SC Department of Mental Health Initial Outpatient Treatment Request Form

Instructions

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

Clinic Information
Phone () -
Fax () -
Clinic's Mailing Address
Patient Information

mm/dd/yyyy

Phone () -
Clinical Information
What Service(s) Are You Requesting? (Choose all that apply.)

Max characters: 1000

mm/dd/yyyy