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Nebraska Partner Application

Let’s get started. Please fill out the form below. We look forward to learning more about you and how we can best work together.

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Agency Details
Agency Corporate Name*
Address*
Street Address City State ZIP Code
Website
List Other Applicable Site Locations
Address
Street Address City State ZIP Code
Address
Street Address City State ZIP Code

Leadership
Chief Agency Executive
Full Name*
Phone*
Email*
Program Administrator
Full Name*
Phone*
Email*
Agency Audit Contact
Name*
Phone*
Email*
Chief Financial Contact
Name*
Phone*
Email*

Agency Information
Brief Synopsis Agency History*
Mission*
Vision*
Values*
Key Success Metrics*

Partnership
Describe how your agency will support Saint Francis Ministries in meeting our mission/vision/values?*
Describe how your agency will support child-focused, family-driven services in Nebraska?*
Describe your agency’s strengths*
What are your agency’s biggest challenges?*

Agency Review

Licensure/Accreditation/Certification
Is your facility/agency licensed by the state?*
- Yes
- No
Please indicate type and include copies of all applicable licenses
Drop files here or

Accepted file types: pdf, doc, docx, jpg, Max. file size: 50 MB.
Has DHHS performed an onsite licensing or other review in the last year?*
- Yes - include date of last survey
- No
Date of last survey*
MM slash DD slash YYYY
Improvement action or activities
Drop files here or

Accepted file types: pdf, doc, docx, jpg, Max. file size: 50 MB.
If yes, were any deficiencies or other improvement action required? Please attach a summary of the improvement action required and current status of these improvement activities. Or, include a copy of the survey results.
Does your facility/agency have a current Provider Agreement with DHHS?*
- Yes
- No
Please indicate which services and include a copy
Drop files here or

Accepted file types: pdf, doc, docx, jpg, Max. file size: 50 MB.
Does your facility/agency currently bill Medicaid for any services?*
- Yes
- No
List applicable Medicaid Provider numbers*
Is your facility accredited?*
- Yes
- No - Skip next question
By which organization(s)?*
When was the last review conducted by your accrediting body, and what is the length of your current accreditation?
Date of last survey
MM slash DD slash YYYY
Length of Accreditation
Improvement action or activities
Drop files here or

Accepted file types: pdf, doc, docx, jpg, Max. file size: 50 MB.
Please provide a copy of the exit summary and if there were any deficiencies or other improvement actions required, please explain the current status of these improvement activities.
Does your facility/agency have current professional and general liability insurance coverage?*
- Yes
- No
Insurance policies
Drop files here or

Accepted file types: pdf, doc, docx, jpg, Max. file size: 50 MB.
If yes, include all applicable copies of insurance policies, including effective dates, or have your agent provide us a summary of the policy terms.
Affiliations
Does your facility/agency have an affiliate or other sub-contract relationship with other facilities/entities?*
- Yes
- No
Affiliates
Drop files here or

Accepted file types: pdf, doc, docx, jpg, Max. file size: 50 MB.
If yes, attach a document showing name, address, and telephone number of each affiliate, along with a brief description of the affiliate’s relationship to facility.

Quality Review
Please attach an explanation or requested documents for any question(s) answered yes.
Are the credentials and/or certifications of professional staff members verified?*
- Yes
- No
By whom and how often?*
Is continuing education and/or recertification required of your staff?*
- Yes
- No
Please make available during the site review visit a list of training and in-service programs offered during the last calendar year.
For residential programs, what is the staff ratio during waking hours?*
Staff ratio during sleeping hours?*
Is there a formal grievance/resolution procedure for your clients?*
- Yes
- No
Please attach a description of the procedure
Drop files here or

Max. file size: 50 MB.
Is there a formal satisfaction program for your clients?*
- Yes
- No
Please provide summarized results*
Does your facility complete an internal record review process?*
- Yes
- No
Please provide summarized results*
Does your facility have a written quality assurance/quality improvement (QA/QI) plan?*
- Yes
- No
Please provide a copy of the plan
Drop files here or

Accepted file types: pdf, doc, docx, jpg, Max. file size: 50 MB.
Has your facility had:
Revocations or suspensions as a Medicaid Provider?*
- Yes
- No
Please provide explanation*
Please provide relevant documentation
Drop files here or

Accepted file types: pdf, doc, docx, jpg, Max. file size: 50 MB.
Agency license actions? (i.e. suspensions, revocations, sanctions, etc.)*
- Yes
- No
Please provide what type of action*
Please provide relevant documentation
Drop files here or

Accepted file types: pdf, doc, docx, jpg, Max. file size: 50 MB.
Judgments or settlements against the facility that pertain to child welfare or behavioral?*
- Yes
- No
Please provide what type of judgement or settlement*
Please provide relevant documentation
Drop files here or

Accepted file types: pdf, doc, docx, jpg, Max. file size: 50 MB.
Financial Review
Does your organization have an annual audit, review or compilation by an independent certified public accounting firm or accountant?*
- Yes
- No
Audited, reviewed, or compiled statements
Drop files here or

Accepted file types: pdf, doc, docx, jpg, Max. file size: 50 MB.
Please provide a copy of your most recent audited, reviewed, or compiled statements, along with any reports on internal controls, as applicable.
Financial statements
Drop files here or

Accepted file types: pdf, doc, docx, jpg, Max. file size: 50 MB.
Please provide a copy of your most recent internally prepared financial statements.

