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2021 Treatment Funding
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Steps
1.
Requirements
(current)
This section is complete
This section is incomplete
2.
Contact Information
This section is complete
This section is incomplete
3.
Program Location(s)
This section is complete
This section is incomplete
4.
Levels of Services
This section is complete
This section is incomplete
5.
Recovery Houses Only
This section is complete
This section is incomplete
6.
Program Summary
This section is complete
This section is incomplete
7.
Logic Model
This section is complete
This section is incomplete
8.
Annual Outcomes
This section is complete
This section is incomplete
9.
Outcome Measurements
This section is complete
This section is incomplete
10.
Program Budget
This section is complete
This section is incomplete
11.
Unit Pricing
This section is complete
This section is incomplete
12.
Attachments
This section is complete
This section is incomplete
13.
Submission
This section is complete
This section is incomplete
Requirements
Important
To submit this form you do not have to sign in or create a Form Center account above. However, you will have to complete the form in its entirety without the option to save your progress unless you do create an account.
Creating A Form Center Account
» Form Center Creation Instructions
Use this link for instructions about how to create a Form Center account. Creating an account will enable you to save your progress while completing a form.
Name Of Your Organization/Agency
*
Name Of Program
*
Name of program for which you are applying for funding.
2021 Substance-Use Disorder Treatment Application
The objectives of the COMBAT Substance-Use Disorder Treatment funding application is to provide treatment services with an over reaching goal of achieving the following general outcomes for those who use drugs:
1) Counseling and/or medical-assisted programs leading to long-term recovery from drug use;
2) Retention in treatment for a period of time that maximizes treatment effects;
3) Improved employment and/or educational status;
4) Elimination of criminal behavior;
5) Improved family relationships and living environment; and
6) Creation or enhancement of a social support system that is conducive to recovery
Requirements
ALL Requirements Must Be Met At Time Of Applying
IMPORTANT:
The online application program will not permit you to continue to the next section of the website until you complete the section on which you are working.
Jackson County Requirments
A) Tax Clearance Required:
Chapter 10, 1003 of the Jackson County Codes states “No person, firm or corporation, residing in Jackson County, or otherwise legally within the taxing jurisdiction of the County, shall be eligible to provide any goods, contractual services or anything covered by this chapter, unless that person, form or corporation is duly listed and assessed on the County tax rolls and is in no way delinquent on any taxes payable to the County” (Ord. 3839, Eff. 11/28/06). Tax Clearance is required for all applicants applying for funding.
B) Goal for Minority Hiring and Employment:
Chapter 93, 9304 of the Jackson County Code regarding COMBAT states “Any proceeds from the Anti-Drug Sales Tax creating jobs and employment shall have a twenty percent goal for minority hiring and employment” (Ord. 1795, Sec. 4; Ord. 1941). Since this is a specific requirement for COMBAT, it is required during the application period and will be monitored.
Each funded organization must provide evidence of
liability insurance
coverage during the time of award of funding from Jackson County.
Applicant organizations must have on file a
Compliance Certificate
from Jackson County before any funding may be awarded.
Certificate Link
Jackson County Compliance Certificate Link
Use this link to complete certification
COMBAT Requirements
A)
Any organization requesting COMBAT funding must provide services to Jackson County residents in Jackson County.
B)
Applicant organizations must provide a copy of a letter from the Internal Revenue Service indicating current 501.c.3 tax-exempt status.
C)
Applicant organizations must provide proof of current Good Standing with the MO Secretary of State.
D)
An applying agency must have been in existence for at least two years.
E)
Applicant organizations must provide a copy of a certified financial audit (within the past two fiscal years).
F)
Applicant organizations must provide a copy of a current IRS form 990 (within past two years) or extension letter.
G)
COMBAT funding is provided on a reimbursement basis, available upon submission of receipts and proof of payment. It is strongly suggested that applicants have at least 10% of their program budget from other sources to provide these up-front funds.
H)
COMBAT funds cannot be used for capital purchases.
