Main Content
SCDMH Enterprise Forms
Form Categories:
- Forms Management
- Administrative General Usage Avatar Inpatient System
- Outcomes Measures
- Community Mental Health Clinics and Centers
- Community Mental Health Clinics and Centers PRINT ONLY
- Information Technology CIO (Telephone)
- Duke Endowment
- Department of Health & Human Services
- Engineering Division Volunteer Emergency Fund Application
- Finance
- Human Resource Services (HRS)
- Workers’ Compensation
- Medical Records (see also C forms) Forms Management
- Medical Records PRINT ONLY
- Nursing Services
- Payroll/Personnel Property Physical Plant Service Public Safety
- Supply and Service Division State Personnel
- Volunteer Services
- Working Patient
|
Form |
Description |
|---|---|
 Forms Management |
|
| MS-4 | Forms Management Forms Specification |
| MS-5 | Forms Mgmt. Signature Authorization |
| MS-11 | Printing Requisition/Job Order Sheet (MS Word) |
| MS-18 | Request for Composition/R2web Format (MS Word) |
| MS-19 SCDMH F-26 |
Receipt Book Proof of Delivery Form (MS Word) |
| MS-21 | Form Justification Sheet |
| S-13 | Request for Issue or Turn-In of Forms (MS Word) |
| S-14 | Request for Issue or Turn-In of Forms (MS Word) |
| A | Administrative General Usage
Avatar Inpatient System |
| A-1A | DMH Electronic E-Mail Letterhead (MS Word) |
| A-6 | Fax Coversheet (MS Word) |
| A-7 | Communications Slip |
| A-10 | Memorandum (MS Word) |
| AS-13 | Permanent Improvement Project Request (MS Word) |
| AS-60 | Greenhouse Request for Plants (MS Word) |
| AS-86 | Camera Index Worksheet (MS Word) |
| AS-86A | Index Worksheet Terminated Personnel Records (MS Word) |
| AVA-101 | AVATAR Problem Report |
| B | Outcomes
Measures |
| PS-200 | BPH Inpatient Survey Rev (PDF) |
| PS-201 | HPH Inpatient Survery Rev (PDF) |
| PS-300 | School Administrator Survey (PDF) |
| PS-301 | 2007 Youth Services Survey for Families (PDF) |
| PS-302 | 2007 Youth Services Survey (PDF) |
| PS-303 | QA Audit Tool (PDF) |
| PS-304 | PSSAM Combined (PDF) |
| PS-305 | 3TMHSIP MST Youth (58394 -) (PDF) |
| PS-306 | 3D MST MHSIP Family Survey (PDF) |
| PS-307 | 3E MHSIP MST Youth (2148 -) (PDF) |
| PS-308 | 3E MST MHSIP Family Survey (PDF) |
| PS-309 | 3G MHSIP MST Youth (38368 ) (PDF) |
| PS-310 | 3G MST MHSIP Family Survey (PDF) |
| PS-311 | 3P MHSIP MST Youth (15724) (PDF) |
| PS-312 | 3P MST MHSIP Family Survey (PDF) |
| PS-313 | 3R MHSIP MST Youth (18200 ) (PDF) |
| PS-314 | 3R MST MHSIP Family Survey (PDF) |
| PS-315 | 3T MST MHSIP Family Survey (PDF) |
| PS-316 | 3D MHSIP MST Youth (5929 ) (PDF) |
| PS-317 | TriCounty Crisis Stabilization (PDF) |
| PS-318 | Georgetown MAC Survey (PDF) |
| PS-319 | Greenville Crisis Stabilization (PDF) |
| PS-320 | Marshall Street Crisis Stabilization (PDF) |
| PS-321 | Spartanburg MHC Dual Diagnosis (PDF) |
| PS-322 | Beckman Co-Occurring Survey (PDF) |
| PS-323 | Lancaster MHSIP MST Youth (PDF) |
| PS-324 | Lancaster MHSIP MST Family (PDF) |
Orangeburg Adult MHSIP 2008 (MS Word) |
|
| PS-394 | Orangeburg YSSF 2008 (MS Word) |
| PS-395 | Orangeburg Annual YSS 2008 (MS-Word) |
| PS-396 | Orangeburg ICS Parents (MS Word) |
| PS-397 | Orangeburg FSS Post Discharge (MS Word) |
| PS-398 | Orangeburg CSS (MS Word) |
| PS-399 | Orangeburg CASS (MS Word) |
| PS-400 | Orangeburg Annual SS (MS Word) |
| PS-401 | Orangeburg FSS Annual (MS Word) |
| PS-402 | Orangeburg ICS Adults (MS Word) |
| PS-403 | Orangeburg Svy (MS Word) |
