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GCBH Agreement No. KITTITAS-MHBG-09/10-00 <br />{3) Inpatient mental health services. <br />(4) Construction and/or renovation. <br />(5) Capitol assets or the accumulation of operating reserve accounts. <br />(6) Equipment costs over $5,000. <br />(7) Cash payments to Consumers. <br />(8) State match for other federal funds. <br />7. Target Population. <br />The Contractor shall ensure that MHBG Funds are used only for services to individuals who are not <br />enrolled in Medicaid, or for services that are not covered by Medicaid, as described below: <br />Consumer is not a Any type Yes No <br />Medicaid recipient <br />Consumer is a Medicaid Allowed under Medicaid No Yes <br />recipient <br />Consumer is a Medicaid Not Allowed under Yes No <br />recipient Medicaid <br />8. MHBG Service Table <br />- <br />Dental Health Block Grant <br />Plan Reference <br />........... .......................... <br />NOM Goal Other Funding <br />Criterion ' Amount <br />i <br />----------------------------------------------- <br />Mental Health Block Grant <br />Planned Services/ Activities <br />Activity Description Deliverable <br />(Please provide measurable goals (For example: # of consumers to <br />that may be easily ` be served, # of svc hours to be <br />monitored/tracked) provided, # of staff to be trained, <br />— etc. <br />1 <br />NOW 2 <br />$36,145 <br />Crisis Services <br />Estimated # of adults to be <br />Go -all. 3 <br />To provide Crisis Mental Health <br />served: 16 <br />1 <br />Services to Non -Medicaid adults <br />I <br />and children. These services <br />Estimated # of children/youth to 3 <br />include crisis services, stabilization <br />be served: 2 <br />services, Involuntary Treatment Act <br />services and Freestanding E&T <br />The contractor will record and <br />services. <br />report the number of individuals, <br />by age group, who receive crisis, <br />i <br />stabilization, involuntary and <br />freestanding E & T services <br />supported by this contract. The <br />contractor will ensure that there is <br />3 <br />a method in place that ; <br />demonstrates the only individuals <br />who are not Medicaid recipients <br />I <br />are supported with these funds. <br />Cost Basis/Justification <br />for the activity <br />above (e.g., <br />actual, budget, industry standard, <br />Fee): Funds will be used for <br />costs associated <br />with the provision of <br />Crisis Mental <br />Health Services. <br />-12- <br />