Wisconsin DHS 35 establishes minimum certification standards for outpatient mental health clinics that receive Medicaid/BadgerCare Plus reimbursement, federal community mental health block grant funds, or state community aids funds. Clinic operators must obtain and maintain certification through the Department of Health Services, meet staffing requirements (including minimum hours of licensed treatment professionals), implement written personnel and clinical supervision policies, and comply with ongoing reporting, consumer rights, and enforcement provisions. The chapter explicitly excludes outpatient programs governed under DHS 75 that serve only alcohol or other drug abuse needs without providing mental health services.
View official sourcePublished under s. 35.93, Wis. Stats., by the Legislative Reference Bureau. 1 DEPARTMENT OF HEALTH SERVICES DHS 35.03 Chapter DHS 35 OUTPATIENT MENTAL HEALTH CLINICS Subchapter I — General Provisions DHS 35.01 Authority and purpose. DHS 35.02 Applicability. DHS 35.03 Definitions. Subchapter II — Certification DHS 35.06 Effect of certification. DHS 35.07 Location of service delivery. DHS 35.08 Certification process. DHS 35.09 Notification of clinic changes. DHS 35.10 Scope and transferability of certification. DHS 35.11 Enforcement actions. DHS 35.12 Waivers and variances. Subchapter III — Personnel DHS 35.123 Staffing requirements for clinics. DHS 35.127 Persons who may provide psychotherapy services through an outpa- tient mental health clinic. DHS 35.13 Personnel policies. DHS 35.14 Clinical supervision and clinical collaboration. DHS 35.15 Orientation and training. Subchapter IV — Outpatient Mental Health Services DHS 35.16 Admission. DHS 35.165 Emergency services. DHS 35.17 Assessment. DHS 35.18 Consent for outpatient mental health services. DHS 35.19 Treatment plan. DHS 35.20 Medication management. DHS 35.21 Treatment approaches and services. DHS 35.215 Group therapy. DHS 35.22 Discharge summary. DHS 35.23 Consumer file. DHS 35.24 Consumer rights. DHS 35.25 Death reporting. Subchapter I — General Provisions DHS 35.01 Authority and purpose. This chapter is promulgated under the authority of ss. 49.45 (2) (a) 11. , 51.04, 51.42 (7) (b) 11., and 227.11 (2) (a), Stats., to establish minimum standards for certification of outpatient mental health clinics that receive reimbursement for outpatient mental health services from the Wisconsin medical assistance and BadgerCare Plus programs or private insurance under s. 632.89 (2) (d), Stats., or that utilize federal community mental health services block grant funds un- der 42 USC section 300x, et.seq., or receive state community aids funds under s. 51.423 (2), Stats. History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09. DHS 35.02 Applicability. (1) This chapter applies to public and private outpatient mental health clinics that request re- imbursement for services from the Wisconsin medical assistance and BadgerCare Plus programs and from private insurance re- quired under s. 632.89 (2), Stats., or who utilize federal commu- nity mental health services block grant funds under 42 USC sec- tion 300x, et.seq., or receive state community aids funds under s. 51.423 (2), Stats. (2) This chapter does not apply to outpatient programs gov- erned under ch. DHS 75 that provide services to persons who have alcohol or other drug abuse related treatment needs but do not provide mental health services. History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09. DHS 35.03 Definitions. (1) “Advanced practice nurse” has the meaning given in s. N 8.02 (1). (1g) “Advanced practice nurse prescriber” means an ad- vanced practice nurse certified to issue prescription orders under s. 441.16 (2), Stats. (1m) “Approved placement criteria” means criteria in the American Society of Addiction Medicine Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions (3rd ed., Oct. 24, 2013) or other similar placement criteria that is approved by the department to develop a place- ment recommendation for an appropriate level of care for a con- sumer who has a substance use disorder. Note: A copy of the ASAM Criteria: Treatment Criteria for Addictive, Sub- stance-Related, and Co-Occurring Conditions (3rd ed., Oct. 24, 2013), published by the American Society of Addiction Medicine, is on file in the department’s division of care and treatment services and the legislative reference bureau, and may be ob- tained from ASAM at 11400 Rockville Pike, Suite 200, Rockville, MD 20852, or at https://www.asam.org /asam-criteria/text. (2) “Available to provide outpatient mental health services” means physical presence at any of the clinic’s offices or via telehealth. (4) “Clinical collaboration” means mental health profession- als working together in a joint intellectual and clinical approach for the therapeutic benefit and favorable outcome of consumers. (5) “Clinical supervision” means any of the following: (a) The supervised practice of psychotherapy as described un- der ch. MPSW 4, 12, or 16, or Psy 2, as applicable. (b) For any staff member, including a substance abuse coun- selor, who provides services to consumers who have a primary diagnosis of substance abuse, “clinical supervision” has the meaning given under s. SPS 160.02 (6) by a clinical supervisor as defined under s. SPS 160.02 (7). Note: Any staff member, including a substance abuse counselor-in training, sub- stance abuse counselor, or clinical substance abuse counselor, providing services to consumers who have a primary diagnosis of substance abuse is required under s. DHS 35.14 (4) (b) to receive clinical supervision from a clinical supervisor as de- fined under s. SPS 160.02 (7). (6) “Consumer” means an individual who receives or re- quests outpatient mental health services from a clinic. (6m) “Deficiency” means a failure to meet a requirement of this chapter. (7) “Department” means the Wisconsin department of health services. (8) “Discharge” has the meaning given in s. 51.01 (7), Stats. Note: Section 51.01 (7) Stats., defines “discharge” for a patient who is under in- voluntary commitment orders as meaning termination of custody and treatment obligations of the patient to the authority to which the patient was committed by court action. For voluntary admissions to a treatment program or facility, s. 51.01 (7), Stats., defines “discharge” as meaning termination of treatment obligations be- tween the patient and the treatment program or facility. (8m) “Functionally equivalent” means a service provided via telehealth where the transmission of information is of sufficient quality as to be the same level of service as an in-person visit. Transmission of voices, images, data, or video must be clear and understandable. (9) “Legal representative” means any of the following: (a) A guardian of the person as defined under s. 54.01 (12), Stats. Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published. Register February 2026 No. 842 Published under s. 35.93, Wis. Stats., by the Legislative Reference Bureau. DHS 35.03 WISCONSIN ADMINISTRATIVE CODE 2 (b) A health care agent as defined in s. 155.01 (4), Stats., if the principal has a finding of incapacity pursuant to s. 155.05 (2), Stats., and if the power to make decisions regarding outpatient mental health services is included in the scope of the agency. (c) A parent of a minor as defined in s. 48.02 (13), Stats., a guardian of a minor as defined in s. 48.02 (8), Stats., or a legal custodian of a minor as defined in s. 48.02 (11), Stats. (9g) “Licensed treatment professional” means an individual licensed as a physician under s. 448.03, Stats., who has com- pleted a residency in psychiatry; a psychologist or a private prac- tice school psychologist licensed under ch. 455, Stats., a marriage and family therapist licensed under s. 457.10 or 457.11, Stats., a professional counselor licensed under s. 457.12 or 457.13, Stats., an advanced practice social worker granted a certificate under s. 457.08 (2), Stats., an independent social worker licensed under s. 457.08 (3), Stats., or a clinical social worker licensed under s. 457.08 (4), Stats.; and includes any of these individuals practic- ing under a currently valid training or temporary license or cer- tificate granted under applicable provisions of ch. 457, Stats. “Licensed treatment professional” does not include an individual whose license or certificate is suspended, revoked, or voluntarily surrendered, or whose license or certificate is limited or re- stricted, when practicing in areas prohibited by the limitation or restriction. (9m) “Major deficiency” means the clinic has repeatedly or substantially failed to meet one or more requirements of this chapter or the department determines that an action, condition, policy or practice of the clinic or the conduct of its staff does any of the following: (a) Creates a risk of harm to a consumer or violates a con- sumer right created by this chapter or other state or federal statutes or rules, including any of the following: 1. A staff member has had sexual contact or intercourse, as defined in s. 940.225 (5) (b) or (c), Stats., with a consumer. 