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Initial Information Request for Recovery Dynamics Certified Facility Contract.

Legal Name of Facility
Address
City
State and Zip Code
Country
Telephone
Fax
Alternate Phone
Contact Person
Title of Contact
Alternate Contact
Title of Alternate
E-mail
Web Site Address
# of Male Clients serviced in 2010
# of Female Clients serviced in 2010
# of Male Clients serviced in 2011
# of Female Clients serviced in 2011
Treatment Setting (Check all that Apply) Inpatient-Hospital
Residential
Outpatient
Correctional
Chemical Free-Living
Other
Treatment Setting Other
# of Clients in each treatment setting offered
Age Range <12
13-17
18-25
26-55
55+
Average Length of each type of treatment setting in days?
Have you used the RD program in the past Yes
No
If yes, last date of use
Will RD be exclusive model offered Yes
No
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