Transcript Document

Center for Mental Health Services
Technical Assistance Conference – January 6-7 and 10-11, 2005
Basics of the Funding Opportunity – Day 1
Nuts and Bolts Discussion
Appendices (1-5)
Mary Phillips, BME
Former Circles of Care Program Coordinator, Oakland and an Evaluator, Los Angeles, CA
I.
Overview
 The appendices should be succinct with information cited in the narrative.
 If submitting hard copies double-check that you have also numbered the
appendices. When copies are made at the Grants Management office they may get
out of order or misplaced.
 The appendices just as the narrative should be single sided.
II.
Items from Standard Infrastructure Program
Announcement and Circles of Care NOFA.
 Appendices 1 through 5 – Use only the appendices listed below.
 If your application includes any appendices not required in the grant
announcement or NOFA, they will be disregarded.
 Do not use more than a total of 30 pages for Appendices 1, 3 and 4 combined.
 There are no page limitations for Appendices 2 and 5.
 Do not use appendices to extend or replace any of the sections of the Project
Narrative unless specifically required in the NOFA. Reviewers will not consider
them if you do.
Appendix 1: Letters of Support
o Since there are a variety of formats out there and not just ‘one’ way to format the
letter this is a suggested Letter of Support format outline:
Important:
Title:
Supporting organization letterhead
Letter of Commitment, Letter of Support, Memorandum of
Understanding
Date:
Usually within 3 months of the due date of the proposal
Heading:
Name, Title (i.e. Project director, President, Chair, signing authority)
Address
Re:Circles of Care proposal to CMHS, SAMHSA
Addressing:
Dear (i.e. Project director, President, Chair, signing authority),
Body:
Name of supporting agency. History of collaborative work or
description of organization. Statement of support. Current contracts or
collaborative projects. A sentence that states what agency will
support/collaborate/participate with the Tribal organization to carry
out aspects of the Circles of Care.
Describe the services or functions the supporting agency will be
providing. List any other Circles of Care support that might transpire.
Closing:
Sincerely,
Signed:
Original signatures required depending on NOFA.
(See electronic sending instructions for signed documents required)
[Supporting/Coordinating Agency Letter Head]
Example:
(also see
sample
forms on
TA CD):
January 6, 2005
Dear Dr. Smith,
This is a letter of coordination between [School] and the [Tribe/Tribal organization].
The [Tribe/Tribal organization] has been the lead agency in the American Indian/Alaska
Native community’s development of a mental health system for youth and their families.
The [Tribe/Tribal organization] provides case management, counseling, cognitive
behavioral therapy, substance abuse, family and mental health services for American
Indian/Alaska Native children and youth. [Tribe/Tribal organization] also provides
substance abuse prevention and education services for these youth at its facility in [city,
state], and also at a variety of outreach sites in the community.
EXAMPLE DOCUMENT
[School] is part of the [city] Unified School District, that will work closely with the
[Tribe/Tribal organization] to increase resources for American Indian/Alaska Native
youth in the [area, community].
Counselors and outreach workers from the [Tribe/Tribal organization] currently provide
services on site at the [School]. These services have been helpful to our students over the
past two (2) years. [School] is committed to continuing this relationship with
[Tribe/Tribal organization] for the duration of the Circles of Care project.
In these times where education needs further support from communities, families, and
school projects, we are grateful to accept any help that would improve the quality of life
for American Indian/Alaska Native students. The Circles of Care approach will allow our
students to have the needed programs to assist in effective programming for the youth of
our community. We would welcome the [Tribe/Tribal organization] on the school
property and or campus to provide counseling, assessment from the Guidebook to design
a Life Skills Learning Plan, behavioral youth prevention therapy, HIV/AIDS education
core curriculum workshops, nutrition and wellness education, and substance abuse.
