To file a complaint about a provider or BHSB, please click on Complaint Form. Learn more about our complaint process here. 

To report a critical incident please complete the Critical Incident Form and email the completed form to [email protected].

For more information about the complaint process contact Diana Long, Incident Management & Investigations Manager at [email protected].

Because each funding opportunity may call for different forms, be sure to check the Word document attached to ensure that the required forms are submitted. Please see individual description for the correct person to contact with questions or concerns.

Key Information for Contracts

• Contractual Requirements at a Glance
• FY 22 Contracts- key information for sub-vendors
• Tobacco Cessation Questionnaire
• BHSB Sub-vendor Equity Survey

Budget Forms

• Annual Report Form 440A-C and Instructions

• Cost Reimbursement Contract-Budget Submission Instructions

• Cost Reimbursement Contract-Sources of Funds

Contract Attachments

Other Forms

• Evidence Based Treatment Therapies Survey
• W-9
• Application for Financial Assistance to Purchase Medication
• Insurance Requirements
• Human Service Agreements Manual
• Agreement to Cooperate

Critical Incident Form

• Critical Incident Form

Forms for Supporting Youth/Caregivers

• Care Coordination Organization Overview
• Youth Support Request Form
• Request Respite Form
• Fillable Care Coordination Referral
• Printable Care Coordination Referral

Forms for Behavioral Health Assisted Living

• Behavioral Health ALF Referral Form
• Behavioral Health ALF Intake Form
• Authorization for PHI Records

Request Form for Letters of Support

• Request Form for Letters of Support

Capitation Provider Forms (Reporting and Budget)

• Monthly Capitation Project Report Form
• Program Budget Form
• Semi-Annual Fiscal Report
• Capitation Project Management Plan Template
• Capitation Project Referral Form

Outcome Reporting Forms

• State Mobile-ACT (Please call 443-615-7806 for instructions and the password for this form.)
• Psychiatric Rehabilitation Program
• Supportive Employment Program

If you have any questions related to the data reporting forms, please call 443-615-7806.