MOU Application Hudson Partnership CMO Memorandum of Understanding Question Title * 1. Provider/Agency Name: Question Title * 2. Primary Address: Street Address City State Zip Code Question Title * 3. Secondary Address (If Applicable) Street Address City State Zip code Question Title * 4. Billing Address (If Different From Primary Address) Street Address City State Zip code Question Title * 5. Contact Person for MOU: Contact Person Contact Telephone Contact Email: Question Title * 6. Referral Information: State Whether You Are Non-Profit, For Profit, or Sole Proprietor Agency/Provider Name Alternative Names Used By Agency/Provider Federal Tax ID Number Medicaid Number (If Medicaid Provider) Cyber ID (If Applicable) Contact Person Primary Phone Number Additional Phone Number Fax General Agency Email Referral Email (If different from general agency email) Services Are Offered In What Language? Do You Have Staff Working In The Hudson County Area? If So, How Many? Are Services In-Person, Virtual, or Hybrid? Question Title * 7. Does your agency have an existing MOU with the Hudson Partnership CMO?' Yes No Question Title * 8. If you answered yes to question number 7, please submit the MOU changes or updates below. You do not need to complete the rest of the application. If you answered no, please provide a brief description of your agency and the services offered below. Question Title * 9. Is your agency currently working with any Hudson Partnership CMO youth? No If Yes, Who Is The Care Manager For The Youth? Question Title * 10. List 3 references the Hudson Partnership CMO can contact (Include phone number & email address) Question Title * 11. Check Any Services Agency/Provider Offers: Behavioral Assistance Groups (Social Skills, Anger Management, Etc.) Individual Support Services Intensive In-Community Services (IIC) Intensive In-Home Serivces (IIH) Outpatient Services Parent Mentoring/Coaching Recreation Specialized Evaluations (i.e. Comprehensive, Family Dynamics, Fire Setting, Psychological, Sexual Offender, Etc.) Specialized Therapies (i.e. ABA, Art Therapy, CBT, DBT, Trauma-Focused CBT, Etc.) Translation Other (Please Specify) Question Title * 12. If you provide evaluations, please list the types of evaluations you provide: Question Title * 13. If you provide specialized therapy, please list the type you provide: Question Title * 14. List fees of the services being provided. Question Title * 15. Do you offer sliding scale or scholarships? Yes No Question Title * 16. If yes, what are the qualifiers? Question Title * 17. Are Provider/Agency services reimbursable through insurance? Yes No Question Title * 18. If yes, please list insurance plans and the covered services. Question Title * 19. Provide A Staff Directory And Indicate Licensed Providers, Unlicensed Providers, & Providers Pending License PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Provide A Staff Directory And Indicate Licensed Providers, Unlicensed Providers, & Providers Pending License Question Title * 20. Can You Confirm Licensed Providers Have Active NJ Licenses? Yes No If No, Indicate Who: Question Title * 21. If A Provider's License Is Up For Renewal, Have They Already Applied For Renewal? Yes No If No, Indicate Who: Question Title * 22. Provide Additional Material (Brochures, Pamphlets, Posters, Etc.) Relating To Your Agency & Its Services That May Be Useful To Your Application & That We Can Provide To Hudson Partnership CMO Staff & Upload To Our Hudson Service Network Site. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Provide Additional Material (Brochures, Pamphlets, Posters, Etc.) Relating To Your Agency & Its Services That May Be Useful To Your Application & That We Can Provide To Hudson Partnership CMO Staff & Upload To Our Hudson Service Network Site. Question Title * 23. CONTINUED: Provide Additional Material (Brochures, Pamphlets, Posters, Etc.) Relating To Your Agency & Its Services That May Be Useful To Your Application & That We Can Provide To Hudson Partnership CMO Staff & Upload To Our Hudson Service Network Site. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File CONTINUED: Provide Additional Material (Brochures, Pamphlets, Posters, Etc.) Relating To Your Agency & Its Services That May Be Useful To Your Application & That We Can Provide To Hudson Partnership CMO Staff & Upload To Our Hudson Service Network Site. Question Title * 24. CONTINUED: Provide Additional Material (Brochures, Pamphlets, Posters, Etc.) Relating To Your Agency & Its Services That May Be Useful To Your Application & That We Can Provide To Hudson Partnership CMO Staff & Upload To Our Hudson Service Network Site. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File CONTINUED: Provide Additional Material (Brochures, Pamphlets, Posters, Etc.) Relating To Your Agency & Its Services That May Be Useful To Your Application & That We Can Provide To Hudson Partnership CMO Staff & Upload To Our Hudson Service Network Site. Question Title * 25. CONTINUED: Provide Additional Material (Brochures, Pamphlets, Posters, Etc.) Relating To Your Agency & Its Services That May Be Useful To Your Application & That We Can Provide To Hudson Partnership CMO Staff & Upload To Our Hudson Service Network Site. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File CONTINUED: Provide Additional Material (Brochures, Pamphlets, Posters, Etc.) Relating To Your Agency & Its Services That May Be Useful To Your Application & That We Can Provide To Hudson Partnership CMO Staff & Upload To Our Hudson Service Network Site. Page1 / 1 100% of survey complete. Done