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