ContractTherapeutic Day Treatment Provider Agreement • July 11th, 2019
Yes No REQUIRED COMPONENTS 1 Copy of Current Triennial License for TDT Services from DBHDS 2 General citation history report from DBHDS:□ No more than three citations without CAP□ No citations in past two years without CAP□ Copy of CAP 3 Certification of no health and safety violation in past year – provide report or statement of certification on letterhead or signed statement of certification oncompany letterhead. 4 List of all staff members and titles with the agency (Updates only if you were an approved provider for 2018-2019 school year.) 5 List of all staff members who will be working in the schools (Updates only if you were an approved provider for 2018-2019 school year.) 6 Names, contact numbers, and qualifications of the individuals serving as supervisorsfor the unlicensed TDT service providers working in a school 7 Certification/evidence of agency employee background check 8 Restraint Training□ Certification□ Name of Technique 9
ContractTherapeutic Day Treatment Provider Agreement • July 14th, 2022
Completed? REQUIRED COMPONENTS 1 Copy of Current Triennial License for TDT Services from DBHDS 2 General citation history report from DBHDS:□ No more than three citations without CAP□ No citations in past two years without CAP□ Copy of CAP 3 Certification of no health and safety violation in past year – provide report or statement of certification on letterhead or signed statement of certification on company letterhead. 4 List of all staff members and titles with the agency (Updates only if you were an approved provider for 2023-2024 school year.) 5 List of all staff members who will be working in the schools (Updates only if you were an approved provider for 2023-2024 school year.) 6 Names, contact numbers, and qualifications of the individuals serving as supervisors for the unlicensed TDT service providers working in a school 7 Certification/evidence of agency employee background check 8 Restraint Training□ Certification□ Name of Technique 9 Signed Contract
MEMORANDUMTherapeutic Day Treatment Provider Agreement • August 1st, 2017
In collaboration with the Virginia Department of Education (VDOE), the Department of Medical Assistance Services (DMAS), and the Virginia Department of Behavioral Health and Developmental Services (DBHDS), Richmond Public Schools (RPS) has created an annual Memorandum of Understanding and contract process for all Therapeutic Day Treatment (TDT) Providers to gain access to schools. Included in this packet is an agreement that needs to be filled out and support documentation must be provided for approval. Information regarding this agreement packet was shared on July 27th’s 2017-2018 TDT meeting.
ContractTherapeutic Day Treatment Provider Agreement • July 14th, 2022
Completed? REQUIRED COMPONENTS 1 Copy of Current Triennial License for TDT Services from DBHDS 2 General citation history report from DBHDS:□ No more than three citations without CAP□ No citations in past two years without CAP□ Copy of CAP 3 Certification of no health and safety violation in past year – provide report or statement of certification on letterhead or signed statement of certification on company letterhead. 4 List of all staff members and titles with the agency (Updates only if you were an approved provider for 2021-2022 school year.) 5 List of all staff members who will be working in the schools (Updates only if you were an approved provider for 2021-2022 school year.) 6 Names, contact numbers, and qualifications of the individuals serving as supervisors for the unlicensed TDT service providers working in a school 7 Certification/evidence of agency employee background check 8 Restraint Training□ Certification□ Name of Technique 9 Signed Contract
ContractTherapeutic Day Treatment Provider Agreement • July 14th, 2022
Completed? REQUIRED COMPONENTS 1 Copy of Current Triennial License for TDT Services from DBHDS 2 General citation history report from DBHDS:□ No more than three citations without CAP□ No citations in past two years without CAP□ Copy of CAP 3 Certification of no health and safety violation in past year – provide report or statement of certification on letterhead or signed statement of certification on company letterhead. 4 List of all staff members and titles with the agency (Updates only if you were an approved provider for 2022-2023 school year.) 5 List of all staff members who will be working in the schools (Updates only if you were an approved provider for 2022-2023 school year.) 6 Names, contact numbers, and qualifications of the individuals serving as supervisors for the unlicensed TDT service providers working in a school 7 Certification/evidence of agency employee background check 8 Restraint Training□ Certification□ Name of Technique 9 Signed Contract
ContractTherapeutic Day Treatment Provider Agreement • July 15th, 2020
Completed? REQUIRED COMPONENTS 1 Copy of Current Triennial License for TDT Services from DBHDS 2 General citation history report from DBHDS:□ No more than three citations without CAP□ No citations in past two years without CAP□ Copy of CAP 3 Certification of no health and safety violation in past year – provide report or statement of certification on letterhead or signed statement of certification on company letterhead. 4 List of all staff members and titles with the agency (Updates only if you were an approved provider for 2019-2020 school year.) 5 List of all staff members who will be working in the schools (Updates only if you were an approved provider for 2019-2020 school year.) 6 Names, contact numbers, and qualifications of the individuals serving as supervisors for the unlicensed TDT service providers working in a school 7 Certification/evidence of agency employee background check 8 Restraint Training□ Certification□ Name of Technique 9 Signed Contract
ContractTherapeutic Day Treatment Provider Agreement • June 22nd, 2021
Completed? REQUIRED COMPONENTS 1 Copy of Current Triennial License for TDT Services from DBHDS 2 General citation history report from DBHDS:□ No more than three citations without CAP□ No citations in past two years without CAP□ Copy of CAP 3 Certification of no health and safety violation in past year – provide report or statement of certification on letterhead or signed statement of certification on company letterhead. 4 List of all staff members and titles with the agency (Updates only if you were an approved provider for 2020-2021 school year.) 5 List of all staff members who will be working in the schools (Updates only if you were an approved provider for 2020-2021 school year.) 6 Names, contact numbers, and qualifications of the individuals serving as supervisors for the unlicensed TDT service providers working in a school 7 Certification/evidence of agency employee background check 8 Restraint Training□ Certification□ Name of Technique 9 Signed Contract
