OMB Control Number: 1660-0085

Expiration Date: 12/31/2009

Crisis Counseling Assistance and Training Program

Immediate Services Program

Application

PAPERWORK BURDEN DISCLOSURE NOTICE, FEMA Form 90-146

Public reporting burden for this form is estimated to average 40 hours
per response. The burden estimate includes the time for reviewing
instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and submitting the data collection. You
are not required to respond to this collection of information unless a
valid OMB control number is displayed in the upper right corner of the
data collection instruments. Send comments regarding the accuracy of the
burden estimate and any suggestions for reducing the burden to:
Information Collections Management, Department of Homeland Security,
Federal Emergency Management Agency, 500 C Street, SW, Washington, DC
20472, Paperwork Reduction Project (1660-0085) NOTE: Do not send your
completed form to this address.

**Application Signature Note:** Fields marked with an \* are required.

  ------------------------------------------------------- ---------------
  **Federal Emergency Management Agency (FEMA) disaster   
  declaration number:**                                   

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

**Director, State Mental Health Authority (SMHA):** The following
individual is responsible for coordinating the mental health response to
this disaster. This person will also have oversight authority for the
application process for Federal funds to provide disaster-related mental
health services.

\*Name:

\*Title:

\*Agency:

\*Address:

\*Phone:

Fax:

E-Mail:

\* \*

**Date Signature, Director, SMHA**

+-----------------------------------------------------------------------+
| **Governor's Authorized Representative (GAR):** The GAR is the State  |
| official authorized to represent the Governor and apply for Crisis    |
| Counseling Assistance and Training Program (CCP) Immediate Services   |
| Program (ISP) funding.                                                |
|                                                                       |
| \*Name:                                                               |
|                                                                       |
| \*Title:                                                              |
|                                                                       |
| \*Agency:                                                             |
|                                                                       |
| \*Address:                                                            |
|                                                                       |
| \*Phone:                                                              |
|                                                                       |
| Fax:                                                                  |
|                                                                       |
| E-Mail:                                                               |
|                                                                       |
| **This application represents the Governor's agreement or             |
| certification of the following**:                                     |
|                                                                       |
| -   The requirements are beyond the State and local governments'      |
|     capabilities.                                                     |
|                                                                       |
| -   The program, if approved, will be implemented according to the    |
|     plan contained in the application approved by the FEMA Disaster   |
|     Recovery Manager (DRM).                                           |
|                                                                       |
| -   The Governor will maintain close coordination with and provide    |
|     reports to the FEMA regional director or the DRM as the delegate  |
|     of the regional director.                                         |
|                                                                       |
| -   The State's emergency plan, prepared under Title II of the        |
|     Stafford Act, will include mental health disaster planning.       |
|                                                                       |
| **\*The State requests \$ for immediate services.**                   |
|                                                                       |
| \* \*                                                                 |
|                                                                       |
| **Date** **Signature, GAR**                                           |
+-----------------------------------------------------------------------+

Attach Standard Form 424 Request for Federal Assistance (SF--424) and
Standard Form 424a Budget Information: Non-Construction Programs
(SF--424a) to the signature sheet.

**Note:** Throughout the ISP application, the terms "State" and "SMHA"
are intended to include all qualified applicants (i.e., States, U.S.
Territories, and federally recognized Tribes).

**Contact Information**

Preparer Information

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

  Prefix                         \*First                 Middle               \*Last                   
                                 Name                    Initial              Name                     

  \*Agency/Organization                                                                                
  Name:                                                                                                

  \*Address Line 1:                                                                                    

  Address Line 2:                                                                                      

  \*City:                                                          \*State:                   \*Zip:   

  \*Phone:                                                         Fax:                                

  E-Mail:                                                                                              
  ----------------------- ------ --------- --------- --- --------- ---------- -------- ------ -------- ---------------

\*Is the application preparer the point of contact? Yes No

Point of Contact Information

  -----------------------------------------------------------------------
  If the application preparer is not the point of contact, please
  complete the information below.

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

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

  Prefix                         \*First                 Middle                  \*Last                   
                                 Name                    Initial                 Name                     

  \*Agency/Organization                                                                                   
  Name:                                                                                                   

  \*Address Line 1:                                                                                       

  Address Line 2:                                                                                         

  \*City:                                                             \*State:                   \*Zip:   

  \*Phone:                                                            Fax:                                

  E-Mail:                                                                                                 
  ----------------------- ------ --------- --------- --- --------- -- ---------- -------- ------ -------- ---------------

**Alternate Point of Contact Information**

  -----------------------------------------------------------------------
  To add an alternate point of contact, please complete the information
  below.

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

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

  Prefix                       First                   Middle                Last                 
                               Name                    Initial               Name                 

  Agency/Organization                                                                             
  Name:                                                                                           

  Address Line 1:                                                                                 

  Address Line 2:                                                                                 

  City:                                                             State:                 Zip:   

  Phone:                                                            Fax:                          

  E-Mail:                                                                                         
  --------------------- ------ ------- --------- ----- --------- -- -------- ------ ------ ------ ---------------

**Part I. Geographic Areas and Initial Needs Assessment**

START: COPY AND PASTE SECTION FOR EACH DESIGNATED SERVICE AREA

**\*A. Center for Mental Health Services (CMHS) Needs Assessment
Formula---Estimated Crisis Counseling Needs**

  --------------------- --------- ----------------------- ----------------------- --
  **CMHS Needs                                                                    
  Assessment                                                                      
  Formula---Estimated                                                             
  Crisis Counseling                                                               
  Needs**                                                                         

