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DocuSign Envelope ID: 5F353138-C664-4703-97A3-A28BCE0500B7 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> m) Program Budget -ATTACHED <br /> 1. Program Budget Detail — Provide description of"other" budget items, not defined. <br /> Other Expenses 2017-18 <br /> Workers Compensation $2,000.00 <br /> Payroll Service $1,500.00 <br /> Background Checks $500.00 <br /> Bookkeeping $1,920.00 <br /> Contract Services $12,110.00 <br /> Bank Service Charges $100.00 <br /> Insurance— General liability, property, D&O, professional liability $3,300.00 <br /> Membership & Professional Dues $500.00 <br /> Marketing & Development $2,000.00 <br /> Translation/Interpretation (20 hours) $550.00 <br /> Total "other expenses" $24,480.00 <br /> 2. This program budget represents what percent of the agency budget? 100% <br /> 3. COST PER INDIVIDUAL <br /> This Cost per Individual must reflect the total program budget divided by the total number of program <br /> individuals in this application. <br /> Actual 2015-16 Estimated 2016-17 Projected 2017-18 <br /> Total Cost of Program 249,841 291,544 297,187 <br /> Total # of Individuals 1072 1200 1200 <br /> Cost Per Individual 233 243 248 <br /> We define "# of individuals" in terms of weighted Units of Service. <br /> UNIT OF SERVICE: reflects the services each student receives in terms of 1:1 time with the <br /> licensed clinical staff, `dosage' of services they receive with guest speakers, group sessions <br /> and academic engagement (tutoring, communicating with teachers, follow-up support), as <br /> well as after school programming (community service, service learning, What's Next?, drop- <br /> in brief crisis counseling, schoolwork help). <br /> 2015-16 <br /> 1 Student 2-4 day ATS = 1 unit of service = 96 units <br /> 1 Students -7 day ATS = 2 units of service = 43x2 = 86 units <br /> 1 Student 8-10+ day ATS = 3 units of service = 28x3 = 84 units <br /> 1 Student Instance CS/SL = 1 unit of service = 382 units <br /> 1 Student receiving intensive follow-up services = 3 units of service = 12x3 = 36 units <br /> 1 Student instance attending What's Next? = 1 unit of service = 102 units <br /> 1 Student instance receiving after school tutoring = 2 units of service = 24x2 = 48 units <br /> 1 Student attending Open Doors (drop in, brief crisis counseling) = 1 unit of service = 238 units <br /> Page 15 of 15 <br />