Crisis Counseling Assistance and Training Program

**Immediate 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 the FEMA
Regional Director or the Disaster Recovery Manager as the delegate of
the Regional Director; 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 Immediate Services:**

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

**Signature, Governor's Authorized Representative**

Name: Phone Number:

Fax: E-mail address:

***(Attach the SF-424 Request for Federal Assistance to the signature
sheet.)***

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

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

\[Insert Text\]

**Part I: Geographic Areas and Initial 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 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 with 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 page 6 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 (second column of the following table). Attach
  a CMHS Needs Assessment Formula sheet [for each designated
  area]{.underline}. See the supplemental guidance (pages 7-10) 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 "Minor    |           |          | 15%      |                 |
| Damage"         |           |          |          |                 |
+-----------------+-----------+----------+----------+-----------------+
| Disaster        |           |          | 15%      |                 |
| Unemployed      |           |          |          |                 |
+-----------------+-----------+----------+----------+-----------------+
| (Ot             |           |          |          |                 |
| hers\--Specify) |           |          |          |                 |
+-----------------+-----------+----------+----------+-----------------+
| **Total         |           |          |          |                 |
| estimated       |           |          |          |                 |
| persons in need |           |          |          |                 |
| of crisis**     |           |          |          |                 |
|                 |           |          |          |                 |
| **Counseling    |           |          |          |                 |
| services (add   |           |          |          |                 |
| total column)** |           |          |          |                 |
+-----------------+-----------+----------+----------+-----------------+

Revised June, 2000

  -----------------------------------------------------------------------
  **C. Description of Crisis Counseling Needs and Special
  Circumstances.** Please provide a description of crisis counseling
  needs within the impacted areas. Describe any special circumstances not
  captured in the CMHS Needs Assessment Formula that will impact the need
  for crisis counseling services. For each identified service area,
  please 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, ethnic and cultural groups, lower
  income populations). For additional tips on completing this section,
  see supplemental instructions, pages 10-11.

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

\[Insert Text\]

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

  -----------------------------------------------------------------------
  Very 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 12 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.
  Provide specific number or estimate of disaster victims who have
  received services up to the date of the application. To the extent
  possible, activities should be described for each service area listed
  in Part I of this application. If no activities have been conducted to
  date, this should be stated as well. Any activities from the date of
  incident for which the State is requesting financial reimbursement from
  FEMA must be described in this section. (For additional information on
  completing this section, see page 13 of the supplemental instructions.)

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

\[Insert Text\]

**Part IV. Plan of Services**

  -----------------------------------------------------------------------
  **A. Service Providers.** In the table provided below, provide a list
  of the service providers included in this project. 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) to be covered by the service provider. Service areas
  should correspond to areas listed in Part I of this application. In the
  right hand column, provide the name of the crisis counseling project
  manager along with contact information. If the project manager has not
  been identified, provide the name of the agency director and indicate
  that the project manager has not yet been identified. For additional
  information on completing this section, see pages 14-15 of the
  supplemental instructions.

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

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

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

  -----------------------------------------------------------------------
  **B. Staffing Plan.** In the table below, provide a list of staff
  positions for which the State is requesting funding through the
  Immediate Services grant. Staff whose services will be provided to the
  project as an in-kind contribution from the State or the service
  provider should also be included in this chart with the words "In-kind"
  in parenthesis next to the position. In-kind positions should be listed
  below those funded through the grant and should be clearly
  distinguished in the totals. This information must be provided for the
  State and for each service provider. In the left hand column list the
  name of the service provider. In the second column, list the number of
  supervisors or team leaders and the percentage of time dedicated to the
  project. In the third column, list the number of outreach workers and
  crisis counselors dedicated to the project. List separately if the
  provider has separate job titles for outreach workers and crisis
  counselors. In the fourth column, list any fiscal or administrative
  positions to be funded. In the fifth column, list the total number of
  full time equivalent (FTE) staff positions to be funded by the project.
  For additional information, see supplemental instructions on page 15.

