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DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 <br /> EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) <br /> Program Name: Newcomer Art Therapy Program <br /> Program Primary Contact and Title: Hillary Rubesin, Executive Director <br /> Telephone Number: 610.348.7253 E-Mail: hrubesin(§D_ncati.org <br /> a) 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 /> b) 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 X X <br /> Food <br /> Transportation <br /> Other: Please specify <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 /> • Cardinal Innovations is a managed care organization that contracts with ATI to provide <br /> services to newcomer clients with Medicaid. They also provide a stipend for ATI's work <br /> with the Carrboro Community Health Center, our uninsured refugee clients, and some of <br /> our required interpretation services. <br /> • The Carrboro Community Health Center/Piedmont Health provides comprehensive <br /> health services and education to all segments of the community, with special emphasis <br /> on vulnerable populations. They refer clients to ATI, sign medical service orders for art <br /> therapy, and provide space for ATI to provide weekly individual art therapy for adults. <br /> • Chapel Hill-Carrboro City Schools: The ESL Director, the EC Program Director, <br /> counselors, ESL and EC teachers, and social workers are all dedicated to partnering <br /> with ATI for continued service to the students in the school system. They are primary <br /> contacts for referral sources to ATI. <br /> • Durham Public Schools: The ESL Director at the Durham Public Schools invited ATI <br /> to a newly formed newcomer coalition of providers in Durham. At the end of 2014, ATI <br /> PROGRAM INFORMATION 1/23/2018 10:01:04 AM Page 13 of 24 <br />