I)
COMBAT requires that all agencies receiving funding for Treatment services be certified by the State of Missouri, Division of Alcohol and Drug Abuse, or accredited or licensed by a nationally recognized accreditation/licensure organization, to provide substance-use disorder treatment services.
J)
COMBAT requires that substance-use disorder treatment programs receiving COMBAT funding must accept referrals from Jackson County Drug Court.
K)
All counseling services for substance-use disorder treatment must be delivered by individuals who are either Licensed or Certified Counselors as defined by the Missouri Division of Alcohol and Drug Abuse according to Certification Standards for Alcohol and Drug Abuse Program, 9 CSR 30-3.110 Section 6.
L)
All COMBAT funded programs must participate in designated reporting systems to track information on COMBAT funded clients and services, including demographics.
M) Background screening
must be performed on all persons providing direct services (paid treatment staff and/or volunteers) prior to their providing direct services in accordance with 9 CSR 10-5.190. Evidence of such checks, and the results obtained, must be kept in the organization’s personnel files and be available for review by COMBAT staff.
Staff Requirements
A)
All counseling services must be delivered by individuals who are either
Licensed
or
Certified Counselors
as defined by the Missouri Division of Alcohol and Drug Abuse according to
Certification Standards for Alcohol and Drug Abuse Program, 9 CSR 30-3.110 Section 6.
Interns cannot be substituted for licensed or certified counselors and if used, must be supervised during sessions.
B)
Any staff person providing
family counseling
must be qualified to provide family counseling according to
Certification Standards for Alcohol and Drug Abuse Program, 9 CSR 30-3.110 Section 6.
C)
Any staff person providing counseling services to
adolescents
must be qualified according to pages 56-58,
Certification Standards for Alcohol and Drug Abuse Program, 9 CSR 30-3.192.
D)
Any staff members providing therapeutic day care, children’s activities, or children’s learning groups must be qualified according to
Certification Standards for Alcohol and Drug Abuse Program 9 CSR 30-3.190.
Acknowledgement
*
I have read all requirements for 2021 COMBAT Substance-Use Disorder Treatment funding.
Agreed
Continue
Contact Information
Contact Information
Organization
*
Name Of Program
*
Treatment program that would receive COMBAT funding
Funding Request
*
Amount of COMBAT funding being applied for
Organization's Mailing Address
*
City
*
State
*
Zip Code
*
Phone
*
Website Address
*
Write "NONE" if no site exists
Primary Contact
Person preparing and submitting this application
Name
*
Title
*
Phone
*
e-mail
*
COMBAT Program Director
Individual who will directing program that would receive COMBAT funding
Name
*
Phone
*
e-mail
*
Organization's Executive Director
Name
*
Phone
*
e-mail
*
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Program Location(s)
Program Service Locations
Address(es) where program services will be provided. List only those locations where the COMBAT-funded program's services will be available, not all locations where your organization provides services.
Location 1
Location Type
*
-- Select One --
Community-Based Agency
Community Center
Community Mental Health Center
Substance Abuse Agency
School
Church
Other
Other
*
If you selected other under "Location Type," specify that location type here.
Name
Include name of commuinity center, school, church, etc. if applicable.
Physical Address
*
City
*
State
*
Zip
*
Program Phone
*
Description of services to be provided at this site
*
Location 2
Location Type
-- Select One --
Community-Based Agency
Community Center
Community Mental Health Center
Substance Abuse Agency
School
Church
Other
Other
If you selected other under "Location Type," specify that location type here.
Name
Include name of community center, school, chruch, etc. if applicable
Physical Address
City
State
Zip
Program Phone
Description of services to be provided at this site
Location 3
Location Type
-- Select One --
Community-Based Agency
Community Center
Community Mental Health Center
Substance Abuse Agency
School
Church
Other
Other
If you selected other under "Location Type," specify that location type here.
Name
Include name of commuinity center, school, church, etc. if applicable.
Physical Addresss
City
State
Zip
Program Phone
Description of services to be provided at this site
Location 4
Location Type
-- Select One --
Community-Based Agency
Community Center
Community Mental Health Center
Substance Abuse Agency
School
Church
Other
Other
If you selected other under "Location Type," specify that location type here.
