2018/02/07 Council Agenda Packet

SECTION III: AGENCY FACILITY AND PERSONNEL INFORMATION ❑ Check if you are sending SECTION III of this application separately at a later date than SECTIONS I and II. Date SECTIONS I and II were sent: AGENCY NAME (as indicated in SECTION I of this application) FACILITY INFORMATION AND MATERIALS Facility Information Street Address for the agency site to be licensed and listed in the Directory of Licensed and Certified Behavioral Health Agencies in Washington State City County State Zip Code Mailing Address to be listed in the Directory. DBHR uses this address to send licensed agency information/documents. ❑Check if same as street address City State Zip Code Agency Phone Number(s)to be listed in the Directory. List up to two numbers. You may add up to Fax Number to be listed ten characters to add extension numbers or other information. See Directory for possible uses. in the Directory of Certified Programs: 0 Check if toll-free Extension number/Additional information ❑Check if toll-free Extension number/Additional information Agency E-Mail Addresses Administrator: Clinical Supervisor: Agency Customer Service: Agency Website Address Agency: Facility Application Materials ALL APPLICANTS MUST SUBMIT THE FOLLOWING WITH SECTION III: ❑ A floor plan of the facility that shows the location where all behavioral health services are to be provided and the dimensions of each room. See the sample floor plan provided with this application. The floor plan may be hand drawn. The reception area must be separate from all counseling and living areas. ❑ A statement assuring the agency meets American Disability Act(ADA)standards and that the facility is appropriate for providing the proposed services. Please complete the Accessibility Barrier Checklist found on our website at https://www.dsh s.wa.goy/bha/d ivisi on-behavioral-health-and-recovery/licensi n g-and-certification-behavioral-health-agencies. RESIDENTIAL APPLICANTS MUST SUBMIT a copy of the RTF or Hospital License issued by the Department of Health. O License enclosed 0 License to follow at a later date(must be received before DBHR grants approval) NON-RESIDENTIAL APPLICANTS MUST SUBMIT THE FOLLOWING WITH SECTION III: ❑ A completed Accessibility Barrier Checklist for the site to be certified. Each element in the checklist must be marked yes, no,or not applicable(NA). Complete the corrective action plan section for any element marked"no." Incomplete forms will be returned. Revised 10/5/17 Page 6 of 8