"Application for Approved Program Status With the Kentucky Department of Corrections for Facilitators of Adult Institutions" - Kentucky

Application for Approved Program Status With the Kentucky Department of Corrections for Facilitators of Adult Institutions is a legal document that was released by the Kentucky Department of Corrections - a government authority operating within Kentucky.

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  • Released on May 1, 2021;
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Rev. 5-2021
Application for Approved Program Status with
The Kentucky Department of Corrections
For Facilitators of Adult Institutions
TYPE OF CLASS TO BE OFFERED
I.
(Check all that apply.)
Portal New Direction (PND)
Moral Reconation Therapy (MRT)
MRT Mentor
MRT Thinking for Good
MRT Anger Management
MRT Staying Quit
MRT Untangling Relationships
MRT Parenting and Family Values
TYPE OF AGENCY
II.
o
Government Agency
o
Non-Profit Agency
o
Private Organization
o
Corporate Agency
IDENTIFICATION
III.
Facilitator Name:
Name of Facility or Group Affiliation:
Physical Location for Class:
(Street)
(City)
(County)
(State)
(Zip Code)
Mailing Address:
(If different from above)
(Street)
(City)
(County)
(State)
(Zip Code)
Telephone Number:
Email Address:
(Primary contact for correspondence)
Name of Supervisor:
IV.
PRIMARY FACILITY/GROUP CONTACT
(if different from section III)
Name:
Address:
(Street)
(City)
(County)
(State)
(Zip Code)
NOTE: Provide the following supporting documentation as an attachment to this application:
The name, mailing address, email address, and phone number of each person or legal entity having an
ownership interest in the facility.
If owned by a corporation, the name, mailing address, email address, and phone number of each officer or
director of the corporation.
If owned by a partnership, the name, mailing address, email address, and phone number of each partner.
V.
PROGRAM EXTENTION SITES
(If more than one extension site, please attach the following information to the
application.)
a.
Number of existing location sites, excluding primary location: _________________________________
pg. 1
Rev. 5-2021
Application for Approved Program Status with
The Kentucky Department of Corrections
For Facilitators of Adult Institutions
TYPE OF CLASS TO BE OFFERED
I.
(Check all that apply.)
Portal New Direction (PND)
Moral Reconation Therapy (MRT)
MRT Mentor
MRT Thinking for Good
MRT Anger Management
MRT Staying Quit
MRT Untangling Relationships
MRT Parenting and Family Values
TYPE OF AGENCY
II.
o
Government Agency
o
Non-Profit Agency
o
Private Organization
o
Corporate Agency
IDENTIFICATION
III.
Facilitator Name:
Name of Facility or Group Affiliation:
Physical Location for Class:
(Street)
(City)
(County)
(State)
(Zip Code)
Mailing Address:
(If different from above)
(Street)
(City)
(County)
(State)
(Zip Code)
Telephone Number:
Email Address:
(Primary contact for correspondence)
Name of Supervisor:
IV.
PRIMARY FACILITY/GROUP CONTACT
(if different from section III)
Name:
Address:
(Street)
(City)
(County)
(State)
(Zip Code)
NOTE: Provide the following supporting documentation as an attachment to this application:
The name, mailing address, email address, and phone number of each person or legal entity having an
ownership interest in the facility.
If owned by a corporation, the name, mailing address, email address, and phone number of each officer or
director of the corporation.
If owned by a partnership, the name, mailing address, email address, and phone number of each partner.
V.
PROGRAM EXTENTION SITES
(If more than one extension site, please attach the following information to the
application.)
a.
Number of existing location sites, excluding primary location: _________________________________
pg. 1
Rev. 5-2021
b.
Location information: (If more than one outpatient extension location exists, provide the following information as an
attachment to this application.)
Name of Extension Site:
Physical Location:
(Street)
(City)
(County)
(State)
(Zip Code)
Telephone Number:
(Include Area Code)
Director/Administrator:
VI.
EVIDENCE BASED CURRICULUM
(Please include information for each evidence-based curriculum used in the program. Attach additional curriculum information to this
application.)
Name of Curriculum: ____________________________________________________________
Who taught staff to facilitate the program: ____________________________________________
When did staff receive training to facilitate the program: _________________________________
Are staff required to receive training or become certified to facilitate?
☐ Yes
☐ No
If yes, how many staff have received the training and/or certified? ____________
VII.
GROUP DYNAMICS
(Check all that apply)
Groups offered:
☐ AM
☐ Afternoon
☐ Evening
Gender Specific Groups:
☐ Yes
☐ No
VII.
ADDITIONAL DOCUMENTATION CHECKLIST
(To be attached.)
Documentation of all program certificates obtained by staff relating to facilitating the program.
o
List of all program staff, including administrative staff not involved in the provision of programming
o
Other Information About Your Agency or Program
o
IX.
SIGNATURE OF AUTHORIZED REPRESENTATIVE
An incomplete application may result in return of the application to the applicant. A completed application should be
submitted to the Kentucky Department of Corrections at the address listed at the bottom of the document.
I understand that any change in the information provided within this application affecting the approval status of this agency or
service will be reported to the Department of Corrections within three (3) business days, Division of Reentry Services and a new
application will be completed or supplemental information will be provided. I certify that the information given in completing this
application is accurate to the best of my knowledge and recognize that falsification of this application may result in denial or
revocation of licensure.
Signature of Authorized Representative
Title
Date
Submit the application and any supportive documentation to:
Kentucky Department of Corrections
Adult Institutions
Debbie Kays, Branch Manager of Programs
275 East Main Street
pg. 2
Rev. 5-2021
Frankfort, KY 40601
debbie.kays@ky.gov
pg. 3
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