Forms and Applications

The following applications and forms are for use by mental health facilities and those seeking an initial license.

The following forms are tools designed to help the Mental Health branch surveyor while conducting state licensure surveys and are not a checklist of items needed to comply with all licensure rules. All Mental Health branch surveyors are trained to use the forms to recognize triggers and assure compliance with core licensure rules. The information contained in these forms is only a snapshot of the actual rule requirements and is not a substitute for obtaining a rule book and developing systems to ensure compliance with core and program specific licensure rules. Providers are welcome to use the forms, but it is not a requirement.

DHHS Incident and Death Report

Facilities that formerly utilized the DHHS Incident and Death Report form are now expected to enter the information with the on-line reporting system. We will continue to make available a copy of the Incident and Death Report (PDF, 55 KB) for reference purposes only. We have also added links to the on-line manuals which will assist in getting on-line and providing accurate information.