Your computer must have the Adobe Acrobat Reader installed in order to view any of these documents.You will need todownload Adobe Acrobat Readerfrom Adobe's website. Serves veterans and their families and ensure they receive the benefits they have earned. You do not need to mail the original. To speak to someone about behavioral health services, call 888.743.1478. DCS 125 CPS (7/04) Author: L1634 You may be trying to access this site from a secured browser on the server. San Bernardino, CA 92415. endstream endobj 48 0 obj <>/Subtype/Form/Type/XObject>>stream Former social worker Eric Bahra has been awarded a $2.5 million jury verdict against San Bernardino County. E\\y\Fz0\.S=3H!C 9 Step 2: Fill out your forms completely. 0.749023 g Office Configuration Safety Standards (12/18/2018) New! of Industrial Relations web site. . 0 k Save or instantly send your ready documents. Mail it to us at: SBCO Welfare Fraud, P.O. In alignment with the Countywide Vision to create a county in which those who reside and invest are able to prosper and achieve well-being, Human Services works to build a healthy community by strengthening individuals and families, enhancing quality of life and valuing people. Report by phone: (877) 605-2321. Human Services works to build a healthy community by strengthening individuals and families, enhancing quality of life, and valuing people. To Report Child Abuse. Mental Health and Alcohol and Drug Services Agency Evaluation, Timely Access Notice (NOABD) (Vietnamese), Mental Health Plan (MHP) to Medi-Cal Plan (MCP) Referral Form For Non Open Cases, Financial Liability Notice (NOABD) (Spanish), Financial Liability Notice (NOABD) (Mandarin), Financial Liability Notice (NOABD) (Vietnamese), myAvatar Program Assignment (Mental Health), myAvatar Program Assignment (Mental Health)(Spanish), myAvatar Initial Contact Form (Mental Health, myAvatar Initial Contact Form (Mental Health) (Spanish), Authorization to Release Protected Health Information (PHI), Authorization to Release Protected Health Information (PHI) (Spanish), Authorization to Release Protected Health Information (PHI) (Vietnamese), Code of Conduct and Code of Conduct Acknowledgement, Notice of Privacy Practices and Acknowledgement of Receipt of Notice of Privacy Practices, Certification Review Hearing Waiver of Presence, Outpatient Treatment Reauthorization Request for Adults, List of Disclosures of Protected Health Information (PHI), Consent for Outpatient Treatment (Spanish), Consent for Outpatient Treatment (Vietnamese), Medical Care Authorization for Minor (Spanish), Consent for Sound and/or Photographic Recordings, Consent for Sound and/or Photographic Recordings (Spanish), Consent to Record and/or Photograph and Authorization for Use or Disclosure, Consent to Record and/or Photograph and Authorization for Use or Disclosure (Spanish), Conflict of Interest Disclosure Statement, Access to Medical Records Request (Spanish), Response to Request to Access Medical Records, Response to Request to Access Medical Records (Spanish), Request to Amend Protected Health Information (PHI), Request Request to Amend Protected Health Information (PHI) (Spanish), Response to Request to Amend Protected Health Information (PHI), Response to Request to Amend Protected Health Information (PHI) (Spanish), Internal Tracking of Request to Access Medical Records, Release of Information: Patients Right of Access to His/Her Own Medical Record, Release of Information: Patients Right of Access to His/Her Own Medical Record (Spanish), Advance Health Care Directive (Brochure) (Spanish), Advance Health Care Directive (Brochure) (Vietnamese), Privacy and Security Agreement Confidentiality Statement, Ineligible Persons Policy Acknowledgement and Attestation, Attestation Regarding Completion of Sanction Checks, Electronic Signature Agreement and E-Signature and Provider Signature List, DBH & BBS Complaint Notifications to Clients (8-20), DBH & BBS Complaint