| Administrative |
| Administration |
| | 0028 | Safety Awareness Report Form | 04/20/2023 |
| | 0033 | Emergency Drill Report | 04/20/2023 |
| | 0040 | Medical Review Questionnaire | 10/19/2023 |
| | 0042 | Vehicle Safety Checklist | 4/20/2023 |
| | 0051 | Fee Re-Determination Worksheet | 12/14/2023 |
| | 0056 | Seizure Record | 09/21/2023 |
| | 0058 | Multi-Consent Form | 9/21/2023 |
| | 0061 | Confidentiality Statement | 09/21/2023 |
| | 0077 | Agency Fax Cover Sheet | 2/15/2024 |
| | 0083 | Acknowledgment of Emergency Care Procedures | 10/19/2023 |
| | 0101 | In-Service Sign In Sheet | 2/15/2024 |
| | 0122 | Travel Voucher | 12/14/2023 |
| | 0128 | Incident Report | 9/21/2023 |
| | 0144 | Records Release | 09/21/2023 |
| | 0206 | Special Out-of-Area Permission | 1/18/2024 |
| | 0218 | Residential Progress Note | 3/21/2024 |
| | 0223 | Individual Rights/Responsibilities | 09/21/2023 |
| | 0226 | Professional Staffing/Transfer/Referral Change Form | 1/18/2024 |
| | 0229 | Medications Which Require Quarterly Routine AIMS Testing | 5/25/2023 |
| | 0231 | Medication Box Set-up Log | 7/27/2023 |
| | 0233 | Report of Incident | 4/20/2023 |
| | 0234 | Initial/Ongoing Psychiatric Services Letter to Physician | 04/20/2023 |
| | 0238 | Committee Decision Memorandum | 9/21/2023 |
| | 0246 | Disposal of Medication | 2/15/2024 |
| | 0247 | OBRA Charge Slip | 7/27/2023 |
| | 0248 | Medication Disbursement Consent Form | 7/27/2023 |
| | 0252 | Inventory Disposal Request | 12/14/2023 |
| | 0269 | Ancillary Individual Encounter Entry Form | 3/21/2024 |
| | 0280 | Exceptions to the Competitive Procurement Process | 10/19/2023 |
| | 0311 | PCP/Individual Plan of Service-Goal/Objective Recommendations | 03/21/2024 |
| | 0317 | Leave of Absence | 5/25/2023 |
| | 0318 | Standing PRN Medical Orders for Crisis Bed Placements | 10/19/2023 |
| | 0320A | Individual Medication Record | 9/21/2023 |
| | 0320B | Individual Medication Record ~ For Programs and Homes | 9/21/2023 |
| | 0321 | Individual Information/ID Record (SIP's) | 9/21/2023 |
| | 0322 | Individual Funds Part I | 07/27/2023 |
| | 0323 | Individual Funds Part II | 7/27/2023 |
| | 0327 | Follow Up and Corrective Action Report | 04/20/2023 |
| | 0331 | Individual Personal ID Card Request Form | 03/21/2024 |
| | 0333 | Residential Progress Note (Landscape) | 3/21/2024 |
| | 0333 A | Residential Progress Note (Sensory Data) | 3/21/2024 |
| | 0334 | Health Visit Record for SIP Homes (2-sided) | 9/21/2023 |
| | 0335 | Skill Building Medication Administrative Consent Form | 10/19/2023 |
| | 0342 | Self Determination Agreement | 03/21/2024 |
| | 0344 | Voter Registration Application | 10/19/2023 |
| | 0344A | PDF of Voter Registration Application | 10/19/2023 |
| | 0350 | Standing Missed Medication Orders | 10/19/2023 |
| | 0354 | Pers.Care/Community Living Support Services Monthly Report & Invoice | 9/21/2023 |
| | 0357 | Annual Tuberculosis Health Questionnaire | 10/19/2023 |
| | 0371 | Invoice for Comprehensive Community Support Services (CCSS) | 9/21/2023 |
| | 0372 | Weekly Comprehensive Community Support Services (CCSS) Log | 9/21/2023 |
| | 0375 | Quarterly Program Status Report | 12/14/2023 |
| | 0378 | SCCMHA Staff/Visitors Sign-in Log | 12/15/2022 |
| | 0384 | Hospital Discharge Plan (2-sided) | 4/20/2023 |
