HomeMy Public PortalAbout1. Grant Application Form_FY22 (2)MASSACHUSETTS DEPARTMENT OF MENTAL HEALTH
JAIL/ARREST DIVERSION GRANT PROGRAM
GRANT APPLICATION FOR M
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:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
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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)
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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 _________________.
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