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Forms
Below are listed DMH’s most commonly used forms. Simply download whatever forms you need. Each form is available in Acrobat Format as well as in Microsoft Word.
If the form you seek is not listed, email us with your request to Forms-Rcds-Manager, DMH or call us at (916) 654-2372. Please make sure to include your contact information and the number of the form you need.
| Form Number | Title | Download |
|---|---|---|
| MH12 | Mental Health Professional Licensing Waiver Request | PDF  Word  |
| MH1760 | Notice of Certification | PDF Word |
| MH1761 | Notice of Certification for Additional 14 Days Intensive Treatment | PDF Word |
| MH300 | Electroconvulsive (ECT), Informed Consent Form | English -PDF , Word Spanish - PDF , Word |
| MH302 | Application for 72 Hour Detention for Evaluation and Treatment | PDF Word |
| MH303 E/S | Involuntary Patient Advisement | English - PDF , Word Spanish - PDF , Word |
| MH306(rev 01-08) | Patient Rights Denial-Monthly Talley | PDF Word |
| MH307 | Denial of Rights/Seclusion & Restraint Monthly | PDF Word |
| MH308 (formerly MH1072) | Denial of Rights/Seclusion and Restraint Quarterly | Contact: Office of Human Rights (916) 654-2327 |
| MH309 | Convulsive Treatments Administered-Quarterly Report |
PDF Excel  |
| MH560 | Authorization for Release of Protected Health Information and Confidential Information | English
- Word
Spanish - Word |
| MH5150 | Annual Blank 5150 Inventory Form | PDF Word |
| MH5388 | Vocational Services Discharge Summary | PDF Word |
| MH5671 | Authorization for Release of Patient Information | PDF |
| MH5756 | Voluntary Admission Application for Mentally Disabled Person | PDF Word |