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

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

+--------------+--------------+--------------+--------------+---------+
| **Agency**   | **Su         | **Outreach   | **Fiscal/**  | **Total |
|              | pervisors/** | Wo           |              | FTE**   |
|              |              | rkers/Crisis | **Ad         |         |
|              | **Team       | Counselors** | ministrative |         |
|              | Leaders**    |              | Staff**      |         |
|              |              |              |              |         |
|              | **(Number of |              |              |         |
|              | Staff)**     |              |              |         |
+--------------+--------------+--------------+--------------+---------+
| Agency Name  | FTE          | FTE          | FTE          | FTE     |
+--------------+--------------+--------------+--------------+---------+
|              |              |              |              |         |
+--------------+--------------+--------------+--------------+---------+
|              |              |              |              |         |
+--------------+--------------+--------------+--------------+---------+
|              |              |              |              |         |
+--------------+--------------+--------------+--------------+---------+
|              |              |              |              |         |
+--------------+--------------+--------------+--------------+---------+
|              |              |              |              |         |
+--------------+--------------+--------------+--------------+---------+
|              |              |              |              |         |
+--------------+--------------+--------------+--------------+---------+
|              |              |              |              |         |
+--------------+--------------+--------------+--------------+---------+
|              |              |              |              |         |
+--------------+--------------+--------------+--------------+---------+
|              |              |              |              |         |
+--------------+--------------+--------------+--------------+---------+
|              |              |              |              |         |
+--------------+--------------+--------------+--------------+---------+
|              |              |              |              |         |
+--------------+--------------+--------------+--------------+---------+
|              |              |              |              |         |
+--------------+--------------+--------------+--------------+---------+
|              |              |              |              |         |
+--------------+--------------+--------------+--------------+---------+
|              |              |              |              |         |
+--------------+--------------+--------------+--------------+---------+

  -----------------------------------------------------------------------
  **C. Organizational Structure.** A simple organizational chart for the
  project is required for the Immediate Services application. An
  organizational chart may be inserted below, or a hand drawn chart may
  be attached to this document. Please indicate below if an
  organizational chart is attached.

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

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

  -----------------------------------------------------------------------
  **D. Job Descriptions.** In the space below, provide simple job
  descriptions (one paragraph) for each category of worker included in
  the project. (See page 16 of the supplemental instructions.) Optional
  job descriptions for the positions of Project Manager, Assistant
  Manager, Fiscal/Contracts Coordinator, and Crisis Counselors/Outreach
  Workers are available in the supplemental instructions and may be
  inserted here.

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

\[Insert job descriptions here\]

+-----------------------------------------------------------------------+
| **E. Brief Plan of Services.** The types of services typically funded |
| by the FEMA/CMHS Crisis Counseling Assistance and Training Program    |
| are outlined in the supplemental instructions (page 17) and in FEMA   |
| regulations and policies and in CMHS Program Guidance documents. In   |
| the space following, please provide a brief description of services   |
| to be provided. This description 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);                               |
|                                                                       |
| ```{=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; and                               |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Staff support mechanisms to be available.                         |
|                                                                       |
| For additional instructions on creating a plan of services, see pages |
| 16-18 of the supplemental instructions.                               |
+-----------------------------------------------------------------------+

\[Insert service plan here.\]

  -----------------------------------------------------------------------
  **F. Training.** Immediate Services 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. Using the check-off boxes and narrative spaces below, please
  provide information on the trainers and proposed training content for
  the project. For additional instructions on training, see pages 19-20
  of supplemental instructions.

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

**1. Selection of Trainers:**

-   Our State has professionals experienced in the FEMA/CMHS Crisis
    Counseling Program who can provide training on the Crisis Counseling
    model. The names, resumes, and contact information for the trainers
    are provided with this application:

> \[Insert trainers' names and contact information.\]

-   Our State is unable to identify an in-state resource for disaster
    mental health training. We request a referral for a crisis
    counseling trainer from CMHS/FEMA.

