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

Address Directory - Where to Send Your Application (Excel) xls format of    application-address-directory.xls


Authorization for Release of Information

An Authorization for the Release of Information (2-way) is included with the above Request for Services Application. 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.

For additional copies of the release forms please visit the DMH Privacy Forms page

For Privacy Practices in additional languages please visit the Privacy Practices (HIPAA) Notices and Acknowledgement forms page.

 

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