SC Department of Mental Health Initial Outpatient Treatment Request Form


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

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


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

Max characters: 1000


Certifications only apply to services authorized for reimbursement in the Clinic Agreement between CBA and SC DMH. Approval of continued services requires the clinic to get further certification from CBA.