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FY24 CJS JCPC YES PROGRAM AGREEMENTDocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 North Carolina Department of Public Sat Juvenile Justice and Delinquency Prevention JCPC Program - Program Agreement SECTION I A: SPONSORING AGENCY AND PROGRAM INFORMATION FUNDING PERIOD: FY 23-24 DPS/JCPC FUNDING # (cont only) 965-XXXX COUNTY: New Hanover AREA: Eastern Area Multi -County: No Multi -Components: Yes NAME OF PROGRAM: Youth Empowerment Services SPONSORING AGENCY: NHC, Community Justice Services, Youth Empowerment Services SPONSORING AGENCY 320 Chestnut Street Suite 518 PHYSICAL ADDRESS: Wilmington NC 28401 SPONSORING AGENCY 320 Chestnut Street Suite 518 MAILING ADDRESS: Wilmington NC 28401 TYPE: Public 38150 FEDERAL ID # 56-600034 COMPONENT ID # NAME OF PROGRAM COMPONENT PROGRAM TYPE TOTAL COST OF EACH COMPONENT 38147 Juvenile Psychological Assessment Assessments $ 187,684 38148 Juvenile Psychological Counseling Family Counseling $ 100,411 38149 Home Based Family Counseling Home Based Family Counseling $ 84,142 38150 Community Service and Restitution Restitution/Community Service $ 321,082 Total cost of components: $ 693,319 Program Manager Name & Address (same person on signature page) Name: James Roten Title: Manager, YES Mailing Address: 320 Chestnut Street Suite 518 City: Wilmington Zip: 28401 Suite 165 Phone: (910) 798-6491 Fax: 1 (910) 798-7813 E-mail: jroten@nhcgov.com Contact Person (if different from program manager) Name: James Roten Title: Manager, YES Mailing Address: 320 Chestnut Street Suite 518 City: Wilmington Zip: 28401 Suite 165 Phone: (910) 798-6491 Fax: 1 (910) 798-7813 E-mail: jroten@nhcgov.com Program Fiscal Officer (cannot be program manager) Name: Eric Credle Title: CFO Mailing Address: 230 Government Center Drive City: Wilmignton Zip: 28403 Suite 165 Phone: (910) 798-7134 Fax: 1 (910) 798-7410 E-mail: ecredle@nhcgov.com Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION I B: PROGRAM COMPONENT DESCRIPTION COMPONENT ID # COMPONENT INFORMATION 38147 NAME OF COMPONENT: Juvenile Psychological Assessment BRIEF DESCRIPTION: The Juvenile Psychological Counseling Program Component provides BRIEF DESCRIPTION: The Juvenile Psychological Assessment Program Component provides individual and family psychotherapy using a Trauma Focused Cognitive Behavioral Therapy Comprehensive Clinical Assessments, Psychological Evaluations, Psychosexual Risk Treatment approach to at risk, delinquent and adjudicated court referred youth and their Assessments and Sex Offense Specific Evaluations that result in diagnoses and treatment families to ultimately improve their targeted delinquent behaviors, familial functioning and intervention/placement recommendations to facilitate appropriate level of behavioral health reduce recidivism by replacing the behaviors with healthy, prosocial behaviors. services to at risk, delinquent and adjudicated court referred youth to ultimately improve their of soft skills necessary to enter the labor force. targeted delinquent behaviors, familial functioning and reduce recidivism. COMPONENT ID # COMPONENT INFORMATION 38148 NAME OF COMPONENT: Juvenile Psychological Counseling BRIEF DESCRIPTION: The Juvenile Psychological Counseling Program Component provides individual and family psychotherapy using a Trauma Focused Cognitive Behavioral Therapy Treatment approach to at risk, delinquent and adjudicated court referred youth and their families to ultimately improve their targeted delinquent behaviors, familial functioning and reduce recidivism by replacing the behaviors with healthy, prosocial behaviors. COMPONENT ID # COMPONENT INFORMATION 38149 NAME OF COMPONENT: Home Based Family Counseling BRIEF DESCRIPTION: The Home Based Family Counseling Program Component provides family counseling using a Trauma Focused Cognitive Behavioral Therapy Treatment approach in the home environment to court referred adjudicated youth transitioning back to their home and community from a residential placement and/or delinquent youth who are at risk of out of home placement in order to maintain the youth successfully in the home. COMPONENT ID # COMPONENT INFORMATION 38150 NAME OF COMPONENT: Community Service and Restitution BRIEF DESCRIPTION: The Community Service and Restitution Program Component provides an intermediate dispositional option to meet the youth and families court ordered or diverted community service and/or restitution obligation by providing the youth opportunities to engage in civic, community and social responsibilities through a service learning model to reduce recidivism and delinquent behaviors while also offering vocational exposure and development of soft skills necessary to enter the labor force. Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION II: COMPONENT STATISTICAL INFORMATION Multi -Components Yes Component Service Statistics PROGRAM COMPONENT INFORMATION - APPLICATION YEAR Component Name: Juvenile Psychological Assessment Component ID # 38147 What is this component's maximum client capacity at any given time? 5 Frequency of client contact per month: 1 Anticipated Average Length of Stay: 1 Days y Total Component Cost: $187,684 - by Estimated # to be served during funding period: 100 Estimated Average Cost Per Youth: 1$1,877 Applies to continuation programs only. Actual number of youth admitted FY 21-22: 118 114 Number of admissions Juvenile Justice Referred 96.61 % of total admissions 0 Number of admissions Law Enforcement Referred 0% of total admissions 0 Number of admissions District Court Referred 0% of total admissions Actual number served FY 21-22: 118 Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 01/09/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION III: COMPONENT SUMMARY NAME OF COMPONENT: Juvenile Psychological Assessment 1. Statement of the Problem: In concise terminology, describe how the program will address continuum need(s) in the county. In New Hanover County, 70% of youth assessed at DJJ intake have moderate to high risk levels, and 58% have medium to high risk levels. Assessed youth have a needs level of "very high" at double the average rate for NC. 59% of youth self reported previous alcohol/drug use, with 48% identifying substance use as having disrupted their functioning, 94% of youth indicate they have no friends, associate with with negative/delinquent influences, gang members, or have family who are gang members. Additionally, 51 % of youth have a "mental health problem" while only 29% are receiving treatment. Lastly, 54% of youth are charged with assault behaviors or assault inflicting serious injury. (2021-2022 NHC JCPC Risk and Needs Committee Report) The Juvenile Psychological Assessment Program addresses the continuum of needs listed above by providing an unbiased and extensive behavioral health assessment in order to ensure that referred youth are recommended for the right type of service given their individual situation, while taking into account what services are currently available given the ever-changing landscape of the behavioral health services array in North Carolina. All assessments contain at a minimum a comprehensive clinical assessment (CCA) utilizing a standardized format including a complete family history, clinical history, ASAM and CALOCUS levels of care and the Achenbach Child Behavior Checklist (Evidence Based Assessment Tool). When full psychological evaluations are needed, psychological testing such as IQ, personality, adaptive functioning, psycho educational screening and developmental functioning assessment are incorporated into the CCA. Psychosexual Risk Assessments and Sex Offense Specific Evaluations include at a minimum, use of the Juvenile Sex Offender Assessment Protocol (JSOAP), Estimate of Risk of Adolescent Sexual Offense Recidivism (ERASOR), Trauma Symptom Checklist, Sexual Offense Body Map, Personal Sentence Completion Inventory, Adolescent Sexual Offender Assessment Packet, and other psychological testing as needed. A thorough review of collateral information such as school records, behavioral health records and legal documentation is routinely included as part of the assessment process. 2. Target Population: Describe the target population, including age, and the steps taken to insure that the target population is served. Target Population: Juveniles between the ages of six (6) and twenty (20) who have been adjudicated delinquent or undisciplined, juveniles under diversion contracts or plan or otherwise under jurisdiction of and referred by juvenile court, including but not limited to, Interstate Compact juveniles that present some behavioral or emotional concerns, which warrant further diagnosis and clarification. 3. Program Goal(s): Provide a brief statement to describe the overall purpose of the program. The Juvenile Psychological Assessment Program Component provides Comprehensive Clinical Assessments, Psychological Evaluations, Psychosexual Risk Assessments and Sex Offense Specific Evaluations to at risk, delinquent and adjudicated youth that result in diagnoses and treatment intervention/placement recommendations to facilitate appropriate level of behavioral health services to youth and their families to ultimately improve their targeted delinquent behaviors, familial functioning and reduce recidivism. This component also aids the court in identifying dispositional alternatives that may be utilized in lieu of secure custody or placement in a Youth Development Center. 4. Measurable Objective(s): State in measurable terms (Yo) the intended effect of the program on specific Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION III: COMPONENT SUMMARY NAME OF COMPONENT: Juvenile Psychological Assessment undisciplined and/or delinquent behaviors. Example: anticipated reductions in court referrals, runaway behavior, disruptive behavior at school, anticipated improved school attendance and academic achievement. These objectives must include impact on participants. 90% Assessments will result from a diversion plan or condition of the court. 80% Assessments will be completed within the timeframe permitted by JCPC policy. 100% Assessments will include treatment recommendations. 5. Elevated Risks and Needs: Describe how program services will address one or more of the elevated risk and needs listed in the most recent JCPC Request for Proposal. In New Hanover County the following Risk Factors for Delinquency or Repeat Delinquency and the following concerns as reported in the Needs Assessments for Adjudicated Youth were identified in the local Request for Proposal: Association with Other Delinquent Peers or Peers Involved with Gangs; Mental Health Needs including Moderate to Serious Behavioral Problems at School; Involvement in Alcohol and Substance Abuse; Prior Assaultive Behavior; Referral to Juvenile Court Prior to Age 12 and Inadequate Supervision by Parents/Guardians. The Juvenile Psychological Assessment Program Component addresses the continuum of needs listed above by providing an unbiased and extensive behavioral health assessment in order to ensure that referred youth are recommended for the right type of service given their individual situation, while taking into account what services are currently available given the ever-changing landscape of the behavioral health services array in North Carolina. All assessments contain at a minimum a comprehensive clinical assessment (CCA) utilizing a standardized format including a complete clinical and family history, ASAM and CALOCUS levels of care, Youth Self Report, and the Achenbach Child Behavior Checklist (Evidence Based Assessment Tool). When full psychological evaluations are needed, psychological testing such as IQ, personality, adaptive functioning, psycho educational screening and developmental functioning assessment are incorporated into the CCA. Psychosexual Risk Assessments and Sex Offense Specific Evaluations include at a minimum, use of the Juvenile Sex Offender Assessment Protocol (JSOAP), Estimate of Risk of Adolescent Sexual Offense Recidivism (ERASOR), Trauma Symptom Checklist, Personal Sentence Completion Inventory, Adolescent Sexual Offender Assessment Packet, and other psychological testing as needed. A thorough review of collateral information such as school records, behavioral health records and legal documentation is routinely included as part of the assessment process in order to fully evaluate any potential need for behavioral health services or natural supports. Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION IV: COMPONENT NARRATIVE (attach for each component) NAME OF COMPONENT: Juvenile Psychological Assessment 1. Location: List physical address(es) and describe where program services are delivered. The Juvenile Psychological Assessment Component is housed on the first floor of the new courthouse, located at 138 N. 4th street. The clinicians proximity to juvenile court counselors promotes efficiency and ease of access for youth/ families and fosters an environment where information is easily accessed and shared. Clinicians are available to court staff on Tuesdays, the day juvenile court is traditionally held, and they attend court sessions when applicable. 2. Operation: Describe the daily/weekly schedule of program operation. Monday - Thursday 7:30 - 6:00 and Friday 7:30 - 5:00 3. Staff Positions: Describe paid or volunteer position qualifications, (certifications, degrees, work experience) and position(s) responsibilities relative to this component. 1 part time (60%) Licensed Clinical Therapist Qualifications: MA Clinical Psychology, Licensed Psychological Associate, NC Licensure #2537, 15+ years post licensure experience Responsibilities: Provide Comprehensive Clinical Assessments and Psychological Evaluations to at risk and adjudicated youth within JCPC mandated timeframes 1 part time (60%) Licensed Clinical Therapist Qualifications: MSW, LCSW, NC Licensure #C009780, 3+ years post licensure experience, Member ATSA Responsibilities: Provide Comprehensive Clinical Assessments, Psychosexual Risk Assessments and Sex Offense Specific Evaluations to at risk and adjudicated youth within JCPC mandated timeframes 1 -part time (10%) Licensed Clinical Therapist Qualifications: MSW, Licensed Clinical Social Worker, Member of ATSA NC Licensure #C002813, 20+ years post licensure experience Responsibilities: See clinical duties above 1 part time (15%) Bi -Lingual Licensed Clinical Therapist Supervisor (Fully Funded by New Hanover County - In Kind) Qualifications: MA Clinical Psychology, Licensed Clinical Mental Health Clinician, NC Licensure #4476, 20+ years post licensure experience. Member of ATSA Responsibilities: Process and assign referrals from DPS Court Counselors and supervise operations of clinical staff, including completion of psychological evaluations, comprehensive clinical assessments and sex offense specific evaluations. Conduct quality assurance meetings and fidelity tool review meetings to facilitate compliance with JCPC guidelines and evidence -based practices 1 part time (5%) YES Manager, (Program Manager) - (Partially Funded by New Hanover County - In Kind) Qualifications: MPA, 10+ years experience with at risk youth Responsibilities: Representing program to promote initiatives by facilitating and attending meetings and monitoring Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION IV: COMPONENT NARRATIVE (attach for each component) NAME OF COMPONENT: Juvenile Psychological Assessment grants; responding to inquiries of stake holders and the public regarding program services to include explaining program guidelines and addressing public citizen groups 1 contracted Licensed Psychologist Responsibilities: Provide clinical supervision and consultation 1 contracted Licensed Clinical Addiction Specialist Responsibilities: Provide assessments and substance use counseling 1 part time (5%) CJS Support Services Coordinator- (Fully Funded by New Hanover County - In Kind) Qualifications: MBA, 20+ years administrative experience Responsibilities: Program financial and budget operations 1 part time (10%) CJS Administrative Support Specialist -(Fully Funded by New Hanover County - In Kind) Qualifications: BA Communication Studies, 15+ years medical record/clerical experience Responsibilities: Admin. duties 1 part time (5%) CJS Director - LPA, Provides Consultation to clinical staff. 4. Service Type SPEP: Describe implementation to include: This program is a STRUCTURE ONLY. 5. Admission Process: Describe the specific referral, screening, admission process (including timeline), the staff responsible for making decisions about admissions and reasons why a referral may not be accepted. The Juvenile Psychological Assessment Program Component admission process begins with a DPS Court Counselor completing a referral to the YES Licensed Clinical Therapist Supervisor requesting assessment/evaluation services for a youth. Upon receipt of the referral, it is reviewed by the Clinical Supervisor and assigned to a Licensed Clinical Therapist immediately. The clinician contacts the youth's parent/guardian routinely within 1-2 business days to schedule an appointment. Once the client is seen, the assessments and evaluations are routinely completed and released to the referring agency within seven business days. Sex Offense Specific Evaluations are typically completed and released within a 30-45 day timeframe. All referrals are accepted; however, a referral may not result in an admission if the youth is already receiving mental health services and/or the parent/guardian chooses to have the requested services provided by a private provider of their choice. 6. Termination Process: Describe the termination process to include the staff responsible for making decisions and the criteria for a successful termination, satisfactory termination, unsuccessful completion and non-compliant termination. For the Juvenile Psychological Assessment Program Component, the Licensed Clinical Therapist who conducts the assessment/evaluation with the youth and parent/guardian is responsible for determining the type of termination. The assessment/evaluation is terminated successfully and/or satisfactorily upon the clinician obtaining the necessary and relevant information from the clinical interview and testing session to make appropriate diagnoses and treatment intervention/placement recommendations. The assessment/evaluation is terminated unsuccessfully if the youth does not provide necessary and relevant information to make appropriate diagnoses and treatment intervention Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION IV: COMPONENT NARRATIVE (attach for each component) NAME OF COMPONENT: Juvenile Psychological Assessment recommendations. The assessment/evaluation is terminated noncompliant if the youth/parent refuses to comply with answering the questions posed to them or engaging in the testing session. How is the referring agency involved with the termination process? The referring agency is involved in the termination process for the assessment/evaluation by being informed/updated by the clinician regarding the status/outcome of the evaluations. 7. Referring Agency Interaction: Describe the interaction with juvenile court counselors and/or other referring agencies including how client progress will be communicated. For the Juvenile Psychological Assessment Program Component, the YES clinical staff attend weekly DPS court staffings and provide appropriate/accurate behavioral health information pertaining to level of treatment and provider services available in the community. The clinical staff releases written assessments, evaluations and reports to DPS Court Counselors upon completion of the assessment/evaluations. The clinical staff provide ongoing verbal information and written documentation on client's progress/status i.e., date/time of client's scheduled appointment, if client cancelled scheduled appointment and rescheduling of appointment, if client no showed for scheduled appointment, if client moved and is no longer in the area, if clinician is not able to contact client, etc. 8. Intervention/Treatment: Describe specifically what the component will do to redirect inappropriate youth behavior or how the component will address the identified needs of the youth and family. What interventions will typically be utilized in this component and how will parents/guardians be involved? The Juvenile Psychological Assessment Program Component addresses the identified needs of the youth and family by providing an unbiased and extensive behavioral health assessment in order to ensure that referred youth are recommended for the right type of service given their individual situation while taking into account what services are currently available given the ever-changing landscape of the behavioral health services array in North Carolina. All assessments contain at a minimum a comprehensive clinical assessment (CCA) utilizing a standardized format including a complete family history (with mandatory parent/guardian participation), ASAM and CALOCUS levels of care, Youth Self Report, and the Achenbach Child Behavior Checklist (Evidence Based Assessment Tool). When full psychological evaluations are needed, psychological testing such as IQ, personality, adaptive functioning, psycho educational screening and developmental functioning assessment are incorporated into the CCA. Psychosexual Risk Assessments and Sex Offense Specific Evaluations include at a minimum, use of the Juvenile Sex Offender Assessment Protocol (JSOAP), Estimate of Risk of Adolescent Sexual Offense Recidivism (ERASOR), Trauma Symptom Checklist, Personal Sentence Completion Inventory, Adolescent Sexual Offender Assessment Packet, and other psychological testing as needed. A thorough review of collateral information such as school records, behavioral health records and legal documentation is routinely included as part of the assessment process in order to fully evaluate any potential need for behavioral health services or natural supports. Crisis consultation/risk assessments are conducted at any time when requested by DPS Court Counselors. Also, all families are offered County funded case management services to help link them with any other identified needs that could help improve family functioning and self sufficiency. Assessments may be completed in person, via. telehealth, or a combination of both methods, depending on unique circumstances and preferences of clients. 9. Best Practice Model: Describe what model or evidence-supported/best practice the program is based upon. The Juvenile Psychological Assessment Component incorporates evidence based best practices in the following ways: each assessment contains, at a minimum, a Comprehensive Clinical Assessment based on a standardized format and Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION IV: COMPONENT NARRATIVE (attach for each component) NAME OF COMPONENT: I Juvenile Psychological Assessment as referenced on the North Carolina Department of Public Safety website, includes the use of the CBCL (Child Behavior Checklist), via the ASEBA (Achenbach System of Empirically Based Assessment), an empirically validated evidence based tool related to the assessment of behavioral health problems with youth. Numerous other evidence based psychological tests are utilized depending on the type of evaluation requested and the clinical presentation of the particular youth to include, intelligence, personality, adaptive functioning and autistic spectrum testing. Juvenile Sex Offense Specific Evaluations include the most widely endorsed and utilized assessment tools such as the Juvenile Sex Offender Assessment Protocol (JSOAP) and the Estimate of Risk of Adolescent Sexual Offence Recidivism (ERASOR). All assessments include the review of multiple sources of collateral information such as school records, past behavioral health treatment records, legal files, etc. Clinically derived DSM 5 diagnoses with specific and relevant treatment recommendations are included in every evaluation. Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION II: COMPONENT STATISTICAL INFORMATION Multi -Components Yes Component Service Statistics PROGRAM COMPONENT INFORMATION - APPLICATION YEAR Component Name: Juvenile Psychological Counseling Component ID # 38148 What is this component's maximum client capacity at any given time? 12 Frequency of client contact per month: 4 Anticipated Average Length of Stay: 120 Days y Total Component Cost: $100,411 - by Estimated # to be served during funding period: 25 Estimated Average Cost Per Youth: $4,016 Applies to continuation programs only. Actual number of youth admitted FY 21-22: 28 28 Number of admissions Juvenile Justice Referred 100% of total admissions 0 Number of admissions Law Enforcement Referred 0% of total admissions 0 Number of admissions District Court Referred 0% of total admissions Actual number served FY 21-22: 35 Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 01/09/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION III: COMPONENT SUMMARY NAME OF COMPONENT: Juvenile Psychological Counseling 1. Statement of the Problem: In concise terminology, describe how the program will address continuum need(s) in the county. In New Hanover County, 70% of youth assessed at DJJ intake have moderate to high risk levels, and 58% have medium to high risk levels. Assessed youth have a needs level of "very high" at double the average rate for NC. 59% of youth self reported previous alcohol/drug use, with 48% identifying substance use as having disrupted their functioning, 94% of youth indicate they have no friends, associate with with negative/delinquent influences, gang members, or have family who are gang members. Additionally, 51 % of youth have a "mental health problem" while only 29% are receiving treatment. Lastly, 54% of youth are charged with assault behaviors or assault inflicting serious injury. (2021-2022 NHC JCPC Risk and Needs Committee Report) The Juvenile Psychological Counseling Program Component will address the needs listed above and the identified needs of the youth aged 6-18 and their family by providing individualized family counseling services via Trauma Focused Cognitive Behavioral Therapy (TF -CBT) to address past traumatic experiences and identify and replace targeted delinquent behaviors with more adaptive and prosocial behaviors to ultimately reduce delinquent behavior, increase familial functioning and reduce recidivism. Outpatient sex offense specific treatment is provided utilizing Timothy J. Kahn's Pathways/Roadmaps to Recovery and Nancy Caleja's Forward Focused treatment models, depending on the age and cognitive functioning level of the particular youth. Outpatient substance use counseling is provided via contracted service with licensed clinical addiction specialist (LCAS). DPS Court Counselors are kept abreast of the client's progress via the 30 day progress reports provided, as well as ongoing verbal/written communication between the clinician and the court counselor at least weekly in the form of consultation/treatment team meetings, weekly staffing, phone calls, etc. 2. Target Population: Describe the target population, including age, and the steps taken to insure that the target population is served. Target Population: Juveniles between the ages of six (6) and eighteen (18) who have been adjudicated delinquent or undisciplined, juveniles under diversion contracts or plan or otherwise under jurisdiction of and referred by juvenile court, including but not limited to, Interstate Compact juveniles to address and correct emotional and/or behavioral concerns that cause the juvenile to be engaged in or at -risk of delinquent behavior. 3. Program Goal(s): Provide a brief statement to describe the overall purpose of the program. The overall purpose of the Juvenile Psychological Counseling Program Component is to provide Individual and Family psychotherapy via Trauma Focused Cognitive Behavioral Therapy to at risk, delinquent and adjudicated youth and their families to ultimately improve targeted delinquent behaviors, familial functioning and improve their ability to effectively cope with complex traumatic experiences in an effort to reduce recidivism. Outpatient substance use counseling provided via contracted service with licensed clinical addiction specialist (LCAS). Outpatient sex offense specific treatment is provided utilizing Timothy J. Kahn's Pathways/Roadmaps to Recovery and Nancy Caleja's Forward Focused treatment models, depending on the age and cognitive functioning level of the particular youth. 4. Measurable Objective(s): State in measurable terms (%) the intended effect of the program on specific undisciplined and/or delinquent behaviors. Example: anticipated reductions in court referrals, runaway behavior, disruptive behavior at school, anticipated improved school attendance and academic achievement. These objectives must include impact on participants. Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION III: COMPONENT SUMMARY NAME OF COMPONENT: Juvenile Psychological Counseling 80% Clients successfully/satisfactorily completing the program will have no new complaints in the 12 months following completion. 80% Clients will have no new complaints with an offense date after the admission date. 80% Clients will have no new adjudications for a complaint with an offense date after the admission date. 80% Clients will reduce specific problem behaviors presented at referral and targeted in the individual service plan. 80% Clients and families will demonstrate enhanced family functioning as a result of program services. 80% Clients will successfully or satisfactorily complete services as intended by the program design/service plan. 80% Clients will demonstrate improvement in targeted skills identified in the individual service plan. 80% Clients successfully/satisfactorily completing the program will have no new adjudications in the 12 months following completion. 80% Clients will demonstrate improvement in replacement behaviors targeted in the individual service plan. 5. Elevated Risks and Needs: Describe how program services will address one or more of the elevated risk and needs listed in the most recent JCPC Request for Proposal. In New Hanover County the following Risk Factors for Delinquency or Repeat Delinquency and the following concerns as reported in the Needs Assessments for Adjudicated Youth were identified in the local Request for Proposal: Association with Other Delinquent Peers or Peers Involved with Gangs; Mental Health Needs including Moderate to Serious Behavioral Problems at School; Involvement in Alcohol and Substance Use; Prior Assaultive Behavior; Referral to Juvenile Court Prior to Age 12 and Inadequate Supervision by Parents/Guardians. The Juvenile Psychological Counseling Program Component will address the needs listed above and the identified needs of the youth aged 6-18 and their family by providing individualized family counseling services via Trauma Focused Cognitive Behavioral Therapy (TF -CBT) to identify and replace targeted delinquent behaviors with more adaptive and prosocial behaviors to ultimately reduce delinquent behavior, increase familial functioning and improve their ability to effectively cope with past traumatic experiences in an effort to reduce recidivism. Outpatient sex offense treatment is provided utilizing Timothy J. Kahn's Pathways/Roadmaps to Recovery and Nancy Caleja's Forward Focused treatment models, depending on the age and cognitive functioning level of the particular youth. DPS Court Counselors are kept abreast of the client's progress via the 30 day progress reports provided, as well as ongoing verbal/written communication between the clinician and the court counselor in the form of consultation/treatment team meetings, weekly staffing, phone calls, etc. Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION IV: COMPONENT NARRATIVE (attach for each component) NAME OF COMPONENT: Juvenile Psychological Counseling 1. Location: List physical address(es) and describe where program services are delivered. The Juvenile Psychological Counseling, Family Counseling Component is housed on the first floor of the new courthouse, located at 138 N. 4th street. The clinicians proximity to juvenile court counselors promotes efficiency and ease of access for youth/families and fosters an environment where information is easily accessed and shared. Clinicians are available to court staff on Tuesdays, the day juvenile court is traditionally held, and they attend court sessions when applicable. 2. Operation: Describe the daily/weekly schedule of program operation. Monday - Thursday 7:30 - 6:00 and Friday 7:30 - 5:00. 3. Staff Positions: Describe paid or volunteer position qualifications, (certifications, degrees, work experience) and position(s) responsibilities relative to this component. 1 part time (15%) Licensed Clinical Therapist Qualifications: MA Clinical Psychology, Licensed Psychological Associate, NC Licensure #2537,15+ years post licensure experience. 1 part time (15%) Licensed Clinical Therapist Qualifications: MSW, Licensed Clinical Social Worker, NC Licensure #C009780, 2+ years post licensure experience. Member of ATSA Responsibilities: Provide Individual and Family psychotherapy via Trauma Focused Cognitive Behavioral Therapy to at risk, and adjudicated youth and their families to improve targeted delinquent behaviors, familial functioning and improve ability to effectively cope with past traumatic experiences in an effort to reduce recidivism. Outpatient sex offense treatment is provided utilizing Timothy J. Kahn's Pathways/Roadmaps to Recovery and Nancy Caleja's Forward Focused treatment models, depending on the age and functioning level of the particular youth. Crisis consultations/risk assessments are conducted upon request from DPS Court Counselors 1 -part time (10%) Licensed Clinical Therapist Qualifications: MSW, Licensed Clinical Social Worker, Member of ATSA, NC Licensure #C002813, 20+ years post licensure experience Responsibilities: See Clinical Duties 1 part time (20%) Licensed Clinical Therapist Supervisor (Fully Funded by New Hanover County - In Kind) Qualifications: MA Clinical Psychology, Licensed Clinical Mental Health Counselor, NC Licensure #4476,20+ years post licensure experience. Member of ATSA Responsibilities: Process and assign referrals from DPS Court Counselors, supervise the operations of the clinical staff, including oversight of Trauma Focused Cognitive Behavioral Therapy and outpatient sex offender treatment. Conduct quality assurance meetings and fidelity review meetings to facilitate compliance with JCPC guidelines and Evidence -based practices 1 part time (5%) YES Manager, (Program Manager) - (Partially Funded by New Hanover County - In Kind) Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION IV: COMPONENT NARRATIVE (attach for each component) NAME OF COMPONENT: Juvenile Psychological Counseling Qualifications: Masters in Public Administration, 10+ years experience with at risk youth Responsibilities: Representing the program to promote initiatives by facilitating and attending meetings, monitoring grants; overseeing the compilation/maintenance of program reports 1 contracted Licensed Psychologist Responsibilities: Provide clinical supervision and consultation 1 contracted Licensed Clinical Addiction Specialist Responsibilities: Provide assessments and outpatient substance use counseling 1 part time (5%) CJS Support Services Coordinator - (Fully Funded by New Hanover County - In Kind) Qualifications: MBA, 20+ years administrative experience Responsibilities: Program financial and budget operations 1 part time (5%) CJS Administrative Support Specialist (Fully Funded by New Hanover County - In Kind) Qualifications: BA Communication Studies, 15+ years medical records/clerical experience 4. Service Type SPEP: Describe implementation to include: Primary Service: Cognitive Behavior; Secondary Service: None Evidence -Based Program Name: Trauma Focused Cognitive Behavioral Therapy Target Weeks: 15; Target Hours: 20 5. Admission Process: Describe the specific referral, screening, admission process (including timeline), the staff responsible for making decisions about admissions and reasons why a referral may not be accepted. The Juvenile Psychological Counseling Program Component admissions process begins with a DPS Court Counselor completing a referral to the Youth Empowerment Services (YES) Licensed Clinical Therapist Supervisor requesting counseling services. Upon receipt of the referral, it is reviewed by the Clinical Supervisor and assigned to a Licensed Clinical Therapist immediately and the referring court counselor is notified in writing regarding the acceptance of the referral. The clinician contacts the youth's parent/guardian within 48 hours to schedule an appointment and conducts appointment reminder calls 24 hours prior to appointment times. All referrals are accepted; however, a referral may not result in an admission if the youth is already receiving mental health services and/or the parent/guardian chooses to have the requested services provided by a private provider of their choice. The Juvenile Psychological Counseling Program Component addresses the identified needs of the youth and family by providing individualized evidence based family counseling services via Trauma Focused Cognitive Behavioral Therapy (TF -CBT). The TF -CBT model includes informed consent from client guardians, explanation of the treatment model and expected number of sessions, pre & post test measurements and use of a TF -CBT fidelity instrument (TF -CBT Brief Practice Checklist). Treatment will be administered in a standardized manner using the TF -CBT PRACTICE clinical treatment model and will include structured curriculum utilized via the TF -CBT Workbook. All youth have an individualized service plan developed that outlines goals specific to the youth and their family and includes specified service interventions and frequency of service specific to the individualized needs of the youth and family. Guardian input is mandatory in the development of all service plans. Outpatient sex offense specific treatment is provided utilizing Timothy J. Kahn's Pathways/Roadmaps to Recovery and Nancy Caleja's Forward Focused treatment models, depending on the age and Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION IV: COMPONENT NARRATIVE (attach for each component) NAME OF COMPONENT: Juvenile Psychological Counseling cognitive functioning level of the particular youth. The treatment models utilized take a cognitive behavioral approach and cover common treatment targets to include responsibility taking, cognitive distortions and thinking errors, victim empathy, intrapersonal and interpersonal skills, boundary setting, sex education, relationship skills, healthy sexuality, arousal control, trauma resolution and improved family functioning. Treatment is individualized and guided by a comprehensive evaluation. Service plans are individualized and guardian participation is mandatory. Counseling may be provided in a face to face setting, via telehealth, or a combination of the two, depending on client preference, unique circumstances, and pandemic related factors. 