Parental Verification For Receipt Of Behavioral Services
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State of California -Health and Human Services Agency
Department of Developmental Services
PARENTAL VERIFICATION FOR RECEIPT OF BEHAVIORAL SERVICES
DS 5862 (6/2011)
Page 1 of 2
1. Consumer Name: ___________________________________________
UCI # : __________________________
(First)
(Last)
2. Vendor Name: _____________________________________________________________________________________
3. Vendor #: ________________________
4. Vendor Phone # _ ______ _________________
5. For Services Provided: Month _______________
Year ________
Name & Credential of
Signature of
Description of Service
Service
Start
End
Date
Location of Service
Person
Parent or
Provided
Code
Time
Time
Providing Services
Legal Guardian
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