endstream endobj 41 0 obj <>/Subtype/Form/Type/XObject>>stream Give your local county office your updated contact information so you can stay enrolled. For your convenience, virtual interviews are available. E-mail: prr@sb-court.org. H237402VH2P0P037U03U(JJ*2T0T0BC#S\.1* e Winner of 82 national awards for innovation, efficiency, and public service. Below are a few helpful hints on how to navigate . Who should report allegations of abuse or neglect? Child Abuse Reporting Policy: 05/13/2021 CHD0303 Child Abuse Reporting Procedure . To speak to someone about behavioral health services, call 888.743.1478. 0 0 8.25 9 re of Industrial Relations web site. Step 2: A Code Enforcement Officer will conduct an exterior inspection of the property to verify compliance with the County's requirements. to resolve your issue through the complaint resolutions listed on the right. Mental Health Consumer Perception Survey-Fall 2019 New! endstream endobj 33 0 obj <>/Subtype/Form/Type/XObject>>stream H*2T0T037U03U(J e-Prescribing Chart Documentation (12/07/2016) New! endstream endobj 40 0 obj <>/Subtype/Form/Type/XObject>>stream Partnering with parents and the community to deliver reliable child support services to make a positive difference in the lives of children. when an social worker,caseworker at CPS has clearly undermine her family for 8 years & others. California Children's Services Forms. If you need CPS help in California, contact Christopher R. Abernathy, APLC, a local practice in San Bernardino, for legal representation. H237402VH2P0P037U03U(JJ*2T0T0BC#S\.1* e This site uses cookies to enhance site navigation and personalize your experience. The California Public Records Act is found in the California Government Code, beginning at Section 6250. endstream endobj 30 0 obj <>/Subtype/Form/Type/XObject>>stream 0 K t 1. Complete the CPS Records Request Form below and fill it out with as much information as possible. A hotline for impacted residents is open from Monday through Friday, 8 a.m. to 7 p.m. at (909) 356-2563. endstream endobj 53 0 obj <>/Subtype/Form/Type/XObject>>stream New Medicare Beneficiary Identifier (MBI) New! endstream endobj 44 0 obj <>/Subtype/Form/Type/XObject>>stream Child Welfare Services Child Abuse Hotline Child Abuse Hotline For more information, or to report suspected child abuse, call 858-560-2191. Child Abuse Hotline (800) 827-8724 Child Abuse Prevention/Safe Kids (909) 383-9677: Child and Family Health . Please enable scripts and reload this page. Step 2: Fill out your forms completely. Please be advised that incomplete or inaccurate information may delay the processing of your request. 0.749023 g Samples can be emailed to you by request at: selfhelpforms@sb-court.org. f endstream endobj 55 0 obj <>/Subtype/Form/Type/XObject>>stream A ^ 0.749023 g Vice Chairman/Supervisor First District Jesse Armendarez 0 0 6.75 7.5 re State of California's, Department 1435 0 obj <>/Encrypt 1346 0 R/Filter/FlateDecode/ID[<335AAE7A7B830041B320609C06D4D458><59DEEA9921E0A542ADF5998D03769A5E>]/Index[1345 242]/Info 1344 0 R/Length 160/Prev 807907/Root 1347 0 R/Size 1587/Type/XRef/W[1 3 1]>>stream f Missing payments increase your amount owed. Easily fill out PDF blank, edit, and sign them. Child Abuse Hotline for San Bernardino County is. endstream endobj 39 0 obj <>/Subtype/Form/Type/XObject>>stream Help Count the Unsheltered and Make a Difference. Complete CA CFS 125 CPS - San Bernardino County 2013-2022 online with US Legal Forms. 90&L$S` V: Follow the installation instructions on Adobe's web site to properly install and configure the Acrobat Reader. H*2T0T0342E\\y\FPn.6RBVT+ Child Abuse Report. the san bernardino county sheriff's department, in partnership with california state university of san bernardino and california baptist university, provides evidence-based interventions for inmates to improve family relations, mitigate factors leading to self-destructive life patterns, reduce recidivism, and promote overall healthy functioning Former foster youth perseveres, becomes veterinarian. Phone : 800.722.3181 Records of San Bernardino County which are not exempt from disclosure are available for inspection and copying in accordance with the California Public Records Act upon a request that reasonably describes an identifiable record or records. f Assistance with Family law, Child support, Landlord/tenant, and more. 1586 0 obj <>stream Rancho Cucamonga. Box 6083 San Bernardino, CA 92412 Fax the completed SS 8572 form to: Children and Family Services at (909) 891-3545 or (909) 891-3560 11-22, Affordable Care Act (ACA) 1557 Grievance Procedure, Behavioral Health Services for Clients/Family, Field Testing of Written Materials Policy, Field Testing of Written Materials Procedure, Providing Interpretation Services Procedure, Providing Written Communications in Threshold/Primary Languages for Consumers/Family Members Policy, Incorporated Employees Fiscal Control Procedures, Guidelines For Psychiatrists Assigned to Outpatient Clinics, Deviation from Standard of Practice of Medicine, Control, Access and Accountability of Medications and Medical Supplies Policy, Control, Access and Accountability of Medications and Medical Supplies Procedure, Controlled Substance Utilization Review and Evaluation System (CURES) Policy, Controlled Substance Utilization Review and Evaluation System (CURES) Procedure, Handling of Contaminated Waste/Needles and Syringes, Consent for Administration of Psychotropic Medication to Minors Policy, Laboratory Services/Physical Assessment Policy, Laboratory Services/Physical Assessment Procedure, Medication Authorization for Dependent Children and Youth Policy, Urgent and Emergency Conditions Procedure, Control and Organization of the Standard Practice Manual (SPM) Policy, Requests to Modify Standard Practice Manual Procedure, Department Vision, Mission and Values Policy, Public Information and Media Release Policy, Reimbursement for Travel and Related Expenses, Use of Supplies and Equipment/Notification of Loss or Damage, Furniture and Equipment Relocation Procedure, Assignment of Pagers to Divisions/Programs and Staff, Facility Physical Security and Access Control Policy, Facility Physical Security and Access Control Procedures, Billing and Collection for Treatment Services Policy, Guidelines for Promotional, Educational, and/or Informational Materials, DBH Review Panel for Promotional, Educations, and/or Informational Materials, Review of Promotional, Educational and/or Informational Materials Procedure, Assignment, Closure, Merger or Relocation of Clinics Policy, Closure of DBH Contract Provider Procedure, Assignment of DBH Contract Provider Procedure, Merger of DBH Contract Provider Procedure, Medi-Cal Claim Certification of Authenticity Policy, Intra-Department Reassignment Policy (Supersedes-Employee Reassignment Requests), Waiver for Pre-Licensed/Out-of-State Licensed Ready Psychologists, Registration and Licensure Requirements for Clinical Therapists, Volunteer Request and Registration Procedure, Non-Discrimination / Equal Employment Opportunity, Time and Attendance Form How to Complete, Position Transfer Reassignment & Borrowing Policy, Position Transfer Reassignment & Borrowing Procedure, Procedure for Purchasing Computer Equipment, Request for Information Technology Support Procedure, Computer and Network Appropriate Use Policy, Superseded by myAvatar User Account Creation and Reinstatement Procedure, QShort-Doyle and Short-Doyle/Medi-Cal Clinic Change of Ownership or Location, Requesting an Initial Choice of Provider or Change of Provider Procedure, Requesting an Initial Choice of Provider or Change of Provider Policy, Quality Management Committee Membership/Participation, Pre State Chart Audit Responsibilities & Procedures, Billing Guidelines for Quality Assurance Activities, Outpatient Chart Audit Site Review Policy, Investigating and Reporting Death of a DBH Client, SAMHSA Block Grant-Annual Program Review Procedure, Standard and Expedited Resolution of Appeals Procedure, Consistency in Inpatient and Outpatient Utilization Review and Authorization Practices Policy, Consistency in Inpatient Utilization Review and Authorization Practices Procedure, Consistency in Outpatient Utilization Review and Authorization Practices Procedure, MHP Point of Authorization Plan for Inpatient Psychiatric Hospitalization Protocol, Selection and Retention of Network Provider Policy, Department Liability for Employees and Volunteers Action Outside Work, Electrical Safety Policy: Personal Appliances, Threats Against Federal or State Officials Policy, Threats and Assault on DBH Staff Procedure, Special Incident Reporting Procedure Client Related, Occupational Injury or Illness Reporting Procedure, Local Community Crisis Incident Response Procedure, Office Ergonomics Intervention Program Policy, Interagency Communication of Unusual Events Procedure. 