"Application for Authorization to Provide Alcohol and Drug Education Traffic School (Adets) for Dwi Offenders" - North Carolina

Application for Authorization to Provide Alcohol and Drug Education Traffic School (Adets) for Dwi Offenders is a legal document that was released by the North Carolina Department of Health and Human Services - a government authority operating within North Carolina.

Form Details:

  • Released on March 14, 2011;
  • The latest edition currently provided by the North Carolina Department of Health and Human Services;
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North Carolina Division of Mental Health, Developmental Disabilities and Substance Abuse Services
APPLICATION
for
AUTHORIZATION
to provide
Alcohol and Drug
Education Traffic School
(ADETS)
for
DWI OFFENDERS
Application for ADETS Services
(Revised 03/14/11)
Office of DWI Services
Justice Systems Innovations Team
Community Policy Management Section
NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services
3008 Mail Service Center
Raleigh, NC 27699-3008
919-733-0566
FAX: 919-508-0963
http://www.ncdhhs.gov/mhddsas
Page - 1 - of 5
North Carolina Division of Mental Health, Developmental Disabilities and Substance Abuse Services
APPLICATION
for
AUTHORIZATION
to provide
Alcohol and Drug
Education Traffic School
(ADETS)
for
DWI OFFENDERS
Application for ADETS Services
(Revised 03/14/11)
Office of DWI Services
Justice Systems Innovations Team
Community Policy Management Section
NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services
3008 Mail Service Center
Raleigh, NC 27699-3008
919-733-0566
FAX: 919-508-0963
http://www.ncdhhs.gov/mhddsas
Page - 1 - of 5
North Carolina Division of Mental Health, Developmental Disabilities and Substance Abuse Services
PACKET CHECKLIST
APPLICATION PACKET: Place an “x” in each box as you complete each step toward
submission of your ADETS application.
Copy of NCSAPPB Credential for all ADETS staff
Copy of ADETS Instructor Certificate for all ADETS staff (if applicable)
Facility Affirmations and Stipulations
Letter of Intent
Send the application packet via mail or fax to:
Department of Health and Human Services
Division of MH/DD/SAS
Office of DWI Services
3008 Mail Service Center
Raleigh, NC 27699-3008
Fax: 919-508-0963
Page - 2 - of 5
North Carolina Division of Mental Health, Developmental Disabilities and Substance Abuse Services
ADET School Application
A. General Information
MHL #:
Exp. Date:
(if applicable)
DWI Facility Code:
Facility Name:
Contact Person for
Email:
ADETS:
Phone:
Fax:
B. Service Provision- non-English speaking clients
Do you provide ADETS services for non-English speaking clients?
Yes
No
If yes, per 10A NCAC 27G .3816, please list all direct care staff name(s) and include a copy of their
NCSAPPB credentials (certificate) and ADETS Instructor Training Certificate.
If no, please list the ADET schools where non-English speaking clients will be referred.
B. Staffing
Certified ADETS Instructor(s):
ADETS Instructor
(Name, Credentials):
ADETS Instructor
(Name, Credentials):
X
Signature/Credentials: (ADETS Instructor)
Date:
X
Signature/Credentials: (Clinical Director)
Date:
Remember to include copies of NCSAPPB credentials and ADETS Instructor
Certificate for all ADETS staff.
Page - 3 - of 5
North Carolina Division of Mental Health, Developmental Disabilities and Substance Abuse Services
LETTER OF INTENT TO PROVIDE:
Alcohol and Drug Education Traffic School (ADETS)
Guidelines and Template Letter
As Per General Statute 122C-142.1 (a) before a private facility located in this State provides the substance
abuse services needed by a person to obtain a certificate of completion, the facility shall notify both the
designated area facility for the catchment area in which it is located and the Department of its intent
to provide ADETS and shall agree to comply with the laws and rules concerning these services that apply
to area facilities.
This letter of intent shall be addressed to the Local Management Entity (LME) in your catchment
area.
The letter should include information about your facility, your mental health license number, location,
contact information, administrative director, clinical director, and the specific DWI services that you propose
to offer as indicated in item B. on the application.
Items to be included in your letter of intent are as follows:
1) Purpose
For example: “The purpose of this letter is to inform you of the intent of this facility to provide
substance abuse services to DWI offenders in the specified catchment area listed below.
Information pertaining to this facility is as follows:”
2) Physical address, phone, and fax number of your facility
3) Mental Health License number (if applicable)
4) Population being served
5) Type of service being provided (ADETS)
6) Hours of operation
7) Names of the Administrative and Clinical Directors of the facility
8) Names of ADETS Instructors (if applicable)
9) Signature of Clinical and/or Administrative Director(s)
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North Carolina Division of Mental Health, Developmental Disabilities and Substance Abuse Services
FACILITY AFFIRMATIONS AND STIPULATIONS
ADETS Providers Only
I agree to provide Alcohol and Drug Education Traffic School in accordance with General Statute 122C-
142.1 and Rules for Mental Health, Developmental Disabilities and Substance Abuse Facilities and
Services 10 NCAC 27G .3800 including, but not limited to, the following:
A. Being an authorized provider of substance abuse services to Driving While Impaired offenders;
A. Offering the curriculum established by the Commission and complying with rules adopted by the
Commission;
B. Providing a properly qualified instructor in each class in accordance with statute and rules above;
C. Remitting to the Division ten percent (10%) of each fee paid by a person who attends the ADET
school on an annual basis;
D. Notifying the designated LME (for the catchment area in which ADETS is located) of its intent to
provide ADETS services with a copy of this notification sent to the Division of Mental Health,
Developmental Disabilities and Substance Abuse Services.
X
Signature/Credentials: (Clinical Director)
Date:
Name/Credentials/Title:
X
Signature/Credentials: (Administrative Director)
Date:
Name/Credentials/Title:
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