Provider Inquiry Form

Use this form to express interest in contracting with Local Mental health Authorities (LMHAs) and Local Behavioral Health Authorities (LBHAs) to provide complete levels of care or specialty services as part of the Local Planning and Network Development (LPND) process.

Instructions:

  1. Before completing this form, review information about each LMHA’s and LBHA’sservice area and capacity on the LPND Information for Potential Providers web page.
  2. Complete the form following instructions provided.
  3. Submit the completed form byFebruary 28, 2018, by emailing it to .
  4. LMHAs or LBHAs you select on the formwill contact youto schedule a meeting or teleconference to discuss local circumstances, needs, and challenges, as well as services you are interested in providing and your service capacity. Meetings or teleconferencesshould occur within 14 daysofinitial contact from the LMHA or LBHA.

In the list below, select the LMHAs or LBHAs with whomyou wouldlike to contract. Please be selective and do not check all.

☐ / Anderson Cherokee Community Enrichment Services (ACCESS)
☐ / Andrews Center
☐ / Behavioral Health Center of Nueces County
☐ / Betty Hardwick Center
☐ / Bluebonnet Trails Community Services
☐ / Border Region Behavioral Health Center
☐ / Burke Center
☐ / Camino Real Community Services
☐ / Center For Health Care Services
☐ / Center For Life Resources
☐ / Central Counties Health Center
☐ / Central Plains Center
☐ / Coastal Plains Community Center
☐ / Community Healthcore
☐ / Denton County MHMR Center
☐ / Emergence Health Network
☐ / Gulf Bend Center
☐ / Heart Of Texas Region MHMR Center
☐ / Helen Farabee Centers
☐ / Hill Country MHDD Centers
☐ / Integral Care
☐ / Lakes Regional Community Center
☐ / LifePath Systems
☐ / MHMR of Tarrant County
☐ / MHMR Authority of Brazos Valley
☐ / MHMR Services For The Concho Valley
☐ / North Texas Behavioral Health Authority
☐ / Pecan Valley Centers
☐ / Permian Basin Community Centers ForMHMR
☐ / Starcare Specialty Health
☐ / Spindletop Center
☐ / Texana Center
☐ / Texas Panhandle MHMR
☐ / Texoma Community Center
☐ / The Gulf Coast Center
☐ / The Harris Center For Mental Health and IDD
☐ / Tri-County Behavioral Healthcare
☐ / Tropical Texas Behavioral Health
☐ / West Texas Centers
Provider Name: Click here to enter text.
Physical Address: Click here to enter text.
City: Click here to enter text. / State: Click here to enter text. / Zip: Click here to enter text.
Mailing Address: Click here to enter text.
City: Click here to enter text. / State: Click here to enter text. / Zip: Click here to enter text.
Contact Person(s) and Title(s): Click here to enter text.
Phone Number(s): / Click here to enter text. / Click here to enter text. /
Fax Number: Click here to enter text.
Email Address: Click here to enter text.
Website (if applicable): Click here to enter text.
Type of Provider / ☐Company/Organization / ☐Individual Practitioner
Please describe your experience delivering mental health services by completing the questions below.
  1. How many years have you been providing mental health services?
    Click here to enter text.
  2. Which populations do you currently serve?
    Click here to enter text.
  3. What types of individuals (e.g., children, youth, and/or adults) do you serve?
    Click here to enter text.
  4. What types of staff do you currently employ (position/credentials)?
    Click here to enter text.
  5. What licensure and/or national certification or accreditation do you maintain?
    Click here to enter text.
  6. Is your company Texas-based or part of a national entity?
    Click here to enter text.
  7. Use this section to provide the LMHA or LBHA additional information about you and/or your company.
    Click here to enter text.

Check the service type(s) you are interested in providing. For each item selected, please be prepared to discuss the specific range of services and capacity you can offerduring the follow-up meeting or teleconference with the LMHAs or LBHAs.

☐Full Levels of Care for adults
☐Full Levels of Care for children and adolescents
☐Crisis and/or residential services
☐Other specialty services Click here to enter text.

Use the following link to access information about Texas Resilience and Recovery and its Levels of Care:

Read the following paragraph. If you agree, then check the box and submit the form byemail to .

☐I have considered all information available about local planning, developing a mental health service delivery network, and the Texas Resilience and Recovery model in use by the State of Texas in its public mental health service system. By completing this Provider Interest Inquiry form in full, I am stating my interest in engaging in a business relationship with the above named LMHAs or LBHAs for the services I have indicated. I understand a representative from the above LMHAs or LBHAs will contact me to discuss my interest in becoming a part of the mental health service network.

Revised October 2017