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Home My WebLink About2016-582-E Finance - Freedom House Recovery Center, Inc. - Outside Agency Performance Agreement DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 OUTSIDE AGENCY PERFORMANCE AGREEMENT THIS AGREEMENT,made and entered into the first day of July 2016, ("Effective Date")by and between the County of Orange, a political subdivision of the State of North Carolina, 200 South Cameron Street, Hillsborough, North Carolina, 27278, ("County") and Freedom House Recovery Center, Inc., a not-for- profit corporation, located at 104 New Stateside Drive, Chapel Hill,NC 27516 ("Provider"). WITNESSETH: WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby enhance its availability to residents of the County, and said program addresses an important community human services need, as identified by the Board of Commissioners; NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set forth, the County and Freedom House Recovery Center, Inc. agree as follows: 1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1, 2016 to June 30, 2017. 2. Scope of Services. a. Provider will provide services, as outlined in the attached Outside Agency Funding Application and any amendments or revision thereto which is attached as Exhibit"A" and incorporated by reference, to the residents of Orange County. The Scope of Services and the Program Budget may be different from the original application based on County appropriation; however, any revisions or amendments to this Agreement must be approved in writing by the County and attached to this Agreement as Exhibit B. b. The Provider shall be solely responsible for the means, methods, techniques, sequence, safety program and procedures necessary to properly and fully complete the work set forth in the Scope of Services. 3. Funding. a. The County agrees to appropriate for the provision of services described in Exhibit A, Scope of Services and more particularly described in the Revised Program Budget, the maximum sum of$35,000. b. All funds appropriated shall be used for purposes described in Exhibit A. Any funds not used for the purposes stated shall be returned to the County. Any changes in the use of funds must be authorized in writing by the County prior to any expenditure of the funds by the Provider. If the funds are expended not in accordance with the Scope of Services, at the discretion of the County the Provider may be required to repay the funds to the County. c. The Provider shall be paid in four equal installments in the amount of $8,750. The first payment is contingent upon receipt of the agency's performance agreement; the remaining payments are contingent upon receipt of the request for reimbursement and related supporting documentation. d. The County's obligation to make the quarterly payments is contingent upon receipt of Progress Reports, which show satisfactory progress toward completion of performance measures and an accounting of expenditures as detailed in the attached Scope of Services. (Freedom House Recovery Center,Inc.) Orange County Outside Agency Performance Agreement Revised 8/2016 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 e. Once Provider has satisfied its obligations as provided in (d) payment will be made 21 days after receipt of the Progress Report and Request for Reimbursement or 21 days after due date of Progress Report whichever is later. f. The County is not obligated to provide any other support to Provider in this or in succeeding fiscal years. 4. Agency Reporting. a. Provider will provide Orange County a Progress Report that includes a fiscal report and updates on performance measures as outlined in the Scope of Services. Progress Report dates are: July 1 —December 31; January 1 —March 31 and April 1 - June 30. Reports are due on January 13,April 14, and July 14 of the program fiscal year. b. Provider agrees to allow the County to inspect its financial books and records, which document costs of those services,upon reasonable notice during normal working hours. 5. Termination. a. In the event of any of the circumstances set forth below (hereinafter referred to as "default"), the County may immediately terminate this Agreement, in whole or in part, and from time to time. Notice of termination must be in writing, state the reason or reasons for the termination, and specify the effective date of the termination: i. In the event that Provider shall cease to exist as an organization or shall enter bankruptcy proceedings, be declared insolvent, or liquidate all or substantially all of its assets, or significantly reduce its services or accessibility to Orange County residents during the term of this Agreement; or ii. In the event that Provider shall fail to render a satisfactory accounting as provided section 4 above, the County may terminate this Agreement and Provider shall return all payments already made to it by the County for services which have not been provided or for which no satisfactory accounting has been rendered; or iii. In the event of any fraudulent representation by the Provider in an invoice or other verification required to obtain payment under this Agreement or other dishonesty on a material matter relating to the performance of services under this Agreement. iv. Nonperformance, incomplete service or performance, or failure to satisfactorily perform any part of the work identified in the Scope of Services or to comply with any provision of this Agreement, as determined by the County in its sole discretion. v. Failure to adhere to the terms of applicable county, state or federal laws, regulations, or stated public policy. b. In the event of default by the Provider, the county may elect to terminate this Agreement, in whole or in part and/or require the Provider to repay the funds within ten(10)business days from written notice of default. The County may (but shall not be required to) grant the Provider an opportunity to cure the default without termination of this Agreement. This clause shall not be interpreted to limit the County's remedies in law or in equity. (Freedom House Recovery Center,Inc.) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 c. Notwithstanding the foregoing, either party may terminate the agreement at any time without penalty; provided that written notice of such termination is furnished to the other party at least 30 days prior to termination. In the event of such termination, any payment due shall be prorated to the date of termination and any unused funds shall be returned to the County within 10 days of termination. d. Any termination of this Agreement for default under this section that is later deemed to be unjustified shall be deemed a termination for convenience. 6. Insurance. a. General Requirements. The Provider shall purchase and maintain, during the period of performance of this Agreement, insurance: i. Worker's Compensation. For protection from claims under workers' or workmen's compensation acts; ii. Comprehensive General Liability Insurance covering claims arising out of or relating to bodily injury, including bodily injury, sickness, disease or death of any of the Consultant's employees or any other person and to real and personal property including loss of use resulting thereof; iii. Comprehensive Automobile Liability Insurance, including hired and non-owned vehicles, if any, covering personal injury or death, and property damage; and iv. Professional Liability Insurance, covering personal injury,bodily injury and property damage and claims arising out of or related to the performance under this Agreement by the Consultant or his agents, consultants and employees. b. Limits of Coverage: Minimum limits of insurance coverage shall be as follows: INSURANCE DESCRIPTION MINIMUM REQUIRED COVERAGE • Worker's Compensation Limits for Coverage A- Statutory State NC& Coverage B -Employers Liability $500,000 each accident, disease policy limit and disease each employee • Commercial General $1,000,000 Each Occurrence Liability $2,000,000 Aggregate • Automobile Liability $500,000 Combined Single Limit • Professional Liability $1,000,000 Each Occurrence $2,000,000 Aggregate c. All insurance policies (with the exception of Worker's Compensation and Professional Liability)required under this Agreement shall name the County as an additional insured party and as a certificate holder. Evidence of such insurance and all correspondence shall be sent to: Orange County Risk Manager Post Office Box 8181 Hillsborough,NC 27278 d. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. (Freedom House Recovery Center,Inc.) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 7. Relationship of the Parties. Provider is an independent contractor of the County. Provider represents that they have or will secure, at his own expense, all personnel required in performing the services under this Agreement. Such personnel shall not be employees or have any contractual relationship with the County. All personnel engaged in work under this Agreement shall be fully qualified and shall be authorized and permitted under federal, state and local law to perform such services. 8. Compliance with all Laws. The Provider, at its sole expense, shall comply with all laws, ordinances, orders and regulations of the federal, state or local governments, as well as their respective departments, commissions, boards, and officers, which are in effect at the time of execution of this Agreement or are adopted at any time following execution of this agreement. 9. Subcontract. The County and Provider deem the services provided under this Agreement to be personal in nature and Provider may not subcontract any rights or duties under this Agreement to any other party without prior written consent from the County. 10. Assignment. The Provider shall not assign this Agreement, including the rights to payment, to any other party without the prior written consent of the County. 11. Indemnification. Provider agrees to defend, indemnify, and hold harmless the County, for all loss, liability, claims or expense (including reasonable attorney's fees) arising from bodily injury, including death or property damage, to any person or persons caused in whole or in part by the negligence or willful misconduct of the Provider, except to the extent same are caused by the negligence or willful misconduct of the County. It is the intent of this section to require Provider to indemnify the County to the extent permitted under North Carolina law. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. 12. Non-Appropriation. This Agreement is subject to the availability of funds to purchase the specified services and may be terminated at any time if such funds become unavailable. 13. Non-Discrimination. Provider agrees as part of consideration of the granting of funds by Orange County the parties hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, familial status or veterans status with reference to any activities carried out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Anti-discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. 14. Living Wage. Orange County is committed to providing its employees with a living wage and encourages agencies if funds to pursue the same goal. The County's living wage is $ 13.15 per hour. To the extent possible, Orange County recommends that Freedom House Recovery Center, Inc.provide a living wage to its employees. 15. Notice. The Parties hereto agree and understand that written notice, mailed or delivered, to the last known address shall constitute sufficient notice to the County and the Provider. All notices required and/or made pursuant to this Agreement to be given to the County and the Provides shall be in writing and mailed to the party addressed as follows: (Freedom House Recovery Center,Inc.) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 County: Finance&Administrative Services Provider: Freedom House Recovery Center, Orange County Inc. Post Office Box 8181 104 New Stateside Drive Hillsborough,NC 27278 Chapel Hill,NC 27516 16. Entire Agreement. This Agreement, including any referenced attachments, constitutes the entire Agreement between the parties and shall supersede, replace or nullify any and all prior Agreements of understandings; written or oral, relating to the matters set forth herein, and any such prior Agreements or understandings shall have no force or affect whatsoever on this Agreement. The County and Provider have read this Agreement and agree to be bound by all of its terms, and further agree that this Agreement constitutes the complete and exclusive statement of the Agreement between the County and Provider. 17. Severability. All clauses found herein shall act independently of each other. If a clause is found to be illegal or unenforceable, it shall have no effect on the other provisions of this Agreement. It is understood by the parties hereto that if any part, term or provision of this Agreement is by the Courts held to be illegal or in conflict with any laws of the State of North Carolina or the United States, the validity of the remaining portions or provisions shall not be affected, and the rights and obligations of the parties shall be construed and enforced as if the Agreement did not contain the particular part, term or provision held to be invalid. a. Governing Law. This Agreement and the duties, responsibilities, obligations and rights of respective parties hereunder shall be governed by the laws of the State of North Carolina. By executing this Agreement Provider affirms that Provider and any subcontractors of Provider are and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147-86.58. 