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Home My WebLink About2005-328s INDIAN RIVER COUNTY GRANT CONTRACT This Grant Contract ("Contract" ) entered into effective this day of October 2005 , by and between Indian River County, a political subdivision of the State of Florida ; 1840 25th Street , Vero Beach , Florida , 32960-3365 ; and The Center for Emotional and Behavioral Health ( Recipient) , of: The Center for Emotional and Behavioral Health (CEBH ) 119037 th Street Vero Beach , Florida 32960 Child/Adolescent Psychiatric Mental Health Clinic Background Recitals A. The County has determined that is in the public interest to promote healthy children in a healthy community. B . The County adopted Ordinance 99- 1 on January 19 , 1999 ("Ordinance") , and established the Children 's Services Advisory Committee to promote healthy children in a healthy community, and to provide a unified system of planning and delivery within which children 's needs can be identified , targeted , evaluated and addressed . C . The Children 's Services Advisory Committee has issued a request for proposals from individuals and entities that will assist the Children 's Services Advisory Committee in fulfilling its purpose . D . The proposal submitted to the Children 's Services Advisory Committee and the recommendation of the Children 's Services Advisory Committee have been reviewed by the County. E . The Recipient, by submitting a proposal to the Children 's Services Advisory Committee , has applied for a grant of money ("Grant") for the Grant Period (as such term is hereinafter defined ) on the terms and conditions set forth herein . F . The County has agreed to provide such Grant funds to the Recipient for the Grant Period (such term is hereinafter defined ) on the terms and conditions set forth herein . NOW THEREFORE , in consideration of the mutual covenants and promises herein contained , and other good and valuable consideration , the receipt and adequacy of which are hereby acknowledged , the parties agree as follows : 1 . Background Recitals . The background recitals are true and correct and form a material part of this contract . 2 . Purpose of the Grant . The Grant shall be used only for the purposes set forth in the complete proposal submitted by the Recipient , attached hereto as Exhibit "A" and incorporated herein by this reference (such purposes hereinafter referenced as "Grant Purposes") . 3 . Term . The Recipient acknowledges and agrees that the Grant is limited to the fiscal year 2005/2006 ("Grant Period" ) . The Grant Period commences on October 1 , 2005 and ends on September 30 , 2006 . - 1 - INDIAN RIVER COUNTY GRANT CONTRACT This Grant Contract ("Contract" ) entered into effective this day of October 2005 , by and between Indian River County, a political subdivision of the State of Florida ; 1840 25th Street , Vero Beach , Florida , 32960-3365 ; and The Center for Emotional and Behavioral Health ( Recipient) , of: The Center for Emotional and Behavioral Health (CEBH ) 119037 th Street Vero Beach , Florida 32960 Child/Adolescent Psychiatric Mental Health Clinic Background Recitals A. The County has determined that is in the public interest to promote healthy children in a healthy community. B . The County adopted Ordinance 99- 1 on January 19 , 1999 ("Ordinance") , and established the Children 's Services Advisory Committee to promote healthy children in a healthy community, and to provide a unified system of planning and delivery within which children 's needs can be identified , targeted , evaluated and addressed . C . The Children 's Services Advisory Committee has issued a request for proposals from individuals and entities that will assist the Children 's Services Advisory Committee in fulfilling its purpose . D . The proposal submitted to the Children 's Services Advisory Committee and the recommendation of the Children 's Services Advisory Committee have been reviewed by the County. E . The Recipient, by submitting a proposal to the Children 's Services Advisory Committee , has applied for a grant of money ("Grant") for the Grant Period (as such term is hereinafter defined ) on the terms and conditions set forth herein . F . The County has agreed to provide such Grant funds to the Recipient for the Grant Period (such term is hereinafter defined ) on the terms and conditions set forth herein . NOW THEREFORE , in consideration of the mutual covenants and promises herein contained , and other good and valuable consideration , the receipt and adequacy of which are hereby acknowledged , the parties agree as follows : 1 . Background Recitals . The background recitals are true and correct and form a material part of this contract . 2 . Purpose of the Grant . The Grant shall be used only for the purposes set forth in the complete proposal submitted by the Recipient , attached hereto as Exhibit "A" and incorporated herein by this reference (such purposes hereinafter referenced as "Grant Purposes") . 3 . Term . The Recipient acknowledges and agrees that the Grant is limited to the fiscal year 2005/2006 ("Grant Period" ) . The Grant Period commences on October 1 , 2005 and ends on September 30 , 2006 . - 1 - 4 . Grant Funds and Payment. The approved Grant for the Grant Period is : SIXTY EIGHT THOUSAND , SIX HUNDRED TWO DOLLARS ($68 , 602 . 00 ) . The County agrees to reimburse the Recipient from such Grant funds for actual documented costs incurred for the Grant Purposes provided in accordance with this Contract. Reimbursement requests may be made no more frequently than monthly. Each reimbursement request shall contain the information , at a minimum , that is set forth in Exhibit "B" , attached hereto and incorporated herein by this reference . All reimbursement requests are subject to audit by the County. In addition , the County may require additional documentation of expenditures , as it deems appropriate . 5 . Additional Obligation of Recipient . 5 . 1 . Records . The Recipient shall maintain adequate internal controls in order to safeguard the Grant . In addition , the Recipient shall maintain adequate records fully to document the use of the Grant funds for at least three (3 ) years after the expiration of the Grant Period . The County shall have access to all books , records , and documents as required in this Section for the purpose of inspection or audit during normal business hours at the County's expense , upon five (5) days prior to written notice . 5 . 2 . Compliance with Laws . The Recipient shall comply at all times with all applicable federal , state , and local laws and regulations . 5 . 3 . Quarterly Performance Reports . The Recipient shall submit quarterly, cumulative , Performance Reports to the Human Services Department of the County, within fifteen ( 15) business days following : December 31 , March 31 , June 30 and September 30 . 5 .4 . Audit Requirements . If Recipient receives $25 , 000 , or more in aggregate, from all Indian River County government funding sources , the Recipient is required to have an audit completed by an independent certified public accountant at the end of the Recipient's fiscal year. Within 120 days of the end of the Recipient's fiscal year, the Recipient shall submit the audit to the Indian River County Office of Management and Budget . The fiscal year will be as reported on the application for funding , and the Recipient agrees to notify the County prior to any change in the fiscal period of Recipient. The Recipient acknowledges that the County may deny funding to any Recipient if an audit required by this Contract for the prior fiscal year is past due and has not been submitted by May 1 . 5 .4 . 1 . The Recipient further acknowledges that, promptly upon receipt of a qualified opinion from its independent auditor, such qualified opinion shall immediately be provided to the Indian River County Office of Management and Budget. The qualified opinion shall thereupon be reported to the Board of Commissioners and funding under this Contract will cease immediately. The foregoing termination right is in addition to any other right of the County to terminate the Contract. 5 .4 . 2 . The Indian River County Office of Management and Budget reserves the right at any time to send a letter to the Recipient requesting clarification if there are any questions regarding a part of the financial statements , audit comments , or notes . 5 . 5 . Insurance Requirements . Recipient shall , no later than September 21 , 2005 provide to Indian River County Risk Management Division a certificate , or certificates , issued by an insurer, or insurers , authorized to conduct business in Florida that is rated not-less-than Category A- :VII by A . M . Best, subject to approval by Indian River County's Risk Manager, of the following types and amounts of insurance : - 2 - 4 . Grant Funds and Payment. The approved Grant for the Grant Period is : SIXTY EIGHT THOUSAND , SIX HUNDRED TWO DOLLARS ($68 , 602 . 00 ) . The County agrees to reimburse the Recipient from such Grant funds for actual documented costs incurred for the Grant Purposes provided in accordance with this Contract. Reimbursement requests may be made no more frequently than monthly. Each reimbursement request shall contain the information , at a minimum , that is set forth in Exhibit "B" , attached hereto and incorporated herein by this reference . All reimbursement requests are subject to audit by the County. In addition , the County may require additional documentation of expenditures , as it deems appropriate . 5 . Additional Obligation of Recipient . 5 . 1 . Records . The Recipient shall maintain adequate internal controls in order to safeguard the Grant . In addition , the Recipient shall maintain adequate records fully to document the use of the Grant funds for at least three (3 ) years after the expiration of the Grant Period . The County shall have access to all books , records , and documents as required in this Section for the purpose of inspection or audit during normal business hours at the County's expense , upon five (5) days prior to written notice . 5 . 2 . Compliance with Laws . The Recipient shall comply at all times with all applicable federal , state , and local laws and regulations . 5 . 3 . Quarterly Performance Reports . The Recipient shall submit quarterly, cumulative , Performance Reports to the Human Services Department of the County, within fifteen ( 15) business days following : December 31 , March 31 , June 30 and September 30 . 5 .4 . Audit Requirements . If Recipient receives $25 , 000 , or more in aggregate, from all Indian River County government funding sources , the Recipient is required to have an audit completed by an independent certified public accountant at the end of the Recipient's fiscal year. Within 120 days of the end of the Recipient's fiscal year, the Recipient shall submit the audit to the Indian River County Office of Management and Budget . The fiscal year will be as reported on the application for funding , and the Recipient agrees to notify the County prior to any change in the fiscal period of Recipient. The Recipient acknowledges that the County may deny funding to any Recipient if an audit required by this Contract for the prior fiscal year is past due and has not been submitted by May 1 . 5 .4 . 1 . The Recipient further acknowledges that, promptly upon receipt of a qualified opinion from its independent auditor, such qualified opinion shall immediately be provided to the Indian River County Office of Management and Budget. The qualified opinion shall thereupon be reported to the Board of Commissioners and funding under this Contract will cease immediately. The foregoing termination right is in addition to any other right of the County to terminate the Contract. 5 .4 . 2 . The Indian River County Office of Management and Budget reserves the right at any time to send a letter to the Recipient requesting clarification if there are any questions regarding a part of the financial statements , audit comments , or notes . 5 . 5 . Insurance Requirements . Recipient shall , no later than September 21 , 2005 provide to Indian River County Risk Management Division a certificate , or certificates , issued by an insurer, or insurers , authorized to conduct business in Florida that is rated not-less-than Category A- :VII by A . M . Best, subject to approval by Indian River County's Risk Manager, of the following types and amounts of insurance : - 2 - (i ) Commercial General Liability Insurance in an amount not less than $ 1 , 000 , 000 combined single limit for bodily injury and property damage , including coverage for premises/operations , product/completed operations , contractual liability, and independent contractors ; ( ii) Business Auto Liability Insurance in an amount not less than $ 1 , 000 , 000 per occurrence combined single limit for bodily injury and property damage , including coverage for owned autos and other vehicles , hired autos and other vehicles , non-owned autos and other vehicles ; and ( iii) Worker's Compensation and Employer's Liability (current Florida statutory limit. ) . 5 . 