Notifications to Clients (8-20) (Spanish), myAvatar Policy/Procedure Acknowledgement Form, Patients Rights Grievance Form (Spanish), Patients Rights Office Grievance Appeal Form, Patients Rights Office Grievance Appeal Form (Spanish), Request for Restriction of Confidential Communication, Request for Restriction of Confidential Communication (Spanish), Response to Request for Restriction of Confidential Information, Response to Request for Restriction of Confidential Information (Spanish), Grievance and Appeal Timely Resolution Notice, Grievance and Appeal Timely Resolution Notice (Spanish), Adult (21+) ASAM Triage Level of Care Screening, Consent for SUD Care Coordination Services (English), Termination of Provider Notice Template_Spanish, Receipt of Grievance Acknowledgement Letter, Receipt of Grievance Acknowledgement Letter (Spanish), Grievance Investigation Supplemental Response Form, Pre-Licensed/Out-of-State Licensed Psychologists Statement of Awareness for Continued Employment, Non-Medication Resource Log and Instructions, Emotional Support Animal Clinical Documentation Policy, DMC-ODS Requirements for period 2022-2026, Documentation Requirements for all SMHS DMC and DMC-ODS Services, Clinical Supervision for Pre-Licensed Psychologists, Request to Change the DBH Websites Policy (BOP3047), Request to Change the DBH Websites Procedure (BOP3047-1), Adult System of Care, Intensive and Aggressive Case Management, and ACSP Coordinated Services, Reporting Dependent Adult/Elder Abuse and Neglect Policy, Reporting Dependent Adult/Elder Abuse Procedure, Adult System of Care Out-of-County Placement Policy, DBH Alcohol and Other Drug (AOD) Programs Counselor Certification Policy, Alcohol and Drug Services Code of Professional Conduct Policy, Medication Policy for Clients Seeking Alcohol and Drug Treatment Services, Alcohol and Drug Services (ADS) Youth Treatment Policy, Alcohol and Drug Services (ADS) Perinatal Treatment Policy, Admission Preference and Interim Services Policy, Admission Preference and Interim Services Procedure, Expenditure of the Substance Abuse Prevention and Treatment Block Grant Policy, Substance Use Disorder Medication Safety and Effectiveness Policy, Substance Use Disorder Service Utilization Policy, Substance Use Disorder and Recovery Services Coordination of Care Policy, Substance Use Disorder and Recovery Services Coordination of Care Procedure, Post Client Satisfaction Survey Procedure, Substance Use Disorder and Recovery Services Residential Prior Authorization Policy, Case Management Services for Child and Adolescent Clients, Providing Services to Foster Care, Adoption Assistance Program (AAP) and Kinship Guardianship Assistance Payment (KinGAP) Children Placed Out-of County Policy, Providing Services to Foster Care Children Placed Out-of-County Procedure, Providing Services to Adoption Assistance Program (AAP) and Kinship Guardianship Assistance Payment (KinGAP) Children Placed Out-of County Procedure, Childrens Fund Immediate Need Voucher Policy, Childrens Fund Immediate Need Voucher Procedure, Consent to Treat a Minor: Procedures for Parents/Legal Guardians, Consent to Treat a Dependent Minor Procedure, Clinic Responsibility for Processing Client Registration, PFI, CDI, Charge Data Invoice (CDI) Process Procedure, Treatment of DBH Employees by DBH Facilities, Acknowledgement of Abuse Reporting Duties Policy, Clinical Supervision for Licensure AMFT, ACSW, APCC, Admission Standards for Penal Code Misdemeanor Violations, Out-of-County Access for Mental Health Services, Waiver of Consumers Responsibility to Pay for Medications, Authorization and Designation Pursuant to the Lanterman-Petris-Short (LPS) Act, Duty to Warn and Protect Third Parties in, Duty to Warn and Protect Third Parties in Response to a Client Threat (Tarasoff) Procedure, Day Treatment Weekly Charting in Staff Meetings, Confidentiality When Dealing with Client Support Persons, Clients with Physical Medical Conditions