18. Signatures. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. IN WITNESS WHEREOF,the Orange County and the Provider have signed this Agreement, effective on the last date this Agreement is signed by both parties as indicated by the dates set forth under signatures below. For and o oka1jn lit ze Provider fiVtSL ikUSSU1 10/25/2016 RA5R71 Qf117R5671 Date For and on , ,,,,:;zolegange County Government 156lAkuit, tka mt-IrStui 10/26/2016 0637-994&73SE47;... Bonnie Hammersley, County Manager Date (Freedom House Recovery Center,Inc.) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 ATTACHMENT "A" Orange County Certifications—FY 2016-17 Outside Agency Performance Agreement Chief Contact,Administrators, Chief Executive Officer and Chief Financial Officer I certify that I have provided a list of the chief contact, administrators, chief executive officer and chief financial officer for my agency with this Agreement and that I will keep it current to the County of Orange. The list should be in writing with the name, title,residential address;phone and email address and if possible, fax number. Officers and Board of Directors I certify that I have provided a current list of the Officers and Board of Directors with this Agreement and that we will continue to update the list as changes occur. The list should be in writing,with the name, physical address,mailing address and if possible,phone, fax and email address. Budget Submission I certify that I have provided a budget for the period to be covered by funding Orange County, and that any substantive changes made to this budget have been in advance authorized in writing by Orange County. Annual Financial Review I certify that I have provided a copy of the latest annual Financial Review for our agency and the budget adopted by the agency for the fiscal years encompassing this Agreement. If not,please explain on a separate sheet of paper. Alignment with Organization's Mission I certify that the programs and services for which this funding is requested align with the mission of the organization. Intended Purpose I certify that the funds provided to the agency under the terms of this Agreement will be used for a public purpose and shall only be used for the purposes intended and any money not used for those purposes will be promptly returned to Orange County. DocuSigned by: ErriSL RtASSt CEO 10/25/2016 Certified by: RASR799CI�7AS479 Title: Date: (Provider's Signature) (Freedom House Recovery Center,Inc.) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 Exhibit A Provider's Outside Agency Application APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY Received By Agency Freedom House Recovery Center Date/Time Program(s) Residential Rehabilitation and Complete YIN Facility-Based Crisis and Detoxification Services Section For CDBG & HOME - Subsection HUD Regulations 1. Cover Page a. r Applicant Contact Information b. Project/Program Contact information c. I1 Funding Requests Identified d. Z Signed Application Cover Page 2. Agency a. I Agency's Years in operation 24 CFR 570.506, Information - b. r Agency's Purpose/Mission 570.507, 570.610; 24 c. Agency's Types of Seivices Provided CFR Parts 84 or 85 d. El Agency's Experience e. Z. Other Pertinent Information 3. Program/ a. Z Type of Application and Program Identified 24 CFR 570.200(a), Project b. I Summary of Program 570.201-570. 208, infer ation 507.503 c. Z Description of Identified Need (for each r Description of Population to be Served program/ e. I1 Activity Manager and Location Description project for which funding f. I Activity Implementation Timeline is requested) g. )■ Agency Collaboration h. 1 Describe Impact of Reduced/No Allocation i. IZ Other Pertinent Information j. A Complete Target Population/Beneficiary Chart k. Z Complete Schedule of Positions I ■ Signed Conflict of Interest Disclosure m. I Complete Work Statement DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION 24 CFR 570.200(a), 4. Financial (for Program Budget Worksheet and Detail should reflect 570.201-570. 208, each expenses for the entire program and ALL sources of 507.503 program/ funding. 24 CFR 570.506, project for 570.507, 570.601, which funding a. Program Budget Worksheet 570.602, 570.607(b), is requested) b. Z Program Budget Detail 570.611 24 CFR c. Z Cost Per Unit 570.502-570.504, d. Agency Operating Budget Worksheet 570.506, 570.507, 570.610; 24 CFR Parts 84 or 85, and OMB Circulars A-87 or A- 122; Treasury Circular 1075 5. Supplemental A. 1:21 Part A: CDBG & HOME Sections (as B. El Part B: Construction/Rehab applicable) 6. Attachments a. Z Audit: Organizations receiving$300,000 or more OMB Circular A-133 in Federal financial assistance, and/or organizations with more than $500,000 of receipts and expenditures in a fiscal year, must secure an audit. b. 1 IRS Federal Form 990 c. Z NC Solicitation License d. Eg IRS Federal Tax-Exemption Letter e. Z Certificate of Insurance f. PI List of Board of Directors 24 CFR Parts 84 or 85 g. IZ Articles of Incorporation/Bylaws 24 CFR 570.208, h. ri Authorization to Request Funds 570.500(c), 570.611 i. IZ Authorized official designation j. Z Solid Waste Program Fee (SWPF) Verification Main Application 1/25/2016 4:55:19 PM Page 2 of 24 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION 1. COVER PAGE (Each program requires a separate application.) a) Applicant Contact Information Applicant Organization's Legal Name: Freedom House Recovery Center, Inc. Applicant Organization's Physical Address: 104 New Stateside Drive Chapel Hill, NC 27516 Applicant Organization's Mailing Address: 104 New Stateside Drive Chapel Hill, NC 27516 Applicant Organization's Web Address: freedomhouserecovery.org Executive Director: Patricia E. Hussey Telephone Number: 919-942-2803 ext. 201 E-Mail: Trish.hafhrecovery.org DUNS Number: 177955887 (Dun & Bradstreet, Inc. provides this number at no charge, and it is required for Federal funding recipients.) b) Project/Program Contact Information Project/Program Name: Chapel Hill Facility-Based Crisis, Detox and Behavioral Health Urgent Crisis Care Services and Alvis Women's and Men's Halfway Houses Project/Program Primary Contact and Title: Trish Hussey, CEO Telephone Number: 919-942-2803 ext. 201 E-Mail: Trish.h@fhrecovery.orci c) Funding Request Identification Total Project/Program Cost: $2,396,990 Total Amount of Funds Requested: $57,000 Proposed Use of Funds Requested (2-3 Line Maximum): We are asking for funding from the Orange County Government to support the day-to-day services(i.e. staffing,facility costs,supplies and equipment)in (1)our residential rehab programs, and(2)to support the Facility Based Crisis and Detox/Behavioral Health Urgent Crisis Care Center in Chapel Hill. Please check all types, sources, and amounts of funding being requested. You must submit an application package for each funding source. *The Participating Jurisdiction reserves the right to fund projects from any funding source, subject to eligibility and funding constraints. LI CDBG Non-Construction (CH) $ El Grant Loan El CDBG Construction (CH) Grant Loan C. HOME CHDO (OC) Grant E Loan LI HOME Other(OC) n Grant C. Loan El Human Services: EI Carrboro $9,000 [X] Chapel Hill $18,000 I Orange County $30,000 d) To the best of my knowledge and belief all information and data in this application is true and current. The document has been duly authorized by the governing board of the applicant. Main Application 1/25/2016 4:55:19 PM Page 3 of 24 DocuSign Envelope ID:636AFD33-DA5C-4855-88DC-03C0863BAFE3 t A - continued Al rovider's 0,tside Agency Application , AIN APPLICATION c---- if, Signature: -7- a , ?-di :MO A • e.,..z. .- Executive Director s." 4 Date Signature: (,,,V ,e'n------ / / —Z/46' oard Chair erson Date Main Application 1/20/2016 1:23:56 PM Page 4 of 23 DocuSign Envelope ID:636AFD33-DA5C-4855-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION 2. AGENCY INFORMATION Please provide the following information about your agency (Limit of 2 pages total): a) Years in Operation, Date of Incorporation (Month/Year) Date of Incorporation: February 1974 Years in Operation: 42 b) Agency's Purpose/Mission Our mission is to promote, enhance and support recovery for men, women and children affected by substance abuse and mental illness by using a holistic, person-centered approach. Our expertise and broad array of treatment services stabilize, nurture and enhance the personal growth and development of those we serve so that they can recover to live rich, full lives. c) Types of Services the Agency Provides Our services include detoxification, mobile crisis management and facility-based crisis services, short and long-term residential rehabilitation/halfway houses, intensive outpatient, aftercare, psychiatric evaluation and medication management, integrated primary health care, parenting education and community intervention support. We serve clients of all ages, regardless of their ability to pay. d) Agency's Experience with Similar Programs as the Funding Request Freedom House Recovery Center began over 40 years ago as a halfway house for recovering alcoholics in Chapel Hill. Since then Freedom House has consistently grown to address the critical and changing needs of the 75,000 North Carolinians in our service area affected by addiction and mental illness by expanding both our services and geographic reach through innovative programs and partnerships. We enjoy the reputation as a leader in our field and have become the largest provider of mental health and substance abuse treatment in our service area. We serve individuals, young children through the senior years, who suffer from mental illness and/or substance use disorders. Our comprehensive, best-practice based programs serve the low-income, uninsured, indigent and homeless populations. Last year, Freedom House served 10,454 individuals, many of whom were unemployed (83%), homeless (65%) or indigent. Over 1,500 were children or adolescents. They were also generally disenfranchised when knowing how best to seek medical or behavioral health care, often using hospital Emergency Departments for this care. Our Orange county programs served 5,690 of these individuals, including 862 who were ages 51 and over, and 651 children and adolescents. Of Orange County clients, 1,522 had annual household incomes under$10,000 and 3,754 earned less than $25,000 per household annually. Additionally, our Chapel Hill integrated Care Clinic provides limited primary care to our behavioral health care clients -- particularly important because chronic conditions such as diabetes, hypertension and other cardiovascular conditions have high comorbidity with mental illness and substance use disorders. Given the nature of mental health issues and lack of, or heavily burdened, community resources, medical conditions often go untreated without this critical continuity of care. Nationally, statistics show that individuals with mental illness die 25 years earlier than others, largely due to treatable medical conditions. (National Association of Main Application 1/25/2016 4:55:19 PM Page 6 of 2 4 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION Mental Health Program Directors, 2006). 75% of clients receiving integrated care at Freedom House experienced a stabilization of their chronic disease. e) Other Pertinent Agency Information • We have been awarded the Community Comprehensive Clinic (CCC) status in Orange County by Cardinal Innovations, which will help make outpatient services to the many indigent clients we serve more sustainable. We are also moving to an Open Access Model of care. • In 2014, we created a stand-alone Child and Family Outpatient Services Clinic in Chapel Hill and now offer the evidence-based parenting education program, Triple Positive Parenting Program to our clients and clients referred to us by other partner agencies committed to the welfare of low-income families with young children. • The State of North Carolina is involved in making important changes in crisis services, and two of our leadership staff are included in the Behavioral Health Urgent Care (Crisis) Task Force, as well as the Crisis Solutions committee. We have been implementing the new best practices in our Crisis Services and are currently working with the Chapel Hill Planning Department to plan for a new Adolescent Facility-Based Crisis Services facility. There is a true deficit of child and adolescent behavioral health services in our state, and we will hopefully be able to provide remedy to our region if we are able to build this new facility. 