Form Mh 678 - Adult Short Assessment - Los Angeles County

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MH 678
ADULT SHORT ASSESSMENT
Page 1 of 3
Revised 6/20/11
Interviewed:
Client and/or
Other (name and relationship): __________________________________________
Special Service Needs:
Non-English Speaking, specify language needs: ________________________
Were Interpretive Services provided for this interview?
Yes
No
Cultural Considerations, specify: ________________________________________________________________
Physically challenged (wheelchair, hearing, visual, etc.) specify: ____________________________________________
Access issues (transportation, hours), specify: __________________________________________________________
I. Reason for Referral/Chief Complaint
See Information on ___________________________________ dated: _____________
Reason for Referral
Current Symptoms/Behaviors
Impairments in Life Functioning (daily living activities, social, employment/education, housing, financial, etc)
II. Psychiatric History
See Information on ___________________________________ dated: _____________
Outpatient and Inpatient, include dates, providers, interventions, and responses
See information on IS Screen Prints
III. Current Risk and Safety Concern
See Information on ___________________________________ dated: _____________
Current Thoughts of Self-Harm/Suicide
Yes
No
Current Thoughts of Harming Another Person
Yes
No
Past Thoughts of Self-Harm/Suicide
Yes
No
Past Thoughts of Harming Another Person
Yes
No
Prior Suicide Attempts/If yes, #____
Yes
No
History of Homicide/Manslaughter
Yes
No
Probation/Parole Involvement
Yes
No
History of Injuring Another Person
Yes
No
Current/History of Injuring Animals
Yes
No
School Issues or IEP in place
Yes
No
Recent Trauma Exposure
Yes
No
Current Substance Use/Abuse
Yes
No
Recent Job Loss
Yes
No
Past Substance Use/Abuse
Yes
No
Victim of Violence/Abuse
Yes
No
Perpetrator of Violence/Abuse
Yes
No
DCFS Involvement
Yes
No
Homeless
Yes
No
Access to Guns/Weapons
Yes
No
Other (specify):
For any risk/safety concerns marked yes, please explain. Identify if any safety measures are needed, required or taken.
IV. Relevant Medical Conditions
See Information on ___________________________________ dated: _____________
Hearing Impairment
Yes
No
Visual Impairment
Yes
No
Motor Impairment
Yes
No
Other Sensory Impairment
Yes
No If yes, specify:
Allergies
Yes
No If yes, specify:
Other Medical Conditions
Yes
No If yes, specify:
Last Physical Exam Date: ____________________
Other Comments Regarding Medical Conditions:
This confidential information is provided to you in accord with State and Federal laws
Name:
IS#:
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
Agency:
Provider #:
representative to whom it pertains unless otherwise permitted by law. Destruction of
Los Angeles County – Department of Mental Health
this information is required after the stated purpose of the original request is fulfilled.
ADULT SHORT ASSESSMENT

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