Providers guide information Question Title * 1. Facility Question Title * 2. Physical Address of Program Question Title * 3. Mailing Address of Program Question Title * 4. Phone Number Question Title * 5. Fax Number Question Title * 6. Referral Contact Information Question Title * 7. Admissions/Contact Information Question Title * 8. Link to website Question Title * 9. Provider type Psychiatric Residential Treatment Facility Group Residential Treatment Emergency Shelter Foster Care Agency Therapeutic Foster Care Community Behavioral Health Acute Hospitalization Other (please specify) Question Title * 10. Level of Care Question Title * 11. Bed Capacity (if coed, please specify gender) Question Title * 12. Gender Served Male Female Both Question Title * 13. Age Range Question Title * 14. Do you accept parental placements? Yes No Question Title * 15. Does your facility have an on-grounds school? Yes No Question Title * 16. Populations served/specialize with (select all that apply): Adjudicated Anxiety Disorders Autism Spectrum Disorder Physically Aggressive Behavior Attention Deficit Hyperactive Disorder Behavioral Problems Conduct Disorder Cruelty to Animals Delinquent Behavior Depression Substance Use Eating Disorders Fire setting Hyperactivity Impulse Control Problems Juvenile Status Offender Intellectual Disability – Borderline Functioning (79-70 IQ) Intellectual Disability – Mild (50-69 IQ) Intellectual Disability – Moderate (36-49 IQ) Intellectual Disability – Severe (20-35 IQ) Mood Swings Oppositional Defiant Behavior Obsessive Compulsive Disorder Post-Traumatic Stress Disorder Runaway Behavior Psychotic Symptoms Attachment/Bonding Difficulties Sexually Inappropriate Behavior Sexually Offending Behavior Suicidal Ideation Suicidal Gesture history Self-Injurious Behavior Transgender Youth LGTBQ Youth Mood Dysregulation Verbally Aggressive/Abusive Enuresis Encopresis Medically fragile/uncontrolled diabetes Pregnant/infant/young child Other (please specify) Question Title * 17. Specialized Treatment/Services Behavior Management Positive Behavioral Support Problematic Sexual Behavior Therapy Play therapy Psychological Testing Art therapy Music therapy Equine therapy Trauma therapy Dialectical Behavioral Therapy Cognitive Behavioral Therapy Parent Child Interaction Therapy Group therapy Family therapy Team Sports Supportive counseling On-site psychiatric services On-site nursing services On-site licensed therapists Other (please specify) Question Title * 18. Additional Comments Submit