Name
Include name of commuinity center, school, church, etc. if applicable.
Physical Address
City
State
Zip
Program Phone
Description of services to be provided at this site
Location 5
Location Type
-- Select One --
Community-Based Agency
Community Center
Community Mental Health Center
Substance Abuse Agency
School
Church
Other
Other
If you selected other under "Location Type," specify that location type here.
Name
Include name of commuinity center, school, church, etc. if applicable.
City
State
Zip
Program Phone
Description of services to be provided at this site
Location 6
Location Type
-- Select One --
Community-Based Agency
Community Center
Community Mental Health Center
Substance Abuse Agency
School
Church
Other
Other
If you selected other under "Location Type," specify that location type here.
Name
Include name of community center, school, church, etc. if appliciable.
City
State
Zip
Program Phone
Description of services to be provided at this site
Location 7
Location Type
-- Select One --
Community-Based Agency
Community Center
Community Mental Health Center
Substance Abuse Agency
School
Church
Other
Other
If you selected other under "Location Type," specify that location type here.
Name
Include name of community center, school, church, etc. if appliciable.
City
State
Zip
Program Phone
Description of services to be provided at this site
Location 8
Location Type
-- Select One --
Community-Based Agency
Community Center
Community Mental Health Center
Substance Abuse Agency
School
Church
Other
Other
If you selected other under "Location Type," specify that location type here.
Name
Include name of community center, school, church, etc. if appliciable.
City
State
Zip
Program Phone
Description of services to be provided at this site
Location 9
Location Type
-- Select One --
Community-Based Agency
Community Center
Community Mental Health Center
Substance Abuse Agency
Schoo
Church
Other
Other
If you selected other under "Location Type," specify that location type here.
Name
Include name of community center, school, church, etc. if appliciable.
City
State
Zip
Program Phone
Description of services to be provided at this site
Location 10
Location Type
-- Select One --
Community-Based Agency
Community Center
Community Mental Health Center
Substance Abuse Agency
School
Church
Other
Other
If you selected other under "Location Type," specify that location type here.
Name
Include name of community center, school, church, etc. if appliciable.
City
State
Zip
Program Phone
Description of services to be provided at this site
Location 11
Location Type
-- Select One --
Community-Based Agency
Community Center
Community Mental Health Center
Substance Abuse Agency
School
Church
Other
Other
If you selected other under "Location Type," specify that location type here.
Name
Include name of community center, school, church, etc. if appliciable.
City
State
Zip
Program Phone
Description of services to be provided at this site
Location 12
Location Type
-- Select One --
Community-Based Agency
Community Center
Community Mental Health Center
Substance Abuse Agency
School
Church
Other
Other
If you selected other under "Location Type," specify that location type here.
Name
Include name of community center, school, church, etc. if appliciable.
City
State
Zip
Program Phone
Description of services to be provided at this site
More
Additional Locations
If more than 12 program addresses, please list remainder here with name, street address, city, state, zip and phone number.
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Levels of Services
Levels Of Service
Check All That Apply
*
2021 Proposal
Level 1 - Social Setting/Modified Medical Detoxification
Level 2 - Residential Inpatient
Level 2 - Partial Hospitalization Treatment
Level 3 - Drug Counseling
Level 4 - Intensive Outpatient Treatment
Level 5 - Medically Managed Intensive Inpatient Treatment
Level 6 - Medically Monitored Intensive Inpatient Treatment
Level 7 - Recovery House
Definitions
Definitions Of Service Levels
Recovery House
*
If you selected "Level 7 - Recovery House" above, you must select at least 1 of 3 levels here:
Recovery House Level I
Recovery House Level II
Recovery House Level III
Definitions
Recovery House Definitions
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Recovery Houses Only
Recovery House Only!
What services are povided in the Recovery House?
How many clients will you house at the Reovery House?
Who will be your live-in monitor? What are their qualifications?
