If you do not see a form you are looking for, please contact us.

Department-wide Forms

• Application for Gubernatorial Appointment to a DMH Committee

• Personal Expense Form

• Critical Incident Reporting Requirements (November 1, 2011)

• State Electronic Critical Incident Report Form

Adult Mental Health Forms

• Adult Statewide Program Standing Committee Application Form

• Local System of Care Plan Form

• Application to Commence Proceedings for the Involuntary Treatment of an Individual Non-Emergency

Community Rehabilitation & Treatment (CRT) Forms:

• CRT Special Services Funding Instructions Memo

• CRT Special Services Funding Request Form 

• CRT Special Services Dental Claim Form

• CRT Cash Payments Reporting Form

Children, Adolescent and Family Mental Health Forms

• Coordinated Services Plan (CSP) and Referral Forms for Local Interagency Team (LIT), State Interagency Team (SIT), & Case Review Committee (CRC)

• Child Placement Agreement Form

Act 264 Forms

• Act 264 Flow Chart for Coordinated Service Plans

You must print out the Coordinated Service Plan for signature and submission.

The Word version can be filled out on the computer.
You can save it to your files for your records, as well as be able to return to the form if you have started to fill it out. You can adjust the "zoom" setting for magnification.

• Coordinated Services Plan (CSP) and Referral Forms for Local Interagency Team (LIT), State Interagency Team (SIT), & Case Review Committee (CRC) (pdf version)

• Coordinated Services Plan (CSP) and Referral Forms for Local Interagency Team (LIT), State Interagency Team (SIT), & Case Review Committee (CRC) (Word document version) 

ISB Forms

• ISB Initial Eligibility Checklist

• ISB Eligibility Checklist (July 1, 2009)

• ISB Continued Eligibility Checklist

• ISB Termination Form

• ISB Services Budget Worksheet (FY 2012)

• ISB Cost Agreement Signature Page

General Child, Adolescent and Family (CAFU) Forms

• Local System of Care Plan Form

• Child Placement Agreement Form

Peggy's Law

• Mandatory disclosure information form for home providers and respite workers

• Mandatory disclosure guidelines

• Question and Answer document

Respite

• Monthly Report Form for Family Specific Request Respite Data

Special Service Funding

• CAFU Special Services Funding Request Form

• CAFU Special Services Policy and Procedure

Enhanced Family Treatment (formerly called Waiver) Forms

• Enhanced Family Treatment Manual

• Waiver Services Budget Worksheet: DMH match (FY 2012)

• Waiver Services Budget Worksheet: DCF match (FY 2012)

• Waiver Suspension Form

• Waiver Notification of Termination Form

• Enhanced Family Treatment Intake Form 

• EFT/Waiver and Individualized Service Budget Signature Sheet

Vermont State Hospital Forms

• Application to Commence Proceedings for the Involuntary Treatment of an Individual Non-Emergency

• Warrant for Immediate Examination

• Application for Emergency Examination