213341

LICENSE NUMBER

 

 

 
 

BOARD OF PAARP

If; REGISTERED WITH MT SEC OF STATE

NAME OF APPLICANT NEW HORIZONS YOUTH RANCH INC.

DATE RECEIVED 1/11/2010

 

Other Names Known As or

DATE APPLICATION EXPIRES

DBA: DEP #357306 5/51'2002 RECEIVED $500 AND $260

 

l? COMPLETED APPLICATION

APPLIQATIQN

FEES RECEIVED . .
IX: REGISTRATION FEE - 0?10 $1,080?

 

 
 

REGISTRATION FEE - 11-25 $2,780.00
REGISTRATION FEE - 26-50 $5,210.00
REG-ISTRATION FEE - 51-100 $8,520.00

LICENSE FEE - 0-10 $270.00

 

LICENSE FEE - 11-2-5 $695.00
1? LICENSE FEE 26-50 $1,300.00
LICENSE FEE - 51-100 $2,130.00

 

Programs with 101 and more participants must contact the board for current information on the average daily census.

 

Xi OWNERS LISTED [327 EMPLOYEES LISTED

 

ACCREDITING. ENTITY

 

931$ REQUIREMENTS

 

  

PERSON IN CHARGE Background Check .-
THOMAS E. HARRELL [7
LI 5 HISTO 
1 LICENSE VERIFICATION LIST STATE OR STATES LICENSED

 

 

RECEIVED
LEGAL ACTION
STATE DISCIPLINARY MISCELLANEOUS COURT OTHER
DOCUMENTS
EERSONNEL INFORMATION

   

PERSONAL HEALTH

IMPAIRMENT ISSUES OTHER
ISSUES 

 

 

[7 BOARD TO I RRESPONDENCE

APPLICANT

DATE DATE GIVEN APPLICATION
COMPLETE TO PM REVIEWED BY

 

INITIALS AND DATE
APPLICATION

REVIEWED BY 
BOARD APPROVAL AND DATE

 

APPROVE 

 

INITIALS AN DATE 1 

DATA COMPLETED WALL CERTIFICATE AND:
COMPUTER LICENSE SENT I

PAP Reg App

REVISED 06/08, MONTANA BOARD OF PRIVATE ALTERNATIVE ADOLESCENT RESIDENTIAL 
5/09 OUTDOOR PROGRAMS #5
Page 3 of 9 (301 PARK, 4TH FLOOR - Delivery) 
PO Box 200513 .4 V5
Helena, Montana 59620-0513 1 
PHONE (406) 841-2392 or (406) 841-2369 (406) 341-2305 . I 95?;9
EMAIL: [1628

i? PROVISIONAL LICENSING REGISTRATION (Include copies of all requested documentation)

AVERAGE DAILY CENSUS: 0-10 Participants [ff 11?25 Participants a? 26-50 Participants
51-100 Participants 101+ Participants

1. BUSINESS ENTITY: Sole Proprietorship Partnership {it Other

i2: Limited Liability Professional Corporation Non-Professional Corporation
2. BUSINESS STATUS: Non-Pro?t For Profit l? In?State l" Out-of-State

If the Business is incorporated out-of-state, list the state of incorporation

 

Please provide the address of your Corporate Headquarters

 

 

Registered in Montana With the Secretary

 

 

 

 

 

 

3. DATE BUSINESS ESTABLISHED 1999 of State? Yes i? No
4. BUSINESS ENTITY NAME New Horizons Youth ranch inc.

5. FEDERAL TAX ID OR SOCIAL SECURITY 

6. BUSINESS PHYSICAL ADDRESS 6442 west Kootenai road, Rexford, Mt. 59930
7. BUSINESS MAILING ADDRESS same

8. BUSINESS TELEPHONE NUMBER {106-889-5192 FAX 406-889-5996
9. BUSINESS EMAIL ADDRESS maii@newhorizonsyouth.com

10. BUSINESS WEB SITE: 

 

 

Would you like your website address listed on the Montana Board of Private Adolescent
Residential or Outdoor Programs Website? [ng Yes if No

