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Please contact us to receive services or to refer a person to the Behavioral Health Department. The staff will walk you through the initial screening process to determine if you are eligible for services and schedule your first appointment at the office.
Following are the intake forms which can be completed prior to your first appointment:
- Client Services Information Sheet
Provides basic demographic information for the person receiving services.
- Behavioral Health Financial Form
Allows us to calculate your sliding scale fee for services.
- Health Questionnaire and Medical History
Provides basic medical history for the person receiving services.
- Notice of Behavioral Health Privacy Practices
Explains the Privacy Practices that the Behavioral Health Department and staff upholds.
- Consent for the Release of Information
Allows the Behavioral Health Department to coordinate care with other individuals and/or agencies, per the direction of the person receiving services.
- Clinical History Form
Your detailed health history.
- Informed Consent Form (CARE-440)
Conditions of involvement with our services.
- Consent for treatment using teleconference equipment
Allows for sessions to be conducted via teleconferencing equipment.
- Consent to Treat
Client gives permission to undergo services with the counselor and expectations of client.
- Informed Consent-SUD 2017
Briefly explains client rights, expectations, community resources, discharge reasons, readmission options, confidentiality, etc.
- Participant Rights
Brief description of client rights with respect to fair treatment of the individual.
- Sierra County AOD Program Services and Fees
Explanation of fees for services provided.
- TB-HIV-STD Information
Brief description of various STD’s and testing available.
Additional materials you will be provided:
- Distribution of Mental Health Plan (MHP) Informing Materials
Master list of the materials you will be provided.
- Advanced Care Directive Brochure and Example Form
Lets you name another individual as your healthcare agent to make medical treatment decisions for you if you become unable to make those decisions.
- Systems of Care (SOC) Family & Client Behavioral Health Services Brochure (CARE-020)
- What you can do if you are not satisfied. Request For Second Opinion Form (CARE-084) and Grievance Form
- Sierra County Provider List
Specialty Mental Health Services
Your regular doctor, sometimes referred to as your primary care physician (PCP), can provide some mental health services. However, sometimes mental health services need to be provided by a specialist. These services are referred to as “specialty mental health services.” These specialty services are provided through the Placer/Sierra County Mental Health Plan or MHP, which is separate from your regular doctor.
Placer/Sierra County Mental Health Plan (MHP)
The MHP works very much like a health insurance plan for “specialty mental health services.” The people who are covered in this Mental Health Plan (MHP) include children, young people, adults, and older adults, who live in Placer or Sierra County and receive Placer or Sierra County Medi-Cal. Each county in California has its own MHP and each MHP works differently. All county MHPs operate under rules set by the State of California and the federal government.
Placer/Sierra Guide to Medi-Cal Mental Health Services (English)
Placer/Sierra Guide to Medi-Cal Mental Health Services (Large Print)
Placer/Sierra Servicios de Salud Mental de Medi-Cal (Spanish)