  Disaster declaration            FEMA--XXXX--DR--State                           
  number:                                                                         

  This is an estimate                                                             
  for the following                                                               
  designated service                                                              
  area:                                                                           

  Date completed:                 Completed by (print                             
                                  name):                                          

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

+-----------------------------------------------------------------------+
| Complete a CMHS Needs Assessment Formula sheet for the entire program |
| service area and each designated area. To complete the sheet:         |
|                                                                       |
| 1.  Identify the number of people for each loss category from         |
|     collected needs assessment information.                           |
|                                                                       |
| 2.  Identify any disaster- or region-specific "other" loss            |
|     categories, and establish a traumatic impact risk ratio for any   |
|     other loss categories. Note that other loss categories are not    |
|     multiplied by the household size multiplier.                      |
|                                                                       |
| 3.  Determine the total people who would benefit from services for    |
|     each loss category by multiplying across each row as follows:     |
|     (number of people) X (household size multiplier) X (traumatic     |
|     impact risk ratio) = (total people who would benefit from         |
|     services).                                                        |
|                                                                       |
| 4.  Add all of the results in the column of total people who would    |
|     benefit from services to determine a sum for the number of people |
|     who would benefit from crisis counseling services.                |
+-----------------------------------------------------------------------+

+---------------+---------+---+----------+---+--------+---+----------------+
| **Loss        | **No.   |   | **H      |   | **Tra  |   | **Total People |
| Category**    | of      |   | ousehold |   | umatic |   | Who Would      |
|               | P       |   | Size     |   | Impact |   | Benefit from   |
|               | eople** |   | Multipl  |   | Risk   |   | Services**     |
|               |         |   | ier^2^** |   | Rati   |   |                |
|               |         |   |          |   | o^3^** |   |                |
|               |         |   | **(ANH = |   |        |   |                |
|               |         |   | 2.5)**   |   |        |   |                |
+---------------+---------+---+----------+---+--------+---+----------------+
| Dead          |         | * | ANH x 4  | * | 100%   | * |                |
|               |         | * |          | * |        | * |                |
|               |         | x |          | x |        | = |                |
|               |         | * |          | * |        | * |                |
|               |         | * |          | * |        | * |                |
+---------------+---------+---+----------+---+--------+---+----------------+
| Hospitalized  |         | * | ANH x 1  | * | 100%   | * |                |
|               |         | * |          | * |        | * |                |
|               |         | x |          | x |        | = |                |
|               |         | * |          | * |        | * |                |
|               |         | * |          | * |        | * |                |
+---------------+---------+---+----------+---+--------+---+----------------+
| No            |         | * | ANH x 1  | * | 50%    | * |                |
| nhospitalized |         | * |          | * |        | * |                |
| Injured       |         | x |          | x |        | = |                |
|               |         | * |          | * |        | * |                |
|               |         | * |          | * |        | * |                |
+---------------+---------+---+----------+---+--------+---+----------------+
| Homes         |         | * | ANH x 1  | * | 100%   | * |                |
| Destroyed     |         | * |          | * |        | * |                |
|               |         | x |          | x |        | = |                |
|               |         | * |          | * |        | * |                |
|               |         | * |          | * |        | * |                |
+---------------+---------+---+----------+---+--------+---+----------------+
| Homes Major   |         | * | ANH x 1  | * | 20%    | * |                |
| Damage        |         | * |          | * |        | * |                |
|               |         | x |          | x |        | = |                |
|               |         | * |          | * |        | * |                |
|               |         | * |          | * |        | * |                |
+---------------+---------+---+----------+---+--------+---+----------------+
| Homes Minor   |         | * | ANH x 1  | * | 10%    | * |                |
| Damage        |         | * |          | * |        | * |                |
|               |         | x |          | x |        | = |                |
|               |         | * |          | * |        | * |                |
|               |         | * |          | * |        | * |                |
+---------------+---------+---+----------+---+--------+---+----------------+
| Disaster      |         | * | ANH x 1  | * | 10%    | * |                |
| Unemployed    |         | * |          | * |        | * |                |
|               |         | x |          | x |        | = |                |
|               |         | * |          | * |        | * |                |
|               |         | * |          | * |        | * |                |
+---------------+---------+---+----------+---+--------+---+----------------+
| Other 1       |         |   |          | * |        | * |                |
| (Specify)^1^  |         |   |          | * |        | * |                |
|               |         |   |          | x |        | = |                |
|               |         |   |          | * |        | * |                |
|               |         |   |          | * |        | * |                |
+---------------+---------+---+----------+---+--------+---+----------------+
| Other 2       |         |   |          | * |        | * |                |
| (Specify)^1^  |         |   |          | * |        | * |                |
|               |         |   |          | x |        | = |                |
|               |         |   |          | * |        | * |                |
|               |         |   |          | * |        | * |                |
+---------------+---------+---+----------+---+--------+---+----------------+
|               |         |   |          |   | **TO   | * |                |
|               |         |   |          |   | TAL:** | * |                |
|               |         |   |          |   |        | = |                |
|               |         |   |          |   |        | * |                |
|               |         |   |          |   |        | * |                |
+---------------+---------+---+----------+---+--------+---+----------------+

^1^If appropriate, the State may identify other loss category groups
related to the disaster. These categories are not multiplied by a
household size multiplier. The State should also identify a traumatic
impact risk ratio for each additional loss category specified. Add rows
as necessary.