PAP Reg App Page 5 of 9
REVISED 06(08, 6f09

For the individual named in Question number 12. (person responsible for the conduct of the

program), and each current professional and supervisory employee listed in your answer to
Question number 13, please list the following: (Please use the "Individual Employee Report Form"
Page 7) for each person named in question #12 and 13).

a. List all other professional licenses (other than your original state of licensure) that
the listed individuals have held and that have been current (whether active or inactive)
at any time during the past five (5) years. If you need additional space, you may
attach a separate sheet of paper. Failure to list all licenses active or inactive
during the previous five years constitutes a falsification of your application
and will result in a denial of your application and/or disciplinary action.

b. For each individual, professional or supervisory personnel referenced in your
answers, indicate whether a licensing agency has ever taken adverse or disciplinary
action against the listed person?s license. (For each person listed above and where i
the answer is "yes" attach agency documents filed in the action including all 3
complaints, initiating documents, orders, final orders, stipulations and consent
and/or settlement agreements.) 3: Yes 33?; No

 

c. For each individual, professional or supervisory personnel referenced 
above, indicate whether heXshe has ever voluntarily surrendered,
cancelled forfeited or failed to renew a license as a result of any of i
the following: having a complaint filed against you; entering into a 
consent agreement with respect to your license as a result of a complaint, 
during an investigation or during disciplinary proceedings. (If yes, attach
a detailed explanation identifying each occasion, the date and the substance
of the allegations, along with agency documents filed in the action including
all complaints, initiating documents, orders, final orders, stipulations and
consent and/or settlement agreements.) Yes 353 No

d. Has any legal or disciplinary action been filed against a persony?individual
referenced above, (including malpractice, etc)? If yes attach a
detailed explanation of each instance including the date of the claim,
name and address of party complaining, name and address of forum or
court where claim was filed, docket or claim number and the substance

of the allegations. 37 Yes No

14. Please list whether your programx?facility is including
registration or licensing through another state agency in Montana.

 

 

 

 

 

Name of Date Granted or
Registering Agency Re-certified Current
None 3PAP Reg App

REVISED 06/08, 6/09

Page 6 of 9
15.

Please list whether your business entity/program is or has been licensed in
another state. List all other professional licenses (other than your original state
of licensure) that the listed business entity/program has held and that has been
current (whether active or inactive) at any time during the past ?ve (5) years.

 


Business Name of Program State in Which

of License
licensed licensure yp

 

 

None

Date of License
number



 

 

16licensing agency ever taken adverse or disciplinary action against your

business entity license? (For each person listed in 12. or 13., and where the

answer is "yes" attach agency documents filed in the action including all

complaints, initiating documents, orders, ?nal orders, stipulations and 
es

consent and/0r settlement agreements.)

Has this business or the person in charge of this business who is listed on the

application ever had an application for a professional or occupational license

refused or denied? If yes, please attach a detailed explanation and provide Yes

supporting documentation from the source.

Has this ousiness Or the person in charge of this business who is listed on the
application ever withdrawn an application for licensure prior to the licensing

agency's decision regarding your application? If yes, please attach a detailed
explanation and provide supporting documentation from the source. i Yes

Has the person in charge of this business who is listed on this application
ever been denied the privilege of taking an examination required for any
professional or occupational license? If yes, please attach a detailed
explanation and provide supporting documentation from the source.

Has the person in charge of this business who is listed on this application
ever withdrawn or been suspended, placed on probation, expelled or
requested to resign from any postsecondary educational program? If yes,

from the sou rce.

Has the person in charge of this business who is listed on this application
ever requested temporary or permanent leave of absence, been paced

on probation, restricted, suspended, revo<ed, allowed to resign, or otherwise
acted against by any professional or occupational education program 
residency, internship, apprenticeship, etc)? If yes, please attach a detailed
explanation and provide supporting documentation from the source.