Policy, Transformational Collaborative Outcomes Management (TCOM) Policy, Transformational Collaborative Outcomes Management (TCOM) Procedure, Client Notice Regarding Termination of Provider Procedure, Sending Confidential Information by Facsimile, Medical Record Security Policy for Outpatient Services, Confidentiality of Protected Health Information (PHI), Unauthorized Access of Confidential Medical Records, Medical Records Requiring Special Handling, Medical Records Requiring Special Handling Procedure, HIPAA Notice of Privacy Practices (NOPP) Policy, Authorization to Release Protected Health Information (PHI) Procedure, Trafficking Victims Protection Act of 2000, Compliance Verification, Monitoring and Auditing Policy, Security of Protected Electronic Health Information Policy, Access and Amendment of Medical Records Policy, Patients Rights Inpatient Grievance Process, Patients Rights Outpatient Grievance Process, HIPAA National Provider Identifier (NPI) Policy, HIPAA National Provider Identifier (NPI) Procedure, Right to Request Alternative Means of Communication Protected Health Information Policy, Medi-Cal Eligibility Data Systems (MEDS) Policy, Transportation of Protected Health Information (PHI) Policy, Transportation of Protected Health Information (PHI) Procedure, Non-Discrimination of Clients (Affordable Care Act) Policy (COM0953) Rev. The applicant must submit a completed Interior Checklist & Owner Acknowledgement to . CFS works to prevent further harm to children from physical or mental injury, sexual abuse, exploitation, or neglect. If you are interested becoming a volunteer and working with social workers at CFS, please apply at: http://hss.sbcounty.gov/VIP/default.asp VIP CFS brochure 2019.pdf Welcome to San Bernardino County America's largest county. To see if you will need any special, local forms, contact your court clerk or check your court's website. Change of Provider Request Form - 18pt. endstream endobj 49 0 obj <>/Subtype/Form/Type/XObject>>stream (PC Section 11165.9.) Claim Against County of San Bernardino (pdf) County of San Bernardino Employees If you need to file a claim for Workers' Compensation please report to your supervisor for appropriate follow-up and related document completion. C 238 0 obj <>stream 0 k Winner of 82 national awards for innovation, efficiency, and public service. hbbd```b``" 0i"H`s.8C>nf"Ynu8X8=L?jd &7$+: ,"y3L`qQr&):w4"3p vkJ4 Revised Child/Adolescent Psychiatric Evaluation CLP014, Regulations Regarding Welfare and Institutions Code WIC, CLP015-1 Child/Adolescent Assessment-CANS-SB 05/02/2017, Implementation of the Diagnostic and Statistical Manual, Medicaid Managed Care Final Rule Implementation, Confidentiality Statement Requirement for Safeguarding, Implementation of Title Change of Marriage and Family, Psychiatric Mental Health Nurse Practitioners, New Mental Health Procedure Codes (10/13/2016), Outpatient Chart Manual and Scope of Practice Guide, Revised Medicare Certification Requirement (01/29/2016), Electronic Mail (e-mail) Encryption (11/19/2015), Contact by Outside State or Federal Agencies, Breining Institute Accreditation Termination, Updates to the Scope of Practice and Billing Guide, Updated DBH Billing Forms and Reference Materials, Medi-Cal Expansion-Determining Tier III Service, ICD-10 Implementation Delayed (04/03/2014), Medicare Updates Regarding ICD-10 (02/20/2014), Updates to the Lanterman-Petris-Short (LPS) Act, Diagnostic and Statistical Manual of Mental Disorder, Discontinuance of Procedure Code 365 (11/05/2015), Non-use of Blood Glucometers (06/02/2015), Marriage and Family Therapist Intern Experience, Board of Behavioral Sciences (BBS) Amendments, Care Necessity Form Revision (09/13/2013), Medicare Administrative Contract Transition 07/15/2013, Mental Health Plan (MHP) Contract Clarifications, Client Index Number (CIN) Policy Enforcement 07/02/2013, Accreditation of Certifying Organizations (04/30/2013), Changes in