Licensure Application Addendum Fact Sheet Form

Summary

LICENSURE APPLICATION ADDENDUM: FACT SHEET FORM
INSTRUCTIONS: This form is an addendum to the application for license and is to be used to describe the facility/service to be operated at a given
site/location. A separate Fact Sheet is required for each location. This completed form must accompany an application for initial license to operate a newly
established facility/service. Current licensees must use this form when applying for a license to operate a newly established site/location, to add a new
category to an existing license, to relocate a currently licensed facility/service to another location, or a major renovation, expansion, or change in use or
occupancy of a currently licensed facility

1. Name of Applicant (if individual) or Company/Licensee Name if registered with TN Secretary of State DATE:
________________________________________________________________________________ ___________________________
2. PURPOSE OF FACT SHEET: Identify the reason for the completion of this fact sheet: (Check one)
a.  Application for license by new applicant to operate a newly established facility/service

(An Initial Application must accompany this Fact Sheet.)
b.  Application by current licensee to establish a new site/location

c.  Application by current licensee to relocate a currently licensed facility/service to another location. (Licenses are not transferrable.)
d.  Application by current licensee to add new category/service to currently licensed site/location

e.  Application by a current licensee for approval of a major renovation, expansion, or change in use or occupancy of a currently licensed
facility. (A new License may be required for certain renovations and expansions.)
3. NAME AND LOCATION OF FACILITY/SERVICE: Identify this facility/service as it is to be named by the applicant, known to the public, and listed on
the license:
Facility/Service Name: ___________________________________________________________________________________________________
Street Address: ________________________________________________________________________________________________________
City: _________________________________________________ Zip Code: __________________ County: _____________________________
Facility/Service Phone Number: ____________________________________ Fax Number: __________________________________________
Is the location of the facility/service inside of city limits? ❑YES ❑NO
4. DISTINCT CATEGORY(IES): Identify the distinct category(ies) of this facility/service as defined in the licensure rules:
(If site is currently licensed, only mark category(ies) that are being added to current site.)
Mental Health Alcohol and Drug Abuse
 Adult Day Treatment Services  DUI School
 Adult Residential Treatment Program (# of beds ______)  Halfway House Treatment (# of beds ______)
 Adult Supportive Residential (# of beds ______)  Non-Residential Office-Based Opiate Treatment (OBOT)
 Crisis Stabilization Unit (# of beds ______)  Non-Residential Office-Based Opiate Treatment (OBOT Plus)
 Hospital (# of beds ______)  Non-Residential Opioid Treatment
 Intensive Day Treatment for Children & Adolescents  Non-Residential Rehab Treatment
 Outpatient  Outpatient Detoxification Treatment
 Partial Hospitalization Programs  Residential Detoxification Treatment (# of beds ______)
 Psychosocial Rehabilitation Program  Residential Rehabilitation Treatment(# of beds ______)
 Residential Treatment for Children & Youth (# of beds ______)  Residential Treatment for Children and Youth (# of beds ______)
 Supportive Living Facility (# of beds ______) Non-Medical Home Health
 Therapeutic Nursery  Personal Support Services Agency
5. SITE MANAGER/DIRECTOR: Identify the person who is charged with the overall daily management of this facility/service:
Name: __________________________________________________________ Title:__________________________________________________
Email Address: __________________________________________________ Phone Number:________________________________________
Has this person ever been convicted of or currently under any charges of a felony offense under the law? ❑YES ❑NO
If yes, attach an explanation of the situation, date, type and place of the charge, court action taken, or current disposition
MH-4386 (Rev 5/15/2020) Page 1 of 3
NOTE: ITEMS NUMBERED (7) THROUGH (22) DO NOT APPLY TO PERSONAL SUPPORT SERVICE AGENCIES, DUI SCHOOLS, OR OBOTS

6. NUMBER OF BUILDINGS: Identify the number of buildings on the site of this facility which are to be used for service recipient residences or other service
recipient programs: ____. If more than one (1) building is to be used at this address, then list each building by its name or location on the premises, the number
of service recipients to reside or to be served in each building, and give the primary use of each building

