Some standards have forms that are referenced in the Table of Evidence. You can find them in your MyCOA account or on COA’s website.

When a form is required, you can use the form provided or attach an existing form in lieu of this document, provided that it captures all of the information requested in the form.

Forms Description
Collaborative Relationships Profile This form is used to provide information about the adoption service providers you partner with in Convention cases. You will need to include contact information for each provider. You will also need to indicate what role each provider takes on when you work on Convention cases together (e.g., primary provider, supervised provider, or exempt provider). You will need to include information about domestic and foreign partners on this form.<br />
Governing Body Profile This form is used to provide information about the members of your Governing Body/Advisory Group. This form is NA for individual practitioners seeking approval.<br />
Employee Profile This form is used to provide information about employees who are involved in the provision of services in Convention cases.<br />
Executive Verification Statement This form is used by your Executive Director and Governing Body Chair to disclose certain information, as required in the standards. This form must be notarized.<br />
State Licensing and Regulatory Profile This form is used to provide information about the state licensing rules or other regulations that apply.<br />


Private Organization Accreditation

Southeastern Regional Mental Health, Developmental Disabilities and Substance Abuse Services is a Local Management Entity, covering the geographic areas of Bladen, Columbus, Robeson, and Scotland counties. SER ensures continuity of care to consumers through access to a quality of care system available 24/7/365 days a year through management of our network provider services.


Jane Bonk, Ph.D., LCSW

Volunteer Roles: Commissioner; Evaluator; Lead Evaluator; Peer Reviewer; Team Leader

Dr. Jane Bonk is a team leader, evaluator, and commissioner who has led over 25 site visits for COA.
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