       *IDesILaytags   FORMS & RECORDS MGMT.DSHS110161072001
10_161.ITP                                                                                                                                                                                                                                                                                                                                                                                                                                                                              l                                                                                                                                                                           6                                                                                                                   F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      \             6          4   @      	|   	   	   *      0       p   r    B          j                                                                                  &    ,    2    8    >    D    J    P    V    \    b    h    n    t    z                            6        ( P9serdict begin /11x17        6    N         Submit             t b        6         }{statusdict /setpageparams        6    B                        params        V  4     "              @                 $Vn           j    nc#nc#nc#   	            propalis                         propalis  N   propalis  H   propalis  B   D G@
 _ D nT    @                        6    T     v exch scale pop pop xl}bdf/o        6  	|  Z          sfd{ps fg 5 -1 rol       N  	  `  8      <                            @fffffff@                 n C""BgHn/. Hn0<N j   pp0NV n C"" n C""BgHn.1&@
  XX    jj2V      XX       d        '              | [M$        
  o  d       
i P% L          	         @      ,@           @               "        ,Vt`vt`Vt`t`t`nj
t`t`                 propalis                        propalis  N   propalis  H   propalis  B   porpsila  f   porpsila     Data      < E                                                Times New Roman                                                         o  6     "               ll29Cell28Cell30Cell31 setlinejoin setlinecap setli            H        H H    @RG(    H H    @    d       '                     `                                                         6  @          76069503821609045              6            oveto}bdf/rm{it rmovet       &  &         	Signaturel  Version)  	Form Info0!!  Graphics	`      <TiffList0p@ 0  TPageList         ZHeaderB  pl  `	FieldList  )  lLayoutProps)  	Blue Keys\       ConvertDataVers  ~DesPathInfo      xCurrSelection  *Con          \      10161072001  ?6  <%  1
%%%% 8         FORMS & RECORDS MGMT.        DSHS xP    @{:      
10_161.ITP  ~@  ĭ      P n         V       3     Submit               v                 6  B  x   this   _ D nT    @        &   6              iv translate newpath 0       &      ?1                    D   MENTAL HEALTHEVALUATION AND TREATMENTAPPLICATION FOR CERTIFICATION       
              V             V        
 R8                        
   V ,  Arial         ( , MENTAL HEALTH                ( : EVALUATION AND TREATMENT               ( H APPLICATION FOR CERTIFICATION             /$                   `p @                               @     l                     d       A`              
   2.  COUNTY                        ` '       p`0 @                               p     l                     e       q               P   3.  REGIONAL SUPPORT NETWORK (RSN)/COUNTY       DESIGNATED ADMINISTRATOR'S NAME                     o         o            
   V                 
o  ,  Arial          ( +3.  REGIONAL SUPPORT NETWORK (RSN)/COUNTY            ( %      DESIGNATED ADMINISTRATOR'S NAME              0`$ @                               @     l                     f       @A$              (   4.  TELEPHONE NUMBER (INCLUDE AREA CODE)                        `        `p @                                    l                     g       p`                 5.  ADDRESS                        ` -       `pP @                                    l                     h       p@                 CITY                        `        `Pp@                                    l                    i       p``                 STATE                         `        `p$ @    	                                l                     j       p$                 ZIP CODE                        ` !       $      $        $                    O$ @                               P     l                     k       Q$                 7.  FACILITY NAME                        ` @        @!p @                                     l                     p        P `                 8.  ADDRESS                        ` -        @p!P @                                     l                     q        P @                 CITY                        `         @P!p@                                     l                    r        P` `                 STATE                         `         @p!$ @                                     l                     s        P $                 ZIP CODE                        ` !       !#/0 @                               "0     l                     t       !"1                  9.  ADMINISTRATOR'S NAME                        ` a       !0#/$ @                               "P     l                     u       !@"Q$              )   10.  TELEPHONE NUMBER (INCLUDE AREA CODE)                        `        # & 0                   # 0$$ @                               #     l                     v       #0@#$              %   12.  HEALTH SERVICES LICENSING STATUS                        `        # 0& $                   $/$$      $0$$       & )$                   ''                  13.          
          g  9        g   9          
 R8                 
g  9 ,  Arial        
 (z 13.             '(#                  My signature represents Regional Support Network approval of this application. I will notify the department of observations  that this provider may not be in compliance with licensing requirements.          
        g 'F     '  g  F          
 R8                                             
g 'F ,  Arial        
   "" (z 1nMy signature represents Regional Support Network approval of this application. I will notify the department of              ( 1Vobservations  that this provider may not be in compliance with licensing requirements.              )0+?$ @                               *P     l                    y       )@*Q$                 DATE                        `         #                  1.  APPLICATION TYPE                         L      $  @                                     l 
                   z       $                 New           
          
   `        p# @                                     l 
                   {       p#                 Renewal           
          
   ` '       `
0                  6.  CERTIFICATION COMPONENT TYPE                               P @    
                                 l 
                  |       P              &   Emergency Crisis Intervention Services           
          
