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DocuSign Envelope ID:4D553CF7-2BBD-4F4E-B84E-E6B8B077A9AB <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> Work Statement <br /> mm) Complete the Work Statement Chart to describe the work to be performed. <br /> This chart is used to document program activities, program goals, performance measures, <br /> and actual results. (Add more rows as needed) If this is a new program, you will only <br /> document the projected information. Every program is required to have AT LEAST 1 Program <br /> Activity, which should be SMART (Specific, Measurable, Achievable, Relevant, and Time- <br /> bound. Click on SMART Goals to learn more. <br /> • Program Activities should outline major activities the agency implements to accomplish its <br /> program goals. (i.e. Deliver meals to elderly/disabled residents.) <br /> • Program Goal should explain what the program is trying to achieve/accomplish. Goals are <br /> statements about what the program should accomplish. (i.e. Deliver 100 meals per day, <br /> Monday-Friday.) <br /> • Performance Measures describe how you will evaluate the degree in which you achieved <br /> the stated goals. (i.e. Will track the number of meals delivered each day.) <br /> • Actual Program Results use program results to indicate the actual measureable <br /> achievement of goals. If goals were not met, please explain. (i.e. Delivered an average of <br /> 105 meals per day.) <br /> Work Statement Chart for Program: Community Mental Health Programs <br /> 7. Program Activity Name PBCN staff will develop and maintain a sufficiently large <br /> network of volunteer licensed mental health providers, <br /> screen and assess callers and match callers with an <br /> appropriate provider for treatment. <br /> Program Goal Uninsured or underinsured Orange County residents will <br /> experience improvement in their mental health <br /> symptoms as a result of receiving 8 free psychotherapy <br /> sessions from a volunteer PBCN therapist. <br /> Performance Measures PBCN volunteer therapists provide feedback regarding <br /> the number of sessions attended, current <br /> outcome/status of each case and availability for <br /> additional PBCN referrals. <br /> Previous Year Program Results 100 individuals received 8 free counseling sessions <br /> from a licensed mental health professional, resulting in <br /> 800 hours of volunteer treatment, for an equivalent of <br /> $80,000 in cost. <br /> Current Year Estimated Results 115 individuals received 8 free counseling sessions <br /> from a licensed mental health professional, resulting in <br /> 920 hours of volunteer treatment, for an equivalent of <br /> $92,000 in cost. <br /> Next Year Projected Results 117 individuals received 8 free counseling sessions <br /> from a licensed mental health professional, resulting in <br /> 936 hours of volunteer treatment, for an equivalent of <br /> $93,600 in cost. <br /> 8. Program Activity Name PBCN staff conduct a clinical evaluation of the client's <br /> DO NOT SUBMIT THIS PAGE 1/31/2017 11:11:58 AM Page 33 of 37 <br />