This page is under development. If a required document is not on this webpage, please email richardsja@saccounty.gov.
Behavioral Health Services Forms & Documents
Adverse Incident ReportAdverse Incident Report - Supplemental Sheet
Staff Registration and Credentialing Forms
Attachment A - QM MHP Staff Reg FormAttachment A1 - QM SUPT Staff Reg FormAttachment B - QM MHP-SUPT Staff Check ListAttachment C - SSN Consent FormAttachment D - Licensed Staff ApplicationAttachment E - Resident/Fellow ApplicationAttachment F - LPHA WaiverAttachment G - Mental Health Professional Licensure WaiverAttachment H - Clinical Trainee ApplicationAttachment H1 - Clinical Trainee Extension RequestAttachment I - MHRS ApplicationAttachment J - AOD Counselor ApplicationAttachment K - Taxonomy CodesEHR Training Registration Form
Mental Health Services Forms & Documents
Access Team Service Request Form
Access Team Service Request Form (PDF).pdf
Online Mental Health Service Request
Acknowledgement of ReceiptAcknowledgement of Receipt (English)Acknowledgement of Receipt (Arabic)Acknowledgement of Receipt (Chinese)Acknowledgement of Receipt (Farsi)Acknowledgement of Receipt (Hmong)Acknowledgement of Receipt (Russian)Acknowledgement of Receipt (Spanish)Acknowledgement of Receipt (Vietnamese)
Appeal Forms Appeal Form (English) Appeal Form (Arabic)Appeal Form (Chinese)Appeal Form (Farsi)Appeal Form (Hmong)Appeal Form (Russian)Appeal Form (Spanish)Appeal Form (Vietnamese)
Brochures Access Team Brochure - EnglishAccess Team Brochure - ArabicAccess Team Brochure - ChineseAccess Team Brochure - FarsiAccess Team Brochure - HmongAccess Team Brochure - RussianAccess Team Brochure - SpanishAccess Team Brochure - Vietnamese
Adult Mental Health Brochure
Advance Medical Directive Brochure (English) Advance Medical Directive Brochure (Arabic)Advance Medical Directive Brochure (Chinese)Advance Medical Directive Brochure (Farsi)Advance Medical Directive Brochure (Hmong)Advance Medical Directive Brochure (Russian)Advance Medical Directive Brochure (Spanish)Advance Medical Directive Brochure (Vietnamese)
Child and Family Integrated System of Care Brochure
Child and Family Psychological Assessment Brochure
Community Support Team Brochure (English)Community Support Team Brochure (Arabic)Community Support Team Brochure (Chinese)Community Support Team Brochure (Hmong)Community Support Team Brochure (Persian)Community Support Team Brochure (Russian)Community Support Team Brochure (Spanish)Community Support Team Brochure (Vietnamese)
HEART Referral Flyer
HEART Referral Form
Mobile Crisis Support Team Brochure (English)Mobile Crisis Support Team Brochure (Arabic)Mobile Crisis Support Team Brochure (Cantonese)Mobile Crisis Support Team Brochure (Farsi)Mobile Crisis Support Team Brochure (Hmong)Mobile Crisis Support Team Brochure (Russian)Mobile Crisis Support Team Brochure (Spanish)Mobile Crisis Support Team Brochure (Vietnamese)
Notice of Privacy Practices (NOPP) Form 2090 Brochure (legal size) Notice of Privacy Practices (NOPP) Form 2090 Brochure (large print)
Therapeutic Behavioral Services (TBS) Brochure (English)
Child and Family FormsTherapeutic Foster Care - Referral FormTherapeutic Foster Care - Screening Tool
Grievance Forms Grievance Form (English) Grievance Form (Arabic)Grievance Form (Chinese)Grievance Form (Farsi)Grievance Form (Hmong)Grievance Form (Russian)Grievance Form (Spanish)Grievance Form (Vietnamese)
Medication Forms Medication Conversion Chart
Members' Problem Resolution Posters Poster (English) Poster (Arabic)Poster (Chinese) Poster (Farsi)Poster (Hmong) Poster (Russian) Poster (Spanish) Poster (Vietnamese)
Problem Resolution GuidesMember Rights & Problem Resolution Guide (English) Member Rights & Problem Resolution Guide (Arabic)Member Rights & Problem Resolution Guide (Chinese)Member Rights & Problem Resolution Guide (Farsi) Member Rights & Problem Resolution Guide (Hmong)Member Rights & Problem Resolution Guide (Russian)Member Rights & Problem Resolution Guide (Spanish) Member Rights & Problem Resolution Guide (Vietnamese)
Psychiatric Advance Directive (PAD) FormsPsychiatric Advance Directive (English)Psychiatric Advance Directive (Spanish)
Request for Change of Provider FormsRequest for Change of Provider (English) Request for Change of Provider (Arabic)Request for Change of Provider (Chinese)Request for Change of Provider (Farsi)Request for Change of Provider (Hmong)Request for Change of Provider (Russian)Request for Change of Provider (Spanish)Request for Change of Provider (Vietnamese)
