Title:Initial Application Form (4 pages) About: This form is used for an organization not previously licensed by the Department to apply to provide behavioral health care services (substance abuse and/or mental health) to adults and substance abuse services to minors. This initial form needs to be submitted only once. The (twelve) licensed services can be chosen from the menu on page 2 (Part III Selected Services Information).
Title:Renewal or Add Services/Site Application Form (3 pages) About: This form is used by Behavioral Healthcare Organizations to: Renew an existing license, add a licensed service/program at an existing site, add a new site for licensed service delivery. Licenses are required to be renewed every two years. An Add Service or Site application may be submitted at any time.
Title:FEIN Addendum (1 page) About: The Department is required to obtain this information. It is to be submitted with each license renewal application. It is not required with an Add Service/Site application.