^2^Household size multiplier means the average number of people per
household (ANH). The national average is 2.5, but applicants should
consult U.S. Census information for State or county averages.

^3^The traumatic impact risk ratio assesses the likelihood of individual
and community adverse reactions to this disaster. In previous versions
of this application, the term "at-risk multiplier" was used.

\*Provide a brief narrative description of the disaster event and its
impact on individuals and communities.

\*Identify the sources of data for the number of people identified in
each loss category. If FEMA preliminary damage assessment data have not
been collected for this disaster, or were not used in specifying the
number of people for each category, please clearly identify alternate
sources of data used (e.g., American Red Cross, State Emergency
Management Agency, media reports).

\*Describe any special circumstances not captured in the CMHS Needs
Assessment Formula that will affect the need for crisis counseling
services.

\*Specify any high-risk groups or populations of special concern
identified through the State's initial needs assessment process (e.g.,
children, adolescents, older adults, ethnic and cultural groups, lower
income populations).

If "other" categories were added to the CMHS Needs Assessment Formula
table, please describe the rationale for including these loss categories
and how the Traumatic Impact Risk Ratios were determined.

Additional comments, if any:

END: COPY AND PASTE SECTION FOR EACH DESIGNATED SERVICE AREA

**\***B. Geographic Areas and Initial Needs Assessment

+-----------------------------------------------------------------------+
| 1\. Complete a CMHS Needs Assessment Formula sheet (see part I.A.)    |
| for each designated service area.                                     |
|                                                                       |
| 2\. Using the information from each CMHS Needs Assessment Formula     |
| sheet, fill in the two columns of the following chart.                |
+-----------------------------------------------------------------------+

+----------------------------------+-----------------------------------+
| **Designated Service Area**      | **Total People Who Would Benefit  |
|                                  | from Services**                   |
+----------------------------------+-----------------------------------+
|                                  |                                   |
+----------------------------------+-----------------------------------+
|                                  |                                   |
+----------------------------------+-----------------------------------+
|                                  |                                   |
+----------------------------------+-----------------------------------+
|                                  |                                   |
+----------------------------------+-----------------------------------+
|                                  |                                   |
+----------------------------------+-----------------------------------+
|                                  |                                   |
+----------------------------------+-----------------------------------+
|                                  |                                   |
+----------------------------------+-----------------------------------+
| > **TOTAL:**                     |                                   |
+----------------------------------+-----------------------------------+

Additional comments, if any:

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

\*Describe State and local crisis counseling activities from the date of
the incident to the date of application. Enter "none" if no activities
have been conducted to date.

Explain the cause of any delays.

\*Explain any measures taken to ensure immediate services will be
implemented.

Additional comments, if any:

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

\*Describe State and local mental health systems and the clients they
serve. Explain why these resources cannot meet the disaster-related
mental health needs.

\*Does the SMHA set aside funds for disaster programs? Explain how funds
are set aside.

\*Are crisis counseling services beyond the SMHA's and local providers'
scope of services?

If the State has existing resources that can be used for disaster mental
health services, describe these resources. These resources should be
outlined as in-kind contributions in the program plan.

Additional comments, if any:

**Part IV. Staffing and Plan of Services**

**\*A. Staffing and Plan of Services---**Summary

+-----------------------------------------------------------------------+
| 1\. Complete a staffing plan sheet (see Part IV.C. Service Providers) |
| for the SMHA and for each service provider.                           |
|                                                                       |
| 2\. Fill in the following table with full-time equivalent (FTE)       |
| totals from the staffing plan sheets.                                 |
|                                                                       |
| 3\. Identify the designated service areas that each provider will     |
| serve.                                                                |
|                                                                       |
| **Note:** Project totals in this table should equal the total         |
| identified in Part I.B. Geographic Areas and Initial Needs            |
| Assessment.                                                           |
+-----------------------------------------------------------------------+

  ---------------- ------------------ ---------- ------------- -------------------
                                      **FTEs**                 

  **Service        **Total People Who **Grant    **Projected   **Designated
  Provider Name**  Would Benefit from Funded**   In Kind**     Service Areas**
                   Services**                                  

  State                                                        

  Service Provider                                             
  1                                                            

  Service Provider                                             
  2                                                            

  Service Provider                                             
  3                                                            

  Service Provider                                             
  4                                                            

  Service Provider                                             
  5                                                            

  **TOTAL:**                                                   
  ---------------- ------------------ ---------- ------------- -------------------

+-----------------------------------------------------------------------+
| In the spaces below, all applicants should do the following:          |
|                                                                       |
| -   Attach an organizational chart. This chart must include the       |
|     program management, fiscal, administrative, data/evaluation, and  |
|     all direct and support services staff positions at the State and  |
|     provider levels. The staff positions and FTEs in the              |
|     organizational chart should correspond with the information       |
|     included in the staffing plan sheets.                             |
|                                                                       |
| -   Describe the organizational structure.                            |
+-----------------------------------------------------------------------+

\*Attach an organizational chart for this project.

\*Describe the rationale for determining the number of FTEs for the
program based on the total people who would benefit from services.

\*Provide a brief description of the organizational and supervisory plan
for the program.

Additional comments, if any:

**\*B. Program Management**

  -----------------------------------------------------------------------
  The following section should be used by the State to describe the
  SMHA's overall plan for program administration, monitoring, and
  oversight.

