Forms
FORMS / A / B / C / D / E / F / G / H / I / J / K / L / M / N / O / P / Q / R / S / T / U / V / W / X / Y / A Access to Recovery III (ATR) - Applications & Guidelines Affirmative Action Grievance/Complaint Form Agency Credentialing Application - Mental Health Waiver Application For Certification of Intermediate Care Beds Application for Employment CT-HR-12 (formerly PLD-1) Applications & Forms Used by Investigators (Institutional Review Board) Application for PACCT Training B Block Grants - State Plan & Applications Bond Fund Application (PDF file) - (MS Word Version of Application) - Bond Fund Application Cover Letter C Career Mobility Application & Guidelines Certification Assistance Application & Guidelines (1199) Chain of Custody Record - Methadone Take-Home Bottles Client Release of Information Forms Client Grievance Form (CMHS) Block Grant Consumer Survey Materials Co-Occurring Disorders Initiative- Information and Materials D DDaP - New Data Collection System Updates DDaP User Documentation and Forms Detox Exception Request and Record of Justification (CSAT/OPAT) Drug Enforcement Agency NTP Registration Form (Form # 363) E Education and Training Applications and Online Registration Employment - State Employment Application CT-HR-12 (formerly PLD-1) Employment - Lateral Transfer Request Form - (MS Word Version) F Fifteen Day (15) Physician's Emergency Certificate Fiscal Services Division Forms Five Day (5) Emergency Commitment Application And Physician's Certificate (FAC-14) G Grievance/Complaint Form (Affirmative Action) Grievance Form (for clients) Grievance Procedure (English) Grievance Procedure (Spanish) H I Insurance and Entitlements - Dept. of Social Services Institutional Review Board (IRB) - Applications & Forms Used by Investigators J K L Lateral Transfer Request Form (pdf file) - (MS Word Version) M Medicaid Rehab Option - Materials & Information Mental Health Waiver - Agency Credentialing Application Mental Health Waiver Request Form Methadone Exception Requests, Federal Methadone Take-Home Bottles - Chain of Custody Record N Naloxone - Statement of Intent to Prescribe O P PACCT Training Application Person Centered Recovery Planning (PCRP) Physician's Certificate and Five Day (5) Emergency Commitment Application (FAC-14) Physician's Emergency Certificate - Fifteen Day (15) Psychologist Emergency Examination Request (MHCC-1A) Q R Recovery Plan - Person Centered (WISE Program) Recovery Plan Review/Revision (WISE Program) Recovery Self-Assessment Tool for Person in Recovery Recovery Self-Assessment Tool for Family/Significant Other Recovery Self-Assessment Tool for Providers Recovery Self-Assessment Tool for Administrators Recovery Supports Program (RSP) Materials Release of Information Forms for Clients S SAPT Block Grant Application Screening Measures - Co-Occurring Disorders Initiative, Statewide Implementation State Employment Application CT-HR-12 (formerly PLD-1) Supported Recovery Housing Services - List of Sample Forms T Transportation Authorization Certificate (MHCC-15) Travel Authorization Request (CO-112) Tuition Reimbursement Application (CO-101) U User Documentation and Forms (DDaP) V W WEBSAS Reports (requires user password) Worker's Compensation Forms Y YAS Discharge Report YAS Discharge Report Instructions YAS report fax cover sheet
FORMS
