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.

Advanced Directives - this brochure explains Advanced Directives and answers questions about Advanced Directives

Advanced Directives (En Espanol) - este folleto explica Directivas Avanzadas y responde preguntas sobre Direcivas Avanzadas.

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.

CIT (Crisis Intervention Team) 911 Assistance - this brochure explains how to prepare for a mental health emergency, and how to interact with the 911 operator to ensure safety in a mental health emergency, and what to expect. Having a completed Historical Information Form (link below) on file prior to a mental health emergency is helpful to all involved.

EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) Services - this brochure explains EPSDT services and answers questions about EPSDT services.

EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) Services (En Espanol) - este folleto explica los servicios de EPSDT y responde preguntas sobre los servicios de EPSDT.

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.

Informed Consent - in order to provide you or your child outpatient behavioral health services, it is necessary to obtain your INFORMED CONSENT. This form explains informed consent and provides the opportunity for your consent.

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

Problem Resolution Process - if you have a suggestion, grievance or wish to file an appeal, this form explains the process and provides you the opportunity to complete the form to be submitted. Interpreter services are available if needed.

TBS (Therapeutic Behavioral Services) - this brochure is for children and young people, under 21 years of age, who have full-scope Medi-Cal and for the families or caregivers of those children and young people. It explain that a Medi-Cal mental health service called Therapeutic Behavioral Services (TBS) is available from Alpine County Behavioral Health Services.