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

\*Describe the State's plan for administrative oversight of the entire
program.

\*Describe the State's plan for monitoring fiscal activity and fiscal
accountability. Include financial documentation procedures.

\*Describe the State's plan for quality control methods to ensure
appropriate services reach disaster survivors.

Evaluation activities must be consistent with the guidelines provided by
FEMA and CMHS. Data should be collected using the data collection tools
approved by the Office of Management and Budget (OMB) and contained in
*Evaluating and Monitoring the Reach, Quality, and Consistency of Crisis
Counseling Programs Manual and Toolkit* included with the application
materials packet sent to States from the Substance Abuse and Mental
Health Services Administration (SAMHSA) Disaster Technical Assistance
Center (DTAC).

\* By checking the box, the State agrees to use the OMB-approved data
collection tools and conduct evaluation activities consistent with FEMA
and CMHS guidelines.

Describe and justify any additional process or program evaluation that
may be conducted during the ISP.

If an evaluation consultant will be used for other evaluation
activities, explain why this consultant was selected and attach a résumé
to the application.

\*Will the State be providing, in addition to oversight, direct crisis
counseling services to survivors? Yes No

If yes, the State must complete part IV.C.1--4, detailing information
concerning the direct services to be provided.

Additional comments, if any:

START: COPY AND PASTE SECTION FOR EACH SERVICE PROVIDER

**\*C. Service Providers**

**Note:** Part IV.C.1--4 should be completed for each service provider.
The SMHA also should complete these sections for itself if State
personnel will be directly providing crisis counseling services to
survivors in addition to carrying out their administrative oversight
role.

**\*1. Contact Information**

  -----------------------------------------------------------------------
  Please provide information on each service provider and the project
  manager point of contact for the provider.

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

Service Provider

  ----------------------- ------ -- ------- ------------ ---------- --------- -------- --------------
  \*Agency/Organization                                                                
  Name:                                                                                

  \*Address Line 1:                                                                    

  Address Line 2:                                                                      

  \*City:                                                \*State:             \*Zip:   

  \*Phone:                                               Fax:                          

  E-Mail:                                                                              

  Director's Name:                                                                     
  ----------------------- ------ -- ------- ------------ ---------- --------- -------- --------------

**CCP Provider Contact/Manager**

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

  Prefix                         \*First                 Middle                  \*Last                      
                                 Name                    Initial                 Name                        

  \*Agency/Organization                                                                                      
  Name:                                                                                                      

  \*Address Line 1:                                                                                          

  Address Line 2:                                                                                            

  \*City:                                                             \*State:                      \*Zip:   

  \*Phone:                                                            Fax:                                   

  E-Mail:                                                                                                    
  ----------------------- ------ --------- --------- --- --------- -- ---------- -------- --------- -------- --------------

**\*2. Service Providers: Estimated Service Targets**

The total number of people who would benefit from services for each
designated service area was identified in Part I.B. Geographic Areas and
Initial Needs Assessment of the ISP application. These figures should be
included in the total provider service targets in the following table.

The provider should then identify how many people its organization
proposes to serve in each designated service area. If one provider is
serving the entire designated service area, the total estimated service
targets will equal the number of provider estimated service targets. If
more than one provider is serving a designated service area, the State
will need to establish service targets for each provider to minimize
duplication of service or gaps in service. Fill out the following chart
for each provider.

+---------------+--------------------------+--------------------------+
| **Designated  | **Total People Who Would | **Provider Service       |
| Service Area  | Benefit from Services**  | Targets**                |
| Name**        |                          |                          |
|               |                          | **(total people targeted |
|               |                          | for services)**          |
+---------------+--------------------------+--------------------------+
|               |                          |                          |
+---------------+--------------------------+--------------------------+
|               |                          |                          |
+---------------+--------------------------+--------------------------+
|               |                          |                          |
+---------------+--------------------------+--------------------------+
| **TOTAL:**    |                          |                          |
+---------------+--------------------------+--------------------------+

**\*3. Service Providers: Staffing Plan**

  ------------- ----- --- ----------------------- ------------------------ --
  **Service                                                                
  Provider                                                                 
  Staffing                                                                 
  Plan**                                                                   

  Disaster                FEMA--XXXX--DR--State                            
  declaration                                                              
  number:                                                                  

  Service                                                                  
  provider                                                                 
  name:                                                                    

  This is an                                                               
  estimate for                                                             
  the following                                                            
  designated                                                               
  service                                                                  
  areas:                                                                   

  Date                    Completed by (print                              
  completed:              name):                                           
  ------------- ----- --- ----------------------- ------------------------ --

  ------------------- ------------ ------------ ------------- ------------
                      **Grant                   **Projected   
                      Funded**                  In Kind**     

  **Type of Staff**   **No. of     **No. of     **No. of      **No. of
                      Staff**      FTEs (based  Staff**       FTEs (based
                                   on 40 hours                on 40 hours
                                   per week)**                per week)**

  State CCP Program                                           
  Manager/Director                                            

  Provider Project                                            
  Manager                                                     

  Team Leader                                                 

  Crisis Counselor                                            

  Fiscal Coordinator                                          

  Administrative                                              
  Assistant/ Data                                             
  Entry Clerk                                                 

  Evaluation                                                  
  Coordinator                                                 

  Other 1 (Specify)                                           

  Other 2 (Specify)                                           

  **TOTAL:**                                                  
  ------------------- ------------ ------------ ------------- ------------

\*Provide a brief job description (one paragraph) for each staff
position included in the program. Sample job descriptions for typical
positions are available in the ISP Supplemental Instructions and may be
modified and inserted here.