2. A staff member has been convicted of abuse under s. 940.285, 940.29 or 940.295, Stats. 3. The health or safety of a consumer is in imminent danger because of any act or omission by the clinic or a staff member. (b) Submits or causes to be submitted one or more statements for purposes of obtaining certification under this chapter that were false. (c) A license, certification or required local, state or federal approval of the clinic has been revoked or suspended or has ex- pired, including termination of a provider’s Medicaid or Medi- care certification for any basis under s. DHS 106.06 or federal law. (d) Constitutes fraud or willful misrepresentation within the meaning of s. DHS 108.02 (9) (d). Note: Under s. DHS 108.02 (9) (d) 1. , the department may withhold MA pay- ments, in whole or in part, to a provider upon receipt of reliable evidence that the circumstances giving rise to the need for withholding of payments involve fraud or willful misrepresentation under the MA program. Reliable evidence of fraud or willful misrepresentation includes, but is not limited to, the filing of criminal charges for those activities against the provider or one of its agents or employees by a prosecuting attorney. The department may withhold payments without first noti- fying the provider of its intention to withhold the payments. A provider is entitled to a hearing under s. DHS 106.12. Note: Willful misrepresentation under this paragraph does not include the sign- ing of a claim for reimbursement by an authorized representative of a clinic who did not perform the service for which reimbursement is claimed, if the individual who performed the service was qualified to do so under this chapter and applicable pro- fessional licensure or certification law and was on the clinic’s staff when the ser- vices were performed. (e) A staff member has a substantiated finding of caregiver misconduct as identified in chs. DHS 12 and 13. (10) “Mental health practitioner” means a person who before January 1, 2012, holds a graduate degree from an accredited col- lege or university in psychology, counseling, marriage and family therapy, social work, nursing or a closely related field, and either has completed the applicable supervised practice requirements under ch. MPSW 4, 12, or 16, or Psy 2 or has 3,000 hours of su- pervised clinical post-graduate degree experience including at least 1,000 hours of face-to-face contact with consumers, and who commences work at a clinic required to be certified under this chapter no later than January 1, 2013. “Mental health practi- tioner” does not include an individual whose professional license is suspended, revoked, or voluntarily surrendered, or whose pro- fessional license or certificate is limited or restricted, when prac- ticing in areas prohibited by the limitation or restriction, irrespec- tive of whether that individual otherwise meets the terms of this definition. Whether a person’s graduate degree is in a “closely related” field will be determined by the department on a case-by- case basis upon application by a clinic. (11) “Mental health professional” means a licensed treatment professional, a mental health practitioner, a qualified treatment trainee, or a recognized psychotherapy practitioner. (12) “Minor” means an individual who is 17 years old or younger. (13) “Outpatient mental health clinic” or “clinic” means an entity that is required to be certified under this chapter to receive reimbursement for outpatient mental health services to consumers. (14) “Outpatient mental health services” means the services offered or provided to a consumer, including intake, assessment, evaluation, diagnosis, treatment planning, psychotherapy and medication management. (15) “Physician” means an individual licensed under ch. 448, Stats., as a physician. (15m) “Physician assistant” means an individual licensed un- der ch. 448, Stats., as a physician assistant. (16) “Prescriber” means a physician, a physician assistant acting within the conditions and limitations set forth in s. Med 8.07, or an advanced practice nurse prescriber acting within the conditions and limitations set forth in s. N 8.06. (17) “Psychotherapy” means any activity that falls within the definitions set forth at s. 457.01 (8m) or 455.01 (6), Stats. (17m) “Qualified treatment trainee” means either of the following: (a) A graduate student who is enrolled in an accredited insti- tution in psychology, counseling, marriage and family therapy, social work, nursing or a closely related field. (b) A person with a graduate degree from an accredited insti- tution and course work in psychology, counseling, marriage and family therapy, social work, nursing or a closely related field who has not yet completed the applicable supervised practice require- ments described under ch. MPSW 4 , 12, or 16, or Psy 2 as applicable. (17r) “Recognized psychotherapy practitioner” means an in- dividual who may lawfully practice psychotherapy within the scope of a license, permit, registration or certificate granted by this state other than under ch. 455 or 457, Stats. Note: Section 457.02 (6) (a), Stats., provides that a license or certificate under ch. 457, Stats., is not required for a person to “lawfully practice within the scope of a license, permit, registration, or certificate granted by this state or the federal gov- ernment.” The department will recognize as a “recognized psychotherapy practi- tioner” for purposes of this chapter any person legally recognized as permitted to provide psychotherapy within the scope of his or her professional credential issued by a state agency. (18) “Recovery” means the process of a consumer’s growth and improvement, despite a history of a mental or substance use disorder, in attitudes, values, feelings, goals, skills and behavior measured by a decrease in dysfunctional symptoms and an in- Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published. Register February 2026 No. 842 Published under s. 35.93, Wis. Stats., by the Legislative Reference Bureau. 3 DEPARTMENT OF HEALTH SERVICES DHS 35.08 crease in maintaining the person’s highest level of health, well- ness, stability, self-determination and self-sufficiency. (18m) “Signature” or “signed” means a signature that meets the requirements in s. 990.01 (38), Stats. (19) “Staff” or “staff member” means an owner of a clinic or an individual employed by or under contract with an outpatient mental health clinic. (20) “Substance” has the meaning given under s. SPS 160.02 (25). (21) “Substance abuse counselor” has the meaning given un- der s. SPS 160.02 (26). (22) “Substance use disorder” has the meaning given under s. SPS 160.02 (28). (22hm) (a) “Telehealth” means the use of telecommunica- tions technology by a certified provider to deliver services allow- able under this chapter, s. DHS 107.02 (5), and ss. 49.45 (61) and 49.46 (2) (b) 21. to 23., Stats., including assessment, diagnosis, consultation, treatment or transfer of medically relevant data in a functionally equivalent manner as that of an in-person contact. (b) “Telehealth” may include real-time interactive audio-only communication. (c) “Telehealth” does not include communication between a certified provider and a recipient that consists solely of an elec- tronic mail, text, or facsimile transmission. (22m) “Treatment records” has the meaning given in s. 51.30 (1) (b), Stats., namely, all records created in the course of provid- ing services to individuals for mental illness, which are main- tained by the department, by boards and their staffs, and by treat- ment facilities. “Treatment records” do not include notes or records maintained for personal use by an individual providing treatment services for the department, a board, or a treatment fa- cility if the notes or records are not available to others. (23) “Trauma” means a single experience, or an enduring or repeating event or events that results in significant distress or im- pairment in social, occupational, or other important areas of functioning for a person. (24) “Variance” means an alternate requirement in place of a non-statutory requirement of this chapter by the department. (25) “Waiver” means an exemption from a non-statutory re- quirement of this chapter by the department. History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09; correction in (5) (b), (20), (21), (22) made under s. 13.92 (4) (b) 7. , Stats., Register November 2011 No. 671; correction in (16) made