| PS-404 | Orangeburg C&A Consumer Survey (MS Word) |
| C | Community
Mental Health Clinics and Centers
|
| C-20 | Screening Information (MS Word) |
| C-39 (MS Word) | Generic Service Ticket (MS Word) |
| C-39 (PDF) | Generic Service Ticket (PDF) |
| C-52 | Discharge Summary or Transition Plan |
| C-69 | Special Client Consumer Notification & Consent |
| C-107 | Consent To Examinations and Treatment(MS Word) |
| C-108 | Crisis Stabilization Form (MS Word) |
| C-166 (MS Word) | W R A P CSN form (MS Word) |
| C-166 (PDF) | W R A P CSN form (PDF) |
| C-168B | Physician’s Medication Orders and Service Notes (MS Word) |
| C-168C | Physician’s Medication Orders and Service Notes (MS Word) |
| C-168D-CA | Community Crisis Communication or Physician's Medication Orders (MS Word) |
| C-174 | Adverse Incident Report (Ms Word) |
| C-175 | Clinical Service Ticket Multi-Client Services (MS Word) |
| C-176 (MS Word) | MIMS Note (MS-Word) |
| C-176 (PDF) | MIMS Note (PDF) |
| C-181 | Plan of Care (MS Word) |
| C-182 (MS Word) | ITP Progress Summary 8x11 (MS Word) |
| C-182 (MS Word) | ITP Progress Summary X2 (MS Word) |
| C-183 | Initial Clinical Assessment |
| C-184 | CAF Initial Clinical Assessment (MS Word) |
| C-188L | PRS Weekly Note w Lines |
| C-188 | PRS Weekly Note w/o Lines |
| C-190L | Daily Clinical Service Note W/Lines (MS Word) |
| C-190 | Daily Clinical Service Note W/O Lines (MS Word) |
| C-192 | Mental Status Exam (MS Word) |
| C-193 | Clinical Assessment Update (MS Word) |
| GRV-35 | Greenville MHC Client Insurance Info (MS Word) |
| ORG-19 | Adverse Drug Reaction Report (MS Word) |
| ORG-22 | Treatment Attendance Agreement (MS Word) |
| ORG-22A | Treatment Attendance Agreement (Altered Margins) (MS Word) |
| C | Community Mental Health Clinics and Centers PRINT ONLY |
| Cola Area-91 | Friendship Center Drop-In Referral Form (MS Word) |
| Cola Area-92 | Friendship Center Treatment Referral Forms (MS Word) |
| Cola Area-93 | Detention Order Request (MS Word) |
| D | Information
Technology CIO (Telephone) |
| CSR | CIO Communication Service Request |
| CSRB | CIO CSR Attachment |
| DP-6A (MS Word) | IT Request for services (MS Word) |
| DP-6B | IT R2Web Publishing Request |
| DP-6B | IT R2Web Publishing Request (MS Word) |
| DP-6C | Web Development Request (MS Word) |
| DP-7 | SCEIS (MS Word) |
| DP-64 | Internet Acceptable Use Policy (MS Word) |
| DP-65 (MS Word) | IT Security Update Request (MS-Word) |
| DP-65S | IT SAP Security Update Request |
| DP-159 | IT Flexible Schedule Request |
| NWS-1 | User Authorization Form |
| NWS-2 | Notebook Computer Use Policy (MS Word) |
| PDR-10 | Monthly Report of NON-DMH Hospitalizations (MS Word) |
| R-25 | Daily Long Distance Telephone Calls |
| VMCSR | CIO Voice Mail CSR |
| VMCSRA | CIO Voice Mail CSR Attachment |
| DE | Duke Endowment |
| Duke-01 | Initial ED Consult (MS Word) |
| Duke-02 | Follow-Up ED Consult (MS Word) |
| Duke-03 | Violence Risk Appraisal (MS Word) |
| Duke-04 | Suicide Risk Appraisal (MS Word) |
| Duke-05 | Telepsychiatry Consult Request Form (MS Word) |
| DHHS | Department of Health & Human Services |
| DHHS-252 | Form 252 09-01-09 Fill-in Secure (PDF) |
| DHHS-254 | Form 254 09-01-09 Fill-in Draft 1 (PDF) |
| E | Engineering Division Volunteer Emergency Fund Application |
| E-21AA | Vehicle Mgmt. Request for Transportation |
| E-22 | Request For Out of State Travel (MS Word) |
| E-26 | Monthly Trip Log (MS Word) |
