Form LIC 9106A. Short-Term Residential Therapeutic Program - California

Form LIC 9106A is used in California for the purpose of applying to establish a Short-Term Residential Therapeutic Program (STRTP). This form plays a crucial role in the licensing process and allows potential providers to seek approval to operate such programs. The main purpose of this form is to gather detailed information from applicants regarding the proposed STRTP, including its structure, staffing, and policies.

The form consists of several sections that require comprehensive information. These sections may include details such as the applicant's personal information, program structure, goals and objectives, staff qualifications and ratios, therapeutic interventions and services provided, admission and discharge procedures, health and safety protocols, and policies related to behavior management and incident reporting.

Important fields on this form include accurately documenting the proposed program's structure, providing detailed information about the qualifications and experience of staff members, outlining the therapeutic approaches and services to be offered, and ensuring compliance with health and safety regulations. It is crucial for applicants to thoroughly fill out all sections of the form and provide supporting documentation to demonstrate their ability to create and maintain a safe and effective Short-Term Residential Therapeutic Program.

Application Example: An organization in California wishes to establish a Short-Term Residential Therapeutic Program for youth with mental health needs. They complete Form LIC 9106A, providing information about the program's structure, staffing plans, therapeutic interventions, and policies. By submitting the completed form, along with supporting documents, the organization seeks approval from the California Department of Social Services to operate the STRTP and provide necessary therapeutic support to vulnerable youth.