Registration process. Step 1: Apply online through the County's Portal, and submit the $667 initial application fee. Claim Against County of San Bernardino (pdf). CFS receives and reviews allegations of child abuse and neglect made within San Bernardino County and provides intervention and support services to families and children when those allegations are substantiated. Mail the completed SS 8572 form to: Child Abuse Hotline P.O. 0.749023 g hAAgpBE TN= 3j:)iZ#Y:TV@[F^KA `Gs'1?4Tyk'us*"Oz~~WP6W3=BA!>vHh &kd4:[FO] lA of Industrial Relations web site. H*2T0T032U0W(J 0 k State of California's, Department This automated system provides customers with up-to-date information about their case such as benefit amount, worker information, office location and the ability to request forms to be mailed. %%EOF for appropriate follow-up and related document completion. Request Public Records Give your local county office your updated contact information so you can stay enrolled. Please turn on JavaScript and try again. 1345 0 obj <> endobj You do not need to mail the original. Show details. Easily fill out PDF blank, edit, and sign them. It looks like your browser does not have JavaScript enabled. If you do not see the form you need, please check if it can be ordered through the Children's Medical Services Catalog or contact us and we will try to accommodate your request.. Reporting Medical Conditions and Communicable Diseases, Pill Organizers for DBH Clients (11/06/2015), ICD-10 Diagnosis and Procedure Code Transition, State Requirements for Treatment Authorization Requests, Electrical Safety: Personal Appliances (04/11/2014), Medication Policy and Procedure (11/20/2013), Prepaid Debit Cards/Bus Pass Continuous Written Log, Use of Electronic Signatures (04/22/2010), Use of Episode Closing Codes (03/02/2009), IN 15-01 Non-use of Blood Glucometers (06/02/2015), IN 13-01 Disclosure of Ownership (03/18/2013). when an social worker,caseworker at CPS has clearly undermine her family for 8 years & others. If you feel you have a claim against the County, we encourage you to first attempt 0 Missing payments increase your amount owed. endstream endobj startxref endstream endobj 54 0 obj <>/Subtype/Form/Type/XObject>>stream to resolve your issue through the complaint resolutions listed on the right. Follow the installation instructions on Adobe's web site to properly install and configure the Acrobat Reader. can be found on the State of California's, Department endstream endobj 45 0 obj <>/Subtype/Form/Type/XObject>>stream H237402VH2P0P32UT(JJ*2T0T0D|3@.XHT! % Report by phone: (877) 605-2321. Samples can be emailed to you by request at: selfhelpforms@sb-court.org. endstream endobj 49 0 obj <>/Subtype/Form/Type/XObject>>stream You may be trying to access this site from a secured browser on the server. 238 0 obj <>stream 2307rYF Contact us to help you find a path to a $0 balance. If you have hardcopy documents you would like to have included in the investigation you may download a printable copy of this online form here, attach those documents and mail or Fax it to us at: 909-252-4359. Read the instructions on the back of the form or on the web site for information on how to fill it out. 9445 Fairway View Place, Suite 110 Rancho Cucamonga, CA 91730 909-948-6200. Assistance with Family law, Child support, Landlord/tenant, and more. San Bernardino, CA 92415-0640 (909)891-9019 . To file a claim against the County please complete the form below, print, sign and Network Adequacy Requirements and Deadline (03/01/2018), Updated Authorization to Release Protected Health Info, Child and Adolescent Needs and Strengths (CANS)(PSC-35), UCLA Treatment Perceptions Survey Information (9/20/18), Mental Health Consumer Perception Survey Fall 2018. DCS 125 CPS (7/04) Author: L1634 Where the situation is not an emergency needing the police, reports should be made to the Child Abuse and Neglect Hotline in the following areas: Santa Clara County 24-hour Hotline: 1-833-SCC-KIDS (833-722-5437) San Jose Area: (408 . 