Please click on a form below to view a PDF printable version.
The files below are in PDF format ()
Materials Order Forms
Sacramento County Low Income Health Program (LIHP) FORMS
Cultural & Linguistic Services Forms
Staying Healthy Assessment Requirement
All managed Medi-Cal members and Healthy Families members
The initial health assessment will be accompanied by an initial health education behavioral assessment, utilizing the DHS produced "Staying Healthy" Assessment that consist of five specific age categories (0-3 years, 4-8 years, 9-11 years, 12-17 years, and 18 and over). Assessment is designed to be self-completed by members age 12 and over and by parents for children age 11 and under, while waiting for their medical visit. If a member or parent requests help with completion, it must be provided. This assessment is designed to initiate dialogue between member and provider facilitating focused health education counseling addressing health behavior change. This assessment must also be done with all existing patients at their next non-acute care visit and when entering into a new age category.
Staying Healthy Assessment Order Form
To download assessment forms and educational tip sheets directly, choose one of the following links:
Staying Healthy Assessment Forms ()
Staying Healthy Tip Sheets ()
If you do not see the form you need, please click here to order it from the Provider Services Department.
Adobe Acrobat Reader is required to view the file(s) above. Download a free version.