Has a licensing agency initiated or completed disciplinary action against

this business or the person in charge of this business who is listed on this
application? If yes, please provide agency documents including the complaint,
initiating documents, orders, final orders, stipulations and consent and/or Yes
settlement agreements directly from the source.
Has this business or the person in charge of this business who is listed on this
application voluntarily surrendered, cancelled, forfeited, failed to renew a

professional or occupational license in anticipation of or during an investigation

or disciplinary proceeding or action? If yes, please attach a detailed explanation

and provide supporting documentation from the source. Yes



l?gNo

FiNo

please attach a detailed explanation and provide supporting documentation 

NO

 

PAP Reg App
REVISED 06/08,

6/09
Page complaint ever been made against this business or person in charge
of this business who is listed on this application with a professional or

occupational licensing agency? If yes, please attach a detailed explanation

and provide supporting documentation from the source.

Has this business or the person in charge of this business who is listed on

this application ever been censured, expelled, denied membership or asked to
resign from a professional organization related to the profession or occupation?

If yes, please attach a detailed explanation and provide documentation from l? Yes No
the source.

Does this busmess or the person in charge of this business who is lis:eci on

this appiication have any initiated or completed action against you by any state,
federal, tribal, or foreign licensing jurisdiction? (For example: Drug
Enforcement Agency; Alcohol, Tobacco and Firearms; Homeland Security;
Indian Health Service, etc) If yes, please attach a detailed explanation and .
provide documentation from the source. 5 Yes l3?" No
Have any civil legal proceedings been filed against this business or the person in

charge of this business who is listed on this application by a (patient/client),

(former patient/client) or employer/employee? If yes, attach a detailed

explanation and documentation from the source including initiating document(s) 

and documentation of ?nal disposition. i . es '7 No

Does this business or the person in charge of this business who is listed on this
application have any criminal charges pending or has this business or the
person in charge of this business ever pled guilty, forfeited bond, or seen
convicted of a crime (whether or not sentence was suspended or deferred), or
has this business ever pled no contest or had prosecution deferred whether or
not an appeal is pending? If yes, attach a detailed explanation and
documentation from the source. You must report but may omit
documentation for: (1) misdemeanor traffic violations resulting in fines of

less than $100; and (2) charges or convictions prior to your 18th birthday Yes 55 No
unless you were tried as an adult.
Has the person in charge of this business who is listed on this application

ever been ciagnosed with chemical dependency or another addiction,

or participated in a chemical dependency or other addiction treatment

program? If yes, please attach a detailed explanation and provide

documentation regarding evaluations, diagnosis, treatment

recommendations and monitoring from the source.

Has the person in charge of this business who is listed on this application
ever been diagnosed with a physical condition or mental health disorder

involving potential health risk to the public? If yes, please provide a 
detailed explanation.

Has the person in charge of this business who is listed on this application
ever been court-martialled or discharged other than honorably from any
branch of the armed service? If yes, attach a detailed explanation and
documentation for the source.

PAP Reg App MONTANA BOARD OF PRIVATE ALTERNATIVE ADOLESCENT RESIDENTIAL

REVISED 06/08,

6,109

OR OUTDOOR PROGRAMS

Page 3 of 9 (301 PARK, 4TH FLOOR - Delivery)

PO Box 200513
Helena, Montana 59620-0513
PHONE (406) 841-2392 OR (406) 841?2369 FAX (406) 841-2305
EMAIL: dlilasdnan@mt.gov. WEBSITE: 

INDIVIDUAL EMPLOYEE REPORT FORM

Please use this form in answering #12 and #13, and on page 5 of the application for
each employee and the person-in-charge of the program. Please make copies as needed and 

attach to application. . 
Employee Name I kpm.q5 ?Curtis ?1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Position QWQ \m-mLx-J?
.i

a. Professional licenses held (active or inactive) at any time during the past five (5) years.

DATE OF LICENSE AND

TYPE OF LICENSE STATE OF LICENSE EXPIRATION
.. 1 1
C?\?ig??nx J?Marx?XOlr-at-k A?L?xlut 
b. Has a licensing agency ever taken adverse or disciplinary action against your  icense(s)?


