• 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 1801 SP: Application for up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment (Spanish)
  
• 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 for Intensive Treatment Pursuant to Section 5250 (14 DaysIntensive Treatment) or 5270.15 (Additional 30 Days Intensive Treatment for Grave Disability) of the Welfare and Institutions Code
• DHCS 1808 SP: Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 DaysIntensive Treatment) or 5270.15 (Additional 30 Days Intensive Treatment for Grave Disability) of the Welfare and Institutions Code (Spanish)
  
• 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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