Charge Data Invoice (CDI) Codes (12/27/2012), Outpatient Chart Manual/Initial Contact Form 12/20/2012, License Denied or Suspended for Failure to Pay Taxes, Requirements for Lactation Accommodations (01/06/2012), Board Referral of Matters to County Staff (10/26/2011), Authorization of Release of Protected Health Info, Sharing of Protected Health Information relating to MH, Medi-Cal Claims Processing Requirements When Other, Scope of Practice and Billing Guide (05/17/2011), Updates to Universal Chart Data Invoice (CDI) Codes, Outpatient Chart Manual (OCM) Revision (05/09/2011), Medi-Cal Eligibility System (MEDS) (01/18/2011), Sanctions for Certification of Excluded, Suspended, Adhering to Educational Regulations (05/26/2010), Providing Written Communication to Consumers/Family, Medicare: Forms Update u0026amp; Review Process (03/01/2010), Certification of Alcohol and Other Drug (AOD) Counselor, Simon Update for Short Doyle/Medi-Cal Phase II, Approval of Promotional, Educational and/or Information, Referral of Clients from Contract Agencies, Health Family SED Services Policy/Procedures 02/11/2009, Outpatient Chart Manual (OCM) Changes (01/26/2009), Inpatient Claims for Medi-Cal Recipients with other, Deficit Reduction Act Compliance (11/24/2008), Incentive Cards Procedure and Controls (12/10/2007), CDPH Orders for Behavioral Health Facilities u0026amp; Workers, Flexibilities for Medicare Telehealth Services, Chart Entry to Address Provider Professional Credentials, New Timeframes for Completion of Progress Notes, myAvatar Chart Documentation Procedural Changes (IIN 21-002), Network Adequacy Certification Tool (NACT) (07/01/2020). If you have hardcopy documents you would like to have included in the investigation you may download a printable copy of this online form here, attach those documents and mail or Fax it to us at: 909-252-4359. You will need to pay the fee or submit a Request to Waive Court Fees. Welcome to San Bernardino County's Career Opportunities page! Employment Information and Recruitment Videos. ENGLISH SPANISH California Children's Services Forms. 2\`q#=csS&c. endstream endobj 42 0 obj <>/Subtype/Form/Type/XObject>>stream #D San Bernardino , San Bernardino 92415 (Physical) Get directions Site Hours Monday through Sunday, 24 hours per day. f Most typically, the CPS/DCFS social worker wants to keep you from knowing exactly what you have been accused of sort of keeping themselves on a "general fishing expedition" but it is required by state and federal law to tell you the exact details of the accusations at first contact with . The San Bernardino County Department of Child Support Services determines paternity, establishes and enforces child support orders, and secures payments to assist the financial and medical needs of their children. . The nature of specific incident(s) you are reportingand, Date(s) and descriptions(s) of the injuries or dangers, Identities of perpetrator(s) and their relationship/s to thechild, Witnesses to the incident(s) and how they may be reached, Details of any physical evidence available, The perpetrator'scurrent access to the child, Present condition/status of the child (for example: inneed of medical attention), Statements from the child(ren) when possible, San Bernardino County Children and Family Find substance use disorders and/or alcohol recovery services? the san bernardino county sheriff's department, in partnership with california state university of san bernardino and california baptist university, provides evidence-based interventions for inmates to improve family relations, mitigate factors leading to self-destructive life patterns, reduce recidivism, and promote overall healthy functioning Americas largest county. Step 1: Apply online through the County's Portal, and submit the $667 initial application fee. f Improves the well-being of children, empowers families and strengthens communities. endstream endobj 29 0 obj <>/Subtype/Form/Type/XObject>>stream Address 150 S. Lena Rd. f County Code and Charter First 5 San Bernardino (909) 387-7706 Fishing (909) 38-PARKS: Fleet Management (909) 387-7870: Flies . 