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AGENCY REQUEST FOR FUNDING FROM Indian River COUNTY FISCAL YEAR 201812019 A. Program Cover Page Telephone: (772) 468-5600 Fax: (M) 468-5606 E -Mail: iromano(cDnhtcinc.orq I certify that information contained in this application accurately reflects the activities of this agency and that the expenditures or portions thereof for which County funds are being requested are not'reimbursed by any othqr source. re John Romano, CEO/President, Print name and title Brief fiescription of the Pro ram for which funding is requested: application 'is, to secure match funding necessary to leverage funding from the Department of Children and Families through their contract with Southeast Florida Behavioral Health Network (SEFBHN). The funds requested will be used to provide services to Indian River County residents ranging from emergency stabilization provided 24/7 to intensive community based programs for children and adults. (A Program Description of all services, locations and service time is attached.) The attached report "Units of Service Report with State Rate" shows the specific services provided and number of residents accessing these -services for the period 10/1/2016 to 09/30/2017. The match grant funding provided by IRBOCC for FY16/17 leveraged over $4 million of State funded services. . Summary Report Amount requested from Indian River County for 201812619: $310,575 Total Proposed Program budget for 2018/2019: $4,992,162 Percent of total Program budget: 6.2% Current Funding (2017/2018) $301,530 Dollar increase/ (decrease) in request: $9,045.90 Percent increase decrease in request: 3% If request increased 5% or more, briefly explain why: The Organization's Board of Directors has approved this appjica" n on March 28,V8: Patricia Austin -Novak Name of President/Chair of the Board Signature John Romano, President/CEO Name of Exec. Director/CEO Si j ature New Horizons of the Treasure Coast, Agency: Inc Contact Person: John Romano Title: CEO/President Address: 4500 W. Midway Road Ft. Pierce, FC. 34981 Website Address: www.nhtcinc.org Program Title: Mental Health and. Substance Abuse Telephone: (772) 468-5600 Fax: (M) 468-5606 E -Mail: iromano(cDnhtcinc.orq I certify that information contained in this application accurately reflects the activities of this agency and that the expenditures or portions thereof for which County funds are being requested are not'reimbursed by any othqr source. re John Romano, CEO/President, Print name and title Brief fiescription of the Pro ram for which funding is requested: application 'is, to secure match funding necessary to leverage funding from the Department of Children and Families through their contract with Southeast Florida Behavioral Health Network (SEFBHN). The funds requested will be used to provide services to Indian River County residents ranging from emergency stabilization provided 24/7 to intensive community based programs for children and adults. (A Program Description of all services, locations and service time is attached.) The attached report "Units of Service Report with State Rate" shows the specific services provided and number of residents accessing these -services for the period 10/1/2016 to 09/30/2017. The match grant funding provided by IRBOCC for FY16/17 leveraged over $4 million of State funded services. . Summary Report Amount requested from Indian River County for 201812619: $310,575 Total Proposed Program budget for 2018/2019: $4,992,162 Percent of total Program budget: 6.2% Current Funding (2017/2018) $301,530 Dollar increase/ (decrease) in request: $9,045.90 Percent increase decrease in request: 3% If request increased 5% or more, briefly explain why: The Organization's Board of Directors has approved this appjica" n on March 28,V8: Patricia Austin -Novak Name of President/Chair of the Board Signature John Romano, President/CEO Name of Exec. Director/CEO Si j ature