0 0 8.25 9 re Mail the completed SS 8572 form to: Child Abuse Hotline P.O. Box 1359 Susanville, CA 96130-1359 Website Los Angeles County Department of Children & Family Services H*2T0T007U0332U(J Information on how to report child abuse or make complaints. 0.749023 g However. of Industrial Relations web site. County Code and Charter Substance Use Disorder and Recovery Services Policy, Substance Use Disorder and Recovery Services Procedure, Naloxone Intranasal Distribution Procedure, Client Tuberculosis (TB) Testing and Services Policy, Client Tuberculosis (TB) Testing and Services Procedure, myAvatar Electronic Health Records Policy, myAvatar User Account Creation and Reinstatement Procedure, myAvatar User Account Modification Procedure, myAvatar User Account Deactivation Procedure, Criteria for Beneficiary Access to SMHS Medical Necessity and other Requirements, No Wrong Door for Mental Health Services Policy, Revised Mental Health Co-Staffing Chart Documentation a, Personal Protective Equipment (PPE) for DBH Programs, Quality Management Chart Documentation Guidance due to, New Classification of Other Qualified Providers, Coronavirus (COVID-19) Information for DBH Workforce, Mental Health Consumer Perception Survey Spring 2019, DMC-ODS UCLA Treatment Perception Survey-October 2019, Notice of Changes to EPSDT Data Collection Requirements, Editing Notice of Adverse Benefit Determination (NOABD). San Bernardino County Workforce Development Board, Community Policy Advisory Committee (CPAC), Cultural Competency Advisory Committee (CCAC), Behavioral Health Commission (BHC) Meeting is Going Dark. 0.749023 g This automated system provides customers with up-to-date information about their case such as benefit amount, worker information, office location and the ability to request forms to be mailed. Winner of 82 national awards for innovation, efficiency, and public service. In cases of an immediate emergency, always call 9-1-1 for Law Enforcement intervention. Get CA CFS 125 CPS - San Bernardino County 2013-2022 Get form. %%EOF 2307rYF %%EOF font (Spanish) 06/28/2022 QM047_S Translation Service Request Form . Services are provided in person, by phone, online, and by email. endstream endobj 26 0 obj <>/Subtype/Form/Type/XObject>>stream 0 `$ IU#q4QCP"@y2P[{[SI(1Yr=MOS`z1 Q`R)d\zOH45|6s5K1)==Aw,13#fR;di$a')0yhLXavVBLjU"5=%PAKaa .IkTf8,MkH63PrQ`5A6LgjZbiT-sIjb$Ujrp[-Dem2S+mL#9by6MZ,U1ejXlFe4&mtN. As a team, Human Services departments collaborate with community partners to provide a wide range of quality programs and services that address the changing and emerging needs of county residents. 0.749023 g Report Suspected Child Abuse or Neglect If you suspect that a child's health or safety is jeopardized due to abuse or neglect by parents or other caretaker who has custody of the child, contact the child protective services agency in your county. endstream endobj 47 0 obj <>/Subtype/Form/Type/XObject>>stream report abuse california. Forms & Publications . endstream endobj 34 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 35 0 obj <>/Subtype/Form/Type/XObject>>stream f In alignment with the Countywide Vision to create a county in which those who reside and invest are able to prosper and achieve well-being, Human Services works to build a healthy community by strengthening individuals and families, enhancing quality of life and valuing people. The Department of Children and Family Services encourages everyone to report suspected child abuse and neglect, however, certain professionsare mandated to report suspected child abuse and neglect. font (English), Adolescent (Age 12-17) and Young Adult ASAM Level of Care Screening. I am an older adult and need help taking care of myself. H*2T0T0 247 West Third Street, 11th Floor. San Bernardino County 211 get connected. 21 0 obj <> endobj Try it today! 0 k Lassen County Community Social Services Department & Children & Family Services Ms. Jenna Ducasse, Director P.O. #D San Bernardino , San Bernardino 92415 (Physical) Get directions Site Hours Monday through Sunday, 24 hours per day. Welcome to San Bernardino County America's largest county. 