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Program Summary
Program Summary
I) Program or Level of Service(s) Description
Please discuss program or level of service(s) Purpose Statement:
The purpose of a program or level of service(s) is to achieve outcomes. It is driven by audience needs and considerations (for whom) It provides a solution to meet those needs (what we do) It fulfills the organization's mission. It defines audience, activities, services, and outcomes.
Please discuss program or level of service(s) goal(s):
Goals are typically broad general statements that describe what the program or level of service(s) plan to accomplish. Goals, establish the overall direction for and focus of a program or level of service(s). Goals define the scope of what the program or level of service(s) should achieve and serves as the foundation for developing program or level of service(s) objectives.
Please discuss the Need:
What problem or opportunity does the program or level of service(s) addresses? Who experiences it?
List prevalent risk-factors that will be addressed in your 2020 proposal.
List which protective-factors will be utilized in buffering prevalent risk-factors.
Expected Effects:
What changes resulting from the program or level of service(s) are anticipated?
What must the program or level of service(s) accomplish to be considered successful?
Intervention Activities:
What steps, strategies, or actions will the program or level of service(s) take to effect change?
Summary
*
Briefly describe your program, addressing the areas you selected on the Cover page. If funded, this will be the program description used by COMBAT on our website and other publications about our funded programs. Be sure to address your target population, services/activities to be provided and expected outcome of your program.
II) Needs Assessment
What is the Problem leading to the program you are proposing? Describe the needs that you see as associated with this problem, using local and current information:
Needs
*
III) Objectives
What are the issues your program will be addressing in the community?
Objectives - Community Needs
*
IV) Outcomes
Pleasse list 3 specific outcomes you expect for clients in your program/project.
Outcome - 1
*
Outcome - 2
*
Outcome - 3
*
V) Target Population
Describe age, ethnic breakdown, gender and geographical area of clients to be served.
Age
Ages 0-5
% In This Age Group
Ages 6-12
% In This Age Group
Ages 13-17
% In This Age Group
Ages 18-24
% In This Age Group
Ages 25-35
% In This Age Group
Ages 36-44
% In This Age Group
Ages 45-60
% In This Age Group
Over 60
% In This Age Group
Gender
Male
% Of Male Clients
Female
% Of Female Clients
Ethnicity
Percentage of clients expected to serve from each of these ethnic/racial groups.
Hispanic or Latino
White
(Not Hispanic or Latino)
Black or African American
American Indian/Alaska Native
Native Hawaiian
(Or Other Pacific Islander)
Asian
Two or More Races
Geography
Geographical Area Program/Project Will Serve
VI) Getting Clients In The Program
Clients
*
How will you get clients into this program?
VII) Current Referral Sources
Currently what are your major referral sources? Please list number of clients referred from each source.
Referral Sources
*
VIII) Follow-up
What type of follow-up services will you provide?
Follow-up Services
*
At what interval do you follow up with clients?
*
IX) Drug Usage
List the drugs reported by clients in this program so far this year, and the number of clients who have reported using each drug to date.
Drug-Use Reports
*
Include Client Numbers
X) Staff Demographics
Gender
Male
% Of Male Staff
Female
% Of Female Staff
Ethnicity
Percentage of Staff Members from each of these ethnic/racial groups.
Hispanic or Latino
White
(Not Hispanic or Latino)
Black or African American
American Indian/Alaska Native
Native Hawaiian
(Or Other Pacific Islander)
Asian
Two or More Races
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Logic Model
Program Logic Model
Needs / Resources Assessment
Identified Needs
Program Objectives
Implementation
Inputs (Resources)
Outputs / Activities
Outcomes - Impact
Short-Term Outcomes
Medium-Term Outcomes
Long-Term Outcomes
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Annual Outcomes
Annual Outcomes
What outcomes have your clients achieved in each of these areas through July 2020? State in terms of % improvement from total % of clients at Intake vs. Total% for clients at time of discharge
Drug Use
*
As Measured By Drug Testing
Retention In Treatment
*
Continue
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Outcome Measurements
Outcome Measurements
Objective
What Data Will Be Collected?
How Will Data Be Collected?
