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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

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

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

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

List applicable Medicaid Provider numbers*

Is your facility accredited?*

Yes

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

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

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

By whom and how often?*

Is continuing education and/or recertification required of your staff?*

Yes

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

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

Please provide summarized results*

Does your facility complete an internal record review process?*

Yes

Please provide summarized results*

Does your facility have a written quality assurance/quality improvement (QA/QI) plan?*

Yes

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

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

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

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

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

Capacity

General Residential Operation (GRO) with Emergency Services

Capacity

General Residential Operation (GRO) without Emergency Services

Capacity

Residential Treatment Center (RTC)

Capacity

Supervised Independent Living (SIL)

Capacity

Transition Living Program (TLP)

Capacity

Treatment Foster Care

Capacity

Service Types

Check all that apply

Child Care Services

Capacity

Assessment Services

Capacity

Intermittent Alternative Care

Capacity

Treatment Services for Children with

Emotional Disorders

Capacity

Intellectual Developmental Disabilities (ICFIDD)

Capacity

Pervasive Developmental Disorders

Capacity

Primary Medical Needs

Capacity

Placement Services/Levels of Care

Check all that apply

Basic LOC

Age Range

Number of Licensed Families

Number of Beds

Moderate LOC

Age Range

Number of Licensed Families

Number of Beds

Specialized LOC

Age Range

Number of Licensed Families

Number of Beds

Intense LOC

Age Range

Number of Licensed Families

Number of Beds

Intense Plus LOC

Age Range

Number of Licensed Families

Number of Beds

Emergency Respite

Age Range

Number of Licensed Families

Number of Beds

Respite

Age Range

Number of Licensed Families

Number of Beds

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

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

ADD / ADHD

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Anxiety Disorder

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Assaultive Behaviors or Homicidal

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Criminal acts – an act that violates the law

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Cruelty to Animals

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Danger to Self

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Danger to Others

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Depression

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Developmental Disorders

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

DSM-IV Axis I & II Diagnosis

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Eating Disorder

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Enuresis/Encopresis

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Fire Setting

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Fire Setting History

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Gang Activity / Affiliation

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Gender Identity Issues/ Sexual Orientation

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Victims of Human Trafficking
Applicable to GROs Providing Treatment Services only

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Impulse Control Disorder

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Learning Disorder

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Targeted Characteristics (con't)

Check all that apply

Maladaptive Behaviors

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Medically Fragile

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Intellectual Disabilities

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Oppositional Defiant

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Pervasive Developmental Disorder

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Physically Abused

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Physically Neglected

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Pregnant

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Primary Medical Needs

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Probation/Parole/TYC/JPC

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Requires Hospitalization

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Runaway History

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Sexual Abuse History

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Sexually Inappropriate / Sexualized Behaviors

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Sexual Perpetrator History

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Special Needs

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Substance Abuse / Use

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Substance Abuse or Dependence with the need for medical detoxification

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Suicidal

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Suicidal Gestures

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Suicidal Ideation

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Verbal Aggression
Threaten, bully or other coercing, including threats of physical harm

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

Other

Does applicant currently serve children with this characteristic?

Yes

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes

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Partner Application

Agency Details

List Other Applicable Site Locations

Leadership

Chief Agency Executive

Program Administrator

Agency Audit Contact

Chief Financial Contact

Agency Information

Partnership

Agency Review

Licensure/Accreditation/Certification

Affiliations

Quality Review

Has your facility had:

Financial Review

Residential Facilities

Service Types

Treatment Services for Children with

Placement Services/Levels of Care

Targeted Characteristics

Targeted Characteristics (con't)

About Us

Services

Locations

Miscellaneous

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