Licensing and Medicaid Certification Unit APPLICATION FOR LICENSURE 14 Central Ave. New Castle, DE 19720 302.255.9441 (Use a separate application for each program requesting licensure.) DATE OF APPLICATION: ____________________ Check one: INITIAL APPLICATION RENEWAL APPLICATION I. ORGANIZATION INFORMATION Name of Organization or Parent Company Street Address City, State, Zip Administrator Telephone Number Fax Number Email Address TYPE OF PROGRAM FOR WHICH APPLICATION IS BEING MADE. Check all that apply. Non-Profit For Profit Public Other (Specify) Private II. LICENSED PROGRAM INFORMATION CHECK HERE IF LICENSED PROGRAM INFORMATION IS THE SAME AS ORGANIZATION INFORMATION. MOVE ON TO SECTION III IF CHECKED. Program Name As It Will Appear On the License Program Address City, State, Zip Contact Person’s Name and Title Telephone Number Fax Number Email Address III. TYPE OF PROGRAM LICENSURE FOR WHICH APPLICATION IS BEING MADE. Check all that apply. Residential Detoxification Non-Residential Detoxification Residential Setting Transitional Residential Setting Outpatient Setting Opioid Treatment Setting IV. AFFILIATION WITH OTHER REGULATORY OR ACCREDITATION BODIES List all licensing, certification and/or accreditation bodies your organization is credentialed by (including those in other states.) Use a separate attachment if necessary. Is your organization affiliated with any other licensing, certification and/or accreditation body? No Yes: If yes, indicate which type: LICENSURE __________________________________________ Licensing Body Expiration Date CERTIFICATION __________________________________________ Certification Body Expiration Date ACCREDITATION __________________________________________ Accreditation Body Expiration Date Has the organization ever had a license, certification or accreditation denied, suspended, and/or revoked for any program it operates? No Yes: If yes, indicate the program, date, and reason(s) for denial, suspension, and/or revocation: The program is applying for Deemed Status under: CARF JCAHO Other (Specify) Complete Attachment C for Deemed Status V. GEORGRAPHIC AREA(S) SERVED BY THE PROGRAM (PLEASE IDENTIFY THE GEOGRAPHIC AREA BY STATE, COUNTY, CITY, MUNICIPALITY ETC…AS APPROPRIATE) _____________________________________ _____________________________ State(s) County(ies) ______________________________________ ____________________________ City(ies) Other FOR INITIAL APPLICANTS: Explain the process you used (e.g. Needs Assessment) to substantiate a need for this type of program, at this time, in this particular geographic area. Attach any documentation that substantiates your explanation. Re-licensure request move onto section VI. VI. HOURS OF OPERATION SUNDAY __________________________________________________ MONDAY _________________________________________________ TUESDAY _________________________________________________ WEDNESDAY ______________________________________________ THURSDAY _______________________________________________ FRIDAY ___________________________________________________ SATURDAY _________________________________________________ VII. FUNDING SOURCES (Please note that licensure does NOT constitute a contract or entitle a program to funding from the Division of Substance Abuse and Mental Health.) Dollar Amount (in thousands) Source Description VII FUNDING SOURCES CONTINUED… VIII POPULATION PLEASE PROVIDE CLIENT DEMOGRAPHIC INFORMATION Children and Youth (17 and under) Adults (18 and over) Male Female List the average number of clients involved (actual/projected) in the program per month by primary diagnosis. Actual Projected Primary Alcohol or Drug Polysubstance Abuse Co-occurring (AOD/MH) 1. Indicate the average length of stay for clients in the program (actual or projected.) Give answers in days if less than 1 month, otherwise give answer in months. Actual Projected 2. Indicate the actual/projected staff to client ratio: a. Complete Attachment A Personnel 3. Indicate the actual number of members of the organizations Governing Body. a. Complete Attachment B Governing Body. 4. If you have or are projecting a waiting list please indicate the number of individuals and the average waiting period preceding admission: 1. Number of clients on waiting list: Actual Projected 2. Average waiting period preceding admission: Actual Projected I hereby confirm that the program for which I am applying for licensure conforms to the Delaware Division of Substance Abuse and Mental Health Substance Abuse Facility Licensing Standards; Del 16 §6000. _______________________________________ ________________________ President of Governing Body/Advisory Council Program Director __________________________ ___________________ Date Date Attachment A: Personnel Page 1 PERSONNEL List administrative and clinical staff that will provide services to consumers enrolled in the program for which you are seeking licensure. Name Position or Office Held FTE PT staff Degree and/or Credential ( Years of experience AOD Tx. Field Attachment A: Personnel Page 2 PERSONNEL (Continued) Name Position or Office Held FTE PTE Degree and/or Credential Years of experience in the AOD Tx Field Attachment B: Governing Body Page 1 GOVERNING BODY List all members of the governing authority (i.e. owner, stockholders, board of directors, advisory board) who have legal and ethical responsibility for the program. Provide all requested information. NOTE: If a member of the Governing Body has a relationship with any person employed by the program, an explanation of the relationship must be provided. (Please photo copy additional pages as needed.) Name of Governing Member Position or Office Held Address Attachment B: Governing Body Page 2 GOVERNING BODY (CONTINUED) Name of Governing Member Position or Office Held Address Attachment B: Governing Body Page 3 GOVERNING BODY (CONTINUED) 1. Please list all Governing Body members who are related to staff members of the program and explain the relationship. 2. Please explain how the Governing Body is representative of the community it serves. 3/18/2009 1 of 10