2023 San Bernardino County | . Website 2\`q#=csS&c. Once completed, the request form may be emailed (preferred method) as an attachment to CPSGatekeeper@saccounty.gov . H237402VH2P0P32UT(JJ*2T0T0D|3@.XHT! % Job Assistance, Stay informed about SB County eventsand news through ourYouTube Playlist, Sat, December 10, 2022, 10:00 AM - Sun, June 11, 2023, 4:00 PM, Wed, January 18, 6:00 PM - 7:00 PM + 6, Click to see more. 123 0 obj <>/Filter/FlateDecode/ID[<4E5FEE2E7615B60FE59503200306F587>]/Index[21 218]/Info 20 0 R/Length 225/Prev 152285/Root 22 0 R/Size 239/Type/XRef/W[1 2 1]>>stream endstream endobj 36 0 obj <>/Subtype/Form/Type/XObject>>stream Request for Second Opinion QM048_E Revised! File a USDA program discrimination complaint? It looks like your browser does not have JavaScript enabled. H237402VH2P0P *{Dt8P *7,Jccd0%m3lz%tDE}vdYiBiplo+4 endstream endobj 22 0 obj <> endobj 23 0 obj <> endobj 24 0 obj <> endobj 25 0 obj <>/Subtype/Form/Type/XObject>>stream 2023 San Bernardino County | Department of Behavioral Health | Privacy Policy | Accessibility | Newsletter Sign-up | Site Map. ,&?(bYY Vb4*LgPr`2GH X, 9974|3/ Wy8L@O q][Wk9URk#w+mr5A! Read more at CountyWire. for appropriate follow-up and related document completion. Call 877.410.8829 Live agents are available Monday-Friday from 7 a.m. - 5 p.m. Stay informed with new authentication options! 0.749023 g For graffiti abatement, call 1.877.442.2283. If you need to file a claim for Workers Compensation please report to your supervisor 11118 Elm Avenue, Rancho Cucamonga, CA 91730. Contact Us Visit Website View Profile. Standing Order Requirement for Administering NARCAN. APS - Central Intake. For Financial Institutions If you are interested in viewing a PowerPoint presentation on financial abuse, please click here: Please turn on JavaScript and try again. endstream endobj 43 0 obj <>/Subtype/Form/Type/XObject>>stream (Courtesy of Eric Bahra) Two children disclosed that the foster father had sexually . San Bernardino County size in square miles, Incorporated cities in San Bernardino County, Auditor-Controller/Treasurer/Tax Collector, George Air Force Base: Commemorating Its Legacy 30 Years Later Exhibit. Services. The forms may be posted on their site. Request for Second Opinion (Spanish) QM048_S Revised! CFS 125 CPS (1/13) SAN BERNARDINO COUNTY CHILDREN and FAMILY SERVICES REPORT OF MEDICAL / DENTAL EXAM FOR HEALTH PASSPORT UPDATE FAX or RETURN in the POSTPAID ENVELOPE FFA must give original to social worker or PHN PUBLIC HEALTH NURSE . hbbd```b``" 0i"H`s.8C>nf"Ynu8X8=L?jd &7$+: ,"y3L`qQr&):w4"3p vkJ4 The applicant must submit a completed Interior Checklist & Owner Acknowledgement to . "San Bernardino County [and] CPS are on notice," Carter warned. font (Spanish), Opioid Agreement for Buprenorphine Medication Assisted Treatment (Spanish), Opioid Agreement for Buprenorphine Medication Assisted Treatment (English), Beneficiary Nondiscrimination Notice (Mandarin), Beneficiary Nondiscrimination Notice (Vietnamese), Your Rights Attachment (NOABD) (Mandarin), Your Rights Attachment (NOABD) (Vietnamese), Change of Provider Request Form 18pt. Step 1: Apply online through the County's Portal, and submit the $667 initial application fee. The San Bernardino County District Attorney's Office serves the residents, business owners, and visitors of San Bernardino County, California. To download a form (in PDF format), click on the form number in the appropriate table. The Hotline is contacted when a member of the community has a concern regarding potential abuse or neglect of a child. Box 1359 Susanville, CA 96130-1359 Website Lassen County Health & Social Services Agency Ms. Barbara Longo, Director P.O. 24 Hour Hotline 1-877-565-2020 : Video Announcements. Americas largest county. If you suspect that a child has been, or is in danger of, abuse or neglect , contact the county Children's Protective Services 24-hour emergency response phone. Improves the well-being of children, empowers families and strengthens communities. Consolidation of Electronic Signature (E-Signature). endstream endobj 45 0 obj <>/Subtype/Form/Type/XObject>>stream To file a claim against the County please complete the form below, print, sign and This year, San Bernardino County settled a lawsuit for $7.5 million in a case that alleged that a county social worker was aware of sexual abuse in the foster care system and failed to report it. H4 07M% HR>pRY=^Xqd wy0` S. You will need to pay the fee or submit a Request to Waive Court Fees. endstream endobj 27 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 31 0 obj <>/Subtype/Form/Type/XObject>>stream Our job is to create a county in which those who reside and invest can prosper and achieve well-being. f Save or instantly send your ready documents. Call (833) 526-5197 to schedule a consultation to get your immediate questions answered and get the legal representation you need. endstream endobj 28 0 obj <>/Subtype/Form/Type/XObject>>stream Enhances the quality of life in the community by administrating support programs to persons in need of financial, nutritional and/or medical assistance while working with families and individuals to attain self-sufficiency. (PC Section 11165.9.) To file a claim against the County please complete the form below, print, sign and send to the address listed on the form. Create this form in 5 minutes! 