Application for Grants to Increase Youth Participation in Quality Programs in the California

Respite Partnership Collaborative

Statement of Qualification deadline: Monday, April 29, 2013, at 12 p.m.

Respite Services Response: 24/7 Mental Health Crisis Respite Read Request for Qualifications carefully before completing this form.

To complete this form, save this document in Microsoft Word and type into each shaded field. Use the TAB key to move from field to field, or click in each field. Limit your responses to the space provided.

Statement of Qualification Information Organization  Address Addres City State Zip Code Phone Ext E-mail Director Title Tax Exempt ID# Web site www.

Application Title Contact Address City State Zip Code Phone Ext E-mail

Sierra Health Foundation: Center for Health Program Management 1 Nonprofits: Use the organization name as it appears on the IRS 501(c)(3) determination letter.

Materials Checklist

Completed Respite Services form (download the form on Sierra Health’s web site, www.sierrahealth.org/rpc), which includes: – Response Cover Sheet – Statement of Qualification

501(c)(3) determination letter (PDF format) (if a public agency, please note below)

If an item on the checklist is not applicable, please briefly explain:

Submit all materials in the checklist above by attaching them to an e-mail and sending to [email protected]. Include the organization name and the telephone number of the person sending the response e- mail in the body of the e-mail so we can contact you if we have questions.

Name of authorized 501(c)(3) or public agency officer Title

Sierra Health Foundation: Center for Health Program Management 2 Statement of Qualification Please answer each of the following questions completely and succinctly. Limit your Statement of Qualification response to a total of seven pages.

1. Name and contact information of the staff lead in developing the proposed 24/7 respite service project. Summary of qualifications and expertise of the responsible staff who will develop and staff the proposed 24/7 mental health crisis respite service. Provide a brief overview of the staffs’ roles in relation to the development and delivery of proposed services.

2. Summary of the organization’s qualifications and experience in providing mental health crisis services to adults 18 years and older in Sacramento County.

3. Summary of the organization’s qualifications and expertise in providing mental health services utilizing a wellness and recovery approach.

4. Description of organization’s expertise and experience in providing culturally competent services.

5. Description of current peer component approach to include those with lived mental health experience in leadership roles as volunteers and/or staff in delivery of mental health services.

6. Summary of qualifications and experience in triaging co-occurring mental health and substance abuse issues.

7. Description of current organizational participation in community partnerships that contribute to mental health, substance abuse and/or primary care referrals and/or linkages that directly lead to stronger support for clients.

Sierra Health Foundation: Center for Health Program Management 3