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Forms
Below are the Alpine County Behavioral Health Services (ACBHS) forms available online.  
Please click the link to access a PDF version of the form that can be downloaded or printed for your use.

Application for Services/Demographics Form

Authorization for the Use and Disclosure of Health Information Form - Blank - this form is used to allow ACBHS to obtain copies of medical information from external sources if needed.

Grievance and Appeal Form - as a client of ACBHS, you have the right to let us know if you are unhappy or dissatisfied with any matter.  For most matters, you may file a grievance.  If the matter involves an action, you have the right to file an appeal.  This form is used for both of these situations.  Once the form is completed, return it to the ACBHS office, attention Director.

Grievance and Appeal Form (En Espanol) - Como cliente del Conadado de ACBHS, usted tiene el derecho de dejarnos saber si usted no esta contento o esta instisfecho con cualquier asunto.  Para la mayoria de las cosas, usted puede presentar una queja.

Historical Information Form - if desired, this form is to be completed by an individual or family member in the community to inform ACBHS of an individual's mental health history prior to the individual accessing ACBHS services.  The intent of this form is to prepare ACBHS and law enforcement of any existing issues or concerns prior to a mental health emergency so that the history is available during the emergency.  Should you desire to complete this form, please forward it to our main office and it will be maintained in a secured database. 

MHSA Program Evaluation Form - this form is used to evaluate the programs offered through the Mental Health Services Act (MHSA)

Notice of Privacy Practices