6 . Insurance Administration . The insurance certificates , evidencing all required insurance coverages shall be fully acceptable to County in both form and content, and shall provide and specify that the related insurance coverage shall not be cancelled without at least thirty (30 ) calendar days prior written notice having been given the County. In addition , the County may request such other proofs and assurances as it may reasonable require that the insurance is and at all times remains in full force and effect. Recipient agrees that it is the Recipient's sole responsibility to coordinate activities among itself, the County, and the Recipient's insurer(s ) so that the insurance certificates are acceptable to and accepted by County within the time limits set forth in this Contract. The County shall be listed as an additional insured on all insurance coverage required by this Contract, except Worker's Compensation Insurance . The Recipient shall , upon ten ( 10) days prior written request from the County, deliver copies to the County, or make copies available for the County's inspection at Recipient's place of business , of any and all insurance policies that are required in this Contract . If the Recipient fails to deliver or make copies of the policies available to the County; fails to obtain replacement insurance or have previous insurance policies reinstated or renewed upon termination or cancellation of existing required coverages ; or fails in any other regard to obtain coverages sufficient to meet the terms and conditions of this Contract, then the County may, at its sole option , terminate this Contract. 5 . 7 . Indemnification . The Recipient shall indemnify and save harmless the County, its agents , officials , and employees from and against any and all claims , liabilities, losses , damage , or causes of action which may arise from any misconduct, negligent act, or omissions of the Recipient, its agents , officers , or employees in connection with the performance of this Contract . 5 . 8 . Public Records . The Recipient agrees to comply with the provisions of Chapter 119 , Florida Statutes ( Public Records Law) in connection with this Contract . 6 . Termination . This Contract may be terminated by either party, without cause , upon thirty (30 ) days prior written notice to the other party. In addition , the County may terminate this Contract for convenience upon ten ( 10 ) days prior written notice to the Recipient if the County determines that such termination is in the public interest . 7 . Availability of Funds . The obligations of the County under this contract are subject to the availability of funds lawfully appropriated for its purpose by the Board of County Commissioners of Indian River County, 8 . Standard Terms . This Contract is subject to the standard terms attached hereto as Exhibit C and incorporated herein in its entirety by this reference . - 3 - IN WITNESS WHEREOF , County and Recipient have entered into this Contract on the date first above written . INDIAN RIVER COUNTY BOARD OF COMMISSIONERS B y y: Thomas S . Lowther, ChairriiaitX', BCC Approved: Attest: J . K . Barto6 , 11tIerR 4' By: Deputy Clerk Approved : Jose h' . Baird County Administrator Zdsform and legal su iciency: yell , A&itc<nt County Attorney RECIPIENT lw- qk By: r ` , % The vCenter f Emotional and Behavioral Health (CEBH ) - 4 - (i ) Commercial General Liability Insurance in an amount not less than $ 1 , 000 , 000 combined single limit for bodily injury and property damage , including coverage for premises/operations , product/completed operations , contractual liability, and independent contractors ; ( ii) Business Auto Liability Insurance in an amount not less than $ 1 , 000 , 000 per occurrence combined single limit for bodily injury and property damage , including coverage for owned autos and other vehicles , hired autos and other vehicles , non-owned autos and other vehicles ; and ( iii) Worker's Compensation and Employer's Liability (current Florida statutory limit. ) . 5 . 6 . Insurance Administration . The insurance certificates , evidencing all required insurance coverages shall be fully acceptable to County in both form and content, and shall provide and specify that the related insurance coverage shall not be cancelled without at least thirty (30 ) calendar days prior written notice having been given the County. In addition , the County may request such other proofs and assurances as it may reasonable require that the insurance is and at all times remains in full force and effect. Recipient agrees that it is the Recipient's sole responsibility to coordinate activities among itself, the County, and the Recipient's insurer(s ) so that the insurance certificates are acceptable to and accepted by County within the time limits set forth in this Contract. The County shall be listed as an additional insured on all insurance coverage required by this Contract, except Worker's Compensation Insurance . The Recipient shall , upon ten ( 10) days prior written request from the County, deliver copies to the County, or make copies available for the County's inspection at Recipient's place of business , of any and all insurance policies that are required in this Contract . If the Recipient fails to deliver or make copies of the policies available to the County; fails to obtain replacement insurance or have previous insurance policies reinstated or renewed upon termination or cancellation of existing required coverages ; or fails in any other regard to obtain coverages sufficient to meet the terms and conditions of this Contract, then the County may, at its sole option , terminate this Contract. 5 . 7 . Indemnification . The Recipient shall indemnify and save harmless the County, its agents , officials , and employees from and against any and all claims , liabilities, losses , damage , or causes of action which may arise from any misconduct, negligent act, or omissions of the Recipient, its agents , officers , or employees in connection with the performance of this Contract . 5 . 8 . Public Records . The Recipient agrees to comply with the provisions of Chapter 119 , Florida Statutes ( Public Records Law) in connection with this Contract . 6 . Termination . This Contract may be terminated by either party, without cause , upon thirty (30 ) days prior written notice to the other party. In addition , the County may terminate this Contract for convenience upon ten ( 10 ) days prior written notice to the Recipient if the County determines that such termination is in the public interest . 7 . Availability of Funds . The obligations of the County under this contract are subject to the availability of funds lawfully appropriated for its purpose by the Board of County Commissioners of Indian River County, 8 . Standard Terms . This Contract is subject to the standard terms attached hereto as Exhibit C and incorporated herein in its entirety by this reference . - 3 - EXHIBIT A (Copy of complete Request for Proposal ) EXHIBIT - A - The Center for Emotional and Behavioral Health — Child/Adolescent Psychiatric Mental Health Clinic — IRC - CSAC PROGRAM COVER PAGE Organization Name : The Center for Emotional and Behavioral Health @ IRMH Director: Mariamma Pyngolil . RN E-mail : mariamma nyngolil(a,irmh org Address : 119037th Street Telephone: 772-563 -4666Ext 1838 Vero Beach, FL 32960 Fax : 772- 770-2025 Program Director: Judy Linger M. D . E-mail : Judy lingerAirmh org Address : 1 .190 37thStreet Telephone: 772-563 -4666 Ext 1793 Vero Beach, FL 32960 Fax : 772-770-2025 wpoll Program Title : hild/Adolescent Psychiatric Mental Health Clinic Priority Need Area Addressed: Therapeutic evaluation and interventions program'for underinsured and uninsured school age children in Indian River County diagnosed with psychiatric or mental health problems. Brief Description of the Program : RR480 Early Intervention for Mental Illness • Programs that identify and provide treatment for individuals whose personal conditions and social experience could potentially produce mental , emotional or social dysfunctions with the objective of preventing their development; or which conduct general screen efforts to achieve early identification and treatment of children who have incipient problems to ensure the best possible prognosis RM-650 Outpatient Mental Health Facilities : Programs that provide walk-in walk-out diagnostic and treatment services for children, adolescents and/or adults who have acute chronic mental or emotional disturbances but who do not need twenty- four hour care ; and/or counseling services for individuals couples families and extended family group who may be experiencing difficulty resolving personal or interpersonal conflicts or making personal adjustments to stressful life situations such as separation divorce widowhood, loss of a child poor health unemployment family violence delinquency or substance abuse. RR-680 Psychopharmacology : Programs that utilize mood altering drugs and other medication in the control and/or treatment of mental or emotional disturbances Services may include an evaluation to determine the need for medication;prescription in modifying the individual ' s behavior, to ensure that undesirable side effects are minimized and to verify that medication is in fact being taken as prescribed . 3 IN WITNESS WHEREOF , County and Recipient have entered into this Contract on the date first above written . INDIAN RIVER COUNTY BOARD OF COMMISSIONERS B y y: Thomas S . Lowther, ChairriiaitX', BCC Approved: Attest: J . K . Barto6 , 11tIerR 4' By: Deputy Clerk Approved : Jose h' . Baird County Administrator Zdsform and legal su iciency: yell , A&itc<nt County Attorney RECIPIENT lw- qk By: r ` , % The vCenter f Emotional and Behavioral Health (CEBH ) - 4 - The Center for Emotional and Behavioral Health — Child/Adolescent Psychiatric Mental Health Clinic — IRC - CSAC SUMMARY REPORT — (Enter Information In The Black Cells 4� - Amount Requested from Funder for 2005 / 2005 000 . 00 Total Proposed Program Budget for 2005 / 2006 $ 283 , 007 . 55 Percent of Total Program Budget : 26 . 9 % Current Program Funding ( 2004 / 05 ) : $ 76 , 000 Dollar increase /( decrease ) in request : $ - Percent increase / ( decrease ) in request * * : 0 . 0 % Unduplicated Number of Children to be served Individually : 100 Unduplicated Number of Adults to be served Individually : Unduplicated Number to be served via Group settings : - Total Program Cost per Client : 2830 . 08 * *If request increased 5 % or more, briefly explain why: If these funds are being used to match another source, name the source and the $ amount : The Organization 's Board of Directors has pprovXthis application n Name of President/Chair of the Board Signa re �.7"e-�� e.�.r 1— • S � s i Name of Executi e Director/CEO e 4 The Center for Emotional and Behavioral Health — Child/Adolescent Psychiatric Mental Health Clinic — IRC - CSAC PROPOSAL NARRATIVE Please respond to each question in the allotted space for each section. In responding to each section of the proposal narrative, please retain the section-label and/or question that you are addressing. Type using 12 pt. font on 8 %" X 11 " paper and number each page. These directions and the graphic boxes may be deleted if space is needed . A. ORGANIZATION CAPABILITY (Entire Section A not to exceed one page) 1 . Provide the mission statement and vision of your organization. Indian River Memorial Hospital strives to be the finest community based health care organization anywhere. Our values are compassion, respect, and teamwork. The Center for Emotional and Behavioral Health A IRMH is committed to provide excellence in Mental Health Care to the individual and families while responding to the needs of the changing community. Our patients can expect quality care with dignity and professionalism through the collaborative efforts of the multidisciplinary team . We will continue to support the Quality First process while working together as a team. The vision of the Child/Adolescent Psychiatric mental health clinic program is to provide compassionate, competent, accessible, and affordable psychiatric care to children of Indian River County. 2 . Provide a brief summary of your organization including areas of expertise, accomplishments, and population served. CEBH is the only Baker Act receiving facility for Indian River County and the only one for children and adolescents for all of the Treasure Coast. CEBH provides behavioral health care services to children, adolescents and adults . The services include : ( 1 ) Assessment and Referral Services, (2) Inpatient Services, (3 ) Outpatient Services for Children and Adolescents and (4) Community Outreach. Assessment and Referral Services provides psychiatric assessment and placement in appropriate level of care 24 hours a day, 7 days a week. The services are offered to anyone seeking help in a behavioral or emotional crisis. Inpatient Services provide short-term acute care and crisis stabilization for all patients who cannot be safely managed in an outpatient setting. Inpatient services are provided on a voluntary or involuntary basis, to all three age groups. The Outpatient Services provide psychiatric and mental health care for about 388 children and adolescents . A board eligible psychiatrist trained in child and adolescent needs and unique developmental characteristics provides psychiatric care which includes comprehensive evaluations, treatment planning and medication management. Masters and doctoral level prepared therapists provide psychotherapy and counseling services to children, adolescents, and their families to enable them to cope with the emotional and behavioral issues. The outpatient services also include a summer camp (Camp Manatee Therapeutic Summer Camp) for ADHD children. Experiential (ROPES teambuilding), parenting classes, group therapy for children and adolescents, urine drug screens/drug free workplace services, and community outreach. The children receiving services range from 3 to 18 years of age. This program has demonstrated success in providing early intervention for children suffering from any emotional , behavioral disorder or acute and traumatic stress . This program also helps to maintain the children in the natural environment, thus preventing acute care hospitalization. The medical director and staff of the Outpatient Clinic collaborate with the school system and the other health care providers in Indian River County to provide clinical and consultative services . 