DJJ Form MHSA014 "Mental Health/Substance Abuse Referral Summary - Sample" - Florida

What Is DJJ Form MHSA014?

This is a legal form that was released by the Florida Department of Juvenile Justice - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2006;
  • The latest edition provided by the Florida Department of Juvenile Justice;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DJJ Form MHSA014 by clicking the link below or browse more documents and templates provided by the Florida Department of Juvenile Justice.

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Download DJJ Form MHSA014 "Mental Health/Substance Abuse Referral Summary - Sample" - Florida

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FLORIDA DEPARTMENT OF JUVENILE JUSTICE
SAMPLE
MENTAL HEALTH/SUBSTANCE ABUSE REFERRAL SUMMARY
D J J F a c i l i t y
C i r c u i t
Yo u t h ’ s N a m e
J J I S #
Yo u t h ’ s D O B :
S e x
R a c e
R E A S O N F O R R E F E R R A L :
1 .
( B e h a v i o r s a n d E v e n t s N e c e s s i t a t i n g Me n t a l H e a l t h o r S u b s t a n c e A b u s e R e f e r r a l )
Ye s
N o
Y O U T H S E L F - R E F E R R A L :
I f y e s , r e c o r d y o u t h ’ s s t a t e m e n t s r e g a r d i n g n e e d f o r m e n t a l h e a l t h s e r v i c e s b e l o w :
2 . R E F E R R E D F O R :
A s s e s s m e n t o f S u i c i d e R i s k
C o m p r e h e n s i v e S u b s t a n c e A b u s e E v a l u a t i o n o r
U p d a t e d E v a l u a t i o n
C r i s i s A s s e s s m e n t / I n t e r v e n t i o n
Me n t a l H e a l t h C o n s u l t a t i o n o r
Me n t a l H e a l t h S u p p o r t S e r v i c e s
Me n t a l H e a l t h A l e r t S t a t u s E xa m
O t h e r :
C o m p r e h e n s i v e Me n t a l H e a l t h
E v a l u a t i o n o r U p d a t e d E v a l u a t i o n
3 . R E F E R R E D T O : ( M
H
/ S
/
)
E N T A L
E A L T H
U B S T A N C E A B U S E P R O V I D E R
P R O F E S S I O N A L
a m e )
( P r o v i d e r T e l e p h o n e n o . )
( P r o v i d e r N
4 . N A R R A R T I V E O F T H E ME N T A L H E A L T H / S U B S T A N C E A B U S E P R O F E S S I O N A L ’ S
C O MME N T S O R I N S T R U C T I O N S :
S i g n a t u r e o f S t a f f Me m b e r Ma k i n g R e f e r r a l
F a c i l i t y S u p e r i n t e n d e n t / D e s i g n e e S i g n a t u r e
D a t e :
T i m e :
Rule 63N-1
MHSA 014
August 2006
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
SAMPLE
MENTAL HEALTH/SUBSTANCE ABUSE REFERRAL SUMMARY
D J J F a c i l i t y
C i r c u i t
Yo u t h ’ s N a m e
J J I S #
Yo u t h ’ s D O B :
S e x
R a c e
R E A S O N F O R R E F E R R A L :
1 .
( B e h a v i o r s a n d E v e n t s N e c e s s i t a t i n g Me n t a l H e a l t h o r S u b s t a n c e A b u s e R e f e r r a l )
Ye s
N o
Y O U T H S E L F - R E F E R R A L :
I f y e s , r e c o r d y o u t h ’ s s t a t e m e n t s r e g a r d i n g n e e d f o r m e n t a l h e a l t h s e r v i c e s b e l o w :
2 . R E F E R R E D F O R :
A s s e s s m e n t o f S u i c i d e R i s k
C o m p r e h e n s i v e S u b s t a n c e A b u s e E v a l u a t i o n o r
U p d a t e d E v a l u a t i o n
C r i s i s A s s e s s m e n t / I n t e r v e n t i o n
Me n t a l H e a l t h C o n s u l t a t i o n o r
Me n t a l H e a l t h S u p p o r t S e r v i c e s
Me n t a l H e a l t h A l e r t S t a t u s E xa m
O t h e r :
C o m p r e h e n s i v e Me n t a l H e a l t h
E v a l u a t i o n o r U p d a t e d E v a l u a t i o n
3 . R E F E R R E D T O : ( M
H
/ S
/
)
E N T A L
E A L T H
U B S T A N C E A B U S E P R O V I D E R
P R O F E S S I O N A L
a m e )
( P r o v i d e r T e l e p h o n e n o . )
( P r o v i d e r N
4 . N A R R A R T I V E O F T H E ME N T A L H E A L T H / S U B S T A N C E A B U S E P R O F E S S I O N A L ’ S
C O MME N T S O R I N S T R U C T I O N S :
S i g n a t u r e o f S t a f f Me m b e r Ma k i n g R e f e r r a l
F a c i l i t y S u p e r i n t e n d e n t / D e s i g n e e S i g n a t u r e
D a t e :
T i m e :
Rule 63N-1
MHSA 014
August 2006