238 0 obj <>stream 2. WHITE COPY-Police or Sheriff's Department; BLUE COPY-County Welfare or Probation Department; GREEN COPY-District Attorney's Office; YELLOW COPY-Reporting Party SS 8572 (12/02) Page 2 of 2 Title H*2T0T0W0332U(J County Budget 2018 Superior Court of California, County of San Bernardino, All Rights Reserved |, COVID-19: COURT OPERATIONS DURING THE COVID-19 PANDEMIC, Family Court Services Orientation Class Info, Failure to Appear/Respond to a Jury Summons, Court Case Information and Document Sales, How to Navigate San Bernardino Superior Court, San Bernardino Superior Court Rules of Practice, Local Emergency Rules Related to COVID-19, Online Form Preparation and Filing (TurboCourt), Online Form Preparation and eFiling (TurboCourt), Stipulation For Settlement (CCP 664.6) (fillable), Proof of Service Notice of Appeal (Code Enforcement), Appeal Procedures for Unlimited Civil Cases (Information on), Declaration of Petitioner and Request for Records Check, General Civil Case At-Issue Memorandum (fillable), Declaration and Order Re: Satisfaction of Judgment, CONFIDENTIAL Referral for CII/Carpos/ICMS Report (Civil) - Form A, Order Request for Review of Denial of Request to Remove Name from Gang Database, Initial Trial Setting Conference Statement, Application for Diversion of Individual with Mental Disorder, Order on Application for Diversion of Individual with Mental Disorder, Declaration and Order for Release of Exhibits, Consent to Bring Prohibited Items into the Courthouse as Exhibits (fillable), Stipulation And Order On Request For Order, Referral for CII/CARPOS/ICMS Report (fillable), Family Law At-Issue Memorandum for Trial Setting, Declaration And Order For Issuance Of Writ Of Execution/Abstract Of Judgment (fillable), Order On Petition For Grandparent Visitation, Response To Petition For Grandparent Visitation, Declaration Re: Compliance with Custody Orders (fillable), Petition for Declaring Child(ren) Free from Parental Custody and Control, Citation - Freedom from Parental Custody and Control, Order Declaring Child(ren) Free from Parental Custody and Control, Order on Petition to Terminate Parental Rights of Alleged Father, Petition to Terminate Parental Rights of Alleged Father, Declaration and Order Dispensing with Notice to Alleged Father, Petition to Obtain Original Unsealed/Un-Redacted Birth Certificate, Order on Petition to Obtain Original Unsealed/Un-Redacted Birth, Order on Petition for Birth Record Information, Application to Obtain Final Adoption Order and Order, Application to Obtain Copies from Adoption Case and Order, Petition for Adoption of Adult or Married Minor, Agreement of Adoption of Adult or Married Minor, Consent of Spouse of Adult or Married Minor to be Adopted, Stipulation for Entry of Judgment Re: Establishment of Parental Relationship, Order for Publication of Citation (Adoption), Application for Order for Publication of Citation (Adoption), Notice of Continuance of Hearing (Family Law), Declaration Regarding Objection to Agreement, Family Law/Child Support Copy Request Form, Affidavit/Certificate/Declaration Re: Military Service in an Adoption and Related Matters, Order for Publication of Summons or Citation, Application for Publication of Summons or Citation, Request for Dismissal -- Small Claims Cases, Declaration of Mailing or Inability to Ascertain Address (fillable), Request to Excuse Notice with Due Diligence Declaration, Audio CD Information Sheet and Order Form, Petition for Release of Jury Records and Order, Objection/Response to Packet (Delinquency), Objection/Response to Packet (Dependency), Certification of Competency (Delinquency), Response to Petition for Resentencing (Juvenile), Proof of Service - Juvenile Restraining Order, Ex Parte Application And Order To Serve Summons By Posting, Application for Judgment for Restitution of Premises Only (CCP1169) (fillable), Pretrial Orders Judgment By Court Unlawful Detainer (fillable), To Set Case for Trial - Unlawful Detainer, Application for Issuance of Writ of