**\*4**. Service Providers: CCP Services Provided

  -----------------------------------------------------------------------
  Select the types of services furnished by the service provider.

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

**\*Primary services provided:**

Brief educational or supportive contact

Individual crisis counseling

Group crisis counseling

Public education

Assessment, referral, and resource linkage

Community networking/support

**\*Secondary services provided:**

Distribution of educational materials

Media and public service announcements

\*Where and how will staff be deployed to provide identified types of
services?

\*What strategies are in place for targeting those identified as in need
of services? Include any special population groups that are identified
in the needs assessment.

\*Describe the staff support mechanisms that will be available.

Additional comments, if any:

END: COPY AND PASTE SECTION FOR EACH SERVICE PROVIDER

**D**. Consultants (Excluding Trainers)

  -----------------------------------------------------------------------
  Please provide a list of consultants you intend to use. Complete a
  consultant information sheet for each consultant. Do not include any
  trainers.

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

**\***Consultants

  ---------------------- --------------------------------- --------------
  **Consultant Name**    **Agency/Organization**           **Phone**

  Consultant 1                                             

  Consultant 2                                             

  Consultant 3                                             
  ---------------------- --------------------------------- --------------

Additional comments, if any:

Consultant Information

  -----------------------------------------------------------------------
  Please provide the following information. If the consultant is
  self-employed, enter his or her name in the agency/organization field
  in addition to the name fields. The address of the consultant should be
  the address of the agency/organization applying for FEMA funds. Résumés
  are required for all consultants.

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

**Consultant**

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

  Prefix                         \*First                       Middle                  \*Last                    
                                 Name                          Initial                 Name                      

  \*Agency/Organization                                                                                          
  Name:                                                                                                          

  \*Address Line 1:                                                                                              

  Address Line 2:                                                                                                

  \*City:                                                                   \*State:                    \*Zip:   

  \*Phone:                                                                  Fax:                                 

  E-Mail:                                                                                                        
  ----------------------- ------ --------- ----- --------- --- --------- -- ---------- -------- ------- -------- ---------------

Types of Services Provided:

**\*E. Training**

  -----------------------------------------------------------------------
  **Note:** Enter only people who are trainers; list consultants in the
  previous section. All program staff must receive training in the FEMA
  crisis counseling requirements.

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

\*Does the State have trainers experienced in the CCP who can provide
training on the CCP model?

Yes No

-   If yes, list these trainers in the table below.

-   If no, contact SAMHSA DTAC for technical assistance or referrals for
    approved trainers (SAMHSA DTAC: 1-800-308-3515, dtac@esi-dc.com).
    The approved trainers must then be listed in the table below.

**\***Trainers

  ------------------ ------------------------- ----------- --------------
  **Trainer Name**   **Agency/Organization**   **Phone**   **FEMA/CMHS
                                                           Approved?**

  Trainer 1                                                

  Trainer 2                                                

  Trainer 3                                                
  ------------------ ------------------------- ----------- --------------

**\***Training Schedule

  ------------------------- ---------- ------------------ -----------------
  **Type of Training**      **Date**   **Trainer**        **Location**

  ^1^Core Content Training                                

  Other:                                                  
  ------------------------- ---------- ------------------ -----------------

^1^The Core Content Training is a mandatory training.

Attach résumés for any proposed trainers who have not been FEMA/CMHS
approved.

Describe and justify other trainings to be offered.

Additional comments, if any:

**\*F. Facilities**

\*Explain whether office space is being provided as an in-kind
contribution to the project by the State or service providers.

If space will be leased for the CCP, explain why this is necessary.

Additional comments, if any:

**Part V**. Budget

+-----------------------------------------------------------------------+
| The budget must be integrated with the needs assessment and the       |
| program plan. A separate budget must be provided for the SMHA and     |
| each service provider. A line-item budget narrative justifying costs  |
| is required for both State and service provider budgets.              |
|                                                                       |
| -   **Note that SF--424a is a required form and represents the total  |
|     budget for the program**.                                         |
|                                                                       |
| -   The applicant should review the detailed guidance on budgeting in |
|     the ISP Supplemental Instructions and the *Crisis Counseling      |
|     Assistance and Training Program Guidance.*                        |
+-----------------------------------------------------------------------+

**\*A. State Budget**

  ---------------------- --------------------------------------------- --
  **ISP Budget Summary                                                 
  for the SMHA**                                                       

  Disaster declaration   FEMA--XXXX--DR--State                         
  number:                                                              
  ---------------------- --------------------------------------------- --

