PART II: RESPONSE ACTIVITIES FROM DATE OF INCIDENT

PAPERWORK BURDEN DISCLOSURE NOTICE

PRIVACY ACT STATEMENT

PART I: GENERAL APPLICATION INFORMATION

Public reporting burden for this form is estimated to average 20 hours per response. The burden estimate includes the time for reviewing instructions, 

searching existing data sources, gathering and maintaining the needed data, and completing, reviewing, and submitting the form. You are not required to 

respond to this collection of information unless a valid OMB control number appears in the upper right corner of this form. Send comments regarding the 

accuracy of the burden estimate and any suggestions for reducing this burden to: Information Collections Management, Department of Homeland Security, 

Federal Emergency Management Agency, 500 C Street, SW, Washington, DC, 20472, Paperwork Reduction Project (1660-0100). NOTE: Do not send 

your completed form to the above address.

GENERAL: The information on this form may be disclosed as generally permitted under 5 U.S.C. § 552a (b) of the Privacy Act of 1974, as amended. This 

includes using this information as necessary and authorized by the routine uses published in DHS/FEMA - 004 Grant Management Information Files System 

of Records, 74 Fed. Reg. 39705 (August 7, 2009) and upon written request, by consent, by agreement, or as required by law. 

AUTHORITY: Section 416 of the Robert T. Stafford Disaster Relief and Emergency Assistance Act, as amended (42 U.S.C. § 5183); 44 C.F.R. § 206.171. 

PURPOSES AND USES: This information is being collected for the primary purpose of determining eligibility for the Crisis Counseling Assistance and 

Training Program, Regular Services Program funding following a Presidentially-declared disaster. 

EFFECTS OF NONDISCLOSURE: The disclosure of information on this form is voluntary; however, failure to provide the information requested may delay 

or prevent FEMA from providing the requested funding.

Completion of this form including applicable attachments satisfies legal requirements for application for the Regular Services Program 

(RSP) under 42 U.S.C. § 5183 as implemented at 44 C.F.R. § 206.171. Failure to use this application may result in a failure to meet these 

requirements and/or a delay in processing the request. This application must be submitted no later than 60 days following the declaration 

of a major disaster. 

4. State, Tribal Government or Territory requesting services:

5. Primary Point of Contact (POC) information for the administration of this program.

5a. POC Name:

5c. POC Mailing Address:

5d. POC E-Mail Address:

7. Describe State and local crisis counseling activities from the date of the incident to the date of this application. Enter "N/A" if no crisis 

counseling activities have been conducted to date.

DEPARTMENT OF HOMELAND SECURITY 

Federal Emergency Management Agency 

APPLICATION FOR CRISIS COUNSELING PROGRAM SERVICES 

(REGULAR SERVICES PROGRAM)

OMB. Number: 1660-0085 

Expires 03-31-2026

5b. POC Organization:

FEMA Form FF-104-FY-21-149 (formerly 003-0-2) (12/22) Page 1 of 10

1. Request Date: 2. Declaration #: 3. Declaration Date:

6. Amount requested for Regular Services Program (RSP) funding (please round to nearest dollar). 

5e. POC Phone Number
8. Please provide a brief summary of the ISP currently in place. Please include information on the population served, any extensions (date 

and amount), the number of providers, the start and end dates of the program, and summarize any trends. Include any best practices as 

well as any challenges and describe how those challenges were addressed or will be addressed in the RSP. 

9. If applicable, explain why any service providers not included in the ISP were added to this RSP application. Additionally, explain why 

any service providers included in the ISP are excluded from the proposed RSP. 

10. Describe how the RSP will build on the work done in the ISP. Describe how contacts and resources identified during the ISP will be 

leveraged during the RSP. 

If an Immediate Services Program (ISP) was implemented for this disaster, please answer questions #8-10 below. Otherwise, skip 

to question #11.

FEMA Form FF-104-FY-21-149 (formerly 003-0-2) (12/22) Page 2 of 10
11. Please provide a brief summary that provides key information on the scope and magnitude of the disaster, how the Grantee and 

providers propose to provide services during the RSP, and the nature and location of the proposed services. Please include a 

description of the length of time services will be required and describe how long-term cases will be handled. Please describe the 

nature of psychological and social problems observed and the types of mental health problems encountered by disaster survivors. 

FEMA Form FF-104-FY-21-149 (formerly 003-0-2) (12/22) Page 3 of 10
PART III: GEOGRAPHIC AREAS AND NEEDS ASSESSMENT

OPTION B: Use the following table to estimate the impacted population for each requested service area (county, parish, tribal land, 

etc.). Populate the table using census data for the total population for each designated service area. Please select a "Percentage 

Impact Factor" between .75% (multiply the “Total Census Population by 0.0075) and 2% (multiply the “Total Census Population” by 

0.02) to determine “Estimated Population to be Served”. Please also list the number of direct and direct support staff anticipated. 

Provide a brief justification for the “Percentage Impact Factor” chosen in the box below. Please also list the proposed providers and 

the number of direct and support staff anticipated.

12. Estimated Population to be served:

OPTION A: Federal award applicants may opt to use their own method for determining the estimated population to be served. Please

cite data sources used. Please also list the proposed providers and the number of direct and non-direct staff anticipated.

Service Provider 

Name (if known) and 

Requested Declared 

Service Areas 

Total Census 

Population in 

Requested Declared 

Service Areas 

Percentage Impact 

Factor (.75%)

Estimated 

Population to be 

Served during the 

RSP

Number of Direct 

Staff FTE's (Crisis 

Counselors, Team 

Leads) (Typically a 

300:1 ratio)

Number of Non-Direct 

Staff FTE's (Admin., 

Fiscal, Data etc.) 

