Form 2691 "Verification for Participation in a Mental Health or Substance Misuse Treatment Program" - New Hampshire

What Is Form 2691?

This is a legal form that was released by the New Hampshire Department of Health and Human Services - a government authority operating within New Hampshire. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2020;
  • The latest edition provided by the New Hampshire Department of Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 2691 by clicking the link below or browse more documents and templates provided by the New Hampshire Department of Health and Human Services.

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Download Form 2691 "Verification for Participation in a Mental Health or Substance Misuse Treatment Program" - New Hampshire

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STATE OF NEW HAMPSHIRE
Department of Health and Human Services
Form 2691
Division of Economic and Housing Stability
May 2020
Bureau of Child Development and Head Start Collaboration
VERIFICATION FOR PARTICIPATION IN A
MENTAL HEALTH OR SUBSTANCE MISUSE TREATMENT PROGRAM
SECTION I: CLIENT INFORMATION
Full Name:
DHHS Case #:
Address:
Email:
I certify that I am participating in an approved Mental Health Treatment Program
I certify that I am participating in an approved Substance Misuse Treatment Program
By signing this form, I authorize the release of this information to the Department of Health and Human Services
(DHHS). I understand information will be held in strictest confidence and will be reviewed by, or shared with,
authorized DHHS staff involved in the authorization of the NH Child Care Scholarship Program.
Client’s Signature:
Date:
SECTION II: LICENSED PROFESSIONAL
“Licensed Professional” means one of the following: attending physician, physician’s assistant, advance practice
registered nurse, licensed mental health professional, licensed behavioral health professional, licensed alcohol and drug
counselor, certified recovery support worker or board certified psychologist
Name:
License/Certification #:
Business Name:
Address:
Email:
Telephone #:
The individual’s treatment need(s) is: (check as many as apply)
Mental Health Treatment Program
Substance Misuse Treatment Program
How many hours per week is treatment provided?
Length of expected duration of the treatment program (not to exceed 12 months from the date below ):
I attest that:
I am the individual’s attending physician; physician’s assistant; advance practice registered nurse; licensed
mental health professional; licensed behavioral health professional; licensed alcohol and drug counselor;
certified recovery support worker; or board certified psychologist and I am providing ongoing treatment.
Signature
Title
Date
BCDHSC
Form 2691
Page 1 of 2
May 2020
STATE OF NEW HAMPSHIRE
Department of Health and Human Services
Form 2691
Division of Economic and Housing Stability
May 2020
Bureau of Child Development and Head Start Collaboration
VERIFICATION FOR PARTICIPATION IN A
MENTAL HEALTH OR SUBSTANCE MISUSE TREATMENT PROGRAM
SECTION I: CLIENT INFORMATION
Full Name:
DHHS Case #:
Address:
Email:
I certify that I am participating in an approved Mental Health Treatment Program
I certify that I am participating in an approved Substance Misuse Treatment Program
By signing this form, I authorize the release of this information to the Department of Health and Human Services
(DHHS). I understand information will be held in strictest confidence and will be reviewed by, or shared with,
authorized DHHS staff involved in the authorization of the NH Child Care Scholarship Program.
Client’s Signature:
Date:
SECTION II: LICENSED PROFESSIONAL
“Licensed Professional” means one of the following: attending physician, physician’s assistant, advance practice
registered nurse, licensed mental health professional, licensed behavioral health professional, licensed alcohol and drug
counselor, certified recovery support worker or board certified psychologist
Name:
License/Certification #:
Business Name:
Address:
Email:
Telephone #:
The individual’s treatment need(s) is: (check as many as apply)
Mental Health Treatment Program
Substance Misuse Treatment Program
How many hours per week is treatment provided?
Length of expected duration of the treatment program (not to exceed 12 months from the date below ):
I attest that:
I am the individual’s attending physician; physician’s assistant; advance practice registered nurse; licensed
mental health professional; licensed behavioral health professional; licensed alcohol and drug counselor;
certified recovery support worker; or board certified psychologist and I am providing ongoing treatment.
Signature
Title
Date
BCDHSC
Form 2691
Page 1 of 2
May 2020
STATE OF NEW HAMPSHIRE
Department of Health and Human Services
Form 2691(i)
Division of Economic and Housing Stability
May 2020
Bureau of Child Development and Head Start Collaboration
Instructions to the “Verification for Participation In A
Mental Health or Substance Misuse Treatment Program”
PURPOSE:
The “Verification for Participation in a Mental Health or Substance Misuse Treatment Program” is used to verify that
the client is participating in an approved mental health or substance misuse treatment program. Pursuant to RSA
167:83, II, to be eligible for the NH Child Care Scholarship Program for a mental health treatment program or
substance misuse treatment program the client must be a recipient of the New Hampshire Employment Program
(NHEP) or the Family Assistance Program (FAP).
INSTRUCTIONS:
The client and the licensed professional must print or type the information to complete Form 2961. The client must
sign and date the form, authorizing the release of information to DHHS and provide it to the Attending Physician,
Physician’s Assistant, Advance Practice Registered Nurse, Licensed Mental Health Professional, Licensed
Behavioral Health professional, Licensed Alcohol and Drug Counselor, Certified Recovery Support Worker or Board
Certified Psychologist and return it as below. All sections MUST be complete. An incomplete form will NOT be
accepted and no eligibility can be authorized.
FORM COMPLETION:
SECTION I: Client’s Information
o Enter the client’s full name;
o Enter the client’s DHHS case number;
o Enter the client’s address;
o Check off the certification for which the client is participating;
o Sign and date the form to authorize the release of information;
o Provide the form to the licensed professional for verification.
SECTION II: Licensed Professional
o Enter the licensed professional’s full name, license/certification number, telephone number, business name,
if applicable address and email;
o Indicate the individual’s treatment need(s);
o Enter how many hours per week treatment is provided;
o Indicate the length of the expected duration of the treatment program (not to exceed 12 months from the
date of licensed professional’s signature);
o Indicate attestation of the licensed professional’s role; and
o Sign, enter the professional’s title and date the form.
The Licensed Professional should confirm with the client that they are a recipient of NHEP or FAP.
Either the client or the licensed professional may return the completed form to:
DHHS Centralized Scanning Unit,
P.O. Box 181, Concord, NH 03302.
RETENTION:
Form 2691 will be retained in the eligibility record.
BCDHSC
Form 2691(i)
Page 2 of 2
May 2020
Page of 2