Data Collection Form

The Medical Facilities Planning Branch's 2012 data collection form for Substance Abuse Residential Facilities is now available for download. Though the form is supplemental to and different from the renewal license application for MH/DD/SAS facilities, data will be used to project need for substance abuse treatment services in the 2013 North Carolina State Medical Facilities Plan.

Please download the form, complete all sections and return to the Medical Facilities Planning Branch by Friday, February 10, 2012.

  1. Complete and sign the form
  2. Return the form by one of two methods:
    1. Email a scanned copy to DHSR.SMFP.Registration-Inventory@dhhs.nc.gov
    2. Mail the form to Kelli Fisk, Medical Facilities Planning Branch, 2714 Mail Service Center, Raleigh, N.C. 27699-2714

Form

If you have questions, call Tom Elkins in the Medical Facilities Planning Branch at 919-855-3865 or email DHSR.SMFP.Registration-Inventory@dhhs.nc.gov.