Support Services
Please select all that are applicable
Adoption Home Study
- Adoption Home Study
Caseload Size
Better Together (HFS)
- Better Together (HFS)
Caseload Size
Crisis Stabilization
- Crisis Stabilization
Caseload Size
Day or Evening Reporting – Full Day
- Day or Evening Reporting – Full Day
Caseload Size
Day Services – Full Day
- Day Services – Full Day
Caseload Size
Day Services – Half Day
- Day Services – Half Day
Caseload Size
Domestic Violence Education – BIP Intake
- Domestic Violence Education – BIP Intake
Caseload Size
Domestic Violence Education – BIP Ongoing
- Domestic Violence Education – BIP Ongoing
Caseload Size
Domestic Violence Education – Intake
- Domestic Violence Education – Intake
Caseload Size
Domestic Violence Education – Ongoing
- Domestic Violence Education – Ongoing
Caseload Size
Drug Testing Adult – Oral Fluid Test
- Drug Testing Adult – Oral Fluid Test
Caseload Size
Drug Testing Adult – Breathalyzer with Drug Test
- Drug Testing Adult – Breathalyzer with Drug Test
Caseload Size
Drug Testing Adult – Breathalyzer w/o Drug Test
- Drug Testing Adult – Breathalyzer w/o Drug Test
Caseload Size
Drug Testing Adult – Hair Follicle Test
- Drug Testing Adult – Hair Follicle Test
Caseload Size
Drug Testing Adult – Hair Follicle Test Lab Drug TK
- Drug Testing Adult – Hair Follicle Test Lab Drug TK
Caseload Size
Drug Testing Adult – Sweat Patch (includes lab)
- Drug Testing Adult – Sweat Patch (includes lab)
Caseload Size
Drug Testing – ETG Only
- Drug Testing – ETG Only
Caseload Size
Drug Testing – Youth Paternity Test Drug TK
- Drug Testing – Youth Paternity Test Drug TK
Caseload Size
Family Group Conferencing
- Family Group Conferencing
Caseload Size
Family Preservation
- Family Preservation
Caseload Size
Family Support Service Preparation
- Family Support Service Preparation
Caseload Size
Family Support Service
- Family Support Service
Caseload Size
Intensive Family Preservation Tier I
- Intensive Family Preservation Tier I
Caseload Size
Intensive Family Preservation Tier I Daily Rate
- Intensive Family Preservation Tier I Daily Rate
Caseload Size
Intensive Family Preservation Tier II
- Intensive Family Preservation Tier II
Caseload Size
Intensive Family Preservation Tier II Daily Rate
- Intensive Family Preservation Tier II Daily Rate
Caseload Size
Intensive Family Preservation Tier III
- Intensive Family Preservation Tier III
Caseload Size
Intensive Family Preservation Tier III Daily Rate
- Intensive Family Preservation Tier III Daily Rate
Caseload Size
Intensive Family Reunification Tier I
- Intensive Family Reunification Tier I
Caseload Size
Intensive Family Reunification Tier II
- Intensive Family Reunification Tier II
Caseload Size
Intensive Family Reunification Tier III
- Intensive Family Reunification Tier III
Caseload Size
Intermittent Monitoring
- Intermittent Monitoring
Caseload Size
Interpreter/Translation Services
- Interpreter/Translation Services
Caseload Size
Mediation and Facilitation
- Mediation and Facilitation
Caseload Size
Parenting Time/Supervised Visitation
- Parenting Time/Supervised Visitation
Caseload Size
Pathways to Permanency Census
- Pathways to Permanency Census
Caseload Size
Placement
- Placement
Caseload Size
Planned Respite - Daily
- Planned Respite - Daily
Caseload Size
Planned Respite - Hourly
- Planned Respite - Hourly
Caseload Size
Relinquishment Counseling – Per Person
- Relinquishment Counseling – Per Person
Caseload Size
Relinquishment Counseling – Session
- Relinquishment Counseling – Session
Caseload Size
Respite Crisis
- Respite Crisis
Caseload Size
Safety Monitoring (aka In Home Safety)
- Safety Monitoring (aka In Home Safety)
Caseload Size
Termination of Parental Rights Review
- Termination of Parental Rights Review
Caseload Size
Tracker Services
- Tracker Services
Caseload Size
Transportation Services
- Transportation Services
Caseload Size
Updated Adoption Home Study
- Updated Adoption Home Study
Caseload Size

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785.825.0541 ᛫ 800.423.1342 ᛫ 110 West Otis Avenue ᛫ Salina, KS 67401

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785.825.0541 ᛫ 800.423.1342
110 West Otis Avenue ᛫ Salina, KS 67401

© 2023 Saint Francis Ministries ᛫ Privacy (HIPAA) ᛫ Sitemap ᛫ Terms ᛫ Accreditation ᛫