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HomeMy WebLinkAbout2018-751-E Finance - The Art Therapy Institute performance agreement DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 OUTSIDE AGENCY AND CARDINAL MANAGED CARE FUNDS PERFORMANCE AGREEMENT THIS AGREEMENT,made and entered into the first day of July 2018, ("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, 2018 to June 30, 2019. 2. Scope of Services. a. Provider will provide services to the residents of Orange County, as outlined in the attached Outside Agency Funding Application and any amendments or revision thereto which is attached as Exhibit "A" AND the Cardinal Managed Funds Work Statement and any amendments or revisions thereto which is attached as Exhibit B, both of which are incorporated by reference. The Scope of Services and the Program Budgets 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. 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. Outside Agency Funding. i. Outside Agency Funding. The County agrees to appropriate funds for the provision of services described in Exhibit A, Scope of Services and may be more particularly described in the Revised Program Budget in Exhibit C, the maximum sum of 3,555 in Outside Agency Funds. ii. The Provider shall be paid Outside Agency Funds in four equal installments in the amount of 888.75. 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. b. Cardinal Managed Care Funding. (The Institute of Art Therapy) Orange County Outside Agency and Cardinal Managed Care Fund Performance Agreement Revised 812018 Page I of 9 DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 i. Cardinal Managed Care Funding. The County agrees to appropriate funds for the provision of services described in Exhibit B,Work Statement and may be more particularly described in the Revised Program Budget in Exhibit D,the maximum sum of 27,600in Cardinal Managed Care Funds. ii. The Provider shall be paid Cardinal Managed Care Funds in twelve equal monthly installments in the amount of 2,300. 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. c. All funds appropriated shall be used for purposes described in Exhibit A and 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 and Work Statement, at the discretion of the County the Provider may be required to repay the funds to the County. d. The County's obligation to make the payments is contingent upon receipt of Progress Reports and/or request for reimbursement as provided in Section 4 below, which show satisfactory progress toward completion of performance measures and an accounting of expenditures as detailed in the attached Scope of Services and Work Statement. e. Once Provider has satisfied its obligations as provided in Sections 3 and/or 4 payment will be made 21 days after receipt of the Progress Report or Request for Reimbursement. f. The County is not obligated to provide any other support to Provider in this or in succeeding fiscal years. 4. Agency Reporting. a. Outside Agency Funds Reporting. Provider will provide Orange County a Quarterly Progress Report for Outside Agency funds 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 I —March 31 and April I -June 30. Reports are due on January 11,April 15,and July 8 of the program fiscal year. b. Cardinal Managed Funds Reporting. Provider will provide Orange County a Monthly Progress Report for Cardinal Managed Care funds that includes a fiscal report and updates on performance measures as outlined in the Work Statement. Progress Reports are due by the 151h of the next month following the month being reported. c. 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: (The Institute of Art Therapy) Orange County Outside Agency Performance Agreement Page 2 of 9 Rev. 8118 DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 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 shall pay Provider that portion of the fees and expenses that it has earned to the date of termination, less any costs or expenses incurred or anticipated to be incurred by the County due to errors or omissions of the Provider. 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. 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. e. Should this Agreement be terminated, the Provider shall deliver to the County within seven (7) days, at no additional cost, all deliverables including any electronic data or files relating to the Project. £ Waiver. The payment of any sums by the County under this Agreement or the failure of the County to require compliance by the Provider with any provisions of this Agreement or the waiver by the County of any breach of this Agreement shall not constitute a waiver of any claim for damages by the County for any breach of this Agreement or a waiver of any other required compliance with this Agreement. 6. Insurance. (The Institute of Art Therapy) Orange County Outside Agency Performance Agreement Page 3 of 9 Rev. 8118 DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 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. 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 (The Institute of Art Therapy) Orange County Outside Agency Performance Agreement Page 4 of 9 Rev. 8118 DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 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. Limitation and Assignment. The County and the Provider each bind themselves, their successors, assigns and legal representatives to the terms of this Agreement. Neither the County nor the Provider shall assign or transfer its interest in this Agreement or the rights to payment to any other party without the written consent of the other. 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. Dispute Resolution. Any and all suits or actions to enforce, interpret or seek damages with respect to any provision of, or the performance or non-performance of, this Agreement shall be brought in the General Court of Justice of North Carolina sitting in Orange County, North Carolina. It is agreed by the parties that no other court shall have jurisdiction or venue with respect to such suits or actions. Binding arbitration may not be initiated by either Party,however, the Parties may agree to nonbinding mediation of any dispute prior to the bringing of such suit or action. 15. 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 $ 14.25 per hour. To the extent possible, Orange County recommends that The Institute of Art Therapy provide a living wage to its employees. 16. 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 5 of 9 Rev. 8118 DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 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 17. 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. 18. 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. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor identified, on the list created by the State Treasurer pursuant to G.S. 147-86.81. 