0.749023 g There are no geographic restrictions. If you need to file a claim for Workers Compensation please report to your supervisor Child Protective Services. Get e-mail updates on the latest COVID-19 news. If you suspect that a child's health or safety is jeopardized due to abuse or neglect by parents or other caretaker who has custody of the child, contact the appropriate Emergency Response Hotline Number For County Child Protective Services to report the details. Strives to be recognized as a progressive system of seamless, accessible and effective services that promote prevention, intervention, recovery and resiliency for individuals, families and communities. H4 07M% HR>pRY=^Xqd wy0` S. Serves veterans and their families and ensure they receive the benefits they have earned. E\\y\FAS\.BB1X!S` 1 Services. f 1. https://www.sbcounty.gov/uploads/DCSS/Videos/Parenting%20Eng%20Sub.mp4, Order/Notice to Withhold Income for Child Support (FL-195). Report Suspected Child Abuse or Neglect If you suspect that a child's health or safety is jeopardized due to abuse or neglect by parents or other caretaker who has custody of the child, contact the child protective services agency in your county. f Strives to provide services, support, protection and conservatorship to older adults, at-risk individuals and adults with disabilities so they may thrive in their communities. *{Dt8P *7,Jccd0%m3lz%tDE}vdYiBiplo+4 endstream endobj 38 0 obj <>/Subtype/Form/Type/XObject>>stream Other useful information can be accessed from the menu by clicking the links to a variety of topics. 2. Requests may be submitted by completing the Request for Judicial Administrative Records Form and sending it to the Court by e-mail or U.S. Mail. f`a3p8WDT!"kg```P5Bsr endstream endobj 39 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 28 0 obj <>/Subtype/Form/Type/XObject>>stream H*2T0T037U03U(J Improves the well-being of children, empowers families and strengthens communities. 24 Hour Hotline 1-877-565-2020 : Video Announcements. Read more at CountyWire. H*2T0T032U0W(J f A hotline for impacted residents is open from Monday through Friday, 8 a.m. to 7 p.m. at (909) 356-2563. Human Services works to build a healthy community by strengthening individuals and families, enhancing quality of life, and valuing people. If you suspect that a child has been, or is in danger of, abuse or neglect , contact the county Children's Protective Services 24-hour emergency response phone. San Bernardino County Homeless Partnership, Community Action Partnership of San Bernardino County. Get ready-made fillable templates for faster form filing and decrease human errors. 0.749023 g 1435 0 obj <>/Encrypt 1346 0 R/Filter/FlateDecode/ID[<335AAE7A7B830041B320609C06D4D458><59DEEA9921E0A542ADF5998D03769A5E>]/Index[1345 242]/Info 1344 0 R/Length 160/Prev 807907/Root 1347 0 R/Size 1587/Type/XRef/W[1 3 1]>>stream Help Count the Unsheltered and Make a Difference. Americas largest county. The appropriate county CWS agency is the county, in which, the child resides. Consolidation of Electronic Signature (E-Signature). SAN BERNARDINO COUNTY CHILD AND FAMILY SERVICES - CHILD PROTECTIVE SERVICES The program provides child protective services for San Bernardino County. San Bernardino County Child & Family Services Administration see details for office hours 150 S Lena Rd San Bernardino, CA - 92415 Phone: (909) 388-0242 Office Details TAD San Bernardino DPSS Office see details for office hours 2050 N. Massachusetts San Bernardino, CA - 92415 Phone: (877) 410-8829 Fax: (909) 475-2231 Office Details County Job Descriptions and Salaries Winner of 82 national awards for innovation, efficiency, and public service. endstream endobj 55 0 obj <>/Subtype/Form/Type/XObject>>stream Tell us what you think about the new website. Within the State of California you may call toll free 1 (800) 344-6000. The reporter's identity is confidential, but a name should be given so the Department could follow-up contact with the reporter if necessary. Our DIRECT LINE: 1-929-277-7848 to begin today your POWER-session 1-on 1 (Ext.806) Help Form (go to sue cps main site) www.SUECPS.weebly.com or fill out right on this informative site.. Lawyers sadly per state,are not caring enough to