Empowering Recovery and Inspiring Connection in Henrico

Username*

Email Address*

Create the Password for the Account*

Do you provide services in Central VA?*

YesNo

Do you provide Treatment Services?*

YesNo

Do you provide Recovery Housing?*

YesNo

This service/agency does not discriminate based on race, religion, color, sex, national origin, disability, veteran status, gender identify, age, sexual orientation or any other basis prohibited by law.*

TrueFalse

Is your facility ADA accessible (ex. wheelchair ramps, bathrooms, elevators, rails, doorways and parking)?*

YesNo

Treatment Provider Information

Treatment Provider Name*

Address*

City*

State*

Zip*

Website

Treatment Provider Phone Number*

Treatment Provider Fax Number

Are you licensed by DBHDS?*

YesNo

How does a client request services?*

Do you provide Medication Assisted Treatment?*

YesNo

How quickly can a new client see a prescriber?*

How quickly can a new client meet with a clinician?*

Are peer services offered?*

YesNo

What ASAM levels of service do you provide?*

1.0 Outpatient2.1 Intensive Outpatient

2.5 Partial Hospitalization3.1 Clinically Managed Low Intensity Residential

3.3 Clinically Managed Low Intensity Residential (Specific Population)3.5 Clinical Managed Medium Intensity Residential

3.7 Medically Monitored High Intensity Inpatient4.0 Medically Monitored Intensive Inpatient

OTPOBOT

Do you accept insurance?*

YesNo

Do you accept all Medicaid MCOs?*

YesNo

Are you able to assist the client with applying for Medicaid?*

YesNo

Are you willing to begin services prior to Medicaid being approved and bill Medicaid for services provided from the date of the application?*

YesNo

Do you have a sliding scale for indigent citizens? *

YesNo

Are you willing to provide reports to the courts with a release signed by the client? *

YesNo

Are you willing to coordinate with other providers? *

YesNo

Recovery Housing Information

Recovery Provider Name*

Address*

City*

State*

Zip*

Website

Provider Phone Number*

Recovery Provider Fax Number

Are you licensed by VARR?*

YesNo

Are you CHIRP accredited?*

YesNo

How does a client request services?*

How quickly can someone be housed? *

Are peer services offered by a certified peer specialist?*

YesNo

Do you provide a licensed 3.1, 3.3, or 3.5 ASAM level of care?*

YesNo

Are you willing to provide reports to the courts? *

YesNo

Are you willing to coordinate with treatment providers?*

YesNo

Is drug screening randomized?*

YesNo

How frequently are residents drug screened? *

Please Explain

Do you send out positive drug tests for verification? *

YesNo

If yes, where do you send them?

Are residents permitted to seek the treatment provider of their choice?*

YesNo

How long must a house manager be abstinent prior to becoming a house manager?*

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