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Maternity Home Inquiry
The inquiry form has been made available via the internet. The form can be downloaded in either microsoft word or as a pdf document. The microsoft word document is interactive. Answer the questions in the computer, print the form, sign the form and mail it to the address indicated.
| Maternity Home Inquiry Form | Word Version | PDF Version |
Once the form is completed please print the form and attach the following:
Attach the Following:
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A Needs Assessment for the county/counties you plan to serve [At a minimum describe the clients you plan to serve, the number of clients you anticipate needing your service, funding sources, referral sources (list agencies that will refer clients to you), any other documentation that describes the need for your service(s)].
- A proposed line-item budget detailing expenses and revenues. Include your fee schedule and specific sources of revenues. You will not be eligible to receive State Maternity Home Funds until you have been licensed, in business for a year, submitted an audit and met the requirements established by the DHHS Controller’s Office for a per diem rate. Describe your plan for meeting your budgetary needs during the first year of operation.
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The names of three references with addresses and phone numbers [two of the references must be from current or former employers]. If you operated a maternity home, child-placing agency, or residential child care facility (group home) in another state provide the name, address and phone number of a contact person with the licensing authority in that state.
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A list of all the owners (co-owners, partners, shareholders, principals, affiliates) of the maternity home with their addresses and phone numbers. Indicate percentage of ownership for each owner.
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A list of the Board of Directors with addresses, classifications and terms of service.
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A certified copy of your college transcripts. [Please note the Administrator must have a bachelor's degree from a college or university accredited by the Association of Colleges and Schools and no less than four years work experience in a human services program including supervision, administration, and management. The social work supervisor must have at a minimum a master's degree in social work or related area of study from an accredited school, and at least two years of social work experience; or a bachelor's degree and four years of experience in social work or related field. Social Workers must have either a master's degree in social work or related field of study from an accredited school, or a bachelor's degree in social work or a related field and two years experience working directly in human services}.
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Documentation that you have at least four years experience in a human services program including supervision, administration, and management.
- Approval from the local Zoning Authority