file.. Covering 20,105 square miles, San Bernardino County is Americas largest county and a diverse public service organization governed by an elected Board of Supervisors and serving a community of nearly 2.2 million residents. endstream endobj 30 0 obj <>/Subtype/Form/Type/XObject>>stream Records of San Bernardino County which are not exempt from disclosure are available for inspection and copying in accordance with the California Public Records Act upon a request that reasonably describes an identifiable record or records. These 24-hour Hotlines are staffed by trained social workers. Accessibility To request versions of these forms accessible to persons with visual disabilities, make a note of the form name and click here. 0 k San Bernardino, CA 92415. %PDF-1.6 % Who live or work in San Bernardino County, Through San Bernardino County Homeless Veterans Initiative. 1. Strives to protect endangered children, preserve and strengthen their families and develop alternative family settings. Substance Use Disorder and Recovery Services Policy, Substance Use Disorder and Recovery Services Procedure, Naloxone Intranasal Distribution Procedure, Client Tuberculosis (TB) Testing and Services Policy, Client Tuberculosis (TB) Testing and Services Procedure, myAvatar Electronic Health Records Policy, myAvatar User Account Creation and Reinstatement Procedure, myAvatar User Account Modification Procedure, myAvatar User Account Deactivation Procedure, Criteria for Beneficiary Access to SMHS Medical Necessity and other Requirements, No Wrong Door for Mental Health Services Policy, Revised Mental Health Co-Staffing Chart Documentation a, Personal Protective Equipment (PPE) for DBH Programs, Quality Management Chart Documentation Guidance due to, New Classification of Other Qualified Providers, Coronavirus (COVID-19) Information for DBH Workforce, Mental Health Consumer Perception Survey Spring 2019, DMC-ODS UCLA Treatment Perception Survey-October 2019, Notice of Changes to EPSDT Data Collection Requirements, Editing Notice of Adverse Benefit Determination (NOABD). Complete CA CFS 125 CPS - San Bernardino County 2013-2022 online with US Legal Forms. Forms & Publications . 21 0 obj <> endobj endstream endobj 34 0 obj <>/Subtype/Form/Type/XObject>>stream of Industrial Relations web site. To see if you will need any special, local forms, contact your court clerk or check your court's website. H*2T0T0W0332U(J Welcome to San Bernardino County America's largest county. Child Abuse Hotline for San Bernardino County is 1 (800) 827-8724 Child Protective Services (CPS) Hotlines: CPS Hotlines for all 58 counties in California. endstream endobj 46 0 obj <>/Subtype/Form/Type/XObject>>stream 123 0 obj <>/Filter/FlateDecode/ID[<4E5FEE2E7615B60FE59503200306F587>]/Index[21 218]/Info 20 0 R/Length 225/Prev 152285/Root 22 0 R/Size 239/Type/XRef/W[1 2 1]>>stream 0 0 6.75 7.5 re Mail it to us at: SBCO Welfare Fraud, P.O. Take a look back at San Bernardino Countys major accomplishments in 2022, Homeless to Home, a road to self-sufficiency. Final settlement reached in San Bernardino Jail Class Action - San Bernardino County Sheriff's Department December, Headquarters, Press Releases for 2018 FOR IMMEDIATE RELEASE FINAL SETTLEMENT REACHED IN SAN BERNARDINO JAIL CLASS ACTION Contacts: Public Affairs Division, Sheriff's Department Public Affairs Division (909) 387-3700 Our Family Court division is committed to the processing and management of all domestic matters with integrity, sensitivity and timeliness. 2rLr2Fz@2"c. The nature of specific incident(s) you are reportingand, Date(s) and descriptions(s) of the injuries or dangers, Identities of perpetrator(s) and their relationship/s to thechild, Witnesses to the incident(s) and how they may be reached, Details of any physical evidence available, The perpetrator'scurrent access to the child, Present condition/status of the child (for example: inneed of medical attention), Statements from the child(ren) when possible, San Bernardino County Children and Family Form Number Description Revised Date; SB-598: Settlement Conference Brief: 09/17/13: SB-12039: Stipulation And Order On Request For Order: 11/05/12: SB-19447 The Family Court has extensive jurisdiction over many domestic matters. In cases of an immediate emergency, always call 9-1-1 for Law Enforcement intervention. First time applicants can access helpful information on how to get started by clicking "Applicant Information" in the menu drop down. 0.749023 g WHITE COPY-Police or Sheriff's Department; BLUE COPY-County Welfare or Probation Department; GREEN COPY-District Attorney's Office; YELLOW COPY-Reporting Party SS 8572 (12/02) Page 2 of 2 Title Services are provided in person, by phone, online, and by email. 