under s. 13.92 (4) (b) 7., Stats., Register Feb- ruary 2014 No. 698; CR 23-053: am. (2), cr. (8m), (18m), (22hm) Register Septem- ber 2023 No. 813, eff. 10-1-23; CR 25-055: am. (1m), (5) (a) Register February 2026 No. 842, eff. 3-1-26. Subchapter II — Certification DHS 35.06 Effect of certification. (1) PUBLIC FUND- ING. Unless certified under this chapter, an outpatient mental health clinic is not eligible to receive funding from the Wisconsin medical assistance or BadgerCare Plus programs under ss. 49.45 and 49.471, Stats., federal community mental health services block grant funds under 42 USC section 300x, et. seq., or state community aids funds under s. 51.423 (2), Stats., in connection with the provision of outpatient mental health services. (2) PRIVATE INSURANCE. An outpatient mental health clinic certified under this chapter is certified by the department within the meaning of s. 632.89 (1) (e) 1., Stats., for purposes of the pro- visions of s. 632.89 (2), Stats., relating to required coverage of treatment for certain conditions under certain policies issued by private insurers. History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09. DHS 35.07 Location of service delivery. (1) A clinic may provide outpatient mental health services at one or more of- fices. If a clinic provides outpatient mental health services at more than one office, all of the following apply: (a) The clinic shall designate one office as its main office. (b) All notices under this chapter will be sent to the main office. (c) The clinic administrator shall be primarily located at the main office. (d) Both the clinic as a whole and the main office shall com- ply with the staffing requirements of s. DHS 35.123 (2). (e) The clinic shall adopt policies and procedures that are ad- equate to ensure that the clinic administrator is able to carry out the oversight and other responsibilities specified under ss. DHS 35.123 (1), 35.14 (1), and 35.15 (1) and (2) with respect to all other offices, given the location of the clinic’s offices and their distance from the main office. (2) A clinic may provide outpatient mental health services at its offices, except in instances where therapeutic reasons are doc- umented in the consumer file to show that it is appropriate to use an alternative location such as a nursing home, school, medical clinic, the consumer’s home, or other location appropriate to sup- port the consumer’s recovery. The clinic may also deliver ser- vices via telehealth. History: CR 06-080: cr. Register May 2009 No. 641 , eff. 6-1-09; CR 23-053: am. (2) Register September 2023 No. 813, eff. 10-1-23. DHS 35.08 Certification process. (1) INITIAL APPLI- CATION. Application to the department for initial outpatient mental health clinic certification shall be made to the department on a form provided by the department and shall include applica- ble fees, proof of malpractice and liability insurance for the clinic and each staff member who provides psychotherapy or who is a prescriber, and all of the information requested in the application. Additional offices do not require separate certification, but the clinic shall identify each office location and respond to any ques- tions regarding each office in the application for initial certification. Note: Fees are set and periodically revised by the department’s Division of Qual- ity Assurance. Fees may vary based on a number of factors including the number of offices at which the clinic provides services. Note: Application materials may be obtained from and submitted to the Behav- ioral Health Certification Section, Division of Quality Assurance, PO Box 2969, Madison, WI 53701-2969 (2) COMPLIANCE REVIEW. (a) Upon receipt of a complete ini- tial application, department staff may conduct an on-site inspec- tion of any office identified in the clinic application and may re- view any of the following information to determine if the clinic is in compliance with this chapter: 1. Statements made by the applicant or a staff member. 2. Documentary evidence. 3. On-site observations by a representative of the department. 4. Reports by consumers regarding the clinic’s operations. (b) The clinic shall make available for review by the depart- ment’s designated representative all documentation necessary to establish whether the applicant and each of the applicant’s offices is in compliance with the standards in this chapter, including written policies and procedures of the clinic, work schedules of staff members, credentials of staff members, consumer files and treatment records, information from grievances filed concerning the clinic, records of consumers who have been discharged, and evidence of contractual staffing. (c) The designated representative of the department shall pre- serve the confidentiality of all consumer information obtained Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published. Register February 2026 No. 842 Published under s. 35.93, Wis. Stats., by the Legislative Reference Bureau. DHS 35.08 WISCONSIN ADMINISTRATIVE CODE 4 during the certification process, to the extent required by ch. DHS 92 and 45 CFR Parts 160, 162 and 164 and other applicable state and federal statutes and regulations. (3) ISSUANCE OF CERTIFICATION. (a) Action on application. 1. Within 60 days after receiving a complete application for ini- tial certification, the department shall grant the clinic initial cer- tification or deny certification. 2. If the department determines that a clinic applying for ini- tial certification has a deficiency that is not a major deficiency as defined under s. DHS 35.03 (9m) , the department may grant or deny certification to the clinic. If the department grants initial certification to a clinic with a deficiency, the department shall is- sue a notice of deficiency under s. DHS 35.11 (1m) (a). 3. If the department determines that a clinic applying for ini- tial certification has a major deficiency, the department shall is- sue a notice of deficiency under s. DHS 35.11 (1m) (a) and may deny initial certification, whichever is applicable. (b) Duration of certification. 1. Certification remains valid until it is suspended or terminated by the department in accor- dance with s. DHS 35.11 (2) 2. Certification becomes invalid due to non-submission of the biennial report or non-payment of biennial fees in accordance with sub. (4). (4) BIENNIAL REPORT AND FEES. (a) Every 24 months, on a date determined by the department, the program shall submit a biennial report on the form provided by the department and shall submit payment of the certification continuation fees under s. 51.04, Stats. (b) The department shall send the certification continuation materials to the provider, which the provider is expected to com- plete and submit to the department according to the instructions provided (c) A certification shall be suspended or terminated if bien- nial reports and fees are not submitted prior to the end of the bi- ennial cycle. (5) DENIAL OF CERTIFICATION. The department may deny certification based on any major deficiency. A denial of certifi- cation shall be in writing and shall contain the reason for the de- nial and notice of opportunity for a hearing under s. DHS 35.11 (3). History: CR 06-080: cr. Register May 2009 No. 641 , eff. 6-1-09; CR 22-078: renum. (1) (a) to (1) and am., r. (1) (b), am. (2) (a) (intro.), r. (2) (d), am. (3) (a), r. and recr. (3) (b), (4) Register July 2023 No. 811, eff. 8-1-23; correction in (1) (b) made under s. 35.17, Stats., Register July 2023 No. 811. DHS 35.09 Notification of clinic changes. The clinic shall notify the department of any changes in administration, ownership or control, office location, clinic name, or program, and any change in the clinic’s policies or practices that may affect clinic compliance by no later than the effective date of the change. History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09. DHS 35.10 Scope and transferability of certifica- tion. Certification is issued only for the offices identified in the application for initial certification and only for the individual or individuals, corporations or other legal entities named in the ap- plication for initial certification. Certification may not be trans- ferred or assigned, including by change of ownership or control of a corporation or other legal entity named in the certification. A change in ownership or control includes a majority change in the shares of stock held or in the board of directors of a corporation certified under this chapter, or any other change that results in transfer of control or transfer of a majority share in the control of the operations of a clinic. A change in ownership requires appli- cation for new certification. Additional offices at which services are provided do not require separate certification but shall be identified in the application for initial certification. History: CR 06-080: cr. Register May 2009 No. 641 , eff. 6-1-09; CR 22-078: am. Register July 2023 No. 811, eff. 8-1-23. DHS 35.11 Enforcement actions. (1) UNANNOUNCED VISITS. The department may make unannounced on-site inspec- tions of any office of a clinic at any time to conduct complaint or death investigations involving the clinic, its staff members, or outpatient mental health services provided by the clinic, or to de- termine a clinic’s progress toward compliance after citation of a major deficiency. (1m) NOTICE OF DEFICIENCIES. (a) If the department deter- mines that a clinic has a deficiency, the department shall issue a notice of deficiency to the clinic. The department may place re- strictions on the activities of the clinic, or terminate or summarily suspend the clinic’s certification. (b) 1. If requested by the department, the clinic shall submit a plan of correction to the department within 30 days of the date of the notice of deficiency issued under par. (a), or other time designated by the department in the notice of deficiency. If the plan of correction submitted by the clinic is not acceptable to the department, the department may impose a plan of correction. 