Texans Together – Network Partner Profile
This is an opportunity for us to learn more about your organization and explore how we can build a strong, supportive partnership that meets the needs of children and families in our community.
ORGANIZATIONAL INFORMATION
Agency Name:
*
Is your agency name different than your Licensed Entity Name?
*
Yes
No
Licensed Entity Name (if different):
*
Federal Tax ID:
State Vendor ID:
Mailing Address
*
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Website (if applicable):
Primary Contact Name
*
First Name
Last Name
Primary Contact Title:
*
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address:
*
example@example.com
Back
Next
Save
PROGRAM TYPE & CAPACITY
Which services is your facility licensed to provide? (select yes for all that apply)
Child Placing Agency (CPA)
*
Yes
No
How many branches does your agency have?
*
Please Select
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30+
Address for Branch 1
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Address for Branch 2
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Address for Branch 3
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Address for Branch 4
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Address for Branch 5
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Address for Branch 6
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Address for Branch 7
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Address for Branch 8
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Address for Branch 9
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Address for Branch 10
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Address for Branch 11
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Address for Branch 12
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Address for Branch 13
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Address for Branch 14
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Address for Branch 15
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Address for Branch 16
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Address for Branch 17
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Address for Branch 18
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Address for Branch 19
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Address for Branch 20
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Address for Branch 21
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Address for Branch 22
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Address for Branch 23
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Address for Branch 24
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Address for Branch 25
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Address for Branch 26
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Address for Branch 27
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Address for Branch 28
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Address for Branch 29
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Address for Branch 30
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Child Placing Agency (CPA) - Adoption Only
*
Yes
No
General Residential Operation (GRO)
*
Yes
No
GRO operating as a Emergency Shelter (ES)
*
Yes
No
GRO operating as a Residential Treatment Center (RTC)
*
Yes
No
Supervised Independent Living (SIL)
*
Yes
No
Do you hold an active contract with DFPS in Region 6? Select all that apply:
*
Yes
No
Only Child Specific Contracts
No, however application submitted to DFPS
Other
Does your organization provide on-call or after-hours services?
*
Yes
No
Do you conduct in state adoptions?
*
Yes
No