3. PROJECT/PROGRAM INFORMATION — Agency& Program Name: Freedom House Recovery Center/Facility-Based Crisis and Detox and Alvis Women's and Men's Halfway Houses in Chapel Hill As you complete your application, complete only those sections that pertain to the type of application you are submitting. The application is divided into several sections and not all sections apply to every project. Every applicant MUST complete the main application. a) Check the type of funding request for this application package submittal and complete the required application and required supplemental sections (Parts) as specified below: El Human Services (Main Application Only) • CDBG Non-Construction—(Main Application AND Part A) LI CDBG Construction —(Main Application AND Part A AND Part B) D HOME CHDO Set-aside —(Main Application AND Part A) LI HOME Other—(Main Application AND Part A AND Part B) Main Application 1/25/2016 4:55:19 PM Page 6 of 24 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION Indicate the type of program for which you are requesting funding: Disabled Public Housing Program Category Youth Adult Elderly (not elderly) Neighborhoods/Residents Education X X X X X Health and Nutrition X X X X X Job Training X X X X X Sports and Arts Activities X X X Pre-School Activities After-School Activities Mentoring X X X X X Transportation X X X X X Housing X X X Other: Please specify • I am/• - - • i (Label your responses as outlined below; not to exceed 3 pages.) Please provide the following information about the proposed program/project: b) Summarize the program services proposed and how the program will address the chosen Town/County priority? Freedom House provides a comprehensive array of individualized, wrap-around behavioral health care services to youth and adults through four main programs in Orange County; Facility-Based Crisis and Detox/Behavioral Health Urgent Crisis Care, Residential Rehabilitation, Outpatient, and Child and Family Services. We are one of the few providers in NC that offers a full continuum of care regardless of ability to pay. Our programs directly address the second-highest Town/County priority as outlined in the 2012 assessment, Human Services Needs in Chapel Hill: Affordable Health Care, with a focus on mental health options and substance abuse programs. Freedom House is seeking support from the Towns of Chapel Hill and Carrboro and Orange County to support our Facility-Based Crisis and Detox/Behavioral Health Urgent Crisis Care Program and Residential Rehabilitation Program. Facility-Based Crisis and Detox/Behavioral Health Urgent Crisis Program This 24/7/365 program is generally the first step toward wellness and recovery for people, and it meets the community's need for immediate response to crises. Instead of going to the local ED or being incarcerated, crisis services provide the urgent treatment needed. During a stay in the crisis/detox unit, we are able to assess the person's needs, and make thoughtful and informed decisions, together with the individual, as to the next step in their treatment. Freedom House is partnering with UNC Hospitals to provide integrated care for patients with mental illness and/or substance use disorders who are in need of continued recovery treatment and care. The goals of the partnership are: (1)to provide continuity of care and improved outcomes for patients, including low-income and indigent patients and reduce ED usage and readmission rates at UNC Hospitals. Diverting referrals to our local crisis unit instead of high cost State and local hospitals, not only saves money, but it also provides a stronger continuum of care for individuals as they discharge from the crisis unit and into longer term care. Our diversion rate was 94% last year. Main Application 1/2512016 4:55:19 PM Page 7 of 24 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION Chapel Hill Residential Rehab Programs Freedom House works to provide effective, economical community services that break the cycle of poverty, substance use disorders and mental illness by providing residential rehab treatment to men and women whose illnesses have left them homeless, disenfranchised, and without work. This long-term treatment program gives the support needed for these men and women to find strong recovery and re-enter their lives with jobs and housing, and more importantly, with a sustaining recovery from their illnesses. We provide structured case management support to meet the needs of the men and women in the residential rehab programs, often focusing on housing, job readiness, interpersonal and financial skills, education and family reunification. For example, 43% of clients are parents whose children are in custody of DSS or in temporary custody of a family member. Staff assists residents in developing an appropriate dialogue with DSS with the goal of reunification after treatment. We also involve family members in the treatment of the residents, working not only toward healing the client, but also helping to heal the relationship of the entire family. Last year, 79% of clients were reunited with their family. c) Describe the local need or problem to be addressed in relation to the Consolidated Plan or other community priorities (i.e. Council/Board Goals). Cite local data to support the need for this program and the population being served. Thousands of people in Orange County are touched by the diseases of alcoholism, drug addiction, and mental illness. There are more than 59,000 adolescent and adult residents are affected by alcohol drug abuse/addiction (Alcohol/Drug Council of NC). Substance abuse costs Orange County residents over$195 million every year.Additionally, mental illness afflicts 24% of North Carolina's population and costs the state $4.8 billion (28,000 of these are Orange County residents). According to County Health Rankings and Roadmaps, Orange County citizens report 3.1 poor mental health days per month and 16% report they drink excessively, higher than the state average (University of Wisconsin Population Health Institute). North Carolina has a goal to reduce the number of poor mental health days to 2.8 per month by 2020 (Healthy NC 2020). The last several years have been devastating for low-income North Carolinians in need of health care, especially those suffering from mental illness and for substance addiction. As communities and agencies work to provide the best care for the mentally ill and addicted, as well as work toward improved health outcomes at the county and state level, the NC Mental Health system continues to be in transition. Two landmark decisions were made recently that impacted our agency, (1) the Governor's Office refused a large percentage of the Medicaid matching expansion funding from the Federal Government, and (2) the Federal government slashed block grant funding by more than 10% (funding that impacts programs for women, including crisis services.) Although the state has a goal to reduce the rate of mental-health visits to emergency departments by 2020, reduced funding levels have led to fewer services for this vulnerable population and in turn to crowded emergency rooms. Recently, the Centers for Disease Control reported that nearly 10% of all Emergency Department visits in North Carolina list mental illness as a diagnosis. The national average is 5%. Substance use disorders and untreated mental illness are directly connected with indigence, unemployment, adolescent pregnancy, school dropout, crime, chronic illness and death. Freedom House has developed community partnerships and programs that build the Main Application 1125120164:55:19 PM Page 8 of 24 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION necessary skills and connections to employment, education and housing clients will need when they reenter the community. Their recovery can diminish the societal and economic costs to their families and communities. For instance, for every $1 spent on addiction treatment, the community saves $7 in criminal justice costs and $12 in related health-care costs (Alcohol and Drug Council). d) Describe the population to be served or the area to benefit and indicate how you will identify beneficiaries. The population to be served is men and women who suffer from mental illness and/or substance use disorders, and who often have chronic medical conditions related to their mental illness, addiction or medication used to treat illness. Our programs will serve the low-income, uninsured, indigent and homeless populations in Orange County. Clients come to Freedom House most often by referral from hospitals, clinics, physicians, local social service agencies, law enforcement or the court system. Clients also come to Freedom House on their own accord, without referral. We gather necessary demographic data during the intake process. e) Who specifically will carry out the activities and in what location will they be carried out? Our caring treatment team includes physicians, psychiatrists, psychologists, psychiatric nurse practitioners, nurses, licensed clinical social workers, licensed clinical addiction specialists, certified substance abuse counselors and other qualified professionals. Programs will be carried out on our Chapel Hill campus. f) Describe specifically the period over which the activities will be carried out, the frequency with which the activities will be carried out, and the frequency with which services will be delivered. Include an implementation timeline. These programs are well-established, ongoing programs on which the community depends. Activities are carried out daily. Our Crisis and Detox/Behavioral Health Urgent Crisis Care services are 24/7/365 and our halfway houses are staffed 24/7/365 as well. This funding request covers activities occurring in FY 2016-2017. g) Provide a bulleted list of other agencies, if any, with which your agency coordinates/collaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. For each, give specific examples of the coordinated/collaborative efforts. Freedom House partners with numerous organizations, too many to list in space allowed. However, below are a few: • Job Links and the Orange site of Durham Community College: to help individuals with their GED. • Orange Vocational Rehabilitation: to provide job trainings skills. • Orange County Health Department and Carolina Health Net: to refer indigent clients to a medical home, as well as to provide primary health care to indigent clients within our Freedom House Integrated Care Clinic. • Local police and Sheriff's departments CIT(Community Intervention Training) project: to train law officers to understand more fully how to work with individuals in our community who are chronically mentally ill or addicted. • Orange Rape Crisis: to provide the needed support for women who come to us with recent and historical sexual abuse. • Community Care of North Carolina:work closely with CCNC to become a designated Access to Care Clinic for low-income and indigent individuals and families. • Interfaith Council: to provide behavioral health care to their homeless clients. • Interfaith Food Shuttle: to provide fresh and healthy food for our residential clients. Main Application 1/25/2016 4:55:19 PM Page 9 of 24 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION h) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. The number of individuals served would be negatively impacted by a reduction in or absence of funding. Our licensed halfway houses are not a Medicaid billable service and are funded at a very low State rate that does not cover the cost of running the programs, making it difficult to sustain these critical treatment/housing programs which have a higher rate of success than other programs in the state and nation. Facility Based Crisis and Detox/Behavioral Health Urgent Crisis Care services are historically underfunded by State IPRS dollars, as well as Medicaid. The requirements of the Service Definitions that oversee these types of licensed programs exceed the billing rate for the service. Funding is tight for crisis services, and every dollar we receive is critical in maintaining crisis services. i) Include any other pertinent information. Freedom House tracks success through a variety of measures which relate to the quality of outcomes of our clients. Measures can include sobriety post discharge, emergency department or crisis recidivism, improvements in physical health and medication adherence, quality of life improvements such as decent housing, employment, family reunification, etc. By tracking our performance, Freedom House can monitor the effectiveness of our programs and practices and make adjustments. Program/Project Information j) Complete the Target Population and Program Beneficiary Demographics Chart k) Complete the Schedule of Positions Chart for Program Staff I) Disclosure of Potential Conflicts of Interested must be signed m) Complete the Work Statement Chart to describe the work to be performed, and be sure to attach copies of all data collection tools that will be used to verify achievement of program goals and objectives. Describe who will be responsible for monitoring progress. Information to Complete j.)Target Population Complete the following tables to the best of your ability. Show numbers of participants and percentages, as applicable, in each category. Please indicate whether this project/program will serve: II Persons E Households El Units Program: Facility-Based Crisis, Detox,and Behavioral Health Urgent Crisis Care Program Beneficiary Demographics Actual Estimated Projected 2014-15 2015-16 2016-17 Gender Male 1,123 1,363 1,410 Female 906 1,179 1,229 Total 2,029 2,542 2,639 Main Application 1/25/2016 4:55:19 PM Page 10 of 24 1 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued l Provider's Outside Agency Application MAIN APPLICATION Of the females, how many are single- female Head of Households (Omit for Human Services) 425 456 472 Ethnicity African-American 929 1,062 1,324 American Indian or Alaska Native 10 18 22 Asian 19 32 36 Caucasian 984 1,328 1,212 Native Hawaiian or other Pacific Islander 0 Other 87 102 145 Total 2,029 2,542 2,639 I Of the above, how many Hispanic/Latino 87 102 145 Of the above, how many non- Hispanic/Latino 1,942 2,440 2,494 Total 2,029 _ 2,542 2,639 Age 0-5 years 6-18 years 24 49 58 19-50 years 1,496 1,541 1,580 51-61 years 470 870 914 62+ years 39 82 87 • Total 