| E-26A | Monthly Trip Log Continuation (MS Word) |
| V-16E | Dr. Irwin E.Phillips Emergency Fund Application |
| F | Finance |
| F-10 | Composite Bank Account Deposit |
| F-11 | Invoice |
| F-11A (MS Word) | Invoice Voucher (MS Word) |
| F-11A (PDF) | Invoice Voucher (PDF) |
| F-12 | FMS Employee Travel Document (MS-Word) |
| F-12 (No Calc) | Employee Travel Document No Calculation (MS Word) |
| F-12C (MS Word) | Employee Travel Document Supplement (MS Word) |
| F-12C (PDF) | Employee Travel Document Supplement (PDF) |
| F-19 | Journal Entry Request (MS Word) |
| F-22 | Request for Patient Fund Withdrawal (MS Word) |
| F-102 | Confidentiality Information Form |
| F-159 | Flexed Work Schedule |
| F-160 | Employee Time Sheet |
| F-162 | Request for Overtime Comp Time (MS-Word) |
| F-163 | Statement of Services Rendered (MS Word) |
| F-194 | Adjustment to Time-Attendance |
| F-191 | Authorization Agreement for Electronic Deposits (MS Word) |
| F-196 | Financial Support to Promote Community Housing (MS Word) |
| FAT | Fiscal Analysis Tracking Form |
| H | Human
Resource Services (HRS) |
| DIPS-14 | Conflict of Interest Form (MS Word) |
| HRS-3A | Employment Reference Check |
| HRS-3B (PDF) | Dual Employment Request (PDF) |
| HRS-3B (MS Word) | Dual Employment Request (MS-Word) |
| HRS-4 | Applicant Interview Form |
| HRS-7 | Applicant Listing and MTE Determination |
| HRS-10 | Grant Position Agreement (MS Word) |
| HRS-13 | Property and Fiscal Responsibilities (MS Word) |
| HRS-17 | Employee Harassment Form with Policy |
| HRS-18 | Performance Commendation (Ms Word) |
| HRS-20 | Nov 2007 Request for Salary Approval |
| HRS-20A | New Employee Salary Documentation (MS Word) |
| HRS-22 | Bonus Award Form (MS Word) |
| HRS-23 | Light Duty Request/Approval Form (Ms Word) |
| HRS-24 | Affidavit of Common Law Marriage (Ms word) |
| HRS-27 (PDF) | EPMS Rating (PDF) |
| HRS-27 (MS Word) | EPMS Rating (MS-Word) |
| HRS-27 | EPMS Rating expanded format (MS-Word) |
| HRS-33 | Request for Personnel Action/Employee Change (MS-Word) |
| HRS-35 | Notice of Personnel Separation (MS-Word) |
| HRS-40 | Certificate of Service (MS Word) |
| HRS-66 | Employee Substandard Performance Warning |
| HRS-93 | Request for Consideration (Ms Word) |
| HRS-102 | Exit Interview |
| HRS-115 | Grievance Review Request |
| HRS-140 (PDF) | Position Description (PDF) |
| HRS-140 (MS Word) | Position Description (MS-Word) |
| HRS-146 | Time Away From Duty |
| HRS-153 | Written Warning |
| HRS-154 | Notice of Suspension |
| HRS-155 | Record of Employee Counseling (MS Word) |
| HRS-159 | Request to Fill Position |
| HRS-161 | Outstanding Employee Nomination (Ms Word) |
| HRS-166 | Leave Donation Request (MS Word) |
| HRS-167 | Recipient Leave Request (MS Word) |
| HRS | Workers’ Compensation |
| HRS-16 | Report of Injury (MS-Word) |
| HRS-147 | Workers' Compensation Election Form (MS Word) |
| HRS-148 | SCDMH Employee/Supervisor Notification (MS Word) |
| M | Medical
Records (see also C forms)
Forms Management |
| CBHS3 | Code Blue Critique (MS Word) |
| CBHS3A | Code Blue Medical Emergency Practice Drill (MS Word) |
| CMT-21 | Resident Count Sheet |
| CMTNCC-129 | Hydration Risk Appraisal Checklist |
| Forensic 07 | DIS Forensic Ongoing Master Treatment Plan |
| Forensic 08 - Page 1 | DIS Forensic Treatment Plan Page 1 |
| Forensic 08 - Page 2 | DIS Forensic Treatment Plan Page 2 |
| Forensic 09 | Annual Social Work Assessment Summary |