+--------------------+------------+------------+-----------+----------+
| **Budget Line      | **Interim  | *          | **Total   | *        |
| Item**             | Costs      | *Projected | Costs**   | *In-Kind |
|                    | (costs     | Costs      |           | Costs**  |
|                    | incurred   | (costs     | **(add    |          |
|                    | from date  | from the   | interim   | **(costs |
|                    | of         | immediate  | and       | con      |
|                    | incident   | services   | projected | tributed |
|                    | to the     | a          | costs)**  | to the   |
|                    | a          | pplication |           | project  |
|                    | pplication | deadline   |           | per      |
|                    | dea        | to 60 days |           | a        |
|                    | dline---14 | or last    |           | gency)** |
|                    | days       | day of     |           |          |
|                    | following  | program)** |           |          |
|                    | the        |            |           |          |
|                    | decl       |            |           |          |
|                    | aration)** |            |           |          |
+====================+============+============+===========+==========+
| **Dates of         |            |            |           |          |
| Service**          |            |            |           |          |
+--------------------+------------+------------+-----------+----------+
| Salaries and Wages |            |            |           |          |
| **(a.)^1^**        |            |            |           |          |
+--------------------+------------+------------+-----------+----------+
| Fringe %           |            |            |           |          |
| **(b.)**^1^        |            |            |           |          |
+--------------------+------------+------------+-----------+----------+
| Subtotal Personnel |            |            |           |          |
| Costs              |            |            |           |          |
+--------------------+------------+------------+-----------+----------+
| Travel **(c.)**^1^ |            |            |           |          |
+--------------------+------------+------------+-----------+----------+
| Equipment          |            |            |           |          |
| **(d.)**^1^        |            |            |           |          |
+--------------------+------------+------------+-----------+----------+
| Supplies           |            |            |           |          |
| **(e.)**^1^        |            |            |           |          |
+--------------------+------------+------------+-----------+----------+
| Contractual        |            |            |           |          |
| Consultant/Trainer |            |            |           |          |
| Costs              |            |            |           |          |
+--------------------+------------+------------+-----------+----------+
| Contractual        |            |            |           |          |
| Media/Public       |            |            |           |          |
| Information Costs  |            |            |           |          |
+--------------------+------------+------------+-----------+----------+
| Other Contractual  |            |            |           |          |
| Costs              |            |            |           |          |
+--------------------+------------+------------+-----------+----------+
| Subtotal           |            |            |           |          |
| Contractual Costs  |            |            |           |          |
| **(f.)**^1^        |            |            |           |          |
+--------------------+------------+------------+-----------+----------+
| Other Direct State |            |            |           |          |
| Costs **(h.)**^1^  |            |            |           |          |
+--------------------+------------+------------+-----------+----------+
| **Total            |            |            |           |          |
| Contractual and    |            |            |           |          |
| Direct Costs:**    |            |            |           |          |
+--------------------+------------+------------+-----------+----------+
| ^1^Letters in      |            |            |           |          |
| parentheses        |            |            |           |          |
| indicate the       |            |            |           |          |
| corresponding      |            |            |           |          |
| budget category on |            |            |           |          |
| the SF--424a.      |            |            |           |          |
+--------------------+------------+------------+-----------+----------+

In the following table, include a detailed line-item narrative
justifying costs. Please review the detailed guidance on the budget
narrative included in the ISP Supplemental Instructions and the *Crisis
Counseling Assistance and Training Program Guidance.*

  ------------------ ---- ------------------------------------------------
  **ISP Line-Item         
  Budget Narrative        
  for the SMHA**          

  Disaster                FEMA--XXXX--DR--State
  declaration             
  number:                 

  Period of               
  performance:            
  ------------------ ---- ------------------------------------------------

  ------------------------ -------------------- ---------------------------- --------- ----------- ----------- --- ---------- -- -----
  **Budget\                **Item Description**                              **Total                                             
  Line\                                                                      Cost**                                              
  Item**                                                                                                                         

  **[Direct                                                                                                                      
  Costs]{.smallcaps}**                                                                                                           

  **Direct Personnel                                                         **No. of  **Hours**   **Weeks**       **Rate**      
  Costs**                                                                    FTE**                                               

  Salaries and Wages       (Itemize position                                                                                     
                           titles from part                                                                                      
                           IV.C.3. here. Add                                                                                     
                           rows as needed.)                                                                                      

                                                                                                                                 

  *Subtotal Salaries and                                                                                                         
  Wages*                                                                                                                         

  Fringe                                                                     \%                                                  

  *Subtotal Direct                                                                                                               
  Personnel Costs*                                                                                                               

  **Direct Travel Costs **                                                             **Miles**   **Weeks**       **Rate**      

                           (Itemize travel                                                                                       
                           types here; include                                                                                   
                           estimated mileage                                                                                     
                           rate, air, lodging,                                                                                   
                           and per diem costs                                                                                    
                           incurred directly by                                                                                  
                           the State. Do not                                                                                     
                           include                                                                                               
                           consultant/trainer                                                                                    
                           travel costs. Add                                                                                     
                           rows as needed.)                                                                                      

                                                                                                                                 

  *Subtotal Direct Travel                                                                                                        
  Costs*                                                                                                                         

  **Direct Equipment                                                                               **Unit          **No.**       
  Costs **                                                                                         Cost**                        

                           (Itemize equipment                                                                                    
                           costs here.                                                                                           
                           Individual expenses                                                                                   
                           under \$5,000 must                                                                                    
                           be listed under                                                                                       
                           supplies. Add rows                                                                                    
                           as needed.)                                                                                           

                                                                                                                                 

  *Subtotal Direct                                                                                                               
  Personnel Costs*                                                                                                               

  **Direct Supplies                                                                                **Unit          **No.**       
  Costs **                                                                                         Cost**                        

                           (Itemize supply                                                                                       
                           costs here. Add rows                                                                                  
                           as needed.)                                                                                           

                                                                                                                                 

  *Subtotal Direct                                                                                                               
  Personnel Costs*                                                                                                               

  ***Subtotal Direct                                                                                                             
  Costs***                                                                                                                       

  **[Contractual                                                                                                                 
  Costs]{.smallcaps}**                                                                                                           

