Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
2017-707-E Finance - Institute of Art Therapy outside agency agreement
DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 OUTSIDE AGENCY PERFORMANCE AGREEMENT THIS AGREEMENT,made and entered into the first day of July 2017, ("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 The Institute of Art Therapy, a not-for-profit corporation, located at 200 N. Greenboro St., Suite D-6, Carrboro,NC 27510("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 The Institute of Art Therapy agree as follows: 1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1, 2017 to June 30, 2018. 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 B, Scope of Services and more particularly described in the Revised Program Budget, the maximum sum of 300 b. All funds appropriated shall be used for purposes described in Exhibit B. 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 75. 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. (The Institute of Art Therapy) Orange County Outside Agency Performance Agreement Revised 712017 Page I of 7 DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 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 12,April 13, and July 13 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. (The Institute of Art Therapy) Orange County Outside Agency Performance Agreement Page 2 of 10 Rev. 7117 DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 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. (The Institute of Art Therapy) Orange County Outside Agency Performance Agreement Page 3 of 10 Rev. 7117 DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 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 Non-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 $ 13.75 per hour. To the extent possible, Orange County recommends that The Institute of Art Therapy 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: (The Institute of Art Therapy) Orange County Outside Agency Performance Agreement Page 4 of 10 Rev. 7117 DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 County: Finance&Administrative Services Provider: The Institute of Art Therapy Orange County 200 N. Greenboro St., Suite D-6 Post Office Box 8181 Carrboro,NC 27510 Hillsborough,NC 27278 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. 18. 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. Provider shall at all times remain in compliance with all applicable local, state, and federal laws, rules, and regulations including but not limited to all state and federal anti-discrimination laws, policies, rules, and regulations and the Orange County Non-Discrimination Policy and Orange County Living Wage Policy (each policy is incorporated herein by reference and may be viewed at http://www.orangecountync.gov/departments/purchasing_division/contracts.php). Any violation of this requirement is a breach of the Agreement and County may immediately terminate this Agreement without further obligation on part of the County. This paragraph is not intended to limit and does not limit the definition of breach to discrimination. 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. 19. 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. Fc oocu5igned b,: the Provider C1l��Pl LSilrt. 11/22/2017 09EBECCF336445C... Date (The Institute of Art Therapy) Orange County Outside Agency Performance Agreement Page 5 of 10 Rev. 7117 DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 For an °OCA$1gnedby, cnty Government bltilnll. �"A�wt#.Y'SG.� 11/27/2017 E0637994B755E477 ... Bonnie Hammersley, County Manager Date (The Institute of Art Therapy) Orange County Outside Agency Performance Agreement Page 6 of 10 Rev. 7117 DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION FY 2017-2018 Outside Agency Funding Application HUMAN SERVICES • ORANGE COUNTY • TOWN OF CARRBORO • TOWN OF CHAPEL HILL Orange County (OC) Town of Carrboro (CA) Town of Chapel Hill (CH) 200 S. Cameron Street 301 W. Main Street 405 Martin Luther King, Jr. Blvd. Hillsborough, NC 27278 Carrboro, NC 27510 Chapel Hill, NC 27514 r� 'err 4 + a`�tiyror DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION INFORMATION Each year, Orange County Government, the Town of Carrboro and the Town of Chapel Hill invite program funding requests from non-profit providers that support the delivery of vital community services. The application process is very competitive and not all applicants will be awarded funding. Recommendations for funding may be for an award amount less than that requested by the applicant. Agencies that are currently receiving funds from Orange County, the Town of Carrboro, or the Town of Chapel Hill local governments, and are also applying for new funds, must be in compliance with all terms of their current agreement(s) and must not have any outstanding audit findings, monitoring findings or concerns as determined by the municipality. Recipients are required to submit written progress reports on their SMART Measures that include: goals, description of activities/challenges, revisions of timelines/budgets, and other relevant information Funded projects will be monitored for progress and performance, financial and administrative management, and compliance with the terms of Performance/Development Agreement(s). Monitoring may involve site and/or office visit(s). Once applications are received, they are reviewed by staff for completeness and eligibility. The applications are presented to a specific application review group, depending on the funding source. The review group will make a recommendation, based on available funding and the priorities identified by the participating jurisdiction. The recommendation is presented to the appropriate Board/Council for consideration and approval. The Board/Council approves/adopts the final allocations. TIMELINE November 15 Funding Application Posted on Websites November 29 Funding Application Workshop Held October 18-January 23 Agency Prepares Application January 10 Q&A Session Held January 31 Application Submissions are Due March - May Application Review & Agency Presentations June Agency Funding Approval by Board/Council July Contracts Executed & Programs Begin DO NOT SUBMIT THIS PAGE 2/8/2017 3:01 :12 PM Page 2 of 20 DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION SUBMITTAL INFORMATION Welcome to the Outside Agency Common Funding application for local/general funds, which will be distributed through this competitive application process. All entities or organizations requesting funds must complete and submit this application prior to the deadline to be considered for FY 2017-2018 funding. The Application Submittal Deadline is: Tuesday, January 31, 2017 5:00 PM In the event of inclement weather, check the website for each Town/County you are applying to, for further instructions. Please note that late, handwritten, or incomplete applications will not be accepted. (Applications not signed by the Chair or President of the Board of Directors, are considered incomplete.) An application orientation workshop will tentatively be held on Tuesday, November 29, 2016 at 9 AM to Noon to review the application and submittal requirements. SUBMITTAL REQUIREMENTS FOR EACH MUNICIPALITY Human Services— Town Of Carrboro Applications are accepted once a year and reviewed by the Town's Human Services Advisory Commission, which makes a recommendation for funding to the Board of Aldermen for final approval. For more information about the Town of Carrboro Human Services program, see here. Questions and submittals should be directed to: Annette Stone, 301 W. Main Street Carrboro, NC 27510 919-918-7319 astone cj�townofcarrboro.org Submission: We strongly encourage applications to be single-spaced, with 12-point arial font and normal margins. Application: One (1) original plus Two (2) paper copies of the application must be hand delivered or mailed to Annette Stone, 301 West Main Street, Carrboro, NC 27510; AND One Application and Attachments files must be submitted by email. Any .pdf files must be accompanied by the original file format of .doc, .xIs, etc. DO NOT SUBMIT THIS PAGE 2/8/2017 3:01 :12 PM Page 3 of 20 DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Human Services — Town Of Chapel Hill In 1982, the Town established local funding to support local nonprofit organizations that carry out human service work throughout the community. Applications are accepted once a year and reviewed by the Town's Human Services Advisory Board, which makes a recommendation for funding to the Town Council for final approval. For more information about the Town of Chapel Hill Human Services program, see here. Questions and submittals should be directed to: Jackie Thompson 405 Martin Luther King Jr. Blvd. Chapel Hill, NC 27514 919-969-5081 jhompson(c�townofchapelhill.org Submission: ➢ We strongly encourage applications to be single-spaced, with 12-point arial font and normal margins. Application: Two (2) paper copies of the application with ORIGINAL signatures must be hand delivered or mailed to Jackie Thompson, 405 Martin Luther King, Jr. Blvd., Chapel Hill, NC 27514; AND Attachments: The application submittal must be accompanied by a flash drive with the application and all attachment files in electronic format. Any .pdf files must be accompanied by the original file format of .doc, .xIs, etc. Human Services— Orange County For more information about the Orange County Human Services program, see here. Questions and submittals should be directed to: Allen Coleman PO Box 8181 Hillsborough, NC 27278 (919) 245-2151 acoleman(a-)_orangecountync.gov Submission: Email application and ALL Attachments prior to the deadline. Any .pdf files must be accompanied by the original file format of .doc, .xIs, etc. Please request a delivery receipt of email with application and attachments. DO NOT SUBMIT THIS PAGE 2/8/2017 3:01 :12 PM Page 4 of 20 DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION FOR OFFICE USE ONLY Agency The Art Therapy Institute Received By Program: Newcomer's Art Therapy Program Date/Time / Section Subsection 1. Cover Page a. ❑ Applicant Contact Information b. ❑ Funding Requests C. ❑ Signed Application Cover Page d. ❑Signed Disclosure of Conflicts of Interest and Clause 2. Agency Information a. ❑ Agency's Years in operation b. ❑ Agency's Purpose/Mission c. ❑ Agency's Types of Services Provided d. ❑ Agency's Experience with Programs e. ❑ Other Pertinent Agency Information f. ❑ Schedule of Positions g. ❑ Living Wage h. ❑ Agency Budget 3. Program Information a. ❑ Human Services Needs Priority b. ❑ Type of Program A separate Section 3 is c. ❑ Agency Collaboration required for each program. d. ❑ Summary of Program e. ❑ Description of Identified Need f. ❑ Description of Population to be Served g. ❑ Program Staffing, Capacity, & Expertise h. ❑ Program Implementation Timeline i. ❑ Value of Investment j. ❑ Impact of Reduced/No Allocation k. ❑ Other Pertinent Information I. ❑ Target Population/Beneficiary Chart M. ❑ Work Statement n. ❑ Program Budget, Detail, & Cost per Individual 4. Attachments a. ❑ Audit: Organizations receiving $300,000 or more 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. ❑ IRS Federal Form 990 c. ❑ NC Solicitation License d. ❑ IRS Federal Tax-Exemption Letter e. ❑ Certificate of Insurance f. ❑ List of Board of Directors g. ❑ Solid Waste Program Fee (SWPF) Verification Application Submittal Checklist 2/8/2017 3:01:12 PM Page 5 of 20 DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 1. COVER PAGE a) Applicant Contact,Information. Applicant Organization's Legal Name: Institute of Art Therapy,-fnc. Applicant Organization's Physical Address; 2a O N. Gre nsbor_o_St._Stea-D-6,__CarrbnroNC Applicant Organization's Mailing Address: Same Applicant Organization's Web Address: www.ncatiarg Executive Director: Kristin Linton Telephone Number: 919_381-6(}68 E-Mail: klinton mcati,org- Tax ID Number: 26-3447555 b) Funding Request List all FYI 7-18 9 urnan Services Funding Being Requested — For.All„Prpgrra;ro ) and the Proposed Use of Funds (2-3 lines or less) fragcam CaWboro. Chapel [}rag e Total -HS Hill-BS Count -HS Ex. Youth Afterschooi Program $10,000 $15,000 $5,000 $30,000 Afterschool Program Coordinator salary and materials for youth activities and projects The Newcomers Art Therapy Program `y $5000 $5000 $5000 _ $15000 Totals - c) 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: -- - -- f I- Executive Director Date Signature: Board Chairperson Date AGENCY INFORMAT10N 115/2017 12:59:10 PM DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION d) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON DISCRIMINATION CLAUSE Are any of the Board Members or employees of the ardency which will be carrying out this program or members of their immediate families, or their business associates... YES ISO 0 Z a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? © b) Members of or closely related to members of the governing bodies of the Town of Carrboro,-the Town of Chapel Hill, or Orange County` [] } c) Current beneficiaries of the program for which funds are being requested? Q 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. NON-DISCRIMINATION Provider agrees as part of consideration of the granting of funds by funding agencies to the parties hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any mariner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, gender identityfexpression, 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 Change 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 ether 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. 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 program ineligible for funding, but the exist ncq__!Pf._Rn undisclosed_conflict ay_result ire the.terrrain�taan.Qf any grant awarded. Executive Director Dat Signature: - ..: �'�. � 17 -- -- Board Chairperson Date AGENCY INFORMATION 1/512017 12:58:45 PM DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 2. AGENCY INFORMATION (Be Very Brief and Concise) Please provide the following information about your agency (2 pages OR LESS): a) Years in Operation, Date of Incorporation (Month/Year): Sept., 2009 b) Agency's Purpose/Mission (no more than a few sentences): The Art Therapy Institute is an organization of mental health professionals inspired by the healing power of the arts. We provide clinical art therapy services to diverse populations, empowering clients to develop their artistic identities. We also offer training to allied professionals and seek to raise awareness in the general community about our profession and the benefits of art therapy. c) Types of Services the Agency Provides (bullet format): ATI's masters-level clinicians provide community-based services and improve access to mental health services for underserved populations. By approaching mental health issues through the healing components of the arts, ATI provides support that is culturally sensitive to a wide range of populations and prevents the need for more intensive interventions. ATI currently serves the following populations through our diverse programs: • Refugees from Burma, Syria, and many other countries • General ESL newcomers from many countries • Children with intellectual and physical disabilities • Adults with mental illness • Children receiving bone marrow transplants or treatment for cancer • Elderly patients with Alzheimer's and dementia • General art therapy referrals from community members • Continuing Education and Workshops for Allied Mental Health Providers d) Agency's History with Providing These Services: ATI has been working on the Newcomer Art Therapy Program since 2008, and has grown this program very slowly from its initial focus on children who are refugees from Burma to refugees from many countries. This growth has occurred thoughtfully with substantial input from community members, clients, and key stakeholders. We continue to monitor and evaluate our program to ensure effectiveness and alter goals and desired outcomes as needed so we continue to meet our refugee client's needs as they shift as well. This program has grown tremendously since inception. Beginning in a similar, grassroots manner, the executive director (ED) of ATI started an art therapy program for students with exceptional needs in the Chapel Hill/Carrboro schools in 2005, in one school, prior to founding ATI. The contract was brought in house to ATI and we have been serving the entire Exceptional Children's (EC) program since. This contract continues to grow in scope, and we currently serve all of the self-contained classrooms in the district, providing services to over 140 students annually. We work closely with the administration, teachers, and other staff to deliver art therapy services that enhance the growth, development, and opportunity for success for all of our students. Our other programs, while smaller in scope, remain passion projects of our clinicians, and we work with children in pediatric oncology at Duke and UNC, elders in memory care Agency Information 2/8/2017 3:01:12 PM Page 8 of 20 DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION groups at assisted living facilities, and adults with severe and persistent mental illness. Through all of our programming, we provided art therapy services to over 500 individuals in the community in 2016. In addition, we provided workshops and trainings to over 40 professionals through our continuing education series. We have a proven track record of being fiscally responsible in order to support a wide range of services. We work to get art supplies donated whenever possible and continuously pursue diverse funding streams in order to increase our program sustainability. We have created a committed community supporting our work, who attends our art shows and community fundraisers in large numbers, and continues to volunteer, intern, and donate time and funding with ATI in growing capacity as we continue to utilize a wide variety of resources and talent. e) Other Pertinent Agency Information Over the past several years, ATI has undergone extensive capacity building with three separate contracts through the Executive Service Corp (ESC) of the Triangle. We have undergone strategic planning including a SWOT analysis, a revised mission and vision, and a case statement, which we in turn used for board development. This board development began with outreach into the community with the goal of finding diverse and qualified individuals committed to our mission and we now have a fully functioning, working board (10 people). Finally, an executive coaching contract for our ED, which lasted an entire year, ensured that we increased our ability to grow in a sustainable manner with strong leadership at the helm. We have hosted two annual board development meetings, board and clinician retreats, and are currently working on our next 5-year strategic planning cycle to incorporate all of our work up to now into our guiding document. In addition, ATI has brought all of our insurance billing in house and hired two of our contracted staff members as employees to continue to passionately carry out our mission in a sustainable way. Intentionally, we have grown slowly and with realistic goals and ideas about this expansion to ensure that we continue to serve our clients and our community for years to come. f) Schedule of Positions (For Entire Agency) • Full Time Equivalent (FTE) • Calculate a Full Time Equivalent for all recorded volunteer hours using the following: Total Volunteer Hours = Volunteer FTE / 2080 # of FTE - Full-Time Paid Positions: 3 # of FTE - Paid Part-Time Positions: 4 # of Volunteers: 103 # of FTE - Volunteers: 5 g) Living Wage Does this agency pay permanent employees a minimum living wage? (Yes/No) Yes If yes, is this agency an Orange County Living Wage Certified Employer? We applied h) Agency Budget i. Is your agency currently receiving and/or requesting other local government funding? No ii. Submit your agency's budget. You may complete the provided template (separate xis file) or you may submit your own budget file). Attached iii. Does your agency budget show a Surplus or Deficit? Surplus Is there a significant change? Yes/No No iv. What is your agency's fiscal year? Jan. 1, 2016-Dec. 31, 2016 Agency Information 2/8/2017 3:01:12 PM Page 9 of 20 DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Newcomer's Art Therapy Program Program Primary Contact and Title: Kristin Linton Telephone Number:919-381-6068 E-Mail: klinton(a).ncati.org a) Indicate the type of Human Service Needs Priority, if program applicable: ® Priority Area #1: safety-net services for disadvantaged residents ® Priority Area #2: education, mentorship, and afterschool programming for youth facing a variety of challenges ® Priority Area #3: programs aimed at improving health and nutrition of needy residents b) Indicate the type of program for which you are requesting funding (Check all that apply to this program) Program Category Youth Adult Elderly Disabled Public Housing Neighborhoods/Residents Affordable Housing Affordable Healthcare x x x x Education Family Resources x x x Jobs/Jobs Training x Food Transportation Other: Please specify c) 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, briefly describe the coordinated/collaborative efforts. • Cardinal Innovations is a managed care organization that contracts with ATI to provide services to many of our clients who have Medicaid. They also provide a stipend for our work at the Carrboro Community Health Center, a women's group, some of our uninsured students, and some translation services. • The Carrboro Community Health Center/Piedmont Health provides comprehensive health services and education to all segments of the community, with special emphasis on vulnerable populations. They refer clients to ATI, sign medical service orders for art therapy, and provide space for ATI to provide weekly individual art therapy for adults. • Chapel Hill-Carrboro City Schools: The ESL Director, the EC Program Director, counselors, ESL and EC teachers, and social workers are all dedicated to partnering PROGRAM INFORMATION 2/8/2017 3:01:12 PM Page 10 of 20 DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION with ATI for continued service to the students in the school system and are primary contacts for referral sources to ATI. • Durham Public Schools: The ESL Director at the Durham Public Schools invited ATI to a newly formed newcomer coalition of providers in Durham. At the end of 2014, ATI received our first contract with DPS to run 6 art therapy groups with their growing newcomer students. • Refugee Health Coalition brings together the Orange County health department, social service providers, schools, two local healthcare systems, and four resettlement agencies. ATI clinicians attend the Refugee Health Coalition monthly meeting to keep up-to-date on refugee health issues and receive support from other organizations. • Refugee Mental Health Coalition subcommittee was formed as a special task force of mental health providers specifically focused on refugees. ATI collaborates with others on this committee, has hosted a meeting at ATI and regularly contributes to this subcommittee. • UNC Gillings School of Global Public Health has provided two teams of master's students to work with ATI over the course of 2 years to create a sustainable evaluation for the Burma (Newcomer's) Art Therapy Program. Two MPH Graduates from UNC serve on our Board and continue to help with the evaluation of our Burma Program work. We are currently working with our third team. • Transplanting Traditions is a community farm whose mission is to provide refugee adults and youth access to land, healthy food and agricultural and entrepreneurial opportunities. In 2015 and 2016, ATI collaborated with refugee farmers to harvest and prepare traditional Burmese food for our community art event. • Families Moving Forward (FMF) is a nonprofit offering a temporary home to families with children in the crisis of homelessness. They create a path to stability and self- sufficiency through personalized services and community support such as art therapy groups for parents provided by ATI. • Church World Service (CWS) is a nonprofit connecting newcomers with community resources and social integration opportunities in order to meet their immediate needs as well as promote long-term self-sufficiency as they build new futures in the US. ATI offers weekly women's groups to newly arrived refugees. PROGRAM INFORMATION 2/8/2017 3:01:12 PM Page 11 of 20 DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Description (3 pages OR LESS) Please provide the following information about the proposed program: d) Summarize the program services proposed and how the program will address a Town/County priority/goal? "Something you should know about me is that 1 really like art, and art is important. Because if you don't know what's happening and you can't speak the language, you can draw for them, and they will know exactly what you mean."-Refugee student from Burma, age 7 ATI contributes to the health and wellbeing of the growing population of newly arrived immigrants and refugees, hereafter referred to as "newcomers", in Chapel Hill, Carrboro, and Orange County. ATI provides counseling services to approximately 230 newcomers from the Middle East, Southeast Asia, Central and Northeastern Africa, and Central America children. Of these newcomers, 143 are students in Chapel Hill, Carrboro, Orange County schools. ATI is seeking funding to 1) support group art therapy work for newcomers which cannot be billed to insurance, 2) expand art therapy services to reach newcomers that either do not have or lose insurance, and 3) cover the cost of art supplies. Grant funds are primarily spent on direct services with some additional funding earmarked for evaluation. ATI has already demonstrated its potential to serve as a national model for art therapy service delivery and evaluation through two research manuscripts published in 2016 with researchers from UNC.1,2 As ATI continues to grow and provide services, funding is essential to help all newcomers benefit from art therapy services. ATI's activities align well with town (Chapel Hill and Carrboro) and county (Orange) priorities. Specifically, ATI provides counseling services for many disadvantaged residents (i.e., newcomers) which helps residents cultivate wellness and avoid having to seek other services, such as medical care (priority #1). ATI provides counseling and mentorship for refugee youth who already face academic, mental health, and social challenges; this positively impacts their education (priority area #2). ATI seeks to directly improve the health, mental health, and wellbeing of newcomers (priority area #3). By aligning with all three priority areas through its focus on health and wellbeing for residents in need, ATI is uniquely situated to serve town and county residents. In fact, the Newcomer Art Therapy Program began as a response to a community needs assessment from UNC-Chapel Hill. e) Describe the community need or problem to be addressed in relation to the Chapel Hill Human Services Needs Assessment, Orange County BOCC Goals and Priorities, Town of Chapel Hill Council Goals, Carrboro goals, or other community priorities (i.e. Council/Board Goals). Reference local data (using the provided links, i.e. Chapel Hill Human Services Needs Assessment) to support the need for this program. Kowitt,S. D.,Emmerling, D., Gavarkavich, D., Mershon,C. H.,Linton,K., Rubesin, H.,Agnew-Brune, C.,&Eng, E. (2016).A Pilot Evaluation of an Art Therapy Program for Refugee Youth From Burma.Art Therapy, 33(1), 13-20. 2 Rubesin, H.(2016).The stories we share: Reflections on a community-based art exhibit displaying work by refugees and immigrants.Journal of Applied Arts&Health, 7(2), 159-174. PROGRAM INFORMATION 2/8/2017 3:01:12 PM Page 12 of 20 DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Studies of refugee children indicate that up to 40% may have psychiatric disorders, such as post-traumatic stress disorder, depression, and anxiety.3 Compounding these problems, evidence suggests that newcomers, particularly youth, underuse mental health care services due to stigma, lack of appropriate translators, financial limitations, and insufficiency of mental health care services. Moreover, data from the most recent Chapel Hill Human Services Needs Assessment indicate that residents need additional mental health service options, especially for young and vulnerable populations (page 6). Locally, evaluations of ATI's services have shown that newcomer students are often at risk for mental health conditions, academic problems, and difficulties socializing. For instance, in a published pilot evaluation of ATI's work, 44% of sampled students were symptomatic for depression and 50% had abnormal classroom behavior and emotional symptoms.4 To meet the needs of newcomer students and improve mental health, academic, and social wellbeing, all of ATI's services are evidence based. For instance, in the past year through pre- and post-evaluations, 71% of measured students reported fewer depressive symptoms; 57% reported fewer anxiety symptoms; and 52% reported increased happiness. ATI is thus meeting needs of newcomers that few other organizations provide. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? We are seeking funding to continue support for the most vulnerable newcomers—those without insurance—and for group art therapy sessions, which cannot be billed to insurance. Newcomer students are referred for art therapy by teachers, social workers, counselors, medical professionals, and other community members involved with the local newcomer population. Reasons for student referrals include, but are not limited to, academic struggles; behavioral, emotional, and social issues; and/or knowledge of family discord or trauma. After receiving the referrals, therapists visit referred students' homes with an interpreter, meet with the families, describe art therapy, develop treatment plans, and obtain all necessary consent and release forms. g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) All ATI therapists have master's degrees in art therapy or related fields and are all fully licensed or working towards full Iicensure. All clinicians receive weekly group supervision and individual supervision as needed, according to client load and level of Iicensure. The ED and Associate Director have a combined experience practicing in the field for over 20 years and the Associate ED is actively pursuing her PhD in expressive art therapy with her dissertation research focused on refugee mental health. Art therapy activities for this program will be carried out by six ATI therapists and three ATI masters level interns in 17 participating Chapel Hill, Carrboro, Orange County, and Durham Public schools. In addition, we have collaborated with three UNC School of Public Health Capstone teams to help us design, implement and publish results from our annual evaluations. 3 Hodes, M.(2000). Psychologically distressed refugee children in the United Kingdom. Child Psychology and Psychiatry Review, 5(02), 57-68. °Kowitt,S. D.,Emmerling, D., Gavarkavich, D., Mershon,C. H.,Linton, K., Rubesin, H.,Agnew-Brune, C.,&Eng, E. (2016).A Pilot Evaluation of an Art Therapy Program for Refugee Youth From Burma.Art Therapy, 33(1), 13-20. PROGRAM INFORMATION 2/8/2017 3:01:12 PM Page 13 of 20 DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION h) Describe the specific period over which the activities will be carried out and include an implementation timeline. Approximately 20-24 sessions for newcomer students will be conducted per school year (August to May), each lasting 45-55 minutes. Sessions will include individual art therapy or group-art therapy, which is used to foster social relationships and build social skills. Evaluation activities will also occur over the school year. 3 measures will be delivered at baseline over a period of 4 weeks (October) and 2 measures will be delivered at follow-up over a period of 3 weeks (May). i) Why is funding this program a good investment for the community? How does funding this program add value to the community? (250 words OR LESS) Our program allows vulnerable students to better participate and contribute to their communities. Children who are refugees face a unique set of challenges as they acculturate to North Carolina. Art therapy allows children to cultivate healing and health even when they are not able to fully communicate their experience with words. By providing students with the mentorship and counseling they need, this program helps youth achieve their full potential, thrive in their new homes, and take advantage of their time in school. j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. ATI continues to grow in a thoughtful and sustainable manner and is actively utilizing the resources and surrounding community to strengthen and guide organizational efforts. Programming will continue if funding is not provided. However, the most vulnerable students will most likely not be seen. These students often have the least parental support in qualifying for and keeping health insurance, which funds most of the school based therapy. ATI can only provide complete therapy to students without matching insurance coverage through grant funding. k) Include any other pertinent information. In addition to sharing evidence, resources, and best practices with the greater community, ATI is honored to share the stories of newcomer clients through their artwork. Every year, we have a Spring Artshow, free to the public, where our newcomer clients display their artwork and stories. ATI is proud to use our art therapy programming to help the newcomer community tell their stories and make connections within the greater community. ATI also works to strengthen work with newcomers through presenting at national conferences such as The American Art Therapy Association, the Association of Licensed Professional Counselors, and the American Public Health Association conferences and through publishing peer reviewed journal articles on best practices in supporting mental health for newcomer youth. Funding ATI in our evaluation work could not only improve the lives of newcomers locally, but also nationally, as we disseminate the results of our work. We credit our funders who make this work possible in all presentations, publications, and communications with our community helping to raise the profile of funders in helping us do this important work. PROGRAM INFORMATION 2/8/2017 3:01:12 PM Page 14 of 20 DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Additional Program Information 1) Target Population Complete the following tables, with numbers (not percentages) of individuals served and to be served, to the best of your ability Program Target Population Demographics Actual Estimated Projected 2015-16 2016-17 2017-18 Gender Male 96 126 125 Female 67 104 120 Total 163 230 245 Ethnicity African-American 4 5 5 American Indian or Alaska Native Asian 99 150 160 Caucasian Native Hawaiian or other Pacific Islander Other: specify:Latino/Latina 60 75 80 Total 163 230 245 Of the above, how many Hispanic/Latino 60 75 80 Of the above, how many non-Hispanic/Latino 103 155 165 Total 163 230 245 Age 0-5 years 6-18 years 151 200 215 19-50 years 12 15 15 51+ years 15 15 Total 163 230 245 Geographic Location Alamance County Chatham County Durham County 40 50 50 Wake County Orange County Breakdown Chapel Hill Public Housing 30 30 35 Town of Chapel Hill (Non-Public Housing) 32 80 85 Town of Carrboro 61 70 75 Town of Hillsborough City of Mebane (Orange County) Orange County(Outside Municipalities) Total 1 163 230 245 PROGRAM INFORMATION 2/8/2017 3:01:12 PM Page 15 of 20 DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Work Statement m) Complete the Work Statement Chart to describe the work to be performed. This chart 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. Every program is required to have AT LEAST 1 Program Activity, which should be SMART(,apecific, Measurable, Achievable, Relevant, and Time-bound. Click on SMART Goals to learn more. • Program Activities should outline major activities the agency implements to accomplish its program goals. (i.e. Deliver meals to elderly/disabled residents.) • Program Goal should explain what the program is trying to achieve/accomplish. Goals are statements about what the program should accomplish. (i.e. Deliver 100 meals per day, Monday-Friday.) • Performance Measures describe how you will evaluate the degree in which you achieved the stated goals. (i.e. Will track the number of meals delivered each day.) • Actual Program Results use program results to indicate the actual measureable achievement of goals. If goals were not met, please explain. (i.e. Delivered an average of 105 meals per day.) Work Statement Chart for Program: Newcomer's Art Therapy Program 1. Program Activity Name Newcomer's Art Therapy Program Program Goal Reach and Retention Performance Measures Session notes filed by clinicians indicating the number of students participating in the individual and group art therapy sessions Previous Year Program Results ATI clinicians delivered sessions to 185 newcomers. While this is (2015-2016) slightly below our goal of 210 students, this was an expansion from the previous year, and we did not receive our full funding ask which would have supported the full number of students. Current Year Estimated Results We estimated that ATI clinicians will have delivered art therapy (2016-2017) sessions to 177 newcomer clients. At current date, we have seen 230 ESL clients this year. Next Year Projected Results By follow-up, ATI clinicians will have delivered art therapy sessions (2017-2018) to 245 newcomer clients. 2. Prog ram Activity Name Newcomer's Art Therapy Program Program Goal Depression Performance Measures Hopkins Symptoms Checklist-25 (according to scale scoring instructions, when the mean depression score exceeds 1.75, then a client is "symptomatic"for depression). Previous Year Program Results By follow-up, 71% of participating clients experienced fewer total depression symptoms. Current Year Estimated Results We have estimated that among the newcomer clients symptomatic for depression at baseline, 30% will not be symptomatic for depression at follow-up. However, since our results rely on baseline and follow-up data (collected in Spring 2017), we do not yet have current estimated results for this year. Next Year Projected Results Among the newcomer clients symptomatic for depression at baseline, 30% will not be symptomatic for depression at follow-up. 3. Program Activity Name Newcomer's Art Therapy Program Program Goal Emotional Difficulties PROGRAM INFORMATION 2/8/2017 3:01:12 PM Page 16 of 20 DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Performance Measures Strengths and Difficulties Questionnaire (total number of emotional difficulties) Previous Year Program Results By follow-up, 45% of newcomer clients experienced fewer emotional difficulties Current Year Estimated Results From baseline to follow-up, we have estimated that 50% of newcomer clients will experience fewer emotional difficulties. Next Year Projected Results By follow-up, 50% of newcomer clients will have experienced fewer emotional difficulties. 4. Program Activity Name Newcomer's Art Therapy Program Program Goal Self-esteem Performance Measures Piers-Harris Self-Concept Scale (total number of happiness items) Previous Year Program Results By follow-up, 52% of newcomer clients experienced greater happiness. Current Year Estimated Results We have estimated that from baseline to follow-up, 50% of newcomer clients will report greater happiness. However, since our results rely on baseline and follow-up data (collected in Spring 2017), we do not yet have current estimated results for this year. Next Year Projected Results By follow-up, 50% of newcomer clients will have experienced greater happiness. Program Activity Name Newcomer's Art Therapy Program Program Goal Anxiety Performance Measures Hopkins Symptoms Checklist-25 (total number of anxiety Symptoms) Previous Year Program Results By follow-up, 57% of participating clients experienced fewer total anxiety symptoms. Current Year Estimated Results We have estimated that from baseline to follow-up, 60% of newcomer clients will suffer fewer symptoms of anxiety. However, since our results rely on baseline and follow-up data (collected in Spring 2017), we do not yet have current estimated results for this year. Next Year Projected Results By follow-up, 60% of newcomer clients will have experienced fewer total anxiety symptoms. Newcomer'sArt TherapyProgram Program Activity Name Newcomer's Art Therapy Program Program Goal Community-based /strengths based goals Performance Measures Session notes indicating the number of students participating in the individual and group art therapy sessions delivered. Previous Year Program Results This activity was not assessed as a goal in previous years. Current Year Estimated Results ATI partnered with CWS and FMF, two community agencies, to increase our collaborative programming and offer art therapy in community settings where we can provide additional supports in partnership. These have been very well attended, and the partnership between agencies has strengthened our work as well. Next Year Projected Results We plan to continue to do community outreach and offer art therapy groups through partnerships throughout the community. PROGRAM INFORMATION 2/8/2017 3:01:12 PM P a g e 17 of 2 0 DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION n) Program Budget 1. Submit your program budget. You may complete the provided template (separate xls file) or you may submit your own budget file (as long as it contains the same information, in the same format, as requested in the provided template). Program Budgets are required to define budget amounts for the previous program year, current program year, and next program year for the following categories: • Revenues o Private Donations o Program Generated Revenue o Local Government Grants ■ Carrboro Human Services ■ Carrboro Other • Chapel Hill Human Services ■ Chapel Hill Other (DO NOT include CDBG funding here) ■ Orange County Human Services ■ Orange County Other (DO NOT Include HOME funding here) o Other Government Grants ■ Triangle United Way ■ State Government ■ Federal Government (CDBG/HOME/etc.) ■ Private Foundation Grants o Other Revenue • Expenditures o Compensation o Rent & Utilities o Supplies & Equipment o Travel & Training o Other Expenses 2. Program Budget Detail — Provide description of "other" budget items, not defined. 3. This program budget represents what percent of the agency budget? 63% 4. COST PER INDIVIDUAL This Cost per Individual must reflect the total program budget divided by the total number of program individuals in this application. Actual 2015-16 Estimated 2016-17 Projected 2017-18 Total Cost of Program $123,800 $136,000 Total # of Individuals 230 245 Cost Per Individual $538 $555 PROGRAM INFORMATION 2/8/2017 3:01:12 PM P a g e 18 of 2 0 DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Agency Budget Operating Budget for Entire Agency AGENCY NAME: The Art Therapy Institute Actual Estimated Projected Percent AGENCY REVENUE 2015-16 2016-17 2017-18 Change Private Donations $ 26,000 $ 28,000 $ 28,000 0% Agency Generated Revenue (fees) $ 135,000 $ 158,000 $ 165,000 4% Local Government Grants: Human Services -Town of Carrboro $ 3,500 $ 4,000 $ 5,000 25% Other- Town of Carrboro $ - $ - $ - 0 Human Services -Town of Chapel Hill $ 2,000 $ 3,000 $ 5,000 67% Other-Town of Chapel Hill $ - $ - $ - 0 Human Services - Orange County $ 1,000 $ 1,000 $ 5,000 400% Other- Orange County $ - $ - $ - 0 Other- Town of Hillsborough $ - $ - $ - 0 Other Government Grants Triangle United Way $ - $ - $ - 0 State Government $ - $ - $ - 0 Federal Government (CDBG/HOME/etc.) $ - $ - $ - 0 Private Foundation Grants $ 5,000.00 $ 13,000.00 $ 13,000.00 $ - Other Revenue $ 3,000 $ 1,000 $ 3,000 $ 2.00 Total Agency Revenue $ 175,500 $ 208,000 $ 224,000 8% AGENCY EXPENSES Compensation $ 145,000 $ 177,000 $ 190,000 7% Rent & Utilities $ 10,500 $ 10,500 $ 10,500 0% Supplies & Equipment $ 4,500 $ 5,500 $ 6,500 18% Travel &Training $ 2,000 $ 2,500 $ 3,500 40% Other Expenses: $ 7,000 1 $ 7,500 1 $ 8,000 1 7% Total Agency Expenses $ 169,000 $ 203,000 1 $ 218,500 1 8% SURPLUS/(DEFICIT) FOR PERIOD: $ 6,500 $ 5,000 $ 5,500 10% FY 2015-16 Comparative Agency Budget Revised 9/29/2014 DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME The Art Therapy Institute Actual Estimated Projected Percent PROGRAM REVENUE 2015-16 2016-17 2017-18 Change Private Donations $ 7,000 $ 8,000 $ 8,000 0% Program Generated Revenue $ 85,000 $ 114,000 $ 124,000 9% Local Government Grants: Human Services-Town of Carrboro $ 3,500 $ 4,000 $ 5,000 25% Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ 2,000 $ 3,000 $ 5,000 67% Other-Town of Chapel Hill $ - $ - $ - 0 Human Services-Orange County $ 1,000 $ 1,000 $ 5,000 400% Other-Orange County $ - $ - $ - 0 Other-Town of Hillsborough $ - 1 $ - 1 $ - 0 Other Government Grants ME Triangle United Way $ - $ - $ - 0 State Government $ - $ - $ - 0 Federal Government(CDBG/HOME/etc.) $ - $ - $ - 0 Private Foundation Grants $ - $ - $ - 0 Other Revenue $ 3,000 $ 3,000 $ 1,000 $ (0.67) Total Program Revenue rs 101,500 $ 133,000 $ 148,000 11% PROGRAM EXPENSES Compensation $ 85,000 $ 112,000 $ 122,000 9% Rent&Utilities $ 2,600 $ 3,500 $ 4,000 14% Supplies & Equipment $ 3,600 $ 4,000 $ 4,500 13% Travel &Training $ 700 $ 800 $ 1,500 88% Other Expenses: $ 2,500 $ 3,500 $ 4,000 14% Total Program Expenses $ 94,400 $ 123,800 1 $ 136,000 1 10% SURPLUS/(DEFICIT) FOR PERIOD: 1 $ 7,100 $ 9,200 1 $ 12,000 1 307/6 DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 4. ATTACHMENTS Description of Required Attachments a) Financial Audit A recent financial audit that should cover CY 2015, for calendar year agencies, and FY 2015-16, for fiscal year agencies. For agencies with prior year revenues totaling $500,000 or more a financial audit, prepared by a certified public accountant is required. Agencies with prior year revenues of less than $500,000 may submit a completed Schedule of Receipts and Expenditures form (see application materials), in lieu of an audit/report. Agencies with a certified audit/report should not complete the form. b) IRS Federal Form 990 A copy of the agency's 2014 Form 990 is required. The specific form depends upon the agency's financial activity. Review the IRS' table guide, for more details. For Form 990-N (e- postcard) filers, include a copy of the postcard, with the agency's application materials. c) NC Solicitation License A copy of the agency's current solicitation license is required. Organizations that solicit contributions in North Carolina, directly or through a third party, must renew their licenses annually. For more details, refer to the NC Secretary of State's licensing website and its Frequently Asked Questions Guide (PDF), about exemptions. If exempt per N.C.G.S. § 131 F-3, include a copy of the exemption letter with the agency's application materials. d) IRS Federal Tax-Exemption Letter A copy of the agency's IRS tax-exempt letter that confirms its nonprofit status is required. An agency can request a copy of its letter from the IRS' Customer Account Services. e) Certificate of Liability Insurance A copy of the agency's current certificate, from the agency's insurance carrier. Table 1 below outlines insurance types and minimums required, for each jurisdiction. If exempt from Worker's Compensation compliance, include a statement explaining why, with the agency's application materials. *Note: If Approved for Funding: Approved agencies must provide an updated insurance certificate. The update should reflect the funding jurisdiction as an additional insured party and certificate holder and provide coverage for the duration of the funding period (July 1 — June 30). Renewal certificates must be sent to the jurisdiction 30 days prior to any expiration date, cancellation or modification of any stipulated insurance coverage. ATI is exempt from Worker's Compensation at this time because minimum number of employees required for NC is 3, and ATI does not meet this criteria. Our clinicians are all conract based at this time. DO NOT SUBMIT THIS PAGE 2/8/2017 3:01:12 PM P a g e 1 9 o f 2 0 DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Table 1. Forms of Liability Insurance and Minimum Policy Amounts Required INSURANCE TOWN OF CARRBORO TOWN OF CHAPEL HILL ORANGE COUNTY3 Worker's Limits for Coverage Compensation' A - Statutory State Limits for Coverage A - Limits for Coverage A - NC, for each Statutory State NC, for Statutory State NC, for employee each employee each employee Limits for Coverage Limits for Coverage B - Limits for Coverage B - B - Employers Employers Liability of: Employers Liability of: Liability of: $100,000 Each Occurrence $500,000 each $1 million Each $100,000 BID for each accident, $500,000 Occurrence employee BID for each employee $1,000,000 BID $500,000 BID limit $500,000 for BID limit limit Commercial $100,000 Property General Damage Liability $1 million Each Liability $1,000,000 Bodily $1 million Each Occurrence Occurrence Injury and Property $2 million Aggregate � ry p y $2 million Aggregate Damage Limit Automobile Not Applicable $1 million Each Occurrence $500,000 Each Liability Occurrence Professional $1 million Each Liability Not Applicable Not Applicable Occurrence $2 million Aggregate 1. Visit the NC Industrial Commission's website for more information regarding Coverage A. Also, note that if an agency uses subcontractors, it must require subcontractors to have workmen's compensation insurance. 2. Bodily Injury by Disease (BID) 3. Please visit Orange County's contracts webpage for more information about the County's risk assessment procedures. f) List of Board of Directors Provide the following information about each board of director's member: name, telephone number, address, occupation or affiliation of each member and the list must identify the principal officers of the governing body, and length of term. g) Solid Waste Program Fee (SWPF) Verification This fee finances Orange County's recycling and waste reduction program. Submit either a.) proof of payment of the agency's FY 2016-17 Solid Waste Program Fee, OR b.) a statement on agency letter head indicating exemption and specify the person(s), business, etc. that is responsible for paying this fee. DO NOT SUBMIT THIS PAGE 2/8/2017 3:01:12 PM Page 20 of 20 DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 EXHIBIT "B" Scope of Services—l~Y 2017-18 Outside Agency Performance Agreement Agency Name: The Art Therapy Institute Program Name: The Newcomer Art Therapy Project Funding Award: $3300.00 Outline how the agency will spend Orange County's funding award. Expense Description Amount 20 art therapy groups($100 per hour-long group pays for clinician fee, supervision of clinician, $2000 __planning,preparation,research and evaluation costs 10 art therapy sessions with individuals without insurance ($100 per hour-long session pays for $1000 clinician fee,supervision of clinician,planning,preparation, research and evaluation costs Art supplies for individual and group sessions $10 x 30 sessions/groups) $300 Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2018. • Provide 20, ]-hour art therapy groups to newcomers residing in Orange County (between 2-30 newcomers served in each group) • Deliver 10 individual art therapy sessions for newcomers without insurance in Orange County • Weekly clinical supervision will be provided for all therapists providing services to newcomers. • ATT will engage in rigorous evaluation protocols to assess and report on program goals Anticipated Outcomes The Anticipated Results column must include quantifiable results in the form of number of persons/units served within Oran-ge 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 By follow-up,ATI clinicians will have delivered art therapy sessions to 128 group and 128 clients individual newcomers clients in Orange County. (*128 =66%of the 195 clients we originally served proposed seeing in Orange County,since we only received 66%of proposed funding) By follow-up, 50%of newcomer clients will have experienced fewer emotional difficulties(5 64 clients with out of 10 clients)according to the Strengths and Difficulties Questionnaire completed by less emotional teachers,social workers, or counselors, difficulties OocuSigned by: rll� C,SiV►. 11/22/2017 Interim Director, ATI 09EMCCFnG445C... Certified b Title: � , ►� /}Tl Date: Pr vt er s ure) DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 ATTACHMENT "A" Orange County Certifications—FY 2017-18 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. OocuSigned�by: l LSiVi. 11/22/2017 Certified by: _ ogEBE�DFnG445r-... Title: Interim Director, ATI Date: (Provider's Signature) (The Institute of Art Therapy) Orange County Outside Agency Performance Agreement Page 10 of 10 Rev. 7117 DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 HEALTHCARE PROVIDERS SERVICE CNA ORGANIZATION PURCHASING GROUP MHPSO Certificate of 3lt5uranre FkAhcar,pnmdcrnS—ieel'plli_atinn- OCCURRENCE POLICY FORM Print Date: 6/02/2017 Producer Branch Prefix Policy Number Policy Period 018098 970 HPG 0613252987 from 06/15/17 to 06/15/18 at 12:01 AM Standard Time Named Insured and Address: Program Administered by: Institute of Art Therapy, Inc. dba The Art Thera Healthcare Providers Service Organization Institute 159 E. County Line Road 200 N Greensboro St Ste D6 Hatboro, PA 1 9040-1 21 8 Carrboro, NC 27510-1849 1-888-288-3534 www.hpso.com Medical Specialty: Code: Insurance is provided by: Art Therapist Firm 80967 American Casualty Company of Reading, Pennsylvania Excludes Cosmetic Procedures 333 S. Wabash Avenue, Chicago, IL 60604 Professional Liability $1,000,000 each claim $ 3,000,000 aggregate Your professional liability limits shown above include the following: * Good Samaritan Liability * Malplacement Liability Personal Injury Liability * Sexual Misconduct Included in the PL limit shown above subject to $25,000 aggregate sublimit Coverage Extensions License Protection $ 25,000 per proceeding S 25,000 aggregate Defendant Expense Benefit S 1,000 per day limit S 25,000 aggregate Deposition Representation S 10,000 per deposition '310.000 aggregate Assault S 25,000 per incident $25.000 aggregate Includes Workplace Violence Counseling Medical Payments $ 25,000 per person S 100,000 aggregate First Aid S 10,000 per incident $ 10.000 aggregate Damage to Property of Others S 10,000 per incident S 10.000 aggregate Enterprise Privacy Protection- Claims Made $ 25,000 per incident $ 25,000 aggregate Retroactive Date: 6/15/2016 (Defense inside limits) General Liability General Liability $1,000,000 each claim 1 $3,000,000 aggregate Fire &Water Legal Liability Included in the GL limit shown above subject to$250,000 aggregate sublimit Total: $3,845.00 Base Premium $3,845.00 Policy Forms& Endorsements(Please see attached list for a general description of many common policy forms and endorsements.) G-121500-D GSL10546NC G-121501-C G-145184-A G-147292-A GSL15564 GSL15565 GSL17101 GSL13424 GSL13425 CNA80052 G-123846-C32 CNA81753 CNA81758 CNA82011 CNA79516NC CNA79575 G-121487-B G-121504-C G-123827-B G-123828-B Keep this document in a safe place-It f and proof of payment are your proof coverage. There is no coverage in force unless the premium is paid in hill.In order Chairman of th Board Secretary to activate your coverage, please remit premium in full by the effective date of this Certificate of insurance. Master Policy# 188711433 G-141241-B(03/2010) Coverage Change Date: Endorsement Change Date: DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 POLICY FORMS & ENDORSEMENTS The following are the policy forms and endorsements that apply to your current professional liability insurance policy. COMMON POLICY FORMS& ENDORSEMENTS FORM # DESCRIPTION G-121500-D Common Policy Conditions GSL10546NC North Carolina Amendatory Endorsement G-121501-C Occurrence Policy Form G-145184-A Policyholder Notice-OFAC Compliance Notice G-147292-A Policyholder Notice-Silica, Mold &Asbestos Disclosure GSL15564 Sexual Misconduct Sublimity of Liability Professional Liability& Sexual Misconduct Exclusion GSL15565 Healthcare Providers Professional Liability Assault Coverage GSL17101 Exclusion of Specified Activities Reuse of Parenteral Devices and Supplies GSL13424 Services to Animals GSL13425 Business Owner Coverage Extension Endorsement CNA80052 Distribution or Recording of Material or Information in Violation of Law Exclusion Endorsement G-123846-C32 North Carolina Cancellation and Non-Renewal CNA81753 Coverage &Cap on Losses from Certified Acts Terrorism CNA81758 Notice- Offer of Terrorism Coverage& Disclosure of Premium CNA82011 Related Claims Endorsement CNA79575 Exclusion of Cosmetic Procedures CNA79516NC Enterprise Privacy Protection G-121487-B Amendment to Certificate G-121504-C General Liability Form G-123827-B Additional Insured General Liability G-123828-B Certificate Holder PLEASE REFER TO YOUR CERTIFICATE OF INSURANCE FOR THE POLICY FORMS & ENDORSEMENTS SPECIFIC TO YOUR STATE AND YOUR POLICY PERIOD, For NJ residents: The PLIGA surcharge shown on the Certificate of Insurance is the NJ Property& Liability Insurance Guaranty Association. For KY residents: The Surcharge shown on the Certificate of Insurance is the KY Firefighters and Law Enforcement Foundation Program Fund and the KY LGPT is the KY Local Government Premium Tax which includes charges at a municipality andfor county level. For WV residents: The surcharge shown on the Certificate of Insurance is the WV Premium Surcharge. For FL residents: The FICA Assessment shown on the Certificate of Insurance is the FL Insurance Guaranty Association -2012 Regular Assessment. Form#:G-141241-13(03/2010) Named Insured:Institute of Art Therapy Master Policy#:188711433 Policy#:0613252987