Crisis Counseling Assistance and Training Program

**Regular Services Program**

**Pilot Application Signature Sheet**

**State Disaster Mental Health Coordinator.** The following individual
is the primary contact person for coordinating the mental health
response to this disaster. This person will also be the State
coordinator for the application process for Federal funds to provide
disaster-related mental health services.

Contact person:

Title:

Agency:

Address:

Phone:

Fax:

E-mail address:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

***Signature,* Director, State Mental Health Authority**

Name: Phone number:

Fax: E-mail address:

**This application represents the Governor's agreement and/or
certification**:

1\. That the requirements are beyond the State and local governments'
capabilities;

2\. That the program, if approved, will be implemented according to the
plan contained in the application approved by the FEMA Disaster Recovery
Manager (DRM);

3\. To maintain close coordination with and provide reports to CMHS
Project Officer; and

4\. To include mental health disaster planing in the State's emergency
plan prepared under title II of the Stafford Act.

**The State requests \$ for Regular Services:**

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Signature, Governor's Authorized Representative**

Name: Phone Number:

Fax: E-mail address:

(Attach completed and signed sections of Form PHS 5161-1 including
Standard Form 424 and the assurances (SF-424B) to the signature sheet.)

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  **FEMA Disaster Number.** Enter the FEMA Disaster declaration number
  below.

  -----------------------------------------------------------------------

\[Insert Text\]

Executive Summary

  -----------------------------------------------------------------------
  In [one page or less]{.underline}, provide a brief description of the
  overall proposal, including key details about the disaster and the
  State's initial response. For more information and tips on completing
  an executive summary, see page 7 of the supplemental instructions.

  -----------------------------------------------------------------------

Part I: Disaster Description, Geographic and Demographic Information

  -----------------------------------------------------------------------
  **A. Description of Disaster.** Provide a brief description of the
  disaster, its scope and overall impact. This description should include
  the following: a) narrative information on the type of disaster (e.g.
  earthquake, hurricane, tornado, flood, fire), b) the timeframe during
  which the disaster occurred, c) the date of the Presidential disaster
  declaration, d) a description of the geographic area(s) affected by the
  disaster, and e) examples of major damage caused by the disaster and
  the overall impact on survivors. For additional information on
  completing this section, see page 8 of the supplemental instructions.

  -----------------------------------------------------------------------

\[Insert Text\]

  -----------------------------------------------------------------------
  **B Map of Disaster Area.** Provide a map of the area included in the
  Presidential disaster declaration and identify the areas to be served
  under the Regular Services Crisis Counseling Program. This map may be
  inserted below or attached to the application. For additional
  information on completing this section, see page 9 of the supplemental
  instructions.

  -----------------------------------------------------------------------

\[Insert Map or Indicate if Map is Attached\]

**Part II. State and Local Resources and Capabilities**

  -----------------------------------------------------------------------
  Briefly describe the State and local mental health systems. Explain why
  these resources cannot meet the disaster related mental health needs.
  (For additional information on completing this section see page 10 of
  the supplemental guidance.)

  -----------------------------------------------------------------------

\[Insert Text\]

**Part III. Response Activities from Date of Incident**

  -----------------------------------------------------------------------
  Provide a description of State and local crisis counseling activities
  from the date of the incident to the date of application submission. If
  the State received an Immediate Services Crisis Counseling Program
  grant, this section should be used to complete the requirements under
  FEMA regulations for a mid-program report. A format for satisfying
  these reporting requirements is provided below. If the State did not
  receive an Immediate Services Program grant, a description should be
  provided of any crisis counseling services provided using State and/or
  local community resources (this description may be in any format). If
  no crisis counseling services have been provided by State and local
  service providers, this should be stated as well. (For additional
  information on completing this section, see page 11 of the supplemental
  instructions.)

  -----------------------------------------------------------------------

\[Insert text or complete reporting format below.\]

  -----------------------------------------------------------------------
  **A. List of Immediate Services Crisis Counseling Service Providers.**
  In the table below, list the agencies providing crisis counseling
  services under the Immediate Services Program. In the left hand column,
  provide the name of the service provider along with the address and
  contact information for the agency. In the center column, list the
  service area(s) covered by the service provider In the right hand
  column, provide the name of the crisis counseling project manager along
  with contact information. (For additional information on completing
  this section, see page 11 of the supplemental instructions.)

