Family First in Colorado > Resources > Application > CDHS Provider License — Original Application

CDHS Provider License — Original Application

Last updated: November 14, 2023

Resource Type: Application

This application must be submitted at least 90 days prior to proposed opening date. For additional questions please email: cdhs_dcw-facilitylicenseapps@state.co.us.

1General Information

2Personnel & Attestations

3Attachments & Uploads

Do you currently hold a CDHS provider license? *

Yes
No, I am here to apply for a new license

Are you applying for changes to this license ? *

Yes
No, I am applying for a new license

I am applying for License Type

I am applying for changes to existing License Type

License Type

Existing License Number

Do you want to *

add an additional service type to this license?
move to a new location?
change capacity? (requested capacity listed below)
change age range? (requested age range listed below)

No additional service types are available with this License type, please contact your licensing specialist for further direction.

Child Placement Agency sub-categories

Treatment Foster Care
Therapeutic Foster Care
Foster care and Private Adoption

Check any/all that apply

Residentail Child Care Facility sub-categories

Homeless Youth Services
Psychiatric Residential Treatment*
Qualified Residential Treatment Program*
Shelter Care Services

Select any that apply * if box is checked, no other boxes in this section should be selected

Specialized Group Facility sub-categories

Group Home
Group Center

Choose one

PROVIDER INFORMATION

Name of provider agency/facility/clinic *

For a change of address, use the new address information to fill out the fields below

Location Address *

Address Line 1

Address Line 2

City

State

Zip Code

Is there a mailing address that is different from the location address?

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

General contact email address *

School District *

Website

Phone *

Federal Employer ID number *

Do not use social security number

Non-profit status *

Non-profit (make sure to include 501(c)3 certificate in attachments folder)
Private for-profit

Days open and office hours *

Months of operation, days and hours of operation *

Requested Capacity

Number of Youth *

Gender Identity *

Age Range *

Days and hours open/Dates facility will be closed.

ADMINISTRATIVE INFORMATION

Name of individual that will sign for certified mailed license *

First

Last

Legal name of governing body *

Address of governing body *

Address Line 1

Address Line 2

City

State

Zip Code

Name of current president of the Board of Directors *

First

Last

Phone of current president of the Board of Directors *

Sponsoring Agency

Phone

License #

Signature of Sponsoring Agency

Clear Signature

Print name

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Personnel

Director/Administrator’s Name *

Scheduled work hours *

Director/Administrator’s qualifications *

Placement Supervisor’s Name *

Scheduled work hours *

Placement Supervisor’s qualifications *

BUILDING SITE

If the child care facility is in a public building, please give the building name

Directions to the agency/child care facility *

Building Codes Department Review Completed

Zoning Approval Completed

Date Building Codes Department Review Completed

Date Zoning Approval Completed

Zoning Approval Upload

Drag & Drop Files, Choose Files to Upload

(PDF)

IMPORTANT: It is the responsibility of the applicant to check with local zoning and building code officials to ensure compliance with their regulations. Non-compliance with zoning and building codes could give reason for those authorities to close the facility. Written approval from zoning must be attached to this application. (This does not apply to child placement agencies)

FIRE SAFETY

Submission options (Fire)

Use Fire Safety Certification Form (PDF)
Fire department provided its own report, which will be uploaded as a PDF

Fire Safety Certification Form can be downloaded here. Must be filled out complete before being uploaded

Fire Safety Certification Upload

Drag & Drop Files, Choose Files to Upload

(PDF)

Date Fire Approval Completed

HEALTH/SANITATION CERTIFICATION

Submission options (Health/Sanitation)

Use Health/Sanitation Certification Form (PDF)
Health/Sanitation department provided its own report, which will be uploaded as a PDF

Health/Sanitiation Certification Form can be downloaded here. Must be filled out complete before being uploaded

Health/Sanitation Approval Upload

Drag & Drop Files, Choose Files to Upload

(PDF)

Date Health/Santiation Approval Completed

Attestations

The undersigned hereby applies for a license to operate a child care agency/facility under 26-6-901 et seq, current Colorado Revised Statutes, as amended, and certifies the following:

I have read and am fully familiar with the licensing rules regulating child care facilities issued by the Colorado Department of Human Services, including the General Rules for Child Care Facilities, and I agree to fully comply with them.