Service VerificationService Verification Report GridService Verification Card (English)Service Verification Card (Arabic)Service Verification Card (Chinese)Service Verification Card (Hmong)Service Verification Card (Russian)Service Verification Card (Spanish)Service Verification Card (Vietnamese)
Suggestion FormsSuggestion Form (English) Suggestion Form (Arabic)Suggestion Form (Chinese)Suggestion Form (Farsi)Suggestion Form (Hmong)Suggestion Form (Russian)Suggestion Form (Spanish)Suggestion Form (Vietnamese)
Uniform Method of Determining Ability to Pay (UMDAP) Forms Financial Information Form UMDAP Request for Fee Waiver/Reduction UMDAP Worksheet
Other Forms Adult Mental Health Intensive Services Request Form
ADS Counselor Application
Alcohol and Drug Services Staff Registration Form
Community Support Team Referral Form
Crisis Residential Program Extension Request Form
Crisis Residential Program Referral Form
Level of Care Recommendation and Response Form
Level of Intensity Screening Tool (LIST)
Level of Intensity Screening Tool (LIST) Instruction Manual
Level of Intensity Screening Tool (LIST) Recorded Training
Licensed Professional Clinical Counselor Application
LPHA Licensure Waiver Application (AMFT, ASW, APCC)
LPHA Licensure Waiver Application (Registered Psychologist and Psychological Assistant)
Mental Health Assistant Application
Mental Health Rehabilitation Specialist Application
Mental Health Staff Registration Form
National Provider Identifier (NPI) Application Information
Student Application
Transition of Care Tool for Medi-Cal Mental Health Services
Substance Use Prevention and Treatment Services Forms & Documents
Acknowledgment of ReceiptAcknowledgement of Receipt (English)Acknowledgement of Receipt (Arabic)Acknowledgement of Receipt (Cantonese)Acknowledgement of Receipt (Farsi)Acknowledgement of Receipt (Hmong)Acknowledgement of Receipt (Russian)Acknowledgement of Receipt (Spanish)Acknowledgement of Receipt (Vietnamese)
Advance Medical DirectiveAdvance Medical Directive (English)Advance Medical Directive (Arabic)Advance Medical Directive (Cantonese)Advance Medical Directive (Farsi)Advance Medical Directive (Hmong)Advance Medical Directive (Russian)Advance Medical Directive (Spanish)Advance Medical Directive (Vietnamese)
Appeal FormsAppeal Form (English)Appeal Form (Arabic)Appeal Form (Cantonese)Appeal Form (Farsi)Appeal Form (Hmong)Appeal Form (Russian)Appeal Form (Spanish)Appeal Form (Vietnamese)
Drug Medi-Cal Organized Delivery System (DMC-ODS) Member Handbook for BeneficiariesDMC-ODS Member Handbook - EnglishDMC-ODS Member Handbook – ArabicDMC-ODS Member Handbook – CantoneseDMC-ODS Member Handbook – FarsiDMC-ODS Member Handbook – HmongDMC-ODS Member Handbook – RussianDMC-ODS Member Handbook – SpanishDMC-ODS Member Handbook – Vietnamese
Grievance FormsGrievance Form (English)Grievance Form (Arabic)Grievance Form (Cantonese)Grievance Form (Farsi)Grievance Form (Hmong)Grievance Form (Russian)Grievance Form (Spanish)Grievance Form (Vietnamese)
Language Assistance PosterLanguage Assistance Poster
Member Rights & Problem Resolution GuideMember Rights & Problem Resolution Guide (English)Member Rights & Problem Resolution Guide (Arabic)Member Rights & Problem Resolution Guide (Cantonese)Member Rights & Problem Resolution Guide (Farsi)Member Rights & Problem Resolution Guide (Hmong)Member Rights & Problem Resolution Guide (Russian)Member Rights & Problem Resolution Guide (Spanish)Member Rights & Problem Resolution Guide (Vietnamese)
Member SuggestionMember Suggestion (English)Member Suggestion (Arabic)Member Suggestion (Cantonese)Member Suggestion (Farsi)Member Suggestion (Hmong)Member Suggestion (Russian)Member Suggestion (Spanish)Member Suggestion (Vietnamese)
Notice of Privacy Practices BrochuresNotice of Privacy Practices (NOPP) Form 2090 Brochure (legal size) Notice of Privacy Practices (NOPP) Form 2090 Brochure (large print)
Problem Resolution PosterBeneficiary Problem Resolution Poster
Referral Forms for Substance Use Treatment ServicesAdult Substance Use Disorder Universal Referral FormYouth Substance Use Disorder Universal Referral Form
Substance Use Prevention and Treatment BrochureSubstance Use Prevention and Treatment Brochure (English) Substance Use Prevention and Treatment Brochure (Arabic) Substance Use Prevention and Treatment Brochure (Cantonese)Substance Use Prevention and Treatment Brochure (Farsi) Substance Use Prevention and Treatment Brochure (Hmong) Substance Use Prevention and Treatment Brochure (Russian) Substance Use Prevention and Treatment Brochure (Spanish) Substance Use Prevention and Treatment Brochure (Vietnamese)
