Licensing Forms

Complete and submit the following forms to Regional Office of Licensure nearest the location to be licensed.

           1. Initial Application     

           2. Fact Sheet     

           3. Background Check and Privacy Statement Form

           4. Financial Statement

TDMHSAS Licensing forms are available in both printable PDF and web-based formats.  Choose the version below that meets your needs and follow the directions on the form for submission.

Initial Application (Print)
Initial Application (Web-based)

Change of Status (Print)
Change of Status (Web-based)

Fact Sheet (Print)
Fact Sheet (Web-based)

Financial Statement (Print)
Financial Statement (Web-based)

Background Check and Non-Criminal Justice Privacy Rights  (Print)
Background Check and Non-Criminal Justice Privacy Rights (Web-based)

Reportable Incident (Print)
Reportable Incident (Web-based)
Incident Reporting Requirements (Word .doc download)

Patient Risk Assessment and Evaluation of Capability Form (Print)
Patient Risk Assessment and Evaluation of Capability Form (Web-based)