2,029 2,542 2,639 Geographic Location Durham City Durham County 21 30 32 Carrboro 624 752 778 Chapel Hill 638 764 789 Chapel Hill Public Housing Residents 32 41 Orange County 676 859 879 Raleigh Wake County 13 16 Other(Person, Chatham, Caswell, Alamance, Vance, Warren) 70 92 104 Total 2,029 2,542 2,639 Income Level —See following chart (Omit for HS) <30%Area Median Income 1,055 1,390 1,429 31-50%Area Median Income 742 891 932 51-80%Area Median Income 163 179 170 > 80%Area Median Income 69 82 108 Total 2,029 _ 2,542 2,639 Special Needs (Omit for HS) Elderly(Over 62) 39 82 87 Disabled (not elderly) 49 63 72 Main Application 1/25/2016 4:55:19 PM Page 'VI of 24 DocuSign Envelope ID:636AFD33-DA5C-4855-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION Homeless 997 1,096 1,146 People with HIV/Aids 44 41 46 Total 1,129 1.282 1,351 Please indicate whether this project/program will serve: Persons n Households E Units Program: Alvis Women's and Men's Halfway Houses—residential rehabilitation Program Beneficiary Demographics Actual Estimated Projected 2014-15 2015-16 2016-17 Gender Male 49 50 51 Female 56 57 58 Total 105 107 109 Of the females, how many are single- female Head of Households(Omit for Human Services) 37 38 39 Ethnicity African-American 53 55 54 American Indian or Alaska Native Asian Caucasian 45 46 49 Native Hawaiian or other Pacific Islander Other 7 6 6 Total 105 107 109 Of the above, how many Hispanic/Latino 6 6 7 Of the above, how many non- Hispanic/Latino 99 101 102 Total 105 107 109 Age 0-5 years 6-18 years 2 3 5 19-50 years 86 89 88 51-61 years 13 15 16 62+ years 4 Total 105 _ 107 109 Geographic Location Durham City Durham County Carrboro 23 23 24 Main Application 1/25/2016 4:55:19 PM Page 12 of 24 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION Chapel Hill 36 37 37 Chapel Hill Public Housing Residents _—_—_- Orange County 36 Raleigh Wake County Other(Person, Chatham, Caswell, Alamance, Vance, Warren) 10 12 11 Total 105 107 109 Income Level—See following chart (Omit for HS) < 30%Area Median Income 71 72 74 31-50% Area Median Income 23 25 24 51-80% Area Median Income 10 8 9 > 80%Area Median Income 1 2 2 Total 105 107 109 Special Needs (Omit for HS) Elderly(Over 62) 2 3 4 Disabled (not elderly) 3 3 4 Homeless 62 64 65 People with HIV/Aids 3 4 3 Total 70 74 76 CDBG & HOME ONLY - Area Benefit Activities (Infrastructure and Public Facilities) Street Census Tract Block Group Total Persons #LM1 Persons 2015 Area Median Family income Limits U.S. Department of Housing & Urban Development (HUD) 2015 Area Median Family Income Limits Effective March 15, 2015 Income 1 2 3 4 5 6 7 8 Level person people people people people people people people 30%AM! $14,150 $16,200 $20,090 $24,250 $28,410 $32,570 $36,730 $40,890 Main Application 1/25/2016 4:55:19 PM Page 13 of 24 DocuSign Envelope ID:636AFD33-DA5C-4855-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION 50%AMI $23,600 $27,000 $30,350 $33,700 $36,400 $39,100 $41,800 $44,500 80% AMI $37,750 $43,150 $48,550 $53,900 $58,250 $62,550 $66,850 $71,150 100%AMI $47,188 $53,938 $60,688 $67,375 $72,813 $78,188 $83,563 $88,937 115% AMI $54,266 $62,028 $69,791 $77,481 $83,734 $89,916 $96,097 $102,278 http://www.hudusenorg/portal/datasets/i1/0151FY2015 IL nc.pdf Main Application 1/25/2016 4:55:19 PM Page 1 4 of 24 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION k.) Schedule of Positions Please include program staff positions followed by volunteer positions; these financial figures should match the personnel figures in your Agency Comparative Budget Excel Form. Similar positions can be combined. (i.e., 8 Occupational Therapists can be inserted as one line item). if provided, indicate: Position Titles (R) FTE* Actual Estimated Projected %Total * = Position , Program Retirement 2014-16 2015-16 2016-17 Budget Vacant Staff+ Plan (H) Health Plan Notes: • Similar positions can be combined: i.e. 8 Occupational Therapists can be inserted as one line item. • ** Full Time Equivalent staff will be noted as 1.00; half time as.50; quarter time as .25, etc. • + Denotes the percentage of staff time involved with this program. • Calculate a Full Time Equivalent for all recorded volunteer hours using the following: Total Volunteer Hours=Volunteer FTE 1,960 Main Application 1/25/2016 4:55:19 PM Page 15 of 24 1 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION I.) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST Are any of the Board Members or employees of the agency which will be carrying out this project, or members of their immediate families, or their business associates: YES NO El El a) Employees of or closely related to employees of the Town of Chapel Hill, Orange County, Carrboro, or Hillsborough? Z b) Members of or closely related to members of the governing bodies of Chapel Hill, Carrboro, Hillsborough, or Orange County? El c) Current beneficiaries of the project/program for which funds are requested? 1-1 E3) d) Paid providers of goods or services to the program or having other financial interest in the program? If you have answered YES to any question, please provide a full explanation below. To the best of my knowledge and belief all of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of interest does not necessarily make the project ineligible for funding, but the existence of an undisclosed conflict ma result in the t-miination of any grant awarded. C3-7 Signature: - 2- ? Executive Direct;IL - Date Signature: A.,i66rt? , 1 1-..2 -4; Board Chairperson Date Main Application 1/20/2016 1:27:47 PM Page 16 of 2 :3 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION m.) Work Statement This form is used to document program activities, program goals, performance measures, and actual results. (Add more rows as needed) If this is a new program, you will only document the projected information. • Program Activities should outline major activities the agency implements to accomplish its program goals. • Program Goal should explain what the program is trying to achieve/accomplish. Goals are statements about what the program should accomplish. SMART Goals • Performance Measures describe how you will evaluate the degree in which you achieved the stated goals. • Actual Program Results use program results to indicate the actual measureable achievement of goals. If goals were not met, please explain. Main Application 1/25/2016 4:55:19 PM H I 7 of 000vSign Envelope ID:030Aro33'oAnC-4enn-88oC-03C0803eArE3 i /\ - COOtiOU8d Provider's Outside Agency Application Facility-Based Crisis and Detox/Behavioral Actual Estimated Projected Health Urgent Crisis 2014-2015 2015-2016 2016-2017 Care Services Provide services to alt Provide services to all Provide services to all referrals from the referrals from the referrals from the community that meet community that meet community that meet Program Activity 1 admission criteria. admission criteria. admission criteria. Provide services to 2,029 Provide services to 2,542 Provide services to 2,639 individuals in need of individuals in need of individuals in need of addiction or mental health addiction or mental health addiction or mental health Program Goal treatment. treatment. treatment. We will use ourEW1R We will use our EW1R We will use our EMR system to track these system to track these system to track these Performance Measures numbers. numbers. numbers. We anticipate seeing an We anticipate seeing an We anticipate seeing an increase from the increase from the increase from the previous FY in clients previous FY in clients previous FY in clients Program Results served in the Crisis Unit. served in the Crisis Unit, served in the Crisis Unit. Crisis staff begin discharge Crisis staff begin discharge Crisis staff begin discharge planning with each client planning with each client planning with each client in the crisis unit,using in the crisis unit, using in the crisis unit,using motivational interviewing motivational interviewing motivational interviewing techniques to incentivize techniques to incentivize techniques to incentivize clients to move into the clients to move into the clients to move into the next appropriate level of next appropriate level of next appropriate level of Program Activity 2 care. care. care. Provide treatment Provide treatment Provide treatment planning to refer 100%of planning to refer 100%of planning to refer 100%of those served to the next those served to the next those served to the next Program Goal appropriate level of care. appropriate level of care. appropriate level of care. Our[MR system tracks Our[MR system tracks Our EMR system tracks this information and flow this information and flow this information and flow Performance Measures of client services, of client services, of client services. Crisis staff provide Crisis staff provide Crisis staff provide treatment and discharge treatment and discharge treatment and discharge planning for 100%of all planning for 100%of all planning for 100%of all Program Results diems. clients. clients. 000vSign Envelope ID:030Aro33'oAnC-4enn-88oC-03C0803eArE3 i /\ - COOtiOU8d Provider's Outside Agency Application Freedom House Crisis Freedom House Crisis Freedom House Crisis Care Coordinators work Care Coordinators work Care Coordinators work with UNC ER staff, with UNC ER staff, with UNC ER staff, individuals and our individuals and our individuals and our doctors and clinicians to doctors and clinicians to doctors and clinicians to admit difficult cases into admit difficult cases into admit difficult cases into the crisis unit,diverting the crisis unit,diverting the crisis unit,diverting them from the local or them from the local or them from the local or Program Activity 3 State hospitals. State hospitals. State hospitals. Divert 94%of those Divert 95%of those Divert 96%of those referred to the crisis unit referred to the crisis unit referred to the crisis unit from our local hospital ER from our local hospital ER from our local hospital ER and expensive State and expensive State and expensive State Program Goal hospitals. hospitals. hospitals. Care Coordinators track all Care Coordinators track all Care Coordinators track all referrals and their referrals and their referrals and their outcomes using a referral outcomes using a referral outcomes using a referral Performance Measures tracking log. tracking log. tracking log. Diverting referrals to our Diverting referrals to our Diverting referrals to our crisis unit instead of high crisis unit instead of high crisis unit instead of high cost State and local cost State and local cost State and local hospitals not only saves hospitals not only saves hospitals not only saves money,but it also money,but it also money, but it also provides a stronger provides a stronger provides a stronger continuum of care for continuum of care for continuum of care for individuals as they individuals as they individuals as they discharge from the crisis discharge from the crisis discharge from the crisis Unit and into longer term unit and into longer term unit and into longer term Program Results care. care. care. Residential Rehabilitation-Men's Halfway and Alvis Women's Houses Staff will work with Staff will work with Staff will work with stakeholders and stakeholders and stakeholders and community partners(IJNC community partners(UNC community partners(UNC Hospitals,the Court Hospitals,the Court Hospitals,the Court system, IFC shelter,etc.) system, IFC shelter,etc.) system, IfC shelter,etc.) to identify referrals for to identify referrals for to identify referrals for individuals in our individuals in our individuals in our community who need community who need community who need long-term halfway house long-term halfway house long-term halfway house Program Activity 1. services. services. services. 105 men and women 107 men and women 109 men and women receive long-term(3-6 receive long-term(3-6 receive long-term(3-6 months)recovery and months)recovery and months) recovery and community support community support community support Program Goal services. services. services. 000wSigm Envelope ID:030Aro33-Dw5C-4o55-88oC-03C0803oArE3 t /\ - COOtiOU8d Provider's Outside Agency Application | Outcomes are evaluated Outcomes are evaluated Outcomes are evaluated using NCTOPPS too and using NCTOPPS tool and using NCTOPPS tool and Performance Measures our EMR. our EMR. our EMR. Provide services to 105 Provide services to 107 Provide services to 109 individuals and maintain a individuals and maintain a individuals and maintain a Program Results 98%utilization rate. 98%utilization rate. 98%utilization rate. Staff develops a Person- Staff develops a Person- Staff develops a Person- Centered Plan for each Centered Plan for each Centered Plan for each individual,with a goal of individual,with a goal of individual,with a goal of self-sufficiency and self-sufficiency and self-sufficiency and Program Activity 2 sobriety upon graduation. sobriety upon graduation. sobriety upon graduation 75%of all clients will 76%of all clients will 77%of all clients will graduate from the graduate from the graduate from the program and re-enter the program and re-enter the program and re-enter the Program Goal community and/or family. community and/or family. community and/or family. Clinical staff will regularly Clinical staff will regularly Clinical staff will regularly monitor the case planning monitor the case planning monitor the case planning activities for each client activities for each client activities for each client during their stay in the during their stay in the during their stay in the Performance Measures program. program. program. - Of the 75%of clients who Of the 76%of clients who Of the 77%of clients who graduate from the graduate from the graduate from the program,another 10%will program,another 10%will program, another 10%will successfully discharge to successfully discharge to successfully discharge to ADATC or other ADATC or other ADATC or other Program Results appropriate level of care. appropriate level of care. appropriate level of care. Staff develops a Person- Staff develops a Person- Staff develops a Person- Centered Plan for each Centered Plan for each Centered Plan for each Individual,with a goal of individual,with a goal of Individual,with a goal of self-sufficiency and self-sufficiency and self-sufficiency and Program Activity 3 . sobriety upon graduation. sobriety upon graduation, sobriety upon graduation. 