LOS ANGELES COUNTY

ASSESSMENT TOOL- ADULTS (PAPER VERSION)

Based on the ASAM Criteria [3rd Edition] Multidimensional Assessment

Demographic information
Name: Date: Phone Number:
Okay to leave voicemail? ☐ Yes ☐ No
Address:

Date of Birth: Age: Gender:

Race/Ethnicity: Preferred Language: Medi-Cal ID #:
Other ID# (Plan):

Insurance Type: ☐ None ☐ MyHealthLA ☐ Medicare ☐ Medi-Cal ☐ Private ☐ Other

(Plan): (Plan): (Plan): (Plan):

Living Arrangement: ☐ Homeless ☐ Independent living ☐ Other (specify):

Referred by (specify):

Explanation of why patient is currently seeking treatment: Current symptoms, functional impairment, severity, duration of
symptoms (e.g., unable to work/school, relationship/housing problems):

Dimension 1: Substance Use, Acute Intoxication and/or Withdrawal Potential

1. Substance use history:
Alcohol and/or Drug Types Recently Used? Prior Use? Route Frequency Duration Date of Last
(Past 6 Months) (Lifetime) (Inject, Smoke, Snort) (Daily, Weekly, Monthly) (Length of Use) Use
Amphetamines
(Meth, Ice, Crank)
Alcohol
Cocaine/Crack
Heroin
Marijuana
Opioid Pain Medications
Misuse or without prescription
Sedatives
(Benzos, Sleeping Pills)
Misuse or without prescription
Hallucinogens
Inhalants
Over-the-Counter
Medications
(Cough Syrup, Diet Aids)
Nicotine

Other:

This confidential information is provided to you in accord with State and Federal laws
and regulations including but not limited to applicable Welfare and Institutions Code,
Client Name: _______________________________ Medi-Cal ID:______________________
Civil Code and HIPAA Privacy Standards. Duplication of this information for further
disclosure is prohibited without the prior written authorization of the patient/authorized
representative to who it pertains unless otherwise permitted by law. Treatment Agency: __________________________________________________________
Revised: 07/31/17 1
Additional Information:

2. Do you find yourself using more alcohol and/or drugs than you intend to? ☐Yes ☐No
Please describe:

3. Do you get physically ill when you stop using alcohol and/or drugs? ☐ Yes ☐ No
Please describe:

4. Are you currently experiencing withdrawal symptoms, such as tremors, excessive sweating, rapid heart rate,
blackouts, anxiety, vomiting, etc.? ☐ Yes ☐ No
Please describe specific symptoms and consider immediate referral for medical evaluation:

5. Do you have a history of serious withdrawal, seizures, or life-threatening symptoms during withdrawal? ☐ Yes ☐ No
Please describe and specify withdrawal substance(s):

6. Do you find yourself using more alcohol and/or drugs in order to get the same high? ☐ Yes ☐ No
Please describe:

7. Has your alcohol and/or drug use changed recently (increase/ decreased, changed route of use)? ☐ Yes ☐ No
Please describe:

8. Please describe family history of alcohol and/or drug use:

This confidential information is provided to you in accord with State and Federal laws
and regulations including but not limited to applicable Welfare and Institutions Code,
Client Name: _______________________________ Medi-Cal ID:______________________
Civil Code and HIPAA Privacy Standards. Duplication of this information for further
disclosure is prohibited without the prior written authorization of the patient/authorized
representative to who it pertains unless otherwise permitted by law. Treatment Agency: __________________________________________________________
Revised: 07/31/17 2
 Please circle one of the following levels of severity

Severity Rating- Dimension 1 (Substance Use, Acute Intoxication and/or Withdrawal Potential)
0 1 2 3 4
None Mild Moderate Severe Very Severe
No signs of Mild/moderate intoxication, May have severe intoxication but Severe intoxication with Incapacitated. Severe signs and
withdrawal/intoxication interferers with daily responds to support. Moderate imminent risk of danger to symptoms. Presents danger, i.e.
present functioning. Minimal risk of risk of severe withdrawal. No self/others. Risk of severe seizures. Continued substance use
severe withdrawal. No danger danger to self/others. manageable withdrawal. poses an imminent threat to life.
to self/others.

