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DocuSign Envelope ID:4D553CF7-2BBD-4F4E-B84E-E6B8B077A9AB <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> Program Name: Community Mental Health Programs: Pro Bono Counseling Network, Compeer and <br /> Family Advocacy Network <br /> Program Primary Contact and Title: Trish Hussey <br /> Telephone Number: 919-942-2803 E-Mail: trish.h(cfhrecovery.orq <br /> aa) Indicate the type of Human Service Needs Priority, if program applicable: <br /> Priority Area #1: safety-net services for disadvantaged residents <br /> ❑ 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 /> bb)Indicate the type of program for which you are requesting funding <br /> (Check all that apply to this program) <br /> Program Category Youth Adult Elderly Disabled Public Housing <br /> Neighborhoods/Residents <br /> Affordable Housing <br /> Affordable Healthcare X X X X X <br /> Education X X X X X <br /> Family Resources X X X X X <br /> Jobs/Jobs Training <br /> Food <br /> Transportation <br /> Other: Please specify <br /> cc)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 /> • UNC CECMH (Center for Excellence in Community Mental Health) — <br /> When PBCN staff screen a client who has severe and persistent mental <br /> illness, such as Bipolar Disorder or psychosis, a referral is made to UNC <br /> CECMH. The majority of Compeer referrals come from staff at the UNC <br /> CECMH in the Dept. of Psychiatry. <br /> • Club Nova — Many Compeer Friends are also members of Club Nova. Club <br /> Nova staff also help coordinate Compeer referrals. <br /> • Juvenile Court — FAN receives many of its referrals through Juvenile Court, <br /> and provides feedback and reports to Juvenile Court Counselors regarding <br /> parent involvement in FAN services and improved functioning at home, school <br /> and in the community for their children. <br /> • Orange County Department of Social Services (DSS) — FAN collaborates <br /> with DSS by providing parent skills building training to parents referred by <br /> DSS social workers, utilizing the "Common Sense Parenting" best practices <br /> curriculum and providing one-on-one support to help referred clients be <br /> compliant with court or department orders. <br /> DO NOT SUBMIT THIS PAGE 1/31/2017 11:11:58 AM Page 26 of 3 <br />