DBHDD
| | |
| |Georgia Department of Behavioral Health & Developmental Disabilities |
| |Frank W. Berry, Commissioner |
| |Behavioral Health Licensing Unit |
| |Two Peachtree Street NW, Suite 23.277, Atlanta, GA 30303-3142 Telephone: 404-657-1652 Fax: 770-359-4655 |
CRISIS STABILIZATION UNIT
Bed Count Change/Request for Approval
|CSB Agency Name: | |
|CSU Program Name: | |
Request for Bed Count Change[1]
|Residential Bed |Current Count: | |To: | |
|Transitional Bed |Current Count: | |To: | |
|Reason For Change Request: | |
|Consumer Impact: | |
|Fiscal Impact: | |
|Effective Date: | |
Program Staff Information
|Nursing Administrator: | |
|Medical Director: | |
CEO/Director
|Name: | |
|Title: | |
|Signature: | |
|Date: | |
[pic]
DBHDD Approval:
|DBHDD Regional Coordinator: | |
|Signature: | |
|Date: | |
|Behavioral Health Licensing Unit: | |
|Signature: | |
|Date: | |
CSU mail original to: Regional Coordinator
Regional Coordinator mail signed original to: Send copy to:
DBHDD John Quesenberry
Behavioral Health Licensing Unit DBHDD
2 Peachtree Street NW 2 Peachtree Street NW
Suite 23.392 Suite 25-402
Atlanta, Georgia 30303-3142 Atlanta, Georgia 30303-3142
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[1] All 4 counts required even if no change
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