909-484-7667. Child Abuse Hotline for San Bernardino County is 1 (800) 827-8724 Child Protective Services (CPS) Hotlines: CPS Hotlines for all 58 counties in California. . endstream endobj 50 0 obj <>/Subtype/Form/Type/XObject>>stream 1586 0 obj <>stream Strives to protect endangered children, preserve and strengthen their families and develop alternative family settings. Health and Human Services Public Safety and Justice Community Services Recreation and Culture Government Services Board of Supervisors Col. Paul Cook (Ret.) E\i\\ Childrens Interagency Authorization to Exchange Confidential Health Information (PHI) Superseded by COM025_E, Childrens Interagency Authorization to Exchange Confidential Health Information (PHI) (Spanish) Superseded by COM025_S, Therapeutic Behavioral Services Service Assessment, Therapeutic Behavioral Services Risk Assessment, Therapeutic Behavioral Services Referral Form, Childrens Interagency Authorization to Exchange Confidential Health Information (PHI), Childrens Interagency Authorization to Exchange Confidential Health Information (PHI) (Spanish), Child/Adolescent Psychiatric Evaluation and Update, Child/Adolescent Clinical Assessment-CANS-SB, Request to Waive Consumers Responsibility to Pay for Medications, Caregivers Authorization Affidavit (Spanish), Request for Verification of Veterans Status for Mental Health and/or Substance Abuse Services, Consent and Authorization to Exchange Confidential Information for Veterans Status, Medication Support Services Plan (Spanish), Release and Hold Harmless Agreement (Spanish), Interdisciplinary Care Team (ICT) Referral Form, Annual Psychiatric Assessment Review Form, Guidelines for Completing Referral Summary for Referral to Managed Care Plan (MCP) Attachment, Tier Transition Letter Attachment II (Spanish), Beneficiary Nondiscrimination Notice (Spanish), Delivery System Notice (NOABD) (Vietnamese), Delivery System Notice (NOABD) (Mandarin), QM030_S Modification Notice (NOABD) (Spanish), Change of Provider Request Form (Spanish). endstream endobj 41 0 obj <>/Subtype/Form/Type/XObject>>stream Get e-mail updates on the latest COVID-19 news. Please turn on JavaScript and try again. If you feel you have a claim against the County, we encourage you to first attempt Disaster Response Requirements (02/01/2017) New! Read more at CountyWire. Mental Health Consumer Perception Survey-Fall 2019 New! and at-risk adults in our county. Box 1359 Susanville, CA 96130-1359 Website Lassen County Health & Social Services Agency Ms. Barbara Longo, Director P.O. 2018 Superior Court of California, County of San Bernardino, All Rights Reserved |, COVID-19: COURT OPERATIONS DURING THE COVID-19 PANDEMIC, Family Court Services Orientation Class Info, Failure to Appear/Respond to a Jury Summons, Court Case Information and Document Sales, How to Navigate San Bernardino Superior Court, San Bernardino Superior Court Rules of Practice, Local Emergency Rules Related to COVID-19, Online Form Preparation and Filing (TurboCourt), Online Form Preparation and eFiling (TurboCourt), Stipulation For Settlement (CCP 664.6) (fillable), Proof of Service Notice of Appeal (Code Enforcement), Appeal Procedures for Unlimited Civil Cases (Information on), Declaration of Petitioner and Request for Records Check, General Civil Case At-Issue Memorandum (fillable), Declaration and Order Re: Satisfaction of Judgment, CONFIDENTIAL Referral for CII/Carpos/ICMS Report (Civil) - Form A, Order Request for Review of Denial of Request to Remove Name from Gang Database, Initial Trial Setting Conference Statement, Application for Diversion of Individual with Mental Disorder, Order on Application for Diversion of Individual with Mental Disorder, Declaration and Order for Release of Exhibits, Consent to Bring Prohibited Items into the