   `        Pp$                  Complete one application per facility.  Use this application to establish or renew certification for the following components of a county's evaluation and treatment program:           
        NN K  wK    N    K  K   w        
 R8                 
 K  wK ,  Arial         
 ( ] '~Complete one application per facility.  Use this application to establish or renew certification for the following components             ( i '/of a county's evaluation and treatment program:              p`              *   >  Emergency Crisis Intervention Services:           
              
         )      
              0`
$             L   (WAC 388-865-0468):   In order to provide emergency services to a consumer who may need to be detained or who has been detained, the service provider must be licensed for emergency crisis intervention services and be certified by the Mental Health Division to provide involuntary treatment services consistent with WAC 388-865-0484.           
         i  K        i  K           
 K  wK                                             
 i  K ,  Arial         
   * ( { J(WAC 388-865-0468):   In order to provide emergency services to a consumer                                           (  Jwho may need to be detained or who has been detained, the service provider                                          . (  Omust be licensed for emergency crisis intervention services and be certified by                                         8 (  Othe Mental Health Division to provide involuntary treatment services consistent                (  with WAC 388-865-0484.              0p	                 >  Outpatient Certification:           
              
               
              @	@$             N   (WAC 388-865-0466):   In order to provide services on a less restrictive alternative court order, providers must be licensed to provide the psychiatric and medical service component of community support services and be certified by the Mental Health Division to provide involuntary treatment services consistent with WAC 388-865-0484.           
           K          K           
 R8                                             
   K ,  Arial         
    (  a(WAC 388-865-0466):   In order to provide services on a less restrictive alternative court order,                                         (  Vproviders must be licensed to provide the psychiatric and medical service component of                                           (  Tcommunity support services and be certified by the Mental Health Division to provide                 (  @involuntary treatment services consistent with WAC 388-865-0484.              pP              0   > Inpatient Evaluation and Treatment Facilities:           
              
         /      
              0$                (WAC 388-865-0500):  The Mental Health Division certifies facilities to provide involuntary inpatient evaluation and treatment services for more than 24-hours.  Facilities must be certified in order to provide services to consumers who are authorized by regional support network or mental health prepaid health plan to receive psychiatric inpatient evaluation and treatment services on an involuntary basis.           
        FF  =K    F      K  =        
   K                                             
  =K ,  Arial         
   (  G(WAC 388-865-0500):  The Mental Health Division certifies facilities to                                        `  (  Hprovide involuntary inpatient evaluation and treatment services for more                                           ( Lthan 24-hours.  Facilities must be certified in order to provide services to                                         UU ( Bconsumers who are authorized by regional support network or mental                                            (# Jhealth prepaid health plan to receive psychiatric inpatient evaluation and                 (/ +treatment services on an involuntary basis.             @ @                                     l 
                  }       P                 Outpatient Certification           
          
   ` e         @                                     l 
                  ~                     -   Inpatient Evaluation and Treatment Facilities           
          
   `        P @                                     l 
                         P                 Adults           
          
   `        @ @                                     l 
                         P                 Children           
          
   ` (       *p.+02      *p0+00      +.+2$      +0+0$       #@#	0                 11.  LEGAL STATUS (CHECK ONE)                         u      #$p @                                     l 
                          #$p              
   Individual           
          
   ` /       $`%0` @                                     l 
                          $p%0P                 Proprietary Corporation           
          
   ` m       % %` @                                     l 
                          %0%P                 Governmental Agency           
          
   ` i       #$p @                                     l 
                          #$pp                 Partnership           
          
   ` 5       $`%0 @                                     l 
                          $p%0p                 Non-Profit Corporation           
          
   ` i       /0@	              *   DSHS 10-161 (REV. 08/2001) ( A/C 01/2005)                        w      ,0-P              )    
RETURN COMPLETED APPLICATION ORIGINAL TO:      	                Y6      Y    6          
 R8                 
 Y6 ,  Arial          ( c)RETURN COMPLETED APPLICATION ORIGINAL TO:             , /0 0              k    
 DSHS MENTAL HEALTH DIVISIONQUALITY ASSURANCE AND IMPROVEMENT SECTIONPO BOX 45320OLYMPIA WA  98504-5320      	             HH&    H&              
 Y6                 
& ,  Arial          (0             (0DSHS MENTAL HEALTH DIVISION            (0*QUALITY ASSURANCE AND IMPROVEMENT SECTION            (0PO BOX 45320           (0OLYMPIA WA  98504-5320               @                                     l 
                                       /   Evaluation and Treatment Facility Certification           
          
   `                           ((  $        $0&$ @                               %      l                           $@%!$                 DATE LICENSE ISSUED                        ` R       pp0               2   > Evaluation and Treatment Facility Certification:           
              
