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: Supporting organization letterheadTitle: Letter of Commitment, Letter of Support, Memorandum of

UnderstandingDate: Usually within 3 months of the due date of the proposalHeading: Name, Title (i.e. Project director, President, Chair, signing authority)

AddressRe:Circles of Care proposal to CMHS, SAMHSAAddressing: 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)

Example: (also see sample forms on

TA CD):

EXAMPLE DOCUMENT

[Supporting/Coordinating Agency Letter Head] 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. [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: 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 Forms used in the clinical setting

o Form used for students at the public school to receive/refer services.

o Forms to exchange client information to interagency team or assigned counselors.

o Forms that allow children to receive services from the clinic or youth services.

Example (also see sample forms

on TA CD):

EXAMPLE DOCUMENT

[Mental Health Agency Letter Head]

Informed Consent to Treatment

1. In signing my name below, I acknowledge that I am giving my informed consent to treatment at the [mental health agency], City, State.

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.

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 This is 1 page of the Appendice sectiono SSA – Single State Agencyo SPOC-Single Point of Contact o 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 county-identified 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 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”.

o 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.

o 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.

Example letter to SSA (See TA

CD):

EXAMPLE DOCUMENT

[Agency Letter Head] 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. 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

Example letter from the State or county indicating that the proposed project addresses a State- or county-identified priority(See example TA CA):

EXAMPLE DOCUMENT

[Letter Head State Department of Mental Health] 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 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 #45-6681) 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