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DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) <br />Program Name: Club Nova <br />Program Primary Contact and Title: Steven Warnock, Associate Director of Program <br />Telephone Number: 919- 968 -6682 <br />E -Mail: admin(@,clubnova.org <br />a) Indicate the type of Human Service Needs Priority, if program applicable: <br />M 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 />b) Indicate the type of program for which you are requesting funding <br />(Check all that apply to this program) <br />* *Club Nova works with adults 78+ who live with serious mental illness. <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 />Mental health Care Services- Club Nova Community, Inc. coordinates its' services with <br />other agencies involved with our members. For example, some of our members receive <br />outpatient services from the UNC Center for Excellence in Mental Health. When members <br />and staff create their person centered plan, we include the psychiatrist and therapist's input <br />in the plan. The psychiatrist will sign the Person Centered Plan for our service order, <br />meaning the psychiatrist agrees that our services are needed. We maintain periodic contact <br />to review progress and to exchange any needed information. Some of our partners include: <br />■ UNC Center for Excellence in Mental Health, including Assertive Community <br />Treatment Team (ACTT), STEP, and Oasis <br />UNC Department of Psychiatry and Walk -In Clinic <br />PROGRAM INFORMATION 1/23/2018 1:58:29 PM Page 1 4 o f 31 <br />Public Housing <br />Program Category <br />Youth <br />Adult <br />Elderly <br />Disabled <br />Neighborhoods /Residents <br />Affordable Housing <br />X <br />Affordable Healthcare <br />X <br />Education <br />X <br />Family Resources <br />Jobs /Jobs Training <br />X <br />Food <br />X <br />Transportation <br />X <br />Other: Please specify <br />Crisis Prevention and <br />Intervention <br />- Outreach <br />- Benefits and Entitlements <br />-Supported Housing <br />X <br />* *Club Nova works with adults 78+ who live with serious mental illness. <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 />Mental health Care Services- Club Nova Community, Inc. coordinates its' services with <br />other agencies involved with our members. For example, some of our members receive <br />outpatient services from the UNC Center for Excellence in Mental Health. When members <br />and staff create their person centered plan, we include the psychiatrist and therapist's input <br />in the plan. The psychiatrist will sign the Person Centered Plan for our service order, <br />meaning the psychiatrist agrees that our services are needed. We maintain periodic contact <br />to review progress and to exchange any needed information. Some of our partners include: <br />■ UNC Center for Excellence in Mental Health, including Assertive Community <br />Treatment Team (ACTT), STEP, and Oasis <br />UNC Department of Psychiatry and Walk -In Clinic <br />PROGRAM INFORMATION 1/23/2018 1:58:29 PM Page 1 4 o f 31 <br />