DIVISION OF SUBSTANCE ABUSE AND MENTAL HEALTH 
APPLICATION FOR LICENSURE - INSTRUCTIONS FOR 
ALCOHOLISM AND/OR DRUG ABUSE PROGRAMS 
1. DSAMH Licensure Standards should be carefully reviewed. Programs shall 
comply with all applicable portions of Sections 5 through 14, unless otherwise 
waived. 
2. FOR INITIAL APPLICANTS ONLY: 
After reviewing the DSAMH Standards, each standard should be self-rated 
according to the following scale: 
1. Program is in full compliance with this standard. 
2. Program is not in compliance. Could be in compliance within 180 days. 
(Next to the standard indicate briefly the steps you will take to bring your 
program into full compliance with this standard.) 
3. Program is not in compliance. Would need longer than 180 days to bring 
into full compliance. 
4. Program is applying for a waiver of this standard. 
5. This standard does not apply to this program since it refers to a service not 
provided by the program. 
Be sure to rate all applicable portions of each Standard. 
3. When completing the application, the following points should be noted: 
• PROGRAM NAME: The full official title of the program must be used. • ADDRESS: The full address of the program's headquarters. If the program 
uses more than one facility, provide addresses for all facilities used on a 
supplemental sheet. 
• TELEPHONE: The telephone number of the program's headquarters. If 
the program has more than one facility, provide telephone numbers of all 
facilities on a supplemental sheet. 
• Under II(B) PROGRAM MANAGEMENT, "Race" is asked to ensure 
that as per Standard 5.1.1.: "The governing body or advisory groups shall 
be representative of the community." 
4. ANY QUESTIONS CONCERNING LICENSURE SHOULD BE 
DIRECTED TO THE LICENSING OFFICE @ 255-9441, 255-9442, 
255-9443 or 302/424-2947
STATE OF DELAWARE 
DELAWARE HEALTH AND SOCIAL SERVICES 
DIVISION OF SUBSTANCE ABUSE AND MENTAL HEALTH 
1901 N. DuPont Highway 
New Castle, DE 19720 
APPLICATION FOR LICENSURE 
DATE OF APPLICATION: ____________________ 
Check one: INITIAL APPLICATION RENEWAL APPLICATION 
I. PROGRAM IDENTIFICATION 
A. Name: 
B. Address: 
C. Telephone: Area Code:_____Number: _______________ 
D. Type of Program Licensure for which application is being made. 
Check the appropriate box or boxes 
Detoxification Alcohol Program 
Residential Setting Drug Program 
Outpatient Setting Alcohol & Drug Program 
Prevention Private 
Public Profit 
APPLICATION FOR LICENSURE - Page 2 
Non-profit Emergency Telephone Service 
DUI Outpatient Treatment Setting DUI Education Setting 
Evaluation/Screening Setting Other (specify) 
E. Geographical area(s) served by program: 
F. Days and Hours of Operation: 
G. Funding sources: 
Dollar Amount (in thousands) Source Description 
H. Is the program currently licensed, certified, or accredited by any local, state, 
federal, or private body? 
No Yes: If yes, indicate which type: LICENSURE 
CERTIFICATION ACCREDITATION, from 
what agency: ,and date of expiration: . 
I. Has the program ever had a license denied, suspended, and/or revoked? 
No Yes: If yes, indicate the agency, date, and reason(s) for denial, 
suspension, and/or revocation: 
APPLICATION FOR LICENSURE - PAGE 3 
II. PROGRAM MANGEMENT 
A. Name of Director: 
Address: 
Title: 
B. GOVERNING BOARD OR ADVISORY COUNCIL: On Form A of this 
application indicate the name, address, occupation, relation to staff and race of 
your Governing Board and/or Advisory Council. Attach additional sheets if 
necessary. 
NOTE: If the program has both a Governing Board and an Advisory Council 
complete two lists using Form A, checking off the appropriate box to indicate 
which is the Governing Board and which is the Advisory Council. 
III. PROGRAM PERSONNEL 
Please indicate on Forms B and C the number of program personnel in each 
occupational category. Indicate whether they are full or part-time employees, 
volunteers or consultants. Full - time is defined as working more than 30 hours 
per week. Volunteer services should be expressed in terms of hours per week. 
Consultant's time should be expressed in terms of hours per month. APPLICATION FOR LICENSURE - PAGE 4 
IV. INFORMATION ON CURRENT OF PROJECTED CLIENT 
POPULATION 
A. CLIENT DEMOGRAPHIC INFORMATION 
1. Age: (Check one or more as applicable) 
Children and Youth (17 and under) 
Adults (18 and over) 
2. Sex: (Check on or more as applicable) 
Male Female 
B. CLIENT STATISTICAL INFORMATION 
1. List the average number of clients involved (actual/projected) in 
the program per month by primary substance of abuse at admission 
Actual Projected 
Primary Alcohol 
Primary Drug 
Polysubstance Abuse 
2. Indicate the average length of stay for clients in the program (actual 
or projected) - Give answers in days if under 1 month, otherwise 
give answer in months. 