62%of clients who 63%of clients who 64%of clients who graduate will secure graduate will secure graduate will secure Program Goal housing upon discharge. housing upon discharge. housing upon discharge. Follow up surveys and a 3 Follow up surveys and a 3 Follow up surveys and a 3 month follow-up plan are month follow up plan are month follow-up plan are used to gain this used to gain.this used to gain this information regarding information regarding information regarding Performance Measures hougn& housing. housing. 62%of clients who 63%of clients who 64%of clients who graduate will secure graduate will secure graduate will secure Program Results housing upon discharge. housing upon discharge. housing upon discharge. , � 000vSign Envelope ID:030Aro33'oAnC-4enn-88oC-03C0803eArE3 i /\ - COOtiOU8d Provider's Outside Agency Application Staff develops a Person- Staff develops a Person- Staff develops a Person- Centered Plan for each Centered Plan for each Centered Plan for each individual,with a goal of individual,with a goal of individual,with a goal of self-sufficiency and self-sufficiency and self-sufficiency and Program Activity 4 sobriety upon graduation, sobriety upon graduation. sobriety upon graduation. 69%of clients will find 70%of clients will find 71%of clients will find employment while in our employment while in our employment while in our Program Goal programs. programs. programs. Stable employment will be Stable employment will be Stable employment will be measured through client's measured through client's measured through client's attainment of paid attainment of paid attainment of paid employment upon employment upon employment upon Performance Measures discharge. discharge. discharge. 69%of clients will find 70%of clients will find 71%of clients will find employment while in our employment while in our employment while in our Program Results programs. programs. programs. DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION 4. FINANCIAL INFORMATION FOR SERVICE PROGRAMS a.) Program Budget Please complete a Program Budget Excel Form for each requested program. The Program Budget should reflect only figures and amounts associated with the Program(s) for which you are seeking funding and not the total agency budget. If the program's finances experienced significant changes that you would like to explain, please use the space below. It is required that your Excel budget worksheet be embedded on the next page. You must also submit an electronic copy of the MS Excel file with your application, as a separate file. Main Application 1/25/2016 4:55:19 PM Page 19 of 24 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION a.) Program Budget Detail What is the cost to deliver your project/program? List each project/program element in the table below, including the cost of each element, the quantity and unit of measure, and the subtotal for each element. Where necessary, allocate costs to the use of shared space, vehicles or equipment. Example Program: Credit Counseling Class Cost Elements Cost($) Quantity/Unit of Measure Subtotal ($) Credit Counseling Teacher–in class $25 96 hours(8 hrs/mth x 12 months) $2,400 Credit Counseling Teacher—class prep $25 48 hours(4hrs/mth x 12 mths) $1,200 Credit Counselor—one-on-one $20 120 hours (10 hrs/mth x12 mths $2,400 Materials $25 120 course packets/credit reports $3,000 Total $9,000 Com•Iete the table below for the •ro'ect/•ro•ram for which ou are re•uestin• funds. Attach additional rows/pages, as needed. Program: Facility-Based Crisis and Detox/Behavioral Health Urgent Crisis Care Services Cost Elements Cost($) Quantity/Unit of measure Subtotal ($) Staff $4,608.65 One Bed Day (24 hours) X 365 $1,682,160 Utilities $119.18 One Bed Day (24 hours) X 365 $43,500 Supplies and Equipment $270,68 One Bed Day (24 hours)X 365 $98,800 Travel and Training $12.71 One Bed Day(24 hours)X 365 $4,640 Mortga•e $211.23 One Bed Day(24 hours)X 365 $77,100 Total 1,906,200 b.) Cost per Unit Actual 2014-15 Estimated 2015-16 Projected 2016-17 Total Cost of Program $1,824,056 $1,875,549 $1,906,200 Total # of Units 5673 5735 5792 Cost Per Unit $321.53 $327.04 $329.11 This Cost Per Unit must reflect the total program budget and the total number of program beneficiaries (households or persons) in this application and must be consistent with report submittals from previous years (if applicable). Main Application 1/25/2016 4:55:19 PM Page 21 of 24 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION b.) Program Budget Detail What is the cost to deliver your project/program? List each project/program element in the table below, including the cost of each element, the quantity and unit of measure, and the subtotal for each element. Where necessary, allocate costs to the use of shared space, vehicles or equipment. Example Program: Credit Counseling Class Cost Elements Cost($) Quantity/Unit of Measure Subtotal ($) Credit Counseling Teacher–in class $25 96 hours (8 hrs/mth x 12 months) $2,400 Credit Counseling Teacher—class prep $25 48 hours(4hrs/mth x 12 mths) $1,200 Credit Counselor—one-on-one $20 120 hours (10 hrs/mth x12 mths $2,400 Materials $25 120 course packets/credit reports $3,000 Total $9,000 Complete the table below for the proiect/program for which you are requesting funds. Attach additional rows/pages, as needed. Program: Chapel Hill Residential Rehab Services Cost Elements Cost($) Quantity/Unit of measure Subtotal ($) Staff $948.12 One Bed Day(24 hours)X 365 $346,064 Utilities $53.42 One Bed Day(24 hours)X 365 $19,500 Supplies and Equipment $292.60 One Bed Day(24 hours) X 365 $106,800 Travel and Training $21.17 One Bed Day(24 hours)X 365 $7,726 Other Expenses $29.32 One Bed Day(24 hours) X 365 $10,700 Total $490,790 C.) Cost per Unit Actual 2014-15 Estimated 2015-16 Projected 2016-17 Total Cost of Program $465,810 $482,675 $490,790 Total # of Units 7201 7228 7235 Cost Per Unit $64.69 $66.78 $67.84 This Cost Per Unit must reflect the total program budget and the total number of program beneficiaries (households or persons) in this application and must be consistent with report submittals from previous years (if applicable). Main Application 1/25/2016 4:55:19 PM Page 22 of 24 DocuSign Envelope ID:636AFD33-DA5C-4855-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION c.) Agency Operating Budget Please show all sources and amounts of funding for your entire current fiscal year. What is your agency's fiscal year? Example: July 1, 2016 through June 30, 2017. It is required that your Excel budget worksheet be embedded on the next page. You must also submit an electronic copy of the MS Excel file with your application, as a separate file. Main Application 1/25/2016 4:55:19 PM Page 23 of 24 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application Section VI. Financial Data Comparative Budget for Entire Agency AGENCY NAME: Freedom House Recovery Center Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Change Private Donations $ 117,793 $ 125,000 $ 175,000 40% Agency Generated Revenue (fees) $ 197,269 $ 350,340 $ 364,000 4% Local Government Grants: Orange County $ 29,000 $ 29,000 $ 30,000 3% Town of Chapel Hill $ 17,000 $ 17,000 $ 18,000 6% Town of Carrboro $ 8,000 $ 8,100 $ 9,000 11% Other Local: MCO Contracts $ 11,544,351 $ 10,469,625 $ 9,431,837 -10% Other Local: TECS Grant $ 180,894 $ 206,600 $ 245,000 19% Other Local: --- 0 If more than 3 sources,please provide a separate list. Non-Local Government Grants Triangle United Way $ 44,187 $ 44,187 $ 44,187 0% State Government $ 700,000 $ 700,000 $ 700,000 0% Federal Government --- 0 Other Grants: Kate B. Reynolds $ 246,100 $ 246,100 $ 450,000 83% Other Grants: $ 7,500 $ 40,000 $ 45,000 13% Miscellaneous/Other Revenue $ 2,462 $ 3,750 $ 6,900 84% Please list 3 largest Miscellanous sources: Interest Income $ 2,714.00 Gains $ (252.00) Total Agency Revenue $ 13 094 556 $ 12 239 702 $ 11 518 924 -6% AGENCY EXPENSES Compensation $11,590,863 $10,787,099 $10,046,424 -7% Rent& Utilities $ 283,164 $ 281,799 $ 285,000 1% Supplies &Equipment $ 959,905 $ 932,504 $ 952,200 2% Travel &Training $ 79,474 $ 65,000 $ 63,000 -3% Other Expenses: $ 181,288 $ 173,300 $ 172,300 -1% Please list 3 largest"Other Expenses": Mortgages/amortization $ 181,288.00 Total Agency Expenses $13 094 694 $12 239 702 $11 518 924 -6% SURPLUS/(DEFICIT) FOR PERIOD: $ (138)1 $ - I $ - I 0 FY 2016-17 Comparative Agency Budget Revised 9/29/2014 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY Received By Agency Mental Health America of the Triangle Date/Time / 1 Complete Y/N Program(s) Family Advocacy Network Section Subsection For CDBG & HOME - HUD Regulations 1. Cover Page a. X Applicant Contact Information b. X Project/Program Contact Information c. X Funding Requests Identified d. X Signed Application Cover Page 2. Agency a. X Agency's Years in operation 24 CFR 570.506, Information - b. X Agency's Purpose/Mission 570.507, 570.610; 24 c. X Agency's Types of Services Provided CFR Parts 84 or 85 d. X Agency's Experience e. X Other Pertinent Information 3. Program/ a. X Type of Application and Program Identified 24 CFR 570.200(a), Project b. X Summary of Program 570.201-570. 208, Information - c. X Description of Identified Need 507.503 (for each d. X Description of Population to be Served program/ project for e. X Activity Manager and Location Description which funding f. X Activity Implementation Timeline is requested) g. XAgency Collaboration h. X Describe Impact of Reduced/No Allocation i. X Other Pertinent Information j. X Complete Target Population/Beneficiary Chart k. X Complete Schedule of Positions I. X Signed Conflict of Interest Disclosure m. X Complete Work Statement DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION 24 CFR 570.200(a), 4. Financial (for Program Budget Worksheet and Detail should reflect 570.201-570. 208, each expenses for the entire program and ALL sources of 507.503 program/ funding. 24 CFR 570.506, project for 570.507, 570.601, which funding a. X Program Budget Worksheet 570.602, 570.607(b), is requested) b. X Program Budget Detail 570.611 24 CFR c. X Cost Per Unit 570.502-570.504, d. X Agency Operating Budget Worksheet 570.506, 570.507, 570.610; 24 CFR Parts 84 or 85, and OMB Circulars A-87 or A- 122; Treasury Circular 1075 5. Supplemental A. ❑ Part A: CDBG & HOME N/A Sections (as B. ❑ Part B: Construction/Rehab applicable) 6. Attachments a. [' Audit: Organizations receiving $300,000 or more OMB Circular A-133 in Federal financial assistance, and/or organizations with more than $500,000 of receipts and expenditures in a fiscal year, must secure an audit. b. X IRS Federal Form 990 c. X NC Solicitation License d. X IRS Federal Tax-Exemption Letter e. X Certificate of Insurance f. X List of Board of Directors 24 CFR Parts 84 or 85 g. X Articles of Incorporation/Bylaws 24 CFR 570.208, h. X Authorization to Request Funds 570.500(c), 570.611 i. X Authorized official designation j. ❑ Solid Waste Program Fee (SWPF) Verification (Exempt due to leasing office space) Main Application 5/25/2016 9:20:28 AM 0 I:° 2 of 2 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION 1. COVER PAGE (Each program requires a separate application.) a) Applicant Contact Information Applicant Organization's Legal Name: Mental Health America of the Triangle Applicant Organization's Physical Address: 3729 Murphy School Road, Durham, NC 27705 Applicant Organization's Mailing Address: P.O. Box 16246 Chapel Hill, NC 27516 Applicant Organization's Web Address: www.mhatriangle.org Executive Director: Marci White, MSW Telephone Number: 919-942-8083 (o); (919 616-7772 (c) E-Mail: mwhite@mhatriangle.orq DUNS Number: N/A (Dun & Bradstreet, Inc. provides this number at no charge, and it is required for Federal funding recipients.) b) Project/Program Contact Information Project/Program Name: Family Advocacy Network Project/Program Primary Contact and Title: Marci White, MSW — Executive Director Telephone Number: 919-942-8083 (o); (919 616-7772 (c) E-Mail: mwhite@mhatriangle.orq c) Funding Request Identification Total Project/Program Cost: $130,027 Total Amount of Funds Requested: $9,000 Proposed Use of Funds Requested (2-3 Line Maximum): Provide Common Sense Parenting Classes through the Family Advocacy Network for Orange/CH/TOC residents, especially those who are DSS-involved. Please check all types, sources, and amounts of funding being requested. You must submit an application package for each funding source. *The Participating Jurisdiction reserves the right to fund projects from any funding source, subject to eligibility and funding constraints. ❑ CDBG Non-Construction (CH) $ ❑ Grant ❑ Loan ❑ CDBG Construction (CH) $ ❑ Grant ❑ Loan ❑ HOME CHDO (OC) $ ❑ Grant [' Loan ❑ HOME Other (OC) $ ❑ Grant ❑ Loan X Human Services: X Carrboro $2,000 X Chapel Hill $2,000 X Orange County $5,000 d) To the best of my knowledge and belief all information and data in this application is true and current. The document has been duly authorized by the governing board of the applicant. Signature: Airmzt, Ll:;.)46, 1/25/2016 Executive Director Date Signature: ( I Board Chairperson 1/25/2016 Main Application 5/25/2016 9:20:28 AM .. g , 3 of 20 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION 2. AGENCY INFORMATION Please provide the following information about your agency (Limit of 2 pages total): a) Years in Operation, Date of Incorporation (Month/Year) b) Agency's Purpose/Mission c) Types of Services the Agency Provides d) Agency's Experience with Similar Programs as the Funding Request e) Other Pertinent Agency Information For over fifty years, Mental Health America of the Triangle has continued its Mission "to improve the lives of those touched by mental illness, and to unite the mental health community by serving as a clear, unwavering voice of advocacy and hope." Initially founded as the Mental Health Association of Orange County (MHAOC), it began serving the community in 1966 as an unincorporated nonprofit affiliate of the North Carolina Mental Health Association. The organization recognized and worked to reduce the impact of mental illness on the individual, family, and community through multiple community-based programs. To broaden its scope and reach, the organization was incorporated in August 2010 in North Carolina as Mental Health America of the Triangle (MHAT), secured nonprofit status with the IRS, and obtained a Charitable Solicitation License as its new entity. MHAT is affiliated with the national organization, Mental Health America, but operates autonomously financially here in the local community. Mental Health America of the Triangle's approach is both comprehensive and responsive to identified community needs — by targeting high-risk populations as well as individuals and families who "fall through the cracks"; those without adequate healthcare coverage or resources to meet their mental health needs; and those families in need of parenting skills who are at risk of disruption due to abuse or neglect allegations. As an established community- based agency, MHAT has consistently demonstrated its ability to recognize community needs for high-risk populations and tailor programs to address those specific needs. MHAT's long-standing programs are innovative and cost-effective — they are preventative, proactive, solution-centered, and wellness-orientated, and they harness the power of specially trained and dedicated staff and volunteers to provide services to those in the community who otherwise would not have the means of receiving treatment at all. MHAT's programs are administered by a small staff of incredibly driven, part-time professionals. These programs focus on empowering individuals to take ownership of their own mental health and recovery, so that they can be healthier, happier, more productive members of their families and community. MHAT provides supports to individuals, families and children through three unique programs: • Family Advocacy Network (FAN) - see below • Pro Bono Counseling Network—Through our network of volunteer therapists, we are able to offer uninsured individuals in our community up to eight free counseling sessions - often enough to get them back on their feet. • Compeer- Our evidence-based Compeer Program matches adults recovering from severe and persistent mental illness with a volunteer friend to help them engage in social activities of mutual interest. In addition to MHAT's three signature programs, it also has fiscal and programmatic partnerships with two other community projects - the Orange Partnership for Alcohol and Drug- Free Youth and the Family Success Alliance. Both programs fit seamlessly into MHAT's Main Application 5/25/2016 9:20:28 AM .. g of 20 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION preventative and proactive approach to addressing the critical needs of the community, and through cost-effective collaboration, MHAT has been able to further address and meet the needs of individuals and families in our county who otherwise would not have access to vital resources needed to live healthy, fulfilling lives. The Family Advocacy Network (FAN) began in 2000 in response to the need for a child- focused, family-driven System of Care to meet the mental health needs of the community's children. Since then, through the work of program staff Family Advocates, MHAT continues to provide critical support and assistance to parents raising school-age children with emotional or behavioral issues, mental health issues, learning differences, high-functioning Autism, substance abuse problems, and other challenges. FAN Advocates have received best-practice training and offer empathy and insights gained through their own experience as parents raising children with special needs. Advocates also offer one-on-one and group support, advocacy, and parenting skills training to help improve family/youth outcomes. In addition to strengthening parenting skills, parents are connected to community resources and taught appropriate and effective advocacy skills that better equip them to interact and navigate with multiple systems - school and special education, dependency and juvenile court, and treatment services - educating and empowering them to advocate on behalf of their children. To effectively reach the community, FAN Advocates maintain a strong presence in juvenile and dependency court proceedings, court planning, and truancy courts. They also participate in Child and Family Team (CFT) meetings, Individual Education Plan (IEP) meetings, one-on-one family meetings, and frequently communicate with court counselors, DSS social workers, educators, as well as providers in face-to-face conversations, telephone and email contact. The compassionate, nonjudgmental support and services that FAN Advocates provide can be lifelines for parents juggling challenges at home, school, extra medical needs, increased stress, strained relationships, and lost work hours as they struggle to meet their children's needs. Main Application 5/25/2016 9:20:28 AM .. g 5 of 20 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION 3. PROJECT/PROGRAM INFORMATION Agency & Program Name: Mental Health America of the Triangle– Family Advocacy Network As you complete your application, complete only those sections that pertain to the type of application you are submitting. The application is divided into several sections and not all sections apply to every project. Every applicant MUST complete the main application. a) Check the type of funding request for this application package submittal and complete the required application and required supplemental sections (Parts) as specified below: X Human Services (Main Application Only) ❑ CDBG Non-Construction — (Main Application AND Part A) ❑ CDBG Construction — (Main Application AND Part A AND Part B) ❑ HOME CHDO Set-aside — (Main Application AND Part A) ❑ HOME Other — (Main Application AND Part A AND Part B) Indicate the type of program for which you are requesting funding: Program Category Youth Adult Elderly Disabled Public Housing (not elderly) Neighborhoods/Residents Education X X X Health and Nutrition Job Training Sports and Arts Activities Pre-School Activities After-School Activities Mentoring/Ongoing Friendship X X X Transportation Housing Other: Please specify– Parenting Skills Building and Parent Advocacy X X X Program/Project Description (Label your responses as outlined below; not to exceed 3 pages.) Please provide the following information about the proposed program/project: b) Summarize the program services proposed and how the program will address the chosen Town/County priority? FAN's staff are trained, professional Family Advocates, who are themselves parents of special needs children. They provide services to other parents, including: supportive counseling, developing family strengths, parenting skills building, parent education workshops and navigation support for accessing needed mental health treatment, special Main Application 5/25/2016 9:20:28 AM P 6 of 20 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION education, and social services - all of which together form a vital safety net for some of our community's most vulnerable children and families. FAN Program goals are to increase parenting and system access skills in order to reduce the frequency of juvenile criminal justice system conflicts; increase school attendance and academic success; and increase parenting skills for DSS-involved parents to facilitate reunification with their children or to prevent removal from the home due to abuse or neglect allegations. Family Advocates provide support, case management, coaching, and education to better equip parents to be effective advocates for their children with mental health and substance abuse issues. c) Describe the local need or problem to be addressed in relation to the Consolidated Plan or other community priorities (i.e. Council/Board Goals). Cite local data to support the need for this program and the population being served. Research shows that half of all lifetime cases of mental illness begin by age 14. Scientists are discovering that changes in the body leading to mental illness may start much earlier, long before any symptoms appear. Through greater understanding and research into child brain development, we are learning more about the early stages of a wide range of mental illnesses that appear later in life. Once mental illness develops, it becomes a regular part of a child's behavior and more difficult to treat. Though significant advances have been made to better treat many disorders, the National Institute of Mental Health reports that many children with mental illness do not get the treatment they need. While approximately one in five children under the age of 18 live with a diagnosable mental health condition, between 50-75% of these children do not receive treatment. According to the 2013 Orange County Census Report, there are an estimated 140,352 residents, 20.5% of whom are under age 18. Of the over 28,770 youth in the community, an estimated 5,754 are currently living with a mental health condition, meaning that here in Orange County, somewhere between 2,500 and 3,800 youth are not receiving needed treatment. 40% of the clients served by the FAN Advocates are through direct Orange County DSS referrals or self-referrals, usually DSS-involved families. In these situations, parenting classes are essential for maintaining their family units, or reunifying after removal has already taken place. Due to limited resources, FAN has been unable to meet the ever- growing demand for parenting classes - classes that are necessary for fostering healthy families in our county. Funding from JCPC does not support the parenting skills building classes. d) Describe the population to be served or the area to benefit and indicate how you will identify beneficiaries. Stigma around mental illness is a common factor among people who don't seek treatment. Parents often hesitate, not wanting their child to be labeled. In some circumstances, families are unable to afford treatment services, or treatment is otherwise inaccessible. Parents of these youth often do not understand mental illness and blame the child for making willful choices when, in fact, it is a health condition that causes the behaviors. The parents' denial of their child's mental health concerns can cause other problems within the family dynamic, including increased risk of abuse and neglect of children, and even set the stage for divisions between parents and other siblings. Youth may engage in negative behaviors, such as stealing, truancy, or fights at school, that cause the court system to become involved in the family's life. Likewise, mental illness can dramatically impact a young student's success in the public school system. Whether due to negative behaviors, severe depression, anxiety, or psychosis, parents and teachers Main Application 5/25/2016 9:20:28 AM P g of 20 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION struggle to provide these children a positive school experience. In addition, parents struggling to meet the basic needs of their families often have their own mental health needs that make them more vulnerable to the family stressors described above. In such situations, DSS may become involved due to concerns about abuse and neglect. If parents do not receive needed support, treatment, skills building, and education, they risk losing their children or being unable to reunify after removal. These issues place extraordinary stress on parents, families, and the community, and these families are most in need of the safety net of services and supports that MHAT provides through its FAN program. e) Who specifically will carry out the activities and in what location will they be carried out? Trained staff, FAN Advocates, engage parents in case management-like services that include help in navigating multiple systems (juvenile court, social services, school/special education, treatment services, and community resources), while also providing opportunities for one-on-one and group support. FAN Advocates offer specialized training through workshops and parent skills building classes to empower parents to improve outcomes for their children living with mental illness, as well as for their entire family. FAN Advocates spend at least 12 hours when working one-on-one with parents and upwards of 100 hours providing case management-like services. The duration of service is individually based on the parents' and families' unique needs, averaging 6 - 9 months. For other parents, FAN Advocates provide brief consultation services by phone, email, and/or one- one-one meetings ranging from one to four hours of service to help parents better identify needs, assist with navigation, provide support or coaching, and/or connect them to resources. Services are provided in the community (school, court, home and other places), as well as at the MHAT office. f) Describe specifically the period over which the activities will be carried out, the frequency with which the activities will be carried out, and the frequency with which services will be delivered. Include an implementation timeline. FAN will provide 11 six-week Common Sense Parenting Classes during FY16-17, scheduling 2 to 3 each quarter of the year. Throughout the year, FAN staff will continue to provide 1:1 support for parents of children with mental health needs, as well as short-term consultation and referral for parents seeking appropriate mental health and/or education services for their children. g) Provide a bulleted list of other agencies, if any, with which your agency coordinates/collaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. For each, give specific examples of the coordinated/collaborative efforts. • Juvenile Court — FAN receives many of its referrals through Juvenile Court, and provides feedback and reports to Juvenile Court Counselors regarding parent involvement in FAN services and improved functioning at home, school and in the community for their children. • Orange County Department of Social Services (DSS) — FAN collaborates with DSS by providing parent skills building training to parents referred by DSS social workers, utilizing the "Common Sense Parenting" best practices curriculum and providing one-on-one support to help referred clients be compliant with court or department orders. • Orange County/Chapel Hill-Carrboro Schools —As with Juvenile Court and DSS, FAN receives referrals from school personnel for its services; and attends IEP meetings as warranted and provides supports to parents in order to improve their children's functioning in school. Main Application 5/25/2016 9:20:28 AM .. g of 20 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION • KidSCope — FAN partners with this agency to provide professional development for FAN staff and provide trainings in FAN's "Common Sense Parenting" to their parents of toddlers/preschoolers with emotional-behavioral challenges, reinforcing the concept that mental illness is treatable and early intervention works. • Family Success Alliance — FAN accepts referrals from FSA for individuals in Zone 4 who are in need of FAN services. FSA staff are co-located at the MHAT office, and assist each other with resource and referral information for the families each program serves. • Orange County Care Review — A FAN staff member attends Care Review meetings to support the family's voice when a parent is applying for out-of-home placement for their child with at-risk behaviors. • Orange County Collaborative —A FAN staff member attends monthly collaborative meetings, which is a working group designed to learn from other members, identify gaps and needs for mental health services delivered to youth under age 18, and work in partnership with the committee to develop ways to fill the identified gap in treatment services and skills building to parents, youth, and families. • Volunteers for Youth — FAN partners with Volunteers for Youth to help youth who are court-involved comply with community service hours, as well as provide support and training opportunities to parents of youth in their mentoring and restitution programs. h) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. Since the FAN Program's inception in 2000, demand for program services continues to grow exponentially each year. FAN services are essential to parents raising children with at-risk behaviors rooted in mental health conditions. Referrals for services come from a variety of resources — the juvenile court system, DSS, schools, treatment providers, churches, other community agencies, friends or family members who have previously and successfully utilized FAN services, and self-referrals. FAN has always adapted to fit the needs of the community, though limited staff and resources have prevented them from fully meeting the demonstrated need. JCPC funding does not include support for FAN's Common Sense Parenting classes or for the increasing number of referrals for short-term consultation and assistance accessing and navigating needed services for their children. We are seeking a small amount of new funding from Orange County ($5,000) to increase our ability to provide these classes. Parenting classes were cut from 15 in FY14-15 to only 6 in FY15-16 due to staff reductions. i) Include any other pertinent information. Program/Project Information j) Complete the Target Population and Program Beneficiary Demographics Chart k) Complete the Schedule of Positions Chart for Program Staff I) Disclosure of Potential Conflicts of Interested must be signed m) Complete the Work Statement Chart to describe the work to be performed, and be sure to attach copies of all data collection tools that will be used to verify achievement of program goals and objectives. Describe who will be responsible for monitoring progress. Information to Complete j.) Target Population Main Application 5/25/2016 9:20:28 AM .. g of 20 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION Complete the following tables to the best of your ability. Show numbers of participants and percentages, as applicable, in each category. Please indicate whether this project/program will serve: X Persons ❑ Households ❑ Units Program: Family Advocacy Network Program Beneficiary Demographics Actual Estimated Projected 2014-15 2015-16 2016-17 Gender Male 312 189 212 Female 143 136 153 Total 345 325 365 Ethnicity African-American 72 68 77 American Indian or Alaska Native Asian Caucasian 249 234 263 Native Hawaiian or other Pacific Islander Other 24 23 25 Total 57 325 365 Of the above, how many Hispanic/Latino 138 130 146 Of the above, how many non- Hispanic/Latino 111 104 219 Total 345 325 365 Age 0-5 years 6-18 years 57 55 62 19-50 years 192 182 204 51-61 years 88 81 92 62+ years 8 7 7 Total 345 325 365 Geographic Location Durham City Durham County 68 74 84 Carrboro 31 33 37 Chapel Hill 92 91 102 Chapel Hill Public Housing Residents Orange County 154 127 142 Raleigh Wake County Total 345 325 365 I Main Application 5/25/2016 9:20:28 AM P 10 of 2 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION k.) Schedule of Positions Please include program staff positions followed by volunteer positions; these financial figures should match the personnel figures in your Agency Comparative Budget Excel Form. Similar positions can be combined. (i.e., 8 Occupational Therapists can be inserted as one line item). If provided, indicate: Position Titles % (R) *= Position FTE* Program Actual Estimated Projected %Total Retirement Vacant Staff+ 2014-15 2015-16 2016-17 Budget Plan (H) Health Plan Executive Director .5 25% $ 14,000 $ 8,800 $ 12,653 10% FAN Coordinator .5 100% $ 34,231 $ 11,688 = 0% $43,338 Family Advocate .8 100% $26,725 $ 37,045 (1.0 FTE) 33% $41,733 2 Family Advocates .75 100% $40,092 $29,605 (1.2 FTE) 32% Marketing Director .5 22% - - $4,286 3% Notes: • Similar positions can be combined: i.e. 8 Occupational Therapists can be inserted as one line item. • ** Full Time Equivalent staff will be noted as 1.00; half time as .50; quarter time as .25, etc. • + Denotes the percentage of staff time involved with this program. • Calculate a Full Time Equivalent for all recorded volunteer hours using the following: Total Volunteer Hours = Volunteer FTE 1,960 Main Application 5/25/2016 9:20:28 AM P 11 of 20 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION I.) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST Are any of the Board Members or employees of the agency which will be carrying out this project, or members of their immediate families, or their business associates: YES NO X a) Employees of or closely related to employees of the Town of Chapel Hill, Orange County, Carrboro, or Hillsborough? X b) Members of or closely related to members of the governing bodies of Chapel Hill, Carrboro, Hillsborough, or Orange County? X c) Current beneficiaries of the project/program for which funds are requested? X d) Paid providers of goods or services to the program or having other financial interest in the program? If you have answered YES to any question, please provide a full explanation below. To the best of my knowledge and belief all of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of interest does not necessarily make the project ineligible for funding, but the existence of an undisclosed conflict may result in the termination of any grant awarded. Signature: hia4C1.1 " /1/ ' 1/25/2016 Executive Director Date Signature: 1-1 I 1/25/2016 Board Chairperson Date Main Application 5/25/2016 9:20:28 AM .. g 12 of 20 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION m.) Work Statement This form is used to document program activities, program goals, performance measures, and actual results. (Add more rows as needed) If this is a new program, you will only document the projected information. • Program Activities should outline major activities the agency implements to accomplish its program goals. • Program Goal should explain what the program is trying to achieve/accomplish. Goals are statements about what the program should accomplish. SMART Goals • Performance Measures describe how you will evaluate the degree in which you achieved the stated goals. • Actual Program Results use program results to indicate the actual measureable achievement of goals. If goals were not met, please explain. Main Application 5/25/2016 9:20:28 AM P 13 of 2 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION Actual Estimated Projected 2014-2015 2015-2016 2016-2017 Parenting Skills Classes Parenting Skills Classes Parenting Skills Classes- FAN advocates provided FAN advocates will provide FAN advocates will provide small group parenting skills small group parenting skills small group parenting skills classes,in English and classes,in English and classes,in English and Program Activity 1 Spanish Spanish Spanish Improve parent/child Improve parent/child Improve parent/child relationship;improve relationship;improve relationship;improve parents'skills to handle parents'skills to handle parents'skills to handle problem behaviors with problem behaviors with problem behaviors with positive and effective positive and effective positive and effective strategies;improve parent strategies;improve parent strategies;improve parent effectiveness to prevent effectiveness to prevent effectiveness to prevent removal of children and/or removal of children and/or removal of children and/or Program Goal enable reunification enable reunification enable reunification At least 80%of the parents At least 80%of the parents At least 80%of the parents of-children living with a of children living with a of children living with a mental health condition,co- mental health condition,co- mental health condition,co- occurring mental illness or occurring mental illness or occurring mental illness or substance abuse who substance abuse who substance abuse who complete parent skill- complete parent skill- complete parent skill- building training(6 weeks) building training(6 weeks) building training(6 weeks) will report increased will report increased will report increased competencies in the areas of competencies in the areas of competencies in the areas of 1)reducing child's problem 1)reducing child's problem 1)reducing child's problem behavior;2)improved family behavior;2)improved family behavior;2)improved family relationships;3)conflict relationships;3)conflict relationships;3)conflict resolution,and 4)coping resolution,and 4)coping resolution,and 4)coping Performance Measures skills_ skills_ skills_ 6 class series to be provided;est.30 parents to 11 class series to be 14 class series provided;75 complete.3 class series provided;est.55 parents to parents completed;91%of provided through 12/31/15; complete.80%of parents parents reported increased 90%of parents reported will report increased competencies in target increased competencies in competencies in target Program Results areas. targe areas. areas. Main Application 5/25/2016 9:20:28 AM P 1 of 2 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION Actual Estimated Projected 2014-2015 2015-2016 2016-2017 Family Consultations/ Family Consultations/ Family Consultations/ Referrals: FAN Referrals: FAN Referrals: FAN advocates provided advocates provide advocates will provide support, advocacy and support, advocacy and support, advocacy and information/referral information/referral information/referral assistance for parents assistance for parents assistance for parents who called MHAT/FAN who call MHAT/FAN for who call MHAT/FAN for for help with services for help with services for help with services for their child. FAN their child. FAN their child. FAN advocates spent advocates spend advocates will spend approximately 1-4 hours approximately 1-4 