5 EXHIBIT A (Copy of complete Request for Proposal ) EXHIBIT - A - r The Center for Emotional and Behavioral Health — Child/Adolescent Psychiatric Mental Health Clinic — IRC - CSAC Be PROGRAM NEED STATEMENT (Entire Section B not to exceed one page) 1 . a) What is the unacceptable condition requiring change? b) Who has the need? c) Where do they live? d) Provide local, state, or national trend data, with reference source, that corroborates that this is an area of need. Loss of function in a child ' s life as a result of stress or psychiatric disorder interferes with their ability to perform in school, maintain relationships and meet the ordinary demands of life. As reported in the proceedings based on the Surgeon General ' s Conference on mental health, the nation is facing a public crisis in mental healthcare for infants, children, and adolescents. Many children have mental health problems that interfere with normal development and functioning. According to the Surgeon General ' s report 20% of the children are estimated to have mental disorders with at least mild functional impairments . Five to nine percent of children ages 9 to 17 have serious emotional disturbances, (e. g. : anxiety disorder, mood disorders, disruptive disorder, schizophrenia, substance abuse, eating disorders and attention deficit disorders) . Applying the national prevalence rates to Indian River County, 20% of the children, or 4,609 children and adolescents may have a diagnosable disorder or functional impairment. Five to nine percent, or 1 , 152 to 2,074 children and adolescents may have a serious emotional disorder. Suicide is the fourth leading cause of death among youth ages 10- 14 and third among youth ages 15 -24, as per the Center for Disease Control Statistics, 2001 . Unmet need for services remains as high now as it was 20 years ago . Recent evidence compiled by the World Health Organization indicates that by the year 2020, childhood neuropsychiatric disorders will rise proportionately by over 50 percent, internationally, to become one of the five most common causes of morbidity, mortality, and disability among children. There is broad evidence that the nation lacks a unified infrastructure to help these children who are not identified as having mental health problems, who do not receive services, and end up in jail . Children and families are suffering because of missed opportunities for prevention and early identification, fragmented treatment services, and low priorities for resources . (Surgeon General ' s Conference on Mental Health, June 2000) . This program seeks to provide early intervention for children suffering from psychiatric and mental health disorders to prevent debilitative effects of mental illness and maintain function. 2 . a) Identify similar programs that are currently serving the needs of your targeted population ; b) Explain how these existing programs are under-serving the targeted population of your program. Similar programs available for Indian River County residents are limited to the Suncoast Mental Health Center which provides a child psychiatrist 2 days a month for up to 8- 16 hours a month. The Center for Emotional and Behavioral Health has served 388 unduplicated children, year to date. The number of children served in FY 2004 was 350 . We anticipate a 20% increase this year. As per the national trend data, this may only represent 50 percent of the children needing services . Pediatricians in the area are not comfortable treating psychiatric disorders and defer such treatment to psychiatrists . Therefore it is a reasonable assumption that children ' s mental health services will continue to be a priority need. The Center for Emotional and Behavioral Health was able to accommodate for the growth because of funding from the Children ' s Services Advisory Committee. 6 The Center for Emotional and Behavioral Health — Child/Adolescent Psychiatric Mental Health Clinic — IRC - CSAC C. PROGRAM DESCRIPTION (Entire Section C, I — 6, not to exceed two pages) 1 . List Priority Needs area addressed. Therapeutic evaluation and interventions program for underinsured and uninsured school age children in Indian River County diagnosed with psychiatric or mental health problems . 2 . Briefly describe program activities including location of services. Any child or adolescent from Indian River County seeking evaluation and treatment of psychiatric or mental health issues will be provided a comprehensive evaluation by the psychiatrist. Based on the findings of the evaluation, a treatment plan is formulated and discussed with the child/adolescent and family. The treatment may include medication management, individual and/ox group therapy. In addition, all families are encouraged to attend and participate in the parenting classes . The psychiatrist will collaborate with family, school and other health care providers to coordinate the care. The child/adolescent will be seen at regular intervals based on the unique needs of each child . The services are provided at The Center for Emotional and Behavioral Health, 3 . Briefly describe how your program addresses the stated need/problem. Describe how your program follows a recognized "best practice" (see definition on page 12 of the Instructions) and provide evidence that indicates proposed strategies are effective with target population. Providing comprehensive treatment involving medication management, psychotherapy, active involvement with the family and school and teaching specific social skills and behavior program will provide the child or adolescent with an opportunity to regain and maintain function. Recent research shows that certain types of psychotherapy, particularly cognitive behavior therapy (CBT), can help relieve depression in children and adolescents. (Birmaher B , Brent DA, Benson, RS , 1998) (Jayson D, Wood A, Kroll C, et all 1998) In addition, safety and efficacy of six general classes of medication have been researched ; psycho stimulants (Greenhill et al . , 1998), mood stabilizers (Ryan et al . , 1999) selective serotonin reuptake inhibitors (SSRI ' s) (Emslie et al . , 1999), antidepressants (Geller et al, 1998), antipsychotic agents (Campbell et al, 1999), and other miscellaneous agents (Riddle et all, 1998) . Review of comprehensive body of research indicates strong support for safety and efficacy of SSRI ' s for childhood depression and psycho stimulants for ADHD. However, for many other disorders and medication, information from rigorously controlled trials is sparse or absent (Surgeon Generals Conference on Mental Health, June 2000). Addressing these, NIMH has _ initiated a large scale study involving clinical trials at 10 sites across the US to compare the long term effectiveness of medication, CBT and a combination of these for treatment of depression in adolescents . 7 The Center for Emotional and Behavioral Health — Child/Adolescent Psychiatric Mental Health Clinic — IRC - CSAC PROGRAM COVER PAGE Organization Name : The Center for Emotional and Behavioral Health @ IRMH Director: Mariamma Pyngolil . RN E-mail : mariamma nyngolil(a,irmh org Address : 119037th Street Telephone: 772-563 -4666Ext 1838 Vero Beach, FL 32960 Fax : 772- 770-2025 Program Director: Judy Linger M. D . E-mail : Judy lingerAirmh org Address : 1 .190 37thStreet Telephone: 772-563 -4666 Ext 1793 Vero Beach, FL 32960 Fax : 772-770-2025 wpoll Program Title : hild/Adolescent Psychiatric Mental Health Clinic Priority Need Area Addressed: Therapeutic evaluation and interventions program'for underinsured and uninsured school age children in Indian River County diagnosed with psychiatric or mental health problems. Brief Description of the Program : RR480 Early Intervention for Mental Illness • Programs that identify and provide treatment for individuals whose personal conditions and social experience could potentially produce mental , emotional or social dysfunctions with the objective of preventing their development; or which conduct general screen efforts to achieve early identification and treatment of children who have incipient problems to ensure the best possible prognosis RM-650 Outpatient Mental Health Facilities : Programs that provide walk-in walk-out diagnostic and treatment services for children, adolescents and/or adults who have acute chronic mental or emotional disturbances but who do not need twenty- four hour care ; and/or counseling services for individuals couples families and extended family group who may be experiencing difficulty resolving personal or interpersonal conflicts or making personal adjustments to stressful life situations such as separation divorce widowhood, loss of a child poor health unemployment family violence delinquency or substance abuse. RR-680 Psychopharmacology : Programs that utilize mood altering drugs and other medication in the control and/or treatment of mental or emotional disturbances Services may include an evaluation to determine the need for medication;prescription in modifying the individual ' s behavior, to ensure that undesirable side effects are minimized and to verify that medication is in fact being taken as prescribed . 3 The Center for Emotional and Behavioral Health — Child/Adolescent Psychiatric Mental Health Clinic — IRC - CSAC 4 . List staffing needed for your program, including required experience and estimated hours per week in program for each staff member and/or volunteers (this section should conform with the information in the Position Listing on the Budget Narrative Worksheet) . Child/adolescent psychiatrist for 16 hours per week. This includes comprehensive evaluation, follow up visits, treatment plan coordination, and collaboration with school and family. Outpatient Coordinator 8 hours per week for scheduling and coordination of the program. Outpatient Therapists, providing supportive individual .or group therapy. 5 . How will the target population be made aware of the program? The target population will be made aware of the program through active collaboration with Indian River County Schools, health department, mental health association, substance abuse council, mental health program office, and local health care providers . In addition, information will be mailed to all of the above agencies along with all other agencies receiving funds from Indian River County Children ' s Services Advisory Committee. Ongoing community outreach programs at schools and others communities will also be utilized to market the program. 6. How will the program be accessible to target population (i.e., location, transportation, hours of operation) ? The outpatient clinic is located at Center for Emotional and Behavioral Health, across the street from Indian River Memorial Hospital and easily accessible from US 1 or Indian River Boulevard. Parents or responsible adults will be expected to provide transportation. The program is available Monday through Friday 10 a.m. to 5 p .m . 8 The Center for Emotional and Behavioral Health — Child/Adolescent Psychiatric Mental Health Clinic — IRC - CSAC D. MEASURABLE OUTCOMES (Description of Intent) Use the Measurable Outcomes form. This descri tion a e does not need to be included in the ro osal. In order to show the impact that your program is having on the target population and the community, the funders are requiring measurable outcomes . Please review the examples and summaries below to insure your understanding of what is expected . OUTCOMES : Describes what you want to achieve with the target population. Indicates the results of the services you provide, not the services you provide. Outcomes utilize action words such as maintain, increase, decrease, reduce, improve, raise and lower. ACTIVITIES : Describes the tasks that will be accomplished in the program to achieve the results stated in the outcomes. Activities utilize action words such as complete, establish, create, provide, operate, and develop. The activities should reflect the services described in the PROGRAM DESCRIPTION (C2) . Use the following elements to develop your outcomes. All elements must be included: • Direction of change • Timeframe • Area of change • As measured by • Target population • Baseline: The number that you will be • Degree of change measuring against Example 1 (Outcome) : To decrease (direction of change) number of unexcused absences (area of change) of enrolled boys and girls (targetpopulation) by 75 % (degree of change) in one year (timeframe) as reported by the 2003 School Board attendance records (as measured by). Baseline : 2003 School Board attendance records for enrolled boys and girls. Example 1 (Activity) : To provide anger management classes to enrolled boys and girls 2 times a week for 12 weeks . Example 2 (Outcome) : 75 % (degree of change) of youth (target population) who have participated in the academic enrichment activities (as measured by) for 6 months or more (timeframe), will improve (direction of change) their scores in one or more subject area (area of change) . 