  -----------------------------------------------------------------------

+-----------------------+-----------------------+-----------------------+
| **Agency**            | **Service Areas**     | **Immediate           |
|                       |                       | Services**            |
|                       |                       |                       |
|                       |                       | **Project Manager**   |
+-----------------------+-----------------------+-----------------------+
| #### Name             | Cite geographic or    | Name                  |
|                       | organizational        |                       |
| Address               | designation           | Address               |
|                       |                       |                       |
| Phone                 |                       | Phone                 |
|                       |                       |                       |
| Fax                   |                       | Fax                   |
|                       |                       |                       |
| Director's Name       |                       |                       |
+-----------------------+-----------------------+-----------------------+
|                       |                       |                       |
+-----------------------+-----------------------+-----------------------+
|                       |                       |                       |
+-----------------------+-----------------------+-----------------------+
|                       |                       |                       |
+-----------------------+-----------------------+-----------------------+
|                       |                       |                       |
+-----------------------+-----------------------+-----------------------+
|                       |                       |                       |
+-----------------------+-----------------------+-----------------------+
|                       |                       |                       |
+-----------------------+-----------------------+-----------------------+
|                       |                       |                       |
+-----------------------+-----------------------+-----------------------+
|                       |                       |                       |
+-----------------------+-----------------------+-----------------------+
|                       |                       |                       |
+-----------------------+-----------------------+-----------------------+
|                       |                       |                       |
+-----------------------+-----------------------+-----------------------+
|                       |                       |                       |
+-----------------------+-----------------------+-----------------------+
|                       |                       |                       |
+-----------------------+-----------------------+-----------------------+

  -----------------------------------------------------------------------
  **B. Immediate Services Program Data.** Using the table format below,
  provide service data from the Immediate Services Program. Reporting
  items in this format are based on data elements in the CCP "Data
  Management Tool Kit" which is recommended for use in the Immediate and
  Regular Services Programs. Separate reporting tables should be created
  for the each service provider in the Immediate Services grant and a
  combined table should be created for the overall project. (For
  additional information on completing this section, see supplemental
  instructions, pages 11-13.)

  -----------------------------------------------------------------------

\[Sample tables are provided for duplication. Include separate tables
for each service provider and one combined table for entire State
project\]

+------------------+--------------+--------------------+--------------+
| **INDIVIDUAL     |              |                    |              |
| CRISIS           |              |                    |              |
| COUNSELING       |              |                    |              |
| CONTACTS**       |              |                    |              |
|                  |              |                    |              |
| \[Insert Agency  |              |                    |              |
| Name or Name of  |              |                    |              |
| Overall          |              |                    |              |
| Project\]        |              |                    |              |
|                  |              |                    |              |
| **-Demographic   |              |                    |              |
| Information-**   |              |                    |              |
|                  |              |                    |              |
| **Date           |              |                    |              |
| Completed:       |              |                    |              |
| \[Insert date of |              |                    |              |
| data entry\]**   |              |                    |              |
+==================+==============+====================+==============+
| **Age**          | **Contacts** | **Ethnicity**      | **Contacts** |
+------------------+--------------+--------------------+--------------+
| Preschool (0-5)  | \[Insert     | White              | \[Insert     |
|                  | Numbers\]    |                    | Numbers\]    |
+------------------+--------------+--------------------+--------------+
| Childhood (6-11) |              | Hispanic Origin    |              |
+------------------+--------------+--------------------+--------------+
| Preadolescent/   |              | African            |              |
| Adolescent       |              | American/Black     |              |
| (12-17)          |              |                    |              |
+------------------+--------------+--------------------+--------------+
| Adult \[Indicate |              | American           |              |
| Age Range\]      |              | Indian/Alaska      |              |
|                  |              | Native             |              |
+------------------+--------------+--------------------+--------------+
| Older Adult      |              | Other              |              |
| \[Indicate Age   |              |                    |              |
| Range\]          |              |                    |              |
+------------------+--------------+--------------------+--------------+
|                  |              | Don't Know         |              |
+------------------+--------------+--------------------+--------------+
| **Language**     | **Contacts** | **Gender**         | **Contacts** |
+------------------+--------------+--------------------+--------------+
| English          | \[Insert     | Male               | \[Insert     |
|                  | Number\]     |                    | Numbers\]    |
+------------------+--------------+--------------------+--------------+
| Spanish          |              | Female             |              |
+------------------+--------------+--------------------+--------------+
| American Sign    |              |                    |              |
| Language         |              |                    |              |
+------------------+--------------+--------------------+--------------+
| Others \[specify |              |                    |              |
| in text\]        |              |                    |              |
+------------------+--------------+--------------------+--------------+

