Forms

A

 Application for Emergency Examination(PDF)

Application for Emergency Examination

Application for Physicians who can perform Emergency Examination (find quiz under Q)

Application for Gubernatiorial Appointment

C

Court Screening Form

Critical Incident Reporting Form (Designated Agency)

Critical Incident Reporting Form (Designated Hospital)

CRT Cash Payments Reporting Form

CRT Enrollment Form (March 2016)

CRT Disenrollment Form

CRT Mental Health Minimum Standards (September 2016)

D

Designated Agency Master Grant Performance Measure Reporting Template (September 2016)

E

EFT and Individualized Service Budget Signature Sheet

EFT Intake Form (Jan 1, 2015)

EFT Notification of Termination Form (July 1, 2005)

EFT_Self-Audit_Template 2016

EFT Self-Audit Template 2017

EFT Suspension Form (October 1, 2005)

EFT DCF Match FY 2017 Waiver Service Budget Worksheet (September 1, 2016 - December 31, 2016)

EFT FY 2017 Waiver Services Budget Worksheet (September 1, 2016 - December 31, 2016)

Emergency Services Record Review (September 2016)

I

Involuntary Treatment of an Individual Non-Emergency

P

PASRR  - Step One

Personal Expense Form

Physician's Certification Emergency Exam(PDF)

Physician's Certification Emergency Exam

Psychiatrist Second Certification Form

Psychiatric Evaluation Medical Notes for minimum standards chart review  (September 2016)

N

Non-Emergency Services Record Review (September 2016)

Notice of your Rights as a Person n the Custody or Temporary Custody of the Commissioner of Mental Health

Q

Qualified Mental Health Professional (QMHP) Application

Quiz Physicians who can perform Emergency Examinations

S

Special Services Fund Request(Adult)

CAFU Special Services Funding Request Form (July 2007)

Special Services ADA Dental Claim Form

T

Transportation Supervision Checklist for Persons on Involuntary Status (September 2016)

W

Warrant for Emergency Exam(PDF)

Warrant for Emergency Exam

 

For a list of specific Children's forms please go to the Children's Forms page

 

Contact Information

Department of Mental Health
Commissioner Melissa Bailey
280 State Drive, NOB 2 North
Waterbury, VT 05671-2010
Phone:  (802) 241-0090
Fax: (802) 241-0100

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