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Initial Information Request for Recovery Dynamics Certified Facility Contract.
Legal Name of Facility
State and Zip Code
Alternate Phone
Contact Person
Title of Contact
Alternate Contact
Title of Alternate
Web Site Address
# of Male Clients serviced in 2015
# of Female Clients serviced in 2015
# of Male Clients serviced in 2016
# of Female Clients serviced in 2016
Treatment Setting (Check all that Apply)

Treatment Setting Other
# of Clients in each treatment setting offered
Age Range

Average Length of each type of treatment setting in days?
Have you used the RD program in the past
If yes, last date of use
Will RD be exclusive model offered
If no, what other model or method will be used
# of Support Staff
# of Clinical supervisors
# of Counselors that will be involved with RD Model
Total # of Staff
Additional Information
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©2006 Kelly Foundation, Inc.

Kelly Foundation, Inc.
2801 West Roosevelt,
Little Rock, AR 72204
Toll Free (800) 245-6428
(501) 663-6553
Fax: (501) 663-6577
email: kellyadm@kellyfdn.com