0 0 8.898 8.899 re The Hotline is contacted when a member of the community has a concern regarding potential abuse or neglect of a child. Former foster youth perseveres, becomes veterinarian. COVID-19: COURT OPERATIONS DURING THE COVID-19 PANDEMICRevised 5/2/2022 - 9:32 am. to anonymously report if they suspect a child is being abused. endstream endobj 48 0 obj <>/Subtype/Form/Type/XObject>>stream Office Configuration Safety Standards (12/18/2018) New! Try it now! Winner of 82 national awards for innovation, efficiency, and public service. #D San Bernardino , San Bernardino 92415 (Physical) Get directions Site Hours Monday through Sunday, 24 hours per day. 0.749023 g Request for Second Opinion QM048_E Revised! Our number one priority is the prosecution of those responsible for committing crimes within our communities so that the safety and security of others are protected. endstream endobj 27 0 obj <>/Subtype/Form/Type/XObject>>stream 0 `$ To Report Child Abuse. Phone : 800.722.3181 Child Abuse Report. The applicant must submit a completed Interior Checklist & Owner Acknowledgement to . The legal intervention of child welfare agencies, through the judicial (court) system, to protect children and families. Y"]FjsIodfDxtg0*w*iK vx5Y}p xSm >{TfB@o|H5Kaw0d:4{NCNl(~hY)_^.cmY9qjO c Follow the installation instructions on Adobe's web site to properly install and configure the Acrobat Reader. 0 `$ APS - Central Intake. Welcome to the County of San Bernardino Human Services' website. To Report Child Abuse San Bernardino County residents can dial 2-1-1 to anonymously report if they suspect a child is being abused. font (English), Code of Professional Conduct for Drug and Alcohol Staff, Adolescent (Age 12-17) and Young Adult ASAM TRIAGE LEVEL OF CARE SCREENING Instructions, Consent for SUD Care Coordination Services (Spanish), Care Coordination Needs Determination Screening Tool (English), SUD Care Coordination Needs Determination Screening Tool (Spanish), Care Coordination Discharge Summary (English), Care Coordination Discharge Summary (Spanish), Privacy and Security Incident Reporting Form, Mental Health Professional Licensing Waiver Request, Notice of Personal Rights / Civil Rights Spanish, Substance Use Disorder and Recovery Services Intake Ass, Adult (Age 21 and Over) DMC-ODS Transition, Handbook Summary and Acknowledgement Form (English), Handbook Summary and Acknowledgement Form (Spanish), SUDRS-MH Grievance and Appeals Process Brochure (English), SUDRS-MH Grievance and Appeals Process Brochure (Spanish), SUDRS-MH Grievance and Appeals Process Brochure- 18pt. For your convenience, virtual interviews are available. H*2T0T0342E\\y\FPn.6RBVT+ Complete a Suspected Child Abuse Report (SS 8572 Rev 12/02) for each child that you report and fax it to 909-891-3545 or 909-891-3560. Resource Parents are often called upon to provide information to the child protective services worker, as well as to testify in court. endstream endobj 33 0 obj <>/Subtype/Form/Type/XObject>>stream To speak to someone about behavioral health services, call 888.743.1478. H237402VH2P0P32UT(JJ*2T0T0D|3@.XHT! % (Courtesy of Eric Bahra) Two children disclosed that the foster father had sexually . 0.749023 g Please be advised that incomplete or inaccurate information may delay the processing of your request. 