6. Termination Process: Describe the termination process to include the staff responsible for making decisions and the criteria for a successful termination, satisfactory termination, unsuccessful completion and non-compliant termination. For the Juvenile Psychological Counseling Program Component, the Licensed Clinical Therapist who provides psychotherapy to the youth and family is responsible for determining the type of termination. The counseling is terminated successfully and/or satisfactorily upon the client obtaining their goals as identified in their individual service plan and/or making satisfactory progress in achieving those identified goals. The client is terminated unsuccessfully if the youth and family do not engage in psychotherapy and do not make sufficient progress towards achieving the identified goals on the service plan. The client is terminated noncompliant if the youth and family refuses to comply with attending therapy sessions. How is the referring agency involved with the termination process? For the Juvenile Psychological Counseling Program Component, the clinical staff provide the referring agency ongoing verbal and written communication regarding the client/family's progress throughout the course of treatment to include 30 day progress reports as well as the status of the client at termination of treatment. During the termination process the responsible clinician develops an individualized treatment termination summary; including an after-care plan based on interactions and consultation with the juvenile, guardian and referral entity. This plan includes a description of the course of treatment and referrals to appropriate community resources related to the identified needs of the youth. 7. Referring Agency Interaction: Describe the interaction with juvenile court counselors and/or other referring agencies including how client progress will be communicated. For the Juvenile Psychological Counseling Program component, the referring agency is kept abreast of the client's progress or their lack of progress on at least a monthly basis via the 30 day progress reports provided to the DPS Court Counselor by the clinician, as well as ongoing verbal/written communication between the clinician and the court counselor in the form of consultation/treatment team meetings, weekly staffing's, etc. During the termination process the responsible clinician develops an individualized treatment termination summary; including an after-care plan based on interactions and consultation with the juvenile, guardian and the DPS Court Counselor. This plan includes a description of the course of treatment and referrals to appropriate community resources related to the identified needs of the youth. 8. Intervention/Treatment: Describe specifically what the component will do to redirect inappropriate youth behavior or how the component will address the identified needs of the youth and family. What interventions will typically be utilized in this component and how will parents/guardians be involved? The Juvenile Psychological Counseling Program Component addresses identified needs of youth and families by providing individualized evidence based family counseling services via Trauma Focused Cognitive Behavioral Therapy Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION IV: COMPONENT NARRATIVE (attach for each component) NAME OF COMPONENT: I Juvenile Psychological Counseling (TF -CBT). Agency clinicians providing treatment receive ten hours of online TF -CBT specific training from the Medical University of South Carolina and twelve hours TF -CBT specific training from a TF -CBT certified trainer. The implementation of the TF -CBT model includes informed consent from client guardians, explanation of the treatment model and expected number of sessions, pre & post test measurements (Achenbach Child Behavior Checklist and Beck Youth Depression, Anxiety and Self Concept Inventories) and use of a TF -CBT fidelity instrument (TF -CBT Brief Practice Checklist). Treatment is administered in a standardized manner using the TF -CBT PRACTICE clinical treatment model and includes structured curriculum utilized via the TF -CBT Workbook. All youth have an individualized service plan that outlines goals specific to youth and their family and specified service interventions and frequency of service specific to the individualized needs of the youth and family. Guardian input is mandatory in developing of all service plans and their participation in treatment is required. DPS Court Counselors are kept abreast of the client's progress via 30 day progress reports, as well as ongoing verbal/written communication between the clinician and court counselor at least weekly in the form of consultation/treatment team meetings, weekly staffing, phone calls, etc. Specifically, inappropriate youth behaviors are redirected by utilizing TF -CBT coping skills, relaxation exercises, diversion to another therapeutic tool or utilization of youth's crisis plan when necessary. Outpatient substance use counseling provided via contracted service with a licensed clinical addiction specialist (LCAS). Outpatient sex offense specific treatment is provided utilizing Timothy J. Kahn's Pathways/Roadmaps to Recovery treatment models, depending on age and cognitive functioning level of the particular youth. The treatment models utilized take a cognitive behavioral approach and cover common treatment targets, including: responsibility taking, cognitive distortions and thinking errors, victim empathy, intrapersonal and interpersonal skills, sex education, relationship skills, healthy boundaries, arousal control, trauma resolution and improved family functioning. Treatment is individualized and guided by a comprehensive evaluation. Service plans are individualized and guardian participation is mandatory. All families are offered County funded case management services to help link them with any other identified needs that could help improve family functioning and self-sufficiency. Counseling may be provided in a face to face setting, via telehealth, or a combination of the two, depending on client preference, unique circumstances, and pandemic related factors. 9. Best Practice Model: Describe what model or evidence-supported/best practice the program is based upon. For the Juvenile Psychological Counseling Component, the evidence-based/best practice model that clinical staff utilizes is Trauma Focused Cognitive Behavioral Therapy (TF -CBT). TF -CBT is rated as an effective evidence based intervention by the Office of Juvenile Justice and Delinquency Prevention Model Programs Guide. Agency clinicians providing treatment will receive ten hours of online TF -CBT specific training from the Medical University of South Carolina and twelve hours TF -CBT specific training from a TF -CBT certified trainer.TF—CBT is a treatment intervention that integrates cognitive and behavioral interventions with traditional child -abuse therapies. Its focus is to help children talk directly about their traumatic experiences in a supportive environment. The program operates through the use of a parental treatment component and several child—parent sessions. The parent component teaches parents parenting skills to provide optimal support for their children. The parent—child sessions encourage the child to discuss the traumatic events directly with the parent and both the parent and child to communicate questions, concerns, and feelings more openly. Typically, TF—CBT is implemented as a relatively brief intervention, usually lasting from 12 to 18 weekly sessions. These aim to provide the parents and children with the skills to better manage and resolve distressing thoughts, emotions, and reactions related to traumatic life events; improve the safety, comfort, trust, and growth in the child; and develop parenting skills and family communication. For juvenile sex offense specific treatment the evidence supported model utilized is Timothy J. Kahn's Pathways/Roadmaps to Recovery and Nancy Caleja's Forward Focused treatment model, depending on the age and cognitive functioning level of the particular youth. The treatment model utilized takes a cognitive behavioral approach and covers common treatment targets to include responsibility taking, cognitive distortions and thinking errors, victim empathy, intrapersonal and interpersonal skills, Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION IV: COMPONENT NARRATIVE (attach for each component) NAME OF COMPONENT: I Juvenile Psychological Counseling sex education, relationship skills, healthy sexuality, arousal control, trauma resolution and improved family functioning. Treatment is individualized and guided by a comprehensive evaluation. Service plans are individualized for youth in sex offense treatment and guardian participation is mandatory. Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION II: COMPONENT STATISTICAL INFORMATION Multi -Components Yes Component Service Statistics PROGRAM COMPONENT INFORMATION - APPLICATION YEAR Component Name: Home Based Family Counseling Component ID # 38149 What is this component's maximum client capacity at any given time? 5 Frequency of client contact per month: 8 Anticipated Average Length of Stay: 140 Days y Total Component Cost: $84,142 - by Estimated # to be served during funding period: 8 Estimated Average Cost Per Youth: $10,518 Applies to continuation programs only. Actual number of youth admitted FY 21-22: 5 5 Number of admissions Juvenile Justice Referred 100% of total admissions 0 Number of admissions Law Enforcement Referred 0% of total admissions 0 Number of admissions District Court Referred 0% of total admissions Actual number served FY 21-22: 7 Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 01/09/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION III: COMPONENT SUMMARY NAME OF COMPONENT: Home Based Family Counseling 1. Statement of the Problem: In concise terminology, describe how the program will address continuum need(s) in the county. In New Hanover County, 70% of youth assessed at DJJ intake have moderate to high risk levels, and 58% have medium to high risk levels. Assessed youth have a needs level of "very high" at double the average rate for NC. 59% of youth self reported previous alcohol/drug use, with 48% identifying substance use as having disrupted their functioning, 94% of youth indicate they have no friends, associate with with negative/delinquent influences, gang members, or have family who are gang members. Additionally, 51 % of youth have a "mental health problem" while only 29% are receiving treatment. Lastly, 54% of youth are charged with assault behaviors or assault inflicting serious injury. (2021-2022 NHC JCPC Risk and Needs Committee Report) The Home Based Family Counseling (HBFC) Program Component will address the risk factors listed above and other identified needs of the youth and family by providing individualized evidenced based family counseling services via Trauma Focused Cognitive Behavioral Therapy (TF -CBT). The HBFC Program provides intensive services in the community environment (home, school and peer Domains) in an effort to assist youth in the successful transition back into the community from a residential placement and/or keep them stable in their home environment. Also, this service helps bridge the gap when a need arises for immediate intervention combined with intensive home based counseling when not available via traditional funding sources in order to assist court involved youth from being placed outside the home unless it is clinically necessary. 