         1      
              P$             >   (WAC 388-865-0505):  To gain and maintain certification to provide inpatient evaluation and treatment services under Chapter 71.05 and 71.34 RCW, a facility must meet applicable local, state, and federal laws and regulations including Department of Health licensure requirement and WAC 388-865-500 through 388-865-560.           
        / K       /  K          
 R8                                             
/ K ,  Arial         
  8 (AB(WAC 388-865-0505):  To gain and maintain certification to provide                                            (MCinpatient evaluation and treatment services under Chapter 71.05 and                                         E (YI71.34 RCW, a facility must meet applicable local, state, and federal laws                                        m (eDand regulations including Department of Health licensure requirement                 (q(and WAC 388-865-500 through 388-865-560.              )*P              )   14.  RSN/COUNTY ADMINISTRATOR'S SIGNATURE                                                         )   14.  RSN/COUNTY ADMINISTRATOR'S SIGNATURE                      p                INISTRATOR'S SIGNATURE                                          
          - M
     -  
  M        
&                
- M
 ,  Arial       
 (? '            (? -/Evaluation and Treatment Facility Certification           (? :            P$        G     >   *(WAC 388-865-0505):  To gain and maintain certification to provide inpatient evaluation and treatment services under Chapter 71.05 and 71.34 RCW, a facility must meet applicable local, state, and federal laws and regulations including Department of Health licensure requirement and WAC 388-865-500 through 388-865-560.           
        ?      
        / K     /  K          
- M
                                     
/ K ,  Arial       
  8 (AB(WAC 388-865-0505):  To gain and maintain certification to provide                                    (MCinpatient evaluation and treatment services under Chapter 71.05 and                                    (YD71.34 RCW, a facility must meet applicable local, state, and federal                                  I$ (e=laws and regulations including Department of Health licensure                (q4requirement and WAC 388-865-500 through 388-865-560.             )*P       G       )   *14.  RSN/COUNTY ADMINISTRATOR'S SIGNATURE                    *                                     0  	       0  	             0      
   0      
  
 
Ǿ$%Q   
                        ((  $        $0&$ @   Q                            %      l                            $@%!$                  RDATE LICENSE ISSUED                     	                                           
 Ǿ$%Q N       pp                2    Evaluation and Treatment Facility Certification:           
              
         1      
         2      	         3      
         3  	              3      
         3      
          - L
     -  
  L        
&                
- L
 ,  Arial       
 (? '            (? -/Evaluation and Treatment Facility Certification           (? :            @$             >   f(WAC 388-865-0505):  To gain and maintain certification to provide inpatient evaluation and treatment services under Chapter 71.05 and 71.34 RCW, a facility must meet applicable local, state, and federal laws and regulations including Department of Health licensure requirement and WAC 388-865-500 through 388-865-560.           
        >      	        ?  	             ?      
        ?      
        / ~K     /  K  ~        
- L
                                     
