DHS 35 - Forms
Resources for Outpatient Mental Health Clinics

Considerations regarding use of the documents on this DHS 35 webpage

• DHS 35 Compliance Checklist (Word format) - posted 9.17.2009
• Assessments
• Adult Initial Assessment
• Child-Adolescent Initial Assessment
• Suicide Risk Assessment - revised 1.17.2012 (see also Suicide Safety Plan below)
• Consent Forms
• Consent for Adult Admission for Evaluation and/or Treatment - revised 9.30.2010
• Consent for Child Admission for Evaluation and/or Treatment - revised 9.30.2010
• Progress Notes
• Progress Notes - template 1
• Progress Notes - template 2
• Progress Notes - template 3 - small font / 1 page document
• Progress Notes - template 3 - large font / 2 page document
• Questionnaires
• Adult Pretreatment Questionnaire
• Child-Adolescent Pre-treatment Questionnaire
• Intake Questionnaire – Adult
• Intake Questionnaire – Child 
• Intake Questionnaire - computer friendly
• Treatment Plans
• Child or Adult Initial Treatment Plan - template set 1
• Child or Adult Updated Treatment Plan - template set 1
• Child or Adult Discharge Summary - template set 1
• Comprehensive Treatment-Discharge Plan - template 2 - revised 9.28.2010
• Suicide Safety Plan - posted 1.17.2012
• Business Associate Agreement form - includes new HITECH ACT requirements, provided by HIPAA Collaborative of Wisconsin - - Hipaacow.org - (more under Other Resources below)
• GRAD Student – Permission to Audio/Video Tape
• GRAD Student – Permission to Provide Therapy
• Information for Clients – blank
• Joint Notice of Privacy Practices – English
• No Contact Letter – case closing
• Phone Intake – billing info & insurance verification
• Prior Authorization Form: see F-00212 (under "DHS Resources")
• Referral for Psychotherapy (master level therapist)
• Referral for Psychotherapy (psychiatrist)
• Release of Records Log
• Substance Usage – addendum to intake evaluation
• Supervision Case Review
• Welcome Letter - version 1
• Welcome Letter - version 2 - posted 07.2011

(All documents are posted in Microsoft Word 2003 unless otherwise noted. If you receive a "login" prompt when you are trying to save one of these documents to your computer, hit "cancel" in the login box to proceed.)