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DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> Work Statement <br /> m) 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 <br /> Program Activity, which should be SMART(,apecific, Measurable, Achievable, Relevant, and <br /> Time-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: Newcomer's Art Therapy Program <br /> 1. Program Activity Name Newcomer's Art Therapy Program <br /> Program Goal Reach and Retention <br /> Performance Measures Session notes filed by clinicians indicating the number of students <br /> participating in the individual and group art therapy sessions <br /> Previous Year Program Results ATI clinicians delivered sessions to 185 newcomers. While this is <br /> (2015-2016) slightly below our goal of 210 students, this was an expansion from <br /> the previous year, and we did not receive our full funding ask which <br /> would have supported the full number of students. <br /> Current Year Estimated Results We estimated that ATI clinicians will have delivered art therapy <br /> (2016-2017) sessions to 177 newcomer clients. At current date, we have seen <br /> 230 ESL clients this year. <br /> Next Year Projected Results By follow-up, ATI clinicians will have delivered art therapy sessions <br /> (2017-2018) to 245 newcomer clients. <br /> 2. Prog ram Activity Name Newcomer's Art Therapy Program <br /> Program Goal Depression <br /> Performance Measures Hopkins Symptoms Checklist-25 (according to scale scoring <br /> instructions, when the mean depression score exceeds 1.75, then a <br /> client is "symptomatic"for depression). <br /> Previous Year Program Results By follow-up, 71% of participating clients experienced fewer total <br /> depression symptoms. <br /> Current Year Estimated Results We have estimated that among the newcomer clients symptomatic <br /> for depression at baseline, 30% will not be symptomatic for <br /> depression at follow-up. However, since our results rely on baseline <br /> and follow-up data (collected in Spring 2017), we do not yet have <br /> current estimated results for this year. <br /> Next Year Projected Results Among the newcomer clients symptomatic for depression at <br /> baseline, 30% will not be symptomatic for depression at follow-up. <br /> 3. Program Activity Name Newcomer's Art Therapy Program <br /> Program Goal Emotional Difficulties <br /> PROGRAM INFORMATION 2/8/2017 3:01:12 PM Page 16 of 20 <br />