| | 0385 | Crisis Intervention Screening Form Open Consumers/Non-billable Crisis | 1/18/2024 |
| | 0386 | Hepatitis B Consent Form | 2/15/2024 |
| | 0393 | Confidentiality of Individual's Alcohol & Drug Abuse Information | 9/21/2023 |
| | 0394 | Criminal Justice Consent | 10/19/2023 |
| | 0395 | Consent For Release of Confidential Information For Substance Abuse Services | 9/21/2023 |
| | 0400 | Sanilac MH Advance Directives Info | 10/19/2023 |
| | 0401 | Sanilac MH Advance Directives Form | 10/19/2023 |
| | 0403 | Supervisor's New Hire Guide | 03/21/2024 |
| | 0404 | Complaint Form | 12/14/2023 |
| | 0410 | Guideline for Authorization of Average Monthly Respite Hours | 03/21/2024 |
| | 0422 | Appeal to Credentialing or Enrollment Denial | 02/15/2024 |
| | 0427 | Outcome Memo - Practitioner | 2/15/2024 |
| | 0428 | Self-Determination Budget Worksheet | 03/21/2024 |
| | 0434 | Lift Truck Daily Checklist | 10/19/2023 |
| | 0435 | IDDT Program Progress Summary | 9/21/2023 |
| | 0436 | Informed Consent for Use of Behavioral Treatment Plan | 10/19/2023 |
| | 0439 | Supervision Chart Log | 9/21/2023 |
| | 0440 | IDDT Recommendation Follow-Up | 9/21/2023 |
| | 0446 | Transportation Invoice | 4/20/2023 |
| | 0459 | Daily Communication Log | 10/19/2023 |
| | 0463 | DCH PDF - HSW Recertification Worksheet MDHHS-5926 (2-21) | 04/20/2023 |
| | 0467 | Facility Use Form | 5/25/2023 |
| | 0470 | Acknowledgement of Receipt of Grievance & Appeals Information | 10/19/2023 |
| | 0471 | Medication Guidelines to Follow for Crisis Bed Placements | 10/19/2023 |
| | 0472 | Medication Letter for Skill Building Program (Annual) | 10/19/2023 |
| | 0473 | Hospital Payment Letter | 10/19/2023 |
| | 0482 | Outcome Memo - Organizations | 2/15/2024 |
| | 0486 | Psychiatrist Peer Review | 10/19/2023 |
| | 0487 | School/Work Excused Letter | 4/20/2023 |
| | 0489 | Controlled Substance Prescription Agreement | 7/27/2023 |
| | 0502 | SCCMHA Funds Record | 9/25/2023 |
| | 0503 | Detail of OBRA Services Billed | 4/20/2023 |
| | 0504 | Summary of OBRA Screening | 4/20/2023 |
| | 0506 | Medication Consent Letter | 10/19/2023 |
| | 0507 | Health & Safety Inspection | 4/20/2023 |
| | 0508 | Health and Safety Maintenance Inspection | 04/20/2023 |
| | 0510 | Medication for Skill Building Program (Notification of supply) | 10/19/2023 |
| | 0511 | Authorization for Electronic Communication | 7/27/2023 |
| | 0512 | InSHAPE Medical Clearance | 7/27/2023 |
| | 0513 | Health Matters Medical Clearance | 7/27/2023 |
| | 0514 | InSHAPE Personal Contract | 7/27/2023 |
| | 0515 | InSHAPE Authorization | 7/27/2023 |
| | 0516 | InSHAPE Informed Consent Agreement | 7/27/2023 |
| | 0517 | InSHAPE Health Questionaire | 7/27/2023 |
| | 0519 | InSHAPE Code of Conduct | 7/27/2023 |
| | 0520 | Conference Summary | 10/19/2023 |
| | 0521 | Individual Plan of Service Inservice Verification | 7/27/2023 |
| | 0522 | Hepatitis A General Information | 2/15/2024 |
| | 0523 | Safety Plan | 1/18/2024 |
| | 0525 | Mobile Intensive Crisis Stabilization for Children | 2/15/2024 |
| | 0526 | Employee Communication Memorandum (ECM) - Improvement Opportunity | 10/03/2023 |
| | 0527 | Employee Communication Memorandum (ECM) - Accolades | 4/20/2023 |
| | 0528 | Information and Consent Form For Telepsychiatry Services | 10/19/2023 |
| | 0530 | Region 10 PIHP Hospital Discharge | 12/14/2023 |