+------------------+--------------+--------------------+--------------+
| **INDIVIDUAL     |              |                    |              |
| CRISIS           |              |                    |              |
| COUNSELING       |              |                    |              |
| CONTACTS**       |              |                    |              |
|                  |              |                    |              |
| **\[Insert       |              |                    |              |
| Agency Name or   |              |                    |              |
| Name of Overall  |              |                    |              |
| Project**        |              |                    |              |
|                  |              |                    |              |
| **Observed or    |              |                    |              |
| Reported         |              |                    |              |
| Reactions**      |              |                    |              |
+------------------+--------------+--------------------+--------------+
| **Behavioral**   | **Contacts** | **Emotional**      | **Contacts** |
+------------------+--------------+--------------------+--------------+
| Aggression       | \[Insert     | Sadness            | \[Insert     |
|                  | Numbers\]    |                    | Numbers\]    |
+------------------+--------------+--------------------+--------------+
| Excessive        |              | Irritability/Anger |              |
| Activity Level   |              |                    |              |
+------------------+--------------+--------------------+--------------+
| Apathy/Decreased |              | Despair,           |              |
| Energy Level     |              | Hopelessness       |              |
+------------------+--------------+--------------------+--------------+
| Isol             |              | Guilt/Self-Doubt   |              |
| ation/Withdrawal |              |                    |              |
+------------------+--------------+--------------------+--------------+
| Hypervigilance   |              | Mood Swings        |              |
+------------------+--------------+--------------------+--------------+
| Reluctance to    |              | Preoccupation with |              |
| Leave Home       |              | Disaster, Safety   |              |
+------------------+--------------+--------------------+--------------+
| Other \[describe |              | Other \[describe   |              |
| in text\]        |              | in text\]          |              |
+------------------+--------------+--------------------+--------------+
| **Physical**     | **Contacts** | **Cognitive**      | **Contacts** |
+------------------+--------------+--------------------+--------------+
| Headaches        | \[Insert     | Confusion          | \[Insert     |
|                  | Numbers\]    |                    | Numbers\]    |
+------------------+--------------+--------------------+--------------+
| Gastrointestinal |              | Recurring          |              |
| Problems         |              | Dreams/Nightmares  |              |
+------------------+--------------+--------------------+--------------+
| Sleep            |              | Lack Concentration |              |
| Disturbances     |              |                    |              |
+------------------+--------------+--------------------+--------------+
| Memory Problems  |              | Difficulty Making  |              |
|                  |              | Decisions          |              |
+------------------+--------------+--------------------+--------------+
| Appetite Changes |              | Questioning        |              |
|                  |              | Spiritual Beliefs  |              |
+------------------+--------------+--------------------+--------------+
| Worsening of     |              | Other              |              |
| Chronic          |              |                    |              |
| Conditions       |              |                    |              |
+------------------+--------------+--------------------+--------------+
| Fa               |              |                    |              |
| tigue/Exhaustion |              |                    |              |
+------------------+--------------+--------------------+--------------+
| Other \[Describe |              |                    |              |
| in Text\]        |              |                    |              |
+------------------+--------------+--------------------+--------------+

+----------------------------------+-----------------------------------+
| **INDIVIDUAL REFERRALS**         |                                   |
|                                  |                                   |
| **\[Insert Agency Name or Name   |                                   |
| of Overall Project**             |                                   |
+----------------------------------+-----------------------------------+
| **Source**                       | **Number of Referrals**           |
+----------------------------------+-----------------------------------+
| Within Project                   | \[Insert Numbers\]                |
+----------------------------------+-----------------------------------+
| Other Disaster Agencies          |                                   |
+----------------------------------+-----------------------------------+
| Longer Term Mental Health        |                                   |
| Services                         |                                   |
+----------------------------------+-----------------------------------+
| Community Services               |                                   |
+----------------------------------+-----------------------------------+
| Other \[Describe in Text\]       |                                   |
+----------------------------------+-----------------------------------+

+----------------------------------+-----------------------------------+
| **GROUP CONTACTS**               |                                   |
|                                  |                                   |
| **\[Insert Name of Services      |                                   |
| Provider or Name of Overall      |                                   |
| Project\]**                      |                                   |
+----------------------------------+-----------------------------------+
| **Group Crisis Counseling (List  | **Number of Participants**        |
| Groups)**                        |                                   |
+----------------------------------+-----------------------------------+
| \[Insert Descriptive Text -- Add | \[Insert Numbers\]                |
| Rows if Necessary\]              |                                   |
+----------------------------------+-----------------------------------+
|                                  |                                   |
+----------------------------------+-----------------------------------+
|                                  |                                   |
+----------------------------------+-----------------------------------+
|                                  |                                   |
+----------------------------------+-----------------------------------+
| **Group Educational Services     | **Number of Participants**        |
| (List)**                         |                                   |
+----------------------------------+-----------------------------------+
| \[Insert Descriptive Text-- Add  | \[Insert Numbers\]                |
| Rows if Necessary\]              |                                   |
+----------------------------------+-----------------------------------+
|                                  |                                   |
+----------------------------------+-----------------------------------+
|                                  |                                   |
+----------------------------------+-----------------------------------+
|                                  |                                   |
+----------------------------------+-----------------------------------+

