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DocuSign Envelope ID:4D553CF7-2BBD-4F4E-B84E-E6B8B077A9AB <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) <br /> Program Name: 24/365/7 Urgent Behavioral Health Care (Facility-Based Crisis and Detox) <br /> Program Primary Contact and Title: Trish Hussey <br /> Telephone Number: 919-942-2803 E-Mail: trish.h(a.fhrecovery.org <br /> a) Indicate the type of Human Service Needs Priority, if program applicable: <br /> ® Priority Area #1: safety-net services for disadvantaged residents <br /> C Priority Area #2: education, mentorship, and afterschool programming for <br /> youth facing a variety of challenges <br /> ® Priority Area #3: programs aimed at improving health and nutrition of needy residents <br /> b) Indicate the type of program for which you are requesting funding <br /> (Check all that apply to this program) <br /> Public Housing <br /> Program Category Youth Adult Elderly Disabled Neighborhoods/Residents <br /> Affordable Housing <br /> Affordable Healthcare X X X X <br /> Education X X X X <br /> Family Resources X X X X <br /> Jobs/Jobs Training <br /> Food <br /> Transportation X X X X <br /> Other: Please specify <br /> c) Provide a bulleted list of other agencies, if any, with which your agency <br /> coordinates/collaborates to accomplish or enhance the Projected Results in the Program(s) <br /> to be funded. For each, briefly describe the coordinated/collaborative efforts. <br /> • Local EMS: to recognize individuals who are in a mental health or substance <br /> use crisis but not in need of emergency medical services and bring them to our <br /> Urgent Behavioral Healthcare Unit <br /> • Orange County Health Department and Carolina Health Net: to refer <br /> indigent clients to a medical home, as well as to provide primary health care to <br /> indigent clients within our Freedom House Integrated Care Clinic. <br /> • Local police and Sheriff's departments CIT (Community Intervention <br /> Training) project: to train law officers to understand more fully how to work <br /> with individuals in our community who are chronically mentally ill or addicted. <br /> • Orange Rape Crisis: to provide the needed support for women who come to <br /> us with recent and historical sexual abuse. <br /> • Interfaith Council: to provide behavioral health care to their homeless clients. <br /> • Interfaith Food Shuttle: to provide fresh and healthy food for our residential <br /> clients. <br /> DO NOT SUBMIT THIS PAGE 1/31/2017 11:11:58 AM Page 9 of 37 <br />