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Behavioral Health and/or Prevention/Early Intervention RFP
Application Agency
(Required)
Agency Executive Director
(Required)
First
Last
Email
(Required)
Contact Phone Number
(Required)
Agency Primary Contact
Please provide the following information about the Agency Primary Contact for this RFP (concerning all correspondences, questions and related documents)
Name
(Required)
First
Last
Title
(Required)
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
(Required)
Phone
(Required)
Organization Details
Organization Type
(Required)
Non-Profit 501(c)(3)
Other
Federal Tax ID or EIN
(Required)
DUNS Number
(Required)
Business License Number
(Required)
Proposal Details (Part 1)
Proposed Program Name
(Required)
Funding Amount Requested
(Required)
Funding Category
(Required)
Prevention/ Early Intervention
Behavioral Health
Amount of Total Budget
(Required)
Select the zip code(s) you will be serving:
(Required)
A select all option is available at the bottom.
33801
33802
33803
33804
33805
33806
33807
33809
33810
33811
33812
33813
33815
33820
33823
33825
33827
33830
33831
33834
33835
33836
33837
33838
33839
33840
33841
33843
33844
33845
33846
33847
33849
33850
33851
33854
33855
33856
33858
33859
33860
33863
33867
33868
33877
33880
33881
33882
33883
33884
33885
33888
33896
33897
33898
34759
Select All
Describe your organization's experience and strengths relevant to the proposed program.
(Required)
Describe the problem being addressed by your proposal, documenting the need for services with current local data/ statistics (cite your reference).
(Required)
Describe the program for which funding is sought.
(Required)
How long will the typical client be engaged in the program?
(Required)
Proposal Details (Part 2)
How will the services be accessed by the client?
(Required)
Will the program utilize Evidence Based Practices (EBP)?
(Required)
Yes
No
List the EBP that will be utilized.
(Required)
Please provide a web link that documents and described the EBP.
(Required)
Will the program/staff require licenses or permits to operate?
(Required)
Yes
No
Please list the licenses or permits necessary for the program.
(Required)
How will the program be promoted (how will you reach the target audience)?
(Required)
Describe the referral process to be used to generate referrals to the program (include names of agencies and/or programs in your local network which will generate referrals to this program).
(Required)
Describe any collaborative partnerships that directly impact the proposed program; will bring extra value to the clients served; and/or eliminate duplication of services and maximize resources (provide any MOU(s)).
(Required)
What is the minimum number of clients proposed to be served by this program and the requested 12- month funding?
(Required)
Numerical entry only.
Provide SMART Outcome Objectives for the proposed program.
(Required)
A guide for SMART objectives can be found by
clicking on this link.
Describe the data to be collected to document success of the proposed program; how it will be collected; and who is responsible for collecting it.
(Required)
Provide the benchmarks and standards that are applicable to the proposed program.
(Required)
Please provide a timeline for the proposed project as an attached document.
(Required)
Drop files here or
Select files
Max. file size: 300 MB.
Service Focus (Check all that apply)
(Required)
Clinical treatment
Non-clinical, culturally-specific approaches
Focus Zip Code Area #1
(Required)
ZIP / Postal Code
Focus Zip Code Area #2 (if applicable)
ZIP / Postal Code
Number of people to be served each year:
(Required)
Number of people enrolled in existing program (if applicable):
In which zip codes is your program located?
Projected Performance Commitments
Below, please report the projected performance metrics for clients who received behavioral health services and/ or preventative/ early intervention services:
Percent of Clients who feel less stressed, anxious or depressed:
Percent are NEW service users and report increased confidence accessing/ navigating services in the future:
% report progress in one or more of the following areas: individual behavior, family functioning, peer relations, trusted adult to talk to, community attachment:
Documents Upload
In order for your application to be marked complete, you'll need to upload the following documents in their respective fields.
501(c)(3) Determination Letter
(Required)
Drop files here or
Select files
Max. file size: 300 MB.
Narrative Response (8-page limit)
(Required)
Download the Narrative Response Guide and Rating Criteria for your reference.
Drop files here or
Select files
Max. file size: 300 MB.
Proposed Program Budget
(Required)
Download, complete, and upload the Proposed Program Budget form here.
Drop files here or
Select files
Max. file size: 300 MB.
Proposed Personnel Detail Budget
(Required)
Download, complete, and upload the Proposed Personnel Detail Budget form here.
Drop files here or
Select files
Max. file size: 300 MB.
Proposed Fee Schedule when program/service is per attendance charge
Download, complete, and upload the Proposed Fee Schedule form here.
Required for “Fee for Service Programs Only”.
Drop files here or
Select files
Max. file size: 300 MB.
Select the option that best describes your proposal.
(Required)
New Service(s)
Expansion of Services
Continuation of a program that will end due to complete loss of funding
Significant Partnership/Subcontracting with another agency
New Service(s): Attach a start-up timeline for each service.
(Required)
Drop files here or
Select files
Max. file size: 300 MB.
Expansion of Services: Provide successful data of current program to expand.
(Required)
Drop files here or
Select files
Max. file size: 300 MB.
Continuation of a program that will end due to loss of funding: Success of program must be empirically demonstrated.
(Required)
Drop files here or
Select files
Max. file size: 300 MB.
Significant Partnership/Subcontracting with another agency: Attach a signed letter of commitment from that agency’s Director or other authorized representative.
(Required)
Drop files here or
Select files
Max. file size: 300 MB.
Will your agency be working with a collaborative partner agency?
(Required)
Yes
No
Collaborative Partner Agency Details
Contact Name
(Required)
First
Last
Title
(Required)
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
(Required)
Phone Number
(Required)
Description of partner agency proposed activities:
(Required)
Attach a signed letter of commitment from that agency’s Director or other authorized representative.
(Required)
Drop files here or
Select files
Max. file size: 300 MB.
Hidden
Signature of collaborative partner agency representative:
Date
(Required)
MM slash DD slash YYYY
Is there another collaborative partner agency you're working with?
(Required)
Yes
No
Collaborative Partner Agency Details #2
Contact Name
(Required)
First
Last
Title
(Required)
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
(Required)
Phone Number
(Required)
Description of partner agency proposed activities:
(Required)
Attach a signed letter of commitment from that agency’s Director or other authorized representative.
(Required)
Drop files here or
Select files
Max. file size: 300 MB.
Hidden
Signature
Date
(Required)
MM slash DD slash YYYY
Authorized Physical Signature of Applicant/ Lead Organization
To the best of my knowledge and belief, all information in this application is true and correct. The document has been duly authorized by the governing body of the applicant who will comply with all contractual obligations if the applicant is awarded funding.
Name of Authorized Representative
(Required)
First
Last
Title of Authorized Representative
(Required)
Signature of Authorized Representative
(Required)
Date
(Required)
MM slash DD slash YYYY
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