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Mh4024

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C&F-SA Form 4024 1- 4 August 24, 2012
Application for Licensure to
Provide
SUBSTANCE ABUSE
SERVICES
Submission Date
(Month, Day, Year)
New Application
Renewal
Relocation
(Anticipated Relocation Date)
I. SERVICE PROVIDER INFORMATION
FOR PROVIDERS WITH MULITIPLE SITES, ENTER CORPORATE HEADQUARTER INFORMATION
1. Service Provider Name (If multiple locations enter CORPORATE HEADQUARTERS name)
2. Federal ID #
4. Point of Contact Email Address
5. Mailing Address
5a. City
5b. State
Florida
5c. Zip Code
5d. County
6. Street Address (if different than mailing address)
6a. City
6b. State
Florida
6c. Zip Code
6d. County
7. Circuit/Region
8. Telephone (Area Code & Number)
9. Fax Telephone (Area Code & Number)
10. Please check the applicable box(es) below.
Publicly Funded Provider
Privately Funded Provider
Private Practitioner
Faith-Based Provider
Community Substance Abuse Coalition
11. Is the applicant accredited by a certifying organization approved
by the department? If so, please check the applicable box.
Commission on Accreditation of Rehabilitation Facilities (CARF)
Three-Year One-Year
The Joint Commission
Council on Accreditation (COA)
Accreditation Expiration Date
Please submit the most recent accreditation survey report with
this application including changes in accreditation status.
12. Is the agency incorporated with the State of Florida?
Yes No
13. If so, is the corporation for profit?
Yes No
If incorporated, please submit the names of the owner, board members, officers, and shareholders.
14. Name of Owner
15a. Name of Chief Executive Officer
15b. Chief Executive Officer Email Address
16. Name of Chief Financial Officer
17. Name of Staff Training Coordinator
18. Name and professional license number of Medical Director (applies to addictions receiving facilities, detoxification, intensive inpatient
treatment, residential treatment, day or night treatment, and medication and methadone maintenance treatment services.)
An application without the applicable licensure fee as required under section 397.407, Florida Statutes and 65D-30.003(5), Florida
Administrative Code, will be returned to the applicant. An application for renewal of a regular license must be submitted to the
department no later than 60 days before the license expires. A late fee of $100 per license shall be assessed for the late filing of an
application as required under section 397.407(2) Florida Statutes. Please make check payable to the Florida Department of Children
& Families.
C&F-SA Form 4024 2- 4 August 24, 2012
II. PROGRAM COMPONENT INFORMATION
1. Name of Program (e.g., Adult Outpatient Treatment, Youth Residential Treatment, Outreach Prevention, etc.)
2. Street Address
3. Building Number, Room Number, Suite, etc.
4. City
5. State Florida
6. Zip Code
7. Circuit/Region
8. County
9. Telephone (Area Code & Number)
10. Current License Number
11. Current License Number Expiration Date (MM/DD/YY)
12. Name of Program Director
13. Name of Clinical Director
Type of Service Component (please check only one service per component application):
14a. Addictions Receiving Facility:
Addictions Receiving Facility
Bed Capacity
14b. Detoxification Programs:
Residential Detoxification
Bed Capacity
Outpatient Detoxification
Residential Methadone
Detoxification
Bed Capacity
Outpatient Methadone
Detoxification
14c. Intensive Inpatient Treatment
Programs:
Intensive Inpatient Treatment
Bed Capacity
14d. Residential Programs:
Level 1 Bed Capacity
Level 2 Bed Capacity
Level 3 Bed Capacity
Level 4 Bed Capacity
Level 5 Bed Capacity
14e. Day or Night Treatment
Programs with Community Housing:
Day or Night Treatment Programs
with Community Housing
14f. Day or Night Treatment
Programs:
Day or Night Treatment
14g. Intensive Outpatient Programs:
Intensive Outpatient Treatment
14h. Outpatient Programs:
Outpatient Treatment
14i. Aftercare Programs:
Aftercare
14j. Intervention Programs:
Case Management
General Intervention
Employee Assistance Program
Treatment Alternatives for Safer
Communities
14k. Prevention Programs:
Level 1 Prevention
Level 2 Prevention
14l. Medication & Methadone
Maintenance Treatment Programs:
Medication & Methadone
Maintenance Treatment
Satellite Maintenance
15. DCF Contracted Bed Capacity (Residential, Inpatient,
Residential Detox, Addictions Receiving Facilities)
16. Licensed Bed Capacity (Residential, Inpatient, Residential
Detox, Addictions Receiving Facilities)
17. Hours during which the program is open:
18. Please submit evidence of compliance for applicable areas below
(including the expiration date):
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
to
to
to
to
to
to
to
Closed
Closed
Closed
Closed
Closed
Closed
Closed
Fire and Safety Yes No Date:
Health Standards
Facility Inspection Yes No N/A Date:
Food Services Yes No N/A Date:
Zoning Compliance Yes No Date:
Property Insurance Yes No Date:
Professional Liability Yes No Date:
Insurance
Please submit all approval documents with this application
C&F-SA Form 4024 3- 4 August 24, 2012
19. Medication and Methadone Maintenance Treatment
components, (i.e., programs which use methadone or other
medications for treating opioid addiction). Approved by:
20. Have all staff and volunteers who have direct contact with
clients under the age of 18 years been finger printed and
screened in accordance with section 397.451(1)(a), Florida
Statutes?