I understand that before a license is issued, an investigation must be completed, and I will cooperate with the Department of Human Services in its investigation to determine conformity with the regulations.
I understand that if issued a license, it will designate the number of ages of children for which care may be given. Further, I understand that if I fail to maintain the rules and regulations, the license is subject to suspension or revocation or may be changed to probationary and/or the facility may be subjected to fines.

I hereby give authorization to the Department to obtain reports of child abuse and neglect and to review the State Automated Case Management System for child protection issues pursuant to state law. Applicants must sign for their minor children living in the child care facility.

I understand that the owner, applicant, director of agency, and all employees of the child care facility or agency are required to submit a complete set of fingerprints to the Colorado Bureau of Investigation, and that all costs will be borne by the owner, applicant, director, or employee of the child care facility or agency.
I agree to adhere to the non-discrimination provisions of the Title VI of the Civil Rights Act of 1964, The Age Discrimination Act of 1975, and the Rehabilitation Act of 1973, and Titles I through V of the Americans with Disabilities Act, as amended, and their implementation regulations which prohibit discrimination on the grounds of race, color, national origin, age, or disability.

I understand that upon receipt by the Colorado Department of Human Services, this application becomes a public record.

I understand that the original application fee is non-refundable.

I understand that providing false information to the Colorado Department of Human Services could result in my being fined as much as $250 per day to a maximum of $10,000 pursuant to section 26-6-921, C.R.S., and the license application being denied.

I understand that should I knowingly or willfully make a false statement of any material fact or thing in this application, I am guilty of perjury in the second degree as defined in Section 18-8-503, Colorado Revised Statutes, and, upon conviction, shall be punished accordingly.

I understand that as a licensed Child Placement Agency, I must ensure that all foster parent files are maintained in accordance with all applicable requirements, and that if the foster parent files are not maintained in accordance with all applicable requirements, that the child placement agency license is subject to suspension, revocation, or may be changed to probationary, and/or the agency may be fined.

I understand that as a licensed child care facility, I must ensure that all files are maintained with all applicable requirements, and if the files are not maintained in accordance with all applicable requirements, that the child care facility license is subject to suspension, revocation, or may be changed to probationary, and/or the agency/facility may be fined.

Name *

First

Last

Title *

Signature *

Clear Signature

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In order for your license application to be processed, all of the following documents must be submitted to the Placement Services Unit:
All of the attachments listed below A check or money order for the licensing fee payable to the Colorado Department of Human Services (instructions for submitting payment will be provided after clicking the "submit" button on this page)

Link to attachments Dropbox/GDrive or other folder *

Please make sure all attachments are present in the linked folder and are clearly labeled

1. Governing Body: Name and address of individuals who hold primary finacial control, demonstrate financial support to operate and maintain facility according to 7.701.51 *

Uploaded

2. Statement of purpose, program description and population served *

Uploaded

3. Proposed budget of first year of operations and balance sheet *

Uploaded

4. Policy, procedure and record of admission form *

Uploaded

5. Job descriptions, qualifications, and staff file forms *

Uploaded

6. Personnel policies, orientation and training *

Uploaded

7. Policy and procedure of maintence of confientiality and records *

Uploaded

8. Policy regarding discipline *

Uploaded

Attachment 9: A plan for compliance with the availability of medical staff at all times. *