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 11 A 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. F78i" nnsi'�wgbo�half of the Provider 11/20/2018 noFaFnnF3aade�r. Hillary Rubesin,Executive Director Date For DonAdf of Orange County Government 1561A ndt, 6a;KJ -Sbt 11/26/2018 06379946755E477__ Bonnie Hammersley, County Manager Date (The Institute of Art Therapy) Orange County Outside Agency Performance Agreement Page 6 of 9 Rev. 8118 DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION 1. COVER PAGE a) Applicant Contact Information Applicant Organization's Legal Name: Institute of Art Therapy, Inc. Applicant Organization's Physical Address: 200 N. Greensboro St., D-6, Carrboro, NC, 27510 Applicant Organization's Mailing Address: 200 N. Greensboro St., D-6, Carrboro, NC, 27510 Applicant Organization's Web Address: www.ncati.org Executive Director: Hillary Rubesin Telephone Number: 610-348-7253 E-Mail: hrubesin(o)_ncati.org Tax ID Number: 26-3447555 b) Funding Request List all FY18-19 Human Services (HS) Funding Being Requested — For All Programs) and the Proposed Use of Funds (2-3 lines or less) Program Carrboro Chapel Orange Total - HS Hill - HS County-HS Ex. Youth Afterschool Program $10,000 $15,000 $5,000 $30,000 Afterschool Program Coordinator salary and materials for youth activities and projects Newcomer's Art Therapy Program $10,000 $15,000 $5000 $30,000 Clinician pay for newcomer child and adult art therapy services, art materials, art show costs, rent, research, and interpretation. Totals $10,000 1 $15,000 1 $5,000 $30,000 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: � Z 1/21/2018 Executive Nrector Date Signature. �� 1/21/2018 Board Chairperson Date AGENCY INFORMATION 1/23/2018 10:01 :04 AM Page 7 of 24 DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 EXHIBIT 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 agency which will be carrying out this program or members of their immediate families, or their business associates... YES NO ❑ ® 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? ❑ ® 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 manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, gender identity/expression, 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 P! 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. 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 existence of an undisclosed conflict may result in the termination of any grant awarded. Signature: �� 1/21/2018 Executive irector Date Signature: 1/21/2018 Board Chairperson Date AGENCY INFORMATION 1/23/2018 10:01:04 AM Page 8 of 24 DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 EXHIBIT 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): September, 2009 b) Agency's Purpose/Mission (no more than a few sentences): The Art Therapy Institute is an organization of masters-level mental health professionals dedicated to the healing power of the arts. We provide affordable clinical art therapy services to diverse populations and empower clients to develop their identities and strengths. We commit to community-based work in order to meet clients where they are, ensuring access to critical mental health services. In addition to our clinical services, we offer training to allied professionals and seek to raise awareness in the general public about the benefits of art therapy. c) Types of Services the Agency Provides (bullet format): ATI provides art therapy to the following populations (and is always open to expanding our client base!): • Refugees and Immigrants from over 25 countries worldwide • Children with intellectual and physical disabilities • Adults with severe and persistent mental illness • Children receiving bone marrow transplants or treatment for cancer • Elderly patients with Alzheimer's and dementia • Veterans • Victims of domestic violence • Families experiencing homelessness • Private clients from all backgrounds ATI also: • Provides continuing education workshops, supervision, and internships for allied mental health providers and graduate level students • Hosts monthly art shows for the broader public • Conducts ethical, culturally-appropriate research and evaluation to ensure program effectiveness. d) Agency's History with Providing These Services: ATI's Newcomer Art Therapy Program (NATP) began in 2008, serving 13 adolescents from Burma. We now work with approximately 225 refugee and immigrant children and adults annually from over 25 countries worldwide. This tremendous growth over the past decade has occurred with substantial input from community members, clients, and key stakeholders. ATI continues to monitor and evaluate NATP to ensure effectiveness, altering goals, research interventions, and desired outcomes to meet clients' needs as they shift. ATI's first art therapy program was started by one of the co-founders of ATI, Kristin Linton, who began an art therapy program for students with exceptional needs in the Chapel Hill/Carrboro schools in 2005. The contract was brought in house to ATI a few years later, and we currently serve the majority of self-contained EC classrooms in the district, providing art therapy to over 125 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 EC students. Our other programs, while smaller in scope, are equally important to ATI. We bring weekly art therapy sessions to children in pediatric oncology and bone marrow transplant units at Duke and UNC Hospitals. We serve elders in memory care units at assisted living Agency Information 1/23/2018 10:01:04 AM Page 9 of 24 DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION facilities, and our free, open, weekly Arts and Peer Support Group for adults with severe and persistent mental illness has been going strong since 2011. Our more recent programs include domestic violence art therapy groups with Latina women, providing art therapy to adults experiencing homelessness, and working with veterans to explore trauma in creative and safe ways through metal work and mask making. All of these programs are conducted in collaboration with other agencies. We love working with community-based partners! Via the above programs, we provided art therapy services to approximately 500 community members in 2017. In addition to these client numbers, we trained over 50 professionals through our continuing education series, and over 200 community members attended one of our monthly, community-based art shows. We also trained 3 masters-level interns in 2017, and recruited over 20 new volunteers. ATI has a proven track record of fiscal responsibility. We continuously pursue diverse funding streams in order to increase program sustainability and seek out donated art materials and other donated services whenever possible. Due to unanticipated federal and school-based budget cuts in the summer of 2017, we lost $27,000 in funding. We recovered this amount in our year-end fundraiser in 2017 thanks to increased community giving. We are honored and humbled by the growing support we receive from community members (near and far). Our organization is built around community members who believe deeply in our work and help us grow capacity so we can continue to provide much-needed mental health services to amazing and deserving people. e) Other Pertinent Agency Information (Ex. Has the agency experienced any major changes in the past year? Is there a new Executive Director?Are there new initiatives? 2017 brought many changes for ATI; however, all of our previous programming is still going strong, and exciting new initiatives have been established. In August, 2017, founding Executive Director, Kristin Linton, left the agency, and former Associate Director, Hillary Rubesin, stepped into the role. While this was an unexpected shift for the agency, Hillary has been with ATI since 2008, so the transition went relatively smoothly. ATI also voted in a new Board president, Susie McDonald, in the Fall of 2017, who led ATI in the successful year-end fundraising campaign that recovered the lost funding mentioned above. In addition to these changes in leadership, ATI acquired a second office in the YouthWorx building in Carrboro in September 2017. Joining the wonderful community at YouthWorx has opened up new collaborations and capacity-building endeavors for ATI, especially with Youth Forward, who gave ATI a small grant in 2017, and with the Refugee Community Partnership, who ATI works closely with on various newcomer programs. As stated above, ATI also began new program partnerships in 2017. ATI started collaborating with the Compass Center and Interact to provide domestic violence art therapy groups to Latina women. ATI also began collaborating with Liberty Arts to lead metal working groups for veterans living with