NC DMH 1-73-00 2014-2025 free printable template
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Facility Medical Record #:
Last 4 of SSN: ___Admitting State Hospital/ADATC: ___
DATE: ___ TIME: ___NC DIVISION OF MENTAL HEALTH/DEVELOPMENTAL DISABILITIES/SUBSTANCE ABUSE SERVICESRegional Referral
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How to fill out NC DMH 1-73-00
01
Begin by gathering all necessary personal information such as your name, address, and contact details.
02
Fill in the section for demographics, including age, gender, and any relevant identification numbers.
03
Provide details about your current mental health status, including diagnoses and treatment history, if applicable.
04
Complete any required sections on family history related to mental health issues.
05
Indicate your current support systems, including any treatment providers or community resources.
06
Review the form for completeness and accuracy before submitting.
07
Sign and date the form where indicated.
Who needs NC DMH 1-73-00?
01
Individuals seeking mental health services from the North Carolina Department of Mental Health.
02
Service providers required to document and report client information for treatment purposes.
03
Administrators and coordinators managing mental health programs needing client data for compliance and planning.
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What is NC DMH 1-73-00?
NC DMH 1-73-00 is a form used for reporting mental health services in North Carolina to the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services.
Who is required to file NC DMH 1-73-00?
Providers of mental health services in North Carolina are required to file NC DMH 1-73-00 as part of their compliance with state reporting regulations.
How to fill out NC DMH 1-73-00?
To fill out NC DMH 1-73-00, gather required patient information, service details, and outcome measures, then complete all sections of the form accurately and submit it to the appropriate authority.
What is the purpose of NC DMH 1-73-00?
The purpose of NC DMH 1-73-00 is to collect data for the assessment and improvement of mental health services in North Carolina, ensuring accountability and quality care.
What information must be reported on NC DMH 1-73-00?
The information required includes patient demographics, types of services provided, dates of service, treatment outcomes, and any other data necessary for state records.
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