Contract Provider Forms
Welcome to the Fresno County Mental Health Plan, we have provided the following links for your convenience.
If you have additional questions please feel free to contact a Utilization Review Specialist at (559) 600-4645
ATD Form(DOCX, 78KB)- NEW
California Child and Adolescent Needs and Strengths Form (CANS-50-English Only)(PDF, 136KB)
Clinical Face Sheet(DOC, 48KB)
IHBS Authorization Form - NEW(PDF, 237KB)
Discharge Summary and Plan(DOCX, 55KB)- NEW
Fresno County MHP Assessment 2022(DOC, 118KB)- NEW
IHBS Authorization Form(PDF, 237KB)- NEW
IHBS Reauthorization Form update v2(PDF, 149KB)- NEW
Mental Health Access Form (paper version)(DOCX, 186KB)
NOABD Delivery System & Denial Notice (English)(DOCX, 456KB)- NEW
NOABD Delivery System & Denial Notice (Spanish)(DOCX, 456KB)- NEW
NOABD Delivery System & Denial Notice (Hmong)(DOCX, 454KB)- NEW
NOABD Termination Notice - Direct Service Providers(DOCX, 463KB)- NEW
NOABD Termination Notice - Direct Service Providers (Spanish)(DOCX, 455KB)- NEW
NOABD Termination Notice - Direct Service Providers (Hmong)(DOCX, 462KB)- NEW
NOABD Timely Access Notice (English)(DOCX, 459KB) - NEW
NOABD Timely Access Notice (Spanish)(DOCX, 458KB)- NEW
NOABD Timely Access Notice (Hmong)(DOCX, 459KB)- NEW
Pediatric Symptom Checklist (PSC-35-English)(PDF, 56KB)
Pediatric Symptom Checklist (PSC-35-Hmong)(PDF, 413KB)
Pediatric Symptom Checklist (PSC-35-Spanish)(PDF, 234KB)
TBS Referral Form RVD 2.2021(PDF, 268KB)
Treatment Plan- Option No. 1(DOC, 98KB)
Treatment Plan- Option No. 2(PDF, 269KB)
If you have a Behavioral Health emergency
please call 9-1-1
For Access to Services or the Crisis Line,
1 800 654-3937
CalHOPE Warm Line
1 833 317-HOPE(4673)
Central Valley Suicide Prevention Lifeline
1 800 273-8255