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Office of Mental Health

OMH Field Offices | Patient Safety Standards Guidelines | Mental Health Services Council | FAQ's

Prior Approval Review
Sample Letter of Intent
Agency Provides Mental Health Services, but Not Licensed by OMH

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Letter of Intent

To:
Local Government Unit
Office of Mental Health Field Office
From:
Agency name
Agency address

For projects proposed by an agency that currently provides mental health services authorized (but not licensed) by OMH.

Identify type of services:

Proposed Action: Identify type of project

Narrative: Please provide a brief description of proposed project, identifying the county/borough involved and include anticipated effective date.

Circle type of application to be submitted: EZ Prior Approval Review (PAR) / Comprehensive PAR

Chief Executive Officer (CEO)/Executive Director:

Contact Person: name & title

Telephone #:

Email address:

Comments or questions about the information on this page can be directed to the Bureau of Inspection and Certification.