  **Contractual                                                                                    **Daily         **No. of      
  Consultant/Trainer                                                                               Rate**          Days**        
  Costs**                                                                                                                        

  **Rates**                (Itemize contractual                                                                                  
                           consultant/trainer                                                                                    
                           costs here. Add rows                                                                                  
                           as needed.)                                                                                           

                                                                                                                                 

  **Travel**               (Itemize                                                                                              
                           consultant/trainer                                                                                    
                           travel costs here.                                                                                    
                           Add rows as needed.)                                                                                  

                                                                                                                                 

  *Subtotal Contractual                                                                                                          
  Consultant/Trainer                                                                                                             
  Costs*                                                                                                                         

  **Contractual                                                                                                                  
  Media/Public Information                                                                                                       
  Costs**                                                                                                                        

                           (Itemize contractual                                                                                  
                           media and public                                                                                      
                           information costs                                                                                     
                           here. Add rows as                                                                                     
                           needed.)                                                                                              

                                                                                                                                 

  *Subtotal Contractual                                                                                                          
  Media/Public Information                                                                                                       
  Costs*                                                                                                                         

  **Other Contractual                                                                                                            
  Costs**                                                                                                                        

                           (Itemize other                                                                                        
                           contractual costs                                                                                     
                           here. Add rows as                                                                                     
                           needed.)                                                                                              

                                                                                                                                 

  *Subtotal Other                                                                                                                
  Contractual Costs*                                                                                                             

  ***Subtotal Contractual                                                                                                        
  Costs***                                                                                                                       

  **[Other Direct                                                                                                                
  Costs]{.smallcaps}**                                                                                                           

  **Other Direct State                                                                                                           
  Costs**                                                                                                                        

                           (Itemize other                                                                                        
                           direct State costs                                                                                    
                           here. Add rows as                                                                                     
                           needed.)                                                                                              

                                                                                                                                 

  ***Subtotal Other Direct                                                                                                       
  State Costs***                                                                                                                 

  ***[Total Contractual                                                                                                          
  and Direct                                                                                                                     
  Costs:]{.smallcaps}***                                                                                                         
  ------------------------ -------------------- ---------------------------- --------- ----------- ----------- --- ---------- -- -----

START: COPY AND PASTE SECTION FOR EACH SERVICE PROVIDER

**\*B. Individual Provider Budgets**

Complete an Individual Service Provider Budget for each service
provider.

<table>
<colgroup>
<col style="width: 13%" />
<col style="width: 9%" />
<col style="width: 7%" />
<col style="width: 1%" />
<col style="width: 16%" />
<col style="width: 3%" />
<col style="width: 15%" />
<col style="width: 17%" />
<col style="width: 11%" />
<col style="width: 3%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="10"><strong>ISP Individual Service Provider Budget
Summary</strong></td>
</tr>
<tr class="even">
<td colspan="3">Name of service provider:</td>
<td colspan="6"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4">Disaster declaration number:</td>
<td colspan="5">FEMA–XXXX–DR–State</td>
<td></td>
</tr>
<tr class="even">
<td colspan="2">Designated areas:</td>
<td colspan="7"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="6">Total people who would benefit from services:</td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td>Total FTE:</td>
<td colspan="8"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="7"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="3"><strong>Budget Line Item</strong></td>
<td colspan="2"><p><strong>Interim Costs</strong></p>
<p><strong>(costs incurred from date of incident to the application
deadline—14 days following the declaration)</strong></p></td>
<td colspan="2"><strong>Projected Costs (costs from the immediate
services application deadline to 60 days or last day of
program)</strong></td>
<td><p><strong>Total Costs</strong></p>
<p><strong>(add interim and projected costs)</strong></p></td>
<td colspan="2"><p><strong>In-Kind Costs</strong></p>
<p><strong>(costs contributed to the project per
agency)</strong></p></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>Dates of Service</strong></td>
<td colspan="2"> </td>
<td colspan="2"> </td>
<td> </td>
<td colspan="2"> </td>
</tr>
<tr class="even">
<td colspan="3">Salaries and Wages</td>
<td colspan="2"> </td>
<td colspan="2"> </td>
<td></td>
<td colspan="2"> </td>
</tr>
<tr class="odd">
<td colspan="3">Fringe %</td>
<td colspan="2"> </td>
<td colspan="2"> </td>
<td></td>
<td colspan="2"> </td>
</tr>
<tr class="even">
<td colspan="3">Subtotal Personnel Costs</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="3">Travel</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="3">Equipment</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="3">Supplies</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="3">Consultant/Trainer Costs</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="3">Media/Public Information Costs</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="3">Other Service Provider Costs</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>Total Provider Costs
(f.)<sup>1</sup>:</strong></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="10"><sup>1</sup>Letters in parentheses indicate the
corresponding budget category on the SF–424a.</td>
</tr>
</tbody>
</table>

\*In the following table, include a detailed line-item narrative
justifying costs. Complete a line-item narrative for each service
provider. Please review the detailed guidance on the budget narrative
included in the ISP Supplemental Instructions and the *Crisis Counseling
Assistance and Training Program Guidance.*

