Clinical Documentation Forms
Contact Information
Contra Costa County Mental Health
Clinical Questions:
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Technical Questions:
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Administrative Forms
- MHA002 - Change of Therapist/Doctor or Change of Diagnosis Form (4/17)
- MHA-013 - ShareCare and Report Folder Access Request Form (2/21)
- MHA-021 - Unusual Occurrence Notification (8/21)
- MHA-031 - MRN/Demographic Update Request (02/21)
- MHA036 - Request for Eligibility Verification (01/18)
- MHA066 - Void & Replace Request (8/21)
- MHA094 - CCMHP Insurance-Medicare Verification Notification Form (10/15)
- MHA095 - CCMHP Insurance-Medicare Payment Notification Form (06/18)
- MHA098 - Appeal Submission Checklist (06/18)
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Clinical Forms
- MHC015 - TBS Monthly Service Authorization (04/18)
- MHC017 - Progress Note/Service Entry (3/22)
- MHC021-7 - Partnership Plan for Wellness Template | Spanish (3/14)
- MHC022 - Discharge Summary/Billing Form (3/22)
- MHC023 - TBS Addendum Treatment Plan (04/18)
- MHC024 - Vocational Services Referral (3/10)
- MHC025 - TBS Monthly Report (04/18)
- MHC026 - TBS Termination Report (04/18)
- MHC027 - TBS Preliminary Treatment Plan (04/18)
- MHC028-4 - CSI Periodic Data Form (10/08)
- MHC029 - Informed Consent for Psychotropic Medications | Spanish (10/18)
- MHC030 - Adult Needs and Strengths Assessment - Full (08/20)
- MHC031 - Adult Needs and Strengths Assessment - Brief (08/20)
- MHC-032 - Initial Clinical Assessment 0-5 years old (3/22)
- MHC-033 - Initial Clinical Assessment - Clients 6-20 years old (3/22)
- MHC036-6 - Service Authorization (04/17)
- MHC046-2 - Physician Orders & Medication Record (7/09)
- MHC047 - TBS Final Treatment Plan (04/18)
- MHC055 - Psychiatric Progress Note/Billing Form (3/22)
- MHC058 - Referral for Therapeutic Behavioral Services (10/20)
- MHC062-4 - WRAP Progress Note/Billing Form (3/22)
- MHC-065 - Annual Clinical Assessment 0-5 years old (3/22)
- MHC-066 - Annual Clinical Assessment – Clients 6-20 Years Old (3/22)
- MHC085 - TBS Provider Request for Payment & Authorization (04/18)
- MHC-096 - Registration | Spanish (08/20)
- MHA098 - Appeal Submission Checklist (06/18)
- MHC-099A - Admission (06/18)
- MHC-099B - Discharge (06/18)
- MHC100 - Initial Clinical Assessment for Clients Age 21 and Above (3/22)
- MHC102 - Annual Clinical Update for Clients Age 21 and Above (3/22)
- MHC105 - Psychiatric Partnership Plan Template | Spanish (7/17)
- MHC-107 - Financial Information | Spanish (08/20)
- MHC110 - Psychiatrist-RN TxPlan Child (12/12)
- MHC113 - Initial Psychiatric Assessment (3/22)
- MHC114 - Annual Psychiatric Assessment (3/22)
- MHC118 - Child and Adolescent Needs and Strengths (CANS) | Spanish (12/20)
- MHC-120 - Pediatric Symptom Checklist | Spanish (10/18)
- MHC300 - ICC Eligibility Evaluation (3/22)
- MHC301 - CFT Meeting Action Plan and Progress Summary (04/17)
- MHC302 - IHBS Referral and Authorization (07/21)
- MHC303 - IHBS 9 Month Treatment Review (04/17)
- MHC304 - IHBS 12 Month Treatment Review (04/17)
- MHC305 - ICC Referral (08/21)
- MHC306 - Telepsychiatry Progress Note/Billing Form (3/22)
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Intake Forms
- Adult - Patient Health Questionnaire - PHQ9 - GAD7
- Authorization to Receive Medical Information MR15-A
- MR463-1 - Consent to Service | MR463A-1/Spanish
- MR673 - Caregiver's Authorization Affidavit | MR674/Spanish
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Documents
- Clinical Documentation Manual Revised June 2021
- Inpatient Included Diagnosis List (2/08/21)
- Outpatient Included Diagnosis List (2/09/21)
- DSM5 Update: 2017 | 2016
- Q&A: Functional Assessment Tool for Children and Youth
- CANS Manual
- Notice of Privacy Practices | Spanish (11/10/16)
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CalAIM forms for 7/1/22
- MHC017 - Progress Note/Service Entry
- MHC018 - Client Problem List
- MHC033 - Clinical Assessment – Under 21
- MHC054 - Nursing Progress Note/Billing
- MHC055 - Psychiatrist Progress Note/Billing
- MHC100 - Clinical Assessment – 21 and Over
- MHC301 - Child and Family Team Meeting Action Plan – Client Plan of Care
- MHC306 - Telepsychiatry Services Progress Note/Billing