Do you conduct out of state adoptions?
*
Yes
No
Do you conduct private adoptions?
*
Yes
No
Back
Next
Save
PROGRAM TYPE & CAPACITY
Which Regions are you contracted to serve? (select yes for all that apply)
Child Placing Agency (CPA)
CPA: Region 1
*
Yes
No
CPA: Region 2
*
Yes
No
CPA: Region 3W
*
Yes
No
CPA: Region 3E
*
Yes
No
CPA: Region 4
*
Yes
No
CPA: Region 5
*
Yes
No
CPA: Region 6A
*
Yes
No
CPA: Region 6B
*
Yes
No
CPA: Region 7A
*
Yes
No
CPA: Region 7B
*
Yes
No
CPA: Region 8A
*
Yes
No
CPA: Region 8B
*
Yes
No
CPA: Region 9
*
Yes
No
CPA: Region 10
*
Yes
No
CPA: Region 11A
*
Yes
No
CPA: Region 11B
*
Yes
No
Which Regions are you contracted to serve? (select yes for all that apply)
General Residential Operation (GRO): including GRO operating as a Emergency Shelter (ES) and GRO operating as a Residential Treatment Center (RTC)
GRO: Region 1
*
Yes
No
GRO: Region 2
*
Yes
No
GRO: Region 3W
*
Yes
No
GRO: Region 3E
*
Yes
No
GRO: Region 4
*
Yes
No
GRO: Region 5
*
Yes
No
GRO: Region 6A
*
Yes
No
GRO: Region 6B
*
Yes
No
GRO: Region 7A
*
Yes
No
GRO: Region 7B
*
Yes
No
GRO: Region 8A
*
Yes
No
GRO: Region 8B
*
Yes
No
GRO: Region 9
*
Yes
No
GRO: Region 10
*
Yes
No
GRO: Region 11A
*
Yes
No
GRO: Region 11B
*
Yes
No
Which Regions do you serve? (select yes for all that apply)
Supervised Independent Living (SIL)
SIL: Region 1
*
Yes
No
SIL: Region 2
*
Yes
No
SIL: Region 3W
*
Yes
No
SIL: Region 3E
*
Yes
No
SIL: Region 4
*
Yes
No
SIL: Region 5
*
Yes
No
SIL: Region 6A
*
Yes
No
SIL: Region 6B
*
Yes
No
SIL: Region 7A
*
Yes
No
SIL: Region 7B
*
Yes
No
SIL: Region 8A
*
Yes
No
SIL: Region 8B
*
Yes
No
SIL: Region 9
*
Yes
No
SIL: Region 10
*
Yes
No
SIL: Region 11A
*
Yes
No
SIL: Region 11B
*
Yes
No
Back
Next
Save
SPECIAL POPULATIONS & CLINICAL CAPACITY
Which services are you licensed to provide? (select yes for all that apply)
Child Placing Agency (CPA)
CPA: Child Care Services
*
Yes
No
CPA: Treatment for Emotional Disorders
*
Yes
No
CPA: Treatment for Intellectual Disabilities
*
Yes
No
CPA: Treatment for Autism Spectrum Disorder
*
Yes
No
CPA: Primary Medical Needs
*
Yes
No
CPA: Victims of Human Trafficking
*
Yes
No
CPA: Transitional Living Program
*
Yes
No
CPA: Assessment Services Program
*
Yes
No
CPA: Respite Child Care Services
*
Yes
No
CPA: Therapeutic Foster Care
*
Yes
No
Which services are you licensed to provide? (select yes for all that apply)
General Residential Operation (GRO): including GRO operating as a Emergency Shelter (ES) and GRO operating as a Residential Treatment Center (RTC)
GRO: Child Care Services
*
Yes
No
GRO: Treatment for Emotional Disorders
*
Yes
No
GRO: Treatment for Intellectual Disabilities
*
Yes
No
GRO: Treatment for Autism Spectrum Disorder
*
Yes
No
GRO: Medical Needs
*
Yes
No
GRO: Human Trafficking Victims Services
*
Yes
No
GRO: Emergency Care Services
*
Yes
No
GRO: Transitional Living Program
*
Yes
No
GRO: Assessment Services Program
*
Yes
No
GRO: Therapeutic Camp Services
*
Yes
No
GRO: Respite Child Care Services
*
Yes
No
GRO: Is your General Residential Operation (GRO) licensed to serve both male and female children and youth?
*
Yes
No
If no, please specify:
*
Please Select
Male only
Female only
What age ranges is your General Residential Operation (GRO) licensed to serve? (select yes for any category that include the age(s) served by your agency)
General Residential Operation (GRO): including GRO operating as a Emergency Shelter (ES) and GRO operating as a Residential Treatment Center (RTC)
GRO: Ages 5-9 years
*
Yes
No
GRO: Ages 10-13 years
*
Yes
No
GRO: Ages 14-17 years
*
Yes
No
GRO: Ages 18-22 years
*
Yes
No
Which services do you provide? (select yes for all that apply)
Supervised Independent Living (SIL)
SIL: Do you provide Extended Case Management (ECM) services?