**2. Training Content:**

-   Our State will be using the training outline provided in the
    FEMA/CMHS *Training Manual for Mental Health and Human Services
    Workers in Major Disasters, 2^nd^ Edition.* Our State will be
    distributing FEMA/CMHS Program Guidance documents at the training.

```{=html}
<!-- -->
```
-   Our State will be using the attached training outline. (Attach the
    outline at the end of the application.)

3.  **Dates of Training:**

Projected dates for training activities are listed below:

\[Insert projected dates of training\]

**Part V. 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 21-23. Sample formats are provided on the following pages.      |
+-----------------------------------------------------------------------+

**Immediate Services Program**

**Summary of Costs for Entire Project**

Disaster Declaration Number: FEMA-XXXX-DR-STATE

+-----------+-------------+-------------+-------------+-------------+
| *         | **State     | **Service   | **Total     | **In-Kind   |
| *Budget** | Budget:**   | P           | Costs**     | Costs**     |
|           |             | rovider(s): |             |             |
| **C       | **Total     | Total       | of          | Costs       |
| ategory** | Estimate**  | Es          | Immediate   | **co        |
|           |             | timates\*** | services.   | ntributed** |
|           |             |             | Add State   | to the      |
|           |             | \*Note:     | and Service | project per |
|           |             | attach      | Provider    | agency.     |
|           |             | Budget per  | total       |             |
|           |             | service     | estimates.  |             |
|           |             | provider    |             |             |
|           |             | area        |             |             |
+-----------+-------------+-------------+-------------+-------------+
| **Dates   |             |             |             |             |
| of        |             |             |             |             |
| S         |             |             |             |             |
| ervices** |             |             |             |             |
+-----------+-------------+-------------+-------------+-------------+
| Salaries  |             |             |             |             |
| and Wages |             |             |             |             |
|           |             |             |             |             |
| Fringe    |             |             |             |             |
| Benefits  |             |             |             |             |
| (%)       |             |             |             |             |
|           |             |             |             |             |
| **Total   |             |             |             |             |
| Pe        |             |             |             |             |
| rsonnel** |             |             |             |             |
| **Costs** |             |             |             |             |
+-----------+-------------+-------------+-------------+-------------+
| **C       |             |             |             |             |
| onsultant |             |             |             |             |
| Costs**   |             |             |             |             |
+-----------+-------------+-------------+-------------+-------------+
| **Office  |             |             |             |             |
| S         |             |             |             |             |
| upplies** |             |             |             |             |
+-----------+-------------+-------------+-------------+-------------+
| *         |             |             |             |             |
| *Travel** |             |             |             |             |
+-----------+-------------+-------------+-------------+-------------+
| **T       |             |             |             |             |
| raining** |             |             |             |             |
+-----------+-------------+-------------+-------------+-------------+
| Med       |             |             |             |             |
| ia/Public |             |             |             |             |
| In        |             |             |             |             |
| formation |             |             |             |             |
| Costs     |             |             |             |             |
+-----------+-------------+-------------+-------------+-------------+
| **Total   |             |             |             |             |
| Costs**   |             |             |             |             |
+-----------+-------------+-------------+-------------+-------------+