When Will Data Be Collected?
What Type of Analysis?
Projected Outcomes
Objective
What Data Will Be Collected?
How Will Data Be Collected?
When Will Data Be Collected?
What Type Of Analysis?
Project Outcomes
Objective
What Data Will Be Collected?
How Will Data Be Collected?
When Will Data Be Collected?
What Type of Analysis?
Project Outcomes
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Program Budget
Program Budget Information
Restrictions
1)
COMBAT funds may not be used to provide capital improvements (Article 6, Section 23 of the Mo. Constitution).
2)
Funds may not be used to pay salaries for functions that have traditionally been performed by volunteers.
3)
COMBAT funds may not be used to pay rent, utilities, equipment or for out of town travel.
Personnel (Salaries)
COMBAT Budget
Proposed
Other
Other Funding Amount
Total
Total Cost
Funding Sources
Number of Other Sources
Fringe Benefits
Maximum 10% of Salaries (Describe Benefits Below)
COMBAT Budget
Proposed
Other
Other Funding Amount
Total
Total Cost
Funding Sources
Number of Other Sources
Description of Fringe Benefits
Auditing/Accounting Services
COMBAT Budget
Proposed
Other
Other Funding Amount
Total
Total Cost
Funding Sources
Number of Other Sources
Evaluation
COMBAT Budget
Propsed
Other
Other Funding Amount
Total
Total Cost
Funding Sources
Number of Other Sources
Postage
COMBAT Budget
Proposed
Other
Other Funding Amount
Total
Total Cost
Funding Sources
Number of Other Sources
Printing
COMBAT Budget
Proposed
Other
Other Funding Amount
Total
Total Cost
Funding Sources
Number of Other Sources
Meeting Expense
COMBAT Budget
Proposed
Other
Other Funding Amount
Total
Total Cost
Funding Sources
Number of Other Sources
Mileage (Local Travel)
COMBAT Budget
Proposed
Other
Other Funding Amoung
Total
Total Cost
Funding Sources
Number of Other Sources
Training
COMBAT Budget
Proposed
Other
Other Funding Amount
Total
Total Cost
Funding Sources
Number of Other Sources
Memberships
COMBAT Budget
Proposed
Other
Other Funding Amount
Total
Total Cost
Funding Sources
Number of Other Sources
Insurance
COMBAT Budget
Proposed
Other
Other Funding Amount
Total
Total Cost
Funding Sources
Number of Other Sources
Program Supplies
COMBAT Budget
Proposed
Other
Other Funding Amount
Total
Total Cost
Funding Sources
Number of Other Sources
Indirect (Max. 7% Of Total)
COMBAT Budget
Proposed
Other
Other Funding Amount
Total
Total Cost
Funding Sources
Number of Other Sources
Other
Specify
COMBAT Budget
Proposed
Other
Other Funding Amount
Total
Total Cost
Funding Sources
Number of Other Sources
Other
Specify
COMBAT Budget
Propsed
Other
Other Funding Amount
Total
Total Cost
Funding Sources
Number of Other Sources
Other
Specify
COMBAT Budget
Proposed
Other
Other Funding Amounts
Total
Total Cost
Funding Sources
Number of Other Sources
TOTAL PROPOSED BUDGET
COMBAT Budget
Proposed
Other
Other Funding Amount
Total
Total Cost
Funding Sources
Number of Other Sources
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Unit Pricing
Unit Pricing
Note
Level 1, 2 and 3 services are paid on an all-inclusive per diem rate.
