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Cover Page P a g e 9 o f 55 <br />Psychiatric <br />Rehabilitation <br />Services – ACTT <br />Members <br />$18,000 Personnel & <br />Operations <br />$18,000 <br />Totals $22,000 $22,000 $120,000 $164,000 <br />TOCH – Impact <br />Award – <br />Comprehensive <br />Integrated Critical <br />Safety Net <br />$50,000 $50,000 <br />Briefly explain your proposed use of funds: <br />To the best of my knowledge and belief all information and data in this <br />application is true and current. The document has been duly authorized by <br />the governing board of the applicant. <br />Signature: 1/14/2021 <br /> Executive Director Date <br />The Outside Agency funding will provide for staffing and other costs to operate Club <br />Nova, an accredited Clubhouse Model. The Clubhouse Model is one of the most <br />comprehensive, integrated, effective, community-based approaches in addressing <br />the health, safety, social, and economic risks of serious mental illness and provides <br />a critical safety net for individuals living with serious mental illness. <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />DocuSign Envelope ID: 11DA72B8-CC83-439E-A25C-F64DE607C614