FEMA Form FF-104-FY-21-149

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DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
APPLICATION FOR CRISIS COUNSELING PROGRAM SERVICES
(REGULAR SERVICES PROGRAM)
PAPERWORK BURDEN DISCLOSURE NOTICE

Public reporting burden for this form is estimated to average 20 hours per response. The burden estimate includes the time for reviewing instructions,
searching existing data sources, gathering and maintaining the needed data, and completing, reviewing, and submitting the form. You are not required to
respond to this collection of information unless a valid OMB control number appears in the upper right corner of this form. Send comments regarding the
accuracy of the burden estimate and any suggestions for reducing this burden to: Information Collections Management, Department of Homeland Security,
Federal Emergency Management Agency, 500 C Street, SW, Washington, DC, 20472, Paperwork Reduction Project (1660-0100). NOTE: Do not send
your completed form to the above address.

PRIVACY NOTICE
GENERAL: This information is being collected for the primary purpose of determining eligibility for the Crisis Counseling Assistance and Training Program,
Immediate Services Program (ISP) funding following a Presidentially declared disaster.
AUTHORITY: Section 416 of the Robert T. Stafford Disaster Relief and Emergency Assistance Act, as amended (42 U.S.C. § 5183) and 44 C.F.R. 206.171.
USES AND SHARING: FEMA may share the information, including personally identifiable information with our federal partners at the Substance Abuse and
Mental Health Services Administration (SAMHSA), within the U.S. Department of Health and Human Services (DHHS). Further information regarding
FEMA’s use and sharing of information can be found with the DHS/FEMA/PIA – 013 Grants Management Programs Privacy Impact Assessment. The
Department’s list of Privacy Impact Assessments can be found on the Department's website at Privacy Impact Assessments | Homeland Security..
EFFECTS OF NONDISCLOSURE: The disclosure of information on this form is voluntary; however, failure to provide the information requested may delay
or prevent FEMA from providing the requested funding.

PART I: GENERAL APPLICATION INFORMATION
Completion of this form including applicable attachments satisfies legal requirements for application for the Regular Services Program
(RSP) under 42 U.S.C. § 5183 as implemented at 44 C.F.R. § 206.171. Failure to use this application may result in a failure to meet these
requirements and/or a delay in processing the request. This application must be submitted no later than 60 days following the declaration
of a major disaster.
1. Request Date:

2. Declaration #:

3. Declaration Date:

4. State, Tribal Government or Territory requesting services:
5. Primary Point of Contact (POC) information for the administration of this program.
5a. POC Name:
5b. POC Organization:
5c. POC Mailing Address:
5d. POC E-Mail Address:
5e. POC Phone Number
6. Amount requested for Regular Services Program (RSP) funding (please round to nearest dollar).

PART II: RESPONSE ACTIVITIES FROM DATE OF INCIDENT
7. Describe State and local crisis counseling activities from the date of the incident to the date of this application. Enter "N/A" if no crisis
counseling activities have been conducted to date.

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If an Immediate Services Program (ISP) was implemented for this disaster, please answer questions #8-10 below. Otherwise, skip
to question #11.
8. Please provide a brief summary of the ISP currently in place. Please include information on the population served, any extensions (date
and amount), the number of providers, the start and end dates of the program, and summarize any trends. Include any best practices as
well as any challenges and describe how those challenges were addressed or will be addressed in the RSP.

9. If applicable, explain why any service providers not included in the ISP were added to this RSP application. Additionally, explain why
any service providers included in the ISP are excluded from the proposed RSP.

10. Describe how the RSP will build on the work done in the ISP. Describe how contacts and resources identified during the ISP will be
leveraged during the RSP.

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11. Please provide a brief summary that provides key information on the scope and magnitude of the disaster, how the Grantee and
providers propose to provide services during the RSP, and the nature and location of the proposed services. Please include a
description of the length of time services will be required and describe how long-term cases will be handled. Please describe the
nature of psychological and social problems observed and the types of mental health problems encountered by disaster survivors.

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PART III: GEOGRAPHIC AREAS AND NEEDS ASSESSMENT
12. Estimated Population to be served:
OPTION A: Federal award applicants may opt to use their own method for determining the estimated population to be served. Please
cite data sources used. Please also list the proposed providers and the number of direct and non-direct staff anticipated.

OPTION B: Use the following table to estimate the impacted population for each requested service area (county, parish, tribal land,
etc.). Populate the table using census data for the total population for each designated service area. Please select a "Percentage
Impact Factor" between .75% (multiply the “Total Census Population by 0.0075) and 2% (multiply the “Total Census Population” by
0.02) to determine “Estimated Population to be Served”. Please also list the number of direct and direct support staff anticipated.
Provide a brief justification for the “Percentage Impact Factor” chosen in the box below. Please also list the proposed providers and
the number of direct and support staff anticipated.
Service Provider
Total Census
Name (if known) and
Population in
Requested Declared Requested Declared
Service Areas
Service Areas

Percentage Impact
Factor (.75%)

Estimated
Population to be
Served during the
RSP

Number of Direct
Staff FTE's (Crisis
Counselors, Team
Leads) (Typically a
300:1 ratio)

Number of Non-Direct
Staff FTE's (Admin.,
Fiscal, Data etc.)
Typically 15-20%

TOTALS:
Describe any circumstances not captured in the table above that will have an impact on the need for and equitable delivery of crisis
counseling services during the RSP. Include any high-risk groups or populations of concern (e.g., children; adolescents; older adults;
individuals with disabilities; cultural needs; access and functional needs; lower income populations; first responders; etc.). Please include
your plan to ensure the RSP is accessible.