2. Target Population: Describe the target population, including age, and the steps taken to insure that the target population is served. Target Population: Juveniles between the ages of six (6) and eighteen (18) who have been adjudicated delinquent or undisciplined, juveniles under diversion contracts or plan or otherwise under jurisdiction of and referred by juvenile court, including but not limited to, Interstate Compact juveniles to address and correct emotional and/or behavioral concerns that cause the juvenile to be at -risk for removal from the home. 3. Program Goal(s): Provide a brief statement to describe the overall purpose of the program. The Home Based Family Counseling (HBFC) Program Component provides family counseling in the home environment to court referred adjudicated youth transitioning back to their home from a residential placement to successfully maintain them in the home and community environments. The program also prioritizes referrals for court adjudicated/diverted youth who need immediate intervention to keep them from being placed outside the home through home and community based counseling services to promote success of court diverted, and adjudicated, youth to remain in their community receiving services as opposed to an out of home placement. 4. Measurable Objective(s): State in measurable terms (%) the intended effect of the program on specific undisciplined and/or delinquent behaviors. Example: anticipated reductions in court referrals, runaway behavior, disruptive behavior at school, anticipated improved school attendance and academic achievement. These objectives must include impact on participants. 70% Clients successfully/satisfactorily completing the program will have no new adjudications in the 12 months following completion. 70% Clients will successfully or satisfactorily complete services as intended by the program design/service plan. Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION III: COMPONENT SUMMARY NAME OF COMPONENT: Home Based Family Counseling 70% Clients will reduce specific problem behaviors presented at referral and targeted in the individual service plan. 70% Clients and families will demonstrate enhanced family functioning as a result of program services. 70% Clients will have no new complaints with an offense date after the admission date. 70% Clients will comply with the permanency plan as described in the individual service plan. 70% Clients successfully/satisfactorily completing the program will have no new complaints in the 12 months following completion. 70% Clients will demonstrate improvement in replacement behaviors targeted in the individual service plan. 70% Clients will have no new adjudications for a complaint with an offense date after the admission date. 5. Elevated Risks and Needs: Describe how program services will address one or more of the elevated risk and needs listed in the most recent JCPC Request for Proposal. In New Hanover County the following Risk Factors for Delinquency or Repeat Delinquency and the following concerns as reported in the Needs Assessments for Adjudicated Youth were identified in the local Request for Proposal: Association with Other Delinquent Peers or Peers Involved with Gangs; Mental Health Needs including Moderate to Serious Behavioral Problems at School; Prior Assaultive Behavior; Involvement in Alcohol and Substance Use; Referral to Juvenile Court Prior to Age 12 and Inadequate Supervision by Parents/Guardians. The Home Based Family Counseling (HBFC) Component will address the needs listed above and the identified needs of youth aged 6-18 and their family by providing individualized HBFC services via Trauma Focused Cognitive Behavioral Therapy (TF -CBT). The HBFC Program provides intensive services in the community environment (Home, School and Peer Domains) in an effort to assist youth in the successful transition back into the community from a residential placement and keep them in their home environment. In addition, HBFC provides services to all participating family members across multiple community settings in order to ensure our at risk families have the services in place needed to be successful. DPS Court Counselors are kept abreast of the family's progress via the 30 day progress reports, as well as ongoing verbal/written communication between the clinician and the court counselor at least weekly in the form of consultation/treatment team meetings, weekly staffing, phone calls, etc. Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION IV: COMPONENT NARRATIVE (attach for each component) NAME OF COMPONENT: Home Based Family Counseling 1. Location: List physical address(es) and describe where program services are delivered. The Juvenile Psychological Counseling, Home Based Family Counseling Component is housed on the first floor of the new juvenile courthouse, located at 138 N. 4th street. The clinicians proximity to juvenile court counselors promotes efficiency and ease of access for youth/families and fosters an environment where information is easily accessed and shared. Clinicians are available to court staff on Tuesdays, the day juvenile court is traditionally held, and they attend court sessions when applicable. At least 50% of direct services are provided in the youth/family home environment. Services are also provided in school and community settings as needed. 2. Operation: Describe the daily/weekly schedule of program operation. Flexible schedule, Monday - Friday 7:30 a.m. - 8:00 p.m. and Saturday appointments as needed. 3. Staff Positions: Describe paid or volunteer position qualifications, (certifications, degrees, work experience) and position(s) responsibilities relative to this component. 1 -part time (60%) Licensed Clinical Therapist (Fully Funded by New Hanover County - In Kind) Qualifications: MSW, Licensed Clinical Social Worker, Member of ATSA NC Licensure #C012288, 15+ years post licensure experience Responsibilities: Provide individualized Home Based Family Counseling (HBFC) services via Trauma Focused Cognitive Behavioral Therapy with the aim of increasing individual and familial functioning and reducing recidivism 1 part time (5%) Licensed Clinical Therapist Supervisor (Fully Funded by New Hanover County - in Kind) Qualifications: MA Clinical Psychology, Licensed Clinical Mental Health Counselor, NC Licensure #4476,20+ years post licensure experience. Member of the Association for the Treatment of Sexual Abusers. Responsibilities: Process and assign referrals from DPS Court Counselors and supervise the operations of the clinical staff, including oversight of the Home Based Family Counseling Program. Conduct quality assurance meetings and fidelity tool review meetings, to facilitate compliance with JCPC guidelines and evidence -based practices 1 part time(5%) YES Manager, (Program Manager) - (Partially Funded by New Hanover County - In Kind) Qualifications: Masters in Public Administration, 10+ years experience with at risk youth Responsibilities: Representing the program to promote initiatives by facilitating and attending meetings and monitoring grants; responding to inquiries of stake holders and the public regarding program services to include explaining program guidelines and addressing public citizen groups; overseeing the compilation and maintenance of program reports detailing HBFC operations and activities as mandated by County, State, and Federal regulations and as requested by various officials to include maintaining data pertaining to youth; and assuring compliance with State, Federal and Local laws pertaining to specific grants and programs 1 -part time (5%) CJS Support Services Coordinator (Fully Funded by New Hanover County - In Kind) Qualifications: MBA, 15+ years administrative experience Responsibilities: Program financial and budget operations 1 -part time (5%) CJS Administrative Support Specialist (Fully Funded by New Hanover County - In Kind) Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION IV: COMPONENT NARRATIVE (attach for each component) NAME OF COMPONENT: Home Based Family Counseling Qualifications: BA Communication Studies, 15+ years medical records/clerical experience Responsibilities: Administrative duties 4. Service Type SPEP: Describe implementation to include: Primary Service: Cognitive Behavior; Secondary Service: None Evidence -Based Program Name: Trauma Focused Cognitive Behavioral Therapy Target Weeks: 15; Target Hours: 45 5. Admission Process: Describe the specific referral, screening, admission process (including timeline), the staff responsible for making decisions about admissions and reasons why a referral may not be accepted. For the Home Based Family Counseling (HBFC) Program Component, at the onset of a youth transitioning from a residential placement or identified to be at risk of an out of home placement due to delinquent behavior, a DPS Court Counselor completes a referral to the HBFC program for the youth/family that are identified as appropriate for the service. Upon receipt of the referral, the Licensed Clinical Therapist contacts the youth's parent/guardian within 48 hours to schedule an appointment and provides reminder calls 24 hours prior to appointments. All referrals are accepted; however, a referral may not result in an admission if the youth/family is already receiving behavioral health services, or a higher level of treatment is deemed more clinically appropriate and/or the parent/guardian chooses to have the services requested provided by a private provider of their choice. The HBFC Program Component will address the identified needs of the youth and family by providing individualized evidence based family counseling services via Trauma Focused Cognitive Behavioral Therapy (TF -CBT). Agency clinicians providing treatment will receive ten hours of online TF -CBT specific training from the Medical University of South Carolina and twelve hours of TF -CBT specific training from a TF -CBT certified trainer. The TF -CBT model includes informed consent from client guardians, explanation of the treatment model and expected number of sessions, pre & post test measurements (Achenbach Child Behavior Checklist and Beck Youth Depression, Anxiety and Self Concept Inventories) and use of a TF -CBT fidelity instrument (TF -CBT Brief Practice Checklist). Treatment will be administered in a standardized manner using the TF -CBT PRACTICE clinical treatment model and will include structured curriculum utilized via the TF -CBT Workbook. All youth have an individualized service plan developed that outlines goals specific to the youth and their family and includes specified service interventions and frequency of service specific to the individualized needs of the youth and family. Guardian input is mandatory in the development of all service plans. DPS Court Counselors are kept abreast of the client's progress via the 30 day progress reports provided, as well as ongoing verbal/written communication between the clinician and the court counselor at least weekly in the form of consultation/treatment team meetings, weekly staffings, phone calls, etc. 6. Termination Process: Describe the termination process to include the staff responsible for making decisions and the criteria for a successful termination, satisfactory termination, unsuccessful completion and non-compliant termination. For the Home Based Family Counseling (HBFC) Program Component, the Licensed Clinical Therapist who provides counseling to the youth and their family is responsible for determining the type of termination. The counseling is terminated successfully and/or satisfactorily upon the client/family obtaining the goals as identified on the service plan and/or making satisfactory progress in achieving those identified goals. The client is terminated unsuccessfully if the youth/family does not engage in counseling and make sufficeint progress towards achieving the identified goals on the service plan. The client/family is terminated noncompliant if the youth/family refuses to comply with the HBFC services. How is the referring agency involved with the termination process? Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION IV: COMPONENT NARRATIVE (attach for each component) NAME OF COMPONENT: Home Based Family Counseling The referring agency is heavily involved with the clinician and family throughout the treatment process. Prior to the client's termination all pertinent communication has been relayed regarding the status of the client's ongoing progress as well as the court counselor attending treatment team meetings and provided 30 day progress reports. During the termination process the HBFC therapist develops a treatment termination summary; including an individualized after- care plan based on interactions and consultation with the juvenile, guardian and referral entity. This plan includes a description of the course of treatment and referrals to appropriate community resources related to the identified needs of the youth. 7. Referring Agency Interaction: Describe the interaction with juvenile court counselors and/or other referring agencies including how client progress will be communicated. For the Home Based Family Counseling (HBFC) Program Component, the referring agency is kept abreast of the client's progress all throughout the treatment service to include the ongoing verbal/written communication between the clinician and the court counselor in the form of consultation, treatment team meetings, weekly staffing's, and 30 day progress reports. During the termination process the HBFC therapist develops an individualized after-care plan based on interactions and consultation with the juvenile, guardian and the DPS Court Counselor. This plan includes a description of the course of treatment and referrals to appropriate community resources related to the identified needs of the youth. 8. Intervention/Treatment: Describe specifically what the component will do to redirect inappropriate youth behavior or how the component will address the identified needs of the youth and family. What interventions will typically be utilized in this component and how will parents/guardians be involved? The Home Based Family Counseling (HBFC) Program Component will address the identified needs of the youth and family by providing individualized evidence based family counseling services via Trauma Focused Cognitive Behavioral Therapy (TF -CBT). Agency clinicians providing treatment will receive ten hours of online TF -CBT specific training from the Medical University of South Carolina and twelve hours of TF -CBT specific training from a TF -CBT certified trainer. The TF -CBT model includes informed consent from client guardians, explanation of the treatment model and expected number of sessions, pre & post test measurements (Achenbach Child Behavior Checklist, Youth Self Report, and Beck Youth Depression, Anxiety and Self Concept Inventories) and use of a TF -CBT fidelity instrument (TF -CBT Brief Practice Checklist). Treatment is administered in a standardized manner using the TF -CBT PRACTICE clinical treatment model and includes structured curriculum utilized via the TF -CBT Workbook. All youth have an individualized service plan that outlines goals specific to the youth and their family and includes specified service interventions and frequency of service specific to the individualized needs of the youth and family. Guardian input is mandatory in the development of all service plans and their participation in treatment is required. DPS Court Counselors are kept abreast of the client's progress via the 30 day progress reports provided, as well as ongoing verbal/written communication between the clinician and the court counselor at least weekly in the form of consultation/treatment team meetings, weekly staffings, phone calls, etc. Specifically, maladaptive youth behaviors are targeted by utilizing TF -CBT coping skills, relaxation exercises, diversion to other therapeutic tools, emotional regulation, cognitive reframing, and utilization of the youth's crisis plan when necessary. The Licensed Clinical Therapist who provides HBFC to the youth and family is responsible for determining the type of termination. HBFC is terminated successfully and/or satisfactorily upon the client obtaining their goals as identified in their individual service plan and/or making satisfactory progress in achieving those identified goals. The client is terminated unsuccessfully if the youth and family do not engage in services and make sufficient progress towards achieving the identified goals on the service plan. The client is Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION IV: COMPONENT NARRATIVE (attach for each component) NAME OF COMPONENT: Home Based Family Counseling terminated noncompliant if the youth and family refuses to comply with therapy sessions. All termination information including DPS identified measurable objectives are entered into the NC ALLIES web based tracking system for monitoring purposes. HBFC is provided by a licensed clinician (LCSW) with experience providing outpatient therapy to at risk youth and their families. All families are offered County funded case management services to help link them with any other identified needs that could help improve family functioning and self sufficiency. 9. Best Practice Model: Describe what model or evidence-supported/best practice the program is based upon. For the Home Based Family Counseling Component, the evidence-based/best practice model that clinical staff utilizes is Trauma Focused Cognitive Behavioral Therapy (TF -CBT). TF -CBT is rated as an effective evidence based intervention by the Office of Juvenile Justice and Delinquency Prevention Model Programs Guide. TF—CBT is a treatment intervention that integrates cognitive and behavioral interventions with traditional child trauma therapies. Its focus is to help children talk directly about their traumatic experiences in a supportive environment. The program operates through the use of a parental treatment component and several child—parent sessions. The parent component teaches parents parenting skills to provide optimal support for their children. The parent—child sessions encourage the child to discuss the traumatic events directly with the parent and both the parent and child to communicate questions, concerns, and feelings more openly. Typically, TF—CBT is implemented as a relatively brief intervention, usually lasting from 12 to 18 weekly sessions. These aim to provide the parents and children with the skills to better manage and resolve distressing thoughts, emotions, and reactions related to traumatic life events; improve the safety, comfort, trust, and growth in the child; and develop parenting skills and family communication. Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION II: COMPONENT STATISTICAL INFORMATION Multi -Components Yes Component Service Statistics PROGRAM COMPONENT INFORMATION - APPLICATION YEAR Component Name: Community Service and Restitution Component ID # 38150 What is this component's maximum client capacity at any given time? 60 Frequency of client contact per month: 4 Anticipated Average Length of Stay: 90 Days y Total Component Cost: $321,0821 - by Estimated # to be served during funding period: 180 Estimated Average Cost Per Youth: 1$1,784 Applies to continuation programs only. Actual number of youth admitted FY 21-22: 119 62 Number of admissions Juvenile Justice Referred 52.1 % of total admissions 4 Number of admissions Law Enforcement Referred 3.36% of total admissions 0 Number of admissions District Court Referred 0% of total admissions Actual number served FY 21-22: 132 Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 01/09/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION III: COMPONENT SUMMARY NAME OF COMPONENT: Community Service and Restitution 1. Statement of the Problem: In concise terminology, describe how the program will address continuum need(s) in the county. In New Hanover County, 70% of youth assessed at DJJ intake have moderate to high risk levels, and 58% have medium to high risk levels. Assessed youth have a needs level of "very high" at double the average rate for NC. 59% of youth self reported previous alcohol/drug use, with 48% identifying substance use as having disrupted their functioning, 94% of youth indicate they have no friends, associate with with negative/delinquent influences, gang members, or have family who are gang members. Additionally, 51 % of youth have a "mental health problem" while only 29% are receiving treatment. Lastly, 54% of youth are charged with assault behaviors or assault inflicting serious injury. (2021-2022 NHC JCPC Risk and Needs Committee Report) The Community Service and Restitution (CSR) Program Component addresses a priority for JCPC funding as defined by NC General Statutes GS 143B-549: "Each County Council shall ensure that appropriate intermediate dispositional options are available and shall prioritize funding for dispositions of intermediate and community -level sanctions for court -adjudicated juveniles under minimum standards adopted by the Department (of Juvenile Justice and Delinquency Prevention)". CSR provides an intermediate dispositional option to meet the youth and families court ordered or diverted community service and/or restitution obligation by providing the youth opportunities to engage in civic, community and social responsibilities through a service learning model to reduce recidivism and delinquent behaviors while also offering vocational exposure and service opportunities focused on development of soft skills necessary to enter the labor force. The soft skill development and vocational training is provided through a partnership with Cape Fear Community College (CFCC) under an established MOU allowing for increased CSR youth utilization of CFCC resources and expertise. 2. Target Population: Describe the target population, including age, and the steps taken to insure that the target population is served. Target Population: Juveniles between the ages of six (6) and eighteen (18) who have been adjudicated delinquent or undisciplined, juveniles under diversion contracts or plan or otherwise under jurisdiction of and referred by juvenile court, including but not limited to, Interstate Compact juveniles and juveniles who may be referred by Teen Court Programs or other Law Enforcement Diversion Programs. 3. Program Goal(s): Provide a brief statement to describe the overall purpose of the program. The Community Service and Restitution Program Component facilitates juveniles completing their court ordered and/ or diverted obligations successfully and in a timely manner while teaching, modeling and encouraging civic, community and social responsibilities to the youth served through a service learning model to reduce recidivism and delinquent behaviors while also offering vocational exposure and the development of soft skills necessary to enter the labor force. The CSR program strives to provide youth with a meaningful service experience that will promote engagement in community organizations/activities and lower the likelihood of further DJJ involvement. Since Raise the Age, program staff have expanded services to meet the needs of older youth being served by utilizing a partnership with CFCC and Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION III: COMPONENT SUMMARY NAME OF COMPONENT: Community Service and Restitution leveraging NHC resources to maximize impact. The program also works closely with the youth/family to develop an aftercare plan for youth following completion of services, outlining opportunities for continued community involvement, and identifying resources accessible to the youth. 4. Measurable Objective(s): State in measurable terms (%) the intended effect of the program on specific undisciplined and/or delinquent behaviors. Example: anticipated reductions in court referrals, runaway behavior, disruptive behavior at school, anticipated improved school attendance and academic achievement. These objectives must include impact on participants. 80% Clients will complete restitution or community service within the timeframe permitted by JCPC policy. 80% Clients will have no new complaints with an offense date after the admission date. 80% Clients will demonstrate accountability by actively participating in restitution/community service activities. 80% Clients successfully/satisfactorily completing the program will have no new complaints in the 12 months following completion. 80% Clients will successfully or satisfactorily complete services as intended by the program design/service plan. 80% Clients successfully/satisfactorily completing the program will have no new adjudications in the 12 months following completion. 