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Get the free MH and CD Request Form (prototype 3)

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Submit requests directly through CIM (cim6.phtech.com). Or fax form to 5033455754 or 8002707737 Request for: Mental Health and Chemical Dependency Treatment Date: Member Name: Member DOB: Member ID:
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Who needs mh and cd request?

01
Individuals or patients seeking mental health (mh) support or services may need to fill out mh and cd requests.
02
Individuals or patients requiring counseling or therapy services may need to submit cd requests.
03
Families or caregivers of individuals dealing with mental health issues may also need to fill out mh and cd requests.
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Healthcare professionals or service providers responsible for facilitating access to mental health resources may require mh and cd requests.
05
Educational institutions or organizations offering mental health support or resources may need to collect mh and cd requests from their students or members.
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Mh and cd request stands for Mental Health and Crisis Diversion request. It is a formal request made to provide assistance to individuals experiencing mental health crisis.
Emergency response teams, law enforcement agencies, and mental health professionals are required to file mh and cd request.
To fill out mh and cd request, one must provide detailed information about the individual in crisis, the nature of the crisis, and any relevant medical history.
The purpose of mh and cd request is to ensure that individuals experiencing mental health crisis receive appropriate assistance and support.
Information such as the individual's name, age, address, a description of the crisis situation, any known medical conditions, and contact information for family or next of kin must be reported on mh and cd request.
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