PTSD. New partnerships in the newcomer community began as well, as ATI started providing new groups with Church World Service, the Refugee Community Partnership, and the Duke Kenan Refugee Project. Finally, ATI is working on new capacity-building endeavors. We hired two part-time research assistants to help with program evaluation. We hired a refugee woman from Burma as a part-time accountant and bookkeeper. We continue collaborating with the UNC School of Social Work on both our newcomer programming and our Arts and Peer Support Group, and a group of MA-level students from Duke are currently helping us with fundraising and strategic planning. ATI is very excited about all of these changes in 2017, and is hopeful for the year ahead! Agency Information 1/23/2018 10:01:04 AM P a g e 1 0 o f 2 4 DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION f) Schedule of Positions (For Entire Agency) • Full Time Equivalent (FTE) staff will be noted as 1.00; half time as .50; quarter time as .25, etc. • Calculate a Full Time Equivalent for all recorded volunteer hours using the following: Total Volunteer Hours = Volunteer FTE 2,080 # of FTE - Full-Time Paid Positions: 3 # of FTE - Paid Part-Time Positions: 4 # of Volunteers: 116 # of FTE -Volunteers:1.5 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? Yes If no, please explain. h) Agency Budget i. Is your agency currently receiving and/or requesting other (non-Human Services) local (Town of Carrboro, Town of Chapel Hill, Orange County) government funding? (Yes/No) No If yes, please list below: Include all programs that have funding requests/awards/totals from Carrboro, Chapel Hill, and Orange County governments (other than Human Services). DO NOT include federal funding sources, such as CDBG and HOME. Program FYI 7-18 FYI 8-19 Source Award Request Ex: Affordable Rental 0 $20,000 Carrboro -Affordable Housing Rehabilitation Ex: Agency Administration $15,000 $15,000 Carrboro— Other Ex. Total $15,000 $35,000 Carrboro Total Funding *Add rows or attach additional page, if needed. ii. Submit your agency's budget. You may complete the provided template (separate As file) or you may submit your own budget file (as long as it contains the same information, and in a similar format, as requested in the provided template). Agency Information 1/23/2018 10:01:04 AM Page 11 of 24 DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Agency 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 0 iii. Does your agency budget show a Surplus or Deficit? Surplus Is there a significant change? Yes/No No Please provide a brief explanation for Surplus or Deficit, and significant changes. ATI's budget for 2017 shows a surplus in spite of$27,000 in budget cuts, due to a major increase in fundraising efforts in the second half of 2017 to help offset unexpected financial losses. iv. What is your agency's fiscal year? Jan 1, 2017 through Dec 31, 2017 (Example: July 1, 2016 through June 30, 2017) Agency Information 1/23/2018 10:01:04 AM P a g e 1 2 o f 2 4 DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Newcomer Art Therapy Program Program Primary Contact and Title: Hillary Rubesin, Executive Director Telephone Number: 610.348.7253 E-Mail: hrubesin(§D_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 X Education X X X X X Family Resources X X X X X Jobs/Jobs Training X 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 newcomer clients with Medicaid. They also provide a stipend for ATI's work with the Carrboro Community Health Center, our uninsured refugee clients, and some of our required interpretation 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 with ATI for continued service to the students in the school system. They 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 PROGRAM INFORMATION 1/23/2018 10:01:04 AM Page 13 of 24 DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION received our first contract with DPS to run 6 art therapy groups with their growing newcomer students. This contract continues today, with potential growth in 2018. • 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 quarterly meetings 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 sits on this committee, collaborates with other committee members, and has hosted meetings at our offices. • Duke Interdisciplinary Social Innovators are masters level Duke students who provide a variety of consultancy services for social organizations, including impact evaluation, capacity building, strategy, technology integration, and finance. ATI is currently working with them on strategic planning, marketing, and development to increase program and agency sustainability and outreach. • UNC School of Social Work: ATI collaborates with the Refugee Mental Health and Wellness Initiative (A program of UNC's School of Social Work) to offer refugee women's groups in Orange County. ATI refers clients to RW and acts as a referral source for RW. ATI has also informally enlisted RW students in research endeavors. • 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. ATI collaborates with refugee farmers to harvest and prepare traditional Burmese food for our community art events. • Refugee Community Partnership (RCP) is a community-driven organization working to build unique, holistic, and comprehensive support infrastructure for relocated families. ATI currently shares an administrative office with RCP and collaborates on various refugee-based programs, including an ongoing refugee women's group for women from Burma. • 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 bi-weekly art therapy groups to newly arrived refugees. • Lutheran Family Services is another program supporting newly arrived refugees in the Triangle. ATI has offered pro-bono art therapy groups to children through their program. • UNC-Greensboro Center for New North Carolinians: ATI's Executive Director is currently a research fellow at UNC-G's CNNC. By participating in this research group, ATI is able to share their own research methods and results with allied professionals and learn from other local researchers engaging in refugee-based programs. • Duke Kenan Refugee Project: The Kenan Institute for Ethics has engaged in a multi- site community-based research project that has included sites in eastern Nepal; Cairo, Egypt; Jordan; northeastern Kenya; and Durham exploring the effects of displacement and resettlement upon refugees. In 2018, ATI plans to co-lead weekly art therapy groups for both women and children through the Durham-based project. • Lincoln Community Health Center: ATI has been working with pediatricians at Lincoln Center to increase art therapy services for refugee children in Durham in 2018. • Doris Henderson Newcomers School: ATI is scheduled to meet with representatives from this Greensboro-based school in January 2018 to explore options for collaboration. • USCRI-Raleigh: ATI is meeting with this resettlement agency in January 2018 to explore the possibility of expanding art therapy services to newcomers in Wake County. PROGRAM INFORMATION 1/23/2018 10:01:04 AM Page 14 of 24 DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Program Description (3 pages OR LESS). Please provide the following information about the proposed program: Summarize the program services proposed and how the program will address a Town/County priority/goal? "When I had art therapy, I had a grown up I could go to and talk to for advice... This made me realize how you were such a good part of my middle school years, and how art therapy wasn't just a fun art thing, because that was how I viewed it back then, but no! It was a room filled with fun, colors, excitement, and a room where I could find a way to express myself, my feelings. It was really helpful to have it. I thank you for it." -grn grade refugee student from Burma, reflecting on