Level 1 - Social Setting/Modified Medical Detoxification
Clients
Number Expected To Serve
Units
Number of Units
Unit Price
Total Amount
Units x Unit Price
Level 2 - Residential Inpatient
Clients
Number Expected To Serve
Units
Number of Units
Unit Price
Total Amount
Units x Unit Price
Level 2 - Partial Hospitalization Treatment
Clients
Number Expected To Serve
Units
Number of Units
Unit Price
Total Amount
Units x Unit Price
Level 3 - Drug Counseling
Clients
Number Expected To Serve
Units
Number of Units
Unit Price
Total Amount
Units x Unit Price
Level 4 - Intensive Outpatient Treatment
Clients
Number Expected To Serve
Units
Number of Units
Unit Price
Total Amount
Units x Unit Price
Level 5 - Medically Monitored Intensive Inpatient Treatment
Clients
Number Expected To Serve
Units
Number of Units
Unit Price
Total Amount
Units x Unit Price
Level 6 - Medically Monitored Intensive Inpatient Treatment
Clients
Number Expected To Serve
Units
Number of Units
Unit Price
Total Amount
Units x Unit Price
Recovery House Level 1
Clients
Number Expected To Serve
Units
Number of Units
Unit Price
Total Amount
Units x Unit Price
Reovery House Level 2
Clients
Number Expected To Serve
Units
Number of Units
Unit Price
Total Amount
Units x Unit Price
Recovery House Level 3
Clients
Number Expected To Serve
Units
Number of Units
Unit Price
Total Amount
Units x Unit Price
Assessment
Clients
Number Expected To Serve
Units
Number of Units
Unit Price
Total Amount
Units x Unit Price
Group Counseling
Clients
Number Expected To Serve
Units
Number of Units
Unit Price
Total Amount
Units x Unit Price
Group Education
Clients
Number Expected To Serve
Units
Number of Units
Unit Price
Total Amount
Units x Unit Price
Family Therapy
Clients
Number Expected To Serve
Units
Number of Units
Unit Price
Total Amount
Units x Unit Price
Individual Therapy
Clients
Number Expected To Serve
Units
Number of Units
Unit Price
Total Amount
Unit x Unit Price
Therapeutic Child Care
Clients
Number Expected To Serve
Units
Number of Units
Unit Price
Total Amount
Units x Unit Price
Children's Supportive Care
Clients
Number Expected To Serve
Units
Number of Units
Unit Price
Total Amount
Units x Unit Price
Community Support
Clients
Number Expected To Serve
Units
Number of Units
Unit Price
Total Amount
Units x Unit Price
Drug Testing
Clients
Number Expected To Serve
Units
Number of Units
Unit Price
Total Amount
Units x Unit Price
Other
Clients
Number Expected to Serve
Units
Number of Units
Unit Price
Total Amount
Units x Unit Price
Specify "Other" Services
TOTAL
Clients
Number Expected To Serve
Units
Number of Units
Unit Price
Total Amount
Units x Unit Price
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Attachments
Required Documents
MUST BE PROVIDED
These documents MUST be attached in the spaces below before submitting. PDF, Word and Excel documents are accepted.
Attachment 1
*
Jackson County Compliance Report Form completed and signed or existing certificate (if you have one).
Download This Form (PDF)
Attachment 2
*
Copy of Paid Jackson County Property tax receipt or current exemption certificate.
Attachment 3
*
Copy of evidence of liability insurance coverage for at least $1 million.
Attachment 4
*
Copy of current IRS Form 990 (within past two fiscal years 2018 or 2019).
Attachment 5
*
Copy of full Certified Financial Audit (within past two fiscal years 2018 or 2019).
Attachment 6
*
Copy of letter indicating current IRS 501(c)(3) tax-exempt status (if applicant is not a governmental agency, e.g., city, school district or court in Jackson County).
Attachment 7
*
Certificate of Good Standing from the Missouri Secretary of State.
Attachment 8
*
List of Staff with titles and copies of certifications
Attachment 9
*
List of Board of Directors
Partnership Letter
Program Summary: XI) Key Partners
You must include a current letter stating that these partners are aware that they will be part of a COMBAT project.
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Submission
Acknowledgement
*
By clicking "Agree," you agree and acknowledge that information and statements provided in this application are, to the best of your knowledge, true and accurate.
Agree
By typing your name in the "Signature" box below, you acknowledge that this "electronic signature" is valid and binding upon you to the same force and effect of a traditional handwritten signature.
Signature
*
Date
*
Date
Leave This Blank:
Receive an email copy of this form.
Email address
This field is not part of the form submission.
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