Family and Social Services Administration
Forms
- Statement of Understanding and Compliance 440 IAC 4.4 Required for Outpatient Certification
- Required Attachments for Addiction Services Providers
- Application for Certification of Licensure - State Form 48161
- Approved Accreditation Bodies
- Documentation of Direct Services Providers State Form 52810
- Facility Facts Record - State Form 48160
- Indiana Division of Mental Health and Addiction Approved Addictions Counseling Credentials
- Memo of Clarification and Revised Gambling Services Policy
- Required Attachments for Residential Care Provider Certification
- Required Attachments for Sub Acute Facility Certification for Residential Care Providers
- Required Attachments for Supervised Group Living Home (SGL) License Request for Residential Care Providers
- State Hospital Referral - State Form 52179
- The Residential/Hospital/Sentinel Event/A.C.T. Incident Report form can be found online. (State Form 53808 (12-08) / DMHA 1011). The form may be printed and manually filled out or may be filled out electronically. However, please be advised that electronically this is a “fill in” PDF form which can be filled out electronically and printed but cannot be saved.
Online Services