Additional Comments:

Dimension 2: Biomedical Conditions and Complications

9. Please list known medical provider(s)

Physician Name Specialty Contact Information

10. Do you have any of the following medical conditions:

☐ Heart Problems ☐ Seizure/Neurological ☐ Muscle/Joint Problems ☐ Diabetes

☐ High Blood Pressure ☐ Thyroid Problems ☐ Vision Problems ☐ Sleep Problems

☐ High Cholesterol ☐ Kidney Problems ☐ Hearing Problems ☐ Chronic Pain

☐ Blood Disorder ☐ Liver Problems ☐ Dental Problems ☐ Pregnant

☐ Stomach/Intestinal Problems ☐ Asthma/Lung Problems ☐ Sexually Transmitted Disease(s): _________________

☐ Cancer (specify type[s]):____________________________ ☐ Infection(s): __________________________________

☐ Allergies: ________________________________________ ☐ Other: ______________________________________

This confidential information is provided to you in accord with State and Federal laws
and regulations including but not limited to applicable Welfare and Institutions Code,
Client Name: _______________________________ Medi-Cal ID:______________________
Civil Code and HIPAA Privacy Standards. Duplication of this information for further
disclosure is prohibited without the prior written authorization of the patient/authorized
representative to who it pertains unless otherwise permitted by law. Treatment Agency: __________________________________________________________
Revised: 07/31/17 3
11. Do any of these conditions significantly interfere with your life? ☐ Yes ☐ No
Please describe:

12. Provide additional comments on medical conditions, prior hospitalizations (include dates and reasons):

13. Question to be answered by interviewer: Does the patient report medical symptoms that would be considered life-
threatening or require immediate medical attention? ☐ Yes ☐ No
* If yes, consider immediate referral to emergency room or call 911

14. List all current medication(s) for medical condition(s):

Medication Dose/Frequency Reason Effectiveness/Side Effects

Please circle one of the following levels of severity

Severity Rating- Dimension 2 (Biomedical Conditions and Complications)
0 1 2 3 4
None Mild Moderate Severe Very Severe
Fully functional/ Mild to moderate symptoms Some difficulty tolerating physical Serious medical problems neglected Incapacitated with
able to cope with interfering with daily problems. Acute, nonlife during outpatient or intensive severe medical
discomfort or pain. functioning. Adequate ability threatening problems present, or outpatient treatment. Severe medical problems.
to cope with physical serious biomedical problems are problems present but stable. Poor
discomfort. neglected. ability to cope with physical problems.
Additional Comments:

Dimension 3: Emotional, Behavioral, or Cognitive Conditions and Complications

This confidential information is provided to you in accord with State and Federal laws
and regulations including but not limited to applicable Welfare and Institutions Code,
Client Name: _______________________________ Medi-Cal ID:______________________
Civil Code and HIPAA Privacy Standards. Duplication of this information for further
disclosure is prohibited without the prior written authorization of the patient/authorized
representative to who it pertains unless otherwise permitted by law. Treatment Agency: __________________________________________________________
Revised: 07/31/17 4
15. Do you consider any of the following behaviors or symptoms to be problematic?
Mood
☐ Depression/sadness ☐ Loss of Pleasure/Interest ☐ Hopelessness ☐ Irritability/Anger
☐ Impulsivity ☐ Pressured Speech ☐ Grandiosity ☐ Racing Thoughts
Anxiety
☐ Anxiety/Excessive Worry ☐ Obsessive Thoughts ☐ Compulsive Behaviors ☐ Flashbacks
Psychosis
☐ Paranoia ☐ Delusions: ______________________ ☐ Hallucinations: ____________________
Other
☐ Sleep Problems ☐ Memory/Concentration ☐ Gambling ☐ Risky Sex Behaviors

☐ Suicidal Thoughts: please describe

☐ Thoughts of Harming Others: please describe

☐ Abuse (physical, emotional, sexual): please describe

☐ Traumatic Event(s): please describe

☐ Other:

16. Have you ever been diagnosed with a mental illness? ☐Yes ☐No ☐Not Sure
Please describe (e.g., diagnosis, medications?)

