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.
Once
the form is completed please print the form and attach the following:
-
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.
-
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.
-
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.
-
A
list of the Board of Directors with addresses, classifications and
terms of service.
-
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}.
-
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
Submit this
Inquiry Form to:
North Carolina Division of Social Services
Regulatory and Licensing Services
952 Old US Highway 70
Black Mountain, North Carolina 28711
Administrative
Rules for Maternity Homes are found in North Carolina Administrative
Code Chapter 10A, Subchapters 70F
and 70K.
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