Commonwealth of Massachusetts Autism Division of the Department of Developmental Services
APPLICATION TO QUALIFY AS A PROVIDER OF AUTISM SUPPORT SERVICES

Name:                                                                                   _____                 Date: ______________
Address: _____________________________________________
               _____________________________________________
SSN: ______________   E-Mail: __________________________      Phone: ___________________

Waiver Program Services:
Expanded Habilitation, Education 
Please indicate your experience level by checking boxes for the service(s) you wish to provide and the boxes in the right column for the information you are including with your application.  Omission of required documentation may delay or deny approval to provide services.  Please check all that apply.

SENIOR LEVEL THERAPIST (Expanded Habilitation only): Role is to oversee the development and implementation of the Expanded Habilitation, Education Intervention Plan (“HIP”). This includes the creation of the HIP as well as Quarterly Progress Reports.
Requirements
•	Doctoral Degree in psychology, medicine, or related field
•	Applicable License
•	1500 hours of training including course work in positive behavioral supports, learning and behavioral therapy, child development, and a range of comprehensive interventions for children with autism
•	2 years of experience in a lead role in designing and  implementing behaviorally based therapies for     children with ASD
•	Experience using data based decision making, including data collection and analysis           	
Individuals must submit the following information with the application: 
•	Copy of Current Professional License
•	Copy of Resume
•	Copy of Transcript (to confer training hours)
•	Any other relevant certification documents
•	Copy of MA License or ID Card	

                      -OR-
Requirements: 
•	Master’s Degree in psychology, education, or related field
•	Applicable License
•	2000 hours of training including course work in positive behavioral supports, learning and behavioral therapy, child development, and a range of comprehensive interventions for children with autism
•	3 years of experience in a lead role in designing and  implementing behaviorally based therapies for children with ASD (4yrs required if 1 year MS/MA/Med program)
•	Experience using data based decision making, including data collection and analysis
•	Ongoing training and supervision	
Individuals must submit the following information with the application: 
•	Copy of Current Professional License
•	Copy of Resume
•	Copy of Transcript (to confer training hours)
•	Any other relevant certification documents
•	Copy of MA License or ID Card	

THERAPIST (Expanded Habilitation only): Families may choose to use a therapist to provide one-to-one staff support for the implementation of the Habilitation Plan (HIP) and related tasks as assigned by the Senior Therapist. However this is the choice of the family to hire either a therapist or a direct staff person for the implementation of the plan for the individual receiving Expanded Habilitation, Education.
Requirements
•	Master’s Degree
•	2000 hours of Course Work including course work in relevant training (including positive behavioral supports, child development, and a range of comprehensive interventions for children with autism)
•	2 years of experience in a lead role in designing and  implementing behaviorally based therapies for     children with ASD
•	Experience using data based decision making, including data collection and analysis
•	8 hours annually of Professional Development	
Individuals must submit the following information with the application: 

•	Copy of Current Professional License (If Applicable)
•	Copy of Resume
•	Copy of Transcript (to confer training hours)
•	Any other relevant certification documents
•	Copy of MA License or ID Card	

             -OR-
Requirements
•	Bachelor’s Degree in psychology, education or related field
•	800 hours of Course Work/Training about the characteristics, therapies curriculum, assessments, and documentation involving children with ASD
•	Experience in Development and Implementation of positive behavioral therapies for children with ASD
•	5 years Supervised, Post-Degree Experience
•	10 hours annually of Professional Development	
Individuals must submit the following information with the application: 
•	Copy of Current Professional License (If Applicable)
•	Copy of Resume
•	Copy of Transcript (to confer training hours)
•	Any other relevant certification documents
•	Copy of MA License or ID Card	

             -OR-
Requirements
•	Bachelor’s Degree in non-related related field
•	800 hours of Course Work/Training about the characteristics, therapies curriculum, assessments, and documentation involving children with ASD
•	Experience in Development and Implementation of positive behavioral therapies for children with ASD
•	7 years Supervised, Post-Degree Experience
•	15 hours annually of Professional Development	
Individuals must submit the following information with the application: 
•	Copy of Current Professional License (If Applicable)
•	Copy of Resume
•	Copy of Transcript (to confer training hours)
•	Any other relevant certification documents
•	Copy of MA License or ID Card	

DIRECT SUPPORT STAFF (Expanded Habilitation only): Role is to implement the Habilitation, Intervention Plan as designated by the Senior Therapist including one-to-one behavioral interventions and skills training and community integration activities for individuals receiving Expanded Habilitation, Education Services.
Requirements
•	18 years or older
•	Bachelor’s Degree
•	120 hours of Supervised Training, of which at least 30 hours, in positive behavioral support interventions for children with autism
•	Direct Experience working one-to one with children with an Autism Spectrum Disorder if not 160 hours of supervised training required
•	2 Personal or Professional References	
Individuals must submit the following information with the application: 

•	Copy of Resume
•	Copy of Diploma
•	Copy of Transcript (to confer training hours)
•	Names and Contact information of two references
•	Copy of MA License or ID Card	

Waiver Program Services:
Behavioral Consultation
Please indicate your experience level by checking boxes for the service(s) you wish to provide and the boxes in the right column for the information you are including with your application.  Omission of required documentation may delay or deny approval to provide services.  Please check all that apply.

