If a required document is not on this webpage, please email richardsja@saccounty.gov.
Forms & Documents
Behavioral Health Services Forms & Documents
Staff Registration and Credentialing Forms
- Attachment A - QM MHP-Staff Registration Form
- Attachment A1 QM SUPT Staff Registration Form
- Attachment B - QM MHP and SUPT Staff Reg Check List
- Attachment C - SSN Consent Form
- Attachment D - Licensed Staff Application
- Attachment E - Resident-Fellow Application
- Attachment F - LPHA Waiver
- Attachment G - DHCS-Form-LPHA Pysch Waiver
- Attachment H - Clinical Trainee (Student) Application 2024
- Attachment H1 - Clinical Trainee Extension Application 2024
- Attachment I - MHRS Application
- Attachment J - AOD Counselor
- Attachment K - CHW Attestation
- Attachment L - Taxonomy Codes
- Sac County BHS EHR Training Registration Form
Mental Health Services Forms & Documents
Behavioral Health Services Screening and Coordination Service Request Forms
Acknowledgement of Receipt
Brochures
- Behavioral Health Services Screening and Coordination (BHS SAC) Team Brochure (English)
- Behavioral Health Services Screening and Coordination (BHS SAC) Team Brochure (Arabic)
- Behavioral Health Services Screening and Coordination (BHS SAC) Team Brochure (Chinese)
- Behavioral Health Services Screening and Coordination (BHS SAC) Team Brochure (Farsi)
- Behavioral Health Services Screening and Coordination (BHS SAC) Team Brochure (Hmong)
- Behavioral Health Services Screening and Coordination (BHS SAC) Team Brochure (Russian)
- Behavioral Health Services Screening and Coordination (BHS SAC) Team Brochure (Spanish)
- Behavioral Health Services Screening and Coordination (BHS SAC) Team Brochure (Vietnamese)
- Adult Mental Health Brochure
- Advance Medical Directive - Arabic
- Advance Medical Directive Brochure (Chinese)
- Advance Medical Directive Brochure (English)
- 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)
- Co-Response Crisis Intervention Team Brochure (English)
- HEART Referral Flyer
- HEART Referral Form
- Notice of Privacy Practices (NOPP) Form 2090 Brochure (legal size)
- Notice of Privacy Practices (NOPP) Form 2090 Brochure (large print/ADA)
- Therapeutic Behavioral Services (TBS) Brochure (English)
Medication Forms
Members' Problem Resolution Posters
Problem Resolution Guides
- Member 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) Forms
Request for Change of Provider Forms
- Request 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 Verification
Uniform Method of Determining Ability to Pay (UMDAP) Forms
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)- Updated January 2025
- LIST Instruction Manual- Updated January 2025
- LIST Training Recording - 1/13/2025
- National Provider Identifier (NPI) Application Information
- Authorization to Release Information to Multidisciplinary Team
- Authorization to Release Health Records and Information Collaborative Behavioral Health Courts
- Transition of Care Tool for Medi-Cal Mental Health Services
Substance Use Prevention and Treatment Services Forms & Documents
Acknowledgment of Receipt
Advance Medical Directive
Language Assistance Poster
Member Rights & Problem Resolution Guide
- Member 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)
Notice of Privacy Practices Brochures
Problem Resolution Poster
Referral Forms for Substance Use Treatment Services
Substance Use Prevention and Treatment Brochure
- Substance Use Prevention and Treatment Brochure (English)
- Substance Use Prevention and Treatment Brochure (Arabic)
- Substance Use Prevention and Treatment Brochure (Chinese)
- 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)