/ ~K ,  Arial       
   (AB(WAC 388-865-0505):  To gain and maintain certification to provide                                  @  (MCinpatient evaluation and treatment services under Chapter 71.05 and                                  . (YI71.34 RCW, a facility must meet applicable local, state, and federal laws                                    (eDand regulations including Department of Health licensure requirement                 (q(and WAC 388-865-500 through 388-865-560.             )*@              )   R14.  RSN/COUNTY ADMINISTRATOR'S SIGNATURE                    *      	         *               *                
        .2111 Cfn275.9875 395.6765 m275.9875 393.7696 L275.9875 393.7696 276.0283 393.3515 276.4361 393.0048 C276.8846 392.6173 277.9551 392.5051 277.9551 392.5051 C283.7149 392.5051 L283.7149 392.5051 284.245 392.4439 284.4183 391.8219 C284.5916 391.21 284.5406 390.9959 284.3571 390.639 C284.1838 390.2923 276.2016 369.826 276.2016 369.826 C276.2016 369.826 275.437 368.3474 277.0172 367.7151 C278.2303 367.2358 279.2294 368.9184 279.2294 368.9184 C287.0688 389.6702 L287.0688 389.6702 287.3645 391.3222 287.3441 391.9137 C287.3033 392.5051 287.599 393.688 286.5795 394.5956 C285.5397 395.5134 285.2237 395.5949 284.8669 395.6357 C284.5101 395.6561 276.0283 395.6765 276.0283 395.6765 C275.9875 395.6765 Lfn305.2658 395.6561 m290.7388 395.6561 L290.7388 395.6561 289.4747 395.5236 288.8325 394.6976 C288.18 393.8716 287.8436 392.5153 287.8538 390.9857 C287.8538 390.7104 287.8538 368.9184 287.8538 368.9184 C287.8538 368.9184 287.8946 367.5826 289.4238 367.5826 C290.9529 367.5826 291.0345 368.9898 291.0345 368.9898 C291.0345 391.8525 L291.0345 391.8525 291.0549 392.2298 291.2384 392.4133 C291.4117 392.5867 291.5238 392.6479 291.7685 392.6989 C304.1037 392.6989 L304.1037 392.6989 305.2658 392.9538 305.2658 394.0551 C305.2658 395.1361 305.2658 395.6459 305.2658 395.6459 C305.2658 395.6561 Lfn248.2078 387.386 m248.2078 389.0278 L248.2078 389.0278 248.3458 389.4059 248.5442 389.5377 C248.84 389.7341 249.3904 389.8742 249.3904 389.8742 C254.9667 389.864 L254.9667 389.864 255.405 389.7926 255.3235 390.1189 C255.2419 390.4554 251.7962 391.6995 251.7962 395.5134 C251.7962 399.3068 254.7118 401.2851 257.5357 401.2341 C257.5357 401.2341 262.8674 401.0302 263.0712 395.9825 C263.2445 391.4956 259.5032 390.4962 259.5847 389.9965 C259.6357 389.6906 259.6153 389.762 260.0129 389.762 C260.1862 389.762 265.5179 389.762 265.5179 389.762 C265.5179 389.762 266.5883 389.762 266.8432 389.3337 C267.0165 389.038 267.1796 388.3752 267.0878 387.335 C260.1353 387.335 L260.1353 387.335 259.3707 387.284 258.6571 387.9876 C257.9536 388.6913 257.7192 389.1094 257.7192 389.7008 C257.7192 390.2923 257.5357 391.2304 258.6571 392.0564 C259.7784 392.8824 260.9814 393.7696 260.8998 395.4828 C260.8387 396.9512 259.7071 398.8887 257.4643 398.8887 C255.2216 398.8887 253.9982 396.9104 253.9982 395.7275 C253.988 393.841 254.406 393.0762 256.3633 392.0564 C256.3633 392.0564 257.3012 391.3528 257.1891 389.762 C257.1891 389.762 257.1279 388.936 256.5366 388.4567 C255.9454 387.9876 255.1808 387.3962 254.2939 387.3962 C253.407 387.3962 248.5238 387.3962 248.5238 387.3962 C248.2078 387.386 Lfn248.2282 386.7843 m254.8036 386.7843 L254.8036 386.7843 255.772 386.6314 256.2818 385.9278 C256.7711 385.2139 256.9852 385.1528 256.9852 384.4797 C256.9852 383.7965 257.0463 382.2669 256.5672 381.0636 C256.0983 379.8501 251.47 368.7043 251.47 368.7043 C251.47 368.7043 250.5831 367.0829 249.319 367.5826 C248.0447 368.0924 248.4933 369.877 248.4933 369.877 C254.5079 383.4498 L254.5079 383.4498 254.6201 383.7251 254.5283 384.0106 C254.406 384.3879 253.8453 384.4797 253.8453 384.4797 C249.5433 384.4797 L249.5433 384.4797 248.6462 384.5409 248.4219 385.0202 C248.2894 385.3057 248.167 385.683 248.167 385.8972 C248.167 386.1011 248.167 386.7742 248.167 386.7742 C248.2282 386.7843 Lfn267.0267 386.8659 m259.9008 386.8659 L259.9008 386.8659 257.6172 386.1011 257.5357 384.133 C257.4541 382.1445 257.7702 381.4409 257.7702 381.4409 C263.8766 368.7043 L263.8766 368.7043 264.7227 367.2256 266.0582 368.0516 C267.0674 368.6737 266.7922 369.7648 266.7922 369.7648 C260.3085 382.9195 L260.3085 382.9195 259.9518 383.4804 260.227 383.98 C260.4819 384.4797 260.7265 384.5409 261.1139 384.5103 C261.4911 384.4797 265.9664 384.5103 265.9664 384.5103 C265.9664 384.5103 266.4762 384.5409 266.7718 384.857 C267.0674 385.1935 267.1286 385.9176 267.1184 386.3255 C267.1184 386.6212 267.1184 386.8659 267.1184 386.8659 C267.0267 386.8659 Lfnvmrs%%IncludeFont: Palatino-ItalicMacVec 256 array copy/f1 /|______Palatino-Italic dup RF findfont def{f1 [7.662811 0 0 7.666779 0 0] makesetfont306.406494 392.820801 m0 0 32 0 0 (W) ts313.487473 392.820801 m0 0 32 0 0 (ashington State) ts} [0 0 0 1]stsvmrs%%IncludeFont: Palatino-RomanMacVec 256 array copy/f2 /|______Palatino-Roman dup RF findfont def{f2 [7.662811 0 0 7.666779 0 0] makesetfont296.136459 384.56398 m0 0 32 0 0 ( ) ts298.12886 384.56398 m0 0 32 0 0 (DEP) ts312.663132 384.56398 m0 0 32 0 0 (AR) ts323.459549 384.56398 m0 0 32 0 0 (TMENT ) ts354.595322 384.56398 m0 0 32 0 0 (OF) ts295.317047 378.076706 m0 0 32 0 0 (SOCIAL) ts323.734558 378.076706 m0 0 32 0 0 (    HEAL) ts352.526215 378.076706 m0 0 32 0 0 (TH) ts311.704346 371.589432 m0 0 32 0 0 (SER) ts325.104919 371.589432 m0 0 32 0 0 (VICES) ts} [0 0 0 1]stsq[0.101944 0 0 0.101974 244.007721 353.255142] concatvmsu832.6 288.7 m832.6 288.7 834.2 290.9 834 293.2 C833.7 295.5 832.2 300.4 826.3 300 C820.4 299.8 809.5 297 809.5 285.3 C809.8 273.8 812.3 276.3 812.3 276.3 C812.3 276.3 798.7 273.6 798.7 259.3 C798.7 245.3 812 243.1 816.6 243.1 C825.2 242.9 844.1 251.9 844.1 264.5 C844.1 264.5 844.1 267.9 843.2 269.5 C843.2 269.5 853.9 272.2 853.2 279.2 C853.2 279.2 853.2 282.6 852.3 283.7 C852.3 283.7 852.5 280.3 848.7 278.1 C844.8 275.8 823.8 273.1 823.1 267 C823.1 267 822.9 263.9 824.2 261.1 C824.2 261.1 825.2 266.3 831.9 266.3 C838.7 266.3 837.4 263.6 837.6 262 C837.6 260.5 836.9 249.9 820 249.9 C820 249.9 805.5 249.2 805.5 261.1 C805.5 273.1 821.8 274.2 823.3 274.5 C824.7 274.7 825.2 276 824.9 276.9 C824.7 278.1 824.2 279.2 823.3 279.2 C822.4 279.4 814.5 279 814.5 286 C814.5 293.2 822 294.8 824.2 294.8 C826.7 294.8 830.1 293.9 830.8 288.9 C830.8 288.9 830.8 286.9 831.5 287.1 C832.4 287.1 832.6 288.7 832.6 288.7 C[0 0 0 1] kafnUvmrQUUvmr%%Trailerend  % FreeHandDictend  % FHIODict   `   d                          `  d    ]                `   d    ]                    @    d                   ( ]   D   MENTAL HEALTHEVALUATION AND TREATMENTAPPLICATION FOR CERTIFICATION       
