Form Sr 2c - Mental Health Component Program Worksheet

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
MENTAL HEALTH COMPONENT PROGRAM
WORKSHEET (SR 2C)
PROVIDER NAME
PROGRAM NUMBER
MONTH/YEAR
COLUMN A
COLUMN B
COLUMN C
COLUMN D
COLUMN E
Total M.H.
Verified Hours
Mental Health Professional Level
Direct Mental
Reported
Mental Health Professional
Health Hours
Professional
Wt. Hours
Psychiatrist
Psychologist
LCSW
MFT
MH Other
(FCARB Use Only)
Worked/Performed
Weightings
(5.0)
(5.0)
(2.5)
(2.5)
(1.0)
(Column A x C)
TOTAL:
TOTAL:
GH REP
FCARB REP
DATE
SR 2C (6/03)
Page ______ of ______

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