2. A plan of correction submitted by a clinic or imposed by the department under subd. 1. shall identify the specific steps the clinic will take to correct the deficiency; the timeline within which the corrections will be made; and the staff members who will implement the plan and monitor for future compliance. (2) TERMINATION AND SUMMARY SUSPENSION OF CERTIFICA- TION. (a) The department may terminate certification at any time for any major deficiency upon written notice to the clinic. The notice shall specify the reason for the department action and the appeal information under sub. (3). (b) 1. The department may summarily suspend a clinic’s cer- tification if the department believes immediate action is required to protect the health, safety, and welfare of consumers. Notice of summary suspension of certification may be written or verbal and shall specify the reason for the department action and the date the action becomes effective. Within 10 working days after the order is issued, the department shall either allow continuance of the clinic’s certification or proceed to terminate the clinic’s certification. 2. Unless waived by the clinic, the division of hearings and appeals shall hold a hearing within 10 working days after the ef- fective date of the order in subd. 1. to determine if certification should remain suspended during termination proceedings. The division of hearings and appeals shall give written notice of the hearing to the clinic and the department. (3) APPEALS. (a) If the department denies or terminates cer- tification, the clinic may request a contested case hearing under ch. 227, Stats. (b) A clinic’s request for hearing shall be submitted in writing to the department of administration’s division of hearings and ap- peals within 30 days after the date of the notice of the depart- ment’s action. If the clinic makes a timely request for hearing on the department’s decision to terminate or deny certification, that action is stayed pending a decision on the appeal, unless the certi- fication has been summarily suspended. Note: A request for hearing may be delivered in person or mailed to the Division of Hearings and Appeals, 5005 University Avenue, Suite 201, Madison, WI 53707- 7875. An appeal may be sent by fax to the Division’s facsimile transmission number at (608) 264-9885. History: CR 06-080: cr. Register May 2009 No. 641 , eff. 6-1-09; CR 22-078: am. (3) (b) Register July 2023 No. 811, eff. 8-1-23. Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published. Register February 2026 No. 842 Published under s. 35.93, Wis. Stats., by the Legislative Reference Bureau. 5 DEPARTMENT OF HEALTH SERVICES DHS 35.13 DHS 35.12 Waivers and variances. (1) A clinic may apply to the department for a waiver or a variance at any time. Each request shall be made in writing to the department and shall include all of the following: (a) Identification of the rule provision from which the waiver or variance is requested. (b) The time period for which the waiver or variance is requested. (c) If the request is for a variance, the specific alternative ac- tion that the outpatient clinic proposes. (d) The reasons for the request. (e) Supporting justification. (f) Any other information requested by the department. Note: An application for a waiver or variance should be addressed to the Behav- ioral Health Certification Section, Division of Quality Assurance, P.O. Box 2969, Madison, WI 53701-2969. (2) The department may grant a waiver or variance permit- ting a clinic to use new concepts, methods, procedures, tech- niques, equipment, personnel qualifications, or the conducting of pilot projects in the interest of better care or management, if the department finds that the waiver or variance will not adversely af- fect the health, safety, or welfare of any consumer. (2m) The department may grant a variance to a clinic that is unable to meet the minimum staffing requirements under s. DHS 35.123 (2). To be eligible for a variance under this subsection, the clinic shall establish that it has made and continues to make a good faith effort to recruit and retain a sufficient number of staff with the qualifications specified in s. DHS 35.123 (2). In addi- tion to any other conditions the department may impose on a variance issued under this paragraph, the department shall re- quire that the clinic submit evidence on a continuous basis of the clinic’s good faith efforts to recruit and retain qualified staff. (3) The department shall provide its determination on a re- quest for a waiver or variance to the clinic in writing. The depart- ment may impose restrictions on any waiver or variance it grants, including limiting the duration of any waiver or variance and may withdraw the waiver or variance if a clinic is not in compliance with one or more of the restrictions. The terms or restrictions of a variance may be modified upon agreement between the depart- ment and the clinic. (4) (a) Within 60 days of the receipt of a request for waiver, the department shall grant or deny the waiver in writing. If the department denies a request for a waiver or variance, or revokes a waiver or variance, the reason for the denial or revocation shall be included in the notice. (b) The department may revoke a waiver or variance if any of the following occurs: 1. The actions taken as a result of the waiver or variance have or will adversely affect the health, safety or welfare of a consumer. 2. The clinic has failed to comply with the variance as granted. 3. The clinic notifies the department that it wishes to relin- quish the waiver or variance. 4. There is a change in applicable law. 5. For any other reason the department finds the revocation is necessary to protect the health, safety, or welfare of a consumer. History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09. Subchapter III — Personnel DHS 35.123 Staffing requirements for clinics. (1) Each clinic shall have a clinic administrator who is responsible for clinic operations, including ensuring that the clinic is in com- pliance with this chapter and other applicable state and federal law. A clinic administrator may be a licensed treatment profes- sional or mental health practitioner. (2) In addition to the clinic administrator, the clinic shall have a sufficient number of qualified staff members available to pro- vide outpatient mental health services to consumers admitted to care. Except as provided in s. DHS 35.12 (2m), the clinic shall implement any one of the following minimum staffing combina- tions to provide outpatient mental health services: (a) Two or more licensed treatment professionals who com- bined are available to provide outpatient mental health services at least 60 hours per week. (b) One or more licensed treatment professionals who com- bined are available to provide outpatient mental health services at least 30 hours per week and one or more mental health practition- ers or recognized psychotherapy practitioners who combined are available to provide outpatient mental health services at least 30 hours per week. (c) One or more licensed treatment professionals who com- bined are available to provide outpatient mental health services at least 37.5 hours per week, and at least one psychiatrist or ad- vanced practice nurse prescriber who provides outpatient mental health services to consumers of the clinic at least 4 hours per month. (2m) If a clinic has more than one office, both the clinic as a whole and its main office shall comply with the requirements