            p/@#    d    ]           Red            p@P    d                  Cell1]p h  d              d               d  j   d d     l                          d                          @    d    T               (   (   
   2.  COUNTY                           P@    d                  Cell2    ]  d              d               d   j   d d     l                          e                         `1    d    T               (   (   P   3.  REGIONAL SUPPORT NETWORK (RSN)/COUNTY       DESIGNATED ADMINISTRATOR'S NAME                           @#    d                  Cell3    ]  d              d               d  j   d d     l                          f                         #    d    T               (   (      4.  TELEPHONE NUMBER                          0     d                   (  ]      (            )       	    
        @ pP                     Cell4    ]                             d   j   d d     l                          g                         P @    d    T               (   (      5.  ADDRESS                          @P0                     Cell5    ]                             d   j   d d     l                          h                         P`     d    T               (   (      CITY                          @0P                     Cell6    ]                             d   j   d d     l                          i                         P@@    d    T               (   (      STATE                           @P#                     Cell7    ]                             d   j   d d     l                          j                         P`#    d    T               (   (      ZIP CODE                          ~ p#    d    
           Red p#     #    d    ]           Red          @ p#    d                  Cell8    ]  d              d               d   j   d d     l                          k                         P #    d    T               (   (      7.  FACILITY NAME                           pP                     Cell9    ] 	                            d@  j   d d     l                          p                          Q@    d    T               (   (      8.  ADDRESS                          P0                     Cell10   ] 
                            d@  j   d d     l                          q                         `Q     d    T               (   (      CITY                          0P                     Cell11   ]                             d@  j   d d     l                          r                         @Q@    d    T               (   (      STATE                           P#                     Cell12   ]                             d@  j   d d     l                          s                         `Q#    d                   (   (      ZIP CODE                           p!     d                  Cell13   ]  d              d               d  j   d d     l                          t                               d    T               (   (      9.  ADMINISTRATOR'S NAME                          ! #    d                  Cell14   ]  d              d               d  j   d d     l                          u                          #    d    T               (   (      10.  TELEPHONE NUMBER                          @      d                   (  ]      (            )       	    
        !  p%    d    ]           Red          ! #@#                     Cell15   ]                             d!  j   d d     l                          v                         ! !#    d    T               (   (   %   12.  HEALTH SERVICES LICENSING STATUS                          ! %#    d    ]           Red          #>#B#    d    
           Red#@#@#     % p)@#    d    ]           Red          &P '    d    
               (  ]       13.                  &P("    d    \               (  ]      I am hereby submitting this certification application to the Department of Social and Health Services (DSHS) per the requirements of WAC 275-55-293(1)(a).  The component(s) requiring certifications prepared to meet all of the applicable certification requirements.                  )@ p+                     Cell17   ]                             d*   j   d d     l                          x                         )P *     d    T               (   (   )   14.  RSN/COUNTY ADMINISTRATOR'S SIGNATURE                          )@+#                     Cell18   ]                             d*   j   d d     l                          y                         )P *#    d    T               (   (      DATE                          0"    d                   (  ]      1.  APPLICATION TYPE                   `0#    d                    Cell19]p h               d                 d  j   d     l                         z                         p@#    d    T               (   (      New                         #    d                    Cell20   ]               d                 d  j   d     l                         {                         0 #    d    T               (   (      Renewal                         0
@    d    \               (  ]       6.  CERTIFICATION COMPONENT TYPE                   `0    d                    Cell21   ]               d                 d  j   d     l                         |                         p@    d    T               (   (   	   Emergency                        @P"    d                   (  ]      Complete one application per facility.  Use this application to establish or renew certification for the following components of a county's evaluation and treatment program:           	        @ 	P    d    (               (  ]      R  Emergency component:       	    
               	              	               	        `	
 "0    d    (               (  ]  E   WAC 275-55-281(1) defines this component as a hospital emergency room or equivalent setting where immediate therapeutic intervention occurs.  The term "emergency" refers to a set of circumstances (physiological, psychological, and/or social) posing an imminent threat to the safety and/or well being of the patient or others.           	        
p	    d    (               (  ]      R  Outpatient component:       	    
               	              	               	        
