N.J. Admin. Code § 10:43-3.3

Current through Register Vol. 56, No. 24, December 18, 2024

Section 10:43-3.3 - Clinical assessment

(a) A clinical assessment shall be conducted by a clinician to assess the individual's decision-making abilities and to make a recommendation regarding the need for a guardian.

(b) The clinical assessment process shall begin with the presumption that the individual has capacity to make all decisions.

(c) The clinical assessment shall include the following components:

1. Clinical interview. The clinician shall conduct a clinical interview to attempt to elicit information about the person's life experiences, his or her interpretation of those experiences and what he or she wants for himself or herself in the future, as well as his or her understanding of guardianship. The clinician shall assess both the information and the opportunities that have been afforded to that individual, including decisions the person has made in the past and decisions the individual is currently making. Other factors that may impact upon decision-making include, but are not limited to: severe emotional disturbance, chronic mental disorder, lack of opportunity to make or express decisions. The need for guardianship may be affected by the extent to which these factors interfere with the individual's capacity for self-direction.

i. The clinician shall determine the individual's communication style, including, but not limited to, primary language, verbal/non-verbal ability, assistive devices and alternative modes of communication;

2. Collateral interviews. The clinician shall conduct collateral interviews, to the extent deemed necessary according to his or her professional judgment, with family, friends, supportive personnel and/or caregivers to provide comparison data on skills performed by the individual in different environments. The clinician shall consider the perspective of the interviewees as an important source of information;

3. Adaptive functioning. The clinician shall either administer a scale of adaptive functioning in accordance with professional standards or review the most recently completed scale of adaptive functioning;

4. Cognitive functioning. The clinician shall administer, to the extent possible, the appropriate instrument for cognitive functioning in accordance with professional standards and the requirements of the individual being tested, or review the most recently completed instrument for cognitive functioning;

5. Record review. The clinician shall review all available, relevant portions of the individual's record and other records as provided;

6. Areas for decision-making. The clinician shall assess the individual's ability to make decisions in areas of life that include, but are not limited to, the following:

i. Residence;

ii. Employment and/or vocational training;

iii. Education;

iv. Legal matters; and

v. Medical decisions that require informed consent;

7. Rights and responsibilities. The clinician shall assess the individual's understanding of legal rights and obligations at a basic level. The clinician shall also assess the individual's understanding of guardianship; and

8. Recommendation. The clinician shall make a recommendation regarding the need for guardianship based upon the integration of findings. The findings may lead to one of the following recommendations:

i. The individual does not need a guardian;

ii. The individual should be restored to capacity;

iii. The individual needs a limited guardian for specific areas of life; or

iv. The individual needs a general guardian.

N.J. Admin. Code § 10:43-3.3

Recodified from N.J.A.C. 10:43-3.1 by and amended R.2010 d.280, effective 12/6/2010.
See: 42 N.J.R. 1288(a), 42 N.J.R. 2954(b).
Added new (a); and recodified former (a) and (b) as (b) and (c).