Exhibit XIX ADJC Census Report.doc

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Master Agreement AZ|CTR071412
Contract number
CTR071412
Issued by
Arizona

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This document is an Exhibit XIX ADJC (Arizona Department of Juvenile Corrections) Census Report template designed for out-of-home residential contractors providing youth residential services in Arizona. The report is to be submitted bimonthly (on the 1st and 15th of each month) to the ADJC Community Program Service Office (CPSO) via email, with contact support available at 602-527-5267.

The census report requires contractors to detail their bed space availability across different residential program levels, including behavioral health intervention foster care (BHIF), behavioral health residential facilities (BHRF), group homes, and other specialty programs. Contractors must provide comprehensive information such as their specialized care type, gender focus, age range, number of open beds, location by city, and indication of upcoming discharges. The report serves as a tracking mechanism for residential placement capacity and availability for juvenile justice residential services in Arizona.

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EXHIBIT XIX

ADJC Census Report

Out-of-Home residential Contractors, please provide your bed space availability for AZ residential programs. Email the completed report on 1st and 15th of the month by 10:00 AM to the ADJC Community Program Service Office (CPSO) at communityprogramservice@azdjc.gov For training or assistance regarding this report, please contact the CPSO at 602-527-5267.

Contractor name:
Census for the week of

Contact person phone and email:

Level of Care

(BHIF, BHRF, Group Home or Other)

Specialty
Gender
Age

Range # of open beds Location (City) Upcoming

Discharges

(Y or No)

REV 6/20/22

File details come from the government source that posted it. Updated .