Forms
APPLICATION FOR PROVIDER NETWORK
Application for Credentialing and Privileges, Licensed Independent Practitioners (MidState Health Network)
Application for Credentialing, Organizational Providers
Disclosure of Ownership & Controlling Interest Form
Authorization for Recipient Rights Check
Authorization to Obtain Information and General Release
BEHAVIOR TREATMENT
Behavior Treatment Committee (BTC) Review Form (920)
First Step Behavior Plan Instructions
First Step Behavior Plan - Monitoring Form
Behavior Treatment Committee (BTC) Review Form (920)
Psychiatric Staff Report Form (922)
Functional Assessment Screening Tool (FAST)
Positive Behavior Support Plan
CIGMMO
CONSENTS/LEGAL
Advance Directive Acknowledgement Form
Advance Directive for Mental Health Care
Consent for Medical Services Consent for Medical Services Instructions
Consent for Participation in CMHCM Services
Consent to Share Information for Care Coordination
HIPAA Acknowledgement and Consent to Contact
Power of Attorney for Minor Child
CRISIS/SAFETY
Crisis Prevention & Safety Planning (Individual)
Crisis Safety Plan (Youth/Family)
IPOS
Addendum to Person/Family Centered Plan
IPOS Training Record IPOS Training Record Instructions
HCBS
HCBS Guidance for Residential Settings
HCBS NEW Residential Provisional Approval Application and Guidance Document
HCBS NEW Non-Residential Provisional Approval Application and Guidance Document
MDHHS BHDDA New Home and Community Based Services Provider Requirements
HCBS FAQ for Individuals and Family Members
MDHHS BHDDA HCBS Guardianship FAQs
HCBS Guide for Individuals and Family Members
HCBS Person Centered Planning: The HCBS Rule Toolkit for Individuals and Family Members
Summary of Resident's Rights
RECIPIENT RIGHTS
Complaint Form—MDCH Recipient Rights
Critical Incident Analysis Form/Examples/Instructions
Incident Report Form—MDCH Recipient Rights
SERVICES DOCUMENTATION
ABA
2025 Master Template for Monthly Reports
ABA Treatment Plan Training Record (ABA Training Record Instructions)
Autism Program Attendance Procedure
CLS
CLS Overnight Time Study Intervention Log
CLS and Overnight Health & Safety Services Progress Note (December 8, 2023 updated form)
Overnight Health & Safety Services Progress Note
Out-of-Home Non-Vocational Habilitation (HAB) Progress Note
(fillable version) (handwritten version)
SPECIALIZED RESIDENTIAL
Specialized Residential Daily Data (Samples: Group Home or Family Home)
Specialized Residential Progress Note with Daily Data Form A
(fillable version) (handwritten version)
(Samples: Group Home or Family Home)
Specialized Residential Progress Note with Daily Data Form B
(fillable version) (handwritten version) (Sample: Group Home)
Specialized Residential Progress Note without Daily Data (fillable version) (handwriten version)
Specialized Residential Progress Note Instructions
Home Provider's Monthly Report & Community Outing logs
(fillable version) (handwritten version) updated 4/25/25
EMPLOYMENT
Pre-Vocational Service Progress Note
(fillable version) (handwritten version)
Skill-Building Progress Note
(fillable version) (handwritten version)
Supported Employment Progress Note
(fillable version) (handwritten version)