Residential Child Care 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 children you plan to serve, the number of children 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. Include specific sources of revenues. Describe your plan for meeting your budgetary needs during the first year of operation.
• A list of all the owners (co-owners, partners, shareholders, principals, affiliates) of the residential child care facility (group home) with their full legal names, addresses, phone numbers and social security numbers. Indicate percentage of ownership for each owner.
• 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 residential child care facility (group home), child-placing agency or maternity 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 the Board of Directors with addresses, classifications and terms of service.
• 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 Residential Child-Care Facilities are found in North Carolina Administrative Code Chapter 10A NCAC Subchapters 70I and 70J.