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This address already registered. Please enter another address or change the answer of 'Is this form an update to a previously submitted form?' to 'Yes'
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| Please enter Full name of person or government entity operator. |
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| Full name of the parent company is required. If not applicable, write NA in box. |
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| Full name of affiliated behavioral health organization is required. If not applicable, write NA in box. |
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| Please enter Primary telephone number for recovery housing residence operator.
Please enter valid phone in (###) ###-#### or ###-###-#### format.
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| Please enter Email address for recovery housing residence operator.
Please enter valid email address
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| Website address for recovery housing residence is required. If not applicable, write NA in box.
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| Please select an option is the recovery housing residence already open? |
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| Anticipated date of accepting residents is required
Please enter a future date
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| Date that first resident occupied the residence is required
Please enter a date earlier or equal today
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| Please enter Number of beds in the home for residents.
Please enter valid number for number of beds |
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| Please select accreditation or certification status. |
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| Please select Accreditor. |
| *Please note that as of January 1, 2025, COA and CARF are not designated by DBH as acceptable accreditation organizations for recovery housing residences |
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| Please select Date of initial accreditation or certification.
Please enter a date earlier or equal today.
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| Please select Date of last renewal accreditation or certification.
Please enter a date earlier or equal today
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| Please answer 'When do you anticipate accreditation or certification to be granted?'
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| Please select NARR level |
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Please select at least one population. |
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| Please select an option if this home specialize in serving specific populations? |
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| Please select specific populations. |
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| Please answer is this residence handicap accessible. |
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| Please select an option if this is an update to previously submitted form. |
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| Please enter 'What information changed since the last time you completed this form?' |
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Fraud warning: Any registrant who knowingly submits false or misleading information in this process is subject to criminal or civil penalties. By submitting and signing this document, registrant acknowledges and confirms information contained herein is true and accurate.
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