her past art therapy experience ATI contributes to the mental health and general wellbeing of newly-arrived immigrants and refugees, hereafter referred to as "newcomers", in Chapel Hill, Carrboro, Orange, and Durham Counties. ATI provides arts-based counseling services to approximately 225 newcomer adults and children from over 25 countries across the world. Of these newcomers, approximately 125 are students in Chapel Hill, Carrboro, and Orange County schools. Approximately 25 are refugee women residing in Chapel Hill, Carrboro, and Orange County. ATI is currently seeking funding to 1) support group art therapy work for newcomer adults and children 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, interpreters, and research and evaluation costs. Specifically, ATI will use requested funds to run 6 art therapy groups for adults and children across the county ($15,000/20 sessions, incl. two art therapists per group and art supplies); research and evaluation costs ($4000/20 wks); Interpretation ($6000/20 wks); and individual sessions for uninsured clients ($5000/20 wks). ATI's activities align well with town and county priorities. Specifically, ATI provides counseling services for many disadvantaged residents (i.e., newcomers) which help residents cultivate wellness and avoid having to seek more intensive medical services (priority#1). ATI provides counseling, mentorship, health and wellness education, and vocational support for newcomers who already face academic, mental health, and social challenges. These hybrid services positively impact education and job readiness (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. 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 Board Priorities, 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. The Newcomer Art Therapy Program (NATP) began in response to a community needs assessment from UNC-Chapel Hill in 2008 and has expanded programming efforts and reach ever since. ATI's NATP directly addresses numerous town and county needs and priorities. ATI is committed to cultural sensitivity (Carrboro Board Priority A), social justice work, and the bridging of diverse cultures (Orange County overarching goals), through its ongoing efforts of cultural humility and cultural safety in counseling and research practices. These practices acknowledge the power dynamics inherent between community members of different cultures and positions, and commit to providing resources and settings that are familiar and empowering to historically disenfranchised communities. ATI's programming also relates to Chapel Hill's "Develop Good Places, New Spaces" initiative in that we bring creative arts and social programming to diverse communities, PROGRAM INFORMATION 1/23/2018 10:01:04 AM Page 15 of 24 DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION especially residents of the Northside neighborhood and the Rogers Road Habitat Housing development (where many of our clients reside). Our program also aligns with Chapel Hill's goal to "Create a Place for Everyone" through cultural arts engagement. ATI's art therapy program brings free, arts-based services to some of our county's most disadvantaged residents, who wouldn't normally have access to or know how to access these types of programs. Finally, data from the Chapel Hill Human Services Needs Assessment indicate that residents need affordable healthcare, education and family resources, and jobs and job training. ATI's NATP addresses all these needs in different ways. First and foremost, through grants, private donations, and Medicaid billing, we provide mental health services free of charge to newcomer clients. Our adult services, in particular, include "hybrid groups" focusing on health education, family education, and resource sharing. We also provide vocational support to high school students and newcomer adults. Finally, we hire newcomers to interpret, provide cultural trainings to staff members, and most recently, for billing/accounting support! Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? ATI is 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. Funding will be used to support services for both newcomer students in the local schools, as well as adults in the greater community. Students are referred for art therapy by school staff, 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 meet with the students' families, describe art therapy, develop treatment plans, and obtain all necessary consent and release forms. Newcomer adults are referred to ATI through various partnering resettlement agencies and community-based refugee support programs. Reasons for adult referrals generally include symptoms of PTSD, anxiety, and depression, other mental health concerns, social isolation, or acculturation issues. Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) ATI therapists have Masters degrees in art therapy or related fields and are all fully licensed or working towards full licensure as professional counselors in NC. All clinicians receive weekly group supervision and individual supervision as needed, according to client load and level of licensure. ATI therapists and interns have a combined 50+ years of experience working with newcomers, and receive annual training in multicultural competencies. In addition to this extensive clinical experience and training, the ED is actively pursuing her PhD in expressive arts therapy, with a dissertation focused on refugee mental health. Research on newcomer programming is conducted in collaboration with various universities including UNC-Chapel Hill, UNC-Greensboro, Duke University, Lesley University, and other community-based agencies. Describe the specific period over which the activities will be carried out and include an implementation timeline. With the requested funding amount, ATI can conduct approximately 20 weeks of group and individual art therapy services for 150 newcomers from over 25 countries between July 1, 2018 and June 30, 2019. Research/evaluation efforts will be conducted within the same time frame. Most of the clinical programming will be conducted during the school year, unless the schools or partnering refugee agencies feel that summer services are more beneficial for newcomer clients. 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 (and amazing!) newcomer children and adults to better participate in and contribute PROGRAM INFORMATION 1/23/2018 10:01:04 AM P a g e 1 6 o f 2 4 DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION to their communities. Newcomer women and children face a unique set of challenges as they resettle to North Carolina. Art therapy allows newcomers to cultivate healing and health even when they are not able to fully communicate their experience with words. By providing newcomers with the affordable and culturally-responsive support and counseling they need and deserve, this program helps newcomers achieve their goals, thrive in their new homes, and build important relationships within their wider communities. Additionally, while the group services require ongoing grant funding, these groups are instrumental in providing ongoing social support that builds important social skills, normalizes and validates newcomers' experiences, and decreases debilitating social isolation. Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. ATI is committed to providing art therapy services to newcomer adults and children regardless of the funding amount awarded by the towns and counties. ATI works hard to maintain and build sustainability in all of its programming, as evidenced by the fact that when ATI unexpectedly lost $27,000 in CHCCS funding for 2017-2018, ATI ramped up fundraising efforts and increased private donation and foundation grant support by 400% over previous years. Unfortunately, some of these foundation grants can only be awarded for one year, and CHCCS funding has not yet been reinstated for the upcoming 2018-2019 school year, which is why we are requesting increased funding from the towns and counties, so that we can continue to serve our community's most vulnerable populations. What percentage of your target population is low-moderate income? 