25 % of participants in academic enrichment activities will maintain the initial level of performance assessed at entry. Baseline: Pre-test scores from the academic enrichment test . Example 2 (Activity) : 1 ) Provide pre and post-test exercises on the Advanced Learning System software; 2) Participants will go through the one lesson per week and be graded for 10 weeks . IMPORTANT NOTE : Keep in mind when developing your PROGRAM OUTCOMES , that if funded, this will be what _ you are held accountable to accomplish. Also, the PROGRAM OUTCOMES should reflect the information described in the PROGRAM NEED STATEMENT (B 1 ) . All Program Need Statements should flow from the Mission & Vision. Measurable Outcomes should be based on and measure program needs. Activities are the tasks you do that are going to influence the outcome and impact the unacceptable condition in your Program Need Statement. 9 The Center for Emotional and Behavioral Health — Child/Adolescent Psychiatric Mental Health Clinic — IRC - CSAC SUMMARY REPORT — (Enter Information In The Black Cells 4� - Amount Requested from Funder for 2005 / 2005 000 . 00 Total Proposed Program Budget for 2005 / 2006 $ 283 , 007 . 55 Percent of Total Program Budget : 26 . 9 % Current Program Funding ( 2004 / 05 ) : $ 76 , 000 Dollar increase /( decrease ) in request : $ - Percent increase / ( decrease ) in request * * : 0 . 0 % Unduplicated Number of Children to be served Individually : 100 Unduplicated Number of Adults to be served Individually : Unduplicated Number to be served via Group settings : - Total Program Cost per Client : 2830 . 08 * *If request increased 5 % or more, briefly explain why: If these funds are being used to match another source, name the source and the $ amount : The Organization 's Board of Directors has pprovXthis application n Name of President/Chair of the Board Signa re �.7"e-�� e.�.r 1— • S � s i Name of Executi e Director/CEO e 4 The Center for Emotional and Behavioral Health — Child/Adolescent Psychiatric Mental Health Clinic — IRC - CSAC PROPOSAL NARRATIVE Please respond to each question in the allotted space for each section. In responding to each section of the proposal narrative, please retain the section-label and/or question that you are addressing. Type using 12 pt. font on 8 %" X 11 " paper and number each page. These directions and the graphic boxes may be deleted if space is needed . A. ORGANIZATION CAPABILITY (Entire Section A not to exceed one page) 1 . Provide the mission statement and vision of your organization. Indian River Memorial Hospital strives to be the finest community based health care organization anywhere. Our values are compassion, respect, and teamwork. The Center for Emotional and Behavioral Health A IRMH is committed to provide excellence in Mental Health Care to the individual and families while responding to the needs of the changing community. Our patients can expect quality care with dignity and professionalism through the collaborative efforts of the multidisciplinary team . We will continue to support the Quality First process while working together as a team. The vision of the Child/Adolescent Psychiatric mental health clinic program is to provide compassionate, competent, accessible, and affordable psychiatric care to children of Indian River County. 2 . Provide a brief summary of your organization including areas of expertise, accomplishments, and population served. CEBH is the only Baker Act receiving facility for Indian River County and the only one for children and adolescents for all of the Treasure Coast. CEBH provides behavioral health care services to children, adolescents and adults . The services include : ( 1 ) Assessment and Referral Services, (2) Inpatient Services, (3 ) Outpatient Services for Children and Adolescents and (4) Community Outreach. Assessment and Referral Services provides psychiatric assessment and placement in appropriate level of care 24 hours a day, 7 days a week. The services are offered to anyone seeking help in a behavioral or emotional crisis. Inpatient Services provide short-term acute care and crisis stabilization for all patients who cannot be safely managed in an outpatient setting. Inpatient services are provided on a voluntary or involuntary basis, to all three age groups. The Outpatient Services provide psychiatric and mental health care for about 388 children and adolescents . A board eligible psychiatrist trained in child and adolescent needs and unique developmental characteristics provides psychiatric care which includes comprehensive evaluations, treatment planning and medication management. Masters and doctoral level prepared therapists provide psychotherapy and counseling services to children, adolescents, and their families to enable them to cope with the emotional and behavioral issues. The outpatient services also include a summer camp (Camp Manatee Therapeutic Summer Camp) for ADHD children. Experiential (ROPES teambuilding), parenting classes, group therapy for children and adolescents, urine drug screens/drug free workplace services, and community outreach. The children receiving services range from 3 to 18 years of age. This program has demonstrated success in providing early intervention for children suffering from any emotional , behavioral disorder or acute and traumatic stress . This program also helps to maintain the children in the natural environment, thus preventing acute care hospitalization. The medical director and staff of the Outpatient Clinic collaborate with the school system and the other health care providers in Indian River County to provide clinical and consultative services . 5 The Center for Emotional and Behavioral Health — Child/Adolescent Psychiatric Mental Health Clinic — IRC - CSAC D . MEASURABLE OUTCOMES (Entire Section D not to exceed two pages) OUTCOMES ACTIVITIES Add all of the elements for the Measurable Outcome(s) Add the tasks to accomplish the Outcome(s) 95 % of children will demonstrate improvement C-GAS scores will be collected initially and in level of functioning as measured by then quarterly thereafter. improvement in scores of Children Global Assessment of Functioning Scale. Patient will attend an initial psychiatric evaluation with psychiatrist and will then Baseline : Children ' s Global Assessment of attend follow up with medication and therapy Functioning Scale sessions (weekly, bi-weekly, monthly, or as needed) . Patient will be discharged from services based on psychiatrist' s final evaluation. 10 The Center for Emotional and Behavioral Health — Child/Adolescent Psychiatric Mental Health Clinic — IRC - CSAC E. COLLABORATION (Entire Section E not to exceed one page) 1 . List your program ' s collaborative partners and the resources that they are providing to the program beyond referrals and support. (See individual funder requirements for inclusion of collaborative agreement letters .) Collaborative Agency . . Resources provided to the program Indian River Memorial Provides physical plant for the outpatient clinic, Hospital/CEBH provides secretarial and administrative support for the program, provides support for the incremental growth of the program, through availability of the psychiatrist. Indian River County Health Provide consultation and follow-through for continuum Department of care. Indian River County Schools Provide consultation and follow-through for continuum of care. Mental Health Association Provide consultation and follow-through for continuum of care. Substance Abuse and Mental Health Provide consultation and follow-through for continuum Division of Department of Children of care, provides support for children ' s psychotherapy and Families and counseling services for uninsured children. Local Health Care Providers Provide consultation and follow-through for continuum of care. 11 r The Center for Emotional and Behavioral Health — Child/Adolescent Psychiatric Mental Health Clinic — IRC - CSAC Be PROGRAM NEED STATEMENT (Entire Section B not to exceed one page) 1 . a) What is the unacceptable condition requiring change? b) Who has the need? c) Where do they live? d) Provide local, state, or national trend data, with reference source, that corroborates that this is an area of need. Loss of function in a child ' s life as a result of stress or psychiatric disorder interferes with their ability to perform in school, maintain relationships and meet the ordinary demands of life. As reported in the proceedings based on the Surgeon General ' s Conference on mental health, the nation is facing a public crisis in mental healthcare for infants, children, and adolescents. Many children have mental health problems that interfere with normal development and functioning. According to the Surgeon General ' s report 20% of the children are estimated to have mental disorders with at least mild functional impairments . Five to nine percent of children ages 9 to 17 have serious emotional disturbances, (e. g. : anxiety disorder, mood disorders, disruptive disorder, schizophrenia, substance abuse, eating disorders and attention deficit disorders) . Applying the national prevalence rates to Indian River County, 20% of the children, or 4,609 children and adolescents may have a diagnosable disorder or functional impairment. Five to nine percent, or 1 , 152 to 2,074 children and adolescents may have a serious emotional disorder. Suicide is the fourth leading cause of death among youth ages 10- 14 and third among youth ages 15 -24, as per the Center for Disease Control Statistics, 2001 . Unmet need for services remains as high now as it was 20 years ago . Recent evidence compiled by the World Health Organization indicates that by the year 2020, childhood neuropsychiatric disorders will rise proportionately by over 50 percent, internationally, to become one of the five most common causes of morbidity, mortality, and disability among children. There is broad evidence that the nation lacks a unified infrastructure to help these children who are not identified as having mental health problems, who do not receive services, and end up in jail . Children and families are suffering because of missed opportunities for prevention and early identification, fragmented treatment services, and low priorities for resources . (Surgeon General ' s Conference on Mental Health, June 2000) . This program seeks to provide early intervention for children suffering from psychiatric and mental health disorders to prevent debilitative effects of mental illness and maintain function. 2 . a) Identify similar programs that are currently serving the needs of your targeted population ; b) Explain how these existing programs are under-serving the targeted population of your program. Similar programs available for Indian River County residents are limited to the Suncoast Mental Health Center which provides a child psychiatrist 2 days a month for up to 8- 16 hours a month. The Center for Emotional and Behavioral Health has served 388 unduplicated children, year to date. The number of children served in FY 2004 was 350 . We anticipate a 20% increase this year. As per the national trend data, this may only represent 50 percent of the children needing services . Pediatricians in the area are not comfortable treating psychiatric disorders and defer such treatment to psychiatrists . Therefore it is a reasonable assumption that children ' s mental health services will continue to be a priority need. The Center for Emotional and Behavioral Health was able to accommodate for the growth because of funding from the Children ' s Services Advisory Committee. 6 The Center for Emotional and Behavioral Health — Child/Adolescent Psychiatric Mental Health Clinic — IRC - CSAC C. PROGRAM DESCRIPTION (Entire Section C, I — 6, not to exceed two pages) 1 . List Priority Needs area addressed. Therapeutic evaluation and interventions program for underinsured and uninsured school age children in Indian River County diagnosed with psychiatric or mental health problems . 2 . Briefly describe program activities including location of services. Any child or adolescent from Indian River County seeking evaluation and treatment of psychiatric or mental health issues will be provided a comprehensive evaluation by the psychiatrist. Based on the findings of the evaluation, a treatment plan is formulated and discussed with the child/adolescent and family. The treatment may include medication management, individual and/ox group therapy. In addition, all families are encouraged to attend and participate in the parenting classes . The psychiatrist will collaborate with family, school and other health care providers to coordinate the care. The child/adolescent will be seen at regular intervals based on the unique needs of each child . The services are provided at The Center for Emotional and Behavioral Health, 3 . Briefly describe how your program addresses the stated need/problem. Describe how your program follows a recognized "best practice" (see definition on page 12 of the Instructions) and provide evidence that indicates proposed strategies are effective with target population. Providing comprehensive treatment involving medication management, psychotherapy, active involvement with the family and school and teaching specific social skills and behavior program will provide the child or adolescent with an opportunity to regain and maintain function. Recent research shows that certain types of psychotherapy, particularly cognitive behavior therapy (CBT), can help relieve depression in children and adolescents. (Birmaher B , Brent DA, Benson, RS , 1998) (Jayson D, Wood A, Kroll C, et all 1998) In addition, safety and efficacy of six general classes of medication have been researched ; psycho stimulants (Greenhill et al . , 1998), mood stabilizers (Ryan et al . , 1999) selective serotonin reuptake inhibitors (SSRI ' s) (Emslie et al . , 1999), antidepressants (Geller et al, 1998), antipsychotic agents (Campbell et al, 1999), and other miscellaneous agents (Riddle et all, 1998) . Review of comprehensive body of research indicates strong support for safety and efficacy of SSRI ' s for childhood depression and psycho stimulants for ADHD. However, for many other disorders and medication, information from rigorously controlled trials is sparse or absent (Surgeon Generals Conference on Mental Health, June 2000). Addressing these, NIMH has _ initiated a large scale study involving clinical trials at 10 sites across the US to compare the long term effectiveness of medication, CBT and a combination of these for treatment of depression in adolescents . 