Execution Per CCP 712.010, Small Claims/Landlord Tenant Copy Request Form, Order Appointing Counsel For Conservatee, Probate Code Sections 1470, 1471, and 2356.5(f)(1), Petition for Visitation (Guardianship Cases Only), Order on Petition for Visitation (Guardianship Cases Only), Order Appointing Counsel For Minor, Probate Code Sections 1470 and 1516.5 (fillable), Notification of Court of Conservatorship Address, Confidential Guardianship Questionnaire and Authorization for Release of Information, List of Required Contact Information for Conservatorships, Optional Attachment to List of Required Contact Information for Conservatorships, Confidential General Care Plan of Conservatee, Ex Parte Petition to Dispense with Accounting and Order (fillable), Request for Deferment of Court Investigator Fee and Order, Affidavit to Comply with California Probate Code 13100-13115, Termination of Guardianship - Parent Questionnaire, Notification of Disqualification from Voting, Notice of Commencement of Proceedings for a Court Supervised Trust, Confidential Information Sheet - Conservatorship, Confidential Information Sheet - Guardianship, Confidential Information Sheet - Intestate Probate, Confidential Information Sheet - Testate Probate, Confidential Information Sheet - Trust Matters, Request for Consideration of Ability to Pay, Waiver of Arraignment & Court Trial Setting. H*2T0T007 *CASES IN SAN BERNARDINO COUNTY* Please review the following San Bernardino County sample forms: Form CFS 2w -Grievance Procedures Regarding Placement, Care and Removal of Children Form CFS 7D - Notice of Removal and Grievance Review Request (fill out second page to request a grievance review hearing). H237402VH2P0P0342E\i\\ Submit the original + 2 copies of ALL the completed paperwork to the clerk's office in San Bernardino at 247 W. 3rd Street, 2nd Floor. 1. can be found on the State of California's, Department Use Arrears calculator to figure out balance. Final settlement reached in San Bernardino Jail Class Action - San Bernardino County Sheriff's Department December, Headquarters, Press Releases for 2018 FOR IMMEDIATE RELEASE FINAL SETTLEMENT REACHED IN SAN BERNARDINO JAIL CLASS ACTION Contacts: Public Affairs Division, Sheriff's Department Public Affairs Division (909) 387-3700 0 0 6.75 7.5 re to anonymously report if they suspect a child is being abused. The Court Executive Office's hours are 8:00 a.m. to 5:00 p.m., Monday through Friday, excluding court holidays. . Who live or work in San Bernardino County, Through San Bernardino County Homeless Veterans Initiative. If you do not see the form you need, please check if it can be ordered through the Children's Medical Services Catalog or contact us and we will try to accommodate your request.. Request for Second Opinion Procedure QM6053-1 New! To submit a form via email, users must first download the form to their device and then click "submit" on the completed form. 0 Childrens Interagency Authorization to Exchange Confidential Health Information (PHI) Superseded by COM025_E, Childrens Interagency Authorization to Exchange Confidential Health Information (PHI) (Spanish) Superseded by COM025_S, Therapeutic Behavioral Services Service Assessment, Therapeutic Behavioral Services Risk Assessment, Therapeutic Behavioral Services Referral Form, Childrens Interagency Authorization to Exchange Confidential Health Information (PHI), Childrens Interagency Authorization to Exchange Confidential Health Information (PHI) (Spanish), Child/Adolescent Psychiatric Evaluation and Update, Child/Adolescent Clinical Assessment-CANS-SB, Request to Waive Consumers Responsibility to Pay for Medications, Caregivers Authorization Affidavit (Spanish), Request for Verification of Veterans Status for Mental Health and/or Substance Abuse Services, Consent and Authorization to Exchange Confidential Information for Veterans Status, Medication Support Services Plan (Spanish), Release and Hold Harmless Agreement (Spanish), Interdisciplinary Care Team (ICT) Referral Form, Annual Psychiatric Assessment Review Form, Guidelines for Completing Referral Summary for Referral to Managed Care Plan (MCP) Attachment, Tier Transition Letter Attachment II (Spanish), Beneficiary Nondiscrimination Notice (Spanish), Delivery System Notice (NOABD) (Vietnamese), Delivery System Notice (NOABD) (Mandarin), QM030_S Modification Notice (NOABD) (Spanish), Change of Provider Request Form (Spanish). 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