Behavioral Health Services - OC Health Care Agency 2026

1. Click ‘Get Form’ to open the Behavioral Health Services application in the editor.
2. Begin by entering your Avatar Staff ID Number if known, followed by selecting whether this is a new application or an update.
3. Fill in the agency details including Agency Name, Phone Number, Contact Person, Date, and Contact Email.
4. Provide the Program Name and complete the address fields: Street, City, and Zip Code.
5. In the Applicant section, enter your name (Last, First, M.I.), Date of Birth (DOB), Social Security Number (SSN), and any previous names or AKAs.
6. Indicate your gender and any secondary language you may speak. Fill in your Date of Employment and Employment Status (Full Time, Part Time, etc.).
7. Select your Mental Health Professional Classification from the provided options and attach any necessary licenses or certifications.
8. Complete additional fields such as Registration/License numbers and Certification Organization Name as required.
9. If applicable, indicate if co-signature is always required and whether you hold a dual ADS/Mental Health role classification.
10. Finally, provide the Date of Termination if relevant. Once completed, send the form via email or fax as indicated at the bottom of the document.

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