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
Bi-Directional Transition of Care Request (p.1) & Sacramento County Adult Medi-Cal Mental Health Screening Tool (p.2) 
Intensive Services Request 
LOCUS Progress Notes 
Transfer Form

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

Advanced Medical Directive Brochure (English)
Advanced Medical Directive Brochure (Arabic)
Advanced Medical Directive Brochure (Chinese)
Advanced Medical Directive Brochure (Hmong)
Advanced Medical Directive Brochure (Russian)
Advanced Medical Directive Brochure (Spanish)
Advanced Medical Directive Brochure (Vietnamese)

Alcohol & Drug Adult System of Care Brochure (English)
Alcohol & Drug Adult System of Care Brochure (Chinese)

Alcohol & Drug Options for Recovery Brochure (English)
Alcohol & Drug Options for Recovery Brochure (Chinese)
Alcohol & Drug Options for Recovery Brochure (Hmong)

Alcohol & Drug Prevention Services Brochure (English)
Alcohol & Drug Prevention Services Brochure (Chinese)
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 (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)

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Brochure - English
EPSDT Brochure - Chinese  
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 - English 
Grievance Forms - Arabic 
Grievance Forms - Chinese 
Grievance Forms - Hmong 
Grievance Forms - Russian 
Grievance Forms - Spanish 
Grievance Forms - Vietnamese 

Medication Forms 
Medication Conversion Chart 

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

Problem Resolution Guides
Problem Resolution Guide - English
Problem Resolution Guide - Arabic 
Problem Resolution Guide - Chinese
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 - 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 Verification
Service Verification Report Grid
Service Verification Card - English
Service Verification Card - Chinese
Service Verification Card - Hmong
Service Verification Card - Russian
Service Verification Card - Spanish
Service Verification Card - Vietnamese 

Suggestion Forms
Suggestion 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
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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