Your Federal Quarterly Tax Payments are due April 15th Get Help Now >>

DCF - by broverya77

VIEWS: 0 PAGES: 2

									DCF -
Rev. 8-1-08

                      DEPARTMENT OF CHILDREN AND FAMILIES
                              505 HUDSON STREET
                              HARTFORD, CT 06106

                          DCF LICENSE APPLICATION


____________________________________               _______________________________
  CORPORATE NAME OF APPLICANT                             NAME OF PROGRAM

________________________________                   _______________________________


________________________________                   _______________________________
      CORPORATE ADDRESS                                    PROGRAM ADDRESS

____________         ____________                      ____________    ____________
   PHONE                 FAX                               PHONE           FAX

______________________________                         _____________________________
E-MAIL ADDRESS                                         E-MAIL ADDRESS

TYPE OF LICENSE APPLIED FOR: NEW RENEWAL

TYPE OF PROGRAM APPLIED FOR: RESIDENTIAL TREATMENT RESIDENTIAL
EDUCATIONSAFE HOMEGROUP HOMETEMPORARY SHELTER  CHILD PLACING
AGENCY EXTENDED DAY TREATMENT OUT-PATIENT PSYCHIATRIC CLINIC FOR CHILDREN

A SEPARATE APPLICATION MUST BE SUBMITTED FOR EACH TYPE OF PROGRAM. IF ONE TYPE OF
PROGRAM IS OFFERED AT DIFFERENT LOCATIONS, THE ADDRESS OF EACH LOCATION AND ITS
CAPACITY / GENDER WILL BE IDENTIFIED AT THE BOTTOM OF THE LICENSE. PLEASE IDENTIFY
BELOW THE NAME, ADDRESS, CAPACITY AND GENDER FOR EACH LOCATION

       NAME                      ADDRESS                        LBC     SEX       AGE

1. ____________________    ________________________________      ____ ________ ____ - ____
2. ____________________    ________________________________      ____ ________ ____ - ____
3. ____________________    ________________________________      ____ ________ ____ - ____




  FOR ALL OUTPATIENT CLINIC AND CHILD PLACING AGENCY APPLICANTS PLEASE LIST BELOW
  ALL SATELLITE SITES (OPCC'S) OR ADDITIONAL OFFICE LOCATIONS (CPA'S)

       ADDRESS                                            PHONE NUMBER        FAX NUMBER

1. _________________________________________________      _______________     _______________
2. _________________________________________________      _______________     _______________
3. _________________________________________________      _______________     _______________
PROGRAM DESCRIPTION ( CONCISE ): PLEASE INCLUDE; STATEMENT OF PURPOSE; A DESCRIPTION
OF THE OVERALL APPROACH TO TREATMENT/SERVICES AND FAMILY INVOLVEMENT; THE TYPES
OF SERVICES PROVIDED; THE CHARACTERISTICS OF THE CHILDREN TO BE SERVED; AND THE
CHARACTERISTICS OF THOSE CHILDREN NOT APPROPRIATE FOR THE PROGRAM.




FOR RENEWALS ONLY: PLEASE DESCRIBE ANY SIGNIFICANT CHANGES TO THE LICENSED
PROGRAM THAT HAVE OCCURRED SINCE THE CURRENT LICENSE WAS ISSUED. SUCH CHANGES
INCLUDE BUT ARE NOT LIMITED TO; CHANGES IN UPPER MANAGEMENT SUCH AS EXECUTIVE
DIRECTOR, MEDICAL DIRECTOR, CLINICAL DIRECTOR, RESIDENTIAL DIRECTOR, OR PROGRAM
DIRECTOR; CHANGES IN PROGRAM MODEL; OR SUBSTANTIAL PHYSICAL PLANT RENOVATIONS OR
ADDITIONS:




FOR CHILD PLACING AGENCY APPLICATION ONLY: IF APPLICANT IS A MULTI-PROGRAM AGENCY
IDENTIFY THE ENTITY WHICH WILL BE RESPONSIBLE FOR CARRYING OUT THE RESPONSIBILITIES
OF THE CHILD PLACING AGENCY:



PRINTED NAME :___________________________     PRINTED NAME:________________________


SIGNATURE :_______________________________    SIGNATURE:____________________________
      EXECUTIVE DIRECTOR            DATE         CHAIRMAN OF THE BOARD         DATE

								
To top