Department of Health Services

​​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

Alcohol & Drug Services Forms & Documents

Alcohol & Drug Options for Recovery Brochure (English)
Alcohol & Drug Options for Recovery Brochure (Arabic)
Alcohol & Drug Options for Recovery Brochure (Chinese)
Alcohol & Drug Options for Recovery Brochure (Hmong)
Alcohol & Drug Options for Recovery Brochure (Russian)
Alcohol & Drug Options for Recovery Brochure (Spanish)
Alcohol & Drug Options for Recovery Brochure (Vietnamese)

Alcohol & Drug Prevention Services Brochure (English)
Alcohol & Drug Prevention Services Brochure (Arabic)
Alcohol & Drug Prevention Services Brochure (Chinese)
Alcohol & Drug Prevention Services Brochure (Hmong)
Alcohol & Drug Prevention Services Brochure (Russian)
Alcohol & Drug Prevention Services Brochure (Spanish)
Alcohol & Drug Prevention Services Brochure (Vietnamese)

Alcohol & Drug Adult System of Care Brochure (English)
Alcohol & Drug Adult System of Care Brochure (Arabic)
Alcohol & Drug Adult System of Care Brochure (Chinese)
Alcohol & Drug Adult System of Care Brochure (Hmong)
Alcohol & Drug Adult System of Care Brochure (Russian)
Alcohol & Drug Adult System of Care Brochure (Spanish)
Alcohol & Drug Adult System of Care Brochure (Vietnamese)

Alcohol & Drug Youth Treatment Services Brochure (English)
Alcohol & Drug Youth Treatment Services Brochure (Arabic)
Alcohol & Drug Youth Treatment Services Brochure (Chinese)
Alcohol & Drug Youth Treatment Services Brochure (Hmong)
Alcohol & Drug Youth Treatment Services Brochure (Russian)
Alcohol & Drug Youth Treatment Services Brochure (Spanish)
Alcohol & Drug Youth Treatment Services Brochure (Vietnamese)

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
Problem Resolution Guide (English) 
Problem Resolution Guide (Arabic)
Problem Resolution Guide (Chinese)
Problem Resolution Guide (Hmong)
Problem Resolution Guide (Russian)
Problem Resolution Guide (Spanish)
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
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​