Los Angeles County Government Forms

Form Title	Agency	Topics
1004482_DeclarationForm7rev2016.pdf	Medical Examiner-Coroner
15-03: Revised Service Request Log (SRL)	Department of Mental Health
15-04: New Email Address on Treatment Update to DCFS	Department of Mental Health
15-05: Updated Diagnosis Related Forms for ICD-10-CM	Department of Mental Health
15-06: Provider Communication & Urge to Drink/Use Scales	Department of Mental Health
15-07: Crisis Evaluation Progress Note, Suicide Risk Assessment, Outpatient Medication Review	Department of Mental Health
16-01: SRL, COS, Community Functioning Evaluation	Department of Mental Health
16-02: C-SSRS Screener, SRL, Outcomes Measures Application Forms	Department of Mental Health
16-03: Outpatient Medication Review	Department of Mental Health
16-04: Immediate/Same Day Assessment, Authorization for Request or Use/Disclosure of PHI	Department of Mental Health
17-01: DTI Daily Note, DTI Weekly Clinical Summary, and DTI Day Rehab Weekly Progress Note	Department of Mental Health
17-02: Service Request Log	Department of Mental Health
17-03: Juvenile Justice Medication Consent and Provider Communication (Forensic Consultation)	Department of Mental Health
17-04: Adult and Child Full Assessment Form	Department of Mental Health
17-05: Notice of Action A and E	Department of Mental Health
18-01: HIPAA forms, HIE, Med Consent/MSS Treatment Plan	Department of Mental Health
18-02: Mental Health Triage and Contact Information	Department of Mental Health
19-01: Katie A Form and Consent of Secure Text Messaging	Department of Mental Health
19-02: Service Request Log (SRL)	Department of Mental Health
19-03: CANS-IP, PSC-35, Consent for TMS, TMS Referral	Department of Mental Health