Application Instructions

Georgia Department of Behavioral Health and Developmental Disabilities
DUI Intervention Program
Website

Welcome!

Georgia Department of Behavioral Health and Developmental Disabilities CLINICAL EVALUATOR/TREATMENT PROVIDER INFORMATION CHANGE FORM
* = REQUIRED INFORMATION
REMEMBER: Only ONE Request per Facility. You must provide your UserId and FacilityID!
Type of Change:* Change Facility Information (Only need to enter the new information below). Add Listing (All fields on this form are required for this option). Delete Facility Listing (No additional information beyond Required Area needed). Describe Desired Change: Type of Provider:* CE TP: Check if New Provider Date: User ID:* Facility ID (*,but not required if a new provider): Facility Name and Address:


Section I - Registry Listing PRINT OR TYPE exactly as you want to appear on the registry Listing
Facility Contact: First Name: M. Last Name:
Credentials (Limit to three e.g. CACII, LPC, LCSW)
Name of Facility /Practice/ Business {Where services are provided)
Facility Street:
Facility City:
Facility County:
Facility Zip:
Appointment Telephone1: Appointment Telephone2:
(Minimum $75): Fee Range To:
Sliding Scale: NO YES:
Languages:
Comments to appear on Registry: (Limit (to 100 spaces):

Section II - Mailing address and Private Contact Information (for Internal DBH/DD Use only) Will not appear on the Registry.

Mailing Address Street:
Mailing Address City:
Mailing Address Zip:
Additional telephone # where we may reach you
FAX#
Email Address:

Section III The following information is for DBH/DD Use Only and will not appear on the Registry

Does your business share space with any other business? (Do not list other businesses in same shopping center or office complex) YES: NO:
Name of business with whom space is shared :
Type of business with whom space is shared :
Contact Person :
Location where DUI client files will be kept: On Site: NO:
If other location, Name of Facility where records are kept: Other Location Street:
Other Location City:
Other Location County:
Other Location Zip:
Contact Person :
Other Location Telephone:

Georgia Department of Behavioral Health and Developmental Disabilities CLINICAL EVALUATOR/TREATMENT PROVIDER INFORMATION CHANGE FORM