Courthouse as Exhibits (fillable), Stipulation And Order On Request For Order, Referral for CII/CARPOS/ICMS Report (fillable), Family Law At-Issue Memorandum for Trial Setting, Declaration And Order For Issuance Of Writ Of Execution/Abstract Of Judgment (fillable), Order On Petition For Grandparent Visitation, Response To Petition For Grandparent Visitation, Declaration Re: Compliance with Custody Orders (fillable), Petition for Declaring Child(ren) Free from Parental Custody and Control, Citation - Freedom from Parental Custody and Control, Order Declaring Child(ren) Free from Parental Custody and Control, Order on Petition to Terminate Parental Rights of Alleged Father, Petition to Terminate Parental Rights of Alleged Father, Declaration and Order Dispensing with Notice to Alleged Father, Petition to Obtain Original Unsealed/Un-Redacted Birth Certificate, Order on Petition to Obtain Original Unsealed/Un-Redacted Birth, Order on Petition for Birth Record Information, Application to Obtain Final Adoption Order and Order, Application to Obtain Copies from Adoption Case and Order, Petition for Adoption of Adult or Married Minor, Agreement of Adoption of Adult or Married Minor, Consent of Spouse of Adult or Married Minor to be Adopted, Stipulation for Entry of Judgment Re: Establishment of Parental Relationship, Order for Publication of Citation (Adoption), Application for Order for Publication of Citation (Adoption), Notice of Continuance of Hearing (Family Law), Declaration Regarding Objection to Agreement, Family Law/Child Support Copy Request Form, Affidavit/Certificate/Declaration Re: Military Service in an Adoption and Related Matters, Order for Publication of Summons or Citation, Application for Publication of Summons or Citation, Request for Dismissal -- Small Claims Cases, Declaration of Mailing or Inability to Ascertain Address (fillable), Request to Excuse Notice with Due Diligence Declaration, Audio CD Information Sheet and Order Form, Petition for Release of Jury Records and Order, Objection/Response to Packet (Delinquency), Objection/Response to Packet (Dependency), Certification of Competency (Delinquency), Response to Petition for Resentencing (Juvenile), Proof of Service - Juvenile Restraining Order, Ex Parte Application And Order To Serve Summons By Posting, Application for Judgment for Restitution of Premises Only (CCP1169) (fillable), Pretrial Orders Judgment By Court Unlawful Detainer (fillable), To Set Case for Trial - Unlawful Detainer, Application for Issuance of Writ of Execution Per CCP 712.010, Small Claims/Landlord Tenant Copy Request Form, Order Appointing Counsel For Conservatee, Probate Code Sections 1470, 1471, and 2356.5(f)(1), Petition for Visitation (Guardianship Cases Only), Order on Petition for Visitation (Guardianship Cases Only), Order Appointing Counsel For Minor, Probate Code Sections 1470 and 1516.5 (fillable), Notification of Court of Conservatorship Address, Confidential Guardianship Questionnaire and Authorization for Release of Information, List of Required Contact Information for Conservatorships, Optional Attachment to List of Required Contact Information for Conservatorships, Confidential General Care Plan of Conservatee, Ex Parte Petition to Dispense with Accounting and Order (fillable), Request for Deferment of Court Investigator Fee and Order, Affidavit to Comply with California Probate Code 13100-13115, Termination of Guardianship - Parent Questionnaire, Notification of Disqualification from Voting, Notice of Commencement of Proceedings for a Court Supervised Trust, Confidential Information Sheet - Conservatorship, Confidential Information Sheet - Guardianship, Confidential Information Sheet - Intestate Probate, Confidential Information Sheet - Testate Probate, Confidential Information Sheet - Trust Matters, Request for Consideration of Ability to Pay, Waiver of Arraignment & Court Trial Setting. 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