Actual Projected 
Primary Alcohol 
Primary Drug 
Polysubstance Abuse 
APPLICATION FOR LICENSURE – PAGE 5 
3. Indicate the actual/projected staff to client ratio: 
4. If you have or are projecting a waiting list please indicate the 
number of individuals and the average waiting period preceding 
admission: 
Number of clients on waiting list: 
Actual Projected 
Average waiting period preceding admission: 
Actual Projected APPLICATION FOR LICENSURE – PAGE 6 
V. All of the following information shall be available for review on site at the time 
of the visit. "R" applies to special instructions for programs seeking relicensure 
A. Annual program goals and objectives. (R - Updated goals and objectives shall include 
action steps, time frames, and staff responsible for achieving the action steps.) 
B. Program services to be provided. (R - only if there are any changes.) 
C. Manual of policies and procedures in administrative, financial, personnel and 
program services management. (R - only those policies and procedures which have 
been updated.) 
D. Program organization chart. (R - only if it has changed.) 
E. Samples of any forms used by program and instructions to these forms. (R - only if 
new ones have been added, or if old ones have been revised.) 
F. Sample client chart. (R - only if the format for the file has been changed.) 
G. Copies of any evaluation reports that may exist in reference to the program. (R - any 
done since the last licensure visit.) 
H. Corporate and/or Advisory Board By-Laws. (R - only if they have been revised or 
amended.) 
I. Staff and Board meeting minutes for the six months prior to the submission of this 
application. 
J. Documentation of any current insurance coverage, i.e., fire, program and counselor 
liability, etc. 
K. Most recent audit report to include sources of funding. 
APPLICATION FOR LICENSURE – PAGE 7 
L. Most recent annual Program Director's report to the Board of Directors including 
program and fiscal aspects. 
M. The completed self-rated Licensure Standards which apply to your program. (R - only 
if the program is asking for licensure of a part of the program not in existence at the 
time of the first license, i.e., if an outpatient program adds a prevention component, or 
if a residential program adds an outpatient component, etc.) 
N. Requests for waivers on standards. (R - only if a new area or areas are being 
requested.) 
_______________________________________ ________________________ 
President of Governing Body/Advisory Council Program Director 
____________________ _______________________ 
Date Date
DSAMH LICENSURE APPLICATION - FORM A 
GOVERNING BOARD AND/OR ADVISORY COUNCIL 
GOVERNING BOARD 
ADVISORY COUCIL 
NOTE: Indicate any relationship between a Board member and a Staff member. Attach additional sheets, if necessary. 
NAME ADDRESS OCCUPATION RELATION TO STAFF RACE 
1
2
3
4
5
6
7
8
9
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20
DSAMH LICENSURE APPLICATION - FORM B 
I. Direct Service Staff (bachelor's degree and above) 
Name Title Degree and/or 
Certification 
Yrs. Of Experience 
Related to the 
Position 
Full- 
Time 
Part- 
Time 
Volunteer Consultant 
1. 
2. 
3. 
4. 
5. 
6. 
7. 
8. 
9. 
II. Direct Service Staff (Less than bachelor's degree) 
Name Title Degree and/or 
Certification 
Yrs. Of Experience 
Related to the 
Position 
Full- 
Time 
Part- 
Time 
Volunteer Consultant 
1. 
2. 
3. 
4. 
5. 
6. 
7. 
8. 
9. Name Title Degree and/or 
Certification 
Yrs. Of Experience 
Related to the 
Position 
Full- 
Time 
Part- 
Time 
Volunteer Consultant 
1. 
2. 
3. 
4. 
5. 
6. 
7. 
8. 
9. 
IV. All other Program Staff - (e.g. clerical, maintenance, cooks, etc.) 
Name Title Degree and/or 
Certification 
Yrs. Of Experience 
Related to the 
Position 
Full- 
Time 
Part- 
Time 
Volunteer Consultant 
1. 
2. 
3. 
4. 
5. 
6. 
7. 
8. 
9. 
DSAMH LICENSURE APPLICATION - FORM C 
III. Administrative Staff - (Staff who devoted 75% or more of their time to administrative as opposed to direct treatment service) 
Name Title Degree and/or 
Certification 
Yrs. Of Experience 
Related to the 
Position 
Full- 
Time 
Part- 
Time 
Volunteer Consultant 
1. 
2. 
3. 
4. 
5. 
6. 
7. 
8. 
9. 
IV. All other Program Staff - (e.g. clerical, maintenance, cooks, etc.) 
Name Title Degree and/or 
Certification 
Yrs. Of Experience 
Related to the 
Position 
Full- 
Time 
Part- 
Time 
Volunteer Consultant 
1. 
2. 
3. 
4. 
5. 
6. 
7. 
8.