Dpss mental health assessment form 2025

1. Click ‘Get Form’ to open the dpss mental health assessment form in the editor.
2. Begin by entering your last name, first name, and date of birth in the designated fields. Ensure accuracy as this information is crucial for identification.
3. In the section labeled 'HEREBY AUTHORIZES', input the facility name, street address, city, state, and zip code from which you are requesting your protected health information.
4. Next, specify the Department of Public Social Services (DPSS) office name and its address where the information will be sent.
5. Indicate an expiration date for this authorization by filling in the appropriate date format (MM/DD/YYYY).
6. Select the type of information to be disclosed by checking either 'Mental Condition' or 'Other', providing details if necessary.
7. Review your rights regarding this authorization and ensure you understand them before proceeding to sign.
8. Finally, sign and print your name along with the date. If applicable, have a witness sign and provide their relationship to you.

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