+----------------------------------+-----------------------------------+
| **Material Distribution**        |                                   |
|                                  |                                   |
| **\[Insert Name of Service       |                                   |
| Provider or Name of Overall      |                                   |
| Project\]**                      |                                   |
+----------------------------------+-----------------------------------+
| **Type of Material               | **Number of Materials             |
| Distribution**                   | Distributed**                     |
+----------------------------------+-----------------------------------+
| Material left in public places   | \[Insert Numbers\]                |
+----------------------------------+-----------------------------------+
| Material handed to people with   |                                   |
| no further interaction           |                                   |
+----------------------------------+-----------------------------------+
| Material handed to people        |                                   |
| followed by a brief discussion   |                                   |
| of the material                  |                                   |
+----------------------------------+-----------------------------------+

  -----------------------------------------------------------------------
  **C. Description of Services and Brief Analysis of Data.** Provide a
  brief description of the services provided during the Immediate
  Services Program including a discussion of any trends or key issues
  based on analysis of the Immediate Services Program data (e.g. what
  percentage of individuals identified in needs assessment received
  services during the Immediate Services Program) or any unique issues in
  the data (e.g. language groups not specified in standard reporting
  format). Describe the primary emphasis of services during the Immediate
  Services Phase (e.g. outreach services to most impacted communities),
  any issues that were unique to specific communities, and any unique
  service issues related to the type of disaster that occurred. For
  additional information on completing this section, see pages 13-14 of
  the supplemental instructions.

  -----------------------------------------------------------------------

\[Insert Text\]

  -----------------------------------------------------------------------
  **D. Immediate Services Program Training Provided.** Describe the
  training provided to Crisis Counseling Staff during the Immediate
  Services Program. Who provided training? When was it provided? What was
  the agenda and focus of training? Please attach a copy of the agenda
  and a list of handouts, videos, or other materials used.

  -----------------------------------------------------------------------

\[Insert Text\]

**Part IV. Needs Assessment**

  -----------------------------------------------------------------------
  **A. Geographic Areas and Estimated Need.** In the table provided
  below, list the areas within the Presidentially-declared disaster area
  for which services will be provided and the estimated number of people
  to be served in each area. List the geographic areas to be served in
  the left hand column. Areas to be served may be listed by service area,
  county, or other geographic or organizational designation identified by
  the State. All areas on the list must be within the disaster area
  declared by the President to be eligible for individual assistance. The
  service areas designated below will form the basis of the program plan
  and budget and therefore should be consistent throughout the
  application. In the right hand column, list the estimated number of
  people to be served in each area based on the CMHS Damage Assessment
  Formula, which is provided on the next page. For additional information
  on completing this section, see pages 15-16 of the supplemental
  instructions.

  -----------------------------------------------------------------------

\[Insert text in table below. Insert additional rows or delete rows as
necessary\]

  ---------------------------------------- ------------------------------
  **Designated Area**                      **Estimated Number to be
                                           Served**

                                           

                                           

                                           

                                           

                                           

                                           

                                           

                                           

                                           

                                           

                                           

                                           

                                           

  **TOTAL**                                
  ---------------------------------------- ------------------------------

  -----------------------------------------------------------------------
  **B. Needs Assessment Formula.** Using the CMHS Needs Assessment
  Formula (located below) estimate the number of persons you will serve
  in each designated area (fourth column of the following table). Attach
  a CMHS Needs Assessment Formula sheet [for each designated
  area]{.underline}. See the supplemental guidance (pages 16-19) for
  additional information on completing the CMHS Needs Assessment Formula.

