Standard Outpatient Treatment Forms

Click below for downloadable versions of UMBH outpatient treatment forms.

You will need Adobe Acrobat Reader to open and fill out these forms. Please fax the completed forms to UMBH at 305-243-7299. 

Suggested Forms

• Informed Consent
• PCP Coordination of Care

Outpatient Care Provider Forms

• Initial Outpatient Clinical Review
• Outpatient Continued Care Assessment
• Child & Adolescent Assessment Checklist
• Transition/Termination/Discharge Plan
• Maintenance Treatment Plan
• Family Therapy Treatment Plan
• Split Treatment Coordination Plan (for Multiple Providers)
• FARS/CFARS Summary of Scores Form  

CMHC Forms

• Medicaid Initial Clinical Review Form
• Medicaid Concurrent Clinical Review Form
• FARS/CFARS Summary of Scores Form 

Request for Printed Materials Forms

• Request form for Mihalik Group’s Medical Necessity Manual for Behavioral Health