17. Are you currently or have you previously received treatment for psychiatric or emotional problems? ☐ Yes ☐ No
Please describe (e.g., treatment setting, hospitalizations, duration of treatment):

18. Do you ever see or hear things that other people say they do not see or hear? ☐ Yes ☐ No
Please describe:

This confidential information is provided to you in accord with State and Federal laws
and regulations including but not limited to applicable Welfare and Institutions Code,
Client Name: _______________________________ Medi-Cal ID:______________________
Civil Code and HIPAA Privacy Standards. Duplication of this information for further
disclosure is prohibited without the prior written authorization of the patient/authorized
representative to who it pertains unless otherwise permitted by law. Treatment Agency: __________________________________________________________
Revised: 07/31/17 5
19. Question to be answered by interviewer: Based on previous questions, is further assessment of mental health
needed? ☐ Yes ☐ No
Please describe:

20. List all current medication(s) for psychiatric condition(s):

Medication Dose Reason Effectiveness/Side Effects

21. Please list mental health provider(s):

Provider Name Contact Information

Please circle one of the following levels of severity

Severity Rating- Dimension 3 (Emotional, Behavioral, or Cognitive Conditions and Complications)
0 1 2 3 4
None Mild Moderate Severe Very Severe
Good impulse control and Suspect diagnosis of EBC, Persistent EBC. Symptoms Severe EBC, but does not Severe EBC. Requires acute
coping skills. No requires intervention, but distract from recovery, but require acute level of care. level of care. Exhibits severe
dangerousness, good social does not interfere with no immediate threat to Impulse to harm self or and acute life-threatening
functioning and self-care, no recovery. Some relationship self/others. Does not prevent others, but not dangerous in symptoms (posing imminent
interference with recovery. impairment. independent functioning. a 24-hr setting. danger to self/others).

This confidential information is provided to you in accord with State and Federal laws
and regulations including but not limited to applicable Welfare and Institutions Code,
Client Name: _______________________________ Medi-Cal ID:______________________
Civil Code and HIPAA Privacy Standards. Duplication of this information for further
disclosure is prohibited without the prior written authorization of the patient/authorized
representative to who it pertains unless otherwise permitted by law. Treatment Agency: __________________________________________________________
Revised: 07/31/17 6
Additional Comments:

Dimension 4: Readiness to Change

22. Is your alcohol and/or drug use affecting any of the following?
☐ Work ☐ Mental Health ☐ Physical Health ☐ Finances
☐ School ☐ Relationships ☐ Sexual Activity ☐ Legal Matters
☐ Handling Everyday Tasks ☐ Self-esteem ☐ Hygiene ☐ Recreational Activities
☐ Other:

23. Do you continue to use alcohol or drugs despite having it affect the areas listed above? ☐ Yes ☐ No
Please describe:

24. Have you received help for alcohol and/or drug problems in the past? ☐ Yes ☐ No
Please list treatment provider(s)
Provider Name Contact Information

25. What would help to support your recovery?

26. What are potential barriers to your recovery (e.g., financial, transportation, relationships, etc.)?

This confidential information is provided to you in accord with State and Federal laws
and regulations including but not limited to applicable Welfare and Institutions Code,
Client Name: _______________________________ Medi-Cal ID:______________________
Civil Code and HIPAA Privacy Standards. Duplication of this information for further
disclosure is prohibited without the prior written authorization of the patient/authorized
representative to who it pertains unless otherwise permitted by law. Treatment Agency: __________________________________________________________
Revised: 07/31/17 7
27. How important is it for you to receive treatment for:
Alcohol Problems: ☐ Not at all ☐ Slightly ☐ Moderately ☐ Considerably ☐ Extremely
Drug Problems: ☐ Not at all ☐ Slightly ☐ Moderately ☐ Considerably ☐ Extremely

Please describe:

Please circle one of the following levels of severity

Severity Rating- Dimension 4 (Readiness to Change)
0 1 2 3 4
None Mild Moderate Severe Very Severe
Willing to engage in Willing to enter treatment, Reluctant to agree to treatment. Unaware of need to change. Not willing to change.
treatment. but ambivalent to the need Low commitment to change Unwilling or partially able to Unwilling/unable to follow
to change. substance use. Passive follow through with through with treatment
engagement in treatment. recommendations for treatment. recommendations.

Additional Comments:

Dimension 5: Relapse, Continued Use, or Continued Problem Potential

28. In the last 30 days, how often have you experienced cravings, withdrawal symptoms, disturbing effects of use?

Alcohol: ☐ None ☐ Occasionally ☐ Frequently ☐ Constantly

Drug: ☐ None ☐ Occasionally ☐ Frequently ☐ Constantly

Please Describe:

29. Do you find yourself spending time searching for alcohol and/or drugs, or trying to recover from its effects?
☐Yes ☐No
Please describe:

30. Do you feel that you will either relapse or continue to use without treatment or additional support? ☐ Yes ☐ No
Please describe:

31. Are you aware of your triggers to use alcohol and/or drugs? ☐ Yes ☐ No
Please check off any triggers that may apply:
☐ Strong Cravings ☐ Work Pressure ☐ Mental Health ☐ Relationship Problems
☐ Difficulty Dealing with Feelings ☐ Financial Stressors ☐ Physical Health ☐ School Pressure
☐ Environment ☐ Unemployment ☐ Chronic Pain ☐ Peer Pressure
☐ Other: __________________________________________

This confidential information is provided to you in accord with State and Federal laws
and regulations including but not limited to applicable Welfare and Institutions Code,
Client Name: _______________________________ Medi-Cal ID:______________________
Civil Code and HIPAA Privacy Standards. Duplication of this information for further
disclosure is prohibited without the prior written authorization of the patient/authorized
representative to who it pertains unless otherwise permitted by law. Treatment Agency: __________________________________________________________
Revised: 07/31/17 8
32. What do you do if you are triggered?

33. Can you please describe any attempts you have made to either control or cut down on your alcohol and/or drug use?

34. What is the longest period of time that you have gone without using alcohol and/or drugs?

35. What helped and didn’t help?

Please circle one of the following levels of severity

Severity Rating- Dimension 5 (Relapse, continued Use, or Continued Problem Potential)

0 1 2 3 4
None Mild Moderate Severe Very Severe
Low/no potential Minimal relapse potential. Impaired recognition of risk Little recognition of risk for No coping skills for relapse/ addiction
for relapse. Good Some risk, but fair coping and for relapse. Able to self- relapse, poor skills to cope problems. Substance use/behavior,
ability to cope. relapse prevention skills. manage with prompting. with relapse. places self/other in imminent danger.

Additional Comments:

Dimension 6: Recovery/Living Environment

36. Do you have any relationships that are supportive of your recovery? (e.g., family, friends)

37. What is your current living situation (e.g., homeless, living with family/alone)?

38. Do you currently live in an environment where others are using drugs? ☐ Yes ☐ No
Please describe:

This confidential information is provided to you in accord with State and Federal laws
and regulations including but not limited to applicable Welfare and Institutions Code,
Client Name: _______________________________ Medi-Cal ID:______________________
Civil Code and HIPAA Privacy Standards. Duplication of this information for further
disclosure is prohibited without the prior written authorization of the patient/authorized
representative to who it pertains unless otherwise permitted by law. Treatment Agency: __________________________________________________________
Revised: 07/31/17 9
39. Are you currently involved in relationships or situations that pose a threat to your safety? ☐ Yes ☐ No
Please describe:

40. Are you currently involved in relationships or situations that would negatively impact your recovery? ☐ Yes ☐ No
Please describe:

41. Are you currently employed or enrolled in school? ☐ Yes ☐ No

Please describe (e.g., where employed, duration of employment, name and type of school):

42. Are you currently involved with social services or the legal system (e.g., DCFS, court mandated, probation, parole)?
Please describe: ☐ Yes ☐ No

If on parole/probation:
Name of Probation/Parole Officer Contact Information

Please circle one of the following levels of severity

Severity Rating- Dimension 6 Recovery/Living Environment

0 1 2 3 4
None Mild Moderate Severe Very Severe
Able to cope in Passive/disinterested Unsupportive environment, Unsupportive environment, Environment toxic/hostile to recovery.
environment/ social support, but still but able to cope with clinical difficulty coping even with Unable to cope and the environment
supportive. able to cope. structure most of the time. clinical structure. may pose a threat to safety.

Additional Comments:

This confidential information is provided to you in accord with State and Federal laws
and regulations including but not limited to applicable Welfare and Institutions Code,
Client Name: _______________________________ Medi-Cal ID:______________________
Civil Code and HIPAA Privacy Standards. Duplication of this information for further
disclosure is prohibited without the prior written authorization of the patient/authorized
representative to who it pertains unless otherwise permitted by law. Treatment Agency: __________________________________________________________
Revised: 07/31/17 10
 Summary of Multidimensional Assessment
Dimension Severity Rating (Based on Ratings Above) Rationale
Dimension 1
Substance Use, Acute ☐ ☐ ☐ ☐
Intoxication and/or 0 1 2 3-4
Withdrawal Potential None Mild Moderate Severe