7 The Center for Emotional and Behavioral Health — Child/Adolescent Psychiatric Mental Health Clinic — IRC - CSAC F. PROGRAM EVALUATION (Entire Section F not to exceed two pages) 1 . DEMOGRAPHICS : What information (data elements) will you need to collect in order to accurately describe your target population including demographics (age, gender, and ethnic background) required by the funder in Section H? What are the pieces of information that qualify them for your target population? How do you document their need for services or their "unacceptable condition requiring change" from Section Bl ? The demographics collected include : age, gender, ethnic background, address, insurance status, school attending, medications & prior treatment, family and other support, monthly income, number of days spent in school . The services will be made available to uninsured and underinsured children needing psychiatric services. The psychiatric evaluation with the score on the Children ' s Global Assessment of Functioning will document the need. 2. MEASURES : What data elements will you need to collect to show that you have achieved (or made progress toward) your Measurable Outcomes in Section D ? What tools or items are you using as measures (grades, survey scores, attendance, absences, skill levels) for your program? Are you getting baseline information from a source on your Collaboration List in Section E ? Are there results from your Activities in Section D that need to be documented? How often do you need to collect or follow-up on this data? Children' s Global Assessment of Functioning is an outcome evaluation used by the State of Florida to measure mental health outcomes . This tool measures the level of functioning on a continuum that ranges from most impaired (needing constant supervision) to the superior functioning. By administering this tool upon admission and quarterly thereafter, we will be able to measure improvement in children ' s functioning. 3 . REPORTING: What will you do with this information to show that change has occurred? How will you use or present these results to the consumer, the funder, the program, and the community? How will you use this information to improve your program? The results of the C-GAS will be shared with children and family to discuss progress towards goals. The results will be included in the quarterly report to the funder. The results will help the psychiatrist and the clinicians to modify treatment approaches to address specific problem areas. 12 The Center for Emotional and Behavioral Health — Child/Adolescent Psychiatric Mental Health Clinic — IRC - CSAC G. TIMETABLE (Section G not to exceed one page) 1 . List the major action steps, activities, or cycles of events that will occur within the program year. New programs should include any start-up planning that may occur outside the funding year. In completing the timetable, review information detailed in prior sections . Month/Period Activities August-September Marketing, develop & mail flyers notifying potential parents, school 2005 professionals and community health providers of the program October 2005- Continues enrolling children in the program, provide treatments, collect September 2006 initial evaluation C-GAS and 3 month C-GAS January 2006 Compile report, evaluate clinical outcomes, revise program and clinical approaches if necessary, evaluate other needs of the program, and collaborate with funder and county health department. January — September Repeat above steps . 2006 13 The Center for Emotional and Behavioral Health — Child/Adolescent Psychiatric Mental Health Clinic — IRC - CSAC 4 . List staffing needed for your program, including required experience and estimated hours per week in program for each staff member and/or volunteers (this section should conform with the information in the Position Listing on the Budget Narrative Worksheet) . Child/adolescent psychiatrist for 16 hours per week. This includes comprehensive evaluation, follow up visits, treatment plan coordination, and collaboration with school and family. Outpatient Coordinator 8 hours per week for scheduling and coordination of the program. Outpatient Therapists, providing supportive individual .or group therapy. 5 . How will the target population be made aware of the program? The target population will be made aware of the program through active collaboration with Indian River County Schools, health department, mental health association, substance abuse council, mental health program office, and local health care providers . In addition, information will be mailed to all of the above agencies along with all other agencies receiving funds from Indian River County Children ' s Services Advisory Committee. Ongoing community outreach programs at schools and others communities will also be utilized to market the program. 6. How will the program be accessible to target population (i.e., location, transportation, hours of operation) ? The outpatient clinic is located at Center for Emotional and Behavioral Health, across the street from Indian River Memorial Hospital and easily accessible from US 1 or Indian River Boulevard. Parents or responsible adults will be expected to provide transportation. The program is available Monday through Friday 10 a.m. to 5 p .m . 8 The Center for Emotional and Behavioral Health — Child/Adolescent Psychiatric Mental Health Clinic — IRC - CSAC D. MEASURABLE OUTCOMES (Description of Intent) Use the Measurable Outcomes form. This descri tion a e does not need to be included in the ro osal. In order to show the impact that your program is having on the target population and the community, the funders are requiring measurable outcomes . Please review the examples and summaries below to insure your understanding of what is expected . OUTCOMES : Describes what you want to achieve with the target population. Indicates the results of the services you provide, not the services you provide. Outcomes utilize action words such as maintain, increase, decrease, reduce, improve, raise and lower. ACTIVITIES : Describes the tasks that will be accomplished in the program to achieve the results stated in the outcomes. Activities utilize action words such as complete, establish, create, provide, operate, and develop. The activities should reflect the services described in the PROGRAM DESCRIPTION (C2) . Use the following elements to develop your outcomes. All elements must be included: • Direction of change • Timeframe • Area of change • As measured by • Target population • Baseline: The number that you will be • Degree of change measuring against Example 1 (Outcome) : To decrease (direction of change) number of unexcused absences (area of change) of enrolled boys and girls (targetpopulation) by 75 % (degree of change) in one year (timeframe) as reported by the 2003 School Board attendance records (as measured by). Baseline : 2003 School Board attendance records for enrolled boys and girls. Example 1 (Activity) : To provide anger management classes to enrolled boys and girls 2 times a week for 12 weeks . Example 2 (Outcome) : 75 % (degree of change) of youth (target population) who have participated in the academic enrichment activities (as measured by) for 6 months or more (timeframe), will improve (direction of change) their scores in one or more subject area (area of change) . 25 % of participants in academic enrichment activities will maintain the initial level of performance assessed at entry. Baseline: Pre-test scores from the academic enrichment test . Example 2 (Activity) : 1 ) Provide pre and post-test exercises on the Advanced Learning System software; 2) Participants will go through the one lesson per week and be graded for 10 weeks . IMPORTANT NOTE : Keep in mind when developing your PROGRAM OUTCOMES , that if funded, this will be what _ you are held accountable to accomplish. Also, the PROGRAM OUTCOMES should reflect the information described in the PROGRAM NEED STATEMENT (B 1 ) . All Program Need Statements should flow from the Mission & Vision. Measurable Outcomes should be based on and measure program needs. Activities are the tasks you do that are going to influence the outcome and impact the unacceptable condition in your Program Need Statement. 9 . . , : 1 d , Numberof Unduplicated Clients by Location Current Fiscal Budget 2004/05 � grime 1 I 1 1 11 is 1 1 . 1 Greater Stuart ne 67WIM � 1 • 1 WIFIRM Martin County Total Port Saint Lucie Si.- Lucie Co. Total Other Locations • 9 ; / � 1 � • 11 11 Number of Unduplicated Clients by Age I L NN Location At _ et 2004/05 5 to 10 - (Elementary) Total Children Total Adults 0111tel • : / 1 • : ■� � � � � Edit this Header. Type the organization and program name and the funder for whom it is being completed. The page # is already set at the bottom right of every page. I. BUDGET FORMS - To open the Budget Forms, please double-click on the icon below. " Core Budget Forms " 15 The Center for Emotional and Behavioral Health — Child/Adolescent Psychiatric Mental Health Clinic — IRC - CSAC D . MEASURABLE OUTCOMES (Entire Section D not to exceed two pages) OUTCOMES ACTIVITIES Add all of the elements for the Measurable Outcome(s) Add the tasks to accomplish the Outcome(s) 95 % of children will demonstrate improvement C-GAS scores will be collected initially and in level of functioning as measured by then quarterly thereafter. improvement in scores of Children Global Assessment of Functioning Scale. Patient will attend an initial psychiatric evaluation with psychiatrist and will then Baseline : Children ' s Global Assessment of attend follow up with medication and therapy Functioning Scale sessions (weekly, bi-weekly, monthly, or as needed) . Patient will be discharged from services based on psychiatrist' s final evaluation. 10 The Center for Emotional and Behavioral Health — Child/Adolescent Psychiatric Mental Health Clinic — IRC - CSAC E. COLLABORATION (Entire Section E not to exceed one page) 1 . List your program ' s collaborative partners and the resources that they are providing to the program beyond referrals and support. (See individual funder requirements for inclusion of collaborative agreement letters .) Collaborative Agency . . Resources provided to the program Indian River Memorial Provides physical plant for the outpatient clinic, Hospital/CEBH provides secretarial and administrative support for the program, provides support for the incremental growth of the program, through availability of the psychiatrist. Indian River County Health Provide consultation and follow-through for continuum Department of care. Indian River County Schools Provide consultation and follow-through for continuum of care. Mental Health Association Provide consultation and follow-through for continuum of care. Substance Abuse and Mental Health Provide consultation and follow-through for continuum Division of Department of Children of care, provides support for children ' s psychotherapy and Families and counseling services for uninsured children. Local Health Care Providers Provide consultation and follow-through for continuum of care. 11 Y Center for Emotional & Behavioral Health! Child Psychiatric Clinic UNIFORM GRANT APPLICATION BUDGET NARRATIVE WORKSHEET IMPORTANT: The Budget Narrative should provide details to justify the amount requested in each line item of the budget for your program. From this worksheet, your figures will be linked to the Total Agency Budget, Total Program Budget and Funder Specific Budget Forms. AGENCY/PROGRAM NAME : Center for Emotional & Behavorial Health/ Child Psychiatric Clinic FUNDER : IRC -CSAC CAUTION : Do not enter any figures where a cell is colored in dark blue - Formulas and/or links are in place. Gray areas should ' be used for calculations and to write information only. emy , ,' ';, Proposed ?otal Program Furi€Ier ` , ' `° REIrENUES # Budget E , �Bfk , t , ... : ,,. 1 Children's Services CounciloSt. Lucie 2 Children's Services Count:114111artin 3 Advisory Committ@e-Indian Rivet167 76,000.00 76,000.00 ,818.1 4 United Way-St Lucie County 5 United Way-Martin County 6 United Way4ndian River CountY 7 Department of Children & Families 8 County Funds 9 Contributions=Cash 10 Program Fees 851000.00 7,300,000. 11 Fund Raising Events-Net 12 Sales to Public - Net 13 Membership Dues 14 Investment Income 15 Miscellaneous 16 Legacies b Bequests 2000 .00 17 Funds from Other Sources . 18 Reserve Funds Used for Operating 19 In4(ind Donations - IRMH 1229007.55 20 TOTAL REVENUES tdoesul include Urs 19 $761 .000.00 $769000. $7,469,818.1 EXXI=IVD/TURr'=S +� aswrt Proposed Tota/ Pr4gram►r Funder �rfx M or&r :: � r Z tallowcucuw Budge , 21 Salaries - (must complete chart on next page 2169383.79 709599.164,202,409.2 s Salary Y: ¢ . 22 FICA - Total salaries x 0.0765 7. 89717.56 51400, 321 ,484.31 Ketirement " Annual pension or qua 23 staff 3.92% 8948224 0.0 164,734.44 ea - edical/Dentatishort-term 24 Disab. 