80% Clients will have no new adjudications for a complaint with an offense date after the admission date. 5. Elevated Risks and Needs: Describe how program services will address one or more of the elevated risk and needs listed in the most recent JCPC Request for Proposal. In New Hanover County the following risk factors for delinquency or repeat delinquency and the following concerns as reported in the Needs Assessments for Adjudicated Youth were identified in the local request for proposal: association with other delinquent peers or peers involved with gangs; mental health needs including school behavior problems; involvement in alcohol and substance use; prior assaultive behavior; referral/involvement with juvenile court prior to age 12; inadequate supervision by parents/guardians and association with delinquent peers. As an intermediate dispositional option in New Hanover County, the Community Service and Restitution (CSR) Program provides juveniles an opportunity to complete their court ordered and/or court diverted obligations while teaching, mentoring, modeling and encouraging civic, community and social responsibilities to the youth served while incorporating a service learning model to reduce recidivism and delinquent behaviors. The CSR component addresses the identified risk and needs across the peer, individual, family and school domains by facilitating youth learning civic, community and social responsibility via individual mentoring and skill development in an effort to model prosocial behavior, promote responsibility/accountability and increase the youth's capacity to interact with the community in a positive way. CSR staff collaborate with over local service providers committed to the well being and success of youth to provide meaningful service opportunities and access to resources. Youth/families are frequently referred to CJS case management services to receive holistic, wrap around, care to address needs of the entire household. These services are free to participants and provided regardless of program status with CSR. Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION IV: COMPONENT NARRATIVE (attach for each component) NAME OF COMPONENT: I Community Service and Restitution 1. Location: List physical address(es) and describe where program services are delivered. The Community Service and Restitution Program Component services are housed in the New Hanover County Juvenile Courthouse, located at 138 N. 4th Street, Wilmington N.C. Additionally, there are 30 community service worksites located throughout New Hanover County where youth have the opportunity to earn hours and develop skills. 2. Operation: Describe the daily/weekly schedule of program operation. Monday - Friday 8:00-7:00 and Saturday 8:00-5:00 The Community Service and Restitution (CSR) Program has a manualized protocol for service delivery summarized below: Intake/orientation procedures are described in detail starting when the program receives a referral from a DPS Court Counselor or other referral agent and includes detailed timelines related to correspondence with the referral source, procedures for conducting intakes immediately after court disposition has been rendered and step by step instructions that should be followed during the face to face intake. Post intake procedures are described and include details related to worksite scheduling, chart construction, data collection procedures needed for NC ALLIES, creation of the online communication log and the process of communicating critical youth information to CSR staff such as emergency contact information, transportation details, etc. All worksite placement procedures are detailed and include the method of selecting an individualized placement for the youth taking into account their specific skill level, age, risk level, interests, compatibility and transportation needs. All worksite projects are planned in advance and include an activity/lesson plan that contains a detailed itinerary and list of objectives related to the activity. Procedures are outlined based upon expectations and timelines related to the communication between staff and both parents/guardians and court counselors or other referral agents. This includes, but is not limited to, reminder calls, maintenance of the monthly activity calendar, worksite sign in procedures and communication with court counselors regarding the number of hours scheduled each month (8 hours minimum) for a particular youth and ongoing summaries of the number of hours completed and the number of hours left to fulfill court ordered or court diverted obligations. Staff expectations related to the supervision of youth at all worksites is also outlined. All guidelines referenced in JCPC Policy and Requirements Procedures Document (Restorative Programs: Restitution) related to the scheduling of services, communication with DPS or other referral sources, youth to staff ratio, admission/termination procedures and staffing are outlined in the CSR Program Manual. Termination procedures are detailed and include specific instructions related to communication with the youth's court counselor/referral agent regarding their termination status, required chart documentation and data entry into NC ALLIES. Prior to termination the CSR Coordinator develops an individualized after-care plan based on consultation with the juvenile, guardian and referral entity. Quality Assurance procedures are listed including details regarding the review and required components of chart documentation, maintenance of the online communication log, follow-up review of terminated records and the contents of the CSR QA checklist, all elements of program evaluation. Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION IV: COMPONENT NARRATIVE (attach for each component) NAME OF COMPONENT: I Community Service and Restitution 3. Staff Positions: Describe paid or volunteer position qualifications, (certifications, degrees, work experience) and position(s) responsibilities relative to this component. 1 FT Community Service and Restitution (CSR) Program Coordinator Qualifications: Bachelors in Psychology, 14+ years of experience with at risk youth. Responsibilities: Planning, coordinating and implementing CSR program services; acquiring and monitoring worksites; conducting intakes and orientation trainings; communicating policies and guidelines to youth and families; scheduling and supervision of youth assigned to worksites; providing on the job training; making public presentations to groups; assisting in the report preparation detailing program activities and operations as mandated by County, State and Federal regulation and maintaining volunteer records. Supervision of three CSR Program Assistants 1 FT CSR Program Assistant Qualifications: Associates in Criminal Justice, 20+ years experience with at risk youth 1 FT CSR Program Assistant Qualifications: Associates in Arts and 12+ years experience with at risk youth. 1 FT (100°/x) CSR Program Assistant — (position paid by county funding - In Kind) Qualifications: 8+ years experience with at risk youth Responsibilities: Providing community service activities and services on site and throughout the community; supervising youth during community service activities; assisting with monitoring community service worksites; providing training for youth on basic job skills needed; assisting with documentation; and addressing public inquiries regarding program services 1 PT (25%) YES Manager (Program Manager) - (this position partially paid by County funding - In Kind) Qualifications: Masters in Public Administration, 10+ years experience with at risk youth Responsibilities: Supervising the CSR Program Coordinator in prioritizing and assigning work; conducting performance evaluations; ensuring staff are trained; making hiring/disciplinary recommendations; planning, coordinating, monitoring and evaluating the operations and activities of CSR program services; representing the program to promote initiatives by facilitating meetings and monitoring grants; responding to inquiries of County officials and the public regarding program services to include explaining program guidelines and addressing public citizen groups; overseeing and maintaining program reports detailing community service/restitution operations and activities as mandated by County, State, and Federal regulations and as requested by various officials to include maintaining data pertaining to youth; and assuring compliance with State, Federal and Local laws pertaining to specific grants and programs 1 PT (5%) CJS Support Services Coordinator, - Fully County funded (In Kind) Qualifications: MBA, 20+ years administrative experience Responsibilities: Program financial and budget operations 1 PT (10%) CJS Administrative Support Technician - Fully County funded (In Kind) Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION IV: COMPONENT NARRATIVE (attach for each component) NAME OF COMPONENT: Community Service and Restitution Qualifications: BS Recreation and Leisure Studies, 15+ years admin experience Responsibilities: Administrative duties 4. Service Type SPEP: Describe implementation to include: Primary Service: Restitution / Community Service; Secondary Service: None 5. Admission Process: Describe the specific referral, screening, admission process (including timeline), the staff responsible for making decisions about admissions and reasons why a referral may not be accepted. Referral Process: The referring DPS Court Counselor completes a written referral form and submits it to the CSR Coordinator requesting services for youth. Youth are typically seen for intake into the program on the same day as their disposition has been rendered in court and community service hours are ordered or at the time a diversion contract has been signed. If the family is unable to complete intake on the day community service hours are court ordered, the coordinator contacts the youth's parent/guardian routinely within 1-2 business days to schedule an intake appointment. Referrals from Wilmington Police Department are faxed to the CSR coordinator who then contacts youth's parent/guardian within 1-2 business days. Teen Court (TC) referrals are received from the TC Coordinator prior to the night TC is held and CSR staff conduct intake orientation meetings following completion of the TC proceedings. Screening Process: All youth are screened during the intake visit and accepted for services unless during the intake visit with the program, the youth is deemed not appropriate to participate. Admission Process: During intake orientation, services are explained to youth and parent, signatures are obtained on relevant paperwork and a pre ethics questionnaire is administered to the youth. If an intake orientation cannot be conducted in person, an intake orientation will be conducted through teleservices and the use of Adobe pro for signatures on intake paperwork. Some of the factors specific to the youth that are taken into consideration and used to develop an individualized plan of care and individual service plan during the intake process include: school schedule, parent/guardian work schedule, location of youth's home in relation to appropriate worksites, specific interests/skills the youth may have, developmental needs expressed by parents/guardians and the youths particular charge and risk level. All families are offered county funded case management services, free of charge, to address any unmet needs identified by the parent or guardian pertaining to the youth or other family members. At the end of the Intake, youth are assigned to a mandatory orientation/training, which includes an introduction to the resources available to access vocational opportunities within the community and Job skill/safety training. Youth are also scheduled for a mandatory tour of the NHC Library, which Includes a tour of the job lab, overview of college assistance programs, free tutoring, a brief history of NHC and instructions for obtaining a library card. Upon completion of orientation, youth are assigned to a community worksite based on Information gathered regarding safety issues, youth's likes/dislikes, transportation issues, etc. Staff responsible for making decisions: The CSR Coordinator Why a referral may not be accepted: Age of youth or other limitations that would possibly endanger the youth to work at a community service worksite. 