Sincerely,
School Principle
Continued from previous requirement
o Letters are an important source for reviewers to find out if the project is working
with other resources in the community to accomplish systems change.
o Begin coordinating the letters as soon as possible. Invariably letters sent to other
organizations will have to go through an approval process, which takes time.
o Before asking the collaborating agency for a support letter prepare information that
will help them understand more of the proposed project. A general summary sheet
or statement that describes the core components of the proposed project, along with
the name of the funder and attach your abstract. In some cases you can expedite the
letter of support process if the body of the letter is written by the requesting agency.
o Make a list of the letters that are needed and keep in mind how each letter will be
obtained. If time is running short (and it will) plan out separate meeting times to get
letter of support signatures from each organization.
 Appendix 2: Data Collection Instruments/Interview Protocols
o No Page Limit
o This can include but not limited to:

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Previously implemented youth/SA/MH GPRA tool.
Consumer Satisfaction & Quality of Services Survey
Initial SA/MH assessment data collection forms.
Parent Surveys
Youth Surveys
 Appendix 3: Sample Consent Forms
o
o
o
o
Forms used in the clinical setting
Form used for students at the public school to receive/refer services.
Forms to exchange client information to interagency team or assigned counselors.
Forms that allow children to receive services from the clinic or youth services.
[Men t al Healt h Ag en cy Let t er Head ]
Informed Consent to Treatment
Example
1. In signing my name below, I acknowledge that I am giving my informed consent to
treatment at the [mental health agency], City, State.
(also see
sample forms
on TA CD):
2. I understand that all information regarding this work will remain confidential and will not
be shared with others outside the [mental health agency] and [other interagency approved
clinics] without my consent. I understand that my counselor may receive supervision for
my case and may need to discuss information about my case with the supervisor.
3. I also understand that there are conditions under which this confidentiality must be
broken and information be shared with the appropriate individuals. These conditions are
as follows:
a. If there is suspicion that a child is being abused;
b. If there is evidence of physical abuse of elder or dependent adult;
c. If I am making serious physical threat against others or myself.
EXAMPLE DOCUMENT
4. I understand that there will be no fee charged for services at the [mental health agency].
If I am unable to make a scheduled appointment, I will call to cancel this appointment
twenty-four (24) hours ahead of time. If I fail o show for two consecutive appointments
without notice, I may be referred elsewhere for services. This is dependent on the
circumstance of the both the client and the mental health provider.
5. I have been informed about the procedures in which I and/or my children will participate
at the [mental health agency], including length of treatment, confidentiality and
exceptions to confidentiality, and nature of the treatment or other procedures. These
procedures may include individual, group or family psychotherapy or counseling,
traditional counseling and psychological testing.
6. I am giving consent to my voluntary participation in therapeutic groups run by a
counselor from the [mental health agency] of that if a part of my treatment plan. I
understands that what is shared in group must be kept confidential. It must not be shared
outside the group with anyone unless the group as a whole gives permission.
7. I understand that I may decline further participation at any time.
Client Signature
_______________________________________
Date
____________
Clinician/Counselor
_______________________________________
Date
____________
Additional Participant _______________________________________
Date
____________
Parent/Guardian
Date
____________
_______________________________________
 Appendix 4: Letter to the SSA (if applicable; see Section IV-4 of
this document)
o
o
o
o
This is 1 page of the Appendice section
SSA – Single State Agency
SPOC-Single Point of Contact
Intergovernmental Review (SPOC List)
http://www.whitehouse.gov/omb/grants/spoc.html
 Appendix 5: A copy of the State or County Strategic Plan, a State
or county needs assessment, or a letter from the State or county
indicating that the proposed project addresses a State- or countyidentified priority.
 Non-tribal applicants must show that identified needs are
consistent with priorities of the State or county that has primary
responsibility for the service delivery system. Include, in Appendix
5, a copy of the State or County Strategic Plan, a State or county
needs assessment, or a letter from the State or county indicating
that the proposed project addresses a State- or county-identified
priority. Tribal applicants must provide similar documentation
relating to tribal priorities. (Standard Infrastructure Program
Announcement, INF 05 PA, p. 22).
Continued from previous requirement
o
o
o
Tribal governments should submit tribal resolution documents that explain how the
proposed project will be aligned with tribal youth mental health priorities. This document is
specific to Tribal guidelines for resolution protocols. Language in the document can include
statements like, “ WHEREAS, [Tribe] is a federally recognized tribe”, WHEREAS [Tribe]
has developed a 6 year Southwest American Indian Systems of Care Strategic Plan that
identifies resources to improve the capacity of the child development and mental
health/substance abuse treatment system to provide services to American Indian/Alaska
Native children, youth and their families”.
Tribal Colleges and Urban programs can find information on the state mental health plan
and priorities at the State Mental Health Department’s website. A list of the state MH
department websites our posted on the National Association of State Mental Health Program
Directors (NASMHPD) URL http://www.nasmhpd.org/mental_health_resources.cfm.
The State Mental Health Plan can sometimes be found in the ‘publications’ link, or through
search engine of the state website. This is the same for the County plans on the web.
[Agency Letter Head]
Example
letter to
SSA
(See TA
CD):
January 6, 2005
Tracy L. Copeland
Manager, State Clearinghouse
Office of Intergovernmental Services
Department of Finance and Admin.
1515 W. 7th St., Room 412
Little Rock, Arkansas 72203
Telephone: (501) 682-1074
Fax: (501) 682-5206
Dear Single State Agency,
This letter is to inform the Single State Agency of the State of Arkansas
Department Mental Health that the Tribe/Tribal Organization is submitting an
application for federal funding from SAMHSA – CMHS.
EXAMPLE DOCUMENT
If the Single State Agency wants to comment on the proposal, its comments
should not be sent later than 60 days after the deadline date for the receipt of
applications to:
Crystal Saunders, Director of Grant Review
Office of Program Services
Substance Abuse and Mental Health Services Administration
Room 3-1044
1 Choke Cherry Road
Rockville, MD 20857
ATTN: SSA – Funding Announcement No. SM 05-008
Sincerely,
[Authorized Signature]
Re: NOFA # SM 05-008
Deadline: February 25, 2005
[Letter Head State Department of Mental Health]
Example letter from the State
or county indicating that the
proposed project addresses a
State- or county-identified
priority(See example TA CA):
July 2, 2003
Kathryn A. Powers
Director, Center for Mental Health Services
Substance Abuse and Mental Health Services Admin.
Rm 12-105 Parklawn Building
5600 Fishers lane
Rockville, MD 20857
EXAMPLE DOCUMENT
Dear Ms. Power:
We have been informed that the Department of Human Services of the City of Oakland in
collaboration with the Native American Health Center, has submitted a proposal for the
Comprehensive Community mental health Services Program for Children and their Families
grant (RFA-03-009) with the Center for Mental Health (CMHS) of SAMHSA. Andrea
Youngdahl, Director of the City of Oakland Department of Human Services is designated as
signee on the CMHS proposal. The Department of Human Services of the City of Oakland will
enter into a subcontract with the Native American health Center, which will provide direct
services. The native American health Center is a Federally Qualified health Center (FQHC):
provider number FHC11743F, as determined by the Health Care Financing Administration,
Center for Medicaid and Medicare Services (CMS). NAHC accepts Medicare (Provider #456681) and Medicaid (Provider #00G533890) under the State of California Medicaid Plan.
The California State Department of Mental Health (CDMH) is committed to supporting
innovative approaches that build upon the strengths of children and young adults, as a positive
means of addressing their mental health needs. CDMH also is devoted to promoting culturally
competent mental health services within California’s Mental Health System as a fundamental
element of the successful implementation and delivery of mental health services. We will
provide the necessary supports within the limitations of our budget and staffing resources to
assist any successful applicant in their implementation efforts.
Please call David Neilsen, Chief, Children and Family Services at (916) 654-2952 if need
additional information.
Sincerely,
00000000000000
STEPHEN W. MAYBERG, Ph.D.
Director, Department of Mental Health
Cc: Ethan Nebelkopf, PhD
Director, FCGC
NAHC