ATTACHMENT 3.docx

This is a Program Information Summary form for Residential Services for Children in South Carolina, used to document program details for contractors providing care services to youth through the state's child welfare system. The form requires providers to specify the type of residential service offered, including options such as Group Care Intensive, Therapeutic Foster Care, Group Care Intermediate, Temporary De-escalation services, Supervised Independent Living, Qualified Residential Treatment Programs, and Intensive In-Home Services, with designations for service intensity levels (I, II, or III). Contractors must also indicate specialized services provided, such as sex offender treatment, pregnancy support, human trafficking services, or autism support, and provide information regarding program licensing and accreditation status, including license numbers and expiration dates.

The form collects operational and resource information necessary for program administration and monitoring, including the number of available beds, client age ranges served, and identification of male and female capacity. Providers must document how medical, dental, mental health, and substance abuse needs will be addressed, as well as educational and vocational opportunities available to clients. The form requires identification of the assigned South Carolina Department of Children and Families program monitor, contact information, and an on-call emergency contact list. Contractors must also designate whether services are provided in-state or out-of-state and identify any transportation services offered as part of their program.