child insurance.
PURPOSE:
Each individual's physical and psychological status and social functioning are assessed through an initial clinical
assessment to determine need for care, the individual’s choice and preferences regarding care, and need for any
further assessment.
PROCEDURES:
1. Anyone who enters the system in a state of crisis will receive services as necessary to resolve the crisis.
2. Following determination of whether or not an emergency exists, and resolution as necessary, Northcare shall make
a preliminary determination concerning the individual’s eligibility for Northpointe intake assessment according to
the Michigan Department of Community Health Managed Care contract and the Prepaid Health Plan. When a
person is found ineligible for services, the person is informed of the reasons, given an Action Notice form by
Northcare Access staff, and recommendations are made for alternatives/referral services, and documentation is
maintain on these actions.
3. Once eligibility has been established, Northpointe Behavioral Healthcare Systems will use an initial clinical
assessment that will be administered to eligible individuals who present for service. Each recipient will be
administered a clinical interview and age-appropriate instrument to measure current symptomatology/severity for
the purpose of determining severity of illness, monitoring treatment changes, and clinical effectiveness or
prescribed interventions. These initial clinical assessments and interviews will be completed by a Licensed
Masters Level Social Worker.
4. Assessments include information obtained from the person served; family members, when applicable or permitted;
friends and peers, when appropriate and permitted; other appropriate and permitted collateral sources (parents,
guardians, teachers, social workers, probation officers, physicians).
5. The licensed Masters Level Social Worker will:
 Obtain consent for treatment form signed by parent or guardian.
 Complete the bio-psychosocial assessment, the preliminary treatment plan which authorizes initial services,
and age-appropriate level of functioning tools.
 Obtain Release of Information to Family Physician and others as deemed appropriate.
 Provide the individual/parent/guardian with “Action Notice” (See Grievance & Appeal Policy & Procedure).
 Utilize the Person-Centered planning process and Northpointe service selection criteria to match individual
needs and services.
 Review case with the clinical treatment team for further recommendation and approval.
 All denials of service for individuals who do not meet priority population criteria shall receive an Action
NORTHPOINTE BEHAVIORAL HEALTHCARE SYSTEMS
POLICY TITLE: Bio-Psychosocial Assessment for Children
PAGE: 2 of 3
MANUAL: Clinical
SECTION: Entry to Care
ORIGINAL EFFECTIVE DATE: 10/1/06
BOARD APPROVAL DATE: 9/26/13
REVIEWED/REVISED ON DATE: 7/29/15
CURRENT EFFECTIVE DATE: 8/1/15
Notice form.
 A review of all denials of service at the initial clinical assessment will be completed by a Clinical Supervisor
who is a Masters Level Social Worker.
 Obtain psychiatrist approval/signature for recipients having BC/BS Health Insurance.
6. The Bio-Psychosocial Assessments gathers sufficient information to develop an individualized personcentered plan for each person served and is written in a “strength-based” terms. The Child Bio-Psychosocial
Assessment shall be conducted appropriate to the individual's care and at a
minimum will include the following components:
a.
Identifying information, information sources.(parental/guardian custodial status);
b.
Referral source / Presenting Problem;
c.
History; social, family and community resources (adjustment to disabilities/disorders).
d.
Developmental history, age factors, motor development and functioning, language functioning, visual,
speech and hearing;
e.
Family Constellation information, cultural/ethnicity;
f.
Financial, employment – current and history;
g.
Family of origin history; mental illness, reports of abuse, neglect; or family violence
h.
Behavioral/Emotional problems;
i.
Education information, school history, learning ability, intellectual functioning;
j.
Other current agency involvement;
k.
Substance abuse – current and history. Prenatal exposure to alcohol, tobacco and other drugs;
l.
Health status, medical history, immunization record, previous mental health services, previous
diagnosis, efficacy of current or previously used medication, current medical needs;
m.
Assessment of risk to self, to others, other risk factors;
n.
Health and safety risk factors identified, and may need to be carried through in the community,
school, or at work as needed;
o.
Functional summary, to include CAFAS, PECFAS, DECA, or I/DD LOF, as appropriate;
p.
Individual strengths, needs, abilities and preferences;
q.
Clinical summary;
r.
Diagnostic information. All provisionary diagnosis for Intellectual/Developmental Disability
individuals will be substantiated by written documentation from a licensed physician, fully licensed
psychologist or licensed master’s level social worker;
s.
Treatment/support recommendations; disposition; applicable signatures that verify supervision and
provide clinical oversight;
t.
Environmental surroundings;
u.
Interaction with peers;
v.
Parent/guardian’s ability or willingness to participate in services, when applicable.
7. Northpointe continuously obtains assessment information for each person served in a manner that is respectful
and considerate of that person’s specific needs. Assessments identify the expectations of the person served
and is responsive to the changing needs of the person served. The use of assistive technology or resources is
provided as needed in the assessment process.
8. The bio-psychosocial assessment is updated annually, in conjunction with the person-centered treatment plan.
Reassessments are also completed following significant life or status changes of the individual and to
substantiate when changing a Level of Care.
9. The Preliminary IPOS is completed at the time of the initial BPS assessment only. which must be completed
no less than 7 days prior to the date of the IPOS, unless otherwise requested by the individual.
CROSS REFERENCE:
Mental Health Code, Chapter 7, Rights of Recipient of Mental Health Services
Written Plan for Professional Services Manual
Bio-Psychosocial Assessment in ELMER
NORTHPOINTE BEHAVIORAL HEALTHCARE SYSTEMS
POLICY TITLE: Bio-Psychosocial Assessment for Children
MANUAL: Clinical
ORIGINAL EFFECTIVE DATE: 10/1/06
REVIEWED/REVISED ON DATE: 7/29/15
Consent for Treatment
Health Assessment Form
Release of Information Form
PAGE: 3 of 3
SECTION: Entry to Care
BOARD APPROVAL DATE: 9/26/13
CURRENT EFFECTIVE DATE: 8/1/15