Connecticut Department of Mental Health & Addiction Services Forms
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Form MHCC-3 "Physician's Emergency Certificate for No More Than 15 Days Care and Treatment in a Hospital for Psychiatric Disabilities" - Connecticut
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Form CT-HR-12 "Dmhas Lateral Transfer Request Form" - Connecticut
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Form MHCC-15 "Transportation Authorization Certificate" - Connecticut
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Form MHCC-1A "Psychologist Emergency Examination Request" - Connecticut
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Form FAC-14 "Five-Day Emergency Commitment Application and Physician's Certificate Alcohol or Drug Detoxification" - Connecticut
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Form AA-100 "Affirmative Action Grievance Form" - Connecticut
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Form 201 "Dmhas Abi Consultation Referral Form" - Connecticut
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Form CVH-184 "Authorization for Use and Disclosure of Protected Health Information" - Connecticut (English/Spanish)
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Form CO-715 "Request for Use of Accrued Leave With Workers' Compensation (Employee's Choice)" - Connecticut
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"Education Assessment Form - Ddap" - Connecticut
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"Pre-trial Intervention Program Assessment Form - Ddap" - Connecticut
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"Health Assessment Form - Ddap" - Connecticut
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"Formulario De Reclamo De Cliente" - Connecticut (Spanish)
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"Ddap Admission Form" - Connecticut
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"Ddap Update/Discharge Form" - Connecticut
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"Ddap Periodic Assessment 6 Month Update Form" - Connecticut
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"Ddap Admission Form - Abbreviated" - Connecticut
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"Ddap Discharge Form" - Connecticut
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"Supportive Housing Assessment Form - Ddap" - Connecticut
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"Ddap Crisis Evaluation Form" - Connecticut
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"Recovery Plan Review/Revision Form" - Connecticut
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"Person Centered Recovery Plan - Dmhas Wise Program" - Connecticut
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"Cuestionario Cage-Aid Adaptado Para Incluir Drogas" - Connecticut (Spanish)
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"Alternate Work Schedule Request" - Connecticut
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"Csat/Opat Detox Exception Request and Record of Justification" - Connecticut
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"Behavioral Health Home Consumer Satisfaction Survey" - Connecticut, 2022
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"Consumer Satisfaction Survey" - Connecticut, 2022
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"Quality of Life Instrument" - Connecticut, 2021
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"Supported Recovery Housing Services" - Connecticut
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"Methadone Take-Home Bottles Chain-Of-Custody Record Form" - Connecticut
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"Application for Certification of Intermediate Duration Acute Care Beds" - Connecticut
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"Fax Cover Report Sheet" - Connecticut
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"Yas Discharge Report Form" - Connecticut
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"Person Centered Care Planning Questionnaire - Person in Recovery (Pir) Version" - Connecticut
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"Ddap Young Adult Services Employment and Education Measures Survey" - Connecticut
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"Buprenorphine Treatment Agreement/Contract" - Connecticut
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"Career Mobility Hours Balance Sheet" - Connecticut
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"Verification of Medical Appointment Form" - Connecticut
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![Form MHCC-3 "Physician's Emergency Certificate for No More Than 15 Days Care and Treatment in a Hospital for Psychiatric Disabilities" - Connecticut](https://data.templateroller.com/pdf_docs_html/1765/17656/1765691/form-mhcc-3-physician-s-emergency-certificate-no-more-than-15-days-care-and-treatment-in-a-hospital-psychiatric-disabilities-connecticut.png "Form MHCC-3 "Physician's Emergency Certificate for No More Than 15 Days Care and Treatment in a Hospital for Psychiatric Disabilities" - Connecticut")