of sub. (2). (3) If a clinic provides services to persons 13 years old or younger, the clinic shall have staff qualified by training and expe- rience to work with children and adolescents. (4) A clinic that is certified before June 1, 2009 shall meet the requirements of subs. (1) and (3) upon June 1, 2009, but shall have until January 1, 2012 to meet the minimum staffing require- ments under sub. (2). (5) A person whose professional license is revoked, sus- pended, or voluntarily surrendered may not be employed or con- tracted with as a mental health professional, or a prescriber. A person whose professional license is limited or restricted, may not be employed or contracted with to practice in areas prohibited by the limitation or restriction. History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09; correction to numbering of (4) and (5) made under s. 13.92 (4) (b) 1., Stats., Register May 2009 No. 641. DHS 35.127 Persons who may provide psychother- apy services through an outpatient mental health clinic. (1) Any mental health professional may provide psy- chotherapy to consumers through a clinic required to be certified under this chapter. (2) A qualified treatment trainee may provide psychotherapy to consumers only under clinical supervision as defined under s. DHS 35.03 (5) (a). (3) A clinic may choose to require clinical supervision of a mental health practitioner or recognized psychotherapy practitioner. (4) A person who has a suspended, revoked, or voluntarily surrendered professional license may not provide psychotherapy to consumers. A person whose license or certificate is limited or restricted, may not provide psychotherapy under circumstances prohibited by the limitation or restriction. History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09. DHS 35.13 Personnel policies. The clinic shall have and implement written personnel policies and procedures that en- sure all of the following: Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published. Register February 2026 No. 842 Published under s. 35.93, Wis. Stats., by the Legislative Reference Bureau. DHS 35.13 WISCONSIN ADMINISTRATIVE CODE 6 (1) Each staff member who provides psychotherapy or who prescribes medications is evaluated to determine if the staff member possesses current qualifications and demonstrated com- petence, training, experience and judgment for the privileges granted to provide psychotherapy or to prescribe medications for the clinic. (2) Compliance with the caregiver background check and misconduct reporting requirements in s. 50.065, Stats., and ch. DHS 12, and the caregiver misconduct reporting and investiga- tion requirements in ch. DHS 13. Note: Forms for conducting a caregiver background check including the back- ground information disclosure form may be obtained from the department’s website at http://dhs.wisconsin.gov/caregiver/index.htm or by writing the department at Of- fice of Caregiver Quality, Division of Quality Assurance, P.O. Box 2969, Madison, WI 53701-2969. Phone: (608) 266-8481, Fax: (608) 267-0352. (3) A record is maintained for each staff member and in- cludes all of the following: (a) Confirmation of an applicant’s current training or profes- sional license or certification, if a training or professional license or certification is necessary for the staff member’s prescribed du- ties or position. All limitations and restrictions on a staff mem- ber’s license shall be documented by the clinic. (b) The results of the caregiver background check including a completed background information disclosure form for every background check conducted, and the results of any subsequent investigation related to the information obtained from the back- ground check. (c) A vita of training, work experience and qualifications for each prescriber and each person who provides psychotherapy. History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09. DHS 35.14 Clinical supervision and clinical collab- oration. (1) (a) The clinic administrator shall have responsi- bility for administrative oversight of the job performance and ac- tions of each staff member and require each staff member to ad- here to all laws and regulations governing the care and treatment of consumers and the standards of practice for their individual professions. (b) Each clinic shall implement a written policy for clinical supervision as defined under s. DHS 35.03 (5), and clinical col- laboration as defined under s. DHS 35.03 (4). Each policy shall address all of the following: 1. A system to determine the status and achievement of con- sumer outcomes, which may include a quality improvement sys- tem or a peer review system to determine if the treatment pro- vided is effective, and a system to identify any necessary correc- tive actions. 2. Identification of clinical issues, including incidents that pose a significant risk of an adverse outcome for one or more consumers of the outpatient mental health clinic that should war- rant clinical collaboration, or clinical supervision that is in addi- tion to the supervision specified under ch. MPSW 4, 12, or 16, or Psy 2, or for a recognized psychotherapy practitioner, in accor- dance with s. DHS 35.03 (5) (a), whichever is applicable. (2) Except as provided under sub. (4) (b), the clinic’s policy on clinical supervision shall be in accordance with ch. MPSW 4, 12, or 16, or Psy 2 , or for a recognized psychotherapy practi- tioner, whichever is applicable. The clinic’s policy on clinical collaboration shall require one or more of the following: (a) Individual sessions, with staff case review, to assess per- formance and provide feedback. (b) Individual side-by-side session while a staff member pro- vides assessments, service planning meetings or outpatient men- tal health services and in which other staff member assesses, and gives advice regarding staff performance. (c) Group meetings to review and assess quality of services and provide staff members advice or direction regarding specific situations or strategies. (d) Any other form of professionally recognized method of clinical collaboration designed to provide sufficient guidance to assure the delivery of effective services to consumers by the staff member. (3) Clinical supervision and clinical collaboration records shall be dated and documented with the signature of the person providing these functions in a supervision or collaboration record, or in the staff record of each staff member who attends the session or review. If clinical supervision or clinical collabora- tion results in a recommendation for a change to a consumer’s treatment plan, the recommendation shall be documented in the consumer file. (4) (a) A qualified treatment trainee who provides psy- chotherapy shall receive clinical supervision. (b) If any staff member, including a staff member who is a substance abuse counselor-in training, substance abuse coun- selor, or clinical abuse counselor, provides services to consumers who have a primary diagnosis of substance abuse, the staff mem- ber shall receive clinical supervision from a clinical supervisor as defined under s. SPS 160.02 (7). History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09; correction in (4) (b) made under s. 13.92 (4) (b) 7., Stats., Register November 2011 No. 671. DHS 35.15 Orientation and training. (1) GENERAL REQUIREMENT. The clinic administrator shall ensure each staff member receives initial and continuing training that enables the staff member to perform staff member’s duties effectively, effi- ciently, and competently. Documentation of training shall be made available to department staff upon request. (2) ORIENTATION. (a) The clinic shall maintain documenta- tion that each staff member who is a mental health professional and who is new to the clinic has completed the training require- ments specified under par. (b), either as part of orientation to the clinic or as part of prior education or training. The clinic admin- istrator shall require all other staff members to complete only the orientation training requirements specified under par. (b) that are necessary, as determined by the clinic administrator, for the staff member to successfully perform the staff member’s assigned job responsibilities. (b) The orientation training requirements under this subsec- tion are: 1. A review of the pertinent parts of this chapter and other applicable statutes and regulations. 2. A review of the clinic’s policies and procedures. 3. Cultural factors that need to be taken into consideration in providing outpatient mental health services for the clinic’s consumers. 4. The signs and symptoms of substance use disorders and reactions to psychotropic drugs most relevant to the treatment of mental illness and mental disorders served by the clinic. 