Clinical Documentation Forms
Contact Information
Contra Costa County Mental Health
Clinical Questions:
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Technical Questions:
ShareCare Forms have now been integrated with the rest of the forms
*MHC - Mental Health Clinical • MHA - Mental Health Administrative
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MHC* Forms
- MHC017 - Progress Note/Service Entry (06/19)
- MHC018-7 - Children/Adolescent Medical Necessity Criteria (04/17)
- MHC021-7 - Partnership Plan for Wellness | Spanish (3/14)
- MHC022 - Discharge Summary (7/13)
- MHC024 - Vocational Services Referral (3/10)
- MHC028-4 - CSI Periodic Data Form (10/08)
- MHC029 - Informed Consent for Psychotropic Medications | Spanish (03/19)
- MHC(SC)-033 - Initial Clinical Assessment for Children (09/18)
- MHC036 - Request for Eligibility Verification (01/18)
- MHC036-6 - Service Authorization (04/17)
- MHC046-2 - Physician Orders & Medication Record (7/09)
- MHC055-9 - Psychiatric Progress Note/Billing Form (04/17)
- MHC058 - Referral for Therapeutic Behavioral Services (07/17)
- MHC062-4 - WRAP Progress Note/Billing Form (04/17)
- MHC(SC)-065 - Annual Clinical Update for Children (09/18)
- MHC(SC)-096 - Registration | Spanish (08/18)
- MHC(SC)-099A - Admission (06/18)
- MHC(SC)-099B - Discharge (06/18)
- MHC100 - Initial Clinical Assessment for Adults (04/17)
- MHC102 - Adult Annual Clinical Assessment Update (04/17)
- MHC105 - Psychiatric Partnership Plan | Spanish (7/17)
- MHC(SC)-107 - Financial Information | Spanish (08/18)
- MHC110 - Psychiatrist-RN TxPlan Child Form (12/12)
- MHC113 - Initial Psychiatric Assessment Form (04/17)
- MHC114 - Psychiatric Assessment Update Form (04/17)
- MHC(SC)-118 - Child and Adolescent Needs and Strengths (CANS) (10/18)
- MHC(SC)-120 - Pediatric Symptom Checklist | Spanish (10/18)
- MHC300 - ICC Eligibility Screening (08/17)
- MHC301 - CFT Meeting Action Plan and Progress Summary (04/17)
- MHC302 - IHBS Referral and Authorization (04/17)
- MHC303 - IHBS 9 Month Treatment Review (04/17)
- MHC304 - IHBS 12 Month Treatment Review (04/17)
- MHC305 - ICC Referral (08/17)
MHA* Forms
- MHA002 - Change of Therapist/Doctor or Change of Diagnosis Form (4/17)
- MHA(SC)-013 - ShareCare Access and Training Request for CBO's (11/18)
- MHA(SC)-031 - MRN/Demographic Update Request (08/18)
- MHA066 - Service Disallowed/Void & Replace Request (2/19)
- MHA094 - CCMHP Insurance-Medicare Verification Notification Form (10/15)
- MHA095 - CCMHP Insurance-Medicare Payment Notification Form (06/18)
- MHA098 - Appeal Submission Checklist (06/18)
- MHA31 - Request for Client Medical Record Number (10/15)
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MHC* Templates (Fillable)
- MHC015T - TBS Monthly Service Authorization (04/18)
- MHC017T - Progress Note/Service Entry Template (06/19)
- MHC021-7T - Partnership Plan for Wellness Template | Spanish (3/14)
- MHC022T - Discharge Summary Template (7/13)
- MHC023T - TBS Addendum Treatment Plan (04/18)
- MHC025T - TBS Monthly Report (04/18)
- MHC026T - TBS Termination Report (04/18)
- MHC027T - TBS Preliminary Treatment Plan (04/18)
- MHC029T - Informed Consent for Psychotropic Medications | Spanish (10/18)
- MHC(SC)-033T - Initial Clinical Assessment for Children (09/18)
- MHC036T - Request for Eligibility Verification (01/18)
- MHC047T - TBS Final Treatment Plan (04/18)
- MHC055-9T - Psychiatric Progress Note/Billing Form Template (04/17)
- MHC058T - Referral for Therapeutic Behavioral Services (06/18)
- MHC062-4T - WRAP Progress Note/Billing Form (04/17)
- MHC(SC)-065T - Annual Clinical Update for Children (09/18)
- MHC085T - TBS Provider Request for Payment & Authorization (04/18)
- MHC(SC)-096 - Registration (08/18)
- MHA098T - Appeal Submission Checklist (06/18)
- MHC(SC)-099AT - Admission (06/18)
- MHC(SC)-099BT - Discharge (06/18)
- MHC100T - Initial Clinical Assessment Adult Template (04/17)
- MHC102T - Adult Annual Clinical Assessment Update Template (4/17)
- MHC105T - Psychiatric Partnership Plan Template | Spanish (7/17)
- MHC(SC)-107 - Financial Information (08/18)
- MHC110T - Psychiatrist-RN TxPlan Child (12/12)
- MHC113T - Initial Psychiatric Assessment Template (4/17)
- MHC114T - Psychiatric Assessment Update Template (4/17)
- MHC(SC)-118T - Child and Adolescent Needs and Strengths (CANS) (10/18)
- MHC(SC)-120T - Pediatric Symptom Checklist | Spanish (10/18)
- MHC300T - ICC Eligibility Screening (08/17)
- MHC301T - CFT Meeting Action Plan and Progress Summary (04/17)
- MHC302T - IHBS Referral and Authorization (04/17)
- MHC303T - IHBS 9 Month Treatment Review (04/17)
- MHC304T - IHBS 12 Month Treatment Review (04/17)
- MHC305T - ICC Referral (08/17)
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Documents
- Outpatient Included Diagnosis List (4/01/19)
- DSM5 Update: 2017 | 2016
- Q&A: Functional Assessment Tool for Children and Youth
- CANS Manual
- Clinical Documentation Manual 2017
- CCMHP Documentation Training Manual 2014
- DSM5 Crosswalk (1/01/18)
- Notice of Privacy Practices | Spanish (11/10/16)