Healthcare Package Purchase Form

Name *

Email address *

Do you currently have CARF/Joint Commission accreditation? *

Yes

No

In Progress

What kind of accreditation support do you need? *

Initial accreditation (preliminary accreditation, no previous accreditation)

Full 3-year accreditation (previously received a year provisional accreditation)

Full 3-year accreditation (previously received a three-year accreditation)

Which Accreditation are you requesting help with? *

Please select at least one option.

CARF

The Joint Commission (TJC)

Accreditation Commission for Health Care (ACHC)

Council on Accreditation (COA)

The National Commission on Correctional Health Care (NCCHC)

Which Program(s) are you seeking accreditation?

Please select at least one option.

Outpatient Mental Health Center Adult (OMHC-A)

Outpatient Mental Health Center Minor (OMHC-M)

PRP/Community Integration Adult (PRP-A)

PRP/Community Integration Minor (PRP-M)

Intensive Outpatient Treatment Level 2.1 Program

Outpatient Treatment Level 1

Partial Hospitalization Program Level 2.5 Program (PHP)

Integrated Behavioral Health Program

DUI Education Program

Early Intervention Level 0.5 Program

Number of Staff: *

Number of Locations: *

Number of Clients: *

Point of Contact for Survey: *

Company Website:

Emails for staff who will be present during the initial consultation.

How do you prefer to be contacted? *

Please select at least one option.

Phone Call

Text

Email

Select a date and time *

Select a date and time

September 2018

Mon

Tue

Wed

Thu

Fri

Sat

Sun

Morning

Afternoon

Evening

No availability, try another day

Harava Group