Apply for Certification "*" indicates required fields Step 1 of 2 50% Organization InformationIs this Application for:* Certification Recertification Both 1. What is the name of your organization?*2. What is the organization's principal address?*3. What is your organization's website?4. What is the admissions phone number?*5. Who will be the point of contact in your organization for certification?*6. Please list this person's phone number*7. Please list this person's email address*8. Mission Statement of Organization*9. Vision Statement of Recovery Housing Program*10. Have you or your organization had a revocation or surrender of a prior license, certificate, or approval issued within the previous five (5) years from any in-state or out-of-state provider?* Yes No If yes, please explain provide any associated deficiency reports or compliance records with this application (via email to info@kyarr.org)11. Have you or the program, corporation, or provider previously or currently associated with this application, surrendered or defaulted on its license, certificate, or approval, within the previous five (5) years, for reasons related to disciplinary action and the nature of the disciplinary action?* Yes No If yes, please explain12. Please list the names of any individual employee, staff member, peer, or volunteer currently associated with the applicant who has had a professional license or certification revoked or suspended or has surrendered a professional license or certification for reasons related to disciplinary action or misconduct, or been convicted of a felony, within the previous ten (10) years, and the nature of the disciplinary action or misconduct or felony:* Individual Residence Information13. What is the name of the residence? (This name will appear on our public database and should not include an address or street name)14. What is the address of the residence? (House Number, Street, City, Zip Code)*15. What county is this residence in?16. What NARR Level/Type is this residence?* Level 1 / Type P Level 2 / Type M Level 3 / Type S Other:17. What population is served at this residence?* Men Women Coed Women with Children Men with Children Couples Other Other18. What is the maximum number of residents expected to live in the residence?*19. How many bedrooms?*20. Is there at least one full bathroom for each six (6) residents?*21. What, if any, services are provided by the residence?*22. Does the residence have paid staff?*23. Do staff live onsite?*24. Would you like to add additional residence(s)?* Yes No Individual Residence Information What is the name of your organization? What is the name of the residence? (This name will appear on our public database and should not include an address or street name) What is the address of the residence? What county is this residence in? What NARR Level/Type is this residence? Other Population Served? How many bedrooms does the residence have? Does each bedroom have at least 50 square feet per person? How many full bathrooms does the residence have? Is there at least one full bathroom for each six(6) residents? Please describe the level of support provided in the residence What, if any, services are provided by the residence Does the residence have paid staff? Do staff live onsite? Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Δ
