DIVISION OF FAMILY AND CHILDREN
SERVICES
FIRST
PLACEMENT BEST PLACEMENT
1. Your Name: ______________________________________________________
2. Title/Position: ______________________________________________________
3. Agency: ______________________________________________________
4. Are you applying to be approved as an individual provider or as an agency?
5. Address (Mailing) ______________________________________________________
______________________________________________________
6 Address (Location) ______________________________________________________
______________________________________________________
7 Phone: ______________________________________________________
8. Fax: ______________________________________________________
9. Email address: ______________________________________________________
10. Add my e-mail address to an "Approved
Assessment Provider" E-mail address book.
Yes: ___ No:
___
11. The following information is required:
11 (a). Copy
of Business License(s) or other appropriate license or documentation (e.g.
Letter of Incorporation)
11 (b). Copy
of proof of general commercial liability coverage.
11 (c). Copy
of other professional credentials e.g. degrees, resume, etc. for the person(s)
who will be completing the assessments/providing services.
11 (d). A
brief statement of your experience in assessing children and families.
11 (e).
Attach two (2) current references (letters) from individuals or
organizations who are familiar with your work. Include their name, address, and
phone number.
11 (f).
Sample of a complete assessment package (must follow the Minimum
Standards for Child and Family Assessments (Form #65). You may review and copy Form #65 on the
Internet at www.gahsc.org
Complete package for
application must include:
1.
A
Developmental Screening for Infant/Toddlers
2.
An
Assessment for Infant/Toddlers
3.
A
Psychological Evaluation for the Child
4.
An
Educational Assessment for the Child
5.
A
Medical Assessment for the Child
6.
A
Family Assessment
12. List any county DFCS offices you are
currently working with or have worked with in the past:
______________________ ______________________ ______________________
______________________ ______________________ ______________________
______________________ ______________________ ______________________
13. Area of the state you wish to
provide services:
NOTE: Applications to provide services in the Metro Atlanta area are not being accepted at this time.
14. Are you a Medicaid provider? ___Yes ___No
15. If so, list your provider # ______________________(for interagency
use only)
16. Signature: ______________________________ Date: ___________________
Title: ________________________________
17.
Application must be
mailed or hand delivered to:
The Georgia
Association of Homes and Services for Children
Attention:
FPBP Statewide Assessment Program
34 Peachtree
Street, NW, Suite 710
Atlanta,
Georgia 30303
(Applications will not be
accepted if they are faxed or emailed)
Please allow 30 days for
processing.
DIVISION OF FAMILY AND CHILDREN
SERVICES
FIRST
PLACEMENT BEST PLACEMENT
PRIVATE PROVIDER
ENROLLMENT APPLICATION
Application
Instructions
1.
Provide
your full name.
2.
Provide
the title of the person on line 1. or the position. For example, Executive Director, or Clinical Director, or Case
Manager
3.
Provide
the name of the organization that that you are applying to be approved
under. Provide the legal name and/or
the name doing business as. For example,
"Comprehensive Family and Health Services" doing business ads
"New Horizons" If applying as an Individual, list the full name of
the individual, including his/her title. For example, Dr. Joe Smith, Ph.D.,
Clinical Psychologist.
4.
This
question is for the purpose of correctly identifying how you want to be listed
on the approved provider list. Check
the appropriate box (only one).
5.
Provide
your official mailing address.
6.
Provide
your organization location address if different from your mailing address. Otherwise enter "SAME"
7.
Business
telephone number.
8.
Business
fax number.
9.
Business
or other e-mail address where you wish to receive e-mail on any aspect of the
application process.
10.
This
e-mail address may be incorporated into an overall e-mail address book of approved
providers. The purpose will be to
disseminate information pertinent to providers doing assessments. Types of information that might be provided
are training topics and dates, alerts to changes in standards, application and
re-application information, and any other information of interest to all
approved private providers.
11.
Provide
the following information:
11 (a) Provide
the appropriate information germane to your organization/agency to operate
legally in the state of Georgia. This
may be a business license (s) or a letter of incorporation. For individuals, it may be a copy of your
professional license.
11 (b) Include
copies of proof of commercial general liability coverage of at least $100,000
per person and $300,000 all occurrences for contractor and its employees. These are the minimum requirements for
implementing a Memorandum of Understanding (MOU) for doing business with any
Georgia County.
11 (c) You
must Include the name and license number of any physicians or clinical
psychologists you will be using to certify and sign off on the psychological
and medical sections of the assessment.
Also, list the credentials of all other individuals who will be
completing any portions of the assessment.
11 (d) The
statement of experience should be specific to the children and families you
plan to assess. Please be specific on who you plan to do assessments on:
infants/toddlers (defined as age 0 to 3.11.31 years old), ages 4-13, 14 &
above, or all ages. Your statement
should reflect your experience in providing assessments to any specific age
group you list.
11 (e) References
should be from individuals who are familiar with your experience in doing
assessments or related type work. They
should be current (within the past two years).
11 (f) This
question is designed to give an applicant the opportunity to become familiar
with the specific standards for doing all aspects of a complete
assessment. The State Provider Review
Committee will evaluate your application on your ability to follow these
standards. You can provide samples of
your actual work that you think meets any of these six specific areas, or
develop samples of what you think should be included in each of the six areas.
The committee will be reviewing this section both for content and format to
insure your understanding of the standard requirements. Please provide a sample for all areas that
you plan to provide services. Only
provide samples of the six areas that match what you say in question 10
(b). Use the following as a guide:
·
For
providers who are requesting approval to specialize in assessing
infants/toddlers, provide samples for sections 1,2,5, and 6.
·
For
providers who are requesting approval to specialize in all children other
than Infants/Toddlers provide samples for sections 3,4,5,and 6.
·
For
providers who are requesting approval for all categories, provide samples for
all sections (1,2,3,4,5, and 6).
12.
Have
you provided any children or family services to any Georgia counties through a
contract, Memorandum of Understanding (MOU), or any other type of arrangement?
List any counties that you are currently working with or have worked with in
the past.
13.
Please
indicate which areas of the state you wish to be approved to provide services
in. If approved, you will be added to the approved list specifically indicating
what geographic regions you will serve.
14.
Only
answer yes to this question if you have a Medicaid provider number.
15.
If
yes, please provide your Medical Provider number here.
16.
The
Executive Director, President or equivalent should sign and date the
application upon completion. If the
application is from an individual as opposed to an organization, then the
individual is responsible for signing the application.
17.
Please
mail the application form and all other accompanying information to:
GAHSC
34 Peachtree St., NW Suite 710
Atlanta GA 30303
Attn: FPBP Statewide Assessment Program