Form Mh 678 - Adult Short Assessment - Los Angeles County Page 2
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3MH 678
ADULT SHORT ASSESSMENT
Page 2 of 3
Revised 6/20/11
V. Medications
Client is currently on medications:
Yes
No
If yes, How many days of medication does the client have left? ______________
If yes, specify medications (include name and if there are any side-effects/adverse reactions).
VI. Substance Use/Abuse
“MH659 -Co-Occurring Joint Action Council Screening Instrument”
1. Were any of the questions checked “Yes” in Section 2 “Alcohol & Drug Use”?
Yes*
No If yes, complete A and B below
No If yes, answer 2a
2. Were any of the questions checked “Yes” in Section 3 “Trauma/Domestic Violence”?
Yes
2a. Was the Trauma or Domestic Violence related to substance use?
Yes*
No If yes, complete A and B below
A. Alcohol Screening Questions
1 Drink = 12 Ounces of Beer
1. How often do you have a drink containing alcohol?
Never
Monthly or
2-4 times
3 times a
4+ times a
less
a month
week
week
If “Never”, proceed to Drug Screening Questions.
1 or 2
3 or 4
5 or 6
7 to 9
10+
1a. How many drinks containing alcohol do you have on a
typical day when you are drinking?
1b. How often do you have six or more drinks on one
Never
Less than
Monthly
Weekly
Daily or
monthly
almost daily
occasion?
B. Drug Screening Questions
1. Have you used any drug in the past 30 days that was NOT prescribed by a doctor?
Yes
No
Recently Used?
2. Drug Type(s) Used
Ever Used?
Route of Administration or other comments
(Past 6 Months)
(Indicate with an “*” which substances are most
(IV use, smoking, snorting, etc.)
No
preferred.)
Yes
No
Yes
Amphetamines
(Meth, crank, ice, etc.)
Cocaine or crack
Hallucinogens
Inhalants
Marijuana
Nicotine
(Cigarettes, cigars, smokeless tobacco)
Opiates
(Heroin, codeine, etc.)
Over the Counter Meds
(Cough syrup, diet aids, etc.)
Sedatives
(Pain meds, etc.)
Other (specify):
C. Additional Comments (i.e. frequency, duration of use, etc.):
VII. Psychosocial
See Information on ___________________________________ dated: _____________
Family & Relationships, Dependent Care Issues (Number of Dependents, Ages, Needs & Special Needs), Current Living Arrangement, Social
Support Systems, Education, Employment History/Readiness/Means of Financial Support, Legal History and Current Legal Status which may
impact linkage/referral.
VIII. Additional Client Contacts/Relationships: Refer to the “MH 525: Contact Information” form.
DCFS
Probation
DPSS
Health
Outside Meds
Regional Center
Substance Abuse/12 Step
Consumer Run/NAMI
Education/AB 3632
Other ________________________________________________
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
this information is required after the stated purpose of the original request is fulfilled.
Los Angeles County – Department of Mental Health
ADULT SHORT ASSESSMENT
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