13.27 289714.13 0.00 55T659.71 Workers ompensa on - # emp yeas x 25 rate 6 1 ,66% 3,591 .97 0.00 699759. Florida Unemployment - I projecteci 26 employees x $7,000 x UCT-6 rate 0.17% 367.85 0 7, 144,1 5/17/2005 B-1 Center for Emotional 8 Behavioral Health/ Child Psychiatric C** SALARIES a B n Gross Annual kala on Proed C % of Gross Annual POSITION LISTING, salary Portion of Program Funder Specific Bu et Salary Position Title / Total Hrs/wk (Agency) Program Ezamp►e Ezecud" Dfrector/ 40hrs 70,00000 10100000 g,UpOOp 7. 1`4% Medical Director/Ps chiabist/40 hrs 209,956.59 209,956.59 70,599.16 33.63% Office Coordinator/40 hrs 32, 136. 6,427.20 0.00° #DIV/0! #DIV/0! #DIV/0 ! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/01 #DIV/01 #DIV/0! #DIV/01 #DIV/0! #DIV/0! . lRemaining positions throughout the ency 3,960,316.68 Total Salaries. 1 $492029409.27 ;216,383.79 $70,599. 1 1.680 �R(IVE BENEFi�TS DETAIL A ( ziftdeeSpcific Budget Funder a ikon Goltimr► C +Dn�y, Hea from line 22 to 27) Specific Flea 7.¢57G (A x �) ►ti, Ins c Budget Positron° T7tle f Total Hrs/wk: f 4 ►Al .'� ti��' 8/ift�i$AY1•�6 h!# ' 5,000.00 382.50 200,i0 Medical Director/Ps chiatrisV40 hrs 70,599. 161 5,400.84 5v400.841 Office Coordinator/40 hrs. 0.001 0.00 0. 0 O.O.q 0.00 0. 0 0.001 0.00 0. 0 0.01 0.00 0. 0 0.001 0.00 0. 0 0.001 0.00 0. 0 0.001 0.00 0.0 0 0.001 0.00 0. 0 0.00 0.00 0. 0 . 0.001 0.00 0. 0 0.01 0.00 0. 0 0.001 0.00 0.0 0 0.001 0.00 0. 0 0. 0.00 0. 0 0.001 0.00 0. 0 0.001 0.00 ;_. _ 0 0 0.01 0.00 0. 0 0.0q 0.00 0.001 "Totbai 0. 0.00 0.001 rRequest Fringe Benefits $70;599. 1 559400. $0.001 $0: $0.00 $0. $52400. 5117/2005 BA The Center for Emotional and Behavioral Health — Child/Adolescent Psychiatric Mental Health Clinic — IRC - CSAC F. PROGRAM EVALUATION (Entire Section F not to exceed two pages) 1 . DEMOGRAPHICS : What information (data elements) will you need to collect in order to accurately describe your target population including demographics (age, gender, and ethnic background) required by the funder in Section H? What are the pieces of information that qualify them for your target population? How do you document their need for services or their "unacceptable condition requiring change" from Section Bl ? The demographics collected include : age, gender, ethnic background, address, insurance status, school attending, medications & prior treatment, family and other support, monthly income, number of days spent in school . The services will be made available to uninsured and underinsured children needing psychiatric services. The psychiatric evaluation with the score on the Children ' s Global Assessment of Functioning will document the need. 2. MEASURES : What data elements will you need to collect to show that you have achieved (or made progress toward) your Measurable Outcomes in Section D ? What tools or items are you using as measures (grades, survey scores, attendance, absences, skill levels) for your program? Are you getting baseline information from a source on your Collaboration List in Section E ? Are there results from your Activities in Section D that need to be documented? How often do you need to collect or follow-up on this data? Children' s Global Assessment of Functioning is an outcome evaluation used by the State of Florida to measure mental health outcomes . This tool measures the level of functioning on a continuum that ranges from most impaired (needing constant supervision) to the superior functioning. By administering this tool upon admission and quarterly thereafter, we will be able to measure improvement in children ' s functioning. 3 . REPORTING: What will you do with this information to show that change has occurred? How will you use or present these results to the consumer, the funder, the program, and the community? How will you use this information to improve your program? The results of the C-GAS will be shared with children and family to discuss progress towards goals. The results will be included in the quarterly report to the funder. The results will help the psychiatrist and the clinicians to modify treatment approaches to address specific problem areas. 12 The Center for Emotional and Behavioral Health — Child/Adolescent Psychiatric Mental Health Clinic — IRC - CSAC G. TIMETABLE (Section G not to exceed one page) 1 . List the major action steps, activities, or cycles of events that will occur within the program year. New programs should include any start-up planning that may occur outside the funding year. In completing the timetable, review information detailed in prior sections . Month/Period Activities August-September Marketing, develop & mail flyers notifying potential parents, school 2005 professionals and community health providers of the program October 2005- Continues enrolling children in the program, provide treatments, collect September 2006 initial evaluation C-GAS and 3 month C-GAS January 2006 Compile report, evaluate clinical outcomes, revise program and clinical approaches if necessary, evaluate other needs of the program, and collaborate with funder and county health department. January — September Repeat above steps . 2006 13 ' a Ld k � . W VA " m �y f f #r o N '�, m ; _ • x zO y% -' v O ° O O ) fir b O O O O • O O O Oca O Y .rA .b•ti � n N v G IV a . :: N . g 4 8 f k tl x M tl ^ ANN ^ s _ MM x N x k IIIL y lyl r w N x .� b x •n FNx xIt • a g g _ tea+ � g0MNQ � m WCCJIL � O U 7 F U 9! N F i O @F- W 6 v d N C < W U .3 JUQ N N h 1y 1h MI � O n a C~ for Emh"l Q Belw oW HeWM OM P"di Crr UNIFORM GRANT APPLICATION TOTAL AGENCY BUDGET AGENCY/PROGRAM NAME:Center for Emotional & Behaviorial Health/ 0 tient Therap FY 03/04 FY 04/05 FY 05106 % INCREASE FYE_9/30/2004 FYE 9/30/2005 FYE_9/30/2006 CURRENT VS. NEXT FY BUDGET A B C D ACTUAL TOTAL PROPOSED (coL Cool. Sycol. B REVENUES BUDGETED BUDGETED 1 Children's Services Council-St Lucie 0.00 #DIV/01 2 Children's Services Council-Martin 0.00 #DIV/01 3 Advisory Committee-Indian River 20 000.00 24 445.00 167981 &1 586.51 % 4 United Wa �St Lucie County 0.00 #DIV/01 5 United Way-Martin County0.00 #DIV/01 6 United Way-Indian River County 0.00 #DIV/01 7 Department of Children S Families 0.00 #DIV/01 a County Funds 0.00 #DIV/01 9 Contributions-Cash 0.00 #DIv101 to Prouram Fees 6 931 ,136,00 629w,000100 79300j000,00 5.80% 11 Fund Raising Events-Net 0.00 #DIV/01 12 Sales to Public-Net 0.00 #DIV/01 13 Membership Dues 0.00 #DIV/01 14 Investment Income 0.00 #DIV/01 16 Miscellaneous 0.00 #DIV/ol 1s L les S Bequests 24000.00 #DIV/0I 17 Funds from Other Sources 0.00 #DIV/01 1a Reserve Funds Used for Operating 0.00 #DIV/01 1!I In•Kind Donations (No(rKwaee in mwn 0.00 #DIV/01 20 TOTAL 6 951 136. 6924446001 724690918,13 7.88% 7777777777 44k . 7= ks?s. EXPENbITURES 21 Salaries 3t676,766.001 4w8809009,00 4w2OZ409,27 3.00% 22 FICA 259,962.001 293l753,00 321 484.31 9.44% 23 Retirement 1",129,231 159 936.35 164j734,44 3.00% 24 LifeAiealth �4971909.85 541417.19 557 659.71 3.00% 2s Workers Compensation 61v034.32 67 728.15 69Q59.99 3.00% 26 Florida Unemployment 6l250,50 61936,02 7144.10 3.00% 27 TravelDally 21710.00 31080,00 317240 3.00% 28 Travel/Conferences/Training 43 995.00 439995, 45w140.40 2.60% . 29 Office Su les 50 219. "IS", 44 529.00 0.00% Telephone 28t589,25 29 473.45 30 385.00 3.09% 31 PostagdShipping 49499,00 Z922.00 69060,00 107.39% 32 Utilities . 68 61200 65 000.00 70 200.00 8.00% 33 Occupancy (Building & Grounds 87Z405,00 888 981 . 891 320.81 0.26% 34 Printing & Publications 857.00 3 000.00 3120.00 4.00% 3s Subscri ues/Membershi 317.00 5g556.00 5j556,00 0.00% 36 Insurance 409j660,00 375t575,00 375*000.00 -0.15% 37 EquipmentRental 3 Maintenance 14 029.00 17 568.00 17 500.00 0,39% 3o Advertising 5 000.00 50000,00 59000.00 0.00% 39 EquipmenIt Purchases:Ca itsl Expense 11g274,00 8s647,00 92000.00 4.08% 4o Professional Fees i Consults 306t287, 228v612,00 228p612. 0.00% 41 Books/Educabonal Materials 20,606,00 29 080.00 29t080100 0.00% 42 Food S Nutrition 137 328,00 141 600. 118A" -16.64% 43 Administrative Costs 424 365.00 430 730.48 472,796,75 9.77% 44 Audit Expense 0.00 0.00 0.00 #DIV/01 SpecMc Assistance to individuals 0.00 0.00 0.00 #DIV/01 Other/Miscellaneous 800.00 800.00 1575.00 96.88% 47 OthedContract 87119W,00 87Z000. 872vOOO.00 0.00% 4s TOTAL 799119509,1 8345 928. 855127618 2.46% . r 49 REVENUES OVER/ ER EXPENDITURES -96Cv373*141 41421 ,483, 49081458.05 -23.92% smnaas e.: . . , : 1 d , Numberof Unduplicated Clients by Location Current Fiscal Budget 2004/05 � grime 1 I 1 1 11 is 1 1 . 1 Greater Stuart ne 67WIM � 1 • 1 WIFIRM Martin County Total Port Saint Lucie Si.- Lucie Co. Total Other Locations • 9 ; / � 1 � • 11 11 Number of Unduplicated Clients by Age I L NN Location At _ et 2004/05 5 to 10 - (Elementary) Total Children Total Adults 0111tel • : / 1 • : ■� � � � � Edit this Header. Type the organization and program name and the funder for whom it is being completed. The page # is already set at the bottom right of every page. I. BUDGET FORMS - To open the Budget Forms, please double-click on the icon below. " Core Budget Forms " 15 i C. fm EM*kwW a Ed.�W HO&W Chou Pwjdwrc Cork UNIFORM GRANT APPLICATION TOTAL PROGRAM BUDGET AGENCY/PROGRAM NAME:Center for Emotional & Behaviorial Health/ atient Thera FY 03/04 FY 04/05 FY 05/06 X INCREASE FYE 913012004 FYE_W30/2005 M CURRENT VS. NEXT FY BUDGET A B C D ACTUAL TOTAL PROPOSED (cd. Cool. B)k0L e REVENUES BUDGETED BUDGETED I Children's Services Council.SL Lucie 0.00 #IDlvro! 2 Children's Services CounciWartin 0.00 #avro! 3 AdvisoryCommitteedndian River 76 000.00 76 000.00 0100% 4 United Way-St Lucie County000 XXVIOI s United Wa -Martin Cou2U0.00 #Dlvro! s United Way-Indian River County0.00 #avro! 7rtment of Children & Families 0.02 #DN/p! a County Funds 000 9 Contributions-Cashp Op 10 P ram Fees 84 452.00 85 000.00 85 000.00 0.00% 11 Fund Raising Events-Net 0.00 #fDIVro! 12 Sales to Public-Net E0.00 #DIVroI 13 MembershipDues 0.00 #lavro! 1 Investment Income 0.00 #DIVroI 1s Miscellaneous: 0.00 . #DIVro! is L acies 8 Bequests 0.00 SgVro! 17 Funds from Other Sources 0.00 #avro! 18 Reserve Funds Used for O ` ratio 0.00 #DIVroI 19 In-Kind Donations (Noe rneweea In eoraq 13105.00 94 396.00 . 122 007.55 29.25% 20 TOTAL 84 452.00 161000. 161 000.00 0.00% EXPENDrfURES 21 Salaries 203 595.51 209,89Z28 216r383,79 . 3.09% 22 FICA 15 575.06 7t573,00 8717,56 15.11 % 23 Retirement 7980.94 81227&78 89482,24 3.09% 24 LifeAiealth 27 017.12 27 $52.71 28o714,13 3.09% 25 Workers Com cation 3 379.69 39484211 - 3 591.97 3.09% 26 Florida Unemployment 346.11 356.82 367.85 3.09% 27 Travel-Daily 0.00 0.00 6DIVro1 28 Travel/ConferencesfTraini 375.00 1 500A0 11500, 0.00% 29 Office Su lies 500.00 750.00 750.00 0.00% 30 Tele hone. . 590.00 590.00 590.00 0.00% 31 Postage/Shipping20.00 50.00 50.00 0.00% 32 Utilities450.00 . 500.00 11.11% 33 Occupancy (Building b Grounds 1 250.00 5 000.00 52150900 3.00% 34 Printin 3 Publications 0.00 0.00 #avrol 35 Subscri onlDrieslUbmbenshi 0.00 200.00 200.00 0.00% 36 Insurance 1 2$0.00 5000. 5250.00 5100% 3 E ui nt:Rental b Maintenance 0100 38 Advertising0.00 200.00 200.00 0.00% 39 Equipment Purchases:C& ' Expense 0100 rot . 40 Professional Fees Consulti 0.00 #fDNro! 41 Books/Educational Materials 300.00 500.00 500.00 0.00% 4 Food & Nutrition 0.00 0.00 #W/Ol 43 Administrative Costs 2,000.001 29000,00 2 O60.00 3.00% 44 Audit Expense 0.00 #avro! 45 Specft Assistance to Individuals 0.00 #DIV/01, 46 Other/Miscellaneous 0.00 0.00 #W101 - - 47 Other/Contract 0.00 #W/Ol 40 TOTAL 264179.43 273 626.7 283w007.55 3.43% 49 REVENUES OVER/ UNDER EXPENDITURES 4791727.4-31- - 79 727.43 -11 626. -122 007.55 8.33% sm�aoas � e Center for Emotional d BehavvimW Health/ Child Psychiatric ChNc UNIFORM GRANT APPLICATION FUNDER SPECIFIC BUDGET PROGRAM EXPENSES AGENCY/PROGRAM NAME : Center for Emotional & Behavioriai Health/ Outpatient Therapy FUNDER :IRC - CSAC A B o FY 05/06 FY 05/06 % OF TOTAL FUNDER TOTAL VS. PROGRAM SPECIFIC FUNDER REQUEST BUDGET BUDGET col. B/col. A EXPENDITURES 21 Salaries 2169383.79 70,599. 16 32.63% 22 FICA . 89717.56 5,400.84 61 .95% 23 Retirement 81482.24 0.00 0.00% 24 Life/Health 289714.13 0.00 0.00% 25 Workers Compensation 31591w97 0.00 0.00% 26 Florida Unemployment , 367.85 0.00 0.00% 27 TravelmDally. 0.00 0.00 #DIV101 28 Travel/Conferences/Training 13500600 0.00 0.00% 29 Office SUP plies 750.00 0.00 0.000/0 30 Telephone 590.00 0.00 - 0.00% 31 Postage/Shipping 50.00 0.00 0.008A 32 Utilities . 500.00 0.00 0.00% 33 Occupancy (Building & Grounds 59150.00 0.00 0.00% 34 Printing & Publications 0.00 0.00 #DIV/01 .. 35 Subscription/Dues/Memberships 200.00 0.00 0.00% 36 Insurance 50250.00 0.00 0.00% 37 E ui ment: Rental & Maintenance 0.00 0.00 #DN/01 38 Advertising 200.00 0.00 0.00% 39 Equipment Purchases: Ca ital Expense 0.00 0.00 #DIV/01 40 Professional Fees (Legal, Consulting) 0.00 0.00 #DIV/01 41 Books/Educational Materials 500.00 0.00 0 .00% 42 Food & Nutrition 0.00 0.00 #DIV/01 43 Administrative Costs 2,060.00 0.00 0 .00% 44 Audit Expense 0.00 0.00 #DIV/01 45 Specific Assistance to Individuals 0.00 0.00 #DIV/01 46 Other/Miscellaneous 0.00 0.00 #DIV/01 47 Other/Contract 0.00 00001 #DIV/01 48 TOTAL $2839007.55 $76,000.00 26.85% er17r2OW 134 Y Center for Emotional & Behavioral Health! Child Psychiatric Clinic UNIFORM GRANT APPLICATION BUDGET NARRATIVE WORKSHEET IMPORTANT: The Budget Narrative should provide details to justify the amount requested in each line item of the budget for your program. From this worksheet, your figures will be linked to the Total Agency Budget, Total Program Budget and Funder Specific Budget Forms. AGENCY/PROGRAM NAME : Center for Emotional & Behavorial Health/ Child Psychiatric Clinic FUNDER : IRC -CSAC CAUTION : Do not enter any figures where a cell is colored in dark blue - Formulas and/or links are in place. Gray areas should ' be used for calculations and to write information only. emy , ,' ';, Proposed ?otal Program Furi€Ier ` , ' `° REIrENUES # Budget E , �Bfk , t , ... : ,,. 