100%! What efforts do you make to seek feedback about your program from your target population (e.g. survey, evaluations, etc.?) Beyond the research evaluations ATI conducts every year to monitor the mental health and social functioning of our clients (see SMART goals for more information), ATI also surveys teachers and clients about their experiences with the program. Finally, ATI also surveys community art show attendees who view the client artwork and stories to evaluate how the program impacts community perceptions of newcomers. Include any other pertinent information. As mentioned above, in addition to sharing evaluation results, resources, and best practices with the greater community, ATI is honored to share the stories of newcomer clients through their artwork and words. Every year, ATI hosts a Spring art show, free to the public, where newcomer clients are invited to 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. Previous surveys of show attendees indicate that these types of art shows can help decrease anti-newcomer sentiment. ATI also works to strengthen knowledge of newcomers through presenting at national conferences such as The American Art Therapy Association, the Association of Licensed Professional Counselors, the North American Refugee Health Conference, and the American Public Health Association conferences, and through publishing peer reviewed journal articles on best practices in supporting mental health for newcomers. 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 who enable us do this critical work. Finally, in addition to quantitative research measures, ATI is committed to conducting anti- oppressive, participatory action research (PAR) with newcomer clients. PAR has been touted as being more respectful, ethical, culturally-appropriate, and efficient in gauging the needs of newcomer community members and making sure newcomers are active participants in research that is conducted by and for them. PROGRAM INFORMATION 1/23/2018 10:01:04 AM P a g e 1 7 o f 2 4 DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Additional Program Information d) 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 2016-17 2017-18 2018-19 Gender Male 126 125 130 Female 104 120 145 Total 230 245 275 Ethnicity African-American 5 5 American Indian or Alaska Native Asian 150 160 135 Caucasian Native Hawaiian or other Pacific Islander Other: specify: Refugees and immigrants from all other countries around the world (non- 75 80 Asian countries) 140 Total 230 245 275 Of the above, how many Hispanic/Latino 75 80 100 Of the above, how many non-Hispanic/Latino 155 165 175 Total 230 245 275 Age 0-5 years 6-18 years 200 215 225 19-50 years 15 15 30 51+ years 15 15 20 Total 230 245 275 Geographic Location Alamance County Chatham County Durham County 50 50 75 Wake County Orange County Breakdown Chapel Hill Public Housing 30 35 50 Town of Chapel Hill (Non-Public Housing) 80 85 110 Town of Carrboro 70 75 100 Town of Hillsborough City of Mebane (Orange County) 5 Orange County (Outside Municipalities) 10 Total 230 245 275 PROGRAM INFORMATION 1/23/2018 10:01:04 AM P a g e 18 of 24 DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Work Statement e) 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(�jpecific, 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 Art Therapy Program 1. Program Activity Name Reach and Retention Program Goal By follow-up of the Newcomer Art Therapy Project,ATI staff will have delivered art therapy sessions to 275 children and adult newcomers as evidenced by#of clients reported in clinical progress notes. Performance Measures Art therapy records of attendance Previous Year Program Results ATI clinicians delivered sessions to 235 newcomers in FY 2016- 2017. Current Year Estimated Results Despite major CHCCS budget cuts to our program, ATI is on track to deliver art therapy services to 245 newcomers (adults and children) in both Orange and Durham Counties this year. Next Year Projected Results With full funding, ATI would be able to provide art therapy services to 275 child and adult newcomers across the Triangle in FY 18-19. 2. Program Activity Name Self-Esteem and Self-Concept Program Goal From baseline to follow-up, 60% of newcomer clients will report improved self-esteem and self-concept, as indicated by total number of improved items on the Piers-Harris Self-Concept Scale. Performance Measures Piers-Harris Self-Concept Scale Previous Year Program Results 53%of sampled students reported greater self-esteem/self-concept. Current Year Estimated Results Post-intervention data has not yet been collected, but it is estimated that 55% of clients assessed will show increased self-esteem/self- concept. 28 individual students out of the 50 assessed for this Next Year Projected Results 60% of clients assessed will report improved self-esteem and self- concept between pre- and post-data collection. (45 students out of the 75 individuals assessed for this.) 3. Program Activity Name Emotional Difficulties Program Goal From baseline to follow-up, 60% of newcomer clients will experience fewer emotional difficulties, as measured by total number of emotional difficulties on the Strengths and Difficulties Questionnaire. Performance Measures Strengths and Difficulties Questionnaire PROGRAM INFORMATION 3/14/2018 11:53:33 AM Page 19 of 24 DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Previous Year Program Results From baseline to follow-up, 48% of newcomer clients experienced fewer emotional difficulties and 22% experienced no change in number of emotional difficulties. Current Year Estimated Results Post-intervention data has not yet been collected, but it is estimated that 55%of clients assessed will show reduced emotional difficulties 55 students out of the 100 assessed for this Next Year Projected Results 60% of clients assessed will report fewer emotional difficulties (90 students out of the 150 assessed for this). 4. Program Activity Name Trauma Symptoms Program Goal From baseline to follow up, 60% of newcomers assessed will report fewer symptoms of trauma. Performance Measures Refugee Health Screener Previous Year Program Results N/A Current Year Estimated Results N/A(Only a small sample of clients are currently being assessed with this scale to test its feasibility and appropriateness.) Next Year Projected Results 60% of clients assessed will report fewer traumatic symptoms at follow-up. 30 out of the 50 adults assessed) 5. Program Activity Name Community Collaborations Program Goal To continue building partnerships with other newcomer-focused agencies to bring art therapy services to more newcomers in need. Performance Measures Number and diversity of collaborating agencies Previous Year Program Results N/A Current Year Estimated Results We have started new collaborations/ newcomer art therapy groups with the Refugee Community Partnership, the Compass Center, and Church World Services this year. Next Year Projected Results We hope to build partnerships with at least 2 new agencies in the upcoming year, while retaining our partnerships with current collaborating agencies. We are currently in conversation with USCRI-Raleigh, the Duke Kenan Refugee Project, and the Doris Henderson Newcomer School. PROGRAM INFORMATION 3/14/2018 11:53:33 AM Page 20 of 24 DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION f) Program Budget 1. Submit your program budget. You may complete the provided template (separate As 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. N/A 3. This program budget represents what percent of the agency budget? 71% 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 2016-17 Estimated 2017-18 Projected 2018-19 Total Cost of Program 123,800 141,500 173,000 Total # of Individuals 230 245 275 Cost Per Individual $538/year $577/year $629/year PROGRAM INFORMATION 1/23/2018 10:01:04 AM Page 21 of 24 DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Agency Budget Operating Budget for Entire Agency AGENCY NAME: Institute of Art Therapy, Inc. Actual Estimated Projected Percent AGENCY REVENUE 2016-17 2017-18 2018-19 Change Private Donations $ 28,000 $ 35,000 $ 36,000 3% Agency Generated Revenue(fees) $ 158,000 $ 160,000 $ 175,000 9% Local Government Grants: Human Services-Town of Carrboro $ 4,000 $ 5,000 $ 10,000 100% Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ 3,000 $ 3,000 $ 15,000 400% Other-Town of Chapel Hill $ - $ - $ - 0 Human Services-Orange County $ 1,000 $ - $ - 0 Other-Orange County $ - $ 3,300 $ 5,000 52% Other-Town of Hillsborough $ - $ - $ - 0 Other Government Grants Triangle United Way $ - $ - $ - 0 State Government $ - $ - $ - 0 Federal Government(CDBG/HOME/etc.) $ - $ - $ - 0 Private Foundation Grants 1 $ 13,000.00 $ 50,000.00 $ 30,000.00 $ 0.40 Other Revenue $ 1,000 $ - $ - 0 Total Agency Revenue $ 208,000 $ 256,300 $ 271,000 6% AGENCY EXPENSES Compensation $ 177,000 $ 200,000 $ 210,000 5% Rent&Utilities $ 10,500 $ 12,000 $ 13,000 8% Supplies& Equipment $ 5,500 $ 6,000 $ 7,000 17% Travel &Training $ 2,500 $ 1,500 $ 5,000 233% Other Expenses: $ 7,500 $ 8,000 $ 10,000 25% Total Agency Expenses $ 2031000 $ 227,500 $ 245,000 8% SURPLUS/(DEFICIT) FOR PERIOD: $ 5,000 1 $ 28,8001 $ 26,000 -10% FY 2018-19 Agency Budget DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME: Newcomers Art Therapy Program Actual Estimated Projected Percent PROGRAM REVENUE 2016-17 2017-18 2018-19 Change Private Donations $ 8,000 $ 10,000 $ 10,000 0% Program Generated Revenue $ 114,000 $ 110,000 $ 130,000 18% Local Government Grants: Human Services-Town of Carrboro $ 4,000 $ 5,000 $ 10,000 100% Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ 3,000 $ 3,000 $ 15,000 400% Other-Town of Chapel Hill $ - $ - $ - 0 Human Services-Orange County $ 1,000 $ - $ - 0 Other-Orange County $ - $ 3,300 $ 5,000 52% Other-Town of Hillsborough $ $ - $ - 0 Other Government Grants Triangle United Way $ $ - $ - 0 State Government $ $ - $ - 0 Federal Government(CDBG/HOME/etc.) $ $ - $ - 0 Private Foundation Grants $ $ 22,000.00 $ 10,000.00 $ 0.55 Other Revenue $ 3,000 $ - $ - 0 Total Program Revenue $ 133,000 $ 153,300 $ 180,000 170 PROGRAM EXPENSES Compensation $ 112,000 $ 120,000 $ 145,000 21% Rent&Utilities $ 3,500 $ 4,000 $ 4,500 13% Supplies&Equipment $ 4,000 $ 5,000 $ 6,000 20% Travel&Training $ 800 $ 2,500 $ 2,500 0% Other Expenses: Research and Evaluation Costs $ 3,500 $ 10,000 $ 15,000 50% Total Program Expenses $ 123,800 $ 141,500 $ 173,000 22% SURPLUS/(DEFICIT) FOR PERIOD: $ 9,200 1 $ 11,800 $ 7,000 1 -41% FY 2018-19 Program Budget DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 EXHIBIT B: PROVIDER'S CARDINAL MENTAL HEALTH APPLICATION FY2018-19 MENTAL HEALTH SERVICES APPLICATION a) Applicant Contact Information Applicant Organization's Legal Name: Institute of Art Therapy, Inc. (DBA: Art Therapy Institute) Applicant Organization's Physical Address: 200 N. Greensboro St., D-6 Carrboro, NC 27510 Applicant Organization's Mailing Address: 200 N. Greensboro St., D-6 Carrboro, INC 27510 Applicant Organization's Web Address: ncati.org Executive Director: Hillary Rubesin Telephone Number: 919-381-6068 E-Mail: hrubesin(a_)ncati.org Tax ID Number: 26-3447555 b) Funding Re uest Program Total Ex. Youth Afterschool Program $30,000 Afterschool Program Coordinator salary and materials for youth activities and projects Newcomers Art Therapy Program: Payment for $27,600 therapy services, cultural/clinical training and supervision, research and evaluation, and interpreter services. Totals $27,600 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:' 8/29/2018 Executive&Jrector Date Signature. SVA� M T M k- 08/29/2018 Board Chairperson Date AGENCY INFORMATION 8/28/2018 5.02.49 PM DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 EXHIBIT B: PROVIDER'S CARDINAL MENTAL HEALTH APPLICATION d) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON DISCRIMINATION CLAUSE Are any of the Board Members or employees of the agency which will be carrying out this program or members of their immediate families, or their business associates... YES NO ❑ ® 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? El E c) Current beneficiaries of the program for which funds are being requested? ❑ ® 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 manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, gender identity/expression, 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. 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 existence of an undisclosed conflict may result in the termination of any grant awarded. Signature: 8/29/2018 Executi irector Date Signature: gm� M e� " 08/29/2018 Board Chairperson Date AGENCY INFORMATION 8/28/2018 5.02.49 PM Page 2 of 12 DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 EXHIBIT B: PROVIDER'S CARDINAL MENTAL HEALTH APPLICATION AGENCY INFORMATION Please provide the following information about your agency: a) Years in Operation, Date of Incorporation (Month/Year): September, 2009 b) Agency's Purpose/Mission (no more than a few sentences): The Art Therapy Institute (ATI) is an organization of mental health professionals dedicated to the healing power of the arts. We provide clinical art therapy services to diverse populations, empowering clients to develop their identities through the art-making process. We also offer training to allied professionals and seek to raise awareness in the general community about our profession and the benefits of arts-based therapy. c) Living Wage: Does this agency pay permanent employees a minimum living wage? (Yes/No) Yes If yes, is this agency an Orange County Living Waste Certified Employer? Yes If no, please explain. # of FTE - Full-Time Paid Positions: 3 # of FTE - Paid Part-Time Positions: 6 # of Volunteers: 116 # of FTE -Volunteers:1.5 Agency Information 8/28/2018 5:02:49 PM P a g e 3 o If 1 2 DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 EXHIBIT B: PROVIDER'S CARDINAL MENTAL HEALTH APPLICATION PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Newcomer Art Therapy Program Program Primary Contact and Title: Hillary Rubesin, Executive Director Telephone Number: 610-348-7253 E-Mail: hrubesinCdQ_gmail.com Program Description (3 pages OR LESS) Please provide the following information about the proposed program: a) 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 Board Priorities, 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. The Newcomer Art Therapy Program (NATP) began in response to a community needs assessment from UNC-Chapel Hill in 2008 and has expanded programming efforts and reach ever since. ATI's NATP directly addresses numerous town and county needs and priorities. AT] is committed to cultural sensitivity (Carrboro Board Priority A), social justice work, and the bridging of diverse cultures (Orange County overarching goals), through its ongoing efforts of cultural humility and cultural safety in counseling and research practices. These practices acknowledge the power dynamics inherent between community members of different cultures and positions, and commit to providing resources and settings that are familiar and empowering to historically disenfranchised communities. ATI's programming also relates to Chapel Hill's "Develop Good Places, New Spaces" initiative in that we bring creative arts and social programming to diverse communities, especially