SR 2C MHV (1/03) - California Department of Social Services - State ... - cdss ca 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out Part I - Child Information. Enter the child's name, including first, middle initial, and last name, followed by their social security number.
3. Proceed to Part II - Mental Health Professional Information. Input the clinic name, your name as the mental health professional, your license or registration number, and the expiration date of your license.
4. Select your professional level by checking the appropriate box. If you are providing services under another individual’s license number, indicate 'Yes' or 'No' and provide the necessary details if applicable.
5. In Part III - Mental Health Services Information, enter the dates of service and total hours of service provided. Check all applicable types of services rendered.
6. Finally, sign and date the form to certify that you provided the listed services.

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