  -----------------------------------------------------------------------

**CMHS Needs Assessment Formula for**

**Estimating Disaster Mental Health Needs Disaster**: FEMA XXXX-DR-State

This is an estimate for the following disaster
area\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Date of Report:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Completed
by:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

+-----------------+-----------+----------+----------+-----------------+
| **Loss          | **Number  | **ANH**  | **Range  | **Total**       |
| Categories**    | of**      |          | Est      |                 |
|                 |           |          | imated** |                 |
|                 | **        |          |          |                 |
|                 | Persons** |          |          |                 |
+-----------------+-----------+----------+----------+-----------------+
| Type of Loss    | Number    | Multiply | At-Risk  | Number of       |
|                 |           |          |          | persons         |
|                 |           | By       | Mu       | targeted per    |
|                 |           |          | ltiplier | loss category   |
|                 |           | ANH[^1]  |          |                 |
+-----------------+-----------+----------+----------+-----------------+
| Dead            |           |          | 100%     |                 |
+-----------------+-----------+----------+----------+-----------------+
| Hospitalized    |           |          | 35%      |                 |
+-----------------+-----------+----------+----------+-----------------+
| N               |           |          | 15%      |                 |
| on-hospitalized |           |          |          |                 |
| Injured         |           |          |          |                 |
+-----------------+-----------+----------+----------+-----------------+
| Homes destroyed |           |          | 100%     |                 |
+-----------------+-----------+----------+----------+-----------------+
| Homes           |           |          | 35%      |                 |
|                 |           |          |          |                 |
| "Major Damage"  |           |          |          |                 |
+-----------------+-----------+----------+----------+-----------------+
| Homes "         |           |          | 15%      |                 |
|                 |           |          |          |                 |
| Minor Damage"   |           |          |          |                 |
+-----------------+-----------+----------+----------+-----------------+
| Disaster        |           |          | 15%      |                 |
| Unemployed      |           |          |          |                 |
+-----------------+-----------+----------+----------+-----------------+
| (Other          |           |          | 10%      |                 |
| Loss---Specify) |           |          |          |                 |
+-----------------+-----------+----------+----------+-----------------+
| **Total         |           |          |          |                 |
| estimated       |           |          |          |                 |
| persons in need |           |          |          |                 |
| of crisis**     |           |          |          |                 |
|                 |           |          |          |                 |
| **Counseling    |           |          |          |                 |
| services (add   |           |          |          |                 |
| total column)** |           |          |          |                 |
+-----------------+-----------+----------+----------+-----------------+

Revised June, 2000

  -----------------------------------------------------------------------
  **C. Description of Crisis Counseling Needs and Data Analysis.** Please
  provide a detailed description of crisis counseling needs within the
  impacted areas. This description should include key data not included
  in the CMHS Needs Assessment Formula, such as information on businesses
  and schools closed as a result of the disaster, information on the
  number of applicants for FEMA individual assistance, and information on
  the demographic characteristics of the impacted communities. For each
  identified service area, identify any high risk groups or populations
  of special concerns identified through the State's initial needs
  assessment process (e.g. children, adolescents, older adults, people
  with disabilities, ethnic and cultural groups, lower income
  populations) and describe any specific issues or needs among these
  population groups. A number of optional tools have been developed to
  assist in completing this section. For additional instructions and
  examples of demographic analysis tools, key informant surveys, and a
  data matrix, see supplemental instructions, pages 20-21.

  -----------------------------------------------------------------------

\[Insert Text\]

**Part V. Plan of Services for Regular Services Grant**

  -----------------------------------------------------------------------
  **A. Service Providers**. In the space below, provide a list of the
  service providers in the Regular Services Program along with a brief
  (one paragraph) description of the service provider agency, its primary
  mission and service area. [Note]{.underline}: If the service providers,
  service areas, and Project Managers from the Immediate Services Program
  will remain the same in the Regular Services Program, this may be noted
  with a reference to the table in Part III. If agencies, service areas,
  or project managers will be different during the Regular Services
  Program, a new separate table should be completed for the Regular
  Services Program noting changes from the Immediate Services Program and
  transition plans for the Regular Services Program. For additional
  information on completing this section, see pages 23-24 of the
  supplemental instructions.

  -----------------------------------------------------------------------

\[Insert text. Insert new table if necessary\]

  -----------------------------------------------------------------------
  **B. Staffing Plan.** Provide an overall staffing plan for the Regular
  Services Program grant. For each services provider, list and describe
  all staff to be funded through the Regular Services grant. Staff whose
  services will be provided to the project as an in-kind contribution
  from the State or the service provider should be described separately
  with a clear indication that positions will not be funded through the
  grant. For each staff position, the description should indicate the
  percentage of time dedicated to the project. Simple job descriptions
  (one paragraph) should be provided for each category of worker included
  in the project. Job descriptions should include specific information on
  responsibilities and expectations during the Regular Services Program.
  For additional information, see supplemental instructions on page 24.