Uploaded

10. Policy and procedure regarding staff screening and hiring procedures

11. Policy regarding transportation

12. Policy and procedure regarding certifying home

13. Foster parent forms

CPA-AF Attachments 10-13 *

Uploaded

10. Policy and procedure regarding adoption

11. Adoptive parent form and disclosure

12. Birth parent form and disclosure

13. Adoptive youth form

CPAAD Attachments 10-13 *

Uploaded

10. Policy, procedure and forms for Case plan and/or Treatment plan

11. Local building department zoning

12. Local health department inspection

13. Local fire department inspection Insurance

14. Written plan for behavioral management with nationally recognized model

15. Educational serivces and local school district

16. Policy and procedure regarding security, control and supervision

17. Policy and procedure regarding medical and health services

18. Youth's daily routine

19. Policy and procedure regarding staff screening and hiring procedures

20. Building and site plans with dimensions

21. Emergency and disaster procedures

22. Procedure regarding case management and review of case plan and/or treatment plan

23. Policy regarding transportation

24. Policy regarding recreational activities

25. Policy for seclusion

26. Policy regarding religion and religious activities

RCCF Attachments 10-26 *

Uploaded

10. Policy, procedure and forms for Case plan and/or Treatment plan

11. Local building department zoning

12. Local health department inspection

13. Local fire department inspection
Insurance

14. Written plan for behavioral management with nationally recognized model

15. Educational serivces and local school district

16. Policy and procedure regarding security, control and supervision

17. Policy and procedure regarding medical and health services

18.Youth's daily routine

19. Policy and procedure regarding staff screening and hiring procedures

20. Building and site plans with dimensions

21. Emergency and disaster procedures

22. Procedure regarding case management and review of case plan and/or treatment plan

23. Policy regarding transportation

24. Policy regarding recreational activities

25.Policy for seclusion

26. Policy regarding religion and religious activities

27. Copy of Residential Child Care License

28. Copy of Designation of Menal Health Services

29. Copy of Trauma-Informed Treatment Model

30. Copy of accreditation

31. Name and verification of individual administering the Child and Adolescent Needs (CANS)

32. Quality improvement plan

33. Name and verification of qualified medical personnel

34. Name and verification of qualified professional to provide clinical services

35. Policy and procedure of compliance regarding medical staff

36. Policy and procedure regarding engagement of youth's family

37. Policy and procedure regarding the initial assessment and stabilization

Policy and procedure regarding discharge

RCCF w/ QRTP Attachments 10-37 *

Uploaded

10. Policy, procedure and forms for Case plan and/or Treatment plan

11. Local building department zoning

12. Local health department inspection

13. Local fire department inspection

14. List of board members: name, address, length of term and title

15. Written plan for behavioral management with nationally recognized model

16. Educational serivces and local school district

17. Policy regarding transportation

18. Policy regarding recreational activities

DT Attachments 10-18 *

Uploaded

10. Policy, procedure and forms for Case plan and/or Treatment plan

11. Local building department zoning

12. Local health department inspection

13. Local fire department inspection

14. List of board members: name, address, length of term and title

15. Insurance

16. Written plan for behavioral management with nationally recognized model

17. Educational serivces and local school district

18. Policy and procedure regarding security, control and supervision

19. Description of library services

20. Policy and procedure regarding medical and health services

21. Youth's daily routine

22. Policy and procedure regarding staff screening and hiring procedures

23. Building and site plans with dimensions

24. Emergency and disaster procedures

25. Policy regarding transportation

26. Policy regarding recreational activities

27. Policy regarding religion and religious activities

SRTC Attachments 10-27 *

Uploaded

10. Policy, procedure and forms for Case plan and/or Treatment plan

11. Local building department zoning

12. Local health department inspection

13. Local fire department inspection

14. Written plan for behavioral management with nationally recognized model

15. Educational serivces and local school district

16. Policy and procedure regarding security, control and supervision

17. Policy and procedure regarding medical and health services

18. Youth's daily routine

19. Policy and procedure regarding staff screening and hiring procedures

20. Building and site plans with dimensions

21. Emergency and disaster procedures

22. Policy regarding transportation

23. Policy regarding recreational activities

24. List of services provided

25. Sponsorship qualifications

26. List of individuals residing within the facility: name, date of birth and role

27. Statement from certified psychologist, psychiatrist or licensed social worker

28. Policy regarding religion and religious activities

SGF Attachments 10-28 *

Uploaded

10. Policy, procedure and forms for Case plan and/or Treatment plan

11. Local building department zoning

12. Local health department inspection

13. Local fire department inspection

14. Insurance

15. Policy and procedure regarding medical and health services

16. Policy and procedure regarding staff screening and hiring procedures

17. Building and site plans with dimensions

18. Emergency and disaster procedures

19. Policy regarding transportation

20. Policy regarding religion and religious activities

21. Name and verification of qualified medical personnel

HYS Attachments 10-21 *

Uploaded

Attachment 14: Copy of 501(c)3 IRS Certificate

Uploaded

If your application package is incomplete, your application will not be processed.

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