Provider Information
Do you intend to become a licensed/designated facility for Substance Use, Controlled Substance, Mental Health Services, or Recovery Support Services?
--None--
Yes
No
Do you currently have a site where you will provide services or plan to only offer telehealth services?
Do you have written Policies and Procedures or are willing to write them?
--None--
Yes
No
Do you have a current Substance Use Disorder License Number, Controlled Substance License Number, RSSO License Number or Mental Health Designation with the BHA?
--None--
Yes
No