Attachment A - Provider Organization Information (pdf)

Attachment A-Provider Organization Information (doc) (Word 97-2003)

Attachment A-Provider Organization Information (docx) (Word 2007)

Provider Organization Information Actual Information
Name:
FEIN Number:
Address:
City, State, Zip
Contact Person:
Contact phone number:
Contact email address:
Locations of offices and sites of services delivery (address/services provided at the address):
Number of unduplicated adult consumers served in FY11:
Number of new patients/ consumers/case openings in FY11:
Number of case closings/ terminations of services in FY11:
Characteristics of adult consumers served in FY11:
% male/female:
% with serious mental illness:
Staffing characteristics:
Total number of staff supporting the provision of psychiatric, mental health or substance abuse services
Number and percentage of total that are administrative and support staff (not providers of direct services).
Number of prescribers of medications. Distinguish between MDs and other prescribers (please identify).
Number of direct service staff board eligible or certified in psychiatry.
Number and percentage of direct service staff qualified as an LPHA (i.e., licensed service providers, including psychiatrists).
For community mental health providers, the number and percentage of direct service staff whose highest qualification is a QMHP.
For community mental health providers, the number and percentage of direct service staff whose highest qualification is an MHP.
For community mental health providers, the number and percentage of direct service staff who are self-identified consumers.
For community mental health providers, the number and percentage of direct service staff who are Certified Recovery Support Specialists.
List of languages spoken by direct service staff including number of staff by credential who speak each language.
List of ethnic groups in which the agency has cultural competence including number of staff by credential with the demonstrated competence for each ethnic group.