If "yes" please attach agency documents filed in the action including all complaints, initiating 3? es
documents, orders, final orders, stipulations and consent and} or settlement agreements.
c. Have you ever voluntarily surrendered, cancelled, forfeited or failed to renew a license as

a result Of any of the following: having a complaint ?led against you, entering into a consent
agreement with respect to your license as a result of a complaint during an investigation or
during disciplinary proceedings.

l1} Yes

If "yes", attach a detailed explanation identifying each occasion, the date and the substance
of the allegations, along with agency documents filed in the action including all complaints,
initiating documents, orders, final orders, stipulations and consent andlor settlement agreements.

d. Has any legal or disciplinary action been filed against you, (including malpractice, etc)?

If ?yes", attach a detailed explanation of each instance including the date of the claim, name and in? Yes
address of party complaining, name and address of forum or court where claim was filed, docket
or claim number and the substance of the allegations.

fl/f/IO

Signature Date

 

XNO

END

 MONTANA BOARD OF PRIVATE ALTERNATIVE ADOLESCENT RESIDENTIAL
6,09 . OR OUTDOOR PROGRAMS
page 8 ofg (301 PARK, 4TH FLOOR - Delivery)
PO Box 200513
Helena, Montana 59620-0513
PHONE (406) 341-2392 OR (406) 841?2369 FAX (406) 841-2305

EMAIL: dlibsdpap?imtgm WEBSITE: 

INDIVIDUAL EMPLOYEE REPORT FORM

Please use this form in answering #12 and #13, and on page 5 of the application for
each employee and the person-in-charge of the program. Please make copies as needed and
attach to application. 

Employee Name @526 

 

 

 

 

 

 

 

 

 

 

 

 

 

Position lgsiilQ/?AW (?ir?hf?i?fbp
a. Professional licenses held (active or inactive) at any time during the past five (5) years.
- 
DATE OF LICENSE AND
TYPE or LICENSE STATE OF LICENSE EXPIRATION
b. Has a licensing agency ever taken adverse or disciplinary action against your license(s)?
Yes 

If "yes" please attach agency documents filed in the action including all complaints, initiating
documents, orders, final orders, stipulations and consent and or settlement agreements.

c. Have you ever voluntarily surrendered, cancelled, forfeited or failed to renew a license as
a result of any of the following: having a complaint filed against you; entering into a consent
agreement with respect to your license as a result of a complaint during an investigation or

during disciplinary proceedings. 
Yes Mo

If ?yes", attach a detailed explanation identifying each occasion, the date and the substance
of the allegations, along with agency documents ?led in the action Including all complalnts,
initiating documents, orders, final orders, stipulations and consent and or settlement agreements.

cl. Has any legal or disciplinary action been filed against you, (including malpractice, etc)?

If "yes", attach a detailed explanation of each instance Including the date of the claim, name and YES MO
address of party complaining, name and address of forum or court where claim was filed, docket
or claim number and the substance of the allegations.

MW .2 513,,

Signature Date

 

 

 08 MONTANA BOARD OF PRIVATE ALTERNATIVE ADOLESCENT RESIDENTIAL
2/09 I OR OUTDOOR PROGRAMS
page 8 0,9 (301 PARK, 4TH FLOOR - Delivery)
Po Box 200513
Helena, Montana 59620-0513
PHONE (406) 341?2392 OR (406) 841-2369 (406) 341-2305

EMAIL: WEBSITE: 
INDIVIDUAL EMPLOYEE REPORT FORM

Please use this form in answering #12 and #13, and on page 5 of the application for
each employee and the person-in-charge of the program. Please make copies as needed and

attach to application. -. . -
Employee Name (Jr: LA M'lv?
Position ,Dv"

Professional licenses held (active or inactive) at any time during the past five (5) years.

a
DATE OF LICENSE AND
TYPE DF LICENSE STATE OF LICENSE ACHVEIINACTIVEIEXPIRED EXPIRATION

1?
unow 6mm

w/ modal)

 

 

 

 

 

 

 

 

 

 

 

 

b. Has a licensing agency ever taken adverse or disciplinary action against your license(s)?