| Forensic 12 | Monthly Progress Report (MS Word) |
| DIPS-17 | Model Reply to Request To Inspect and/or Copy SCDMH Protected Health Information (MS Word) |
| DIPS WSHPI-130 | Psychiatric Social Work Admission Assessment (MS Word) |
| M-005 | Community Hospital EMTALA Transfer (MS Word) |
| M-015 | Application for Child in Need of Emergency Admission (MS Word) |
| M-017 | Part II Certificate of Licensed Physician Examination of Child in Need of Emergency Admission (MS Word) |
| M-108 | HIV Informed Consent, Testing & Counseling (MS Word) |
| M-110 | Neuroleptic (Antipsychotic) Consent Form (MS Word) |
| M-110 CMTNCC | Neuroleptic Medication Consent Form (MS Word) |
| M-111 | IFS Addendum Notice |
| M-122A | Petition for Judicial Admission (MS Word) |
| M-130 | Application for Involuntary Emergency Hospitalization For Mental Illness (MS Word) |
| M-131 | Certificate of Licensed Physician Exam for Emergency Adm, Part II (MS Word) |
| M-134 | (Part One) Application for Involuntary Emergency Admission for Chemical Dependency |
| M-192 | Certification of Medical Infirmity (MS Word) |
| M-193 | Information Sheet for Restoration Patients |
| M-194 | Information Sheet for Defendants Who Are Admitted to the Hospital for Competency Evaluation |
| M-195 | Information Sheet for Defendants Who Are Admitted to the Hospital for Criminal Responsibility Evaluation |
| M-202 | Physician Progress Note |
| M-207B | Organ Tissue Donation Physician Progress Note (MS Word) |
| M-208 | Seclusion / Restraint Letter (MS Word) |
| M-208EEEE CHP/DoIS | Seclusion/Restraint Order Form and Face-To-Face Evaluation (MS Word) |
| M-212 | CMT History and Physical (MS Word) |
| M-214 | Acute Care Certification/Recertification (MS Word) |
| M-217A | Certification Recertification |
| M-226 DIS | DIS Patient Immunizations Assessment and Physician Order (MS Work) |
| M-227 | Practitioner Orders Sliding Scale Insulin (MS Word) |
| M-228 | CBHS Physician Query Form (MS Word) |
| M-230 | DIS Pneumococcal Pneumonia Immunization Ass & Order Form Jan 09 (MS Word) |
| M-232 | Election of Code Status |
| M-303 | Patient Visitor's List |
| M-343 | Wellbeing and Security Preference (Ms Word) |
| M-350C | Mini-Mental Status Exam Bilingual (MS Word) |
| M-357 | Pet Therapy Consent Form |
| M-400 | Multidisciplinary Therapeutic Documentation Record (MS Word) |
| M-402C | Admissions Initial Data Sheet (MS Word) |
| M-402D | Patient Orientation To Unit (MS Word) |
| M-406 | Correspondent and/or Financial Representative Change |
| M-411A | Glucose Monitoring (MS Word) |
| M-412 | CHP Admission Medication Reconciliation and Order Form (MS Word) |
DIPS Special Treatment Procedure Log Feb 2008 (MS Word) |
|
| M-421 | CBHS Agitation Assessment (MS Word) |
| M-426 | CBHS Hospital Transfer Record (MS Word) |
| M-427 | BPH Inpatient Suicide Risk Assessment (MS Word) |
| M-450D | Authorization To Disclose PHI (MS-Word) |
| M-450I | Authorization To Release Information, Request For Payment & Assignment of Benefits (MS Word) |
| M-450J | Authorization to Share Information with Family & Others |
| M-451 | Request to Inspect Protected Health Information (MS Word) |
| M-452 | Request to Amend Protected Health Information (MS Word) |
| M-453 | Accounting Log of PHI Disclosures (MS-Word) |
| M-455 | Patient Medical Equipment/Device Release (MS Word) |
| MV-93 | Patient Orientation (MS Word) |
| MV-106 | Multifamily Group Therapy Progress Notes (MS Word) |