![Form CT-HR-12 "Dmhas Lateral Transfer Request Form" - Connecticut](https://data.templateroller.com/pdf_docs_html/1781/17814/1781404/form-ct-hr-12-dmhas-lateral-transfer-request-form-connecticut.png "Form CT-HR-12 "Dmhas Lateral Transfer Request Form" - Connecticut")
![Form MHCC-15 "Transportation Authorization Certificate" - Connecticut](https://data.templateroller.com/pdf_docs_html/1781/17814/1781439/form-mhcc-15-transportation-authorization-certificate-connecticut.png "Form MHCC-15 "Transportation Authorization Certificate" - Connecticut")
![Form MHCC-1A "Psychologist Emergency Examination Request" - Connecticut](https://data.templateroller.com/pdf_docs_html/1781/17814/1781406/form-mhcc-1a-psychologist-emergency-examination-request-connecticut.png "Form MHCC-1A "Psychologist Emergency Examination Request" - Connecticut")
![Form FAC-14 "Five-Day Emergency Commitment Application and Physician's Certificate Alcohol or Drug Detoxification" - Connecticut](https://data.templateroller.com/pdf_docs_html/1781/17814/1781401/form-fac-14-five-day-emergency-commitment-application-and-physician-s-certificate-alcohol-or-drug-detoxification-connecticut.png "Form FAC-14 "Five-Day Emergency Commitment Application and Physician's Certificate Alcohol or Drug Detoxification" - Connecticut")
![Form AA-100 "Affirmative Action Grievance Form" - Connecticut](https://data.templateroller.com/pdf_docs_html/1781/17813/1781385/form-aa-100-affirmative-action-grievance-form-connecticut.png "Form AA-100 "Affirmative Action Grievance Form" - Connecticut")
![Form 201 "Dmhas Abi Consultation Referral Form" - Connecticut](https://data.templateroller.com/pdf_docs_html/1781/17813/1781389/form-201-dmhas-abi-consultation-referral-form-connecticut.png "Form 201 "Dmhas Abi Consultation Referral Form" - Connecticut")
![Form CVH-184 "Authorization for Use and Disclosure of Protected Health Information" - Connecticut (English/Spanish)](https://data.templateroller.com/pdf_docs_html/2260/22603/2260370/form-cvh-184-authorization-for-use-and-disclosure-of-protected-health-information-connecticut-english-spanish.png "Form CVH-184 "Authorization for Use and Disclosure of Protected Health Information" - Connecticut (English/Spanish)")
![Form CO-715 "Request for Use of Accrued Leave With Workers' Compensation (Employee's Choice)" - Connecticut](https://data.templateroller.com/pdf_docs_html/2218/22180/2218096/form-co-715-request-for-use-of-accrued-leave-with-workers-compensation-employee-s-choice-connecticut.png "Form CO-715 "Request for Use of Accrued Leave With Workers' Compensation (Employee's Choice)" - Connecticut")
!["Education Assessment Form - Ddap" - Connecticut](https://data.templateroller.com/pdf_docs_html/2224/22240/2224055/education-assessment-form-ddap-connecticut.png ""Education Assessment Form - Ddap" - Connecticut")
!["Pre-trial Intervention Program Assessment Form - Ddap" - Connecticut](https://data.templateroller.com/pdf_docs_html/2224/22240/2224048/pre-trial-intervention-program-assessment-form-ddap-connecticut.png ""Pre-trial Intervention Program Assessment Form - Ddap" - Connecticut")
!["Health Assessment Form - Ddap" - Connecticut](https://data.templateroller.com/pdf_docs_html/2218/22183/2218387/health-assessment-form-ddap-connecticut.png ""Health Assessment Form - Ddap" - Connecticut")
!["Formulario De Reclamo De Cliente" - Connecticut (Spanish)](https://data.templateroller.com/pdf_docs_html/2224/22240/2224056/formulario-de-reclamo-de-cliente-connecticut-spanish.png ""Formulario De Reclamo De Cliente" - Connecticut (Spanish)")
!["Ddap Admission Form" - Connecticut](https://data.templateroller.com/pdf_docs_html/2224/22240/2224047/ddap-admission-form-connecticut.png ""Ddap Admission Form" - Connecticut")
!["Ddap Update/Discharge Form" - Connecticut](https://data.templateroller.com/pdf_docs_html/2224/22240/2224052/ddap-update-discharge-form-connecticut.png ""Ddap Update/Discharge Form" - Connecticut")
!["Ddap Periodic Assessment 6 Month Update Form" - Connecticut](https://data.templateroller.com/pdf_docs_html/2224/22240/2224051/ddap-periodic-assessment-6-month-update-form-connecticut.png ""Ddap Periodic Assessment 6 Month Update Form" - Connecticut")
!["Ddap Admission Form - Abbreviated" - Connecticut](https://data.templateroller.com/pdf_docs_html/2224/22240/2224045/ddap-admission-form-abbreviated-connecticut.png ""Ddap Admission Form - Abbreviated" - Connecticut")
!["Ddap Discharge Form" - Connecticut](https://data.templateroller.com/pdf_docs_html/2224/22240/2224046/ddap-discharge-form-connecticut.png ""Ddap Discharge Form" - Connecticut")
!["Supportive Housing Assessment Form - Ddap" - Connecticut](https://data.templateroller.com/pdf_docs_html/2224/22240/2224049/supportive-housing-assessment-form-ddap-connecticut.png ""Supportive Housing Assessment Form - Ddap" - Connecticut")
