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C.° Recovery Support.Smylces:Requiring°Frog ram-Specific Funding .*.Estimated Number of <br /> Certification :::••••Service Hours First 12 <br /> (cp9c1crire:Oox:beside.each:specific-frogram.Servi.cp.for which •• • • <br /> :youragency is seeking certification) .••:•• '•". • '••••••:••• •• ••••••(F;": .404SPrvice) l• <br /> o Employment services(see WAG 385-877A-0330) <br /> • <br /> El Housing services(see WAC 388-877A-0335) <br /> O Peer support services(see WAC 388-877A-0340) <br /> 1:1 Wraparound facilitation services(see WAC 388-877A-0350) <br /> Do you currently provide WISe services or plan on providing these <br /> services? 0 Yes El No <br /> O Medication support services(see WAC 388-877A-0360) • <br /> O Applied behavior analysis(ABA)services(See WAC 388-877A-0370) <br /> I.AIIIINPIIIIIWAVaf-St.ntlgt-E,,MZIWE;SZRWaa,g1-iAaNiiMakaRMRigitMP:8R,IO,xaxai.zoig.isiWgga': <br /> 2:EIRIPIONWait*--700fatifigkift WAGSubstance Use <br /> A. Detoxification•SerViceS*(Withdrawal Management) :.‘Funding Source Total Number of Beds <br /> (Check the box beside.each..specific.program:Service for*high ••:••• (For Each Service) <br /> •". <br /> your agency Is Seeking Certification).-":•::'"•.' •••••••:•.••:•:'•*'-:•::'•"'•'*:-•:::*'••••* •••••' :•••,"••-• • ' • ‘: •• • ••• • * <br /> O Detoxification services(see WAC 388-8778-0100) <br /> O Youth detoxification services(see WAG 388-877B-0130) <br /> S. :Residential Services ••:2. ' • • • •• • -:'':"-'• Funding Source Total Number of Beds <br /> -..(Check the box beside each specific program service for which (ForEacbSeryipe)... <br /> your agency Is seeking certification) <br /> CI Intensive inpatient services(see WAG 388-87713-0250) <br /> D Recovery house services(see WAC 388-877B-0260) <br /> O Long-term treatment services(see WAC 388-877B-0270) <br /> O Youth residential services(see WAC 388-877B-0280) <br /> C. qutpathintlreitment Services • ' **" •• •"•' •*."" •Funding Source ••••' • :'••••• <br /> • <br /> (Check the:hpx:beside each specific program service forwhich • • • ••,• • • •• • •• • • ••••••• • •••.• <br /> •• •.•• ••••• ••• • • .• ..,•::....:: :.• ::,.,.•••...... , •••••:••,... •... ..••• <br /> your agency:1i seeking ....•••••l•:"" ••• " • •• :,•• " .• • • ::.": <br /> O Level It intensive outpatient treatment services <br /> (see WAG.388-8778-0350) <br /> O Level I outpatient treatment services(see WAG 388-8778-0360) <br /> D. Opiate°Substitution:Treatment Senaces" •• • • • • •• • •• • • : Funding Source • • .•• • <br /> • • • • • " "• ." • • ••••• ••• ••,•-: • <br /> (Check the box if you are seeking certification for this service) • : • • • • • ••. <br /> ..,......:,... •. .. • • . • ""......................................... <br /> O Opiate substitution treatment services(see WAC 388-877B-0405) <br /> • Assessment and Assessment Only Services Funding Source. . . . . . <br /> (Check the box beside each specific program service for which ••••' '•••••, •*- "•••"••••"••' ;.••• ••••• *•••••• • <br /> your agency is seeking certification) . <br /> O Assessment only services(see WAC 388-8778-0510) <br /> 1:1 DUI assessment services(see WAC 388-877B-0550) <br /> F. Information and Assistance.Services Funding Source <br /> (Check the box 09„5/ge,each:speciti.;program seryice for which •••• •• "• " • • •"• <br /> , . • <br /> your agency is seeking certification) <br /> O Alcohol and drug information school services(see WAC 388-877B-0630) <br /> O Information and crisis services(see WAC 388-87713-0640) <br /> El Emergency service patrol services(see WAC 388-8778-0650) <br /> 0 Screening and brief Intervention services(see WAC 388-877B-0660) <br /> G. Recovery Support Services Requiring prpgramsp#ofic .Fundipg Source. <br /> Certification ••• • : •• ••• • • • • •• • • • <br /> (Check the box beside each specific program service for which <br /> • your agency is seeking Certification) "" • • ••..... •• " • ••• • ••' •.•-• <br /> • • <br /> cl Employment services(see WAC 388-877B-0730) ........................................................................................................................... <br /> El Housing services(see WAC 388-87713-0740) <br /> V:;.0.610fifinif pitiki1461441:4-4000406001;::,:gmn:.;:e::Nonang: Funding Source <br /> (Check the box if you arèseeking certification for this service) . : <br /> Li Problem and pathological gambling(see WAC 388-877C-0100 <br /> through 388-877C-0130) <br /> Revised 10/5/17 Page 3 of 8 <br />