Service Application Forms and Appeal Guidelines
Request for Services Forms are used when applying for mental health services from the Department of Mental Health (DMH) for adults, children, and adolescents. Instructions for submitting an application are included with each application. If you need assistance with accessing these forms please contact the DMH Information and Referral Line at 1-800-221-0053 (Monday through Friday, 9 am ��� 5 pm).
Request for Services Application
Adult Application for DMH Mental Health Services (PDF) l Word
- Child/Adolescent Application for DMH Mental Health Services (PDF) | Word
Authorization for Release of Information
An Authorization for the Release of Information (2-way) is included with the above Request for Services Application. Please download and print for additional releases. Applicants will need to submit a separate Authorization for Release of Information for each person, agency or facility the applicant authorizes DMH to receive and give information. Applicants are encouraged to submit 2-way releases to efficiently facilitate communication.
Authorization for Release of Information (1-way from DMH) (PDF) | Word
Authorization for Release of Information (1-way to DMH) (PDF) | Word
Authorization for Release of Information (2-way) (PDF) | Word
Authorization for Release of Information (Spanish) (2-way) (PDF) | Word
Appeal Guidelines
Separate Document, not included with the above application forms. Please download and print.
This information is provided by the Department of Mental Health