CalWORKs Treatment Services Verification Form
This file serves as a verification for individuals receiving CalWORKs Specialized Supportive Services. It includes important details about treatment services for mental health, substance abuse, and domestic violence. Providers certify eligibility and necessary information for assistance.
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How do I fill this out?
To fill out the CalWORKs Treatment Services Verification form, start by gathering all the required participant information. Next, ensure you have documentation supporting the treatment services being rendered. Follow the instructions carefully to complete each section accurately.

How to fill out the CalWORKs Treatment Services Verification Form?
1
Gather participant details including name and case number.
2
Select the applicable type of treatment services.
3
Complete the provider certification section.
4
Sign and date the form.
5
Submit the completed form as instructed.
Who needs the CalWORKs Treatment Services Verification Form?
1
California residents seeking CalWORKs services.
2
Treatment providers assisting individuals with mental health issues.
3
Social workers verifying eligibility for county services.
4
Individuals overcoming barriers to employment due to violence or abuse.
5
Participants needing coordinated care for financial assistance.
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Add any necessary annotations or comments.
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What are the instructions for submitting this form?
To submit this form, you can either fax it to (818) 775-6969 or send it by mail to PA 1923 (SSS RR) Centralized Unit, 21415 Plummer Street, Suite B, Chatsworth, CA 91311. Ensure that you include the participant's signature and all relevant details before submission. It's recommended to keep a copy of the submitted form for your records.
What are the important dates for this form in 2024 and 2025?
Please check for potential updates regarding the CalWORKs program deadlines in 2024 and 2025 as policies may evolve. Important dates may include eligibility assessment periods, submission cut-offs, and deadlines for service renewal approvals.

What is the purpose of this form?
The purpose of the CalWORKs Treatment Services Verification form is to ensure that individuals receiving CalWORKs supportive services, such as mental health treatment or substance abuse support, are properly documented and supported. It plays a critical role in verifying eligibility and the provision of necessary services essential for overcoming barriers to employment. This form ensures compliance with requirements set forth by the Department of Public Social Services.

Tell me about this form and its components and fields line-by-line.

- 1. Participant Identification: Contains personal details such as name, case number, and date of birth.
- 2. Type of Treatment Services: Indicates the kind of supportive services being requested or provided.
- 3. Provider Certification: Confirms the eligibility and support from treatment service providers.
- 4. Participant Authorization: Gives consent for information sharing regarding the CalWORKs case.
- 5. County Action: Shows the status of the form submission, whether accepted or rejected.
What happens if I fail to submit this form?
If you fail to submit the CalWORKs Treatment Services Verification form, it may result in a delay or denial of services. Missing the submission deadline can affect your eligibility for ongoing supportive services. It's crucial to adhere to the required timelines set by the Department of Public Social Services to maintain your status.
- Service Denial: Failure to submit could lead to denial of necessary supportive services, impacting your employment.
- Loss of Eligibility: Not submitting on time may result in loss of CalWORKs benefits and related support.
- Impact on Treatment: Delay in submission may hinder access to critical treatment services for participants.
How do I know when to use this form?

- 1. New Enrollment: When a participant begins treatment services.
- 2. Renewal of Services: To confirm ongoing eligibility for current services.
- 3. Service Provider Documentation: For providers to certify that services are being utilized effectively.
Frequently Asked Questions
How do I access the CalWORKs Treatment Verification Form?
You can download the form directly from our website and fill it out online.
What types of treatment services are included?
This form covers mental health, substance abuse, and domestic violence services.
Can I edit the PDF before submitting?
Yes, you can edit the PDF on PrintFriendly before finalizing.
How do I submit this form?
Completed forms can be submitted via fax or mailed to the designated address provided in the instructions.
What happens if I miss the submission deadline?
You should contact your caseworker to discuss options for late submission.
Is there a fee to use PrintFriendly?
No, PrintFriendly offers free access to edit and download your PDFs.
Can I save my edits?
You can download the edited PDF, but saving directly on the site is not available.
What should I do if I have questions about the form?
You can reach out to your social worker for assistance with the form's content.
Is electronic submission available?
Currently, physical submission is required; check back for future updates on electronic submissions.
Can I access the form on mobile devices?
Yes, the form can be accessed and filled out on mobile devices using PrintFriendly.
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