  -----------------------------------------------------------------------

\[Insert text below. Staffing plans may be provided in tables, listings,
or narrative format, but must include key information on all positions
to be funded through the project.\]

  -----------------------------------------------------------------------
  **C. Organizational Structure.** An organizational chart for the
  project is required for the Regular Services grant application. An
  organizational chart may be inserted below, or may be attached to this
  document. Please indicate below if an organizational chart is attached.
  For additional information on completing this section, see page 25 of
  the supplemental instructions.

  -----------------------------------------------------------------------

\[Insert text or organizational chart, or indicate that organizational
chart is attached.\]

+-----------------------------------------------------------------------+
| **D. Plan of Services.** In the space following, describe services to |
| be provided by each service provider included in the application. The |
| Regular Services Program grant application should address special     |
| issues identified in the needs assessment and should include a        |
| separate plan of services [for each service provider.]{.underline}    |
| Service plans should include the following information:               |
|                                                                       |
| -   Types of services to be provided (e.g. individual outreach,       |
|     crisis counseling, services to groups, public education,          |
|     information and referral services, consultation/in-service        |
|     training);                                                        |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   How staff will be deployed to provide these services              |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Strategies for targeting those identified as in need of services, |
|     including special population groups identified in the needs       |
|     assessment;                                                       |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Any quality control methods in place to assure appropriate        |
|     services to disaster survivors;                                   |
|                                                                       |
| -   How services will be coordinated with existing community          |
|     resources; and                                                    |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Any staff support mechanisms to be available (approaches that     |
|     will be taken to maintain staff morale).                          |
|                                                                       |
| For additional instructions on creating a plan of services, see pages |
| 26-28 of the supplemental instructions.                               |
+-----------------------------------------------------------------------+

\[Insert service plan(s) here for each service provider included in the
grant\]

+-----------------------------------------------------------------------+
| **E. Training.** Describe the training plan for this Regular Services |
| grant project. The training plan should cover the following areas:    |
|                                                                       |
| -   [Selection of Trainers]{.underline}: Attach resumes and briefly   |
|     state if the trainers were recommended by CMHS or are in-State    |
|     resources with experience in the FEMA/CMHS Crisis Counseling      |
|     Assistance and Training Program;                                  |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   [Training Content]{.underline}: Attach training agendas and       |
|     describe how the training sessions relate to the phase of the     |
|     disaster;                                                         |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   [Training Schedule and Locations]{.underline}: Attach a copy of   |
|     the training schedule and describe where the training will take   |
|     place;                                                            |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   [Target groups for Training]{.underline}: Describe who will be    |
|     trained and explain whether training will be offered to other     |
|     human service workers not employed through the Crisis Counseling  |
|     Program grant.                                                    |
|                                                                       |
| Funding may be used to support training within established FEMA       |
| training policies. Priority is placed on the use of trainers from     |
| within the State who have experience with the FEMA/CMHS Crisis        |
| Counseling Assistance and Training Program. For additional            |
| instructions on training, see pages 28-29 of the supplemental         |
| instructions.                                                         |
+-----------------------------------------------------------------------+

\[Insert description of training plan here and attach relevant materials
to application.\]

  -----------------------------------------------------------------------
  **F. Facilities.** Provide a description of facilities to be used for
  office space and as a base for outreach services. Explain whether or
  not space is being provided as an in-kind contribution to the project
  by the State and/or service providers. If new space will be leased for
  the Crisis Counseling Program, explain why this is necessary. (For
  additional instructions on completing this section, see supplemental
  instructions, page 29.)

  -----------------------------------------------------------------------

\[Insert text below\]

  -----------------------------------------------------------------------
  **G. Evaluation (Optional).** Provide a description of plans for
  ongoing process evaluation in the Regular Services project. Describe
  any data sources that will be used for evaluation and procedures for
  staff feedback and mid-course program adjustments based on evaluation
  findings. If an evaluation consultant will be used for the Regular
  Services Grant program, explain why this consultant was selected and
  attach a resume to the application. (For additional information on
  completing this section, see page 29 in the supplemental instructions.)

