Department of Mental Health Forms and Office Locations – Government Agency in Los Angeles County, CA

1 - 20 of 58 forms

Form Title	Topics
15-03: Revised Service Request Log (SRL)
15-04: New Email Address on Treatment Update to DCFS
15-05: Updated Diagnosis Related Forms for ICD-10-CM
15-06: Provider Communication & Urge to Drink/Use Scales
15-07: Crisis Evaluation Progress Note, Suicide Risk Assessment, Outpatient Medication Review
16-01: SRL, COS, Community Functioning Evaluation
16-02: C-SSRS Screener, SRL, Outcomes Measures Application Forms
16-03: Outpatient Medication Review
16-04: Immediate/Same Day Assessment, Authorization for Request or Use/Disclosure of PHI
17-01: DTI Daily Note, DTI Weekly Clinical Summary, and DTI Day Rehab Weekly Progress Note
17-02: Service Request Log
17-03: Juvenile Justice Medication Consent and Provider Communication (Forensic Consultation)
17-04: Adult and Child Full Assessment Form
17-05: Notice of Action A and E
18-01: HIPAA forms, HIE, Med Consent/MSS Treatment Plan
18-02: Mental Health Triage and Contact Information
19-01: Katie A Form and Consent of Secure Text Messaging
19-02: Service Request Log (SRL)
19-03: CANS-IP, PSC-35, Consent for TMS, TMS Referral
19-04: Assessment Form Modifications

All 2 contact points

Address:
510 S. Vermont Ave
18th Floor
Los Angeles, CA 90020

Phone numbers:

Emails:

Address:
550 South Vermont Ave.
Los Angeles, CA 90020

Phone numbers:

Fax numbers:

Emails: