Wayne County Community

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201 East Main Richmond, IN 47374

Executive Director: Eric Coulter Vital Records and Environmental Health: Email: [email protected] (765) 973-9245 Clinic and Nursing Division: (765) 973-9294 TTY users call 711

Although the Wayne County Health Department provides many services to the citizens of Wayne County, Indiana our most common inquiry from Internet users is for birth and death certificates for people who are doing genealogical research. To aid these researchers, we have provided scans of the forms used to request certificates through the mail below. Choose the appropriate form, fill it out, and then print the page from your browser. Instructions are on the forms. Note: You must have Adobe Acrobat Reader which you can get for free from Adobe's website

Acceptable payment methods are CHECK or MONEY ORDER ONLY --NO CASH WILL BE ACCEPTED

Address: Wayne County Health Department 201 East Main Richmond, IN 47375

Food Service Establishment Online Applications

Application for Food Service Establishment and/or Mobile Food Unit Permits Application For Not-For-Profit Food Service Establishment Application for Temporary Food Service Permit

Fee Schedule, The following fee schedule as established by the Board of Health and hereby approved by the Board of Commissioners of Wayne County, Indiana, pursuant to Indiana Code Section 16-20-1-27, shall be collected by the Health Department when providing those services described therein, or when furnishing to a person copies of vital records as set out therein:

Retail Food Establishment Permit Up to 3,000 Square feet

Retail Food Establishment Permit From 3,001 Square feet to 8,000 square feet

Retail Food Establishment Permit 8,001 square feet and over

Mobile Retail Food Establishment Permit (12 months)

Temporary Food Establishment Permit

$15.00 per day or $210.00 maximum

Reinstatement of any Retail Food Establishment Permit or Mobile Retail Establishment Permit

Retail Food Establishment Plan Review for new construction (Application filed prior to commencement of any new construction)

Retail Food Establishment Plan Review for new construction (Application filed after commencement of any new construction)

Retail Food Establishment Plan Review for remodel (Application filed prior to commencement of remodel)

Retail Food Establishment Plan Review for remodel (Application filed after commencement of remodel)

Retail Food Establishment Permits-issued after July 1st of any calendar year

One half the applicable annual fee

Note: All Retail Food Establishment fees are to be paid annually based on a calendar year. No fees will be prorated during any calendar year except as noted herein.

Residential Sewage Disposal - Written Permit (New Construction)

Residential Sewage Disposal - Written Permit (Replacement)

Residential Sewage Disposal - Written Permit (Repair)

Registration Fee for Residential Sewage Disposal System (Contractors)

Registration Fee for Residential Sewage Disposal System (Employee of Contractor)

Contractors indemnity bond (minimum amount of bond)

Public and Semi-Public Pool License (12 months)

Public and Semi-Public Pool License (Seasonal-6 months or less)

Wading Pool, Spa, and Diving Pool (12 months)

Wading Pool, Spa, and Diving Pool (6 months)

Birth Certificate- first copy (Paper Copy)

Each additional paper copy of birth certificate when issued at the same time on the same record

Death Ce1iificate (includes $2.00 for Coroner's continuing education fee)

Each additional copy of death certificate when issued at the same time on the same record

Correction to Birth Certificate

Paternity Affidavit Upon Marriage

Primary Focus of the Provider

• Substance Abuse Treatment Services
• Mental Health Treatment Services
• Mix of Mental Health and Substance Abuse
• General health services

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Type of Care

• Mental health treatment
• Substance abuse treatment
• Detoxification
• Methadone maintenance
• Methadone maintenance for predetermined time
• Methadone detoxification
• Buprenorphine maintenance
• Buprenorphine maintenance for predetermined time
• Buprenorphine detoxification
• Relapse prevention from naltrxone
• Buprenorphine used in treatment
• Naltrexone (oral)
• Vivitrol (injectable Naltrexone)
• Methadone
• Transitional housing or halfway house
• Do not treat opiod addiction
• Use methadone/buprenorphoine for pain management or emergency dosing
• Do not use medication for opioid addiction
• Accepts clients on opioid medication
• Prescribes/administer buprenorphine and/or naltrexone
• All Clients in Opioid Treatment Program
• SAMHSA-certified Opioid Treatment Program

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Facility Type

• Psychiatric hospital or psychiatric unit of a general hospital
• Residential treatment center (RTC) for children
• Residential treatment center (RTC) for adults
• Other residential treatment facility
• Partial hospitalization/day treatment
• Outpatient mental health facility
• Community mental health center
• Multi-setting mental health facility (e.g., residential plus outpatient)

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Treatment Approaches

• Individual psychotherapy
• Couples/family therapy
• Group therapy
• Cognitive/behavioral therapy
• Dialectical behavioral therapy
• Behavior modification
• Integrated dual disorders treatment
• Trauma therapy
• Activity therapy
• Electroconvulsive therapy
• Psychotropic medication
• Telemedicine therapy
• Substance abuse counseling approach
• Trauma-related counseling
• Rational emotive behavioral therapy

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Facility Smoking Policy

• Smoking not permitted
• Smoking permitted in designated area
• Smoking permitted without restriction

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Service Setting (e.g., Outpatient, Residential, etc.)