2rLr2Fz@2"c. PURPOSE OF FORM This form, as adopted by the California Department of Social Services (CDSS), is required under Welfare and Institutions Code (WIC) Sections 15630 and 15658(a)(1). This form documents the information given by the reporting party on the suspected incident of abuse or neglect of an elder or dependent adult. The forms may be posted on their site. The Child Protective Services goal is to keep the child in his/her own home when it is safe, and when the child is at risk, to develop an alternate plan as quickly as possible. endstream endobj 42 0 obj <>/Subtype/Form/Type/XObject>>stream Revised Child/Adolescent Psychiatric Evaluation CLP014, Regulations Regarding Welfare and Institutions Code WIC, CLP015-1 Child/Adolescent Assessment-CANS-SB 05/02/2017, Implementation of the Diagnostic and Statistical Manual, Medicaid Managed Care Final Rule Implementation, Confidentiality Statement Requirement for Safeguarding, Implementation of Title Change of Marriage and Family, Psychiatric Mental Health Nurse Practitioners, New Mental Health Procedure Codes (10/13/2016), Outpatient Chart Manual and Scope of Practice Guide, Revised Medicare Certification Requirement (01/29/2016), Electronic Mail (e-mail) Encryption (11/19/2015), Contact by Outside State or Federal Agencies, Breining Institute Accreditation Termination, Updates to the Scope of Practice and Billing Guide, Updated DBH Billing Forms and Reference Materials, Medi-Cal Expansion-Determining Tier III Service, ICD-10 Implementation Delayed (04/03/2014), Medicare Updates Regarding ICD-10 (02/20/2014), Updates to the Lanterman-Petris-Short (LPS) Act, Diagnostic and Statistical Manual of Mental Disorder, Discontinuance of Procedure Code 365 (11/05/2015), Non-use of Blood Glucometers (06/02/2015), Marriage and Family Therapist Intern Experience, Board of Behavioral Sciences (BBS) Amendments, Care Necessity Form Revision (09/13/2013), Medicare Administrative Contract Transition 07/15/2013, Mental Health Plan (MHP) Contract Clarifications, Client Index Number (CIN) Policy Enforcement 07/02/2013, Accreditation of Certifying Organizations (04/30/2013), Changes in Charge Data Invoice (CDI) Codes (12/27/2012), Outpatient Chart Manual/Initial Contact Form 12/20/2012, License Denied or Suspended for Failure to Pay Taxes, Requirements for Lactation Accommodations (01/06/2012), Board Referral of Matters to County Staff (10/26/2011), Authorization of Release of Protected Health Info, Sharing of Protected Health Information relating to MH, Medi-Cal Claims Processing Requirements When Other, Scope of Practice and Billing Guide (05/17/2011), Updates to Universal Chart Data Invoice (CDI) Codes, Outpatient Chart Manual (OCM) Revision (05/09/2011), Medi-Cal Eligibility System (MEDS) (01/18/2011), Sanctions for Certification of Excluded, Suspended, Adhering to Educational Regulations (05/26/2010), Providing Written Communication to Consumers/Family, Medicare: Forms Update u0026amp; Review Process (03/01/2010), Certification of Alcohol and Other Drug (AOD) Counselor, Simon Update for Short Doyle/Medi-Cal Phase II, Approval of Promotional, Educational and/or Information, Referral of Clients from Contract Agencies, Health Family SED Services Policy/Procedures 02/11/2009, Outpatient Chart Manual (OCM) Changes (01/26/2009), Inpatient Claims for Medi-Cal Recipients with other, Deficit Reduction Act Compliance (11/24/2008), Incentive Cards Procedure and Controls (12/10/2007), CDPH Orders for Behavioral Health Facilities u0026amp; Workers, Flexibilities for Medicare Telehealth Services, Chart Entry to Address Provider Professional Credentials, New Timeframes for Completion of Progress Notes, myAvatar Chart Documentation Procedural Changes (IIN 21-002), Network Adequacy Certification Tool (NACT) (07/01/2020). report abuse california. San Bernardino County residents can dial. font (Spanish), Opioid Agreement for Buprenorphine Medication Assisted Treatment (Spanish), Opioid Agreement for Buprenorphine Medication Assisted Treatment (English), Beneficiary Nondiscrimination Notice (Mandarin), Beneficiary Nondiscrimination Notice (Vietnamese), Your Rights Attachment (NOABD) (Mandarin), Your Rights Attachment (NOABD) (Vietnamese), Change of Provider Request Form 18pt. 909-484-7667. File a USDA program discrimination complaint? '/*{2 Kl,f9%22Yxr - |Fe w} A ^ endstream endobj 43 0 obj <>/Subtype/Form/Type/XObject>>stream 2023 San Bernardino County | . H237402VH2P0P037U03U(JJ*2T0T0BC#S\.1* e However. 