1 Children's Services CounciloSt. Lucie 2 Children's Services Count:114111artin 3 Advisory Committ@e-Indian Rivet167 76,000.00 76,000.00 ,818.1 4 United Way-St Lucie County 5 United Way-Martin County 6 United Way4ndian River CountY 7 Department of Children & Families 8 County Funds 9 Contributions=Cash 10 Program Fees 851000.00 7,300,000. 11 Fund Raising Events-Net 12 Sales to Public - Net 13 Membership Dues 14 Investment Income 15 Miscellaneous 16 Legacies b Bequests 2000 .00 17 Funds from Other Sources . 18 Reserve Funds Used for Operating 19 In4(ind Donations - IRMH 1229007.55 20 TOTAL REVENUES tdoesul include Urs 19 $761 .000.00 $769000. $7,469,818.1 EXXI=IVD/TURr'=S +� aswrt Proposed Tota/ Pr4gram►r Funder �rfx M or&r :: � r Z tallowcucuw Budge , 21 Salaries - (must complete chart on next page 2169383.79 709599.164,202,409.2 s Salary Y: ¢ . 22 FICA - Total salaries x 0.0765 7. 89717.56 51400, 321 ,484.31 Ketirement " Annual pension or qua 23 staff 3.92% 8948224 0.0 164,734.44 ea - edical/Dentatishort-term 24 Disab. 13.27 289714.13 0.00 55T659.71 Workers ompensa on - # emp yeas x 25 rate 6 1 ,66% 3,591 .97 0.00 699759. Florida Unemployment - I projecteci 26 employees x $7,000 x UCT-6 rate 0.17% 367.85 0 7, 144,1 5/17/2005 B-1 Center for Emotional 8 Behavioral Health/ Child Psychiatric C** SALARIES a B n Gross Annual kala on Proed C % of Gross Annual POSITION LISTING, salary Portion of Program Funder Specific Bu et Salary Position Title / Total Hrs/wk (Agency) Program Ezamp►e Ezecud" Dfrector/ 40hrs 70,00000 10100000 g,UpOOp 7. 1`4% Medical Director/Ps chiabist/40 hrs 209,956.59 209,956.59 70,599.16 33.63% Office Coordinator/40 hrs 32, 136. 6,427.20 0.00° #DIV/0! #DIV/0! #DIV/0 ! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/01 #DIV/01 #DIV/0! #DIV/01 #DIV/0! #DIV/0! . lRemaining positions throughout the ency 3,960,316.68 Total Salaries. 1 $492029409.27 ;216,383.79 $70,599. 1 1.680 �R(IVE BENEFi�TS DETAIL A ( ziftdeeSpcific Budget Funder a ikon Goltimr► C +Dn�y, Hea from line 22 to 27) Specific Flea 7.¢57G (A x �) ►ti, Ins c Budget Positron° T7tle f Total Hrs/wk: f 4 ►Al .'� ti��' 8/ift�i$AY1•�6 h!# ' 5,000.00 382.50 200,i0 Medical Director/Ps chiatrisV40 hrs 70,599. 161 5,400.84 5v400.841 Office Coordinator/40 hrs. 0.001 0.00 0. 0 O.O.q 0.00 0. 0 0.001 0.00 0. 0 0.01 0.00 0. 0 0.001 0.00 0. 0 0.001 0.00 0. 0 0.001 0.00 0.0 0 0.001 0.00 0. 0 0.00 0.00 0. 0 . 0.001 0.00 0. 0 0.01 0.00 0. 0 0.001 0.00 0.0 0 0.001 0.00 0. 0 0. 0.00 0. 0 0.001 0.00 0. 0 0.001 0.00 ;_. _ 0 0 0.01 0.00 0. 0 0.0q 0.00 0.001 "Totbai 0. 0.00 0.001 rRequest Fringe Benefits $70;599. 1 559400. $0.001 $0: $0.00 $0. $52400. 5117/2005 BA EXHIBIT B ( From policy adopted by Indian River County Board of county Commissioners on February 19 , 2002 ) " D . Nonprofit Agency Responsibilities After Award Funding Indian River County provides funding to all nonprofit agencies on a reimbursement basis only. All reimbursable expenses must be documented by an invoice and/or a copy of the canceled check . Any expense not documented properly to the satisfaction of the Office of Management & Budget and/or the County Administrator may not be reimbursed . If an agency repeatedly fails to provide adequate documentation , this may be reported to the Board of Commissioners . In the event an agency provides inadequate documentation on a consistent basis , funding may be discontinued immediately. Additionally, this may adversely affect future funding requests . Expenditures may only be reimbursed from the fiscal year for which funding was awarded . For example , no expenditures prior to October 1s' may be reimbursed with funds from the following year. Additionally, if any funds are unexpended at the end of a fiscal year, these funds are not carried over to the next year unless expressly authorized by the Board of Commissioners . All requests for reimbursement at fiscal year and (September 30th) must be submitted on a timely basis . Each year, the Office of Management and Budget will send a letter to all nonprofit agencies advising of the deadline for reimbursement requests for the fiscal year. This deadline is typically early to mid October, since the Finance Department does not process checks for the prior fiscal year beyond that point. Each reimbursement request must include a summary of expense by type . These summaries should be broken down into salaries , benefit, supplies , contractual services , etc . If Indian River County is reimbursing an agency for only a portion of an expense (e . g . salary of an employee) , then the method for this portion should be disclosed on the summary. The Office of Management & Budget has summary forms available . Indian River County will not reimburse certain types of expenditures . These expenditure types are listed below. a ) Travel expenses for travel outside the County including but not limited to : mileage reimbursement, hotel rooms , meals , meal allowances , per diem , and tolls . Mileage reimbursement for local travel (within Indian River County) is allowable . b ) Sick or Vacation payments for employees . Since agencies may have various sick and vacation pay policies , these must be provided from other sources . c) Any expenses not associated with the provision of the program for which the County has awarded funding . d ) Any expense not outlined in the agency's funding application . The County reserves the right to decline reimbursement for any expense as deemed necessary. " EXHIBIT - B - NU , 31014 AC.M. CERTIFICATE OF LIABILITY INSURANCE = p PRtTo1)e><R I THIS CER71RCAT'Q IS ISSUED AS A MATTER OF IWORMATION ONLY AND CONFERS NO RIGHTS UPON THE CLENTFFICATE DO NOT U91 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 6529 MOrridon Blvd , , suite 200 ALTER reftCOVERAGEAFFORDED BYTHE POLICIES BELOW, ITbarlotte 9C 28211 thone : 100 - 729w4149 PBx9764 - 365 - 7114 INSURERS AFFORDINGCOYERAM NAICN eIStIRGt rNBURERA: Admiral Invira ee Ca . INSURER B: AMr/M° AutOW69 ,11 5111. a . TAd4aII River et=Qrial Hospital Gre GQOQCTi ttr99t I INSURER C -^�.-- or* beech PL 37360 INsuRRR01 rNSUReu e: COVERAGES THE PatICIft1 Or INSUPAWA LISTED RILOW HAVE SEEN 16SUR0 TO THE INSUMNA4ED AYOVE POR TH/ ROL�CY r+ERI001N010ATE 0. yOTwPrNSTaNOrNG ANY REQUNWWNY, TERM ON omo rNJN or ANY CONTRACT OR OTMER OOOLWNT K'ITM ROPQCT TO WM44 r14 CIRTIFIOATE MAY K ISSUEQ OR MAY PERTAIN, THE INSURAWIX AFTOR0E01)Y THE POLICIES OESCIIIIEC HEREIN M SUBJECT TC ALL 'rHe TMAS. EXCLUSIONS AND CONDMONS OF SUCH PMOM, ACMKCATE UMTS SHOWN MAY MAVE BEEN REDUCED DY PAID CLAIMS, URAN 006ICY NUMUN PA � e d o LlNgrs s MALLMIsAtIY I EACNOCCIJRR�1Ci 1 41S , 000 , 000 X ! E GOM4rEfiCMI OENEitAI Lw.EILIT" CAPTTV>t GSR 11 / 01 /05 11/01/ 06 �PpL11�*f� t X CLAIMS Nw9b .J Daws: �► o ram IAnr we pew) � ..• . I P&MMOL8AVVINMY . 415 . 000 . 000 G$NMRAL AOOREOArG 3 Ca r 00 010 00 tlfr,Tl AOORLOATS Mir APPLIES PER , PROOUC•I'i • COMPIOP AGG 3 $ 5 tf 0 0 0 r 0 0 Q POLICY Mir I LQC - - - - AUTOMODIL6 LUOLTV x ANY AUTO cw11*INEo PROLEuNur f ! (ED IniwrRl ALL OWNED AUTOS I RPDILY INJURY R B X 40HEOULE0AMS � Td7aL8083396? 11 / 01 / 05 11/ 01 / 06 LIIHpe+l°n► a x HRE.DALrrQ3 14ZA60633367 11 / 01 / 05 11 / 01 /06 1dgO,LYIK,uRv 8 x NONAWNWr09 Mz?aBO033367 L1/ 01J05 11 / 01 /06 �s °�0°"O AUs $ i ! I°y "°a4At1 GARM,ELIAI TY AUTO ouLv . EuAACCIOENT f CCEN ANY AUM OTHEt THAN to AUC S 1 AUTO ONLY! AGG S Mr--Ct:7 MIOLLA L"KITr ' CACH OCCUM4CMCL S SZ O r O OO r O D Q A CCOuR a CLAIUSNADE CRL - Mft10013 - 1003 - 04 11 / 03, 105 j 11 / 01 /06 A04PAGATE s fay 0 , OpO , 000 Excess S DEDUCTI6LE Above�SIR RETENTION 3 0 G16/ WMa - T WORK6R6COMPUNBATrONANO I IT011YL"my 5j I ER EiAtPLOYERJ' LIAMLITT E.LEACH ACGfOENT Is C�yytr PROPRSTORkAATNEIVEkECUTH I E.L. OISi1^ • EA EM►L.OV f if ym d "METS ExCLLroEO+ tl d"CAIN Inla°r s�'cMu PRov,sroys ens E.L. DLlFASE • POLICY OMIT I a OTPIKK Of_SCRIPTION OF OPERATIONS I WCATIONS I VfMiCLES I 6XCUMOms ADDED PV 1FADC05rimENT r SPECIAL PROVOONII Certificate Solder is added as Additional rneured with respect to their interest in contract wish the Named Insured , CERTIFICATE tr wept CANCELLATION X1TA22'.ATC SHOULD ANY OF THR AVOW MCA18CO POLCM K CANORLL*C ee aaE TNII 119FIRA DATR TMIMOF, THE 11901«0INSURRP 1V1LL ENDRAVOA TO WWI, 30 DAY* WRrrW NOTICE TO VP% CARTIFIC,ATE HOLOOR NAM*P 1p ?MR \EFTr BVr FAILM TO 00 90 IM" Indian River County INOMNQOBLIGATION ORWWLtrYOFANY MIND UPON TIM It OPI, ftAr,.RNTSOR 1640 2 8th Street NEPR5m- TATNitI Vera leach FL 32460 AUT CPRBIRR6" TA VIE ACO)tO 25 r40it06) 0 ACORD CORPORATION 1 !N ' a Ld k � . W VA " m �y f f #r o N '�, m ; _ • x zO y% -' v O ° O O ) fir b O O O O • O O O Oca O Y .rA .b•ti � n N v G IV a . :: N . g 4 8 f k tl x M tl ^ ANN ^ s _ MM x N x k IIIL y lyl r w N x .� b x •n FNx xIt • a g g _ tea+ � g0MNQ � m WCCJIL � O U 7 F U 9! N F i O @F- W 6 v d N C < W U .3 JUQ N N h 1y 1h MI � O n a C~ for Emh"l Q Belw oW HeWM OM P"di Crr UNIFORM GRANT APPLICATION TOTAL AGENCY BUDGET AGENCY/PROGRAM NAME:Center for Emotional & Behaviorial Health/ 0 tient Therap FY 03/04 FY 04/05 FY 05106 % INCREASE FYE_9/30/2004 FYE 9/30/2005 FYE_9/30/2006 CURRENT VS. NEXT FY BUDGET A B C D ACTUAL TOTAL PROPOSED (coL Cool. Sycol. B REVENUES BUDGETED BUDGETED 1 Children's Services Council-St Lucie 0.00 #DIV/01 2 Children's Services Council-Martin 0.00 #DIV/01 3 Advisory Committee-Indian River 20 000.00 24 445.00 167981 &1 586.51 % 4 United Wa �St Lucie County 0.00 #DIV/01 5 United Way-Martin County0.00 #DIV/01 6 United Way-Indian River County 0.00 #DIV/01 7 Department of Children S Families 0.00 #DIV/01 a County Funds 0.00 #DIV/01 9 Contributions-Cash 0.00 #DIv101 to Prouram Fees 6 931 ,136,00 629w,000100 79300j000,00 5.80% 11 Fund Raising Events-Net 0.00 #DIV/01 12 Sales to Public-Net 0.00 #DIV/01 13 Membership Dues 0.00 #DIV/01 14 Investment Income 0.00 #DIV/01 16 Miscellaneous 0.00 #DIV/ol 1s L les S Bequests 24000.00 #DIV/0I 17 Funds from Other Sources 0.00 #DIV/01 1a Reserve Funds Used for Operating 0.00 #DIV/01 1!I In•Kind Donations (No(rKwaee in mwn 0.00 #DIV/01 20 TOTAL 6 951 136. 6924446001 724690918,13 7.88% 7777777777 44k . 7= ks?s. EXPENbITURES 21 Salaries 3t676,766.001 4w8809009,00 4w2OZ409,27 3.00% 22 FICA 259,962.001 293l753,00 321 484.31 9.44% 23 Retirement 1",129,231 159 936.35 164j734,44 3.00% 24 LifeAiealth �4971909.85 541417.19 557 659.71 3.00% 2s Workers Compensation 61v034.32 67 728.15 69Q59.99 3.00% 26 Florida Unemployment 6l250,50 61936,02 7144.10 3.00% 27 TravelDally 21710.00 31080,00 317240 3.00% 28 Travel/Conferences/Training 43 995.00 439995, 45w140.40 2.60% . 29 Office Su les 50 219. "IS", 44 529.00 0.00% Telephone 28t589,25 29 473.45 30 385.00 3.09% 31 PostagdShipping 49499,00 Z922.00 69060,00 107.39% 32 Utilities . 68 61200 65 000.00 70 200.00 8.00% 33 Occupancy (Building & Grounds 87Z405,00 888 981 . 891 320.81 0.26% 34 Printing & Publications 857.00 3 000.00 3120.00 4.00% 3s Subscri ues/Membershi 317.00 5g556.00 5j556,00 0.00% 36 Insurance 409j660,00 375t575,00 375*000.00 -0.15% 37 EquipmentRental 3 Maintenance 14 029.00 17 568.00 17 500.00 0,39% 3o Advertising 5 000.00 50000,00 59000.00 0.00% 39 EquipmenIt Purchases:Ca itsl Expense 11g274,00 8s647,00 92000.00 4.08% 4o Professional Fees i Consults 306t287, 228v612,00 228p612. 0.00% 41 Books/Educabonal Materials 20,606,00 29 080.00 29t080100 0.00% 42 Food S Nutrition 137 328,00 141 600. 118A" -16.64% 43 Administrative Costs 424 365.00 430 730.48 472,796,75 9.77% 44 Audit Expense 0.00 0.00 0.00 #DIV/01 SpecMc Assistance to individuals 0.00 0.00 0.00 #DIV/01 Other/Miscellaneous 800.00 800.00 1575.00 96.88% 47 OthedContract 87119W,00 87Z000. 872vOOO.00 0.00% 4s TOTAL 799119509,1 8345 928. 855127618 2.46% . r 49 REVENUES OVER/ ER EXPENDITURES -96Cv373*141 41421 ,483, 49081458.05 -23.92% smnaas e.: NU . 4104 Gua AcIaM. CERTIFICATE OF LIA131LITY INSURANCEVATf1VWOWYVY~, IJ - 12,114 / 03 PRoova� TMS CBRTIFICATS I$ ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Florida Hospital Ae4eoc Yns1 Svc HOLDER. THIS CERTIFICATE DOES NOTAMEND, EXTEND OR 1675 Terrell Mill ad * ALTER TME COVERAGE AFFORDED BY THE POLICIES BELONG Ma>rieths GA 30067 Phoa. : 800 - 476 - 7601 Pax : 770 . 850woos $ INSURERS AFFORDING COVERAGE Nom * INSURaRAI craRtaa6�1 CAnwLV 1ro+'r1�7' INSURER ed India& River Memorial Hospital Greg xokvxn 10 (JD 36tS 9tre� I Vero Seaeb, AL 3980 INSUREN6�— w�URf R Q; COK"9s THE POLICIES OF MRANCE LISTED BELOW HAVE BEEN ISSVED TO THE INSL47ED NAND MOVE FOR THE FOXY PQRIDTJ INDICAT6C, NOTW17HSTANOING ANY RECI1MRI!HY, TERM Olt CONDITION OF ANY CONTRAOr OR OTHER DO06WENT WITH RE$PPCTTD WHICH TM13 QFRTICIOATE MAY DE 15"D OR WAY PERTAIN, THC IN/URANCC AFFOIIb=O by THE PCL CRS 00CF06E0 wRRCM113 5ueJECT TC AIA r E 75MM, MXCLU910N8 AND CAHORIONL OF SUCH 10061=9 A00MOAffL 04fT3 e441OWN MAT HAVC eGSN A806 0 AY PAIO CLAIM/. rm "oupa a PDtAQY NUM/ORp LIMITS �•• OW/IUu LULNILITY C1AC11 OCCURRENCE f 1 COIAMEJICULL OENGRAL LIAeILJTY I 1 aC aueReCt € —� CLAVA MAOC L71 OCCUR I MED PX° tM�al16 PMOR) $ _._. _ �� ... 3ERSDMALtA0VINARY S i �WNLRAL AGMQATE S GEN1 ASMOATI JECT MPLrt3P8R PROOWnwCOIA" AGG 15 MUCYSECT LOC 7 lIN>RLTTY j COMBINED &MLE LIMIT ANY AVTO Ise Geed") S ALL CFW14ED AUTOS BODILY IMJ1RY SCMEOVI.EOAUTOS I IPwWe'dNi I f 11000 AUT03 /001LY INJURY : Nowsow"ED AVTIOS I ¢1r eceleee0 � - --•••--�«- - I � F'ROPERIYOAMegGE _ (Per Gwim It CARA= 40JIUrV AM ONLY . FA ACCIDENT / .� -I ANY AUTO OTHER THAN , ..