Mh 709 Form - Service Request Log
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1SERVICE REQUEST
MH 709
LOG
Revised 4/19/16
Provider Number
___________
(5 digit program code):
I. Request Information
Recording Staff: _________________________________
Date of Request: ___________
Time of Request: _______________
Request Type:
Call
Walk-In
Other
SRTS
Reason for Request:
SRTS Reference Number: _________________
II. Requester/Referring Party
Last Name: __________________________
First Name: ______________________
Contact Number: ______________________
Self
Collateral/Family Member
ACCESS
Other
Referring Party
DCFS
Health Provider
Inpatient Facility
School
Role:
Probation/Law Enforcement
APS
Mental Health Provider
DPSS
Referring Facility/Site/School: ___________________________________________
Type of Role: ________________________
Is the client/potential client aware of the referral?
Yes
No
III. Client/Potential Client Information
Existing Client:
Client ID: ________________
Yes
No
Potential Client Last Name: _______________________
Potential Client First Name: _______________________
Potential Client Contact Number: ___________________
Potential Client DOB: ______
Insurance Status:
Indigent
Medi-Cal
Medicare
Medi-Medi
Private Insurance
Unknown
Preferred Language: _________________________
If Minor’s Legal Guardian is not the referring party: Legal Guardian Name: _____________________________________
Contact Number: ______________________
Preferred Language: ____________________
Release From:
If release from inpatient facility, name of facility: _________________
Inpatient
Juvenile Hall
Jail
N/A
Currently Receiving Mental Health Services:
If yes, where/from whom? ___________________________
Yes
No
Undetermined
Emergent Medication Needs?
If undetermined, reason? _____________________________
Yes
No
Undetermined
If emergent, was the medication appointment scheduled for the same day as the assessment appointment entered below:
Yes
No
If no, justification: ________________________________________________________________________________________________
Crisis Referral (this site, 911, FRO)
Assessment Appointment Given This Site
Referred to System Navigation
Referred back to Private Insurance
Referred to Another Mental Health Agency
Referred to Other Type Agency
Disposition
Other
Individual/Collateral Declined Services
Unable to Contact Individual/Collateral
Already Receiving Appropriate MH Services
If appointment given:
Appointment Practitioner: ________________________
Appointment Program: ___________
Appointment Date: ____________ Appointment Time: _________
Was an earlier appointment offered:
If yes, date of first offered appointment: ___________
Yes
No
Disposition Details:
Comments, Cultural Considerations and/or Special Needs:
IV. ACCESS STAFF ONLY
Urgent/Routine:
Urgent
Routine
ACCESS Appointment Line:
Source:
Yes
No
Managed Care Referral
DHS eConsult
Referring
LA Care
Health Net
Beacon Behavioral Health
MHN Behavioral Health
Kaiser
Health
st
Anthem
Care 1
Molina
Other
Indigent
Plan:
________________________________ _____________ ________________________________ _____________
Staff Signature*
Date
Co-Signature*
Date
This confidential information is provided to you in accord with State and Federal laws and regulations including but not limited to applicable Welfare and Institutions code, Civil Code and
HIPAA Privacy Standards. Duplication of this information for further disclosure is prohibited without prior written authorization of the client/authorized representative to whom it
pertains unless otherwise permitted by law. Destruction of this information is required after the stated purpose of the original request is fulfilled.
SERVICE REQUEST LOG (SRL)
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