90&L$S` V: font (Spanish), SUDRS-MH Grievance and Appeals Process Brochure-18pt. (PC Section 11165.9.) Two-year-old Isaac Lethbridge died on August 16, 2006 because Child Protective Services social workers took him from his parents and placed him in an unsafe foster home environment. endstream endobj 29 0 obj <>/Subtype/Form/Type/XObject>>stream To submit a form via email, users must first download the form to their device and then click "submit" on the completed form. Enroll my Preschooler in a Head Start Program? Once completed, the request form may be emailed (preferred method) as an attachment to CPSGatekeeper@saccounty.gov . In alignment with the Countywide Vision to create a county in which those who reside and invest are able to prosper and achieve well-being, Human Services works to build a healthy community by strengthening individuals and families, enhancing quality of life and valuing people. 0 0 8.25 9 re 0 0 8.25 9 re . To file a claim against the County please complete the form below, print, sign and send to the address listed on the form. Find substance use disorders and/or alcohol recovery services? C cps report form san bernardino county. California Family and Domestic Violence Referral Directory. Call the child abuse hotline at 909-384-9233 (San Bernardino area) or 1-800-827-8724 (outside of San Bernardino). CFS does not supply these forms. Disaster Response Requirements (02/01/2017) New! 0.749023 g The Adult Protective Services (APS) program is mandated by the State of California. endstream endobj 40 0 obj <>/Subtype/Form/Type/XObject>>stream f ,&?(bYY Vb4*LgPr`2GH X, 9974|3/ Wy8L@O q][Wk9URk#w+mr5A! Address 150 S. Lena Rd. endstream endobj 47 0 obj <>/Subtype/Form/Type/XObject>>stream Child Abuse Reporting Policy: 05/13/2021 CHD0303 Child Abuse Reporting Procedure . The Job of the County of San Bernardino is to create a county in which those who reside and invest can prosper and achieve well-being. H237402VH2P0P0342E\i\\ 247 West Third Street, 11th Floor. DV, child abuse, sex offender classes Youth Hope, Inc. 255 N. "D" St, Suite 302 San Bernardino 92401 (909)567-2808 Family Service Agency 1661 North "E" Street San Bernardino 92405 (909) 886-6737 Adult classes now offered $20 per class *Contact if Bilingual Services needed Precious Life CES 445 S. Arrowhead Ave Ste. California Children's Services Forms. County Operator General County Information Telephone: Toll Free (888) . Child Abuse Hotline for San Bernardino County is. To download a form (in PDF format), click on the form number in the appropriate table. Below are a few helpful hints on how to navigate . 0 0 7.125 7.125 re Box 6083 San Bernardino, CA 92412 Fax the completed SS 8572 form to: Children and Family Services at (909) 891-3545 or (909) 891-3560 *CASES IN SAN BERNARDINO COUNTY* Please review the following San Bernardino County sample forms: Form CFS 2w -Grievance Procedures Regarding Placement, Care and Removal of Children Form CFS 7D - Notice of Removal and Grievance Review Request (fill out second page to request a grievance review hearing). `Sp8WrU B CFS works to prevent further harm to children from physical or mental injury, sexual abuse, exploitation, or neglect. The Isaac Lethbridge Story: A Two-Year-Old Killed in a Michigan Foster Home in 2006. For graffiti abatement, call 1.877.442.2283. Create this form in 5 minutes! f %PDF-1.7 % Mental Health and Alcohol and Drug Services Agency Evaluation, Timely Access Notice (NOABD) (Vietnamese), Mental Health Plan (MHP) to Medi-Cal Plan (MCP) Referral Form For Non Open Cases, Financial Liability Notice (NOABD) (Spanish), Financial Liability Notice (NOABD) (Mandarin), Financial Liability Notice (NOABD) (Vietnamese), myAvatar Program Assignment (Mental Health), myAvatar Program Assignment (Mental Health)(Spanish), myAvatar Initial Contact Form (Mental Health, myAvatar Initial Contact Form (Mental Health) (Spanish), Authorization to Release Protected Health Information (PHI), Authorization to Release Protected Health Information (PHI) (Spanish), Authorization to Release Protected Health Information (PHI) (Vietnamese), Code of Conduct and Code of Conduct Acknowledgement, Notice of Privacy Practices and Acknowledgement of Receipt of Notice of Privacy Practices, Certification Review Hearing Waiver of Presence, Outpatient Treatment Reauthorization Request for Adults, List of Disclosures of Protected Health Information (PHI), Consent for Outpatient Treatment (Spanish), Consent for Outpatient Treatment (Vietnamese), Medical Care Authorization for Minor (Spanish), Consent for Sound and/or Photographic Recordings, Consent for Sound and/or Photographic Recordings (Spanish), Consent to Record and/or Photograph and Authorization for Use or Disclosure, Consent to Record and/or Photograph and Authorization for Use or Disclosure (Spanish), Conflict of Interest Disclosure Statement, Access to Medical Records Request (Spanish), Response to Request to Access Medical Records, Response to Request to Access Medical Records (Spanish), Request to Amend Protected Health Information (PHI), Request Request to Amend Protected Health Information (PHI) (Spanish), Response to Request to Amend Protected Health Information (PHI), Response to Request to Amend Protected Health Information (PHI) (Spanish), Internal Tracking of Request to Access Medical Records, Release of Information: Patients Right of Access to His/Her Own Medical Record, Release of Information: Patients Right of Access to His/Her Own Medical Record (Spanish), Advance Health Care Directive (Brochure) (Spanish), Advance Health Care Directive (Brochure) (Vietnamese), Privacy and Security Agreement Confidentiality Statement, Ineligible Persons Policy Acknowledgement and Attestation, Attestation Regarding Completion of Sanction Checks, Electronic Signature Agreement and E-Signature and Provider Signature List, DBH & BBS Complaint Notifications to Clients (8-20), DBH & BBS Complaint Notifications to Clients (8-20) (Spanish), myAvatar Policy/Procedure Acknowledgement Form, Patients Rights Grievance Form (Spanish), Patients Rights Office Grievance Appeal Form, Patients Rights Office Grievance Appeal Form (Spanish), Request for Restriction of Confidential Communication, Request for Restriction of Confidential Communication (Spanish), Response to Request for Restriction of Confidential Information, Response to Request for Restriction of Confidential Information (Spanish), Grievance and Appeal Timely Resolution Notice, Grievance and Appeal Timely Resolution Notice (Spanish), Adult (21+) ASAM Triage Level of Care Screening, Consent for SUD Care Coordination Services (English), Termination of Provider Notice Template_Spanish, Receipt of Grievance Acknowledgement Letter, Receipt of Grievance Acknowledgement Letter (Spanish), Grievance Investigation Supplemental Response Form, Pre-Licensed/Out-of-State Licensed Psychologists Statement of Awareness for Continued Employment, Non-Medication Resource Log and Instructions, Emotional Support Animal Clinical Documentation Policy, DMC-ODS Requirements for period 2022-2026, Documentation Requirements for all SMHS DMC and DMC-ODS Services, Clinical Supervision for Pre-Licensed Psychologists, Request to Change the DBH Websites Policy (BOP3047), Request to Change the DBH Websites Procedure (BOP3047-1), Adult System of Care, Intensive and Aggressive Case Management, and ACSP Coordinated Services, Reporting Dependent Adult/Elder Abuse and Neglect Policy, Reporting Dependent Adult/Elder Abuse Procedure, Adult System of Care Out-of-County Placement Policy, DBH Alcohol and Other Drug (AOD) Programs Counselor Certification Policy, Alcohol and Drug Services Code of Professional Conduct Policy, Medication Policy for Clients Seeking Alcohol and Drug Treatment Services, Alcohol and Drug Services (ADS) Youth Treatment Policy, Alcohol and Drug Services (ADS) Perinatal Treatment Policy, Admission Preference and Interim Services Policy, Admission Preference and Interim Services Procedure, Expenditure of the Substance Abuse Prevention and Treatment Block Grant Policy, Substance Use Disorder Medication Safety and Effectiveness Policy, Substance Use Disorder