Department of Public Health
Date: _____________Start time: _______________ Stop time: _______________ Total completion time: _______________Date: _____________Start time: _______________ Stop time: _______________ Total completion time: _______________Thank you for calling the Los Angeles County Substance Abuse Service Helpline (SASH). How did you hear about us? ? Website ? Family/Friend ? Provider ? Other agency (_____________)Are you calling regarding service information for youth under the age of 18?? Yes (If YES, proceed to next question)? No (If NO, proceed to adult prompt/Brief Triage Assessment)Are you calling for yourself or on behalf of someone else?? Self / Youth ? Parent/Guardian of Child ? SUD Provider for patient/client ? Court / Probation officer? Other ________________________________(If caller is a parent or guardian seeking services for a youth, use the parent screener screening is not applicable for other types of caller such as SUD provider or court/probation officer.)Youth Demographic informationYouth Name: Phone Number: ? MobileOkay to leave voicemail? ? Yes ? NoParent / Guardian Name: Address or Zip Code:DOB:Age:Gender: Race/Ethnicity: Preferred Language: Medi-Cal or MyHealthLA ID #:Insurance Type: ? None ? MyHealthLA ? Medicare ? Medi-Cal ? Private ? Other (plan): (plan): (plan): (specify): Living Arrangement: ? Homeless ? Living with family ? Living in foster care ? Other (specify): Referred by (specify): What are the main reasons you are seeking help today? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Are you currently receiving other services such as physical or mental health counseling? Please describe.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Are you currently experiencing any family, financial, legal, or school problems? Please describe.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________S2BI: Screening to Brief InterventionIn the past year, how many times have you used [X]?NeverOnce or TwiceMonthlyWeeklyTobacco Products????Alcohol????Marijuana????Illegal Drugs (i.e. cocaine or Ecstasy)????Prescription drugs that were not prescribed for you (i.e. Pain Medication or Adderall)????Inhalants (i.e. nitrous oxide)????Herbs or synthetic drugs (i.e. salvia, K2, or bath salts)????S2BI Algorithm-952552705Never00Never151447552705Once or Twice00Once or Twice456247552705Weekly Use00Weekly Use303847552705Monthly Use00Monthly Use-9525234315No Substance Use 00No Substance Use 1514475234315No Substance Use Disorder Risk00No Substance Use Disorder Risk4562475237490Severe SUD Risk00Severe SUD Risk3038475234315Mild/Moderate SUD Risk00Mild/Moderate SUD Risk222885019875552959001962153743325186690704850186690-9525215265Positive Reinforcement00Positive Reinforcement3038475215265Brief Intervention/Motivational Intervention: reduce use & risky behavior00Brief Intervention/Motivational Intervention: reduce use & risky behavior1514475215265Brief Advice00Brief Advice52959001587503035410190362Refer to SUD provider for further assessment00Refer to SUD provider for further assessmentThank you for answering these questions. Based on what you shared, we would like to connect you to an agency in your local community (near you) for a further assessment and information about services to assist with your needs. How does that sound?Referral Information:Agency Name: _______________________________________________________________________________Address: ______________________________________________________________________________________Phone: _______________________________________________________________________________________Appointment Date/ Time (if available): ________________________________________________________Placement SummaryLevel of Care Assessment: All youth are to be referred to the closest youth services agency for full ASAM assessment. However, youth who are just exiting residential- of hospital-based withdrawal management and those who are being referred to residential treatment from an outpatient program should be referred to a residential program for assessment.Designated Assessment Location and Provider Name: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Staff/Clinician Name: Signature: Date: _____________________________________________________________________________________________________Supervisor Name: Signature: Date: ................
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