*
Yes
No
Back
Next
Save
SPECIAL POPULATIONS & CLINICAL CAPACITY
What is your agency's current clinical capacity? (select yes for all that apply)
Child Placing Agency (CPA)
CPA: LCSW (part-time, full-time, or contract)
*
Please Select
Part-time LPC
Full-time LPC
Contract LPC
No LPC
CPA: LPC (part-time, full-time, or contract)
*
Please Select
Part-time LPC
Full-time LPC
Contract LPC
No LPC
CPA: In-home Behavioral Supports (part-time, full-time, or contract)
*
Please Select
Part-time In-home Behavioral Supports
Full-time In-home Behavioral Supports
Contract In-home Behavioral Supports
No In-home Behavioral Supports
CPA: Nursing Staff (part-time, full-time, or contract)
*
Please Select
Part-time nursing staff
Full-time nursing staff
Contract nursing staff
No nursing staff
What is your agency's current clinical capacity? (select yes for all that apply)
General Residential Operation (GRO)
GRO: LCSW (part-time, full-time, or contract)
*
Please Select
Part-time LCSW
Full-time LCSW
Contract LCSW
No LPC
GRO: LPC (part-time, full-time, or contract)
*
Please Select
Part-time LPC
Full-time LPC
Contract LPC
No LPC
GRO: Psychiatric Provider (part-time, full-time, or contract)
*
Please Select
Part-time Psychiatric Provider
Full-time Psychiatric Provider
Contract Psychiatric Provider
No Psychiatric Provider
GRO: Nursing Staff (part-time, full-time, or contract)
*
Please Select
Part-time nursing staff
Full-time nursing staff
Contract nursing staff
No nursing staff
What is your agency's current clinical capacity? (select yes for all that apply)
Supervised Independent Living (SIL)
SIL: Psychiatric Provider (part-time, full-time, or contract)
*
Please Select
Part-time Psychiatric Provider
Full-time Psychiatric Provider
Contract Psychiatric Provider
No Psychiatric Provider
What is your agency's current clinical capacity? (select yes for all that apply)
GRO operating as a Residential Treatment Center (RTC)
RTC: LCSW (part-time, full-time, or contract)
*
Please Select
Part-time LCSW
Full-time LCSW
Contract LCSW
No LCSW
RTC: LPC (part-time, full-time, or contract)
*
Please Select
Part-time LPC
Full-time LPC
Contract LPC
No LPC
RTC: Psychiatric Provider (part-time, full-time, or contract)
*
Please Select
Part-time Psychiatric Provider
Full-time Psychiatric Provider
Contract Psychiatric Provider
No Psychiatric Provider
RTC: Nursing Staff (part-time, full-time, or contract)
*
Please Select
Part-time nursing staff
Full-time nursing staff
Contract nursing staff
No nursing staff
Back
Next
Save
Do you currently provide services in the following languages?(select yes for all that apply)
English
*
Yes
No
Spanish
*
Yes
No
Vietnamese
*
Yes
No
Other Language (if applicable)
Back
Next
Save
LEVEL OF CARE & SERVICE TYPES
What level(s) of care does your agency currently provide? (select yes for all that apply)
Child Placing Agency (CPA)
CPA: Basic
*
Yes
No
CPA: Moderate
*
Yes
No
CPA: Specialized
*
Yes
No
CPA: Intense
*
Yes
No
CPA: Intense Plus
*
Yes
No
What level(s) of care does your agency currently provide? (select yes for all that apply)
General Residential Operation (GRO): including GRO operating as a Emergency Shelter (ES) and GRO operating as a Residential Treatment Center (RTC)
GRO: Basic
*
Yes
No
GRO: Moderate
*
Yes
No
GRO: Specialized
*
Yes
No
GRO: Intense
*
Yes
No
GRO: Intense Plus
*
Yes
No
Back
Next
Save
T3C READINESS & SERVICE PACKAGE ALIGNMENT
Texas Child-Centered Care (T3C) is a new model designed to transform the state’s foster care system. Beginning January 2025, DFPS will begin credentialing organizations to deliver T3C services, with the process ending September 2027.
Are you currently T3C credentialed?
*
Yes
No
Are you fully transitioned to T3C? Or are you providing a mix of traditional leveling system and T3C credential?
*
Fully Transitioned to T3C
Mix of Traditional and T3C
T3C READINESS & SERVICE PACKAGE ALIGNMENT
Child Placing Agency (CPA)
CPA: What is your current T3C credential status?
*
Inactive Interim Credential
Inactive Full Credential
Active Interim Credential
Active Full Credential
Not Applicable
CPA: What steps have you already taken toward credentialing?
CPA: What are your barriers to becoming credentialed?
*
Staffing
Financial
Other
CPA: What are your financial barriers?
*
Staffing costs
Insurance requirements
Electronic health record cost
Training cost
Other
CPA: What is your timeframe to apply to become T3C credentialed?
