ADHS Licensing Survey This survey is designed to determine licensing needs among our providers. Question Title * 1. Facility Name Question Title * 2. E-mail address Question Title * 3. License Number Question Title * 4. Your name (first and last): Question Title * 5. Position/Title: Question Title * 6. License Expiration Date 01/01/2013-12/12/2015 Date Question Title * 7. Which bureau or office licenses your facility? Office of Assisted Living Licensing Office of Behavioral Health Licensing Bureau of Long Term Care Licensing Bureau of Medical Facilities Licensing Question Title * 8. What type of facility are you CURRENTLY licensed as: Abortion Clinic Adult Day Health Care Adult Foster Care Adult Therapeutic Foster Home Assisted Living Home- Supervisory Assisted Living Home- Personal Care Assisted Living Home- Directed Care Assisted Living Center- Supervisory Assisted Living Center- Personal Care Assisted Living Center- Directed Care DUI Services Hospital - General Hospital - Rural General Hospital - Special Inpatient- Behavioral Health Facility Level 1 Behavioral Health Residential Treatment Center Level 1 Behavioral Health Sub-Acute Agency Level 1 Behavioral Health Specialized Transitional Agency Level 2 Behavioral Health Residential Agency Level 3 Behavioral Health Residential Agency Level 4 Behavioral Health Transitional Agency Nursing Care Institution Opioid Treatment Center Outpatient Surgical Center Outpatient Treatment Center - Medical Outpatient Clinic- Behavioral Health Recovery Care Center Rural Substance Abuse Transitional Agency Shelter for Victims of Domestic Violence Unclassified Next