!["Ddap Crisis Evaluation Form" - Connecticut](https://data.templateroller.com/pdf_docs_html/2218/22180/2218033/ddap-crisis-evaluation-form-connecticut.png ""Ddap Crisis Evaluation Form" - Connecticut")
!["Recovery Plan Review/Revision Form" - Connecticut](https://data.templateroller.com/pdf_docs_html/1781/17814/1781417/recovery-plan-review-revision-form-connecticut.png ""Recovery Plan Review/Revision Form" - Connecticut")
!["Person Centered Recovery Plan - Dmhas Wise Program" - Connecticut](https://data.templateroller.com/pdf_docs_html/1781/17814/1781412/person-centered-recovery-plan-dmhas-wise-program-connecticut.png ""Person Centered Recovery Plan - Dmhas Wise Program" - Connecticut")
!["Cuestionario Cage-Aid Adaptado Para Incluir Drogas" - Connecticut (Spanish)](https://data.templateroller.com/pdf_docs_html/2244/22447/2244795/cuestionario-cage-aid-adaptado-para-incluir-drogas-connecticut-spanish.png ""Cuestionario Cage-Aid Adaptado Para Incluir Drogas" - Connecticut (Spanish)")
!["Alternate Work Schedule Request" - Connecticut](https://data.templateroller.com/pdf_docs_html/2249/22499/2249971/alternate-work-schedule-request-connecticut.png ""Alternate Work Schedule Request" - Connecticut")
!["Csat/Opat Detox Exception Request and Record of Justification" - Connecticut](https://data.templateroller.com/pdf_docs_html/1781/17813/1781393/csat-opat-detox-exception-request-and-record-justification-connecticut.png ""Csat/Opat Detox Exception Request and Record of Justification" - Connecticut")
!["Behavioral Health Home Consumer Satisfaction Survey" - Connecticut, 2022](https://data.templateroller.com/pdf_docs_html/2384/23846/2384615/behavioral-health-home-consumer-satisfaction-survey-connecticut.png ""Behavioral Health Home Consumer Satisfaction Survey" - Connecticut, 2022")
!["Consumer Satisfaction Survey" - Connecticut, 2022](https://data.templateroller.com/pdf_docs_html/2384/23846/2384614/consumer-satisfaction-survey-connecticut.png ""Consumer Satisfaction Survey" - Connecticut, 2022")
!["Quality of Life Instrument" - Connecticut, 2021](https://data.templateroller.com/pdf_docs_html/2224/22240/2224053/quality-of-life-instrument-connecticut.png ""Quality of Life Instrument" - Connecticut, 2021")
!["Supported Recovery Housing Services" - Connecticut](https://data.templateroller.com/pdf_docs_html/1765/17657/1765764/supported-recovery-housing-services-connecticut.png ""Supported Recovery Housing Services" - Connecticut")
!["Methadone Take-Home Bottles Chain-Of-Custody Record Form" - Connecticut](https://data.templateroller.com/pdf_docs_html/1781/17813/1781388/methadone-take-home-bottles-chain-custody-record-form-connecticut.png ""Methadone Take-Home Bottles Chain-Of-Custody Record Form" - Connecticut")
!["Application for Certification of Intermediate Duration Acute Care Beds" - Connecticut](https://data.templateroller.com/pdf_docs_html/1781/17813/1781391/application-certification-intermediate-duration-acute-care-beds-connecticut.png ""Application for Certification of Intermediate Duration Acute Care Beds" - Connecticut")
!["Fax Cover Report Sheet" - Connecticut](https://data.templateroller.com/pdf_docs_html/1781/17814/1781413/fax-cover-report-sheet-connecticut.png ""Fax Cover Report Sheet" - Connecticut")
!["Yas Discharge Report Form" - Connecticut](https://data.templateroller.com/pdf_docs_html/1781/17814/1781436/yas-discharge-report-form-connecticut.png ""Yas Discharge Report Form" - Connecticut")
!["Person Centered Care Planning Questionnaire - Person in Recovery (Pir) Version" - Connecticut](https://data.templateroller.com/pdf_docs_html/2224/22240/2224072/person-centered-care-planning-questionnaire-person-in-recovery-pir-version-connecticut.png ""Person Centered Care Planning Questionnaire - Person in Recovery (Pir) Version" - Connecticut")
!["Ddap Young Adult Services Employment and Education Measures Survey" - Connecticut](https://data.templateroller.com/pdf_docs_html/2224/22240/2224054/ddap-young-adult-services-employment-and-education-measures-survey-connecticut.png ""Ddap Young Adult Services Employment and Education Measures Survey" - Connecticut")
!["Buprenorphine Treatment Agreement/Contract" - Connecticut](https://data.templateroller.com/pdf_docs_html/2224/22240/2224065/buprenorphine-treatment-agreement-contract-connecticut.png ""Buprenorphine Treatment Agreement/Contract" - Connecticut")
!["Career Mobility Hours Balance Sheet" - Connecticut](https://data.templateroller.com/pdf_docs_html/2224/22240/2224039/career-mobility-hours-balance-sheet-connecticut.png ""Career Mobility Hours Balance Sheet" - Connecticut")
!["Verification of Medical Appointment Form" - Connecticut](https://data.templateroller.com/pdf_docs_html/2260/22603/2260361/verification-of-medical-appointment-form-connecticut.png ""Verification of Medical Appointment Form" - Connecticut")