• Hospital inpatient
• Residential
• Partial hospitalization/day treatment
• Outpatient
• Short-term residential
• Long-term residential
• Residential detoxification
• Outpatient detoxification
• Outpatient methadone/buprenorphine or vivitrol
• Outpatient day treatment or partial hospitalization
• Intensive outpatient treatment
• Regular outpatient treatment
• Hospital inpatient detoxification
• Hospital inpatient treatment
• Computerized treatment
• General Hospital(including VA hospital)
• Psychiatric hospital

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Facility Operation (e.g. Private, Public)

• Private organization
• U.S. Department of Veterans Affairs
• State mental health authority
• Other state government agency
• Regional/district or county, local or municipal government
• Tribal government
• Indian Health Service
• State Government
• Local, county, or community government
• Department of Defense
• State substance abuse agency
• State mental health department
• State department of health
• Hospital licensing authority
• The Joint Commission
• Commission on Accreditation and Rehabilitation
• National Committee for Quality Assurance
• Council on Accreditation
• Healthcare Facilitiues Accreditation Program
• Other national oraganization

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Payment/Insurance Accepted

• No payment accepted
• Cash or self-payment
• Medicaid
• Medicare
• State financed health insurance plan other than Medicaid
• Private health insurance
• Military insurance (e.g., TRICARE)
• IHS/Tribal/Urban (ITU) funds
• Access to recovery (ATR) voucher
• State mental health agency (or equivalent) funds
• State welfare or child and family services funds
• State corrections or juvenile justice funds
• State education funds
• Other State funds
• County or local government funds
• Community Service Block Grants
• Community Mental Health Block Grants
• U.S Department of VA funds
• Federal, or any government funding for substance abuse programs

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Emergency Mental Health Services

• Crisis intervention team
• Psychiatric emergency walk-in services

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Payment Assistance Available

• Sliding fee scale (fee is based on income and other factors)
• Payment assistance (check with facility for details)

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Language Services

• Services for the deaf and hard of hearing
• Spanish
• Native American Indian or Alaska Native languages
• Other languages(excluding Spanish)

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Special Programs/Groups Offered

• Persons with co-occurring mental and substance abuse disorders
• Lesbian, gay, bisexual, or transgender (LGBT) clients
• Veterans
• Active duty military
• Military families
• Clients referred from the court/judicial system
• Seniors or older adults
• Adolescents
• Pregnant/postpartum women
• Adult women
• Adult men
• Persons with HIV or AIDS
• Persons who have experienced trauma
• Persons who have experienced sexual abuse
• Persons who have experienced intimate partner violence, domestic violence
• Children with serious emotional disturbance (SED)
• Persons with serious mental illness (SMI)
• Persons with Alzheimer's or dementia
• Persons with post-traumatic stress disorder (PTSD)
• Persons with traumatic brain injury (TBI)
• Transitional age young adults
• Persons with eating disorders

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Ancillary Services

• Assertive community treatment
• Intensive case management
• Case management
• Chronic disease/illness management
• Consumer-run (peer-support) services
• Court-ordered outpatient treatment
• Diet and exercise counseling
• Education services
• Family psychoeducation
• Housing services
• Illness management and recovery
• Integrated primary care service
• Legal advocacy
• Nicotine replacement therapy
• Non-nicotine smoking/tobacco cessation medications
• Psychosocial rehabilitation services
• Screening for tobacco use
• Suicide prevention services
• Supported employment
• Supported housing
• Therapeutic foster care
• Smoking/tobacco cessation counselling
• Vocational rehabilitation services
• Alcohol Detoxification
• Benzodiazepines Detoxification
• Cocaine Detoxification
• Methamphetamines Detoxification
• Opiods Detoxification
• Treatment for gambling disorder
• Treatment for internet use disorder
• Individual counseling offered
• Group counseling offered
• Family counseling offered
• Marital/couples counseling offered
• 12-step faciltitation approach
• Brief intervention approach
• Contingency management/motivational incentive
• Motivational interviewing
• Anger management
• Martix Model
• Community reinforcement plus vouchers
• Relapse prevention
• Residential beds for clients children

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Age Groups Accepted

• Children/adolescents
• Young adults
• Adults
• Seniors (65 or older)

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Gender Accepted

• Female
• Male

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Exclusive Services

• Methadone and buprenorphine clients only
• Methadone clients only
• DUI/DWI clients
• Serve only DWI clients

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