  -----------------------------------------------------------------------

\[Insert text below\]

**Part VI. Budget**

+-----------------------------------------------------------------------+
| The budget must be integrated with the needs assessment and the       |
| program plan. The applicant may exhibit the budget in any format that |
| is appropriate to the fiscal system of the State as long as the       |
| categories listed in the forms that follow are included. A separate   |
| budget must be provided for each service provider. There are three    |
| sections to the budget:                                               |
|                                                                       |
| 1.  An overall summary of costs                                       |
|                                                                       |
| 2.  Individual budgets for each service provider and the State Mental |
|     Health Authority                                                  |
|                                                                       |
| 3\. A narrative justification of costs                                |
|                                                                       |
| Note: Before completing any of the three budget forms, it is strongly |
| recommended that applicants review the CMHS Program Guidance entitled |
| [Fiscal Guidelines for the Crisis Counseling Assistance and Training  |
| Program (CCP-PG-06)]{.underline}. This guidance is included in the    |
| application package and is available at the CMHS website. In          |
| addition, CMHS has developed a Budget Estimating and Reporting Tool   |
| (BERT) that can assist in developing a budget within FEMA guidelines. |
| This budget tool is available on the CMHS web page.                   |
|                                                                       |
| Additional information is provided in the supplemental guidance on    |
| pages 30-32. Sample formats are provided on the following pages.      |
+-----------------------------------------------------------------------+

#### Regular Services Program

**Summary of Costs for Entire Project**

Disaster Declaration Number: FEMA-XXXX-DR-XX

+-----------+-------------+-------------+-------------+-------------+
| *         | **State     | **Service   | **Total     | **In-Kind   |
| *Budget** | Budget      | P           | Regular     | Costs**     |
|           | Request:**  | rovider(s): | Services    |             |
| **C       |             | Total       | Grant       | **Costs     |
| ategory** | **Total     | Requests**  | Request.    | contributed |
|           | Estimate**  |             | Add State   | to the      |
|           |             | **[Note]{.  | and Service | project per |
|           |             | underline}: | Provider    | agency.**   |
|           |             | attach      | total       |             |
|           |             | budget for  | e           |             |
|           |             | each        | stimates.** |             |
|           |             | service     |             |             |
|           |             | provider    |             |             |
|           |             | area**      |             |             |
+-----------+-------------+-------------+-------------+-------------+
| **Dates   |             |             |             |             |
| of        |             |             |             |             |
| S         |             |             |             |             |
| ervices** |             |             |             |             |
+-----------+-------------+-------------+-------------+-------------+
| Salaries  |             |             |             |             |
| and Wages |             |             |             |             |
| (Describe |             |             |             |             |
| specific  |             |             |             |             |
| positions |             |             |             |             |
| and rates |             |             |             |             |
| in budget |             |             |             |             |
| n         |             |             |             |             |
| arrative) |             |             |             |             |
|           |             |             |             |             |
| Fringe    |             |             |             |             |
| Benefits  |             |             |             |             |
| (%)       |             |             |             |             |
|           |             |             |             |             |
| **Total   |             |             |             |             |
| Pe        |             |             |             |             |
| rsonnel** |             |             |             |             |
| **Costs** |             |             |             |             |
+-----------+-------------+-------------+-------------+-------------+
| **C       |             |             |             |             |
| onsultant |             |             |             |             |
| Costs**   |             |             |             |             |
+-----------+-------------+-------------+-------------+-------------+
| **Office  |             |             |             |             |
| S         |             |             |             |             |
| upplies** |             |             |             |             |
+-----------+-------------+-------------+-------------+-------------+
| *         |             |             |             |             |
| *Travel** |             |             |             |             |
+-----------+-------------+-------------+-------------+-------------+
| **T       |             |             |             |             |
| raining** |             |             |             |             |
+-----------+-------------+-------------+-------------+-------------+
| Med       |             |             |             |             |
| ia/Public |             |             |             |             |
| In        |             |             |             |             |
| formation |             |             |             |             |
| Costs     |             |             |             |             |
+-----------+-------------+-------------+-------------+-------------+
| **Eva     |             |             |             |             |
| luation** |             |             |             |             |
+-----------+-------------+-------------+-------------+-------------+
| **Total   |             |             |             |             |
| Costs**   |             |             |             |             |
+-----------+-------------+-------------+-------------+-------------+