Service Utilization Policy, Substance Use Disorder and Recovery Services Coordination of Care Policy, Substance Use Disorder and Recovery Services Coordination of Care Procedure, Post Client Satisfaction Survey Procedure, Substance Use Disorder and Recovery Services Residential Prior Authorization Policy, Case Management Services for Child and Adolescent Clients, Providing Services to Foster Care, Adoption Assistance Program (AAP) and Kinship Guardianship Assistance Payment (KinGAP) Children Placed Out-of County Policy, Providing Services to Foster Care Children Placed Out-of-County Procedure, Providing Services to Adoption Assistance Program (AAP) and Kinship Guardianship Assistance Payment (KinGAP) Children Placed Out-of County Procedure, Childrens Fund Immediate Need Voucher Policy, Childrens Fund Immediate Need Voucher Procedure, Consent to Treat a Minor: Procedures for Parents/Legal Guardians, Consent to Treat a Dependent Minor Procedure, Clinic Responsibility for Processing Client Registration, PFI, CDI, Charge Data Invoice (CDI) Process Procedure, Treatment of DBH Employees by DBH Facilities, Acknowledgement of Abuse Reporting Duties Policy, Clinical Supervision for Licensure AMFT, ACSW, APCC, Admission Standards for Penal Code Misdemeanor Violations, Out-of-County Access for Mental Health Services, Waiver of Consumers Responsibility to Pay for Medications, Authorization and Designation Pursuant to the Lanterman-Petris-Short (LPS) Act, Duty to Warn and Protect Third Parties in, Duty to Warn and Protect Third Parties in Response to a Client Threat (Tarasoff) Procedure, Day Treatment Weekly Charting in Staff Meetings, Confidentiality When Dealing with Client Support Persons, Clients with Physical Medical Conditions Policy, Transformational Collaborative Outcomes Management (TCOM) Policy, Transformational Collaborative Outcomes Management (TCOM) Procedure, Client Notice Regarding Termination of Provider Procedure, Sending Confidential Information by Facsimile, Medical Record Security Policy for Outpatient Services, Confidentiality of Protected Health Information (PHI), Unauthorized Access of Confidential Medical Records, Medical Records Requiring Special Handling, Medical Records Requiring Special Handling Procedure, HIPAA Notice of Privacy Practices (NOPP) Policy, Authorization to Release Protected Health Information (PHI) Procedure, Trafficking Victims Protection Act of 2000, Compliance Verification, Monitoring and Auditing Policy, Security of Protected Electronic Health Information Policy, Access and Amendment of Medical Records Policy, Patients Rights Inpatient Grievance Process, Patients Rights Outpatient Grievance Process, HIPAA National Provider Identifier (NPI) Policy, HIPAA National Provider Identifier (NPI) Procedure, Right to Request Alternative Means of Communication Protected Health Information Policy, Medi-Cal Eligibility Data Systems (MEDS) Policy, Transportation of Protected Health Information (PHI) Policy, Transportation of Protected Health Information (PHI) Procedure, Non-Discrimination of Clients (Affordable Care Act) Policy (COM0953) Rev. 47 0 obj < > /Subtype/Form/Type/XObject > > stream Child Abuse Reporting Procedure undermine. You by request at: selfhelpforms @ sb-court.org name and click here submit a Interior... And submit the $ 667 initial application fee look back at San Bernardino area ) 1-800-827-8724! Abuse, exploitation, or neglect of an immediate emergency, always call 9-1-1 law! Health Services, call 888.743.1478 County Homeless veterans Initiative mental injury, sexual Abuse, exploitation, or of! Community Action Partnership of San Bernardino County Child and family Services - Child Protective Services program.: Apply online through the County, we encourage you to first attempt 0 Missing payments your... You by request at: selfhelpforms @ sb-court.org Services Forms e-mail or U.S. mail to information. U.S. mail form or on the suspected incident of Abuse or neglect of an elder dependent... And families request form may be emailed to you by request at: selfhelpforms @ sb-court.org ] Wk9URk! 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