Yes WNO

If "yes" please attach agency documents filed In the action including all complaints, initiating
documents, orders, final orders, stipulations and consent and/or settlement agreements.

c. Have you ever voluntarily surrendered, cancelled, forfeited or failed to renew a license as
a result of any of the following: having a complaint filed against you; entering into a consent
agreement with respect to your license as a result of a complaint during an investigation or

during disciplinary proceedings.
Yes 

If "yes", attach a detailed explanation identifying each occasion, the date and the substance
Of the allegations, along with agency documents filed In the action including all complaints,
initiating documents, orders, final orders, stipulations and consent and/or settlement agreements.

d. Has any legal or disciplinary action been filed against you, (including malpractice, etc.)?

If "yes", attach a detailed explanation of each instance including the date of the claim, name and Yes 
address of party complaining, name and address of forum or court where claim was filed, docket
or claim number and the substance of the allegations.

[54/0 

Date 

 

PAP R69 APP MONTANA BOARD OF PRIVATE ALTERNATIVE ADOLESCENT RESIDENTIAL

06?08' OR OUTDOOR PROGRAMS
page 8 0,9 (301 PARK, 4TH FLOOR - Delivery)

PO Box 200513
Helena, Montana 59620-0513
PHONE (406) 841-2392 OR (406) 841-2369 FAX (406) 841-2305
EMAIL: Wmtgov WEBSITE: 

INDIVIDUAL EMPLOYEE REPORT FORM

Please use this form in answering #12 and #13, and on page 5 of the application for
each employee and the person-in?charge of the program. Please make copies as needed and

attach to application. . -
Employee Name IccuAS ?n?sevo 
.

 

 

 

 

 

 

 

 

 

 

 

 

 

Position Coo-s. men on 

a. Professional licenses held (active or inactive) at any time during the past five (5) years.
DATE OF LICENSE AND

TYPE or LICENSE STATE OF LICENSE ACTIVEIINACTIVEIEXPIRED EXPIRATION 

[a

I
b. Has a licensing agency ever taken adverse or disciplinary action against your license(s)?
Yes ii No

If "yes" please attach agency documents fiied in the action including all complaints, initiating
documents, orders, flnal orders, stipulations and consent andlor settlement agreements.

c. Have you ever voluntarily surrendered, cancelled, forfeited or failed to renew a license as
a result of any of the following: having a complaint filed against you; entering into a consent
agreement with respect to your license as a result of a complaint during an investigation or

during disciplinary proceedings.
Yes No
If "yes", attach a detailed explanation identifying each occasion, the date and the substance

of the allegations, along with agency documents filed in the action including all complaints,
initiating documents, orders, final orders, stipulations and consent and or settlement agreements.

d. Has any legal or disciplinary action been flied against you, (including malpractice, etc)?

If "yes", attach a detailed explanation of each instance Including the date of the claim, name and if Yes 527 N0
address of party complaining, name and address of forum or court where claim was filed, docket
or claim number and the substance of the allegations.

Caz/Jag Millage

.

ignature Date

 

 

PAP Reg APP MONTANA BOARD OF PRIVATE ALTERNATIVE ADOLESCENT RESIDENTIAL

233%? 06?08' OR OUTDOOR PROGRAMS
page 3 of 9 (301 PARK, 4TH FLOOR - Delivery)

PO Box 200513
Helena, Montana 59620-0513
PHONE (406) 841?2392 OR (406) 841-2369 FAX (406) 841?2305
EMAIL: WEBSITE: 

INDIVIDUAL EMPLOYEE REPORT FORM

Please use this form in answering #12 and #13, and (cl) on page 5 of the application for
each employee and the person-in?-charge of the program. Please make copies as needed and
attach to application.

