Residential [ ]
Ambulatory [ ]
Application For Approval To
Establish Or Operate Drug Abuse
Treatment And/Or Preventive
Education Programs
(Mental Hygiene Law §81.38)
1.
a. Name
of voluntary agency ____________
b.
Name of corporate entity ____________
c. Address ____________
d. Telephone number ____________
2.
a. List name and address of all members of
the board of directors of the corporation:
b. List name and address of all officers of
the corporation:
c. If corporation
is a subsidiary of any other organization, state name and address of such
controlling entity, and names and addresses of responsible principals of such
controlling entity:
d. Certified
Copy of Certificate of Incorporation must be attached to this application,
together with Copy of Corporate Constitution or by-laws.
3. Explain in detail the need for the type of
program which you intend to conduct and operate; the precise geographic area to
be served; and the number and description characteristics of clients you will
serve. Attach any additional information to this application, including the
name, location capacity and program type of any other agencies known to be
providing drug abuse treatment and/or preventive education programming within
the proposed area to be served.
4.
a. List all corporate financial resources and
assets, including all corporate liabilities:
Assets Liabilities
b. Append copy of annual operating budget for
the fiscal year most nearly conforming to the period of proposed approval, or
the first year thereof.
5. Number and types of staff to be employed.
Give complete description of duties, qualifications and salary scale, for each
type of employee.
6.
a. Set forth complete narrative description
or program to be employed in rehabilitation of clients including, but not
limited to, treatment goals, methods and expected average duration, age groups
sex and source of referrals of clients; whether fees are to be charged and
amounts, and days and hours of operation. Attach any additional description to
this application.
b. Set forth
standards for admission of clients to your program.
c. Set forth required frequency of attendance
at each program component.
d.
Standards to be employed for discharge of clients failing to comply with your
requirements, or failing to benefit from your program. Attach any additional
explanation to this application.
e.
Type and method of accounting system used to monitor client
performance.
7. List
type and location (residential, outpatient, etc.), and telephone number of all
sites to be used in program; including but not limited to, treatment centers,
remote project locations, satellite intake or supervision units, and
administration centers Description should include sufficient information to
readily locate each site for inspection.
8. Attach floor-by-floor scaled sketches for
all buildings.
9. STATEMENT OF
COMPLIANCE:
It is understood that the information given herein or attached
to this application is correct. It is further understood that the applicant
asserts it is in full compliance with all requirements of 14 NYCRR Part 2020,
except as stated by it herein or by appendix to this application; and that the
specific questions and answers included in this application in no way limit the
generality of this statement.
It is also agreed that the voluntary agency will, upon request,
submit to the New York State Drug Abuse Control Commission such other data as
may be requested including, but not limited to its operations and finances.
Furthermore, the agency will make available any additional data needed by the
Commission in connection with this application for approval.
It is also agreed that all facilities and services of the
voluntary agency shall be subject to review and inspection by the Commission or
its duly authorized representatives.
It is understood that all persons entrusted with the care,
treatment and rehabilitation of clients shall be of good moral
character.
It is also understood that personnel will be maintained in
adequate numbers and at appropriate levels of training to provide the services
described herein on a continuing basis.
It is also understood that the granting of a certificate of
approval for purposes of Mental Hygiene Law, §81.38 shall not be construed as a
specific recommendation of the agency's program by the Commission.
STATE OF NEW YORK
COUNTY OF ________
________, being duly sworn, deposes and says that he is
the
(Title)
of the
Signed ________
Subscribed and sworn to before me this
________ day of ________, 19________.
__________
(Notary Public)