*
3 months
6 months
9 months
12 months
15 months +
Application submitted
Which Service Packages have you applied to or plan to apply to? (select yes for all that apply)
Child Placing Agency (CPA)
CPA: Basic Foster Family Home Support Services
*
Yes
No
CPA: Substance Use Support Services
*
Yes
No
CPA: Short-Term Assessment Support Services
*
Yes
No
CPA: Mental & Behavioral Health Support Services
*
Yes
No
CPA: Sexual Aggression/Sex Offender Support Services
*
Yes
No
CPA: Complex Medical Needs or Medically Fragile Support Services
*
Yes
No
CPA: Human Trafficking Victim/Survivor Support Services
*
Yes
No
CPA: Intellectual or Developmental Disability (IDD)/Autism Spectrum Disorder Support Services
*
Yes
No
CPA: T3C Treatment Foster Family Care Support Services
*
Yes
No
CPA: Add-On: Transition Support Services for Youth & Young Adults
*
Yes
No
CPA: Add-On: Kinship Caregiver Support Services
*
Yes
No
CPA: Add-On: Pregnant & Parenting Youth or Young Adults Support Services
*
Yes
No
T3C READINESS & SERVICE PACKAGE ALIGNMENT
General Residential Operation (GRO): including GRO operating as a Emergency Shelter (ES) and GRO operating as a Residential Treatment Center (RTC)
GRO: What is your current T3C credential status?
*
Inactive Interim Credential
Inactive Full Credential
Active Interim Credential
Active Full Credential
Not Applicable
GRO: What steps have you already taken toward credentialing?
GRO: What are your barriers to becoming credentialed?
*
Staffing
Financial
Other
GRO: What are your financial barriers?
*
Staffing costs
Insurance requirements
Electronic health record cost
Training cost
Other
GRO: What is your timeframe to apply to become T3C credentialed?
*
3 months
6 months
9 months
12 months
15 months +
Application submitted
Which Service Packages have you applied to or plan to apply to? (select yes for all that apply)
General Residential Operation (GRO): including GRO operating as a Emergency Shelter (ES) and GRO operating as a Residential Treatment Center (RTC)
GRO Tier 1: T3C Basic Child Care Operations Service to Support Community Transition for Youth & Young Adults who are Pregnant or Parenting
*
Yes
No
GRO Tier 1: Sexual Aggression/Sex Offender Treatment Services to Support Community Transition
*
Yes
No
GRO Tier 1: Substance Use Treatment Services to Support Community Transition
*
Yes
No
GRO Tier 1: Emergency Emotional Support & Assessment Center Services
*
Yes
No
GRO Tier 1: Complex Medical Needs Treatment Services to Support Community Transition
*
Yes
No
GRO Tier 1: Mental & Behavioral Health Treatment Services
*
Yes
No
GRO Tier 1: Intellectual or Developmental Disability(IDD) / Autism Spectrum Disorder Treatment Services to Support Community Transition
*
Yes
No
GRO Tier 1: Human Trafficking Victim/Survivor Treatment Services to Support Community Transition
*
Yes
No
GRO Tier 2: Sexual Aggression/Sexual Offender Services to Support Stabilization
*
Yes
No
GRO Tier 2: Substance Use Services to Support Stabilization
*
Yes
No
GRO Tier 2: Aggression/Defiant Disorder Services to Support Stabilization
*
Yes
No
GRO Tier 2: Complex Medical Services to Support Stabilization
*
Yes
No
GRO Tier 2: Human Trafficking Victim/Survivor Services to Support Stabilization
*
Yes
No
Back
Next
Save
STRATEGIC PARTNERSHIP
Why are you interested in partnering with Texans Together?
*
Describe your agency’s strengths and biggest challenges:
*
What barriers do you foresee in onboarding or delivering services under Community-Based Care?
*
Are you the Signature Authority?
*
Yes
No
Name of Signature Authority:
*
First Name
Last Name
Title of Signature Authority
*
Your Name:
*
First Name
Last Name
Your Title:
*
Signature:
*
Date:
*
-
Month
-
Day
Year
Date
Save
Submit
Should be Empty: