Get Adult Behavioral Health Screening Form - Alameda County - Acbhcs

Filling out the Adult Behavioral Health Screening Form for Alameda County is an important step towards accessing necessary behavioral health services. This guide will provide you with clear, step-by-step instructions to help you fill out the form accurately and efficiently online.

Follow the steps to complete the form online:

1. Click ‘Get Form’ button to access the form and open it in your preferred editing tool.
2. Begin with the member information section. Enter the patient name and date of birth in the designated fields. Please check the box for the gender that applies.
3. Provide the Medi-Cal number and current eligibility status. If there are any specific language or cultural requirements, note them in the designated field.
4. Complete the address section with the patient's address, city, and zip code. If a caregiver or guardian is involved, include their name in the appropriate field.
5. Indicate the behavioral health diagnoses, using the provided spaces. This should include up to three diagnoses if applicable.
6. Indicate if the provisional diagnosis is included for MHP services by selecting yes or no.
7. In the documents included section, check the box for required consent completion and include any relevant medical notes or history.
8. Fill in the primary care provider information, including their name and phone number.
9. For List A, check all conditions that apply based on the patient's history.
10. For List B and List C, similarly check all applicable conditions that relate to the patient’s current mental health status.
11. Follow the Referral Algorithm guide presented in the document to determine the appropriate level of care needed based on the selections made.
12. Complete the referring provider section, including the name and phone number.
13. Provide any pertinent current or past information regarding symptoms and history to assist in evaluation.
14. Lastly, for clinician use only, ensure the assigned case manager, MD, or therapist is recorded along with the communication date of the assessment outcome.
15. Once all sections are completed, save your changes, and choose to download, print, or share the form as necessary.

Take the first step towards receiving support by filling out the Adult Behavioral Health Screening Form online today.