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PART IV: RESOURCES AND CAPABILITIES
13. Describe the current mental health resources and explain why they cannot meet the disaster-related mental health needs caused or
aggravated by this disaster.

14. Has the Federal award applicant received funds for mental health disaster response from any other source (i.e. Department of
Education, Foundations, etc) ? If so, how much and how are these funds used?

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PART V: PROGRAM ADMINISTRATION
15. Will the State, Tribal Government or Territory be providing any direct crisis counseling services?
Yes

No

16. Attach an overall organizational chart for this project

Add Attachments

17. Provide a brief description of administrative oversight plans (supervision and monitoring of crisis counselors, team leads, data
collection efforts, managing and monitoring staff stress, etc).

18. How will the Federal award applicant monitor the organization and deployment of crisis counseling teams? If more than one provider
agency will be delivering services, please describe the plan to coordinate services. If more than one provider will cover a service area,
please include a map that shows how the responsibility for that service area will be divided.

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19. Describe the Federal award applicant's plan for quality control methods to ensure appropriate services reach survivors.

20. With what organizations and community stakeholders will you partner? Select all that apply:
Community Mental Health and Substance Abuse Centers
Schools
Faith-Based Organizations
First Responders
Community-Based Cultural Organizations
Law Enforcement
Local Elected Officials
Long-Term Recovery Groups
Other:
21. Briefly describe how you will engage with the partners identified above.

22. What primary CCP services will you provide? Please select all that apply.
Individual crisis counseling
Group crisis counseling
Brief educational or supportive contact
Public education
Assessment, referral, and resource linkage
Community networking and support
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23. What secondary CCP services will you provide? Please select all that apply.
Development and distribution of educational materials
Media and public service announcements
24. State Staffing Plan. Please provide information on the staffing at the Grantee level. Include leadership positions and direct staff if the
State, Territory or Tribe is providing any direct services. Do not include provider-level staff.
Grant Funded
Type of Staff

# of Staff Members

# of FTE's (based on 40
hours per week)

Projected In-Kind
# of Staff Members

# of FTE's (based on 40
hours per week)

TOTALS:
25. Describe the Federal award applicant's plan to ensure clear program identity (educational materials, wellness messaging, logos, etc.)
and market the program (including website, hotline, social media, public service announcements, etc.)

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26. Briefly describe the facilities to be utilized and your plan for securing office space for this project.

27. The CCP requires mandatory training during the RSP as described in the CCP guidance. Please describe the proposed training
program for project staff, indicating the number of workers needing such training. Also include additional training (if any) that you plan
to provide and the rationale for such training.

28. Does the State, Territory or Tribe have any experienced trainers who can provide training on the CCP model?
Yes

No

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PART VI: BUDGET
29. Attach a Standard Form 424: Request for Federal Assistance (SF-424) and Standard Form 424a: Budget Information - NonConstruction Programs (SF-424a). These forms should include all projected operating costs.
30. Attach a budget narrative explaining each line item on the SF-424a.
Add Attachments

PART VII: ASSURANCES
31. Please indicate whether the following assurances have been completed and submitted with this application:
a. SF-LLL Disclosure of Lobbying Activities

Yes

No

b. Disbarment and Suspension and other Responsibility Matters

Yes

No

c. HHS Project Site Location/Key Contacts Form

Yes

No

32. The Governor or Chief Tribal Executive or their authorized representative agrees to and/or certifies that:
The requirements are beyond the State, local, Territory, or Tribal government's capabilities.
The program, if approved, will be implemented according to the plan contained in the application approved by the Assistant
Administrator for the Recovery Directorate.
The State, Tribal Government or Territory will maintain close coordination with and provide reports to the Regional Administrator, the
Assistant Administrator for the Recovery Directorate and the Secretary.
The State, Tribal Government or Territory's emergency plan, prepared under Title II of the Stafford Act, will include disaster mental
health planning.
33. By signing below, the Governor's Authorized Representative (GAR) or the Chief Tribal Executive affirms that the foregoing questions
have been answered correctly and truthfully to the best of their knowledge.

Signature

Date

PART VIII: APPLICATION CHECKLIST
34. The following documents are being submitted with this grant application:
a. Completed RSP Application

Yes

No

b. Request for Federal Assistance (SF-424)

Yes

No

c. Budget Information - Non-Construction Programs (SF-424a)

Yes

No

d. Assurances for Non-Construction Programs (SF-424b)

Yes

No

e. Budget Narrative

Yes

No

f. Organizational Chart

Yes

No

g. Assurance forms from question 31 above

Yes

No

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