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Forms: DHCS 1000
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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Last modified date: 1/2/2025 3:59 PM
