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DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> groups at assisted living facilities, and adults with severe and persistent mental illness. <br /> Through all of our programming, we provided art therapy services to over 500 individuals in <br /> the community in 2016. In addition, we provided workshops and trainings to over 40 <br /> professionals through our continuing education series. We have a proven track record of <br /> being fiscally responsible in order to support a wide range of services. We work to get art <br /> supplies donated whenever possible and continuously pursue diverse funding streams in <br /> order to increase our program sustainability. We have created a committed community <br /> supporting our work, who attends our art shows and community fundraisers in large <br /> numbers, and continues to volunteer, intern, and donate time and funding with ATI in <br /> growing capacity as we continue to utilize a wide variety of resources and talent. <br /> e) Other Pertinent Agency Information <br /> Over the past several years, ATI has undergone extensive capacity building with three <br /> separate contracts through the Executive Service Corp (ESC) of the Triangle. We have <br /> undergone strategic planning including a SWOT analysis, a revised mission and vision, and <br /> a case statement, which we in turn used for board development. This board development <br /> began with outreach into the community with the goal of finding diverse and qualified <br /> individuals committed to our mission and we now have a fully functioning, working board <br /> (10 people). Finally, an executive coaching contract for our ED, which lasted an entire year, <br /> ensured that we increased our ability to grow in a sustainable manner with strong <br /> leadership at the helm. We have hosted two annual board development meetings, board <br /> and clinician retreats, and are currently working on our next 5-year strategic planning cycle <br /> to incorporate all of our work up to now into our guiding document. In addition, ATI has <br /> brought all of our insurance billing in house and hired two of our contracted staff members <br /> as employees to continue to passionately carry out our mission in a sustainable way. <br /> Intentionally, we have grown slowly and with realistic goals and ideas about this expansion <br /> to ensure that we continue to serve our clients and our community for years to come. <br /> f) Schedule of Positions (For Entire Agency) <br /> • Full Time Equivalent (FTE) <br /> • Calculate a Full Time Equivalent for all recorded volunteer hours using the following: <br /> Total Volunteer Hours = Volunteer FTE / 2080 <br /> # of FTE - Full-Time Paid Positions: 3 <br /> # of FTE - Paid Part-Time Positions: 4 <br /> # of Volunteers: 103 # of FTE - Volunteers: 5 <br /> g) Living Wage <br /> Does this agency pay permanent employees a minimum living wage? (Yes/No) Yes <br /> If yes, is this agency an Orange County Living Wage Certified Employer? We applied <br /> h) Agency Budget <br /> i. Is your agency currently receiving and/or requesting other local government <br /> funding? No <br /> ii. Submit your agency's budget. You may complete the provided template (separate <br /> xis file) or you may submit your own budget file). Attached <br /> iii. Does your agency budget show a Surplus or Deficit? Surplus <br /> Is there a significant change? Yes/No No <br /> iv. What is your agency's fiscal year? Jan. 1, 2016-Dec. 31, 2016 <br /> Agency Information 2/8/2017 3:01:12 PM Page 9 of 20 <br />