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Who We Are
What We Do
Where We Serve
- Location Overview
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Our Blog
Ways to Help
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Contact Us

Texas 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 Texas?*
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 DFPS 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 DFPS?*
- 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
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.

Residential Facilities
Check all that apply
Emergency Shelter
- Emergency Shelter
Capacity
General Residential Operation (GRO) with Emergency Services
- General Residential Operation (GRO) with Emergency Services
Capacity
General Residential Operation (GRO) without Emergency Services
- General Residential Operation (GRO) without Emergency Services
Capacity
Residential Treatment Center (RTC)
- Residential Treatment Center (RTC)
Capacity
Supervised Independent Living (SIL)
- Supervised Independent Living (SIL)
Capacity
Transition Living Program (TLP)
- Transition Living Program (TLP)
Capacity
Treatment Foster Care
- Treatment Foster Care
Capacity
Service Types
Check all that apply
Child Care Services
- Child Care Services
Capacity
Assessment Services
- Assessment Services
Capacity
Intermittent Alternative Care
- Intermittent Alternative Care
Capacity
Treatment Services for Children with
Emotional Disorders
- Emotional Disorders
Capacity
Intellectual Developmental Disabilities (ICFIDD)
- Intellectual Developmental Disabilities (ICFIDD)
Capacity
Pervasive Developmental Disorders
- Pervasive Developmental Disorders
Capacity
Primary Medical Needs
- Primary Medical Needs
Capacity
Placement Services/Levels of Care
Check all that apply
Basic LOC
- Basic LOC
Age Range
Number of Licensed Families
Number of Beds
Moderate LOC
- Moderate LOC
Age Range
Number of Licensed Families
Number of Beds
Specialized LOC
- Specialized LOC
Age Range
Number of Licensed Families
Number of Beds
Intense LOC
- Intense LOC
Age Range
Number of Licensed Families
Number of Beds
Intense Plus LOC
- Intense Plus LOC
Age Range
Number of Licensed Families
Number of Beds
Emergency Respite
- Emergency Respite
Age Range
Number of Licensed Families
Number of Beds
Respite
- Respite
Age Range
Number of Licensed Families
Number of Beds
Other
- Other
Age Range
Number of Licensed Families
Number of Beds

Targeted Characteristics
Check all that apply
Actively Exhibiting Psychotic Behavior
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
ADD / ADHD
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Anxiety Disorder
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Assaultive Behaviors or Homicidal
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Criminal acts – an act that violates the law
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Cruelty to Animals
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Danger to Self
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Danger to Others
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Depression
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Developmental Disorders
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
DSM-IV Axis I & II Diagnosis
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Eating Disorder
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Enuresis/Encopresis
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Fire Setting
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Fire Setting History
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Gang Activity / Affiliation
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Gender Identity Issues/ Sexual Orientation
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Victims of Human Trafficking
Applicable to GROs Providing Treatment Services only
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Impulse Control Disorder
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Learning Disorder
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No

Targeted Characteristics (con't)
Check all that apply
Maladaptive Behaviors
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Medically Fragile
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Intellectual Disabilities
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Oppositional Defiant
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Pervasive Developmental Disorder
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Physically Abused
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Physically Neglected
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Pregnant
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Primary Medical Needs
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Probation/Parole/TYC/JPC
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Requires Hospitalization
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Runaway History
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Sexual Abuse History
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Sexually Inappropriate / Sexualized Behaviors
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Sexual Perpetrator History
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Special Needs
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Substance Abuse / Use
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Substance Abuse or Dependence with the need for medical detoxification
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Suicidal
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Suicidal Gestures
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Suicidal Ideation
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Verbal Aggression
Threaten, bully or other coercing, including threats of physical harm
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No
Other
Does applicant currently serve children with this characteristic?
- Yes
- No
If DFPS needed to place a child with this characteristic, would the child be accepted?
- Yes
- No
If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?
- Yes
- No

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

© 2022 Saint Francis Ministries ᛫ Privacy (HIPAA) ᛫ Sitemap ᛫ Terms ᛫ Accreditation ᛫