Form Dhcs 1010 - California Quarterly Report On Involuntary Detentions - Health And Human Services Agency

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State of California - Health and Human Services Agency
Department of Health Care Services
QUARTERLY REPORT ON INVOLUNTARY DETENTIONS
Year
County Name:
Quarter 1
July 1 to Sept. 30
County Code:
Quarter 2
Oct. 1 to Dec. 31
Quarter 3
Jan. 1 to March 31
Quarter 4
April 1 to June 30
SUMMARY OF INVOLUNTARY DETENTIONS IN COUNTY DESIGNATED FACILITIES
(excluding State Hospitals)
Additional
72-Hr. Eval &
14-Day
30-Day
180-Day
14-Day
Treatment
Provider
Facility Name
Intensive
Intensive
Post
Intens.Treat
Code
Child/Adol
Adult
Treatment
Treatment
Certification
(Suicidal)
(0-17 Yrs)
(18 & Up)
The above information is required by the California Welfare and Institutions Code (WIC) Section
5402(a).
The information provided in this quarterly report will be incorporated into an annual report as required by
WIC Section 5402(d). Please see the next page or reverse side for Reporting Instructions. This
th
quarterly report should be submitted by the 30
of the month following the end of each quarter
via email, fax, or U.S. Mail. If you need assistance preparing this report, please send an email to one
of the persons below.
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
DATE
CONTACT PERSON
PHONE NUMBER
DHCS 1010 (8/12)

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