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<br /> POPULATION GROUP INFORMATION (OPTIONAL)
<br /> Please indicate below the primary population group(s)your agency will serve(up to three)
<br /> 1. 2. 3.
<br /> FUNDING SOURCE INFORMATION
<br /> Is your agency BHO affiliated? El Yes ❑ No
<br /> Please indicate the specific program services)for which your agency isi seeking certification. For each service
<br /> selected below,indicate if the service will receive public or private funding.
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<br /> A :.Outpatient Mental Health Services:. ,�:':::':. . :.::;'.' .:
<br /> Funding Source Estimated.Numberof'
<br /> Check the box beside each specific program service for which Service Hours First 12
<br /> (Check p.. . p 9 Months
<br /> your agency is seeking certification)
<br /> (For each service)
<br /> ❑ Individual treatment services(see WAC 388-877A-0138
<br /> ❑ Brief intervention treatment(see WAC 388-877A-0140)
<br /> ❑ Group therapy services(see WAC 388-877A-0150)
<br /> ID Family therapy services(see WAC 388-877A-0155)
<br /> DI Case management services. (see WAC 388-877A-0170)
<br /> ❑ Psychiatric medication services(see WAC 388_877A_0180)
<br /> ❑ Day support services(see WAC 388-877A-0190)
<br /> -❑ Less restrictive alternative(LRA)support services
<br /> (see WAC 388-877A-0195)
<br /> Required to have Psychiatric Medication with this service
<br /> ❑ Services provided in a residential treatment facility(see
<br /> WAC 388-877A-0197)
<br /> Required to have Case Management,LRA Support,and
<br /> Recovery Medication Support with this service
<br /> B. Crisis Mental Health Services Funding Source Estimated Number of
<br /> (Check the box beside each specific program service for which Service Hours First 12
<br /> your agency is seeking certification) Months
<br /> (For Each Service)
<br /> ❑ Crisis telephone support services(see WAC 388-877A-0230)
<br /> ❑ Crisis outreach services(see WAC 388-877A7-70A240)
<br /> ❑ Crisis stabilization services(see WAC 388-8 -0260)
<br /> ❑ Crisis peer support services(see WAC 388-877A-0270)
<br /> ❑ Emergency involuntary detention services(see WAC 388-877A-0280)
<br /> Revised 10/5/17 Page 2 of 8
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