Community Mental Health Provider Profile Application ALL INFORMATION IS REQUIRED TO BE COMPLETED AND IS SUBJECT TO VERIFICATION Corporate/Legal Name: Organization/DBA Name: Organization Mailing Address: City: State: Zip + 4 code: CORPORATE Billing Address (if different than mailing) INFORMATION Phone:( ) Fax:( ) E-Mail: Chief Administrative Officer: Financial Officer: Chief Medical Officer: Chief Clinical Manager: Respondent for Recipient Rights Complaints: INFORMATION ADMINISTRATIVE Business Manager: Contract Primary Contact Person: E-mail: Phone: Contract Secondary Contact Person: E-mail: Phone: Clinical Director/Supervisor: E-mail: Location : Phone: Clinical Director/Supervisor: E-mail: Location: Phone: Clinical Director/Supervisor: E-mail: Location: PLEASE ATTACH A LISTING OF THE PROGRAM’S CURRENT BOARD OF DIRECTORS (specifying number of primary and secondary consumers on Board) ___ Assertive Community Treatment ___ O.T. ___ P.T. ___ SP & L ___ Assistance w/Challenging Behavior ___ Out of Management Services ___ Children’s Model Waiver ___ Out of Services ___ Children’s Residential ___ Out of County Residential Services ___ Case Management Services ___ Outpatient Clinic Mental Health Services ___ Community Living Supports ( ___ MI or ___ DD) ___ Peer Delivered or Operated Services ___ Crisis Residential (Adult or Child) (Adult or Child) PROGRAM ___ Day Programs ___ Psycho-Social Rehabilitation Programs ___ Emergency/Crisis Unit hospital ___ Residential Group Home that – OF ___ Family Support Services ( ___ MI or ___ DD) ___ Respite Care ___ ___ Services ( ___ MI or ___ DD) (Please ALL ___HabilitativeWaiver Services ___ Supported Independent Program (SIP) ___ Home Based Services ___ Wrap Around Services TYPE ___ Intensive Crisis Stabilization Services ___ Other (specify):
Community Mental Health Provider Profile Application ALL INFORMATION IS REQUIRED TO BE COMPLETED AND IS SUBJECT TO VERIFICATION CORPORATE INFORMATION Corporate/Legal Name: Organization/DBA Name: Organization Mailing Address: City: State: Zip + 4 code: Billing Address (if different than mailing) Phone:( ) Fax:( ) E-Mail: ADMINISTRATIVE INFORMATION Chief Administrative Officer: Financial Officer: Chief Medical Officer: Chief Clinical Manager: Respondent for Recipient Rights Complaints: Business Manager: Contract Primary Contact Person: E-mail: Phone: Contract Secondary Contact Person: E-mail: Phone: Clinical Director/Supervisor: E-mail: Location : Phone: Clinical Director/Supervisor: E-mail: Location: Phone: Clinical Director/Supervisor: E-mail: Location: PLEASE ATTACH A LISTING OF THE PROGRAM’S CURRENT BOARD OF DIRECTORS (specifying number of primary and secondary consumers on Board) TYPE OF PROGRAM (Please ALL that ___ Assertive Community Treatment ___ Assistance w/Challenging Behavior ___ Children’s Model Waiver ___ Children’s Residential ___ Case Management Services ___ Community Living Supports ( ___ MI or ___ DD) ___ Crisis Residential (Adult or Child) ___ Day Programs ___ Emergency/Crisis Unit – hospital ___ Family Support Services ( ___ MI or ___ DD) ___ ___HabilitativeWaiver Services ___ Home Based Services ___ Intensive Crisis Stabilization Services ___ O.T. ___ P.T. ___ SP & L ___ Out of Management Services ___ Out of Services ___ Out of County Residential Services ___ Outpatient Clinic Mental Health Services ___ Peer Delivered or Operated Services (Adult or Child) ___ Psycho-Social Rehabilitation Programs ___ Residential Group Home ___ Respite Care ___ Services ( ___ MI or ___ DD) ___ Supported Independent Program (SIP) ___ Wrap Around Services ___ Other (specify):