Fillable DWI Services Pilot Site Application (North Carolina)

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DWI Services Pilot Site Application (North Carolina)

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The DWI Services Pilot Site Application (North Carolina) form is 1 page long and contains:

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  • 10 check-boxes
  • 13 other fields

Country of origin: US
File type: PDF

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1
N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF MENTAL HEALTH, DEVELOPMENTAL DISABILITIES
AND SUBSTANCE ABUSE SERVICES
DWI Services Pilot Site Application
Section 1. Please complete the information below:
Facility Code:
Facility Name:
Contact Name and Number:
Section 2. Please CHECK ( ! ) all services provided at the agency that is a part of the pilot for
PRIME for Life and/or Solutions:
" ADETS; " Short Term Outpatient Treatment; " Longer Term Outpatient Treatment;
" Day Treatment; " Substance Abuse Intensive Outpatient Treatment;
" Substance Abuse Comprehensive Outpatient Treatment; " Inpatient/Residential.
Please attach a monthly schedule (to show how the pilot will combine closed, sequential PRIME for Life groups
and open therapy groups to ensure that the groups cover a minimum of 30 days for short term and 60 days
for longer term).
Please indicate the Evidence-based Practice programs for the pilot:
" PRIME for Life
" PRIME for Life and Solutions
" Other ________________________________________________________________
Section 3. Staffing (Attach NCSAPPB Documentation)
Staff Name (Printed)
NCSAPPB credentials
Name of applicant (printed): _____________________________________________________________
Signature of applicant: __________________________________________________________________
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DWI Services Pilot Site Application (North Carolina)

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Completed 16 December 2020

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