Alpine County, CA · Alpine County
Historical Information Provided by Family Member or Other Concerned Party
Family members and other concerned parties use this form to share a client’s behavioral health history with Alpine County Behavioral Health Services.
At a glance
- Issued by
- City of Alpine County · Alpine County, Alpine County, California
- Notarization
- Not required: file this form without a notary.
- Official source
- alpinecountyca.gov
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
This form lets family members and other interested parties share a client’s behavioral health history with hospital or outpatient staff, including information about symptoms, treatment, living situation, and possible crisis behaviors. The document says staff place the information in the client’s mental health chart. It also asks whether the submitter wants contact about emergencies and whether the client has a Wellness Recovery Action Plan or Advance Directive.
Who needs it
A family member or other concerned party who wants to provide behavioral health history about a client to treatment staff can complete this form.
How to submit it
The document identifies Alpine County Behavioral Health Services and says staff place the information in the client’s mental health chart, but it gives no submission address or method. Submit it to the county department named on the form; check the county website for current contact details.
About notarization
This document is signed and dated without a notary; the signer provides information and signs the form, with no notarized or sworn attachment identified.
How to submit this form
- 1
Download the Form
Download the Historical Information Provided by Family Member or Other Concerned Party form.
- 2
Complete the Form
Provide the client’s history and information about symptoms, treatment, medications, and current living situation.
- 3
Gather Attachments
If available, attach a copy of the client’s Wellness Recovery Action Plan or Advance Directive.
- 4
Sign and Submit
Sign and date the form, then check the county website for current submission details.
Frequently asked questions
- Do I need a notary for the behavioral health history form?
- No. The form has a signature and date line but no notary block. The document does not identify any notarized or sworn attachment.
- Who can provide information on this form?
- A family member or other concerned party can use the form to share a client’s behavioral health history with hospital or outpatient staff.
- What information does the form ask for?
- It asks about the client’s history, symptoms, treatments, medications, medical information, living situation, and behaviors that may indicate a crisis.
- How do I submit the behavioral health history form?
- The document names Alpine County Behavioral Health Services but does not give a submission address or method. Check the county website for current contact details.