<table style="width:100%;">
<colgroup>
<col style="width: 13%" />
<col style="width: 0%" />
<col style="width: 8%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 20%" />
<col style="width: 9%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 7%" />
<col style="width: 8%" />
<col style="width: 7%" />
<col style="width: 4%" />
<col style="width: 4%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="15"><strong>ISP Line-Item Budget Narrative for the
Individual Service Provider</strong></td>
</tr>
<tr class="even">
<td colspan="6">Disaster declaration number:</td>
<td colspan="8">FEMA–XXXX–DR–State</td>
<td></td>
</tr>
<tr class="odd">
<td colspan="6">Name of service provider:</td>
<td colspan="8"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="3">Designated areas:</td>
<td colspan="11"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="7">Total people who would benefit from services:</td>
<td colspan="7"></td>
<td></td>
</tr>
<tr class="even">
<td>Total FTE:</td>
<td colspan="13"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4">Period of performance:</td>
<td colspan="10"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td colspan="4"></td>
<td colspan="6"></td>
</tr>
<tr class="odd">
<td colspan="2"><strong>Budget Line Item</strong></td>
<td colspan="6"><strong>Item Description</strong></td>
<td colspan="5"></td>
<td colspan="2"><strong>Total Cost</strong></td>
</tr>
<tr class="even">
<td colspan="15"><strong><span class="smallcaps">Provider
Costs</span></strong></td>
</tr>
<tr class="odd">
<td colspan="8"><strong>Personnel Costs</strong></td>
<td colspan="2"><strong>No. of FTE</strong></td>
<td><strong>Hours</strong></td>
<td><strong>Weeks</strong></td>
<td><strong>Rate</strong></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2" rowspan="2">Salaries and Wages</td>
<td colspan="6">(Itemize position titles from part IV.C.3. here. Add
rows as needed.)</td>
<td colspan="2"> </td>
<td> </td>
<td> </td>
<td> </td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="6"> </td>
<td colspan="2"> </td>
<td> </td>
<td> </td>
<td> </td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="13"><em>Subtotal Salaries and Wages</em> </td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2">Fringe</td>
<td colspan="9"> </td>
<td>%</td>
<td> </td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="13"><em>Subtotal Personnel Costs</em>  </td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="10"><strong>Travel Costs </strong></td>
<td><strong>Miles</strong></td>
<td><strong>Weeks</strong></td>
<td><strong>Rate</strong></td>
<td colspan="2"><strong> </strong></td>
</tr>
<tr class="even">
<td colspan="2" rowspan="2"> </td>
<td colspan="8">(Itemize travel types here; include estimated mileage
rate, air, lodging, and per diem costs incurred directly by the State.
Do not include consultant/trainer travel costs. Add rows as
needed.)</td>
<td> </td>
<td> </td>
<td> </td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="8"> </td>
<td> </td>
<td> </td>
<td> </td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="13"><em>Subtotal Travel Costs</em> </td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>Equipment Costs </strong></td>
<td><strong>Unit Cost</strong></td>
<td><strong>No.</strong></td>
<td colspan="2"><strong> </strong></td>
</tr>
<tr class="even">
<td colspan="2" rowspan="2"><p> </p>
<p> </p></td>
<td colspan="9">(Itemize equipment costs here. Individual expenses under
$5,000 must be listed under supplies. Add rows as needed.)</td>
<td></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="9"> </td>
<td></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="13"><em>Subtotal Equipment Costs</em></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>Supplies Costs </strong></td>
<td><strong>Unit Cost</strong></td>
<td><strong>No.</strong></td>
<td colspan="2"><strong> </strong></td>
</tr>
<tr class="even">
<td colspan="2" rowspan="2"><p> </p>
<p> </p></td>
<td colspan="9">(Itemize supply costs here. Add rows as needed.)</td>
<td> </td>
<td> </td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="9"> </td>
<td> </td>
<td> </td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="13"><em>Subtotal Supplies Costs</em> </td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>Consultant/Trainer Costs</strong></td>
<td><strong>Daily Rate</strong></td>
<td><strong>No. of Days</strong></td>
<td colspan="2"><strong> </strong></td>
</tr>
<tr class="even">
<td colspan="2" rowspan="2"> Rates</td>
<td colspan="9">(Itemize contractual consultant/trainer costs here. Add
rows as needed.)</td>
<td> </td>
<td> </td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="9"> </td>
<td> </td>
<td> </td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2" rowspan="2">Travel </td>
<td colspan="9">(Itemize consultant/trainer travel costs here. Add rows
as needed.)</td>
<td colspan="2"> </td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="9"> </td>
<td colspan="2"> </td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="13"><em>Subtotal Contractual Consultant/Trainer
Costs</em></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="15"><strong>Media/Public Information Costs</strong></td>
</tr>
<tr class="even">
<td colspan="2" rowspan="2"><p> </p>
<p> </p></td>
<td colspan="11">(Itemize contractual media and public information costs
here. Add rows as needed.)</td>
<td colspan="2"> </td>
</tr>
<tr class="odd">
<td colspan="11"> </td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="13"><em>Subtotal Contractual Media/Public Information
Costs</em></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="15"><strong>Other Service Provider Costs  </strong></td>
</tr>
<tr class="even">
<td colspan="2" rowspan="2"><p> </p>
<p> </p></td>
<td colspan="11">(Itemize other service provider costs here. Add rows as
needed.)</td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="11"> </td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="13"><em>Subtotal Other Service Provider Costs </em></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="13"><em><strong><span class="smallcaps">Total Provider
Costs:</span></strong></em></td>
<td colspan="2"></td>
</tr>
</tbody>
</table>

END: COPY AND PASTE SECTION FOR EACH SERVICE PROVIDER