Specialized Sexual Assault Services Application Sfy18

SPECIALIZED SEXUAL ASSAULT SERVICES APPLICATION SFY18

ATTACHMENT F

Proposed Services Form

Your region’s plan for Specialized Sexual Assault Services funding is to cover a two-year project period. This form outlines what your agency plans to accomplish in year one of the Specialized grant.All applicants must to complete this form, even if you are requesting a waiver to the planning process.

Please refer to the Service Standards for detailed information about the kinds of activities that are eligible (Appendix A). Eligible services include:

Updated 3/6/2017

SPECIALIZED SEXUAL ASSAULT SERVICES APPLICATION SFY18

ATTACHMENT F

Specialized Sexual Assault Services

• Therapy
• Support Groups
• Medical Social Work

Services for Marginalized and Native American Communities

• Community Organizing, Training and Education
• Community Responding
• Primary Prevention

Enhanced Core Services

• Information, Referral, and Awareness
• Crisis Intervention
• General, Legal, and/or Medical Advocacy
• System Coordination
• Primary Prevention

Updated 3/6/2017

SPECIALIZED SEXUAL ASSAULT SERVICES APPLICATION SFY18

ATTACHMENT F

A sample form is included for reference. The blank form can be found on the last page.

Column 1 – Staff Name and Position

List the name and job title of the person providing the service.

Column 2 – Type of Service

List which Service Standard applies to the activity you want to do.

Column 3 –Geographic Area to Be Served

Describe where you will be providing the service (geographic area). If services will be provided in more than one county and/or geographic area, please indicate this (each area should be a separate line).

Column 4 – Description of Service and Population Served

Provide a brief description of the activity and include the specific community to receive the service.

Column 5 – Approximate Number of People to Receive Service

Provide an approximate number of how many people will receive the service.

Updated 3/6/2017

SPECIALIZED SEXUAL ASSAULT SERVICES APPLICATION SFY18

ATTACHMENT F

SAMPLE Year One Proposed Services Form

Updated 3/6/2017

SPECIALIZED SEXUAL ASSAULT SERVICES APPLICATION SFY18

ATTACHMENT F

Year One Proposed Services Form

Updated 3/6/2017

SPECIALIZED SEXUAL ASSAULT SERVICES APPLICATION SFY18

ATTACHMENT F

Supervision for Support Group and Therapy Services

Supervision and case consultation are a grant requirement. Please list the name(s) and title of the individuals providing this below.

Support Group Facilitators

Therapists

Updated 3/6/2017