Service Areas with City Names County of Los Angeles - Department 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Client Information. Fill in the DMH IS/IBHIS# and date at the top, followed by the client's Social Security Number, last name, first name, date of birth, preferred language, race/ethnicity, age, contact address, gender, and phone number.
3. Next, indicate the current living situation and insurance details. Check all applicable benefits such as Medi-Cal or Medicare and specify if the client has a conservator.
4. In the Referral Source section, provide details about the agency making the referral and any other agency involvement. Ensure to check if the individual is currently receiving mental health services.
5. Complete the Level of Service section by checking one option that best describes the client's service history. Provide additional details if necessary.
6. Finally, review all sections for accuracy before submitting. Use our platform's features to save your progress or share it directly with relevant parties.

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