	@"0    d    \               (  ]     WAC 275-55-271(1) defines this component as a setting where an array of treatment services is provided on a regular basis to patients not in residence in the component.  These services are intended to stabilize, sustain, and facilitate recovery of the individual within his or her environment, and may include such services as day treatment or services provided directly by a licensed physician, or by an agency certified as a component of the program.           	        p    d    (               (  ]   "   R  Short-term inpatient component:       	    
               	              	         !      	         "0    d    (               (  ]      WAC 275-55-291(1) defines this component as a hospital or residential setting where an array of treatment services is provided on a 24-hour per day basis for patients on 72-hour detentions or 14-day commitments.           	             d                    Cell22   ]               d                 d  j   d     l                         }                         0     d    T               (   (   
   Outpatient                        	    d                    Cell23   ]               d                 d  j   d     l                         ~                         	    d    T               (   (      Short-term inpatient                        `0    d                    Cell24   ]               d                 d  j   d     l                                                  p@    d    T               (   (      Adults                             d                    Cell25   ]               d                 d  j   d     l                                                  0     d    T               (   (      Children                        #p@#     d                   (  ]      DATE LICENSE ISSUED                   *+    d    
           Red*+    +~ p+#    d    
           Red+ p+#     !0 !	    d    p               (  ]      11.  LEGAL STATUS (CHECK ONE)                   "P#     d                    Cell16   ]               d                 d  j   d     l                                                  "`#0    d    T               (   (   
   Individual                        ##@    d                    Cell26   ]               d                 d  j   d     l                                                  # #0    d    T               (   (      Proprietary Corporation                        #$@    d                    Cell27   ]               d                 d  j   d     l                                                  #$0    d    T               (   (      Governmental Agency                        "P# `    d                    Cell29   ]               d                 d  j   d     l                                                  "`#0P    d    T               (   (      Partnership                        ##`    d                    Cell28   ]               d                 d  j   d     l                                                  # #P    d    T               (   (      Non-Profit Corporation                        /` `/    d                   (  ]   A   DSHS 10-161 (REV. 07/96)  PROPOSED REVISION - DO NOT PRINT MILLIE                  ,0,    d    (               (  ]   )    
RETURN COMPLETED APPLICATION ORIGINAL TO:                   +.    d    \               (  ]   h    
 DSHS MENTAL HEALTH DIVISIONEVALUATION AND TREATMENT CERTIFICATIONPO BOX 45320OLYMPIA WA  98504-5320                                                                                                               ~                                                                                                                                                                                                                                                          ~                                                                                                                                                                                                                                                          ~                                                                                                                             |                                                                  {                                                                                                                                           ~                                                                                                                                                                                          ~                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   V    f   3     Submit                                  *         XX     jdV       XX        d        '  L         ʼ 9 M      
  o  d             `                         R      -   
@      (@           @                    (VnjvnjVnjnjnjnj
nj   
             propalis                         propalis  N   propalis  H   propalis  B   porpsila  f   porpsila     Data                                                      v  %         0  l  K       t     u               d         B |        = p    L q    \ k    ? r    i s    w     ~          v     z        / }        #     {     e     g     h    # i    + f     j    4 y      MCountyRSNRSNtelephone
RSNaddressRSNcityRSNstate
RSNzipcodeFacilitynameFacilityaddressFacilitycityFacilitystateFacilityzipcodeAdministratornameAdministratortelephoneLicensingstatusSignatureDateNewRenewalECISOCIETFAdultsChildren
IndividualProprietorycorpGovernmentagencyPartnershipNonprofitcorpETFC
Dateissues     6    
               