hours approximately 1-4 hours on one or more phone on one or more phone on one or more phone calls or 1:1 meetings to calls or 1:1 meetings to calls or 1:1 meetings to identify needs, services, identify needs, services, identify needs, services, providing service providing service providing service navigation assistance, navigation assistance, navigation assistance, supporting and coaching supporting and coaching supporting and coaching parents on how to parents on how to parents on how to advocate for needed advocate for needed advocate for needed services and how and services and how and services and how and where to connect youth where to connect youth to where to connect youth to to positive community positive community positive community Program Activity 2 resources. resources. resources. Improve access to services for children Improve access to Improve access to with mental health services for children with services for children with needs; improve parents' mental health needs; mental health needs; ability to advocate improve parents' ability improve parents' ability effectively and secure to advocate effectively to advocate effectively needed services for their and secure needed and secure needed Program Goal children services for their children services for their children Parent reports of satisfaction with Parent reports of Parent reports of information and referral satisfaction with satisfaction with assistance; feedback information and referral information and referral from parents and assistance; feedback from assistance; feedback from community agencies re: parents and community parents and community effectiveness of parent agencies re: effectiveness agencies re: effectiveness Performance advocacy to obtain of parent advocacy to of parent advocacy to Measures needed services obtain needed services obtain needed services Consultations and Referrals provided to Consultations & estimated 225 families Consultations and Referrals provided for (130 families through Referrals provided to Program Results 213 families 12/31/15) estimated 240 families Main Application 5/25/2016 9:20:28 AM P 15 of 2 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION 4. FINANCIAL INFORMATION FOR SERVICE PROGRAMS a.) Program Budget Please complete a Program Budget Excel Form for each requested program. The Program Budget should reflect only figures and amounts associated with the Program(s) for which you are seeking funding and not the total agency budget. If the program's finances experienced significant changes that you would like to explain, please use the space below. It is required that your Excel budget worksheet be embedded on the next page. You must also submit an electronic copy of the MS Excel file with your application, as a separate file. Main Application 5/25/2016 9:20:28 AM P , 16 of 20 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION Section III. Program Information Program Budget Worksheet AGENCY NAME: Mental Health America of the Triangle-Programs:FAN Actual Estimated 2015- Projected 2016- PROGRAM REVENUE 2014-15 16 17 Percent Change Private Donations $ 18,000 $ 1,400 -100% Program Generated Revenue(fees) $ - 0 Local Government Grants: Orange County $ 5,000 0 Town of Chapel Hill $ 2,000 $ 1,000 $ 2,000 100% Town of Carrboro $ 2,000 $ 1,000 $ 2,000 100% Other Local: Orange County-JCPC Match $ 12,217 $ 12,217 $ 12,217 0% Other Local: Durham County $ 18,979 $ 5,088 $ 5,088 0% Other Local: Durham County JCPC $ - $ 14,000 $ 14,000 0% If more than 3 sources,please provide a separate list. Non-Local Government Grants Triangle United Way 0 State Government:JCPC-Orange $ 40,722 $ 40,722 $ 40,722 0% Federal Government 0 Other Grants: Cardinal Innovations $ 49,000 $ 49,000 $ 49,000 0% Other Grants: V` 0 Miscellaneous/Other Revenue $ - $ - $ - 0 Please list 3 largest Miscellanous sources: $ - Total Program Revenue $ 142 918 $ 124 427 $ 130 027 5% PROGRAM EXPENSES Compensation $ 116,624 $ 89,656 $ 102,010 14% Rent&Utilities $ 7,551 $ 6,492 $ 6,500 0% Supplies&Equipment $ 4,221 $ 3,033 $ 4,230 39% Travel&Training $ 4,679 $ 3,632 $ 3,512 -3% Other Expenses: $ 11565 $ 13,153 $ 13,625 4% Please list 3 largest"Other Expenses": Contractual Services $ 6,450 Insurance $ 4,265 Dues,Bank,Adv $ 850 Total Program Expenses $ 144,640 $ 115,967 $ 129,877 12% SURPLUS/(DEFICIT)FOR PERIOD: $ (1,722)1 $ 8,461 1 $ 150 1 -98% Main Application 5/25/2016 9:20:28 AM H '7 0 f 2 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION b.) Program Budget Detail What is the cost to deliver your project/program? List each project/program element in the table below, including the cost of each element, the quantity and unit of measure, and the subtotal for each element. Where necessary, allocate costs to the use of shared space, vehicles or equipment. Example Program: Credit Counseling Class Cost Elements Cost($) Quantity/Unit of Measure Subtotal ($) Credit Counseling Teacher–in class $25 96 hours (8 hrs/mth x 12 months) $2,400 Credit Counseling Teacher—class prep $25 48 hours (4hrs/mth x 12 mths) $1,200 Credit Counselor—one-on-one $20 120 hours (10 hrs/mth x12 mths $2,400 Materials $25 120 course packets/credit reports $3,000 Total $9,000 Complete the table below for the project/program for which you are requesting funds. Attach additional rows/pages, as needed. Program: _Family Advocacy Network Cost Elements Cost( ) Quantity/Unit of measure Subtotal( ) Common Sense Parenting Class–6 $ 240/class 12 hours/class x 11 classes = $ 2,640 sessions, 2 hours each –Teacher in class series 132 hours Common Sense Parenting Class Prep, Set- $240/class 2 hours/session x 6 sessions x $2,640 up-3 hours/class session series 11 classes = 132 hours Parent Consultation and Referral to $ 30 1.5 hours/consultation x 240 $ 7,200 Services consultations = 360 hours Total $ 12,480 C.) Cost per Unit Actual 2014-15 Estimated 2015-16 Projected 2016-17 Total Cost of Program $ 144,640 $ 115,967 $ 129,877 Total # of Units 345 325 365 Cost Per Unit $ 419 $ 479 $ 355 This Cost Per Unit must reflect the total program budget and the total number of program beneficiaries (households or persons) in this application and must be consistent with report submittals from previous years (if applicable). Main Application 5/25/2016 9:20:28 AM .. of 20 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION d.) Agency Operating Budget Please show all sources and amounts of funding for your entire current fiscal year. What is your agency's fiscal year? Example: July 1, 2016 through June 30, 2017. Submit operating budget in your own format. Do not include funds that have been applied for but not yet awarded: If the total revenue is not the same amount as the budget for any fiscal year, please attach a statement explaining the deficit or surplus. It is required that your Excel budget worksheet be embedded on the next page. You must also submit an electronic copy of the MS Excel file with your application, as a separate file. Main Application 5/25/2016 9:20:28 AM .. g of 20 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued Provider's Outside Agency Application MAIN APPLICATION Section Vt.Financial Data Operating Budget for Entire Agency Agency Name: Mental Health America of the Triangle Actual Estim ated Projected Percent Agency Revenue 2014-15 2015-16 2016-17 Change Private Donations $ 84,877 $ 87,185 $ 70,892 -19% Agency Generated Revenue(fees) 0% Local Government Grants: Orange County $ 17,000 0% Town of Chapel Hill $ 5,500 $ 5,500 $ 6,000 9% Town of Carrboro $ 5,500 $ 5,700 $ 6,000 5% Other Local: JCPC Local Match $ 15,605 $ 15,605 $ 15,605 0% Other Local: Durham County $ 23,588 $ 23,588 $ 23,588 0% Other Local: Family Success Alliance $ 38,817 $ 53,000 37% If more than 3 sources,please provide a separate list Non-Local Government Grants Triangle United Way 0% State Government: JCPC Funds-Orange $ 52,024 $ 52,024 $ 52,024 0% Federal Government $ 106,227 $ 125,753 $ 125,753 0% Other Grants: JCPC Funds-Durham $ 14,000 $ 14,000 0% Other Grants: ABC/PUD Funds $ 20,000 $ 20,000 $ 20,000 0% Other Grants: Cardin al Innovations $ 79,000 $ 79,000 $ 79,000 0% Miscellaneous/Other Revenue $ 953 $ 1,000 $ 1,000 0% Please list 3 largest Miscellanous sources: Training Revenue $ 953.00 Total Agency Revenue $ 393,274 $ 468,172 $ 483,862 3% AGENCY EXPENSES Compensation $ 245,364 $ 281,105 $ 337,844 20% Rent&Utilities $ 18,663 $ 20,100 $ 20,100 0% Supplies&Equipment $ 38,766 $ 15,344 $ 14,337 -7% Travel&Training $ 12,212 $ 18,509 $ 13,400 -28% Other Expenses: $ 106,675 $ 123,622 $ 92,166 -25% Please list 3 largest'Other Expenses': Contractual Services $ 91,155.00 Insurance $ 6,261.00 Sues,Bank,Adv,FR Exp $ 9,259.00 Total Agency Expenses $ 421,680 $ 458,680 $ 477,847 4% SURPLUS/(DEFICIT)FOR PERIOD: $ (28,406)1 $ 9,492 J $ 6,015 J -37% Main Application 5/25/2016 9:20:28 AM F a g 20 of 20 DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 EXHIBIT `B" Scope of Services—FY 2016-17 Outside Agency Performance Agreement Agency Name: Freedom House Recovery Center, Inc. Funding Award: $35,000 Outline how the agency will spend Orange County's funding award. Expense Description Amount Personnel—Salaries and FICA 35,000 Program Supplies Program Services For assistance with this or the following section, please reference the Exhibit A instructions and example, located within the contract and reporting memorandum. Outline the major activities the agency will employ to attain the Anticipated Outcomes below,by June 30,2016. • Provide Services to all referrals from the community that meet admission criteria • Crisis staff begins discharge planning with each client in crisis unit, using motivational interviewing techniques to incentivize clients to move into the next appropriate level of care. • Work with UNC ER staff, individuals and our doctors and clinicians to admit difficult cases into the crisis unit, diverting them from the local or state hospitals. Anticipated Outcomes The Anticipated Results column must include quantifiable results in the form of number of persons/units served within Orange County, only (all Towns and municipalities). If you use percentages, you must also provide the total number of participants within that measure's description or for an earlier performance measure. Performance Measures Anticipated Results Divert 96%of those referred to the crisis unit from our local hospital ER and expensive state 96% hospitals Provide services to 2,639 individuals in need of addiction or mental health treatment 2,639 EMR system tracks information and flow of client services 100% Provide class series to parents 1 lseries/ 55 parents Consultations and Referrals provided to families 240 families —DocuSigned by: fiVISL AlASSUI CEO 10 2 5/2016 Certified by: Date: �' 4---.BASB2^ecD7sS,17^... (Provider's Signature) DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 ACC? ° DATE(MMIDDIYYYY) ® CERTIFICATE OF LIABILITY INSURANCE 6/24/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Ellen Walker NAME: Business Insurers of Carolinas (A/C No,Eat): (919)968-4611 FAX No):(919)968^8991 800 Eastowne Drive, Suite 208 ADORless:ewalker @business-MAIL PO Box 2536 INSURER(S)AFFORDING COVERAGE NAIC C Chapel Hill NC 27515-2536 INSURER A:Union Insurance Company A+ XV 25844 INSURED INSuRERB:United Wisconsin Ins Co A- XI 29157 Freedom House Recovery Center, Inc INSURER C: 104 New Stateside Drive INSURERD: INSURER E: Chapel hill NC 27516 ,INSURER F: COVERAGES CERTIFICATE NUMBER:16/17 Revised REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD _.-_.-.. . INDICATED,..NO.TWITHSTANDING_ANY_REQUIREMENT,_TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LIMITS LTR ,INSD,WVD POLICY NUMBER IMMIDDJYYYY) (MM!DD(YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 , , DAMAGE TO RENTED A CLAIMS-MADE X OCCUR PREMISES(a occurrence) $ 1,000,000 . X Professional Liability X CPA427860742 7/1/2016 7/1/2017 MED EXP(Any one person) $ 20,000 i X sexual & Physical Abuse i PERSONAL&ADV INJURY $ 1,000,000 GE AGGREGATELIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 X POLICY I PRO- JECT LOC PRODUCTS-COMP/OPAGG $ ' 3,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1 000,000 (Ea accident) r X ANY AUTO BODILY INJURY(Per person) $ A ALL OWNED SCHEDULED AUTOS AUTOS X CPA427860792 7/1/2016 7/1/2017 BODILY INJURY(Per accident) $ X OWNED PROPERTY $X HIRED AUTOS AUT (Per accident) Medical payments $ 5,000 !, X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 _DEC I RETENTION$ CPA427860742 7/1/2016 7/1/2017 $ WORKERS COMPENSATION X STATUTE OTH- ER AND EMPLOYERS'LIABILITY Y/N j ANY PROPRIETOPJPARTNERIEXECUTIVE N!A E.L.EACH ACCIDENT $ 500,000 B OFFICER/MEMBER in N )EXCLUDED? Y 2000013393 5/16/2016 5/16/2017 EL.DISEASE-EA EMPLOYEE $ 500,000 (Mandatory[n NH) If yes,describe under DESCRIPTION OF OPERATIONS below 1 E.L.DISEASE-POLICY LIMIT $ 500,000 A Employee Dishonesty CPA427860742 7/1/2016 7/1/2017 25,000 DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES(ACORD 101.Additional Remarks Schedule,may be attached If more apace is required) Orange County is also an additional insured with respect to General Liability and Automobile Liability, • required by written contract. Forms attached. CERTIFICATE HOLDER CANCELLATION achambers @orangecountync.g SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orange County THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Loo BOX 8181 ACCORDANCE WITH THE POLICY PROVISIONS. Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE Ellen Walker/ELLEN 1 e� 4 1 Oo 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025f'014m1