5. Techniques for assessing and responding to the needs of consumers who appear to have problems related to trauma; abuse of alcohol, drug abuse or addiction; and other co-occurring ill- nesses and disabilities. 6. How to assess a consumer to detect suicidal tendencies and to manage persons at risk of attempting suicide or causing harm to self or others. 7. Recovery concepts and principles that ensure services, and supports connection to others and to the community. Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published. Register February 2026 No. 842 Published under s. 35.93, Wis. Stats., by the Legislative Reference Bureau. 7 DEPARTMENT OF HEALTH SERVICES DHS 35.18 7m. Appropriate delivery of telehealth services, including is- sues ensuring privacy and confidentiality of recipient informa- tion and communications. 8. Any other subject that the clinic determines is necessary to enable the staff member to perform the staff member’s duties ef- fectively, efficiently, and competently. (3) MAINTAINING ORIENTATION AND TRAINING POLICIES. A clinic shall maintain in its central administrative records the most current copy of its orientation and training policies. History: CR 06-080: cr. Register May 2009 No. 641 , eff. 6-1-09; CR 23-053: am. (2) (b) 7m. Register September 2023 No. 813, eff. 10-1-23. Subchapter IV — Outpatient Mental Health Services DHS 35.16 Admission. (1) The clinic shall establish written selection criteria for use when screening a consumer for possible admission. The criteria may include any of the follow- ing limitations as applicable: (a) Sources from which referrals may be accepted by the clinic. (b) Restrictions on acceptable sources of payment for ser- vices, or the ability of a consumer or a consumer’s family to pay. (c) The age range of consumers whom the clinic will serve based on the expertise of the clinic staff members. (d) Diagnostic or behavioral requirements that the clinic will apply in deciding whether or not to admit a consumer for treatment. (e) Any consumer characteristics for which the clinic has been specifically designed, including the nature or severity of disor- ders that can be managed on an outpatient basis by the clinic, and the expected length of time that services may be necessary. (2) A clinic shall refer any consumer not meeting the clinic’s selection criteria for admission to appropriate services. (3) If a clinic establishes priorities for consumers to be served, a waiting list for consumers to be admitted, or a waiting list for consumers who have been admitted but resources to pro- vide services to these consumers are not yet available, the priori- ties or the procedures for the operation of the waiting list shall be maintained in writing and applied fairly and uniformly. (4) Only a licensed treatment professional, or a recognized psychotherapy practitioner, may diagnose a mental illness of a consumer on behalf of a clinic. The licensed treatment profes- sional, or recognized psychotherapy practitioner shall document, in the consumer file, the recommendation for psychotherapy specifying the diagnosis; the date of the recommendation for psy- chotherapy; the length of time of the recommendation; the ser- vices that are expected to be needed; and the name and signature of the person issuing the recommendation for psychotherapy. (5) If a clinic provides substance use services to a consumer, the clinic shall use a department approved placement criteria tool to determine if a consumer who has a co-occurring substance use disorder requires substance abuse treatment services. If the con- sumer is determined to need a level of substance use services that are above the level of substance use services that can be provided by the clinic, the consumer shall be referred to an appropriate de- partment certified provider. History: CR 06-080: cr. Register May 2009 No. 641 , eff. 6-1-09; CR 14-066: renum. (4) (a) to (4), r. (4) (b) Register August 2015 No. 716, eff. 9-1-15. DHS 35.165 Emergency services. (1) The clinic shall have and implement a written policy on how the clinic will pro- vide or arrange for the provision of services to address a con- sumer’s mental health emergency or crisis during hours when its offices are closed, or when staff members are not available to provide outpatient mental health services. Note: The phrase “available to provide outpatient mental health services” is de- fined under s. DHS 35.03 (2). (2) The clinic shall include, in its written policies, the proce- dures for identifying risk of attempted suicide or risk of harm to self or others. History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09. DHS 35.17 Assessment. (1) (a) A mental health pro- fessional, shall complete an initial assessment of a consumer be- fore a second meeting with a staff member. The information col- lected during the initial assessment shall be sufficient to identify the consumer’s need for outpatient mental health services. (b) A comprehensive assessment shall be valid, accurately re- flect the consumer’s current needs, strengths and functioning, be completed before beginning treatment under the treatment plan established under s. DHS 35.19 (1) , and include all of the following: 1. The consumer’s presenting problems. 2. A diagnosis, which shall be established from the current Diagnostic and Statistical Manual of Mental Disorders, or for children up to age 4, the current Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood. Note: The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. Washington, DC, American Psychiatric Association, 2013. The Diag- nostic and Statistical Manual of Mental Disorders may be ordered through http://www.appi.org/Pages/DSM.aspx or other sources. Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood is published by the National Center for Clinical Infant Programs: Diagnostic Classifi- cation of Mental Health and Developmental Disorders of Infancy and Early Child- hood. Arlington, V A, National Center for Clinical Infant Programs, 1994. The Di- agnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood may be ordered https://secure2.convio.net/zttcfn/site/Ecom- merce?VIEW_PRODUCT=true&product_id=1681&store_id=1121 or other sources. 3. The recipient’s symptoms which support the given diagnosis. 4. Information on the consumer’s strengths, and current and past psychological, social, and physiological data; information re- lated to school or vocational, medical, and cognitive functioning; past and present trauma; and substance abuse. 5. The consumer’s unique perspective and own words about how the consumer views his or her recovery, experience, chal- lenges, strengths, needs, recovery goals, priorities, preferences, values and lifestyle, areas of functional impairment, and family and community support. Note: Nothing in this chapter is intended to interfere with the right of providers under s. 51.61 (6), Stats., to use customary and usual treatment techniques and pro- cedures in a reasonable and appropriate manner in the treatment of patients who are receiving services under the mental health system, for the purpose of ameliorating the conditions for which the patients were admitted to the system. (2) If a consumer is determined to have one or more co-occur- ring disorders, a licensed treatment professional, mental health practitioner, or a recognized psychotherapy practitioner, shall document the treatments and services concurrently received by the consumer through other providers; whether the clinic can serve the consumer’s needs using qualified staff members or in collaboration with other providers; and any recommendations for additional services, if needed. If a clinic cannot serve a con- sumer’s needs, independently, or in collaboration with other providers, the clinic shall refer the consumer, with the consumer’s consent, to an appropriate provider. History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09. DHS 35.18 Consent for outpatient mental health services. (1) If a clinic determines that a consumer is appro- priate for receiving outpatient mental health services through the clinic, the clinic shall inform the consumer or the consumer’s le- gal representative of the results of the assessment. In addition, Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published. Register February 2026 No. 842 Published under s. 35.93, Wis. Stats., by the Legislative Reference Bureau. DHS 35.18 WISCONSIN ADMINISTRATIVE CODE 8 the clinic shall inform the consumer or the consumer’s legal rep- resentative, orally and in writing, of all of the following: (b) Treatment alternatives. (c) Possible outcomes and side effects of treatment recom- mended in the treatment plan. (d) Treatment recommendations and benefits of the treatment recommendations. (e) Approximate duration and desired outcome of