Dimension 2
Biomedical Condition ☐ ☐ ☐ ☐
and Complications 0 1 2 3-4
None Mild Moderate Severe

Dimension 3
Emotional, ☐ ☐ ☐ ☐
Behavioral, or 0 1 2 3-4
Cognitive Condition None Mild Moderate Severe
and Complications

Dimension 4
Readiness to Change ☐ ☐ ☐ ☐
0 1 2 3-4
None Mild Moderate Severe

Dimension 5
Relapse, Continued ☐ ☐ ☐ ☐
Use, or Continued 0 1 2 3-4
Problem Potential None Mild Moderate Severe

Dimension 6
Recovery/Living ☐ ☐ ☐ ☐
Environment 0 1 2 3-4
None Mild Moderate Severe

This confidential information is provided to you in accord with State and Federal laws
and regulations including but not limited to applicable Welfare and Institutions Code,
Client Name: _______________________________ Medi-Cal ID:______________________
Civil Code and HIPAA Privacy Standards. Duplication of this information for further
disclosure is prohibited without the prior written authorization of the patient/authorized
representative to who it pertains unless otherwise permitted by law. Treatment Agency: __________________________________________________________
Revised: 07/31/17 11
 Diagnosis: Diagnostic Statistical Manual, 5th Edition (DSM-5)
Criteria For Substance Use Disorder
Please check off any symptoms that have occurred in the past 12 months.
Name of Substance(s)
Substance Use Disorder Criteria (DSM-5) #1: #2: #3:
____________ ____________ ____________
1 Substance often taken in larger amounts or over a longer
☐ ☐ ☐
period than was intended.
2 There is a persistent desire or unsuccessful efforts to cut
☐ ☐ ☐
down or control substance use.
3 A great deal of time is spent in activities necessary to
obtain the substance, use the substance, or recover from ☐ ☐ ☐
its effects.
4 Craving, or a strong desire or urge to use the substance. ☐ ☐ ☐
5 Recurrent substance use resulting in a failure to fulfill
major role obligations at work, school, or home. ☐ ☐ ☐
6 Continued substance use despite having persistent or
recurrent social or interpersonal problems caused or ☐ ☐ ☐
exacerbated by the effects of the substance.
7 Important social, occupational, or recreational activities are
given up or reduced because of substance use. ☐ ☐ ☐
8 Recurrent substance use in situations in which it is
☐ ☐ ☐
physically hazardous.
9 Continued substance use despite knowledge of having a
persistent or recurrent physical or psychological problem
☐ ☐ ☐
that is likely to have been caused or exacerbated by the
substance.
10 Tolerance, as defined by either of the following:
- A need for markedly increased amounts of the substance to
achieve intoxication or desired effect. ☐ ☐ ☐
- A markedly diminished effect with continued use of the same
amount of the substance.
11 Withdrawal, as manifested by either of the following:
- The characteristic withdrawal syndrome for the substance.
☐ ☐ ☐
- Substance (or a closely related substance) is taken to relieve or
avoid withdrawal symptoms.
Total Number of Criteria
List of Substance Use Disorder(s) that Meet DSM-5 Criteria and Date of DSM-5 Diagnosis (specify severity level):

* The presence of at least 2 of these criteria indicates a substance use disorder.

** The severity of the substance use disorder is defined as:
- Mild: Presence of 2-3 criteria
- Moderate: Presence of 4-5 criteria
- Severe: Presence of 6 or more criteria

This confidential information is provided to you in accord with State and Federal laws
and regulations including but not limited to applicable Welfare and Institutions Code,
Client Name: _______________________________ Medi-Cal ID:______________________
Civil Code and HIPAA Privacy Standards. Duplication of this information for further
disclosure is prohibited without the prior written authorization of the patient/authorized
representative to who it pertains unless otherwise permitted by law. Treatment Agency: __________________________________________________________
Revised: 07/31/17 12
 ASAM LEVEL OF CARE DETERMINATION TOOL
Instructions: For each dimension, indicate the least intensive level of care that is appropriate based on the patient’s severity/functioning and service needs.

