1. Grant Application Form_FY22.pdf

MASSACHUSETTS DEPARTMENT OF MENTAL HEALTH

JAIL/ARREST DIVERSION GRANT PROGRAM

GRANT APPLICATION FORM

RFA Number:

Application Date:

A. Applicant Profile:

Municipality Chief Municipal Official: ____________________________________

Mayor (name)

Town Administrator

Town or City Manager Town Coordinator

Administrative Coordinator

General Manager

Chief Administrative Officer Executive Secretary

Executive Assistant

Municipal Assistant

Board of Selectmen

Business _____________________________________ Type: (C.E.O. name)

Non-Profit Not for Profit For Profit

Individual

Organization/Individual Name:

(Lead Organization, if joint application)

Address:

Contact Person Name:

Title:

Phone:

Email:

FAX:

Applicant is available to start Grant activities as of:_____________________________ (date)

Applicant seeks Grant support to:

Operate a police-based Jail/Arrest Diversion Program Enhance behavioral health training opportunities to Applicant’s law enforcement and/or other first responder personnel Provide a behavioral health training and/or consultation service to law enforcement organizations Provide a community service that supports/receives individuals diverted by law enforcement from arrest, court, or hospital emergency departments.

Organize efforts to improve local collaboration between law enforcement and behavioral/social service systems.

Applicant has not received DMH Grant Support for Jail Diversion Activities in the past.

Applicant has received DMH Grant Support for Jail Diversion activities in the past. This Application is a:

Request for a new grant Request for renewal/continuation of existing grant Request for expansion or change of existing grant

B. Statement of Interest:

Applicant’s Community Implementation Strategy: [see RFA Section (C)] Please state the Applicant’s overarching goal to advance the performance of public safety services in respect to responding to citizens with behavioral health challenges and how the Applicant would envision the requested DMH grant support in furthering the implementation of the Applicant’s specific strategic plan(s) for their community:

Applicant’s Objective(s) (check all that apply)

Increase collaboration between local law enforcement and behavioral health providers through stakeholder meetings and joint initiatives

Increase the number of law enforcement and other first responders trained in behavioral health topics and increase the number and type of trainings available

Increase the quality and consistency of behavioral health training delivered to law enforcement and other first responders

Support law enforcement and other first responder departments to develop policies and procedures that increase safety and effectiveness when responding to citizens with behavioral health challenges

Inform decisions on the use of force and other interventions that are used by law enforcement with new skills acquired through behavioral health training

Increase the likelihood of diversion from arrest for citizens with behavioral health challenges when safe and appropriate to do so.

Other_____________________________________________________________________________________

Applicant’s Intended Outcome(s) from grant activity, relative to citizens with behavioral health challenges (check all that apply):

Positive Change in practice in my community Positive Change in policy/procedure in my community Positive Change in local resources in my community

C. Proposed Project

Applicant requests Grant support for the following Project(s): (Check any/all that you intend to request support for)

C.I.T. Program

Single Department or Regional {Cost Corridor: $40K-$100K}

C.I.T. - T.T.A.C. {Cost Corridor: $60K-$350K}

Co-Response Program

Single Department or Regional {Cost Corridor: $8K-$10K per 0.10 FTE of clinician staffing, per program}

C.R. - T.T.A.C. {Cost Corridor: $60K-$350K}

Component Jail Diversion Program Model

Single Department {Cost Corridor: $20K-$100K}

Regional {Cost Corridor: $30K-$200K}

Training Reimbursement {Cost Corridor: $5K-$100K}

Trainer/Consultant/Research {Cost Corridor: $2K-$250K}

Community Planning {Cost Corridor: $8K-$50K}

Drop-Off Center {Cost Corridor: $120K-$350K}

Behavioral Health Intervention Program {Cost Corridor: $200K-$500K} Single Municipality

Regional

Total Funds Requested (estimated) For FY____ $__________ Is start-up year less than 12 months? □Y □N □Unknown For FY____ $__________ For FY____ $__________

D. Applicant’s Fiscal Condition:

Applicants must be must be of sound financial condition as determined by DMH. Please complete the checklist below:

*DMH reserves the right to request additional financial information from a Bidder/Contractor, at any time throughout the procurement or duration of the applicable Contract if DMH determines that such information is necessary to determine that the Bidder/Contractor is or continues to be in sound financial condition.

Debarment

The Applicant is not now, nor in the last five years, has been subject to debarment for state or Federal procurement purposes.

The Applicant is, or, in the last five years, has been subject to debarment for state or Federal procurement purposes.

Corrective Action Plan The Applicant is not presently under a corrective action plan with any agency of the

Commonwealth

The Applicant is presently under a corrective action plan with an agency of the Commonwealth

Audit Resolution Agreement The Applicant is not presently under an Audit Resolution Agreement with any agency of the Commonwealth

The Applicant is presently under an Audit Resolution Agreement with an agency of the Commonwealth

Individual & Business Applicants only:

Solvency

The Applicant has not been in bankruptcy and/or receivership within the last ten calendar years.

The Applicant has been in bankruptcy and/or receivership within the last ten calendar years.

The Applicant has at least four months of adequate cash reserves.

The Applicant does not have at least four months of adequate cash reserves.

Good Standing If incorporated, the Applicant is in compliance with all filing requirements of the state of incorporation and with the Commonwealth of Massachusetts.

If incorporated, the Applicant is currently out of compliance with all filing requirements of the state of incorporation and with the Commonwealth of Massachusetts.

Tax Compliance

The Applicant is in compliance with all federal and Massachusetts tax laws.

The Applicant is not in compliance with all federal and Massachusetts tax laws.

E. Applicant’s RFA Response:

The following documents are to be included with the initial submission of this Application Packet. Please check off all items you have included with this submission:

Grant Application Form Project Proposal (See ATTACHMENT F for required content) Cost Proposal (See ATTACHMENT G for required content) Commonwealth SDP Form 1 (Supplier Diversity Plan) [if requesting funds greater than 150K] Job Descriptions of any grant funded positions Rate Schedule (provide your payment rate(s) for applicable personnel/services/reimbursements that may be charged to the Grant) Organization Chart 1: Host Department/Agency & Grant Oversight Organization Chart 2: Proposed Grant Program Copies of applicable license(s)/certification(s) [for individual trainers/consultants only] 3 Letters of Support [if an organization Applicant] Resume and 3 Professional References [if an individual Applicant]

F. Applicant’s Official Signature (must be an individual authorized to negotiate for and execute the contract on behalf of the Applicant Organization):

(Signature) (Print Name) (Title) (Date)

FOR DMH USE ONLY

Date Application Received: _____________ Time: _________ Complete: □ yes □ no

Received by: _________________________ Title/Department: ___________________________________

Reply to Applicant sent on: __________________

Applicant/proposed Project is not qualified and/or Approved.

Applicant and proposed Project is Qualified and Approved, effective _________________.