treatment recommended in the treatment plan. (f) The rights of a consumer receiving outpatient mental health services, including the consumer’s rights and responsibili- ties in the development and implementation of an individual treatment plan. (g) The outpatient mental health services that will be offered under the treatment plan. (h) The fees that the consumer or responsible party will be ex- pected to pay for the proposed services. Note: Consumers receiving Medicaid covered services may not be charged any amount in connection with services other than the applicable cost share, if any, spec- ified by the Wisconsin Medicaid Program. (i) How to use the clinic’s grievance procedure under ch. DHS 94. (j) The means by which a consumer may obtain emergency mental health services during periods outside the normal operat- ing hours of the clinic. (k) The clinic’s discharge policy, including circumstances un- der which a patient may be involuntarily discharged for inability to pay or for behavior reasonably the result of mental health symptoms. (2) If a consumer wishes to receive services through the clinic, the consumer or the consumer’s legal representative, where the consent of the legal representative is required for treat- ment, shall sign a clinic form to indicate the consumer’s informed consent to receive outpatient mental health services. (3) If a consumer is prescribed medication as part of the con- sumer’s treatment plan developed under s. DHS 35.19 (1) , the clinic shall obtain a separate consent that indicates that the pre- scriber has explained to the consumer, or the consumer’s legal representative, if the legal representative’s consent is required, the nature, risks and benefits of the medication and that the con- sumer, or legal representative, understands the explanation and consents to the use of the medication. (4) The consent to outpatient mental health services shall be renewed in accordance with s. DHS 94.03 (1) (f). Note: The consent of the patient or legal representative is not required where treatment is ordered pursuant to a court order for involuntary commitment order. History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09. DHS 35.19 Treatment plan. (1) DEVELOPMENT OF THE TREATMENT PLAN. (a) A licensed treatment professional, mental health practitioner, or recognized psychotherapy practitioner, shall develop an initial treatment plan upon completion of the comprehensive assessment required under s. DHS 35.17 (1) (b) . The treatment plan shall be based upon the diagnosis and symp- toms of the consumer and describe all of the following: 1. The consumer’s strengths and how they will be used to de- velop the methods and expected measurable outcomes that will be accomplished. 2. The method to reduce or eliminate the symptoms causing the consumer’s problems or inability to function in day to day liv- ing, and to increase the consumer’s ability to function as indepen- dently as possible. 3. For a child or adolescent, a consideration of the child’s or adolescent’s development needs as well as the demands of the illness. 4. The schedules, frequency, and nature of services recom- mended to support the achievement of the consumer’s recovery goals, irrespective of the availability of services and funding. Note: Nothing in this chapter is intended to interfere with the right of providers under s. 51.61 (6), Stats., to use customary and usual treatment techniques and pro- cedures in a reasonable and appropriate manner in the treatment of patients who are receiving services under the mental health system, for the purpose of ameliorating the conditions for which the patients were admitted to the system. (b) The treatment plan shall reflect the current needs and goals of the consumer as indicated by progress notes and by re- viewing and updating the assessment as necessary. (2) APPROVAL OF THE TREATMENT PLAN. As treatment ser- vices are rendered, the consumer or the consumer’s legal repre- sentative must approve and sign the treatment plan and agree with staff on a course of treatment. If the consumer does not approve of the schedules, frequency, and nature of the services recom- mended, then appropriate notations regarding the consumer’s re- fusal shall be made in the consumer file. The treatment plan un- der this subsection shall include a written statement immediately preceding the consumer’s or legal representative’s signature that the consumer or legal representative had an opportunity to be in- formed of the services in the treatment plan, and to participate in the planning of treatment or care, as required by s. 51.61 (1) (fm), Stats. (3) CLINICAL REVIEW OF THE TREATMENT PLAN. (a) Staff shall establish a process for a clinical review of the consumer’s treatment plan and progress toward measurable outcomes. The review shall include the participation of the consumer and be an ongoing process. The results of each clinical review shall be clearly documented in the consumer file. Documentation shall address all of the following: 1. The degree to which the goals of treatment have been met. 2. Any significant changes suggested or required in the treat- ment plan. 3. Whether any additional assessment or evaluation is rec- ommended as a result of information received or observations made during the course of treatment. 4. The consumer’s assessment of functional improvement to- ward meeting treatment goals and suggestions for modification. (b) A mental health professional shall conduct a clinical re- view of the treatment plan with the consumer as described in par. (a) at least every 90 days or 6 treatment sessions, whichever cov- ers a longer period of time. (4) The clinic shall develop and implement written policies and procedures for referring consumers to other community ser- vice providers for services that the clinic does not or is unable to provide to meet the consumer’s needs as identified in the compre- hensive assessment required under s. DHS 35.17 (1) (b) . The policies shall identify community services providers to which the clinic reasonably determines it will be able to refer consumers for services the clinic does not or cannot provide. History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09. DHS 35.20 Medication management. (1) A clinic may choose whether to provide medication management as part of its services. (2) Consumers receiving only medication management from a clinic shall be referred by the clinic’s prescriber for psychother- apy when appropriate to the consumer’s needs and recovery. Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published. Register February 2026 No. 842 Published under s. 35.93, Wis. Stats., by the Legislative Reference Bureau. 9 DEPARTMENT OF HEALTH SERVICES DHS 35.23 (3) All medications prescribed by the clinic shall be docu- mented in the consumer file as required under s. DHS 35.23 (1) (a) 10. History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09. DHS 35.21 Treatment approaches and services. (1) The clinic shall have and implement a written policy that identifies the selection of treatment approaches and the role of clinical supervision and clinical collaboration in treatment ap- proaches. The treatment approaches shall be based on guidelines published by a professional organization or peer-reviewed jour- nal. The final decision on the selection of treatment approaches for a specific consumer shall be made by the consumer’s therapist in accordance with the clinic’s written policy. (2) The clinic shall make reasonable efforts to ensure that each consumer receives the recommended interventions and ser- vices identified in the consumer’s treatment plan or revision of the treatment plan that is created under s. DHS 35.19 (1), that the consumer is willing to receive as communicated by an informed consent for treatment. History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09. DHS 35.215 Group therapy. The maximum number of consumers receiving services in a single group therapy session is 16, and the minimum staff to consumer ratio in group therapy is one to 8. If different limits are justified based on guidelines pub- lished by a governmental entity, professional organization or peer-reviewed journal indicate, the clinic may request a variance of either the limit of group size or the minimum staff to consumer ratio. History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09. DHS 35.22 Discharge summary. (1) Within 30 days after a consumer’s date of discharge, the licensed treatment pro- fessional, mental health practitioner, or recognized psychother- apy practitioner who was primarily responsible for providing out- patient mental health services for the consumer shall prepare a discharge summary and enter it into the consumer file. The dis- charge summary shall include all of the following: (a) A description of the reasons for discharge. (b) A summary of the outpatient mental health services pro- vided by the clinic, including any medications. (c) A final evaluation of the consumer’s progress toward the goals of the treatment plan. (d) Any remaining consumer needs at the time of discharge and the recommendations for meeting those needs, which may in- clude the names and addresses of any facilities, persons or pro- grams to which the consumer was referred for additional services following discharge. (2) The discharge summary shall be signed and dated by the licensed treatment professional, mental health practitioner, or recognized psychotherapy practitioner who was primarily re- sponsible for providing services to the consumer. History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09. DHS 35.23 Consumer file. (1) RECORDS REQUIRED. (a) The clinic shall maintain a consumer file for each consumer who receives outpatient mental health services. Each consumer file shall be arranged in a format that provides for consistent recordkeeping that facilitates accurate and efficient retrieval of record information. All entries in the consumer file shall be fac- tual, accurate, legible, permanently recorded, dated, and authenti- cated with the signature and license or title of the person making the entry. Treatment records contained in a consumer file are confidential to the extent required under s. 51.30, Stats. An elec- tronic representation of a person’s signature may be used only by the person who makes the entry. The clinic shall possess a state- ment signed by the person, which certifies that only that person shall use the electronic representation via use of a personal pass- word. Each consumer file shall include accurate documentation of all outpatient mental health services received including all of the following: 1. Results of each assessment conducted. 2. Initial and updated treatment plans. 3. The recommendation or prescription for psychotherapy. 4. For consumers who are diagnosed with substance abuse disorder, a completed copy of the most current approved place- ment criteria summary if required by s. DHS 35.16 (5). 5. Documentation of referrals of the consumer to outside resources. 6. Descriptions of significant events that are related to the consumer’s treatment plan and contribute to an overall under- standing of the consumer’s ongoing level and quality of functioning. 7. Progress notes, which shall include documentation of ther- apeutic progress, functional status, treatment plan progress, symptom status, change in diagnosis, and general management of treatment. 8. Any recommended changes or improvement of the treat- ment plan resulting from clinical collaboration or clinical supervision. 9. Signed consent forms for disclosure of information and for medication administration and treatment, and court orders, if any. 10. A listing of medications prescribed by staff prescribers, and a medication administration record if staff dispenses or ad- ministers medications to the consumer. 11. Discharge summary and any related information. 12. Notice of involuntary discharge, if applicable. 13. Any other information that is appropriate for the con- sumer file. (b) Clinics may keep composite consumer files of a family in treatment as a unit. When information is released, provisions shall be made for individual confidentiality pursuant to s. 51.30, Stats., and ch. DHS 92. (2) CONFIDENTIALITY. Treatment records shall be kept confi- dential as required under s. 51.30, Stats., ch. DHS 92 , and 45 CFR Parts 160, 162 and 164, and 42 CFR Part 2 in a designated place in each clinic office at which records are stored that is not accessible to consumers or the public but is accessible to appro- priate staff members at all times. Note: If notes or records, recorded in any medium, maintained for personal use by an individual providing treatment services are available to others, the notes or records become part of the treatment records. See s. 51.30 (1) (b) , Stats., and ss. DHS 92.02 (16) and 92.03 (1) (b). (3) TRANSFERRING TREATMENT RECORDS. Upon written re- quest of a consumer or former consumer or, if required, that per- son’s legal representative, the clinic shall transfer to another li- censed treatment professional, clinic or mental health program or facility the treatment records and all other information in the con- sumer file necessary for the other licensed treatment profes- sional, clinic or mental health program or facility to provide fur- ther treatment to the consumer or former consumer. (4) RETENTION AND DISPOSAL. (a) The clinic shall imple- ment a written policy governing the retention of treatment records that is in accordance with s. DHS 92.12 and any other ap- plicable laws. (b) Upon termination of a staff member’s association with the clinic, the treatment records for which the staff member was re- sponsible shall remain in the custody of the clinic. Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published. Register February 2026 No. 842 Published under s. 35.93, Wis. Stats., by the Legislative Reference Bureau. DHS 35.23 WISCONSIN ADMINISTRATIVE CODE 10 (5) ELECTRONIC RECORD-KEEPING SYSTEMS. (a) Clinics may maintain treatment records electronically if the clinic has a writ- ten policy describing the record and the authentication and secu- rity policy. (b) Electronic transmission of information from treatment records to information systems outside the outpatient mental health clinic may not occur without voluntary written consent of the consumer unless the release of confidential treatment infor- mation is permitted under s. 51.30, Stats., or other applicable law. Note: Transmission of information must comply with 45 CFR parts 160 , 162, and 164, s. 51.30, Stats., and ch. DHS 92. (c) If treatment records are kept electronically, the confiden- tiality of the treatment records shall be maintained as required under subs. (2) to (4). A clinic shall maintain a paper or elec- tronic back-up system for any treatment records maintained electronically. Note: If notes or records, recorded in any medium, maintained for personal use by an individual providing treatment services are available to others, the notes or records become part of the treatment records. See s. 51.30 (1) (b) , Stats., and ss. DHS 92.02 (16) and 92.03 (1) (b). History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09. DHS 35.24 Consumer rights. (1) A clinic shall imple- ment written polices and procedures that are consistent with s. 51.61, Stats., and ch. DHS 94 to protect the rights of consumers. (2) If a staff member no longer is employed by or contracts with the outpatient mental health clinic, the clinic shall offer con- sumers who had been served by that staff member options for on- going services. (3) (a) A consumer may be involuntarily discharged from treatment because of the consumer’s inability to pay for services or for behavior that is reasonably a result of mental health symp- toms only as provided in par. (b). (b) Before a clinic may involuntarily discharge a consumer under par. (a), the clinic shall notify the consumer in writing of the reasons for the discharge, the effective date of the discharge, sources for further treatment, and of the consumer’s right to have the discharge reviewed, prior to the effective date of the dis- charge, by the subunit of the department that certifies clinics un- der this chapter, with the address of that subunit. A review under this paragraph is in addition to and is not a precondition for any other grievance or legal action the consumer may bring in con- nection with the discharge, including a grievance or action under s. 51.61, Stats. In deciding whether to uphold or overturn a dis- charge in a review under this paragraph, the department may consider: 1. Whether the discharge violates the consumer’s rights un- der s. 51.61, Stats. 2. In cases of discharge for behavior that is reasonably a re- sult of mental health symptoms, whether the consumer’s needs can be met by the clinic, whether the safety of staff or other con- sumers of the clinic may be endangered by the consumer’s behav- ior, and whether another provider has accepted a referral to serve the consumer. Note: The address of the subunit of the department that certifies clinics under this chapter is Behavioral Health Certification Section, Division of Quality Assur- ance, PO Box 2969, Madison, WI 53701-2969. History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09. DHS 35.25 Death reporting. The clinic shall report the death of a consumer to the department if required under s. 51.64 (2), Stats. History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09. Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published. Register February 2026 No. 842