Form Sr 1a - Short-Term Residential Therapeutic Program (Strtp) Rate Application Page 2

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PROGRAM NUMBER:
PROPOSED EFFECTIVE DATE:
(18) Data for each facility location for this STRTP program. Attach additional pages if needed.
LICENSE
ZIP
LICENSED
NUMBER, STREET
CITY
NUMBER
CODE
CAPACITY
(19) LIST PLACEMENT AGENCIES USING THIS PROGRAM. LIST PRIMARY USER FIRST AND OTHERS IN DESCENDING ORDER OF USAGE.
(20) LIST THE COUNTY (IES) YOU HAVE A MENTAL HEALTH CONTRACT AND OR CERTIFICATION WITH. (SPECIFY IF IT IS A CONTRACT OR CERTIFICATION)
SR 1A (4/17)
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