Employee Name x} 6711 (A ?if; in?iLO?ji Ci

Position (J

 

 

a. Professional licenses held (active or inactive) at any time during the past five (5) years.
. DATE OF LICENSE AND
TYPE OF LICENSE STATE OF LICENSE EXPIRED EXPIRATION

 

 

veiled/ins) @onlracgicr' MGi?i?i? 03) Lil/l4} I 

 

 

 

 

 

 

 

 

 

lo. Has a licensing agency ever taken adverse or disciplinary action against your license(s"yes" please attach agency documents filed in the action including all complaints, Initiating 
documents, orders, final Orders, stipulations and consent and] or settlement agreements.

c. Have you ever voluntarily surrendered, cancelled, forfeited or failed to renew a license as
a result of any of the following: having a complaint filed against you; entering into a consent
agreement with respect to your license as a result of a complaint during an investigation or

during disciplinary proceedings. 
Yes No
If "yes", attach a detailed explanation identifying each occasion, the date and the substance

of the allegations, along with agency documents ?led in the action Including all complaints,
initiating documents, orders, final orders, stipulations and consent and I or settlement agreements.

d. Has any legal or disciplinary action been filed against you, (including malpractice, etc)?

If "yes", attach a detailed explanation of each instance including the date of the claim, name and in. Yes VNO
address of party complaining, name and address of forum or court where claim was filed, docket
or claim number and the substance of the allegations.

 



?gnature

?mMi/Moiiwjd it: 

PAP Reg App
REVISED OBIDS,
6/09

Page 8 of 9

OR OUTDOOR PROGRAMS
(301 PARK, 4TH FLOOR - Delivery)

MONTANA BOARD OF PRIVATE ALTERNATIVE ADOLESCENT RESIDENTIAL

PO Box 200513
Helena, Montana 59620-0513
PHONE (406) 841-2392 OR (406) 841-2369 FAX (406) 841-2305

EMAIL: comm WEBSITE: WW
INDIVIDUAL EMPLOYEE REPORT FORM

Please use this form in answering #12 and #13, and on page 5 of the application for
each employee and the person-in~charge of the program. Please make copies as,needed and

a: i ?ctr/0f (Mideast)
Position Teacher 7/ Edumtl?om (?wratlwa?iof

a. Professional licenses held (active or inactive) at any time during the past five (5) years.

 

DATE OF LICENSE AND

TYPE OF LICENSE EXPIRATION

STATE OF LICENSE ACTIVEZINACTIVEZEXPIRED

 

Class 

?Ur/20198
Level 

A alive? rm 5 61/30'11'520i3

Montana

 

Foll?d 4* 77016;

 

 

 

 

 

 

 

 

 

b. Has a licensing agency ever taken adverse or disciplinary action against your  icense(s)?

Yes Kilo

If "yes" please attach agency documents filed in the action including all complaints, initiating
documents, orders, ?nal orders, stipulations and consent and! or settlement agreements.

c. Have you ever voluntarily surrendered, cancelled, forfeited or failed to renew a license as
a result of any of the following: having a complaint ?led against you; entering into a consent
agreement with respect to your license as a result of a complaint during an investigation or
during disciplinary proceedings.
l" Yes No

If "yes", attach a detailed explanation identifying each occasion, the date and the substance
ofthe allegations, along with agency documents ?led in the action including all complaints,
initiating documents, orders, ?nal orders, stipulations and consent and/or settlement agreements.

cl. Has any legal or disciplinary action been filed against you, (including malpractice, etc)?

If "yes?, attach a detailed explanation of each instance Including the date of the claim, name and in Yes NO
address of party complaining, name and address of forum or court where claim was filed, docket
or claim number and the substance of the allegations.

#5920/0

Signature Date

 

 

PAP Reg App
REVISED 06f08, 6/09

Page 9 of 9

    

DECLARATION

As the Person-in?Charge, I authorize the release of information concerning the
record, character, license/registration history and competence of this facility,
by anyone who might possess such information, to the Montana Board of
Private Alternative Adolescent Residential or Outdoor Programs.

I hereby declare under penalty of perjury the information included in this
application to be true and complete to the best of my knowledge. In signing
this application, I am aware that a false statement or incomplete answer to
any question may lead to denial of this application or subsequent revocation
of licensure on ethical grounds. I have read and am familiar with the licensing
laws of the State of Montana and instructions to applicants for registration. I
accept the rules and procedures outlined in these documents as the basis for
this application.

19

Date

 






Signature of Person?in-Charge