Name/Location of Building __________________________________________________________________________________________________________
Primary Use of Building ____________________________________________________________________________________________________________
Number of service recipient(s) to reside or to be served in this building ________
Are any of the service recipient(s) six years of age or younger? ❑ YES ❑ NO
Name/Location of Building __________________________________________________________________________________________________________
Primary Use of Building ____________________________________________________________________________________________________________
Number of service recipient(s) to reside or to be served in this building ________
Are any of the service recipient(s) six years of age or younger? ❑ YES ❑ NO
Name/Location of Building __________________________________________________________________________________________________________
Primary Use of Building ____________________________________________________________________________________________________________
Number of service recipient(s) to reside or to be served in this building ________
Are any of the service recipient(s) six years of age or younger? ❑ YES ❑ NO
7. SHARED OCCUPANCY: Are there other activities or occupants in this building(s) which are not under the control of the licensee/applicant?
❑YES ❑ NO If yes, describe:
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
8. HOURS OF OPERATION: Indicate the normal days and hours of facility's operation. ___________________________________________________________
9. MOBILE, NON-AMBULATORY SERVICE RECIPIENTS: Are mobile, non-ambulatory persons (persons using wheelchairs, walkers, etc.) to be served in this
facility? ❑YES ❑NO
If yes, are these persons capable of transferring unassisted from a bed or other fixed position into the wheelchair or other mobility device and traversing a
predefined means of egress from the facility? ❑YES ❑NO
10. SERVICE RECIPIENT SELF-PRESERVATION: Are all of the persons to be served in this facility capable of self-preservation by responding to an emergency
signal, including prompting by voice, and following a pre-taught evacuation procedure from the facility? ❑ YES ❑ NO
Are any individuals to be served in this facility deaf? ❑ YES ❑ NO Are any individuals to be served in this facility blind? ❑ YES ❑ NO
11. SECURITY MEASURES: Are security measures, such as exit doors or windows locked against client egress, restraints, or seclusion, which are beyond
the client's control to be used in this facility? ❑ YES ❑ NO If yes, explain below:
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
12. VOCATIONAL ACTIVITIES: Are vocational activities of an industrial or productive nature such as contract work, assembling, packaging,
woodworking, metalworking, painting, stripping, etc., to be conducted in this facility? ❑YES ❑NO
13. FOOD SERVICE: Are food service, food preparation, and/or meals to be provided by this facility to the service recipients of the facility on a regular basis?
 YES ❑ NO
14. TRANSPORTATION: Will persons served by this facility/service be transported by facility/service staff: ❑YES ❑NO
15. BATHROOM ACCOMMODATIONS: Number of separate bathtubs or shower stalls: _________
Number of toilets: __________________ Number of urinals: _________________ Number of sinks or hand lavatories in bathrooms: _______
16. WATER/SEWER: Is drinking water furnished by a well/spring located on the property? ❑YES ❑NO
Is sewage handled by a septic tank located on the property? ❑YES ❑NO
17. BUILDING CONSTRUCTION: This facility is to be located in: (check one)
❑ A building to be constructed or under construction OR  An existing building to be adapted for the facility's use

A. Number of stories or floors: _____ Basement: ❑YES ❑NO
B. Indicate the building's type of construction: (check one) ❑Wood frame with wood, shingle, or metal siding Wood frame with brick veneer
 Reinforced concrete with steel members  Masonry block, with wood frame members ❑Masonry Block, no wood frame members
 Other, describe: _______________________________________________________________________________________________________
18. SQUARE FOOTAGE: Total occupiable space of facility in square feet:____________________________
MH-4386 (Rev 5/15/2020) Page 2 of 3
19. OWNERSHIP OF PREMISES: Identify the ownership of the buildings, premises, or real property where this facility is to be located: (Check One.)
 Owned by the applicant free of mortgage

 Owned by the State of Tennessee
 Mortgage Lender: Name:_________________________________________________________________________________________
 Leased from: Address:________________________________________________________________________________
 Dona ted by City/State/Zip Code:____________________________________________________________________________________
NOTE: ITEMS 20 THROUGH 22 ARE TO BE ANSWERED ONLY FOR RESIDENTIAL FACILITIES

20. RESIDENTIAL SERVICE RECIPIENTS. Number of services recipients who are to reside in facility: ________
21. LIVE-IN STAFF. Number of staff members, proprietors, or family members of the staff or proprietor who reside or have sleeping arrangements in this facility?
____________
22. NUMBER OF ROOMS. Service recipient bedrooms: _______ Staff or other bedrooms: _______ Bathrooms: _______
Living Rooms: _______ Dens: _______ Dining Rooms: _______ Kitchens: _______
23. OTHER. Use this space to provide any additional information or to explain any of the above items:
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
AUTHENTICATION OF INFORMATION. The information contained in this fact sheet is an addendum to, or a part of the application for a license. The person signing below must
be the individual owner, chief executive officer, executive director, or other member of the governing body on whom rests the authority and responsibility for
maintaining standards, policies, and procedures for the facility/service to be operated

I hereby declare the information contained in this licensure application addendum to be true, correct, and complete to the best of my knowledge. I further declare
my authority and responsibility to certify this information in making application for license to conduct the facility described herein. I agree to comply with the rules
promulgated for the operation of this facility/service under Tennessee Code Annotated Title 33, Chapter 2, Part 4

SIGNATURE OF APPLICANT OR AUTHORIZED AGENT TITLE
_______________________________________________________________ _________________________________________________________
TYPE OR PRINT NAME OF AUTHORIZED AGENT DATE
_______________________________________________________________ _________________________________________________________
(Send completed form to appropriate regional office.)
East Tennessee Regional Office Middle Tennessee Regional Office West Tennessee Regional Office
520 West Summit Hill Drive 500 Deaderick Street 951 Court Avenue
Suite 502 5th Floor, Andrew Jackson Bldg. Memphis, TN 38103
Knoxville, TN 37902 Nashville, TN 37243 Telephone #: 901-543-7442
Telephone #: 865-594-6551 Telephone #: 615-532-6590 Fax #: 844-844-5538
Fax #: 844-340-4482 Fax #: 615-532-7856 Email: [email protected]
Email: [email protected] Email: [email protected]
MH-4386 (Rev 5/15/2020) Page 3 of 3

2. PURPOSE OF FACT SHEET: Identify the reason for the completion of this fact sheet: (Check one) a. Application for license by new applicant to operate a newly established …

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