SC Department of Mental Health Initial Outpatient Treatment Request Form

Fields marked with an asterisk are required. The certification is not valid until a certification number is issued.

Clinic's Name

Phone Area Code () First Three Digits - Last Four Digits

Fax Area Code () First Three Digits - Last Four Digits

Clinic Email

Clinic's NPI

Contact's First Name

Contact's Last Name

Contact's Extension

Mailing Address 1

Address 2

ZIP Code

City

Patient's First Name

Patient's Last Name

Date of Birth

mm/dd/yyyy

ID Card Number

Patient CIN

Phone Area Code () First Three Digits - Last Four Digits

Patient Email

What Service(s) Are You Requesting? (Choose all that apply.)

MMO-Medically Monitored Only

Management & Treatment Services

Injectable Track Services

Diagnosis or Presenting Symptoms: Max characters: 1000

When is the Patient's First Appointment?

mm/dd/yyyy

Last date of full diagnostic assessment

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