^, € AVTOONLY; A00 _ /%Cf?i/RJNPRlLIJ111AiJLRY I CACH OCCURRENCE s OCCVR a CulMannnoE AOGREGAW f I S 19DUCTEL€ + / it WTENTIoN M/ORIC € COMPENSATIONAND XLTDy�M ER arPLovEFle LraelLrY A w - ] 28588436i01 / 01/ 06ANPROPRIFTOPWAp CUTIVE CL. FArMA==NT 1.s1 , 0001 Boo O>:FrwWMEWER EX 1450T I Vf?1. OISf11JE EA EMPLOYE € iz . 000 000 - VQ, deWIkM unQer aPECALPROV64ON/ MNw cL. OI/CWsE • r*OLICVLIMIT s l 000 , 000 GTH/R I i I MPCIOfIt OF OPlRATIORS / LOCATR)NS f YlMIe.L.eS ' lXCLU910N9 ADCfb Gv ENDORSlMlNT 1 rpCCIAL PROVI910NS PrOQ9 of ravccA$r0 Zar Iadian River MealoriaX llfospital . CGKTIFICATE HOLDER CANCELLATION I)MIA NC GNCULP ANY of TME AAOVE 0"OIk1tEb PWCILS De CANO1LL1W /L'FORE TNCEMPMA DATE 7NER60F,, THE ISSURYO INeVRER WILL /NDeiAVO" TO %V6 30 PAYS WWMpj NOTICE TO THE COWW1609 HOLDER NAMD TO "IP LEFT, Or PALLft TO 17230 SN'AL: xn4t alk xive r county IMPOSE NO 06UCA71014 0R l.IAMLFTY0f1 ANY HIND UPON THE N/UREA, ITS AGWS OR 1040 45th Street REGae AT'1'$v � .�.. _ Vero Suac}S FL 32960 AUTIJft A VE Ito ACORG ZS f20alloe) ACORa CORPORATIOIII Mg i C. fm EM*kwW a Ed.�W HO&W Chou Pwjdwrc Cork UNIFORM GRANT APPLICATION TOTAL PROGRAM BUDGET AGENCY/PROGRAM NAME:Center for Emotional & Behaviorial Health/ atient Thera FY 03/04 FY 04/05 FY 05/06 X INCREASE FYE 913012004 FYE_W30/2005 M CURRENT VS. NEXT FY BUDGET A B C D ACTUAL TOTAL PROPOSED (cd. Cool. B)k0L e REVENUES BUDGETED BUDGETED I Children's Services Council.SL Lucie 0.00 #IDlvro! 2 Children's Services CounciWartin 0.00 #avro! 3 AdvisoryCommitteedndian River 76 000.00 76 000.00 0100% 4 United Way-St Lucie County000 XXVIOI s United Wa -Martin Cou2U0.00 #Dlvro! s United Way-Indian River County0.00 #avro! 7rtment of Children & Families 0.02 #DN/p! a County Funds 000 9 Contributions-Cashp Op 10 P ram Fees 84 452.00 85 000.00 85 000.00 0.00% 11 Fund Raising Events-Net 0.00 #fDIVro! 12 Sales to Public-Net E0.00 #DIVroI 13 MembershipDues 0.00 #lavro! 1 Investment Income 0.00 #DIVroI 1s Miscellaneous: 0.00 . #DIVro! is L acies 8 Bequests 0.00 SgVro! 17 Funds from Other Sources 0.00 #avro! 18 Reserve Funds Used for O ` ratio 0.00 #DIVroI 19 In-Kind Donations (Noe rneweea In eoraq 13105.00 94 396.00 . 122 007.55 29.25% 20 TOTAL 84 452.00 161000. 161 000.00 0.00% EXPENDrfURES 21 Salaries 203 595.51 209,89Z28 216r383,79 . 3.09% 22 FICA 15 575.06 7t573,00 8717,56 15.11 % 23 Retirement 7980.94 81227&78 89482,24 3.09% 24 LifeAiealth 27 017.12 27 $52.71 28o714,13 3.09% 25 Workers Com cation 3 379.69 39484211 - 3 591.97 3.09% 26 Florida Unemployment 346.11 356.82 367.85 3.09% 27 Travel-Daily 0.00 0.00 6DIVro1 28 Travel/ConferencesfTraini 375.00 1 500A0 11500, 0.00% 29 Office Su lies 500.00 750.00 750.00 0.00% 30 Tele hone. . 590.00 590.00 590.00 0.00% 31 Postage/Shipping20.00 50.00 50.00 0.00% 32 Utilities450.00 . 500.00 11.11% 33 Occupancy (Building b Grounds 1 250.00 5 000.00 52150900 3.00% 34 Printin 3 Publications 0.00 0.00 #avrol 35 Subscri onlDrieslUbmbenshi 0.00 200.00 200.00 0.00% 36 Insurance 1 2$0.00 5000. 5250.00 5100% 3 E ui nt:Rental b Maintenance 0100 38 Advertising0.00 200.00 200.00 0.00% 39 Equipment Purchases:C& ' Expense 0100 rot . 40 Professional Fees Consulti 0.00 #fDNro! 41 Books/Educational Materials 300.00 500.00 500.00 0.00% 4 Food & Nutrition 0.00 0.00 #W/Ol 43 Administrative Costs 2,000.001 29000,00 2 O60.00 3.00% 44 Audit Expense 0.00 #avro! 45 Specft Assistance to Individuals 0.00 #DIV/01, 46 Other/Miscellaneous 0.00 0.00 #W101 - - 47 Other/Contract 0.00 #W/Ol 40 TOTAL 264179.43 273 626.7 283w007.55 3.43% 49 REVENUES OVER/ UNDER EXPENDITURES 4791727.4-31- - 79 727.43 -11 626. -122 007.55 8.33% sm�aoas � e Center for Emotional d BehavvimW Health/ Child Psychiatric ChNc UNIFORM GRANT APPLICATION FUNDER SPECIFIC BUDGET PROGRAM EXPENSES AGENCY/PROGRAM NAME : Center for Emotional & Behavioriai Health/ Outpatient Therapy FUNDER :IRC - CSAC A B o FY 05/06 FY 05/06 % OF TOTAL FUNDER TOTAL VS. PROGRAM SPECIFIC FUNDER REQUEST BUDGET BUDGET col. B/col. A EXPENDITURES 21 Salaries 2169383.79 70,599. 16 32.63% 22 FICA . 89717.56 5,400.84 61 .95% 23 Retirement 81482.24 0.00 0.00% 24 Life/Health 289714.13 0.00 0.00% 25 Workers Compensation 31591w97 0.00 0.00% 26 Florida Unemployment , 367.85 0.00 0.00% 27 TravelmDally. 0.00 0.00 #DIV101 28 Travel/Conferences/Training 13500600 0.00 0.00% 29 Office SUP plies 750.00 0.00 0.000/0 30 Telephone 590.00 0.00 - 0.00% 31 Postage/Shipping 50.00 0.00 0.008A 32 Utilities . 500.00 0.00 0.00% 33 Occupancy (Building & Grounds 59150.00 0.00 0.00% 34 Printing & Publications 0.00 0.00 #DIV/01 .. 35 Subscription/Dues/Memberships 200.00 0.00 0.00% 36 Insurance 50250.00 0.00 0.00% 37 E ui ment: Rental & Maintenance 0.00 0.00 #DN/01 38 Advertising 200.00 0.00 0.00% 39 Equipment Purchases: Ca ital Expense 0.00 0.00 #DIV/01 40 Professional Fees (Legal, Consulting) 0.00 0.00 #DIV/01 41 Books/Educational Materials 500.00 0.00 0 .00% 42 Food & Nutrition 0.00 0.00 #DIV/01 43 Administrative Costs 2,060.00 0.00 0 .00% 44 Audit Expense 0.00 0.00 #DIV/01 45 Specific Assistance to Individuals 0.00 0.00 #DIV/01 46 Other/Miscellaneous 0.00 0.00 #DIV/01 47 Other/Contract 0.00 00001 #DIV/01 48 TOTAL $2839007.55 $76,000.00 26.85% er17r2OW 134 EXHIBIT B ( From policy adopted by Indian River County Board of county Commissioners on February 19 , 2002 ) " D . Nonprofit Agency Responsibilities After Award Funding Indian River County provides funding to all nonprofit agencies on a reimbursement basis only. All reimbursable expenses must be documented by an invoice and/or a copy of the canceled check . Any expense not documented properly to the satisfaction of the Office of Management & Budget and/or the County Administrator may not be reimbursed . If an agency repeatedly fails to provide adequate documentation , this may be reported to the Board of Commissioners . In the event an agency provides inadequate documentation on a consistent basis , funding may be discontinued immediately. Additionally, this may adversely affect future funding requests . Expenditures may only be reimbursed from the fiscal year for which funding was awarded . For example , no expenditures prior to October 1s' may be reimbursed with funds from the following year. Additionally, if any funds are unexpended at the end of a fiscal year, these funds are not carried over to the next year unless expressly authorized by the Board of Commissioners . All requests for reimbursement at fiscal year and (September 30th) must be submitted on a timely basis . Each year, the Office of Management and Budget will send a letter to all nonprofit agencies advising of the deadline for reimbursement requests for the fiscal year. This deadline is typically early to mid October, since the Finance Department does not process checks for the prior fiscal year beyond that point. Each reimbursement request must include a summary of expense by type . These summaries should be broken down into salaries , benefit, supplies , contractual services , etc . If Indian River County is reimbursing an agency for only a portion of an expense (e . g . salary of an employee) , then the method for this portion should be disclosed on the summary. The Office of Management & Budget has summary forms available . Indian River County will not reimburse certain types of expenditures . These expenditure types are listed below. a ) Travel expenses for travel outside the County including but not limited to : mileage reimbursement, hotel rooms , meals , meal allowances , per diem , and tolls . Mileage reimbursement for local travel (within Indian River County) is allowable . b ) Sick or Vacation payments for employees . Since agencies may have various sick and vacation pay policies , these must be provided from other sources . c) Any expenses not associated with the provision of the program for which the County has awarded funding . d ) Any expense not outlined in the agency's funding application . The County reserves the right to decline reimbursement for any expense as deemed necessary. " EXHIBIT - B - NU , 31014 AC.M. CERTIFICATE OF LIABILITY INSURANCE = p PRtTo1)e><R I THIS CER71RCAT'Q IS ISSUED AS A MATTER OF IWORMATION ONLY AND CONFERS NO RIGHTS UPON THE CLENTFFICATE DO NOT U91 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 6529 MOrridon Blvd , , suite 200 ALTER reftCOVERAGEAFFORDED BYTHE POLICIES BELOW, ITbarlotte 9C 28211 thone : 100 - 729w4149 PBx9764 - 365 - 7114 INSURERS AFFORDINGCOYERAM NAICN eIStIRGt rNBURERA: Admiral Invira ee Ca . INSURER B: AMr/M° AutOW69 ,11 5111. a . TAd4aII River et=Qrial Hospital Gre GQOQCTi ttr99t I INSURER C -^�.-- or* beech PL 37360 INsuRRR01 rNSUReu e: COVERAGES THE PatICIft1 Or INSUPAWA LISTED RILOW HAVE SEEN 16SUR0 TO THE INSUMNA4ED AYOVE POR TH/ ROL�CY r+ERI001N010ATE 0. yOTwPrNSTaNOrNG ANY REQUNWWNY, TERM ON omo rNJN or ANY CONTRACT OR OTMER OOOLWNT K'ITM ROPQCT TO WM44 r14 CIRTIFIOATE MAY K ISSUEQ OR MAY PERTAIN, THE INSURAWIX AFTOR0E01)Y THE POLICIES OESCIIIIEC HEREIN M SUBJECT TC ALL 'rHe TMAS. EXCLUSIONS AND CONDMONS OF SUCH PMOM, ACMKCATE UMTS SHOWN MAY MAVE BEEN REDUCED DY PAID CLAIMS, URAN 006ICY NUMUN PA � e d o LlNgrs s MALLMIsAtIY I EACNOCCIJRR�1Ci 1 41S , 000 , 000 X ! E GOM4rEfiCMI OENEitAI Lw.EILIT" CAPTTV>t GSR 11 / 01 /05 11/01/ 06 �PpL11�*f� t X CLAIMS Nw9b .J Daws: �► o ram IAnr we pew) � ..• . I P&MMOL8AVVINMY . 415 . 000 . 000 G$NMRAL AOOREOArG 3 Ca r 00 010 00 tlfr,Tl AOORLOATS Mir APPLIES PER , PROOUC•I'i • COMPIOP AGG 3 $ 5 tf 0 0 0 r 0 0 Q POLICY Mir I LQC - - - - AUTOMODIL6 LUOLTV x ANY AUTO cw11*INEo PROLEuNur f ! (ED IniwrRl ALL OWNED AUTOS I RPDILY INJURY R B X 40HEOULE0AMS � Td7aL8083396? 11 / 01 / 05 11/ 01 / 06 LIIHpe+l°n► a x HRE.DALrrQ3 14ZA60633367 11 / 01 / 05 11 / 01 /06 1dgO,LYIK,uRv 8 x NONAWNWr09 Mz?aBO033367 L1/ 01J05 11 / 01 /06 �s °�0°"O AUs $ i ! I°y "°a4At1 GARM,ELIAI TY AUTO ouLv . EuAACCIOENT f CCEN ANY AUM OTHEt THAN to AUC S 1 AUTO ONLY! AGG S Mr--Ct:7 MIOLLA L"KITr ' CACH OCCUM4CMCL S SZ O r O OO r O D Q A CCOuR a CLAIUSNADE CRL - Mft10013 - 1003 - 04 11 / 03, 105 j 11 / 01 /06 A04PAGATE s fay 0 , OpO , 000 Excess S DEDUCTI6LE Above�SIR RETENTION 3 0 G16/ WMa - T WORK6R6COMPUNBATrONANO I IT011YL"my 5j I ER EiAtPLOYERJ' LIAMLITT E.LEACH ACGfOENT Is C�yytr PROPRSTORkAATNEIVEkECUTH I E.L. OISi1^ • EA EM►L.OV f if ym d "METS ExCLLroEO+ tl d"CAIN Inla°r s�'cMu PRov,sroys ens E.L. DLlFASE • POLICY OMIT I a OTPIKK Of_SCRIPTION OF OPERATIONS I WCATIONS I VfMiCLES I 6XCUMOms ADDED PV 1FADC05rimENT r SPECIAL PROVOONII Certificate Solder is added as Additional rneured with respect to their interest in contract wish the Named Insured , CERTIFICATE tr wept CANCELLATION X1TA22'.ATC SHOULD ANY OF THR AVOW MCA18CO POLCM K CANORLL*C ee aaE TNII 119FIRA DATR TMIMOF, THE 11901«0INSURRP 1V1LL ENDRAVOA TO WWI, 30 DAY* WRrrW NOTICE TO VP% CARTIFIC,ATE HOLOOR NAM*P 1p ?MR \EFTr BVr FAILM TO 00 90 IM" Indian River County INOMNQOBLIGATION ORWWLtrYOFANY MIND UPON TIM It OPI, ftAr,.RNTSOR 1640 2 8th Street NEPR5m- TATNitI Vera leach FL 32460 AUT CPRBIRR6" TA VIE ACO)tO 25 r40it06) 0 ACORD CORPORATION 1 !N NU . 4104 Gua AcIaM. CERTIFICATE OF LIA131LITY INSURANCEVATf1VWOWYVY~, IJ - 12,114 / 03 PRoova� TMS CBRTIFICATS I$ ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Florida Hospital Ae4eoc Yns1 Svc HOLDER. THIS CERTIFICATE DOES NOTAMEND, EXTEND OR 1675 Terrell Mill ad * ALTER TME COVERAGE AFFORDED BY THE POLICIES BELONG Ma>rieths GA 30067 Phoa. : 800 - 476 - 7601 Pax : 770 . 850woos $ INSURERS AFFORDING COVERAGE Nom * INSURaRAI craRtaa6�1 CAnwLV 1ro+'r1�7' INSURER ed India& River Memorial Hospital Greg xokvxn 10 (JD 36tS 9tre� I Vero Seaeb, AL 3980 INSUREN6�— w�URf R Q; COK"9s THE POLICIES OF MRANCE LISTED BELOW HAVE BEEN ISSVED TO THE INSL47ED NAND MOVE FOR THE FOXY PQRIDTJ INDICAT6C, NOTW17HSTANOING ANY RECI1MRI!HY, TERM Olt CONDITION OF ANY CONTRAOr OR OTHER DO06WENT WITH RE$PPCTTD WHICH TM13 QFRTICIOATE MAY DE 15"D OR WAY PERTAIN, THC IN/URANCC AFFOIIb=O by THE PCL CRS 00CF06E0 wRRCM113 5ueJECT TC AIA r E 75MM, MXCLU910N8 AND CAHORIONL OF SUCH 10061=9 A00MOAffL 04fT3 e441OWN MAT HAVC eGSN A806 0 AY PAIO CLAIM/. rm "oupa a PDtAQY NUM/ORp LIMITS �•• OW/IUu LULNILITY C1AC11 OCCURRENCE f 1 COIAMEJICULL OENGRAL LIAeILJTY I 1 aC aueReCt € —� CLAVA MAOC L71 OCCUR I MED PX° tM�al16 PMOR) $ _._. _ �� ... 3ERSDMALtA0VINARY S i �WNLRAL AGMQATE S GEN1 ASMOATI JECT MPLrt3P8R PROOWnwCOIA" AGG 15 MUCYSECT LOC 7 lIN>RLTTY j COMBINED &MLE LIMIT ANY AVTO Ise Geed") S ALL CFW14ED AUTOS BODILY IMJ1RY SCMEOVI.EOAUTOS I IPwWe'dNi I f 11000 AUT03 /001LY INJURY : Nowsow"ED AVTIOS I ¢1r eceleee0 � - --•••--�«- - I � F'ROPERIYOAMegGE _ (Per Gwim It CARA= 40JIUrV AM ONLY . FA ACCIDENT / .� -I ANY AUTO OTHER THAN , ..^, € AVTOONLY; A00 _ /%Cf?i/RJNPRlLIJ111AiJLRY I CACH OCCURRENCE s OCCVR a CulMannnoE AOGREGAW f I S 19DUCTEL€ + / it WTENTIoN M/ORIC € COMPENSATIONAND XLTDy�M ER arPLovEFle LraelLrY A w - ] 28588436i01 / 01/ 06ANPROPRIFTOPWAp CUTIVE CL. FArMA==NT 1.s1 , 0001 Boo O>:FrwWMEWER EX 1450T I Vf?1. OISf11JE EA EMPLOYE € iz . 000 000 - VQ, deWIkM unQer aPECALPROV64ON/ MNw cL. OI/CWsE • r*OLICVLIMIT s l 000 , 000 GTH/R I i I MPCIOfIt OF OPlRATIORS / LOCATR)NS f YlMIe.L.eS ' lXCLU910N9 ADCfb Gv ENDORSlMlNT 1 rpCCIAL PROVI910NS PrOQ9 of ravccA$r0 Zar Iadian River MealoriaX llfospital . CGKTIFICATE HOLDER CANCELLATION I)MIA NC GNCULP ANY of TME AAOVE 0"OIk1tEb PWCILS De CANO1LL1W /L'FORE TNCEMPMA DATE 7NER60F,, THE ISSURYO INeVRER WILL /NDeiAVO" TO %V6 30 PAYS WWMpj NOTICE TO THE COWW1609 HOLDER NAMD TO "IP LEFT, Or PALLft TO 17230 SN'AL: xn4t alk xive r county IMPOSE NO 06UCA71014 0R l.IAMLFTY0f1 ANY HIND UPON THE N/UREA, ITS AGWS OR 1040 45th Street REGae AT'1'$v � .�.. _ Vero Suac}S FL 32960 AUTIJft A VE Ito ACORG ZS f20alloe) ACORa CORPORATIOIII Mg