**Regular Services Program**

**Budget for State Mental Health Authority**

Disaster Declaration Number: FEMA-XXXX-DR-XX

+-----------------------+---------------------+-----------------------+
| **Budget**            | **Grant Request**   | **In-Kind Costs**     |
|                       |                     |                       |
| **Category**          |                     | **Costs contributed   |
|                       |                     | to the project per    |
|                       |                     | agency.**             |
+-----------------------+---------------------+-----------------------+
| **Dates of Services** |                     |                       |
+-----------------------+---------------------+-----------------------+
| Salaries and Wages    |                     |                       |
| (Describe specific    |                     |                       |
| positions and rates   |                     |                       |
| in budget narrative)  |                     |                       |
|                       |                     |                       |
| Fringe Benefits (%)   |                     |                       |
|                       |                     |                       |
| **Total Personnel     |                     |                       |
| Costs**               |                     |                       |
+-----------------------+---------------------+-----------------------+
| **Consultant Costs**  |                     |                       |
+-----------------------+---------------------+-----------------------+
| **Office Supplies**   |                     |                       |
+-----------------------+---------------------+-----------------------+
| **Travel**            |                     |                       |
+-----------------------+---------------------+-----------------------+
| **Training**          |                     |                       |
+-----------------------+---------------------+-----------------------+
| Media/Public          |                     |                       |
| Information Costs     |                     |                       |
+-----------------------+---------------------+-----------------------+
| **Evaluation**        |                     |                       |
+-----------------------+---------------------+-----------------------+
| **Total Costs**       |                     |                       |
+-----------------------+---------------------+-----------------------+

**\***The State Mental Health Authority and each local provider should
fill out this budget form.

**Regular Services Program**

**Individual Service Provider Budgets**

Name of Service Provider:

+-----------------------+---------------------+-----------------------+
| **Budget**            | **Grant Request**   | **In-Kind Costs**     |
|                       |                     |                       |
| **Category**          |                     | **Costs contributed   |
|                       |                     | to the project per    |
|                       |                     | agency.**             |
+-----------------------+---------------------+-----------------------+
| **Dates of Services** |                     |                       |
+-----------------------+---------------------+-----------------------+
| Salaries and Wages    |                     |                       |
| (Describe specific    |                     |                       |
| positions and rates   |                     |                       |
| in budget narrative)  |                     |                       |
|                       |                     |                       |
| Fringe Benefits (%)   |                     |                       |
|                       |                     |                       |
| **Total Personnel     |                     |                       |
| Costs**               |                     |                       |
+-----------------------+---------------------+-----------------------+
| **Consultant Costs**  |                     |                       |
+-----------------------+---------------------+-----------------------+
| **Office Supplies**   |                     |                       |
+-----------------------+---------------------+-----------------------+
| **Travel**            |                     |                       |
+-----------------------+---------------------+-----------------------+
| **Training**          |                     |                       |
+-----------------------+---------------------+-----------------------+
| Media/Public          |                     |                       |
| Information Costs     |                     |                       |
+-----------------------+---------------------+-----------------------+
| **Evaluation**        |                     |                       |
+-----------------------+---------------------+-----------------------+
| **Total Costs**       |                     |                       |
+-----------------------+---------------------+-----------------------+

**\***The State Mental Health Authority should work with each local
service provider to develop budget and fill out this budget form.

**Regular Service Program**

**Budget Narrative**

A budget narrative is required to document the types of expenditures
included in the budget, justify the funding request, and demonstrate
fiscal accountability. (See pages 30-32 of the supplemental
instruction.) Please provide the following information:

1.  Provide a justification for the specific number of positions to be
    funded. Rates of pay (hourly or monthly), and the amount of time
    dedicated to the project must be provided for all positions. The
    budget narrative must also describe how salary levels and fringe
    benefits were determined. Were they based on comparable positions in
    the local area? (If not, explain why.)

2.  List all consultants, the services they will provide and their
    compensation.

  --------------------- ----------------------- ------------ --------------
  Name of Consultant    Type of Service         Travel Costs Compensation
                                                             Costs

                                                             

                                                             

                                                             

                                                             

                                                             
  --------------------- ----------------------- ------------ --------------

3.  List the types of items listed under office supplies (i.e., cell
    phones, computers, beepers, office supplies and maps). Detail on the
    number of items needed should correspond with the program plan.

4.  List and describe the types of expenditures included in the travel
    category (i.e., mileage/rate, rental cars). Are the expenditures
    based on State rates for allowable travel costs? If not, explain and
    provide a justification.

5.  List the trainers included in the training category.

  --------------------- ----------------------- ------------ --------------
  Name of Trainer       Type of Training        Travel Costs Compensation
                                                             Costs

                                                             

                                                             

                                                             

                                                             

                                                             
  --------------------- ----------------------- ------------ --------------

6.  List and describe the types of expenditures included in the
    media/public information category.

7.  Provide a detailed justification for any evaluation expenditures
    included in the budget.

[^1]: ANH means **A**verage **N**umber of persons per **H**ousehold.
    This figure can be obtained on a county/parish/area basis from the
    Census Bureau. If the State is unable to determine the ANH for an
    area, then use the average figure of 2.5.