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Maryland Department of Health
Behavioral Health Administration
Behavioral Health Administration
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Lisa Bosley
Communications Officer
Office of Government Affairs and Communications
lisa.bosley@maryland.gov
SERVICE RECIPIENTS
Advance Directive for Mental Health Treatment
PROVIDERS
Licensing
DHMH #4781 Agreement to Cooperate (requirement under COMAR 10.63.01.05)
DHMH #4748 Application for a Variance from an BHA Regulation
Operating
DHMH 4749 Notification of Allegation of Sexual Assault-Harassment
DHMH #4364 BHA Report of Death
CC-DC #13 Petition for Emergency Evaluation
CC-DC #14 Certification by Peace Officer
DHMH #4787 Permanent Supportive Housing
State Care Coordination Monthly Data Collection
MD #4813 Residential Rehabilitation Program (RRP) Application
State Care Coordination section
Staff Change Form
SCC Monthly Report Template
SCC Satisfaction Survey
Critical incident.
MDH FACILITIES
Voluntary Admission into a State Facility
DHMH #4 Application for Voluntary Admission
MDH 4A - Application for Voluntary Admission of Disabled Person
MDH 2B - Certificate for Voluntary Admission of Disabled Persons
Involuntary Admission into a State Facility
DHMH #34 Application for Involuntary Admission
DHMH #33 Notification to Individual of Admission Status and Rights
DHMH #2 Certificate to Accompany Application for Involuntary Admission
DHMH #2A Report as to Certification of Commitment
Admission of a Minor
DHMH #6 Application by a Parent or Guardian for Admission of a Minor
DHMH #6A Physician’s or Psychologist’s Endorsement for Child or Adolescent Unit of State -Facilities
Potential Risk to an Adult
MDH # 4806 Hospital Sexual Abuse Risk Screen for Adults - for BHA hospital use only
MDH # 4809 Hospital Sexual Abuse Protection Plan for Adults - for BHA hospital use only
Potential Risk to a Minor
MDH # 4808 Sexual Abuse Risk Screen for RICAs and SGHC Adolescent Unit - for SGHC (Adolescent Unit and RICA use only)
MDH # 4807 Sexual Abuse Protection Plan for RICAs and SGHC Adolescent Unit - for SGHC (Adolescent Unit and RICA use only)
DHMH 4669 Notification of Serious Injury or Suicide Attempt
Operations
DHMH #4465 Maryland BHA - Aftercare Referral Form
MDH #4750 Notification of Elopement or Escape
MD #4813 Residential Rehabilitation Program (RRP) Application
JUSTICE SERVICES – ADDICTIONS
§ 8–507 Court Ordered Commitment
Tx. Admission Verification
Monthly Progress Report 1.2018
Interim Progress Report
Off Grounds Privileges
Request For Immediate Court Action
Discharge Report
Aftercare Continuing Care Plan
CORE SERVICE AGENCY REPORTING FORMS
Housing First Pilot Program
Housing First Pilot Intake Form
Housing First Pilot Rent Calculation Worksheet
Housing First Pilot Determination of Rent Reasonableness
Housing First Pilot Zero Income Statement
HUD-Inspection Form
Miscellaneous
PATH Quarterly Report Form FY 2017
TAMAR Project Form FY18
MCCJTP Quarterly Report FY18
Respite Data Collection Spreadsheet FY17
Crisis Intervention Team Milestones FY18
AA Co.'s Jail Diversion Quarterly Report
MDRN Reporting Form
CONTINUUM OF CARE (PERMANENT SUPPORTED HOUSING)
Continuum of Care Policy and Procedure Manual
1. N Continuum of Care Invoice-Reconciliation
2. O 1 – 2 Policy Regarding Administrative Cost
3. O 3 Administrative Time Tracking Form
4. P Individual Support Services Documentation
5. Q Intake Form
6. R Policy for Participant Terminations
7. Verification of Disability
8. T Service Plan Form
9. U Documentation of Homelessness
10. V Documentation of Legal History
11 .W Participant Agreement
12. W-1 Other Authorized Resident Agreement
13. X Federal Privacy Act for CoC Program
14. Y HUD Housing Inspection Form
15. Y 22 – 24 Owner Certification Form
16. Z Procedures for Annual Housing and Participant Recertification
17. AA 1-3 Policy for Determination of Rent Reasonableness
18. AA 4-5 Determination of Rent Reasonableness
19. BB HUD Environmental Review For Residential Leasing Activities
20. CC Rent Calculation Form
21. DD Zero Income Statement
22. EE Status Change Form
23. FF Policy for Rent Determination and Reporting Income
24. GG Due Process Acknowledgement
25. HH Policy for Verification of Disability
RESIDENTIAL PROGRAMS
RESIDENTIAL REHABILITATION PROGRAM (RRP) CERTIFICATE of DETERMINATION (COD) REVIEW FORM
RESIDENTIAL REHABILITATION PROGRAM DISCHARGE INFORMATION FORM
RESIDENTIAL PROGRAM (Residential Rehabilitation Program (RRP) Group Home for Adults with Mental Illness (GH-A), Residential Crisis Services program (RCS)) CERTIFICATE OF APPROVAL
RESIDENTIAL PROGRAM (Residential Rehabilitation Program (RRP) Group Home for Adults with Mental Illness (GH-A), Residential Crisis Services program (RCS)) APPLICATION FOR APPROVAL OF A RESIDENCE
MD #4813 Residential Rehabilitation Program (RRP) Application
RESIDENTIAL PROGRAM (Residential Rehabilitation Program (RRP) Group Home for Adults with Mental Illness (GH-A), Residential Crisis Services program (RCS)) HOUSING INSPECTION FORM
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