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Sacramento County — Department of Health Services

Mental Health & Substance Use Service Request

Request Date:  |  Printed:
Submitter Information
Submitting Entity Description
Submitting Entity Name
Other Submitting Entity
Requested Action
Contact Name
Contact Phone
Fax
Email Address
Client Information
First Name
Last Name
Birth Name (If different)
Date of Birth
SSN
Gender
Maiden Name
Mother's Maiden Name
Home Phone
Cell Phone
Street Address 1
Street Address 2
City
State
Zip Code
Primary Language
Race
Ethnic Origin
Place of Birth
Country of Origin
Veteran Status
Housing Status
Caregiver Information
Parent / Caregiver / Conservator Name
Relationship to Client
Caregiver Primary Language
Mental Health Presenting Problems / Risk Factors

Associated Populations

  • CPS
  • Homeless
  • Older Adult
  • Other County Medi-Cal
  • Parole
  • Probation
  • Regional Center

CPS Involvement

  • Child a Dependent of Juveline Court
  • Child Detained
  • Child in Parent's Custody
  • Educational Rights Limited
  • No CPS Involvement
  • Parents Maintain Educational Rights
  • Unknown

Presenting Problems

  • Anti-Social Behavior
  • Anxiety
  • Appetite Problems
  • Chronic Pain
  • Cries Excessively
  • Cruelty to Animals
  • Current Suicidal Ideation
  • Defiant/Oppositional
  • Delusions
  • Depressed Mood
  • Development Issues
  • Disorganized Thoughts
  • Does not Bond
  • Enuresis/Encopresis
  • Euphoric
  • Fire Setting
  • Frequent Nightmares
  • Grandiosity
  • Hallucinations
  • Hyperactivity
  • Inappropriate Guilt
  • Inappropriate Sexual Behavior
  • Irritability
  • Obsessive-Compulsive
  • Paranoia
  • Poor Concentration
  • Self-Injurious
  • Sleep Difficulties
  • Tantrums
  • Victimizes Others
  • Withdrawn

Risk Factors

  • Current Homicidal Ideation
  • Current Suicidal Ideation
  • Domestic Abuse
  • Homelessness
  • Recent or Imminent Discharge from a Psychiatric Hospital
  • Sexual Assault

Comments Regarding Presenting Problems / Risk Factors

Current Medications & Prescriber
Psychiatric History / Treatment History
Additional Information
Services Requested
Substance Use and Drug History and Recent Events

Substance Use

  • Admitted drug use
  • Drug arrests
  • Drugs found in home
  • DUI
  • Failure to drug test
  • Infant positive at birth
  • Mother positive at birth
  • Paraphernalia in home
  • Prenatal exposure
  • Prior CPS case with drugs
  • Prior pos-tox births
  • Prior SUD Tx history

Drug(s) of Choice Related to Qualifying Events

  • Alcohol
  • Benzodiazepine
  • Cocaine/Crack
  • Ecstasy/Club Drugs
  • Hallucinogens
  • Heroin
  • Marijuana
  • Methamphetamine
  • Misuse of prescriptions
  • Other

Criminal Justice History

  • 290 Registrant
  • 452 Arson registrant
  • Drug possession
  • Hold from another county
  • Intent to sell
  • Intoxicated in public
  • Pending drug charges
Summary / Reason for Referral
Date of Last Use
Date of Failure to Test

Current Drug Use

Yes No

Current AOD/SUD

Yes No
Additional Information