Behavioral Health Screening Form To Obtain Behavioral Health Assessment Template Page 2
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4Instructions for the Behavioral Health Screening Form to Obtain Behavioral Health Assessment
If this is an emergency situation, please call 911
Abbreviations: H&P: History and Physical Exam
SBI: Screening and Brief Intervention
MH/SUD: Mental Health and Substance Use Disorder
Explanations:
‘Current Eligibility’: Other insurance, i.e., Medicare, private, etc. Note: If patient is a Cal MediConnect member, please
enter: “CMC/(Name of Health Plan)” and the CMC ID #.
‘Caregiver/Guardian’: Parents (for minor), conservator, etc.
‘Required consent completed’: The release of Protected Health Information may require a signed authorization from the client
or his/her representative. Individuals completing this form are advised to refer to their agency policy when making this
determination.
‘Desired/Existing behavioral health clinician/provider/program’: Complete this section if member/client or referral source
prefers a specific program, clinician, or provider that would meet member’s individual needs. If member/client is currently
receiving services from a mental health program, clinician, or provider, please indicate name and contact information.
‘Excessive ER visits or 911 calls’: Check this box if the number of visits or calls exceeds what is reasonably expected as a
result of the patient’s general physical and behavioral health conditions.
Referring provider:
If the Member/Client has an existing behavioral health clinician/provider or an open/active case in a program, please refer
him/her directly to that treating source and send the written consent (or documentation of a verbal consent via phone), when
required, with the screening form to the treating source.
For referrals to County Department of Mental Health Urgent Line, please send the written consent (or documentation of verbal
consent via phone), when required, with the screening form to the ACCESS Urgent Appointment Line via secure email at
screener@dmh.lacounty.gov, fax to (562) 863-3971, or via eConsult and then call the DMH line at (855) 425-8141.
For referrals to County Department of Mental Health ACCESS Center, please call or direct the client to call, the ACCESS
Center at (800) 854-7771. The client may also directly call or walk into a specialty mental health clinic to request services. To
find the nearest specialty mental health clinic, please use the Service Locator at
For referrals to the health plan’s behavioral health network, please send the written consent (or documentation of verbal
consent via phone), when required, with the screening form to the appropriate fax number or e-mail address and then call the
phone number listed (see chart on Page 4 for contact information). Note: For L.A. Care providers with access to the eConsult
platform, you are able to send the screening form via this platform.
For referrals to County Substance Abuse Prevention & Control (SAPC), please send the written consent (or documentation of
verbal consent via phone), when required, with the screening form to the provider referral fax at (626) 458-7637 and then call
the SAPC line at (888) 742-7900.
Receiving clinician:
The “For Receiving Clinician Use ONLY” section must be completed and faxed to the number and person indicated at the top
of the screening form as soon as the disposition of the initial appointment is known.
The “Disposition of Initial Appointment” information must also be entered into the DMH Service Request Tracking System
(SRTS) record.
Rev. 08/24/15
Page 2 of 4
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