Free 45159.FH11 - Indiana

APPLICATION FOR LICENSE TO OPERATE A PRIVATE SECURE FACILITY (INDIANA CODE (IC) 31-27-3)
State Form 45159 (R3 / 3-07) / CW 0051

DEPARTMENT OF CHILD SERVICES (DCS) 402 West Washington Street, Room W364, MS08 Indianapolis, IN 46204

Instructions: 1. 2. 3. 4.

Complete the original and two (2) copies and keep one (1) copy. Send the original and one (1) copy to the Department of Child Services. Applicants initials (Section VII) must be by hand. Forward completed application to address upper right corner of this form.

THIS APPLICATION IS REQUIRED IN ACCORDANCE WITH 465 IAC 2-11: PRIVATE SECURE FACILITIES
AN INSTITUTION SHALL MEET ALL OF THE FOLLOWING CONDITIONS PRIOR TO BEING LICENSED AS A PRIVATE SECURE FACILITY: (1) THE INSTITUTION SHALL HAVE BEEN LICENSED FOR FIVE (5) CONSECUTIVE YEARS AS AN INSTITUTION AND SHALL HAVE PROVIDED A CONTINUUM OF CARE OR A FULL PROGRAM OF LONG TERM RESIDENTIAL TREATMENT DURING THIS SAME FIVE (5) YEAR PERIOD. (2) INSTITUTIONS WHOSE PRIMARY PLACEMENT PROGRAM AND CARE PLAN IS SHORT TERM, TWENTY-FOUR (24) HOUR TEMPORARY CARE FOR NOT MORE THAN SIXTY (60) CONSECUTIVE DAYS TO AN INDIVIDUAL CHILD DO NOT QUALIFY AS MEETING THE REQUIREMENTS OF PROVIDING A CONTINUUM OF CARE OR A FULL PROGRAM OF LONG TERM RESIDENTIAL TREATMENT. [465 IAC 2-11-33(b)] SECTION I Complete or correct the following Private Secure Facility and parent agency information.
1a. Name of Private Secure Facility 1b. Facility telephone number 1c. Location address of this facility 1d. City, State, and ZIP code of facility

(
2a. Private Secure Facility e-mail address

)
2b. Executive director/administrator e-mail address

3a. Name of Parent Agency

3b. Parent Agency telephone number 3c. Location address of Parent Agency

3d. City, State, and ZIP code of Parent Agency

(
4a. Private or Public Auspices 4b. Not-for-Profit or Profit Agency

)

5a. Mailing Address of Parent Agency 5b. City, State, and ZIP code of Mailing Address 6. DCS Assigned License Number

SECTION II Complete the following information regarding the planned capacity for children placed at the facility.
7a. Number of children in care 7b. Age of children in care 7c. Gender of children in care

8a. Per Diem charged for care: Low Rate ENCLOSE ATTACHMENT G

$

8b. Per Diem charged for care: High Rate ENCLOSE ATTACHMENT G

$

SECTION III Complete the following information regarding the President of the governing body of the parent agency and attach a list of all members of the governing body, giving name, full address, occupation and telephone number (Attachment C).
9a. Name of President of governing body 9b. Full address 9c. Occupation 9d. Telephone number

(
SECTION IV

)

Complete the following information regarding the executive director or manager of the Private Secure Facility and attach a complete list of all facility staff members, including employees and volunteers who have or will have direct contact, on a regular and continuing basis, with children who are or will be placed at the facility, giving name, position, and date of employment (Attachment D).
10a. Name of executive director or manager 10b. Official title or position 10c. Date of employment (month, day, year)

(OVER)

SECTION V ATTACHMENTS: All required attachments listed herein must be submitted with the application as designated under 465 IAC 2-11.

A. Criminal history affidavit. Required with initial application and renewal application for person signing application. Use State Form provided. B. Financial resources, financial audit or review. Required with initial application and renewal application. C. List of members of governing body, including name, address, occupation, and telephone number. Required with initial application and renewal application. D. List of facility staff members, including name, proof of educational and professional qualifications, position, date of employment, and assigned facility. Required with initial application and renewal application. E. List of contractual positions, including name, position, and date(s) of contract. Required with initial application and renewal application. F. List of vacant positions in agency. Required with initial application and renewal application. G. Statement of fees charged (per diem) and identification of services included in per diem. Required with initial application and renewal application. H. Plan of operation. Required with initial application and renewal application. I. Incorporation papers, if parent agency is incorporated. Required with initial application, or upon incorporation. J. Personnel policies. Required with initial application and renewal application. K. Policies on admission criteria and admission application. Required with initial application and renewal application. L. Policies on categories of children accepted and not accepted for care. Required with initial application and renewal application. M. Policies and description of care provided. Required with initial application and renewal application. N. Policies on release or discharge of children. Required with initial application and renewal application. O. Religion practices and policies. Required with initial application and renewal application. P. Policies on visiting and correspondence. Required with initial application and renewal application. Q. Statement of area served by the institution or group home. Required with initial application and renewal application. R. Child caring institutions only. Policies on use of mechanical restraints and/or confinement room if either is used. Required with initial application and renewal application.
SECTION VI Statement of certification

I certify that all statements made in this application and any attachments thereto are correct to the best of my knowledge. I further certify that no person, on the grounds of race, religion, color or national origin, shall be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any program or activity for which this institution receives public financial assistance directly or indirectly, including assistance administered by any local DCS office through the payment of per diem.
SECTION VII

Application must be signed by the president of the governing body, the chief executive officer of the organization, or other person designated by the governing body to apply for this license.
Signature of applicant in full (signature must be by hand)

Typed name of applicant

Official title

Date (month, day, year)