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Forms: DHCS 1000
DHCS 1008 (04/22) - Jail Services
DHCS 1009 (04/22) - Conservatorships
DHCS 1010 (04/22) - Involuntary Detentions
DHCS 1011 (11/22) - Quarterly Report for Convulsive Treatments and Psychosurgery Administered
DHCS 1012 (12/22) - Program Flexibility Form for Mental Health Rehabilitation Center
DHCS 1013 (12/22) - Program Flexibility Form for Psychiatric Health Facility
DHCS 1735 Medi-Cal (M/C) Certification Transmittal (09/2014)
DHCS 1736 County-Owned and Operated Certification Application (09/2014)
DHCS 1737 County-Owned and Operated Provider Self-Survey Form (09/2014)
DHCS 1746 Director's Designee Information
DHCS 1800 (MH 300): Electroconvulsive Treatment (ECT), Informed Consent Form
DHCS 1800 SP: Electroconvulsive Treatment (ECT), Informed Consent Form (Spanish)
DHCS 1801 (MH 302): Application for Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment
DHCS 1802 (MH 303): Involuntary Patient Advisement
DHCS 1802 SP: Involuntary Patient Advisement (Spanish)
DHCS 1803 (MH 306): Patient Rights Denial - Monthly Talley
DHCS 1804 (MH 307): Denial of Rights/Seclusion & Restraint - Monthly
DHCS 1805 (MH 308): Denial of Rights/Seclusion & Restraint - Quarterly
DHCS 1806 (MH 309): Convulsive Treatments Administered - Quarterly Report (use DHCS 1011)
DHCS 1807 (MH 560): Authorization for Release of Protected Health Information and Confidential Information
DHCS 1807 SP: Authorization for Release of Protected Health Information and Confidential Information (Spanish)
DHCS 1808 (MH 1760): Notice of Certification
DHCS 1809 (MH 1761): Notice of Certification for Additional 14 Days Intensive Treatment
DHCS 1810: Inventory of County 5150 Designated Facilities
DHCS 1811 (MH 5671): Authorization for Release of Patient Information
DHCS 1812 (MH 5756): Voluntary Admission Application for Mentally Disabled Person
DHCS 1813 Application for Licensure - Mental Health Rehabilitation Center (MHRC)
DHCS 1814 Application for Licensure - Psychiatric Health Facility (PHF)
DHCS 1819 Mental Health Services Act (MHSA) Prudent Reserve Assessment/Reassessment
DHCS 1820 Annual MHSA Revenue and Expenditure Report and Adjustment Worksheet County Certification
DHCS 1821 MHSA: Adjustments to Revenue and Expenditure Summary Worksheet
DHCS 1822A Annual MHSA Annual Revenue and Expenditure Report Template and Instructions
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Last modified date: 3/1/2023 3:46 PM