Senior Behavioral Consultant: Role is to oversee the ongoing implementation of the Expanded Habilitation, Education Intervention Plan (HIP) by the family. This includes adaptation to the HIP as necessary based on the changing needs of the child. This service is only available after the completion of the three years of Expanded Habilitation Education.
Requirements
•	Doctoral Degree in psychology, medicine, or related field
•	Applicable License
•	1500 hours of training including course work in positive behavioral supports, learning and behavioral therapy, child development, and a range of comprehensive interventions for children with autism
•	2 years of experience in a lead role in designing and  implementing behaviorally based therapies for     children with ASD
•	Experience using data based decision making, including data collection and analysis           	
Individuals must submit the following information with the application: 

•	Copy of Current Professional License
•	Copy of Resume
•	Copy of Transcript (to confer training hours)
•	Any other relevant certification documents
•	Copy of MA License or ID Card	

          -OR-
Requirements: 
•	Master’s Degree in psychology, education, or related field
•	Applicable License
•	2000 hours of training including course work in positive behavioral supports, learning and behavioral therapy, child development, and a range of comprehensive interventions for children with autism
•	3 years of experience in a lead role in designing and  implementing behaviorally based therapies for children with ASD (4yrs required if 1 year MS/MA/Med program)
•	Experience using data based decision making, including data collection and analysis
•	Ongoing training and supervision	
Individuals must submit the following information with the application: 

•	Copy of Current Professional License
•	Copy of Resume
•	Copy of Transcript (to confer training hours)
•	Any other relevant certification documents
•	Copy of MA License or ID Card	

Therapist Role is to oversee the ongoing implementation of the Expanded Habilitation, Education Intervention Plan (HIP) by the family. This includes adaptation to the HIP as necessary based on the changing needs of the child. This service is only available after the completion of the three years of Expanded Habilitation Education.
Requirements
•	Master’s Degree
•	2000 hours of Course Work including course work in relevant training (including positive behavioral supports, child development, and a range of comprehensive interventions for children with autism)
•	2 years of experience in a lead role in designing and  implementing behaviorally based therapies for     children with ASD
•	Experience using data based decision making, including data collection and analysis
•	8 hours annually of Professional Development	
Individuals must submit the following information with the application: 

•	Copy of Current Professional License (If Applicable)
•	Copy of Resume
•	Copy of Transcript (to confer training hours)
•	Any other relevant certification documents
•	Copy of MA License or ID Card	

        -OR-
Requirements
•	 Bachelor’s Degree in psychology, education or related field
•	800 hours of Course Work/Training about the characteristics, therapies curriculum, assessments, and documentation involving children with ASD
•	Experience in Development and Implementation of positive behavioral therapies for children with ASD
•	5 years Supervised, Post-Degree Experience
•	10 hours annually of Professional Development	
Individuals must submit the following information with the application: 
•	Copy of Current Professional License (If Applicable)
•	Copy of Resume
•	Copy of Transcript (to confer training hours)
•	Any other relevant certification documents
•	Copy of MA License or ID Card	

        -OR-
Requirements
•	Bachelor’s Degree in non-related related field
•	800 hours of Course Work/Training about the characteristics, therapies curriculum, assessments, and documentation involving children with ASD
•	Experience in Development and Implementation of positive behavioral therapies for children with ASD
•	7 years Supervised, Post-Degree Experience
•	15 hours annually of Professional Development	
Individuals must submit the following information with the application: 
•	Copy of Current Professional License (If Applicable)
•	Copy of Resume
•	Copy of Transcript (to confer training hours)
•	Any other relevant certification documents
•	Copy of MA License or ID Card	

Direct Support Staff: Role is to implement the Habilitation, Intervention Plan as designated by the Senior Behavioral Consultant including one-to-one behavioral interventions and skills training and community integration activities for individuals receiving Behavioral Consultation Services (After 3 years Ex Hab).
Requirements
•	18 years or older
•	Bachelor’s Degree
•	120 hours of Supervised Training, of which at least 30 hours, in positive behavioral support interventions for children with autism
•	Direct Experience working one-to one with children with an Autism Spectrum Disorder if not 160 hours of supervised training required
•	2 Personal or Professional References	
Individuals must submit the following information with the application: 

•	Copy of Resume
•	Copy of Diploma
•	Copy of Transcript (to confer training hours)
•	Names and Contact information of two references
•	Copy of MA License or ID Card	

Waiver Program Services:
 Habilitation/Community Integration
 Family Training
Requirements
•	18 years or older
•	Bachelor’s Degree, High School Diploma or GED
•	Direct Experience working one-to one with children with an Autism Spectrum Disorder
•	Staff members shall have the ability to communicate effectively in the language and communication style of the child to whom they provide services and his or her family
•	If the individual is overseeing the Habilitation or Family Training activity he/she must meet all relevant state and federal licensure or certification requirements in their discipline
•	2 Personal or Professional References	
Individuals must submit the following information with the application: 