residents of the Northside neighborhood and the Rogers Road Habitat Housing development (where many of our clients reside). Our program also aligns with Chapel Hill's goal to "Create a Place for Everyone" through cultural arts engagement. ATI's art therapy program brings free, arts-based services to some of our county's most disadvantaged residents, who wouldn't normally have access to or know how to access these types of programs. Finally, data from the Chapel Hill Human Services Needs Assessment indicate that residents need affordable healthcare, education and family resources, and jobs and job training. ATI's NATP addresses all these needs in different ways. First and foremost, through grants, private donations, and Medicaid billing, we provide mental health services free of charge to newcomer clients. Our adult services, in particular, include "hybrid groups" focusing on health education, family education, and resource sharing. We also provide vocational support to high school students and newcomer adults. Finally, we hire newcomers to interpret, provide cultural trainings to staff members, and most recently, for billing/accounting support! b) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) PROGRAM INFORMATION 8/28/2018 5:02:49 PM P a g e 4 o f 1 2 DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 EXHIBIT B: PROVIDER'S CARDINAL MENTAL HEALTH APPLICATION ATI therapists all have Masters degrees in art therapy or related fields and are all fully licensed or working towards full licensure as professional counselors in NC. All clinicians receive weekly group supervision and individual supervision as needed, according to client load and level of licensure. ATI therapists and interns have a combined 50+ years of experience working with newcomers, and receive annual training in multicultural competencies. In addition to this extensive clinical experience and training, the ED holds a doctorate in expressive arts therapy, with dissertation research focused on refugee mental health. Research on newcomer programming is conducted in collaboration with various universities including UNC-Chapel Hill, UNC- Greensboro, Duke University, Lesley University, and other community-based agencies. c) What efforts do you make to seek feedback about your program from your target population (e.g. survey, evaluations, etc.?) Beyond the research evaluations ATI conducts every year to monitor the mental health and social functioning of our clients, ATI also surveys teachers, school staff, and newcomer clients about their experiences with the program. Finally, ATI also surveys community art show attendees who view the client artwork and stories to evaluate how the program impacts community perceptions of newcomers. PROGRAM INFORMATION 8/28/2018 5:02:49 PM Page 5 of 12 DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 EXHIBIT B: PROVIDER'S CARDINAL MENTAL HEALTH APPLICATION Additional Program Information d) 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 2016-17 2017-18 2018-19 Gender Male 126 125 130 Female 104 120 145 Total 230 245 275 Ethnicity African-American 5 5 American Indian or Alaska Native Asian 150 160 135 Caucasian Native Hawaiian or other Pacific Islander Other: specify 75 80 140 Total 230 245 275 Of the above, how many Hispanic/Latino 75 $0 100 Of the above, how many non-Hispanic/Latino 155 165 175 Total 230 245 275 Age 0-5 years 6-18 years 200 215 225 19-50 years 15 15 30 51+ years 15 15 20 Total 230 245 275 Geographic Location Alamance County Chatham County Durham County 50 50 75 Wake County Grange County Breakdown Chapel Hill Public Housing 30 35 50 Town of Chapel Hill (Non-Public Housing) $0 $5 110 Town of Carrboro 70 75 100 Town of Hillsborough City of Mebane (Orange County) 5 Orange County (Outside Municipalities) 10 Total 230 245 275 PROGRAM INFORMATION 8/28/2018 5:02:49 PM P a g e 6 of 12 DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 EXHIBIT B: PROVIDER'S CARDINAL MENTAL HEALTH APPLICATION Work Statement e) 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(�jpecific, 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 1. Program Activity Name Clinical Therapy Services: Reach and Retention Program Goal With these funds, ATI will reach at least 30 newcomers in Orange County through both individual and group therapy services. (Served weekly or monthly throughout the year) Performance Measures Art therapy records of attendance Previous Year Program Results Cardinal's DFA was not evaluated last year. Current Year Estimated Results Cardinal's DFA was not evaluated this year. Next Year Projected Results At least 30 newcomer adults and children will be provided with weekly or monthly therapy services through this funding. 2. Program Activity Name Training and Supervision Program Goal All ATI clinicians and interns (10) will receive cultural training and clinical supervision as related to this project. (At least 3 hours of cultural training each, and at least 30 hours of supervision each) Performance Measures Records of hours of attendance in training and supervision Previous Year Program Results Cardinal's DFA was not evaluated last year. Current Year Estimated Results Cardinal's DFA was not evaluated last year. Next Year Projected Results 10 ATI clinicians and interns in the NATP program will receive training and supervision. (At least 3 hours of cultural training each, and at least 30 hours of supervision each 3. Program Activity Name Interpretation Program Goal ATI will hire interpreters to serve at least 75 newcomer clients during the 18-19 fiscal year. Performance Measures Record of number of newcomer clients served by interpreters Previous Year Program Results Cardinal's DFA was not evaluated last year. Current Year Estimated Results Cardinal's DFA was not evaluated last year. Next Year Projected Results 75 newcomers will receive interpreter services through ATI. 4. Program Activity Name Research and Evaluation PROGRAM INFORMATION 8/28/2018 5:02:49 PM Page 7 o DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 EXHIBIT B: PROVIDER'S CARDINAL MENTAL HEALTH APPLICATION Program Goal ATI will conduct culturally-congruent research with over 100 newcomer clients in Orange County. Performance Measures Number of newcomers participating in quantitative and qualitative research protocols. Previous Year Program Results Cardinal's DFA was not evaluated last year. Current Year Estimated Results Cardinal's DFA was not evaluated last year. Next Year Projected Results Over 100 newcomers in Orange County will participate in ATI's research practices. Agency Budget (See Excel Spreadsheet) ATI's agency budget was provided for a previous grant. Orange County already has access to this document. i. Is your agency currently receiving and/or requesting other local government funding? (YeslNo) Yes, ATI requested the following amount from the county and towns last January for the NATP, and we were awarded the following amounts for the 18-19 fiscal year. If yes, please list below: Program FY18-19 FY18-19 Source Award Request Ex: Affordable Rental 0 $20,000 Carrboro - Affordable Housing Rehabilitation Ex: Agency Administration $15,000 $15,000 Chapel Hill - Other Ex. Total $15,000 $35,000 Total Funding Newcomer Art Therapy Program $3555 $5,000 Orange County- Outside A enc (Human Services Funding Newcomer Art Therapy Program $3000 $15,000 Chapel Hill- Outside Agency/Human Services Funding Newcomer Art Therapy Program $6000 $10,000 Carrboro- Outside Agency/Human Services Funding TOTAL $12,555 $30,000 Total Funding "Add rows or attach additional page, if needed. ii. Submit your agency's budget. You may complete the provided template (separate xis file) or you may submit your own budget file (as long as it contains the same information, and in a similar format, as requested in the provided template). PROGRAM