Drug Enforcement Administration (DEA)
Substance Abuse and Mental Health Services
Administration (SAMHSA)
State Methadone Authority
Board of Pharmacy
Not Applicable
Please submit copies of approval documents with this
application.
Yes
No
Not Applicable
Please submit the treatment resource affidavit with this
application
21. Please check the client population, which have been targeted for services.
White (Non-Hispanic)
Black (Non-Hispanic)
Hispanic
American Indian
None
Other (please describe)
22. Please list any special population group targeted for services (e.g., hearing impaired, pregnant alcoholics or addicts, youth,
criminal justice clients, etc.)
Children:
Women:
Adolescents:
Homeless:
Criminal Justice-Involved Adults:
Juvenile Justice-Involved Youth:
Pregnant and Post Partum Women:
Pregnant and Post Partum Adolescents:
HIV/AIDS:
Hearing Impaired:
Visually Impaired:
Older Adults:
Co-occurring:
Intravenous Drug Users:
Other:
Please describe other group:
23. Services provided: Please check all major services provided on a regular basis either directly by the program or upon referral.
Program Services
Provided Directly by
Program
Provided by Written
Agreement or Referral
Not Applicable
Individual Counseling
Group Counseling
Family Counseling
Job Consulting and Placement
Job Training
Education Services
Aftercare (Non-Structured)
General Health Care
Legal Services
Social Services (Welfare, Housing, etc.)
Cultural/Recreational Programs
Other (Please Describe)
C&F-SA Form 4024 4- 4 August 24, 2012
24. Do you charge client fees? If so,
please attach a copy of the fee schedule
and fee policy.
Yes No
25. What is the maximum number of
clients that can be served in this
component on a given day?
26. What is your projected operating
budget for the component listed on this
application for the current year?
27. Please list the complete names of agencies or practitioners you have written referral agreements, contracts, or subcontracts with
and check the type of business relationship:
a. Agreement Contract Subcontract Other(Specify)
b Agreement Contract Subcontract Other(Specify)
c. Agreement Contract Subcontract Other(Specify)
d. Agreement Contract Subcontract Other(Specify)
e. Agreement Contract Subcontract Other(Specify)
f. Agreement Contract Subcontract Other(Specify)
g. Agreement Contract Subcontract Other(Specify)
h. Agreement Contract Subcontract Other(Specify)
i. Agreement Contract Subcontract Other(Specify)
j. Agreement Contract Subcontract Other(Specify)
28. Please list the sources of revenue you receive by name and check the type of funds, e.g., state funds, federal funds, fees, etc:
a. State Federal Fees Private Other(Specify)
b State Federal Fees Private Other(Specify)
c. State Federal Fees Private Other(Specify)
d. State Federal Fees Private Other(Specify)
e. State Federal Fees Private Other(Specify)
f. State Federal Fees Private Other(Specify)
g. State Federal Fees Private Other(Specify)
h. State Federal Fees Private Other(Specify)
29. Please further describe your program listed in item #1 on page 2. For counseling programs, this information should include
the number of counseling sessions provided weekly, the duration of each counseling session, and the average length of
stay in the program.
30. Signature of the Chief Executive Officer (Original signature only)
31. Date (Month, Day, Year)
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Completed 22 December 2020

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