Forms & Documents


Mental Health Forms
ACCESS Team Service Request Form
Acknowledgement of Receipt
Adverse Incident Report 
Adverse Incident Report Supplemental Form
Alcohol and Other Drug (AOD) Screening & Service Referral
Avatar Staff Registration Form
Intensive Services Request
LOCUS Progress Notes
Transfer Form

Appeal Forms
Appeal Form - Chinese 
Appeal Form - English 
Appeal Form - Hmong 
Appeal Form - Russian 
Appeal Form - Spanish 
Appeal Form - Vietnamese 

Brochures
Access Team Brochure
Advanced Medical Directive Brochure 
Alcohol & Drug Adult System of Care Brochure (Chinese)
Alcohol & Drug Adult System of Care Brochure (English)
Alcohol & Drug Options for Recovery Brochure (Chinese)
Alcohol & Drug Options for Recovery Brochure (English)
Alcohol & Drug Options for Recovery Brochure (Hmong)
Alcohol & Drug Prevention Services Brochure (Chinese)
Alcohol & Drug Prevention Services Brochure (English)
Alcohol & Drug Prevention Services Brochure (Hmong)
Alcohol & Drug Youth Treatment Services Brochure (English)
Alcohol & Drug Youth Treatment Services Brochure (Chinese)
Child and Family Integrated System of Care Brochure
Child and Family Psychological Assessment Brochure
Community Support Team Brochure (English) 
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) 
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Brochure - Chinese
EPSDT Brochure - English
EPSDT Brochure - Hmong
EPSDT Brochure - Russian
EPSDT Brochure - Spanish
EPSDT Brochure - Vietnamese 
Mobile Crisis Support Team Brochure (English)
Notice of Privacy Practices (NOPP) Form 2090 Brochure (legal size)  
Notice of Privacy Practices (NOPP) Form 2090 Brochure (large print) 
Therapeutic Behavioral Services (TBS) - English 
Therapeutic Behavioral Services (TBS) - Chinese
Therapeutic Behavioral Services (TBS) - Hmong
Therapeutic Behavioral Services (TBS) - Russian
Therapeutic Behavioral Services (TBS) - Spanish 
Therapeutic Behavioral Services (TBS) - Vietnamese

Grievance Forms
Grievance Forms - Chinese
Grievance Forms - English 
Grievance Forms - Hmong 
Grievance Forms - Russian 
Grievance Forms - Spanish 
Grievance Forms - Vietnamese 
  
Informed Consent Forms
Informed Consent (Adults) - English 
Informed Consent (Child) - Chinese
Informed Consent (Child) - English  
Informed Consent (Child) - Hmong
Informed Consent (Child) - Russian  
Informed Consent (Child) - Spanish
Informed Consent (Child) - Vietnamese

Medication Information Sheets
Medication Conversion Chart 
Medication Information Sheets - English 
Medication Information Sheets - Hmong
Medication Information Sheets - Russian
Medication Information Sheets - Spanish
Medication Information Sheets - Vietnamese 

Members' Problem Resolution Posters
Poster - Chinese
Poster - English
Poster - Hmong 
Poster - Russian 
Poster - Spanish 
Poster - Vietnamese

Problem Resolution Guides
Problem Resolution Guide - Chinese 
Problem Resolution Guide - English 
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 - Chinese 
Request for Change of Provider - English
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 - Chinese
Service Verification Card - English
Service Verification Card - Hmong
Service Verification Card - Russian
Service Verification Card - Spanish
Service Verification Card - Vietnamese
 
Suggestion Forms
Suggestion Form - Chinese
Suggestion Form - English 
Suggestion Form - Hmong 
Suggestion Form - Russian 
Suggestion Form - Spanish 
Suggestion Form - Vietnamese

Uniform Method of Determining Ability to Pay (UMDAP) Forms
Frequently Asked Questions: Client and Family Responsibilities for Medi-Cal Billing
Financial Information Form 
UMDAP Request for Fee Waiver/Reduction  
UMDAP Worksheet



 
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