Forms
If you would like to obtain a copy of your mental health records, please complete the attached form and either mail it to Placer County Medical Records, 101 Cirby Hills Drive, Roseville, CA 95678 or send it to [email protected]:
If you would like to request to have mental health records sent to another facility/person, please complete the attached form and either mail it to Placer County Medical Records, 101 Cirby Hills Drive, Roseville, CA 95678 or send it to [email protected].
If you would like to request a Change of Service Provider or a Second Opinion within the Placer County Adult System of Care, please complete the attached form and mail it to Placer County Adult System of Care, 101 Cirby Hills Drive, Roseville, CA 95678.
If you would like to file a Grievance Appeal, please complete the attached form and mail it to Placer County Adult System of Care, 101 Cirby Hills Drive, Roseville, CA 95678.
Complete the attached form to submit an Adult/Elder Abuse Confidential Report. Completed forms can be faxed to Adult Intake at 530-265-9376 or mailed to APS 101 Cirby Hills Drive, Roseville, CA 95678
If you would like to revoke an authorization that was previously requested, please complete the attached form and mail it to Placer County Adult System of Care, 101 Cirby Hills Drive, Roseville, CA 95678 or send it to [email protected]. The revocation will be active upon receipt at our office for processing. Incomplete forms may delay processing.
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Adult Crisis & Intake 24 Hour Phone Line: 916-787-8860 or 1-888-886-5401
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Adult System of Care - Roseville
Physical Address
101 Cirby Hills Drive
Roseville, CA 95678
Phone 916-787-8800Fax 916-872-6521
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Adult System of Care - Auburn
Physical Address
11512 B Avenue
Auburn, CA 95603
Phone 530-889-7240Fax 530-889-7293
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Amy Ellis, MFT
Adult System of Care Division Director