Typically 15-20%

TOTALS: -

FEMA Form FF-104-FY-21-149 (formerly 003-0-2) (12/22) Page 4 of 10

Describe any circumstances not captured in the table above that will have an impact on the need for and equitable delivery of crisis 

counseling services during the RSP. Include any high-risk groups or populations of concern (e.g., children; adolescents; older adults; 

individuals with disabilities; cultural needs; access and functional needs; lower income populations; first responders; etc.). Please include 

your plan to ensure the RSP is accessible.
PART IV: RESOURCES AND CAPABILITIES

13. Describe the current mental health resources and explain why they cannot meet the disaster-related mental health needs caused or 

aggravated by this disaster.

14. Has the Federal award applicant received funds for mental health disaster response from any other source (i.e. Department of 

Education, Foundations, etc) ? If so, how much and how are these funds used?

FEMA Form FF-104-FY-21-149 (formerly 003-0-2) (12/22) Page 5 of 10
PART V: PROGRAM ADMINISTRATION

15. Will the State, Tribal Government or Territory be providing any direct crisis counseling services?

16. Attach an overall organizational chart for this project

17. Provide a brief description of administrative oversight plans (supervision and monitoring of crisis counselors, team leads, data 

collection efforts, managing and monitoring staff stress, etc).

18. How will the Federal award applicant monitor the organization and deployment of crisis counseling teams? If more than one provider 

agency will be delivering services, please describe the plan to coordinate services. If more than one provider will cover a service area, 

please include a map that shows how the responsibility for that service area will be divided.

FEMA Form FF-104-FY-21-149 (formerly 003-0-2) (12/22) Page 6 of 10

Yes No
19. Describe the Federal award applicant's plan for quality control methods to ensure appropriate services reach survivors.

20. With what organizations and community stakeholders will you partner? Select all that apply:

Community Mental Health and Substance Abuse Centers

Schools

Faith-Based Organizations

First Responders

Community-Based Cultural Organizations

Law Enforcement

Local Elected Officials

Long-Term Recovery Groups

Other:

21. Briefly describe how you will engage with the partners identified above.

22. What primary CCP services will you provide? Please select all that apply.

Individual crisis counseling

Group crisis counseling

Brief educational or supportive contact

Public education

Assessment, referral, and resource linkage

Community networking and support

FEMA Form FF-104-FY-21-149 (formerly 003-0-2) (12/22) Page 7 of 10
23. What secondary CCP services will you provide? Please select all that apply.

24. State Staffing Plan. Please provide information on the staffing at the Grantee level. Include leadership positions and direct staff if the

State, Territory or Tribe is providing any direct services. Do not include provider-level staff.

Development and distribution of educational materials

Media and public service announcements

Grant Funded Projected In-Kind

Type of Staff # of Staff Members # of FTE's (based on 40 

hours per week) # of Staff Members # of FTE's (based on 40 hours per week)

TOTALS:

25. Describe the Federal award applicant's plan to ensure clear program identity (educational materials, wellness messaging, logos, etc.)

and market the program (including website, hotline, social media, public service announcements, etc.)

FEMA Form FF-104-FY-21-149 (formerly 003-0-2) (12/22) Page 8 of 10
27. The CCP requires mandatory training during the RSP as described in the CCP guidance. Please describe the proposed training 

program for project staff, indicating the number of workers needing such training. Also include additional training (if any) that you plan 

to provide and the rationale for such training.

26. Briefly describe the facilities to be utilized and your plan for securing office space for this project.

FEMA Form FF-104-FY-21-149 (formerly 003-0-2) (12/22) Page 9 of 10

28. Does the State, Territory or Tribe have any experienced trainers who can provide training on the CCP model? 

Yes No
PART VI: BUDGET

PART VII: ASSURANCES

PART VIII: APPLICATION CHECKLIST

g. Assurance forms from question 31 above

f. Organizational Chart

The State, Tribal Government or Territory will maintain close coordination with and provide reports to the Regional Administrator, the

Assistant Administrator for the Recovery Directorate and the Secretary.

33. By signing below, the Governor's Authorized Representative (GAR) or the Chief Tribal Executive affirms that the foregoing questions

have been answered correctly and truthfully to the best of their knowledge.

34. The following documents are being submitted with this grant application:

a. Completed RSP Application

b. Request for Federal Assistance (SF-424)

c. Budget Information - Non-Construction Programs (SF-424a)

d. Assurances for Non-Construction Programs (SF-424b)

e. Budget Narrative

c. HHS Project Site Location/Key Contacts Form

b. Disbarment and Suspension and other Responsibility Matters

The State, Tribal Government or Territory's emergency plan, prepared under Title II of the Stafford Act, will include disaster mental

health planning.

FEMA Form FF-104-FY-21-149 (formerly 003-0-2) (12/22) Page 10 of 10

29. Attach a Standard Form 424: Request for Federal Assistance (SF-424) and Standard Form 424a: Budget Information - NonConstruction Programs (SF-424a). These forms should include all projected operating costs.

30. Attach a budget narrative explaining each line item on the SF-424a.

31. Please indicate whether the following assurances have been completed and submitted with this application:

a. SF-LLL Disclosure of Lobbying Activities No

Yes

Yes No

No

Yes

32. The Governor or Chief Tribal Executive or their authorized representative agrees to and/or certifies that:

The requirements are beyond the State, local, Territory, or Tribal government's capabilities.

The program, if approved, will be implemented according to the plan contained in the application approved by the Assistant

Administrator for the Recovery Directorate.

No

Yes

No

Yes

No

Yes

Yes No

No

Yes

No

Yes

No

Yes

Signature Date