INFORMATION 8/28/2018 5:02:49 PM P a g e 8 o i 1 2 DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 EXHIBIT B: PROVIDER'S CARDINAL MENTAL HEALTH APPLICATION AT!'s agency budget was provided for a previous grant. Orange County already has access to this document. Agency Budgets are required to define budget amounts for the previous program year, current program year, and next program year for the following categories: • Revenues c Private Donations o Program Generated Revenue o Local Government Grants ■ Carrboro Human Services ■ Carrboro Other • Chapel Hill Human Services ■ Chapel HIII 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 (CDBGIHOMEIetc.) ■ Private Foundation Grants o Other Revenue • Expenditures o Compensation o Rent 8. Utilities o Supplies & Equipment a Travel & Training a Other Expenses iii. Does your agency budget show a Surplus or Deficit? Surplus Is there a significant change? Yes/No No Please provide a brief explanation for Surplus or Deficit, and significant changes. ATI's budget for 2017 shows a surplus in spite of$27,000 in budget cuts, due to a major increase in fundraising efforts in the second half of 2017 to help offset unexpected financial losses. iv. What is your agency's fiscal year? Jan 1, 2018-Dec 31, 2018 (Example: July 1, 2016 through June 30, 2017) PROGRAM INFORMATION 8/28/2018 5:02:49 PM Page 9 of 12 DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 EXHIBIT`B" Scope of Services—FY 2018-19 Outside Agency Performance Agreement Agency Name: Institute of Art Therapy, Inc. (DBA: The Art Therapy Institute) Program Name: Newcomers Art Therapy Program Funding Award: $3555 Outline how the agency will spend Orange County's funding award. Expense Description Amount Clinical compensation for licensed art therapists $2000 Supplies and equipment(art supplies) $505 Cultural trainin s for staff $250 Interpretation costs $500 Research and evaluation of program $300 TOTAL $3555 Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2019. • ATI clinicians will run one local art therapy group for refugees either in the schools or community depending on need. This group will last for 20 hours (1-hour long group for 20 sessions,or a 2-hour long group for 10 sessions). • ATI will spend approximately $25/hour-long group session on high quality art supplies, totaling $505 over the course of the funding period. • ATI will invite in cultural interpreters/cultural brokers to train ATI staff in working with culturally-diverse,refugee communities. • ATI will pay for 10 hours of interpretation costs related to this program(including phone calls to refugee adults/parents/clients, translation of written clinical materials, and home visits to families as needed). • ATI will put $300 of the funding towards research and evaluation efforts to assess the program and make recommendations for further improvement as needed. Two research associates have already been hired to complete this task. 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 Art therapy delivered to 115 newcomers across the Triangle(42%of original number 115 from grant proposal,because we only received 42%of asking amount from CH, Carrboro, and OC) Increase in self-esteem and self-concept for 60% of clients assessed: Only individual 30 clients are arse is measure,ATI serves approx. 50 individual clients/year. L Executive Director, ATI 11/20/2018 Certified by. 09EB6DDF336445C... Title: Date: (Provider's Signature) DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 Performance Measures Anticipated Results Decrease in emotional difficulties for 60% of clients assessed: Approximately 100 60 clients will be assessed through this tool. Trauma symptoms will decrease for 60% of clients assesed: Only clients ages 13+are 15 assesed for this measure (approximately 25 clients in total) Increase and maintenance of community collaborations.We hope to collaborate with 5 at least 5 outside agencies on our newcomer art therapy project. DocuSigned�oby:: ( li" PULSivu Executive Director, ATI 7� 11/20/2018 Certified by: 09EBBDDF336445C... Title: Late: (Provider's Signature) DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 EXHIBIT"B" Scope of Services—FY 2018-19 Outside Agency Performance Agreement Agency Name: Institute of Art Therapy,Inc. (DBA: Art Therapy Institute) Program Name:Newcomers Art Therapy Program(NATP) Funding Award: $27,600 Outline how the agency will spend Orange County's funding award. Expense Description Amount Therapy Services(Payment for clinical services of uninsured child clients,adult clinic clients,and $16,600 refugee women's group;cultural training of clinicians;clinical supervision of NATP clinicians Interpreter Costs(Payment of interpreter services for all NATP needs) $10,000 Additional Program Cost:Research and Evaluation $1000 Program Services Outline the critical services (activities) the agency will employ to attain the Anticipated Outcomes below, by June 30,2019. • Provide individual art therapy services to uninsured newcomer children; Provide individual art therapy sessions to newcomer adults referred by Piedmont Health Services; Provide group art therapy services to refugee women from Burma. • Provide ongoing training and supervision to NATP clinicians in cultural competency,cultural humility,and cultural safety. • Provide appropriate interpreter services for clinical intake sessions, family sessions, and individual therapy sessions as needed. • Conduct culturally-congruent research and evaluation of NATP to assess and improve program outcomes. 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 ATI will reach at least 30 newcomers in Orange County through both individual and group 30 therapy services(Served weekly or monthly throughout the year),as evidenced by agency records of attendance All ATI clinicians and interns(10)will receive cultural training and clinical supervision as related 10 to this project(At least 3 hours of cultural training each,and at least 30 hours of supervision each),as evidenced by agency records of hours of attendance in training and supervision ATI will hire interpreters to serve at least 75 newcomer clients during the 18-19 fiscal year,as 75 evidenced by agency records of number of newcomer clients served by interpreters ATI will conduct culturally-congruent research with over 100 newcomer clients in Orange 100 County,as evidenced by the number of newcomers participating in quantitative and qualitative research protocols. DocuSigned by: C1lI 1.Sll�t, Executive Director, ATI 11/20/2018 45c... Executive Director 8/29/18 Certified by: Title: Date: Provide Signa DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 ATTACHMENT "A" Orange County Certifications—FY 2018-19 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: ( IiLry wsivu Executive Director, ATI 11/20/2018 Certified by: o9EB6DDF336445c... Title: Date: (Provider's Signature) (The Institute of Art Therapy) Orange County Outside Agency Performance Agreement Page 12 of 9 Rev. 8118 DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 A CERTIFICATE OF LIABILITY INSURANCE 03/1 /2018 03/14/2018 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 have ADDITIONAL INSURED provisions or 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 NAME: Affinity Insurance Services Inc. PHONE FAx 847-953-2700 A/C No Ext: 877-738-3714 A/C No 1100�V�irginia Drive, Suite 250 ADDRESS: Wa shington,V ashington, IAA 19034 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: Columbia Casualty Company 31127 INSURED Institute of Art Therapy, Inc. dba INSURERB: The Art Therapy Institute INSURERC: 200 North Greensboro Street, Suite D6 INSURERD: Carrboro, NC 27510 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. NOTWITHSTANDING 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. 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