Mental Health, Alcohol and Other Drug Prevention & Treatment Services

REQUEST FOR INFORMATION

FY 2012 NON-MEDICAID FUNDING MENTAL HEALTH, ALCOHOL AND OTHER DRUG PREVENTION & TREATMENT SERVICES

FACE SHEET

Original Revision Date Submitted:

PROVIDER INFORMATION Agency Name: Address: Telephone #: Fax #:

Agency Web-site Address: Executive Director/CEO: E-mail Address: Fiscal Officer: E-mail Address: Clinical Director: E-mail Address: Board President/Chair: E-mail Address: Statutory Agent on file with Ohio Secretary of State: Federal Tax ID (EIN) #:

AUTHORIZATION

I hereby certify by my signature that this RFI has been approved for submission by this Agency’s governing authority.

Board President / Chair Date Executive Director / CEO Date

ADAMHS Board of Cuyahoga County SFY 2012 Non-Medicaid Funding RFI Face Sheet/Checklist Page 1 of 6 (revised 2.1.11) Page 1 of ADAMHS Board of Cuyahoga County SFY 2012 Non-Medicaid Funding RFI Face Sheet/Checklist Page 2 of 6 (revised 2.1.11) Page 2 of Agency Name:

Current Accreditations and Certifications & Expiration Dates: (check all that apply) ODADAS Certification Expiration Date Expiration Date Expiration Date

JCAHO Outpatient Residential

CARF Intensive Outpatient Detox

COA Opioid Agonist DIP

Other Prevention

ODMH Certification Expiration Date Expiration Date

Crisis Intervention Pharm Manag

MH Assessment Detox

BH Counseling CPST

ACT Consultation

Prevention Referral/Info

Consumer Operated Other MH

MH Education Other MH

Employment/Voc Other MH

Other MH

ADAMHS Board of Cuyahoga County SFY 2012 Non-Medicaid Funding RFI Face Sheet/Checklist Page 3 of 6 (revised 2.1.11) Page 3 of Agency Name:

AOD Services Requested for SFY 2012 Non-Medicaid Funding Consideration: (check all that apply)

AoD Services

Acute Hospital Detoxification – H0009 Medical Community Residential Treatment – Hospital Setting – A1210 Ambulatory Detoxification – H0014 Medical Community Residential Treatment-Non-Hospital Setting – A0230 Assessment – H0001 Non-Medical Community Residential Treatment – A1220 Case Management – H0006 BH Medical Community Residential Treatment-Hospital Setting – H0017 Crisis Intervention – H0007 BH Medical Community Residential Treatment Non-Hospital Setting – H0018 Family Counseling – T1006 Non-Medical Community Residential Treatment – H0019 Group Counseling – H0005 Meals – T1010 BH Counseling & Therapy – H0004 Room & Board – A0740 Intensive Outpatient (IOP) – H0015 Consultation – A0560 Laboratory Urinalysis – H0003 BH Hotline – H0030 Medical/Somatic – H0016 Intervention – H0022 Methadone Administration – H0020 Referral and Information – A0510 Sub Acute Detoxification – H012 Training – H0021 23 Hour Observation Bed - 99236 Child Care – T1009 Urine Dip Screen – A0780 Transportation – A0750 Outreach – H0023 AoD Services not otherwise Classified – H0047 Information Dissemination – A0610 Education – A0620 Community Based Process – A0630 Environmental – A0640 Alternatives – A0660 Problem Identification & Referral – A0650

ADAMHS Board of Cuyahoga County SFY 2012 Non-Medicaid Funding RFI Face Sheet/Checklist Page 4 of 6 (revised 2.1.11) Page 4 of Agency Name:

Mental Health Services Requested for SFY 2012 Non-Medicaid Funding Consideration: (check all that apply)

MH Services

Crisis Intervention MH Services– S9484 Intensive Home Based Treatment (Non-Clinical) – M1810 Psychiatric Diagnostic Interview (Physician) - 90801 Assertive Community Treatment (Non-Clinical) – M1910 MH Assessment (Non-Physician) – H0031 Residential Care (Treatment & Support) – M2200 Pharmacological Mgt - 90862 Community Residence – M2240 BH Counseling & Therapy (Individual)– H0004 Foster Care – M2250 BH Counseling & Therapy (Group)– H0004 Subsidized Housing – M2260 Community Psychiatric Supportive Treatment(Individual) – H0036 Respite Care – M2270 Community Psychiatric Supportive Treatment(Group)– H0036 Crisis Care – M2280 Partial Hospitalization (less than 24hr)– S0201 Temporary Housing – M2290 BH Hotline – H0030 Consumer Operated Services – M3120 Intensive Home Based Treatment (Clinical) – H2016 Self-Help / Peer Support – H0038 Assertive Community Treatment (Clinical) – H0040 Information and Referral – M4130 Occupational Therapy – M1430 Other MH Services (Non-Healthcare) – M3140 Adjunctive Therapy – M1440 Other MH Services (Healthcare) – H0046 School Psychology – M1530 Prevention – M4110 Adult Education – M1540 Consultation – M4120 Social & Recreational – M1550 Mental Health Education – M4140 Employment/Vocational Services – M1620 Other______

ADAMHS Board of Cuyahoga County SFY 2012 Non-Medicaid Funding RFI Face Sheet/Checklist Page 5 of 6 (revised 2.1.11) Page 5 of REQUEST FOR INFORMATION

FY 2012 NON-MEDICAID FUNDING ALCOHOL AND OTHER DRUG AND MENTAL HEALTH TREATMENT SERVICES

SUBMISSION & ORDER OF DOCUMENTS RFI CHECKLIST

(agency name)

Submission Deadline: 4:00 PM on Wednesday, March 2, 2011

NOTE: RFI packets delivered after the deadline will not be considered and returned to the sender.

1. Face Sheet (signed by Executive Director/CEO & Agency Board President/Chair) 2. Completed Checklist 3. Agency Mission and Vision Statements 4. Copies of Proof of Liability Insurance 5. Original RFI (with original signatures throughout) & Nine Copies (total of ten) 6. Logic Model 7. CD with Submitted Documents (Word & Excel in PC format)

COMPLETED CHECKLIST MUST BE SUBMITTED BEHIND FACE SHEET OF RFI PACKET

ADAMHS Board of Cuyahoga County SFY 2012 Non-Medicaid Funding RFI Face Sheet/Checklist Page 6 of 6 (revised 2.1.11) Page 6 of