            0  Z                @@@@   %                             n      n                                  @@                  >X                          
               
         ;          j       L               Q    ~                                        p  $                              
P  
      
         4       
                     H   H           O                   
                     H   H           O                \                    
                     H   H           O                \                    
                     H   H           O                \                    
                     H   H           O                                                                     
                     H   H           O               .                                                                             
                     H   H           O               1                                                                              
                     H   H           O               4                                                                             
                     H   H           O               R                                                                                            
                     H   H           O                                                                                                                        
                     H   H           O                                                                                                                          
                     H   H           O                                                                                                                                
                     H   H           O               X                                                                                               
                     H   H           O               L                                                                                      
                     H   H           O               L                                                                                         
                     H   H           O               I                                                                                          
                     H   H           O               L                                                                                      
                     H   H           O               I                                                                                    
                     H   H           O               F                                                                                   
                     H   H           O               F                                                                                      
                     H   H           O               =                                                                                    
                     H   H           O               @                                                                                   
                     H   H           O               .                                                                             
                     H   H           O               "                                                                          
                     H   H           O               F                                                                                   
                     H   H           O               U                                                                                             
                     H   H           O                                                                                                                                 
                     H   H           O                                                                                                                                 
                     H   H           O                                                                                                                                       
                     H   H           O                                                                                                                        
                     H   H           O               @                                                                                
                     H   H           O               C                                                                                    
                     H   H           O               R                                                                                         
                     H   H           O                                                                                  
                     H   H           O                                                                   
                     H   H           O                                                               
                     H   H           O                                                               
                     H   H           O                                                            
                     H   H           O                                                               
                     H   H           O                                                            
                     H   H           O                                                         
                     H   H           O                x                             
                     H   H           O                x                             
                     H   H           O                x                             
                     H   H           O                x                                
                     H   H           O                u                                 
                     H   H           O                \                    
                     H   H           O                \                    
                     H   H           O                b                       
                     H   H           O                b                       
                     H   H           O                b                       
                     H   H           O                b                       
                     H   H           O                b                       
                     H   H           O                b                       
                     H   H           O                b                       
                     H   H           O                b                       
                     H   H           O                b                       
                     H   H           O                b                       
                     H   H           O                b                       
                     H   H           O                b                       
                     H   H           O                b                       
                     H   H           O                h                          
                     H   H           O               ^                                                                                          
                     H   H           O               a                                                                                           
                     H   H           O               a                                                                                             
                     H   H           O                                                                                                                       
                     H   H           O                                                                                                                                                  
                     H   H           O                                                                                                                                
                     H   H           O                                                                                                                                      
                     H   H           O                                                                                                                                    
                     H   H           O                                                                                                                       
                     H   H           O                                                                                                                       
                     H   H           O                                                                                                                       
                     H   H           O                                                                                                                 
                     H   H           O                                                                                                                  
                     H   H           O                                                                                                                  
                     H   H           O                                                                                                                        
                     H   H           O               j                                                                                             
                     H   H           O               j                                                                                             
                     H   H           O               j                                                                                             
                     H   H           O               j                                                                                             
                     H   H           O               ^                                                                                         
                     H   H           O               v                                                                                               
                     H   H           O                                                                                                                                 
                     H   H           O                                                                                                                                             
                     H   H           O                                                                                                                                             
                     H   H           O                                                                                                                        
                     H   H           O               p                                                                                                  
                     H   H           O               j                                                                                            
                     H   H           O               d                                                                                         
                     H   H           O               m                                                                                                
                     H   H           O                                                                                        
                     H   H           O                                                         
                     H   H           O                                                         
                     H   H           O                                                         
                     H   H           O                                                   
                     H   H           O                                                                   
                     H   H           O                                                                      
 ~                    H   H           O          ~                                                
 }   ~                 H   H           O          }   ~   z                             
 |   }                 H   H           O          |   }   z                             
 {   |                 H   H           O          {   |   z                             
 z   {                 H   H           O          z   {   z                                
 y   z                 H   H           O          y   z   k                           
 x   y                 H   H           O          x   y   \                    
 w   x                 H   H           O          w   x   \                    
 v   w                 H   H           O          v   w   \                    
 u   v                 H   H           O          u   v   \                    
 t   u                 H   H           O          t   u   \                    
 s   t                 H   H           O          s   t   \                    
 r   s                 H   H           O          r   s   \                    
 q   r                 H   H           O          q   r   \                    
 p   q                 H   H           O          p   q   \                    
 o   p                 H   H           O          o   p   \                    
 n   o                 H   H           O          n   o   \                    
 m   n                 H   H           O          m   n   \                    
 l   m                 H   H           O          l   m   \                    
 k   l                 H   H           O          k   l   \                    
 j   k                 H   H           O          j   k   \                    
 i   j                 H   H           O          i   j   b                       
 h   i                 H   H           O          h   i   b                       
 g   h                 H   H           O          g   h   q                              
 f   g                 H   H           O          f   g   q                              
 e   f                 H   H           O          e   f   q                              
 d   e                 H   H           O          d   e   e                           
 c   d                 H   H           O          c   d                                                
 b   c                 H   H           O          b   c  X                                                                                                  
 a   b                 H   H           O          a   b                                                                                                                 
 `   a                 H   H           O          `   a                                                                                                                                              
 _   `                 H   H           O          _   `                                                                                                                                                    
 ^   _                 H   H           O          ^   _                                                                                                                                                    
 ]   ^                 H   H           O          ]   ^                                                                                                                                                 
 \   ]                 H   H           O          \   ]                                                                                                                                               
 [   \                 H   H           O          [   \                                                                                                                                         
 Z   [                 H   H           O          Z   [                                                                                                                             
 Y   Z                 H   H           O          Y   Z  d                                                                                                                  
 X   Y                 H   H           O          X   Y  _                                                                                                               
 W   X                 H   H           O          W   X  e                                                                                                                     
 V   W                 H   H           O          V   W  \                                                                                                        
 U   V                 H   H           O          U   V  \                                                                                                        
 T   U                 H   H           O          T   U                                                                                                                               
 S   T                 H   H           O          S   T  w                                                                                                               
 R   S                 H   H           O          R   S                                                                          
 Q   R                 H   H           O          Q   R  7                                                                                        
 P   Q                 H   H           O          P   Q                                                                          
 O   P                 H   H           O          O   P                                                         
 N   O                 H   H           O          N   O                                                            
 M   N                 H   H           O          M   N                                                            
 L   M                 H   H           O          L   M                                                           
 K   L                 H   H           O          K   L                                                      
 J   K                 H   H           O          J   K   t                             
 I   J                 H   H           O          I   J   n                          
 H   I                 H   H           O          H   I   8           
 G   H                 H   H           O          G   H   8           
 F   G                 H   H           O          F   G   8           
 E   F                 H   H           O          E   F   8           
 D   E                 H   H           O          D   E   8           
 C   D                 H   H           O          C   D   2        
 B   C                 H   H           O          B   C   2        
 A   B                 H   H           O          A   B   2        
 @   A                 H   H           O          @   A   2        
 ?   @                 H   H           O          ?   @   8           
 >   ?                 H   H           O          >   ?   8           
 =   >                 H   H           O          =   >   8           
 <   =                 H   H           O          <   =   8           
 ;   <                 H   H           O          ;   <   8           
 :   ;                 H   H           O          :   ;   8           
 9   :                 H   H           O          9   :   8           
 8   9                 H   H           O          8   9   8           
 7   8                 H   H           O          7   8   8           
 6   7                 H   H           O          6   7   8           
 5   6                 H   H           O          5   6   8           
 4   5                 H   H           O          4   5   8           
 3   4                 H   H           O          3   4   8           
 2   3                 H   H           O          2   3   8           
 1   2                 H   H           O          1   2   H              
 0   1                 H   H           O          0   1   H              
 /   0                 H   H           O          /   0   H              
 .   /                 H   H           O          .   /   H              
 -   .                 H   H           O          -   .   H              
 ,   -                 H   H           O          ,   -   H              
 +   ,                 H   H           O          +   ,   H              
 *   +                 H   H           O          *   +   H              
 )   *                 H   H           O          )   *   H              
 (   )                 H   H           O          (   )   H              
 '   (                 H   H           O          '   (   H              
 &   '                 H   H           O          &   '   H              
 %   &                 H   H           O          %   &   H              
 $   %                 H   H           O          $   %   H              
 #   $                 H   H           O          #   $   H              
 "   #                 H   H           O          "   #   H              
 !   "                 H   H           O          !   "   H              
     !                 H   H           O              !   H              
                      H   H           O                 H              
                     H   H           O                H              
                     H   H           O                H              
                     H   H           O                <           
                     H   H           O                <           
                     H   H           O                <           
                     H   H           O                <           
                     H   H           O                <           
                     H   H           O                <           
                     H   H           O                <           
                     H   H           O                <           
                     H   H           O                <           
                     H   H           O                <           
                     H   H           O                <           
                     H   H           O                2        
                     H   H           O                2        
                     H   H           O                2        
                     H   H           O                2        
                     H   H           O                2        
                     H   H           O                2        
                     H   H           O                &     
 