| | 0531 | Health Matters Fitness Data Collection Form | 2/15/2024 |
| | 0532 | Sanilac CMH Agency Cell Phone Usage | 7/27/2023 |
| | 0533 | SCCMHA/MDHHS Monthly Report | 5/25/2023 |
| | 0534 | Personal Cell Phone Review | 7/27/2023 |
| | 0535 | Program/Law Enforcement Progress Coordination and Monitoring | 10/19/2023 |
| | 0536 | SCCMHA Tobacco Assessment | 10/19/2023 |
| | 0537 | Flex Schedule - Supervisor Response Form | 05/25/2023 |
| | 0538 | Flex Schedule - Request Form | 5/25/2023 |
| | 0539 | Sanilac County CMH Transportation Log | 12/14/2023 |
| | 0541 | Welcome Letter | 03/16/2023 |
| | 0542 | InShape Client Questionnaire | 7/27/2023 |
| | 0543 | Clinical Supervision Log Form | 09/21/2023 |
| | 0544 | Integrated Treatment Fidelity Scale | 12/14/2023 |
| | 0545 | Integrated Treatment Fidelity Scoring Sheet | 12/14/2023 |
| | 0546 | TREM Fidelity Checklist | 12/14/2023 |
| | 0547 | TFCBT Fidelity Checklist | 12/14/2023 |
| | 0548 | EMDR Fidelity Checklist | 12/14/2023 |
| | 0549 | New Staff IT Form | 2/15/2024 |
| | 0550 | Assisted Outpatient Treatment Plan | 10/19/2023 |
| | 0552(A) | Attestation as to Ownership/Controlling Interest - Organization | 2/15/2024 |
| | 0554 | ABA TREATMENT - Audio-Visual, Group Interaction, Information Sharing, and BCBA Consulting Consent, Authorization Consent | 9/21/2023 |
| | 0555 | Student Loan Repayment and Tuition Reimbursement Application | 3/21/2024 |
| | 0556 | Telecommuting Agreement | 7/14/2022 |
| | 0557 | Telecommuting Location Safety Checklist | 7/14/2022 |
| | 0558 | Supervisor's Expectations-Telework | 7/14/2022 |
| | 0559 | Expectations for Sanilac CMH CLS Program | 7/27/2023 |
| | 0560 | Risk Consent (Formerly Swimming/Water Permission Form) | 2/15/2024 |
| | 0561 | OASIS Contract Provider Access Request | 10/19/2023 |
| | 0562 | Clinical Supervision Form | 1/18/2024 |
| | 0563 | Jail Contact Note - Fillable | 03/21/2024 |
| | 0564 | Jail Contact Note - Handwritten | 03/21/2024 |
| | 0565 | Determination/Write -Off of Individual's Self Pay Account | 09/21/2023 |
| | 0566 | Use of Personal Electric Devises on Agency Premises | 3/21/2024 |
| | 1020 | Region 10 PIHP Habilitation Supports Waiver (HSW) Eligibility Certification PDF Form DCH-3894 (Our #1020) | 12/14/2023 |
| | 1021 | OT/PT Medicare Rounds Communication | 5/25/2023 |
| | 1023A | SCCMHA Prescription for OT/PT Professional Assessment Part I: Approval for Evaluation | 5/25/2023 |
| | 1023B | SCCMH Prescription for OT/PT Professional Assessment Part II: Prescription for OT/PT Service and/or Equipment | 5/25/2023 |
| | 1024a | Personal Care & Comp. Community Support Services Log for Licensed Residential Settings | 12/14/2023 |
| | 1025 | Region 10 PIHP HSW Enrollment Evaluation Form (State PDF form) our #1025 | 12/14/2023 |
| | 1026 A | Pre-Admission Screening Form - Handwritten | 1/18/2024 |
| | 1026 B | Pre-Admission Screening Form - Computer | 1/18/2024 |
| | 1034 | SCCMHA Case Consultation | 12/14/2023 |
| | 1035 | SCCMHA Orientation Checklist | 9/21/2023 |
| | 1036 | Sanilac CMH Behavior Management Committee Review | 03/21/2024 |
| | 1300 h | Network Enrollment and Credentialing - Practitioner Application Form - Handwritten Version | 2/15/2024 |
| | 1301 h | Organizational Application Form - Handwritten Version | 2/15/2024 |