| PR-3 | Request for Review (MS Word) |
| PR-11 | Privacy Practices Complaint (MS Word) |
| PR-13 | Request for Review of Designated Record Set (MS Word) |
| PS-132 | CBHS Community Outing (MS Word) |
| R-3 | Notification of Rights, Privacy & Advance Directive Query (MS Word) |
| R-9 | Confidentiality Agreement/Record of Visitation |
| R-40 | Letter Regarding Information |
| WS@CHP-1 | Activity Therapy Department Progress Note Sheet (MS Word) |
| WS@CHP-2 | Activity Therapy Constructive Leisure Monthly Attendance (MS Word) |
| WS@CHP-3 | Activity Therapy Assessment (MS Word) |
| WS@CHP-4 | Activity Therapy Annual Assessment (MS Word) |
| WS@CHP-5 | Wellness and Rehabilitation Assessment (MS Word) |
| WSHPI-137 | CBHS Consent For Minors To Participate in Activities Outside SCDMH (English) (MS Word) |
| WSHPI-144 | WSHPI De-Escalation Preference Form (MS Word) |
| WSHPI-151 | WSHPI-151 Youth Rational Decision Evaluation (MS WORD) |
| MR | Medical
Records PRINT ONLY |
| CHP-04 | Restraint/Seclusion Debriefing Form (MS Word) |
| Cola Area-87 | Medication Management Worksheet (MS Word) |
| Cola Area-88 | Physician's Medication Orders and Service Notes (MS Word) |
| Forensic-11 | Psychiatric Social Work Admission Assessment (Child) (MS Word) |
| M-001 | Identification and Summary Sheet (MS Word) |
CHP Practitioner Orders for Pass/Discharge PRINT ONLY |
|
CHP Pg.1 Admission Orders PRINT ONLY |
|
CHP Pg. 2 Admission Orders PRINT ONLY |
|
MV Admission Orders PRINT ONLY |
|
| M-224 | AIMS Abnormal Involuntary Movement Scale (MS Word) |
| M-225 | Practitioner Orders (MS Word) |
History & Physical MultiDisciplinary Assessment PRINT ONLY |
|
WSHPI Social Work Assessment Addendum PRINT ONLY |
|
| NS-37 | Clinical Opiate Withdrawal Scale (COWS) |
| N | Nursing
Services |
| M-420 | Registered Nurse Seclusion / Restraint Assessment (MS Word) |
| NS-5 | CBHS Code Blue/Medical Emergency Flow Sheet (MS Word) |
| NS-10 | Early Recognition Intervention Criteria (ERIC) (MS Word) |
| NS-27 | Daily Living Flow Sheet (MS Word) |
| NS-36 | CBHS Fall Reduction Interventions (MS Word) |
| P | Payroll/Personnel Property Physical Plant Service Public Safety |
| P-13 | Property/Fiscal Responsibilities |
| Public Safety-13 | Safety/Security Trip Assessment Sheet (MS Word) |
| P-14 | Application for Leave (MS-Word) |
| P-14A | Travel Authorization Form |
| SD-14 | SCDMH Statement Of (MS Word) |
| S | Supply and
Service Division State Personnel |
| S-3 | Non-Expendable Property |
| S-5 | Supplies Issue/Turn-In Request |
| S-5C | Request For Issue or Turn-In Of Supplies |
| S-5E | Surplus Salvage Turn-In Request |
| S-7 | Request Issue/Turn-in of Equipment Over $1,000 |
| S-8 | Property Transfer |
| S-13 | Request for Issue or Turn-In of Forms(MS Word) |
| S-14 (MS Word) | Request for Issue or Turn-In of Forms(MS Word) |
| S-18 | Turn-in Document (TID) (MS Word) |
| SCF-101 | State Job Application |
| V | Volunteer
Services |
| V-5 | One Time Activity Form |
| V-7 | Record of and Receipt for Contributions |
| V-9 | Proposed Fund Raising Activity |
| V-10 | Volunteer Orientation With Resident/Consumer Contact |
| V-11 | Volunteer Services Orientation W/Minimal or no Resident Contact |
| V-12a | Volunteer Report |
| V-16E | Dr. Irwin E.Phillips Emergency Fund Application |
| V-17 | Volunteer Occasional Service Application |
| V-18 | Directive Statements |
| W | Working
Patient |
| WPP-101 | Patient Payroll: Cancel or Supplemental Information |