ICOTP Application

We are a group of addiction treatment providers working to effect changes in our industry that will promote ethical, transparent, and effective practices in addiction treatment that will more reliably provide long lasting success.


The attached application is to be used by current and prospective providers that wish to apply to the ICOTP. If you have any questions regarding the accreditation or the application, please contact ICOTP at +1 (800) 514 – 8911.


Step #1

ICOTP Application Fee

Step #2

Fill out the form

You may use the web form below, OR you may download the PDF version and fax it to us at 323-932-0078.


Application Instructions

Please follow these instructions carefully and submit your application only after it has been properly completed and the required supportive documentation has been prepared.

Please complete all applicable sections of the application. If a line or question does not apply to you, fill the line or question with “N/A.” If an entire section does not apply to your application, place a check mark in the “N/A” box located in the section heading.

You may attach additional documentation if your information does not fit in the appropriate area; however, the spaces for the requested information must be completed.

Financial Disclosures: At the time of audit, you will be asked to provide financial records for the past two years, as well as financial projections for the next 12 months. You will also be audited for any marketing expenses, payments and revenue associated therewith. The audit will also review association with labs and costs, expenses and revenue related therewith. The goal of the audit is full transparency. The CEO of your organization should agree to these terms by signing the bottom of the application.

NOTICE:

Do not navigate away from this page once you have started filling out the form or your data may be lost.

Legal Entity Information

1.
Legal Entity Name:
2.
Program or Facility Name:
3.
Corporate Address:
4.
Mailing Address:
5.
Program Website Address:
6.
Entity Type:
CorporationLLCPartnershipLLPGeneral PartnershipOther
7.
Type of Organization:
ProfitNon-ProfitOther
8.
Is the applicant credentialed with the Joint Commission or any other organization?
YesNo
8.b
Please attach the most recent results of reviews performed by above agency or organization.


9.
Does the applicant have any active licences registered with the state?
YesNo
9.b
If you answered yes to question 9 above, please attach copies of the license for each level of care.


10.
Person to Contact (Preferably CEO, COO, or Clinical Director)
11.
Facility Information
11.b
Facility Ownership Information
Owned by ApplicantOwned by CountyLeasedOther
12.
Does the program have multiple locations?
YesNo
13.
Facility #2 Information
13.b
Facility #2 Ownership Information
Owned by ApplicantOwned by CountyLeasedOther
14.
Facility #3 Information
14.b
Facility #3 Ownership Information
Owned by ApplicantOwned by CountyLeasedOther
15.
Facility #4 Information
15.b
Facility #4 Ownership Information
Owned by ApplicantOwned by CountyLeasedOther

Treatment Provider Information

1.
Type of Services Offered
(Select all that apply EITHER Residential or Non-Residential)
Residential
DetoxificationTreatment PlanningGroup SessionsIndividual SessionsEducational SessionsTransitional Planning
Non-Residential
DetoxificationGroup SessionsIndividual SessionsEducational SessionsOutpatient TreatmentTreatment PlanningIntensive Outpatient Program (IOP)Case ManagementTransitional Planning
2.
Target Population
General PopulationMen OnlyWomen OnlyDual DiagnosisFamilies Co-Ed/Child (under the age of 18) Dual DiagnosisWomen/Child (under the age of 18) Dual DiagnosisWomen/Children (under the age of 18)Co-Ed/Children (under the age of 18)ElderlySpecialty Program (i.e., program designed for First Responders, Lawyers, etc.)Other