**Immediate Services Program**

**Budget for State Mental Health Authority**

Disaster Declaration Number: FEMA-XXXX-DR-STATE

+-----------+-------------+--------------+--------------+-------------+
| *         | **Interim   | **Projected  | **Total      | **In-Kind   |
| *Budget** | Costs**     | Costs**      | Costs**      | Costs**     |
|           |             |              |              |             |
| **C       | Costs from  | Costs from   | Add interim  | Costs       |
| ategory** | the date of | the          | costs and    | **co        |
|           | incident to | Immediate    | projected    | ntributed** |
|           | the         | Services     | costs        | to the      |
|           | application |              |              | project per |
|           | deadline    | application  |              | agency.     |
|           | (14 days    | deadline     |              |             |
|           | following   |              |              |             |
|           | the         | to 60 days   |              |             |
|           | d           | or last day  |              |             |
|           | eclaration) | of program   |              |             |
+-----------+-------------+--------------+--------------+-------------+
| **Dates   |             |              |              |             |
| of        |             |              |              |             |
| S         |             |              |              |             |
| ervices** |             |              |              |             |
+-----------+-------------+--------------+--------------+-------------+
| Salaries  |             |              |              |             |
| and Wages |             |              |              |             |
|           |             |              |              |             |
| Fringe    |             |              |              |             |
| Benefits  |             |              |              |             |
| (%)       |             |              |              |             |
|           |             |              |              |             |
| **Total   |             |              |              |             |
| Personnel |             |              |              |             |
| Costs**   |             |              |              |             |
+-----------+-------------+--------------+--------------+-------------+
| **C       |             |              |              |             |
| onsultant |             |              |              |             |
| Costs**   |             |              |              |             |
+-----------+-------------+--------------+--------------+-------------+
| **Office  |             |              |              |             |
| S         |             |              |              |             |
| upplies** |             |              |              |             |
+-----------+-------------+--------------+--------------+-------------+
| *         |             |              |              |             |
| *Travel** |             |              |              |             |
+-----------+-------------+--------------+--------------+-------------+
| **T       |             |              |              |             |
| raining** |             |              |              |             |
+-----------+-------------+--------------+--------------+-------------+
| Med       |             |              |              |             |
| ia/Public |             |              |              |             |
| In        |             |              |              |             |
| formation |             |              |              |             |
| Costs     |             |              |              |             |
+-----------+-------------+--------------+--------------+-------------+
| **Total   |             |              |              |             |
| Costs**   |             |              |              |             |
+-----------+-------------+--------------+--------------+-------------+

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

**Immediate Services Program**

**Individual Service Provider Budgets**

Name of Service Provider:

+-----------+-------------+--------------+--------------+-------------+
| *         | **Interim   | **Projected  | **Total      | **In-Kind   |
| *Budget** | Costs**     | Costs**      | Costs**      | Costs**     |
|           |             |              |              |             |
| **C       | Costs from  | Costs from   | Add interim  | Costs       |
| ategory** | the date of | the          | costs and    | **co        |
|           | incident to | Immediate    | projected    | ntributed** |
|           | the         | Services     | costs        | to the      |
|           | application |              |              | project per |
|           | deadline    | application  |              | agency.     |
|           | (14 days    | deadline     |              |             |
|           | following   |              |              |             |
|           | the         | to 60 days   |              |             |
|           | d           | or last day  |              |             |
|           | eclaration) | of program   |              |             |
+-----------+-------------+--------------+--------------+-------------+
| **Dates   |             |              |              |             |
| of        |             |              |              |             |
| S         |             |              |              |             |
| ervices** |             |              |              |             |
+-----------+-------------+--------------+--------------+-------------+
| Salaries  |             |              |              |             |
| and Wages |             |              |              |             |
|           |             |              |              |             |
| Fringe    |             |              |              |             |
| Benefits  |             |              |              |             |
| (%)       |             |              |              |             |
|           |             |              |              |             |
| **Total   |             |              |              |             |
| Personnel |             |              |              |             |
| Costs**   |             |              |              |             |
+-----------+-------------+--------------+--------------+-------------+
| **C       |             |              |              |             |
| onsultant |             |              |              |             |
| Costs**   |             |              |              |             |
+-----------+-------------+--------------+--------------+-------------+
| **S       |             |              |              |             |
| upplies** |             |              |              |             |
+-----------+-------------+--------------+--------------+-------------+
| *         |             |              |              |             |
| *Travel** |             |              |              |             |
+-----------+-------------+--------------+--------------+-------------+
| **T       |             |              |              |             |
| raining** |             |              |              |             |
+-----------+-------------+--------------+--------------+-------------+
| Med       |             |              |              |             |
| ia/Public |             |              |              |             |
| In        |             |              |              |             |
| formation |             |              |              |             |
| Costs     |             |              |              |             |
+-----------+-------------+--------------+--------------+-------------+
| **Total   |             |              |              |             |
| Costs**   |             |              |              |             |
+-----------+-------------+--------------+--------------+-------------+

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

**Immediate 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 21-23 of the supplemental
instruction.) Please provide the following information:

1.  How were salary levels and fringe benefits 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, and 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.

[^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.