•	Copy of Resume
•	Copy of Diploma or GED
•	Copy of Transcript (to confer training hours)
•	Names and Contact information of two references
•	Copy of MA License or ID Card	

Additional Waiver Program Services: 
 Respite in the child’s home
 Respite in the home of a caregiver
   REQUIREMENTS FOR ALL RESPITE STAFF: 
Requirements
•	18 years of age or older
•	High School Diploma or GED
•	2 Personal or Professional References
•	Ability to communicate in the language and style of Individual
•	History of working with children with an Autism Spectrum Disorder 	
Individuals must submit the following information with the application: 
•	Copy of Resume (to demonstrate history of working with children with ASD) 
•	Copy of Diploma or GED 
•	Names and Contact information of two references
•	Copy of MA License or ID Card	

 Homemaker 
    REQUIREMENTS: 
Requirements

•	Tax Identification Number
•	Licensed and Bonded for working in someone’s home
•	18 years of age or older
•	2 Personal or Professional References
	
Individuals must submit the following information with the application: 
•	Tax Identification Number
•	Names and Contact information of two references
•	Copy Licensure and Bondage Certification
•	Copy of MA License or ID Card	

	
** All Applicants Must Complete the Following Sections:
Service Area: 
Please indicate geographic region(s) where you are able to provide services (Check all that apply):
West                        Southeast                      Central                    Metro                  Northeast    
If applicable, please list the town/s that you do not provide service to within a particular geographic area: 
1.                                               2.                                               3.                      
Please indicate if you speak a language in addition to English:
Language One:                               Language Two:                                      Language Three:	

Provider Directory: 
 I am applying to qualify to provide service/supports to __________________________ only.
                                                                                                                 Name of Individual
 I am willing to be placed on a Master List of qualified providers to be considered by individuals/families.	

Background Information: 

Have you been convicted of a felony? YES      NO     (Conviction will not necessarily disqualify an applicant from employment.)    If yes, please explain.*  

Have you been convicted of a misdemeanor other than a first misdemeanor conviction for drunkenness, simple assault, speeding, minor traffic violations, affray, or disturbance of the peace within the last 5 years? YES      NO     (Conviction will not necessarily disqualify an applicant from employment.)    If yes, please explain.*  

*“An applicant for employment with a sealed record on file with the Commissioner of Probation may answer ‘no record’ with respect to an inquiry herein relative to prior arrests, criminal court appearances or convictions. In addition, any applicant for employment may answer ‘no record’ with respect to any inquiry relative to prior arrests, court appearances and adjudications in all cases of delinquency or as a child in need of services which did not result in a complaint transferred to the superior court for criminal prosecution.” 
MGL Ch. 276, Section 100A.	

CERTIFICATION
I certify that the statements made by me on this application are true and complete to the best of my knowledge.  I understand that if I knowingly make any misstatement of fact I am subject to disqualification and dismissal and to such other penalties as may be prescribed by law or personnel regulations.  All statements made on this application, including employment information or conviction records, are subject to verification as a condition of employment.  By signing this statement, I hereby give permission for the release of any and all information for the sole purpose of conducting an employment check.  Further, I understand that this will include a mandatory criminal history background check (CORI).

_________________________________     __________________________
                     Applicant’s Signature                                           Date

PLEASE MAIL ONLY TO ONE APPLICATION:
(Please mail only one application even if you are interested in serving a large geographic area)

Mail completed application to:

                                              The Department of Developmental Services
                                                                    Autism Division
                                                               500 Harrison Avenue
                                                                 Boston, MA 02118

CORI REQUEST 
MA ASD WAIVER PROGRAM

Public Partnerships, LLC has been certified by the Criminal History Systems Board for access to conviction and pending criminal case data.  I understand that a criminal record check will be conducted for conviction and pending criminal case information only and that it will not necessary disqualify me.  The information below is correct to the best of my knowledge.

________________________________________________________
APPLICANT SIGNATURE

FIRST NAME			LAST	NAME				 MIDDLE NAME

_________________________________________              ___________________________
MAIDEN NAME OR ALIAS (IF APPLICABLE)            PLACE OF BIRTH

____/____/_______    ________-________-_________  	 ___________________________
DATE OF BIRTH:         SOCIAL SECURITY NUMBER    	MOTHER’S MAIDEN NAME
					
ADDRESS:

PHONE: _____________________

SUPPORT BROKER: 

•	I VERIFY THAT ALL PROVIDER QUALIFICATIONS HAVE BEEN REVIEWED AND COMPLETED

__________________________________	
PRINT SUPPORT BROKER NAME		

________________________________________			________________________________
SIGNATURE OF SUPPORT BROKER 				AUTISM SUPPORT CENTER

ASD WAIVER PROGRAM PARTICIPANT INFORMATION (If Applicable)

FIRST NAME:  _____________________________    LAST NAME: __________________________________

___________________________________________
                                		SIGNATURE OF PPL AUTHORIZED REPRESENTATIVE

Confidentiality Notice
The Documents accompanying this transmission contain confidential information intended for a specific individual and purpose.  The information is private and is legally protected by law.  If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or the taking of any action in relation to the contents of this telecopied information is strictly prohibited.