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 ReportAdverse Incident Report - Supplemental Sheet
Mental Health Services Forms & Documents
Access Team Service Request Form Access Team Service Request Form (PDF)Online Mental Health Service Request
Appeal Forms Appeal Form (English) Appeal Form (Arabic)Appeal Form (Chinese)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 (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 (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 (Hmong)Member Rights & Problem Resolution Guide (Russian)Member Rights & Problem Resolution Guide (Spanish) Member Rights & Problem Resolution Guide (Vietnamese)
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 (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 (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 FormADS Counselor ApplicationAlcohol and Drug Services Staff Registration FormChild/Youth Medi-Cal Bi-Directional Transition of Care Request and Mental Health Screening Tool Community Support Team Referral FormLevel of Care Recommendation and Response FormLicensed Professional Clinical Counselor ApplicationLPHA Licensure Waiver Application (AMFT, ASW, APCC)LPHA Licensure Waiver Application (Registered Psychologist and Psychological Assistant)LOCUS Request FormMental Health Assistant ApplicationMental Health Rehabilitation Specialist ApplicationMental Health Staff Registration FormNational Provider Identifier (NPI) Application InformationStudent Application
Substance Use Prevention and Treatment Services Forms & Documents
Acknowledgment of ReceiptAcknowledgment 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 DirectiveAdvance 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 FormsAppeal Form (English)Appeal Form (Arabic)Appeal Form (Chinese)Appeal Form (Hmong)Appeal Form (Russian)Appeal Form (Spanish)Appeal Form (Vietnamese)
Grievance FormsGrievance Form (English)Grievance Form (Arabic)Grievance Form (Chinese)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 (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)
Member SuggestionMember Suggestion (English)Member Suggestion (Arabic)Member Suggestion (Chinese)Member Suggestion (Hmong)Member Suggestion (Russian)Member Suggestion (Spanish)Member Suggestion (Vietnamese)
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 (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)
