Response to Request for Information #0518-003 Individual Placement Support-Supported Employment (IPS/SE) Please complete the following information: Name of Organization: Organization Type: Hospital Private Organization: not for profit for profit Governmental/Public Facility License Number: Accreditation Type and Source: Primary Client Population: Adults Adolescents Children All ages Mailing Address: Street, City and Zip Code Facility Location Address: Street, City and Zip Code Name of Contact Person: Contact Person Phone # & Email: Please identify other MCOs and health plans with whom you are authorized to provide services: Please indicate in which Iredell county(ies), along with Catawba Lincoln Burke and Catawba, you Cleveland Surry would be interested in Gaston Yadkin providing IPS/SE, if needed in the future: Please respond to the following questions: Describe your organization’s experience providing behavioral health services: Please indicate the number of years’ 0 -1 2-4 5 experience your organization has providing behavioral health services: 6-10 11+ List any other services (including evidence based practices used) your organization currently provides:
Response to Request for Information #0518-003 Individual Placement Support-Supported Employment (IPS/SE) Please complete the following information: Name of Organization: Organization Type: Hospital Private Organization: not for profit for profit Governmental/Public Facility License Number: Accreditation Type and Source: Primary Client Population: Adults Adolescents Children All ages Mailing Address: Street, City and Zip Code Facility Location Address: Street, City and Zip Code Name of Contact Person: Contact Person Phone # & Email: Please identify other MCOs and health plans with whom you are authorized to provide services: Please indicate in which county(ies), along with Burke and Catawba, you would be interested in providing IPS/SE, if needed in the future: Iredell Catawba Lincoln Cleveland Surry Gaston Yadkin Please respond to the following questions: Describe your organization’s experience providing behavioral health services: Please indicate the number of years’ experience your organization has providing behavioral health services: 0 -1 2-4 5 6-10 11+ List any other services (including evidence based practices used) your organization currently provides:
IPS_SE_RFI_0518-003_Response_Form.docx