Form Dhcs 1008 - California Quarterly Report On Services Provided To Persons Detained In Jail Facilities - Health And Human Services Agency Page 2
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2State of California – Health and Human Services Agency
Department of Health Care Services
REPORTING INSTRUCTIONS:
QUARTERLY REPORT ON PERSONS DETAINED IN JAIL FACILITIES (MH 3823)
Persons served in jail programs would be reported by the county in which the jail is located. Do
not count persons from your county who are referred to another county for services.
Do not leave any boxes blank. If there are no jail facilities within your county that provide the
services listed in items 1-3 below, you must still submit this report on a quarterly basis with zero
counts in each of the boxes provided.
Enter your county name in the box provided.
Enter your county code in the box provided.
Enter the quarter and corresponding year in the boxes provided.
Please use one form to report each quarter.
1. Admissions: Enter the number of admissions to inpatient services pursuant to PC 4011.6 or
PC 4011.8 for evaluation and/or treatment in a local mental health facility (hospital setting) or a
community residential treatment center. This should include admissions referred from a court as
well as from a county jail, city jail, or juvenile detention facility. All facilities must be LPS approved
and meet inpatient service requirements as defined in California Administrative Code, TITLE 9,
ARTICLE 3, SECTION 820 & 821, and ARTICLE 10, SECTION 660-663.
2. LPS Approved: Enter the total count of persons who were evaluated and/or treated in inpatient
services within a jail facility. All facilities must be LPS approved and meet inpatient service
requirements as defined in California Administrative Code, TITLE 9, ARTICLE 3, SECTION 820 &
821, and ARTICLE 10, SECTION 660-663.
3. Unduplicated Count of Persons: Enter the unduplicated count of persons receiving outpatient
treatment services in jail facilities. Cost Reporting Outpatient treatment service functions are:
Assessment
Individual Therapy
Medication
Group Therapy
Collateral Services
Crisis Intervention
Date and sign the quarterly report in the space provided. Please include a telephone number of the
county contact for data verification purposes.
Fax, Email or Mail this quarterly report
Fax Number:
(916) 552-8555
Email Address:
bryan.fisher@dhcs.ca.gov
or
kenneth.lee@dhcs.ca.gov
Mailing Address:
DEPARTMENT OF HEALTH CARE SERVICES
Research and Analytic Studies Branch, MS1200
P.O. Box 997413
SACRAMENTO, CA 95899-7413
DHCS 1008 (08/12)
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