Forms & Documents


​​This page is under development.  If a required document is not on this webpage, please email richardsja@saccounty.net.  

Behavioral Health Services Forms & Documents 

Adverse Incident Report
Adverse Incident Report - Supplemental Sheet

Substance Use Prevention and Treatment Services Forms & Documents

Acknowledgment of Receipt
Acknowledgment of Receipt (English)
Acknowledgment of Receipt (Arabic)
Acknowledgment of Receipt (Chinese)
Acknowledgment of Receipt (Hmong)
Acknowledgment of Receipt (Russian)
Acknowledgment of Receipt (Spanish)
Acknowledgment of Receipt (Vietnamese)

Advance Medical Directive
Advance Medical Directive (English)
Advance Medical Directive (Arabic)
Advance Medical Directive (Chinese)
Advance Medical Directive (Hmong)
Advance Medical Directive (Russian)
Advance Medical Directive (Spanish)
Advance Medical Directive (Vietnamese)

Appeal Forms
Appeal Form (English)
Appeal Form (Arabic)
Appeal Form (Chinese)
Appeal Form (Hmong)
Appeal Form (Russian)
Appeal Form (Spanish)
Appeal Form (Vietnamese) 

Grievance Forms
Grievance Form (English)
Grievance Form (Arabic)
Grievance Form (Chinese)
Grievance Form (Hmong)
Grievance Form (Russian)
Grievance Form (Spanish)
Grievance Form (Vietnamese)

Member Rights & Problem Resolution Guide
Member Rights & Problem Resolution Guide (English)

Member Suggestion
Member Suggestion (English)
Member Suggestion (Arabic)
Member Suggestion (Chinese)
Member Suggestion (Hmong)
Member Suggestion (Russian)
Member Suggestion (Spanish)
Member Suggestion (Vietnamese)

Referral Form for Substance Use Treatment Services
Substance Use Disorder Universal Referral Form

Mental Health Services Forms & Documents

Access Team Service Request Forms
Access Team Service Request Form

Appeal Forms
Appeal Form (English) 
Appeal Form (Chinese)
Appeal Form (Arabic)
Appeal Form (Hmong)
Appeal Form (Russian)
Appeal Form (Spanish)
Appeal Form (Vietnamese) 

Brochures
Access Team Brochure

Adult Mental Health Brochure

Advance Medical Directive Brochure (English) 
Advance Medical Directive Brochure (Arabic)
Advance Medical Directive Brochure (Chinese)
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

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 (Russian)
Community Support Team Brochure (Spanish)
Community Support Team Brochure (Vietnamese)

Mobile Crisis Support Team Brochure 

Notice of Privacy Practices (NOPP) Form 2090 Brochure (legal size)  
Notice of Privacy Practices (NOPP) Form 2090 Brochure (large print) 

Grievance Forms
Grievance Form (English) 
Grievance Form (Arabic)
Grievance Form (Chinese)
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 (Hmong) 
Poster (Russian) 
Poster (Spanish) 
Poster (Vietnamese)

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 (Hmong)
Member Rights & Problem Resolution Guide (Russian)
Member Rights & Problem Resolution Guide (Spanish)
Member Rights & Problem Resolution Guide (Vietnamese)

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 (Hmong)
Request for Change of Provider (Russian)
Request for Change of Provider (Spanish)
Request for Change of Provider (Vietnamese) 

Service Verification
Service Verification Report Grid
Service 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 Forms
Suggestion Form (English) 
Suggestion Form (Arabic)
Suggestion Form (Chinese)
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 Medi-Cal Bi-Directional Transition of Care Request and Mental Health Screening Tool 
Adult Mental Health Intensive Services Request Form
ADS Counselor Application
Alcohol and Drug Services Staff Registration Form
Level of Care Recommendation and Response Form
Licensed Professional Clinical Counselor Application
LPHA Licensure Waiver Application (AMFT, ASW, APCC)
LPHA Licensure Waiver Application (Registered Psychologist and Psychological Assistant)
LOCUS Request Form
Mental Health Assistant Application
Mental Health Rehabilitation Specialist Application
Mental Health Staff Registration Form
National Provider Identifier (NPI) Application Information
Student Application



 
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