Clinical Documentation Forms
Contact Information
Contra Costa County Mental Health
Clinical Questions:
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Technical Questions:
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Administrative Forms
Forms Pre 7/1 Post 7/1 MHA-002 - Change of Therapist/Doctor or Change of Diagnosis Form MHA-002 MHA-002 MHA-005 - Client Acknowl of BH Attendance Guidelines Adult MHA-005 /Spanish MHA-005 /Spanish MHA-006 - Client Acknowl of BH Attendance Guidelines Child Adol MHA-006 /Spanish MHA-006 /Spanish MHA-021 - Unusual Occurrence Notification MHA-021 MHA-021 MHA-066 - Void & Replace Request MHA066 coming soon MHA-094 - CCMHP Insurance-Medicare Verification Notification Form MHA094 MHA-094 MHA-095 - CCMHP Insurance-Medicare Payment Notification Form MHA095 MHA-095 -
Clinical Forms
Forms Pre 7/1 Post 7/1 MHC-016 - Targeted Case Management Plan and Level of Care Determination n/a MHC-016 MHC-017 - Progress Note/Service Entry MHC017 MHC-017 MHC-018 Mental Health Client Problem List MHC-018 MHC-018 MHC-022 - Discharge Summary/Billing Form MHC022 MHC-022 MHC-023 - TBS Addendum Treatment Plan MHC023 /Spanish MHC-023 /Spanish MHC-024 - Vocational Services Referral MHC024 MHC024 MHC-025 - TBS Monthly Report MHC025 MHC-025 MHC026 - TBS Termination Report MHC026 MHC-026 MHC-028 - CSI Periodic Data MHC028-4 MHC-028 MHC-029 - Informed Consent for Psychotropic Medications MHC029 /Spanish MHC029 /Spanish MHC030 - Adult Needs and Strengths Assessment - Full MHC030 MHC030 MHC031 - Adult Needs and Strengths Assessment - Brief MHC031 MHC031 MHC-033 - Clinical Assessment - Under 21 MHC-033 use MHC-100 MHC-038 - CSI Timeliness MHC-038 MHC046-2 - Physician Orders & Medication Record MHC046 MHC046 MHC047 - TBS Final Treatment Plan MHC047 /Spanish MHC-047 - TBS Treatment Plan MHC-047 /Spanish MHC-054 - Nursing Progress Note/Billing Form MHC054 MHC-054 MHC-055 - Psychiatrist Progress Note/Billing Form MHC055 MHC-055 MHC-058 - Referral for TBS MHC058 /Spanish MHC-058 - TBS Referral and Authorization MHC-058 /Spanish MHC-096 - Registration MHC096 /Spanish MHC-096 /Spanish MHC-099A - Admission MHC099A use MHC-099 MHC-099B - Discharge: MHC099B use MHC-099 MHC-099 - Admission or Discharge MHC-099 MHC-100 - Clinical Assessment – 21 and Over MHC100 MHC-100 - Clinical/Psychiatric Assessment MHC-100 MHC-107 - Financial Information (Family ATP/UMDAP) MHC107 /Spanish MHC-107 /Spanish MHC-113 - Initial Psychiatric Assessment: MHC-113 use MHC-100 MHC-114 - Annual Psychiatric Assessment: MHC-114 use MHC-100 MHC-118 - Child and Adolescent Needs and Strengths (CANS) MHC-118 /Spanish MHC-118 /Spanish MHC-120 - Pediatric Symptom Checklist MHC-120 /Spanish MHC-120 /Spanish MHC-300 - ICC Eligibility Evaluation MHC300 MHC-300 MHC-301 - CFT Meeting Action Plan - Client Plan of Care MHC-301 MHC-301 MHC-302 - IHBS Referral and Authorization MHC302 MHC-302 MHC-304 - IHBS 12 Month Treatment Review MHC304 MHC-304 MHC-305 - ICC Referral Request MHC305 MHC-305 MHC-306 - Telepsychiatry Progress Note/Billing Form: MHC-306 use MHC-055 -
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 Guide (July 2023)
- ICD-10 Codes
- DSM5 Updates
- Q&A: Functional Assessment Tool for Children and Youth
- CANS Manual
- Notice of Privacy Practices | Spanish (11/10/16)