Response to Request for Information #0518-003

Individual Placement Support-Supported Employment (IPS/SE)

Please complete the following information:

Name of Organization: / Click here to enter text. /
Organization Type: / ☐ Hospital
☐ Private Organization: ☐ not for profit ☐ for profit
☐ Governmental/Public
Facility License Number: / Click here to enter text. /
Accreditation Type and Source: / Click here to enter text. /
Primary Client Population: / ☐ Adults ☐ Adolescents ☐ Children ☐ All ages
Mailing Address: / Street, City and Zip Code Click here to enter text.
Facility Location Address: / Street, City and Zip Code Click here to enter text.
Name of Contact Person: / Click here to enter text. /
Contact Person Phone # & Email: / Click here to enter text. /
Please identify other MCOs and health plans with whom you are authorized to provide services: / Click here to enter text. /
Please indicate in which county(ies), along with Burke and Catawba, you would be interested in providingIPS/SE, if needed in the future: / ☐ Burke ☐ Iredell
☐ Catawba ☐ Lincoln
☐ Cleveland ☐ Surry
☐ Gaston ☐ Yadkin

Please respond to the following questions:

Describe your organization’s experience providing behavioral health services: / Click here to enter text. /
Please indicate the number of years’ experience your organization has providing behavioral health services: / ☐ 0 -1 ☐2-4 ☐ 5
☐ 6-10 ☐ 11+
List any other services (including evidence based practices used) your organization currently provides: / Click here to enter text. /
Indicate where your services are currently located: / Click here to enter text. /
Describe your organization’s capability and capacity for provision of this service based on your current location, organizational structure, staffing and need for supervision: / Click here to enter text. /
If you currently provide IPS/SE please list your most recent fidelity score, review date and location for all teams: / Click here to enter text. /
Please describe how you will establish and increase referrals that meet the TCLI priority population requirements. (Include how you will identify this population; methods used to obtain referrals; and how you will prioritize services for this population) / Click here to enter text. /
Please describe your plan for ensuring availability of qualified and trained staff to provide IPS/SE: / Click here to enter text. /
Describe your plan for managing crisis with recipients of IPS/SE: / Click here to enter text. /
Please describe your plan, including timelines, to become a DVR vendor as well as establish and maintain a collaborative relationship with Vocational Rehabilitation counselors: / Click here to enter text. /
Please describe your plan, including timeline, to co-locate IPS/SE services with behavioral health services: / Click here to enter text. /
Describe how you would engage individuals with severe and persistent mental illness in competitive employment and/or continuing education to obtain competitive employment. / Click here to enter text. /
What processes will you put in place and how will you ensure individuals will be offered opportunities to explore employment goals? / Click here to enter text. /
How would you initiate and maintain job development activities? (please include how you would ensure diversity of job types and employers as well as competitive jobs: / Click here to enter text. /
What supports and other services would be offered? / Click here to enter text. /
Describe how you plan to ensure fidelity to this evidenced-based supported employment model: / Click here to enter text. /
Please how you will ensure receipt of an adequate number of referrals to establish and maintain financial sustainability: / Click here to enter text. /
How many individuals do you target serving in a 12- month period for the following:
  1. Individuals meeting TCLI priority population requirements
  2. At-risk individuals
/ Click here to enter text. /

To acknowledge your understanding of the requirements for providing this service, attest that this information is true and accurate to the best of your knowledge and confirm your organization’s authorization to submit this information, please sign and date below:

Signature: ______Date:______

Email or fax completed form to Vanessa Anderson at or 828-325-8178 by 5 pm on June 27, 2018.

Individual Placement Support-Supported Employment 0518-003 1