                    H   H           O          
      &     
 	   
                 H   H           O          	   
   &     
    	                 H   H           O             	   &     
                     H   H           O                &     
                     H   H           O                &     
                     H   H           O                &     
                     H   H           O                &     
                     H   H           O                &     
                     H   H           O                &     
                     H   H           O                &     
                      H   H           O                                   @      ,@           @               "        ,V G"v G"V G" G" G" G" G"                 propalis                        propalis  N   propalis  H   propalis  B   porpsila  f   porpsila     Data                                       ~    }    |    {    z    y    v    u    t    s    r    q    p    k    j    i    h    g    f    e    d                     < E            Arial                                                           Times New Roman                                                                   [ ^%?hWE)FWE_%FWEsF?WE   WEl8F?WE   WEȓXF ?WE   Z  )YT )FWEIYFtW                WEP;?GtWWE   WEV       @@@@   %                              _      l                                @@                  >X                          
               
         ?            @@                                                                              @@                  >X                          
               
         ?                @@@@   %                             n      n                                  @@                  >X                          
               
         ?Ȥ                 L                           @      ,@           @               "        ,VvV                 propalis                        propalis  N   propalis  H   propalis  B   porpsila  f   porpsila     Data      < E            Arial                                                           Times New Roman                                                                  F  <  N  E        
  /  /               (    )      -           (###) ###-####   (000) 000-0000               ;      -           #####;#####-####             @@                  X           	          	 G."   
       @@                        @@                     @@              @@                       @    @@            `        `      `    `  D       eI D               T X  P fI        D      rYI            $      2uI fI  :uI tI    F .G"xI    D  tD    .G" $     ٩D D      ( .G".G"                 rD    D  _Q    D 2b       @@@@                                 _      l                                @@                 X                      D             @@                                                                             @@                 X                      D                 @@@@                                n      n                                  @@                 X                      D                  L                            L                                                                                                                                                                                                                                                                                                                                                                                                                                                         