Virginia Department of Behavioral Health & Developmental Services
INITIAL PROVIDER APPLICATION FOR LICENSING
Code of Virginia §37.2-405 & §35-46
Please use a typewriter or print legibly using permanent, black ink. The chief executive officer, director, or other member of the governing body who has the authority and responsibility for maintaining standards, policies, and procedures for the service may complete this application.
1.APPLICANT INFORMATION: Identify the person, partnership, corporation, association, or governmental agency applying to lawfully establish, conduct, and provide service:
Organization Name:_____________________________________________________________________________________
Mailing Address________________________________________________________________________________________
City:__________________________ County __________________________________State:___________________________
Zip:___________________ Phone:( )___________________________ Email:_________________________________
Names of all Owners and the percentage (%) of the organization owned by each _____________________________________
___________________________________________________________________________________________________________
Chief Executive Officer or Director. Identify the person responsible for the overall management and oversight of the service(s) to be operated by the applicant.
Name:____________________________________________Title:_______________________________________________
Phone:( )___________________ Fax Number:( )___________________ E-mail:____________________________
All Residential Services: (The liaison is the staff that shall be responsible for facilitating cooperative relationship with neighbors, the school system, local law enforcement, local government officials and the community at large.)
Community Liaison Name: _________________________ Phone ( )_______________ E-mail _____________________
2.ORGANIZATIONAL STRUCTURE: Identify the organizational structure of the applicant’s governing body.
Check one(1) of the following: |
Check one(1) of the following: |
[] Non-Profit |
[] For-Profit |
[] Individual (proprietorship) |
[] Partnership |
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[] Corporation |
[] Unincorporated Organization or Association |
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Public agency: |
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[] State [] Community Services Board |
[] Other _________________________________ |
Identify accrediting or certifying organization from the following, if applicable:
[] Accreditation Council for Services for People with Developmental Disabilities |
[] Virginia Association of Special Education Facilities |
[] Joint Commission on Accreditation of Health Care Organizations |
[] Other associations or organizations: |
[] Commission on Accreditation of Rehabilitation Facilities |
_________________________________________ |
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3.APPLICANT PARENT COMPANY INFORMATION: Identify the parent company of person, partnership, corporation, association, or governmental agency applying to lawfully establish, conduct, and provide service:
Company
Name:_______________________________________________________________________________________________
Mailing Address:______________________ _____City:_____________ County: _____________________ State:_____________
Zip:___________ Phone:( )__________________________ E-mail:_______________________________________________
Name:___________________________________________________Title:_______________________________________
SERVICE TYPE:
Place a check to identify the service type. If the service type is not listed, please note in the service information section. Please note new applicants (no independent service operation experience) are permitted to apply for ONE service on the initial application.
Check |
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one |
Service |
Pgm |
Description |
Licensed As Statement |
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A Level C mental health children's residential service for children with serious |
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14 |
001 |
Level C MH Children Residential Service |
emotional disturbance |
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A Level C mental health children's residential service for children with serious |
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14 |
001 |
Level C MH Children Residential Service |
emotional disturbance |
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A mental health children's residential service for children with serious emotional |
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14 |
004 |
MH Children Residential Service |
disturbance |
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14 |
007 |
SA Children Residential Service |
A substance abuse children's residential service for children |
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A mental health group home residential service for children with serious emotional |
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14 |
008 |
MH Children Group Home Residential Service |
disturbance |
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14 |
033 |
SA Children Group Home Residential Service |
A substance abuse group home residential service for children |
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14 |
035 |
DD Children Group Home Residential Service |
A developmental disability group home residential service for children |
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An intermediate care facility for individuals with a developmental disability (ICF-IDD) |
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14 |
048 |
ICF-IDD Children Group Home Residential Service |
group home residential service for children |
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A residential group home with crisis stabilization REACH service for children and |
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adolescents with a co-occurring diagnosis of developmental disability and behavioral |
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14 |
59 |
REACH Children’s Residential Service |
health needs |
10/6/17 DBHDS
5.SERVICE INFORMATION: Complete for the organization to be licensed by the Department of Behavioral Health and Developmental Services.
Service Director: __________________________________________________________________________________
Phone: ( |
) ________________________________________ E- |
Mail_____________________________________ |
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Client Demographics (check all that apply): |
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[] Male |
[] Female [] Both |
[] Child |
[] Adolescent (Min. & Max. Age Range) _____________ [] Adult |
LOCATION
6.Location Name__________________________________________# of beds:_______________________________
Address:___________________________________________________________________________________________
City:_____________________ County: _____________________ State:________________ Zip:___________________
Location Manager:________________________________ Phone:( )______________ E-
mail:____________________
Directions:_________________________________________________________________________________________
7. NAME AND ADDRESS OF OWNER OF PHYSICAL PLANT
Name
Address
8. RECORDS: IDENTIFY THE LOCATION OF THE FOLLOWING RECORDS
Financial Records
Address: ________________________________________City:___________________ County ___________________
State:________________ Zip:____________
Personnel Records
Address: ________________________________________City:___________________ County ___________________
State:________________ Zip:____________
Residents’ Records
Address: ________________________________________City:___________________ County ___________________
State:________________ Zip:____________
Current/Past Provider Services
Please identify:
1)The legal names and dates of any services licensed in Virginia or other states that the applicant currently holds or has held,
2)Previous sanctions or negative actions against any licensed to provide services that the holds or has held in any other state or in Virginia, and
3)The names and dates of any disciplinary actions involving the applicant’s current or past licensed services. If none, please indicate, “NONE” in the space below.
Current Services:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Past Services:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Sanctions/Negative Actions/Disciplinary Actions:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Certificate of Application
This certificate is to be read and signed by the applicant. The person signing below must be the individual applicant in the case of a proprietorship or partnership, or the chairperson or equivalent officer in the case of a corporation or other association, or the person charged with the administration of the service provided by the appointing authority in the case of a governmental agency.
I am in receipt of and have read the applicable rules and regulations for licensing. It is my intent to comply with the statutes and regulations and to remain in compliance if licensed.
I grant permission to authorized agents of the Department of Behavioral Health and Developmental Services to make necessary investigations into this application or complaints received.
I understand that unannounced visits will be made to determine continued compliance with regulations.
TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL INFORMATION CONTAINED HEREIN IS CORRECT AND COMPLETE. I FURTHER DECLARE MY AUTHORITY AND RESPONSIBILITY TO MAKE THIS APPLICATION.
Signature of Applicant:_______________________________________Title:______________________
Date:_________________
If you have any questions concerning the application, please contact this office at (804) 786-1747. Please return the completed application to:
Office of Licensing
Department of Behavioral Health and Developmental Services
Post Office Box 1797
Richmond, Virginia 23218-1797