Dimension 1 Substance Dimension 2 Dimension 3 Dimension 4 Dimension 5 Dimension 6

ASAM Criteria Level of Care- ASAM Use, Acute Intoxication and/or Biomedical Condition and Emotional, Behavioral, or Readiness to Change Relapse, Continued Use, or Recovery/Living Environment
Withdrawal Management Level Withdrawal Potential Complications Cognitive Condition and Continued Problem Potential
Complications
Severity / Impairment Rating None Mild Mod Sev None Mild Mod Sev None Mild Mod Sev None Mild Mod Sev None Mild Mod Sev None Mild Mod Sev
Ambulatory Withdrawal Management 1-WM
without Extended On-Site Monitoring
Ambulatory Withdrawal Management 2-WM
with Extended On-Site Monitoring
Clinically Managed Residential 3.2-WM
Withdrawal Management
Medically Monitored Inpatient 3.7-WM
Withdrawal Management
Medically Managed Intensive Inpatient 4-WM
Withdrawal Management
ASAM Criteria Level of Care- Other Treatment and Recovery Services
Severity / Impairment Rating None Mild Mod Sev None Mild Mod Sev None Mild Mod Sev None Mild Mod Sev None Mild Mod Sev None Mild Mod Sev
Early Intervention 0.5

Consider referral to mental health facility

Outpatient Services 1
Intensive Outpatient Services 2.1
Partial Hospitalization Services 2.5
Clinically Managed Low-Intensity 3.1
Residential Services
Clinically Managed Population-Specific 3.3
High-Intensity Residential Services
Clinically Managed High-Intensity 3.5
Residential Services
Medically Monitored Intensive Inpatient 3.7
Services
Medically Managed Intensive Inpatient 4
Services
ASAM Criteria Level of Care- Other Treatment and Recovery Services
Severity / Impairment Rating None Mild Mod Sev None Mild Mod Sev None Mild Mod Sev None Mild Mod Sev None Mild Mod Sev None Mild Mod Sev
Opioid Treatment Program OTP

Would the patient with alcohol or opioid use disorders benefit from and be interested in Medication-Assisted Treatment (MAT)? ☐ Yes ☐ No Please describe:
___________________________________________________________________________________________________________________________________
This confidential information is provided to you in accord with State and Federal laws
and regulations including but not limited to applicable Welfare and Institutions Code,
Client Name: _______________________________ Medi-Cal ID:______________________
Civil Code and HIPAA Privacy Standards. Duplication of this information for further
disclosure is prohibited without the prior written authorization of the patient/authorized
representative to who it pertains unless otherwise permitted by law. Treatment Agency: __________________________________________________________
Revised: 07/31/17 13
 Placement Summary

Level of Care: Enter the ASAM Level of Care (e.g., 3.1, 2.1, 3.2, W.M) number that offers the most appropriate treatment
setting given the patient’s current severity and functioning:

Level of Care Provided: If the most appropriate Level of Care is not utilized, then enter the next appropriate Level of Care
and check off the reason for this discrepancy (below):

Reason for Discrepancy:

☐ Not Applicable ☐ Service Not Available ☐ Provider Judgment ☐ Patient Preference

☐ Transportation ☐ Accessibility ☐ Financial ☐ Preferred to Wait

☐ Language/ Cultural Considerations ☐ Environment ☐ Mental Health ☐ Physical Health

☐ Other: __________________________________________

Briefly Explain Discrepancy:

Designated Treatment Location and Provider Name:

_____________________________________________________________________________________________________
Counselor Name (if applicable) Signature Date

_____________________________________________________________________________________________________
Licensed-eligible LPHA Name (if applicable) Signature Date

_____________________________________________________________________________________________________
*Licensed LPHA Name Signature Date

Licensed-eligible LPHA’s are psychological assistants, associate social workers (ASWs), marriage and therapy family interns (MFTI/IMFT),
professional clinical counselor interns (PCCIs).

A Licensed LPHA is required to sign the ASAM assessment. Licensed LPHA (Licensed Practitioner of the Healing Arts) includes: Physicians,
Nurse Practitioners, Physician Assistants, Registered Nurses, Registered Pharmacists, Licensed Clinical Psychologists (LCPs), Licensed
Clinical Social Workers (LCSWs), Licensed Professional Clinical Counselors (LPCCs), and Licensed Marriage and Family Therapists (LMFTs).

This confidential information is provided to you in accord with State and Federal laws
and regulations including but not limited to applicable Welfare and Institutions Code,
Client Name: _______________________________ Medi-Cal ID:______________________
Civil Code and HIPAA Privacy Standards. Duplication of this information for further
disclosure is prohibited without the prior written authorization of the patient/authorized
representative to who it pertains unless otherwise permitted by law. Treatment Agency: __________________________________________________________
Revised: 07/31/17 14