6. Termination Process: Describe the termination process to include the staff responsible for making decisions and the criteria for a successful termination, satisfactory termination, unsuccessful completion and non-compliant Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION IV: COMPONENT NARRATIVE (attach for each component) NAME OF COMPONENT: Community Service and Restitution termination. For the Community Service and Restitution (CSR) Program Component, the CSR Coordinator is responsible for determining the type of termination. The youth is terminated successfully and/or satisfactorily upon the youth completing their court obligated service in a timely fashion within the parameters of their probation or court diverted requirements. The youth is terminated unsuccessfully if the youth does not complete the required community service hours as court ordered. The youth is terminated noncompliant if the youth refuses to comply and does not attend the intake or complete any court ordered community service hours. Upon completion of service, youth are administered a post ethics questionnaire; youth along with parent complete a customer service survey, youth receive a Certificate of Completion and Termination Summary. Adobe pro will be used to send the post ethics questionnaire, customer service survey, certificate of completion and Termination Summary if the youth/guardian are unable to be present to complete the termination paperwork. Prior to termination the CSR Coordinator develops an Individualized after-care plan based on Interactions and consultation with the juvenile, guardian and referral entity. This plan Includes referrals to appropriate community resources related to the Identified need of the youth and Is designed to build upon progress during program stay and promote community Involvement, civic awareness, identify recreational opportunities and outline educational goals communicated by youth/guardian. A comprehensive list of termination procedures is contained within the Community Service and Restitution Program Manual. How is the referring agency involved with the termination process? For the CSR Program Component the referring DPS Court Counselor or other referral agent is informed on an ongoing basis regarding the youth's progress or lack thereof through oral and written communication via email and voicemail messages, and individual progress notes and 30 day progress reports. CSR staff also provides court counselors and other referral agents with monthly activity calendars and notify them of any changes in the youth's status at school or home in order to fully collaborate regarding the progress of the youth. Prior to termination, CSR staff communicates with the youth's court counselor to obtain information regarding the youth's progress with juvenile court and school. The final status of the youth is provided to the court counselor or other referral agent when the youth's service terminates via a written Termination Summary. 7. Referring Agency Interaction: Describe the interaction with juvenile court counselors and/or other referring agencies including how client progress will be communicated. For the Community Service and Restitution Program Component, the referring DPS Court Counselor or other referral agent is informed on an ongoing basis regarding the youth's progress or lack thereof through oral and written communication via email and voicemail messages, individual mid -month progress notes and 30 day progress reports. CSR staff also provide court counselors with monthly activity calendars and notify them of any changes in the youth's status at school or at home in order to fully collaborate regarding the progress of the youth. Prior to termination, CSR staff communicates with the youth's court counselor to obtain information regarding the youth's progress with juvenile court and school. The final status of the youth is provided to the court counselor or other referral agent when the youth's service terminates via a written Termination Summary. The CSR program has staff on site at all juvenile court hearings, Teen Court sessions, and regularly complete intakes at WPD. Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION IV: COMPONENT NARRATIVE (attach for each component) NAME OF COMPONENT: Community Service and Restitution 8. Intervention/Treatment: Describe specifically what the component will do to redirect inappropriate youth behavior or how the component will address the identified needs of the youth and family. What interventions will typically be utilized in this component and how will parents/guardians be involved? The CSR Program Component utilizes the following as Interventions to facilitate the youth learning civic, community and social responsibilities along with age appropriate Job skill development: youth and parent participate in a one-hour Intake conducted by CSR staff where a plan of care is developed and on the job expectations are explained. All families are offered County funded case management services to address unmet needs identified by parent or guardian. Youth attend trainings that include on site demonstrations of proper work techniques and basic Job skills provided by agency staff and/or worksite supervisor. Youth are given an explanation of safety regulations/child labor laws and answer a pre ethics questionnaire. Utilization of small work groups allows CSR staff to place an emphasis on mentoring youth regarding meaningful, prosocial community involvement and useful skill development. CSR staff utilize Microsoft TEAMS to deliver a virtual classroom experience to youth who are unable to attend in person classes. These classes consist of Job skills, WHY TRY life skills, virtual NHC Library tours and a CSR training. Staff also have frequent contact with parents/guardians via reminder calls, providing updates regarding the activity calendar, following up with unexcused absences/behavioral issues, and mailing out of compliance letters when needed. In special circumstances regarding youth who have specific needs, such as, significant behavioral health issues or unique geographical situations, a specific worksite may be developed to help meet the youth's individual needs. Inappropriate behaviors that are displayed by youth are typically handled via individual mentoring, redirection into a new activity or project. and collaboration with parents/guardians and court counselors regarding positive strategies that can be utilized to defuse negative behaviors. Upon completion of their CSR requirements, youth complete a post ethics questionnaire and satisfaction survey. CSR Program effectiveness is tracked in part via NC ALLIES data collected on all youth and includes the completion rate of court ordered community service hours, rate of successful completion and percentage of referrals successfully admitted. Recidivism data is collected at least every 6 months with assistance from DPS Juvenile Justice Staff to access data via NC JOIN in order to determine if new complaints or adjudications have occurred during service delivery or post one year successfully/satisfactorily completing the program. All data related to the evaluation of program effectiveness is maintained either online via NC ALLIES or in the case of recidivism data, a hard copy of the relevant information is kept. All information related to program effectiveness is communicated to the NC Department of Public Safety according to stated reporting requirements. A comprehensive description of CSR Program interventions are contained in the CSR Program Manual. 9. Best Practice Model: Describe what model or evidence-supported/best practice the program is based upon. While the Office of Juvenile Justice and Delinquency Prevention Model Programs Guide does not contain a Community Service and Restitution (CSR) model program, the CSR Program Component is based on the evidenced- supported/best practice model the "balanced approach" to juvenile probation that was introduced by Dennis Maloney, Dennis Romig, and Troy Armstrong. Beginning with recognition of three goals of juvenile corrections, this approach requires that probation services incorporate a balance among: 1. Protecting public safety by effectively monitoring the behavior of juvenile offenders; 2. Holding offenders accountable for their offenses and to their victims; and 3. Facilitating the youth's competency development via rehabilitative and skill building services. Because of its emphasis on atonement, restitution is often an important part of restorative justice models. Community service, like restitution, involves the offender giving something back to the community at large rather than directly to the victim. Both restitution and community service have potential to promote offender accountability to the community or to victims. The best of these activities have desirable competency development benefits to the offenders by poviding meaningful, prosocial Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION IV: COMPONENT NARRATIVE (attach for each component) NAME OF COMPONENT: I Community Service and Restitution community involvement and useful skill development. A review of research suggests that restitution can reduce recidivism to some extent (Lipsey; Schneider). 'But restitution and community service should not be judged solely in terms of recidivism reduction - their value may lie more in their restorative and accountability enhancing functions." The New Hanover County CSR Program incorporates best practices according to cited research to facilitate the youth completing their court ordered and/or diverted obligations successfully and in a timely manner while teaching, modeling and encouraging civic, community and social responsibilities all the while incorporating a service learning model to the youth we serve. Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION V: TERMS OF AGREEMENT This Agreement is entered into by and between Department of Public Safety (hereinafter referred to as DPS), and New Hanover County, (hereinafter referred to as the County), the County's Juvenile Crime Prevention Council (hereinafter referred to as the JCPC) and NHC, Community Justice Services, Youth Empowerment Services (hereinafter referred to as the Sponsoring Agency). DPS, the County, the JCPC and the Sponsoring Agency do mutually agree as follows: Term of Agreement This Agreement shall become effective Jul 1, 2023 and shall terminate Jun 30, 2024. Payment to Sponsoring Agency All parties agree that services will be delivered as described in the approved Program Agreement and that funds will be disbursed in an amount not to exceed the amount $406345 for the term of this agreement, unless amended by an approved Program Agreement Revision. Availability of Funds: All parties to this Agreement agree and understand that the payment of the sums specified in this Program Agreement budget, or most recently approved Program Agreement Revision, is dependent and contingent upon and subject to the appropriation, allocation, and availability of funds for this purpose to DPS. Responsibilities of the Parties DPS shall: 1. Disburse funds monthly to County Governments, for payment to the Sponsoring Agency, from funds appropriated by the General Assembly; 2. Reserve the right to suspend payment to the County for any non-compliance of reporting requirements by the Sponsoring Agency set forth in the DPS JCPC Policy; 3. Immediately notify, in writing, the JCPC, County, and Sponsoring Agency (including the Board of Directors, if applicable), if payments are suspended and again once payments resume; 4. Pay only for work as described in the Program Agreement, or most recently approved Program Agreement Revision, provided by the Sponsoring Agency and approved subcontractors; 5. Provide technical assistance, orientation, and training to the Sponsoring Agency, the County and the JCPC; 6. Monitor the Sponsoring Agency's funded program(s) in accordance with DPS JCPC Policy 3. Operations: Program Oversight and Monitoring; and Form structure last revised 12/20/2013 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 7. Notify parties entering into this Agreement of all due dates in a timely manner in order for reports to be submitted by the established due dates. The Sponsoring Agency shall: 1. Comply with all laws, ordinances, codes, rules, regulations, and licensing requirements that are applicable to the conduct of its business, including those of Federal, State, and local agencies having jurisdiction and/or authority; 2. Comply with all Federal and State laws relating to equal employment opportunity; 3. Keep as confidential and not divulge or make available to any individual or organization without the prior written approval of DPS any information, data, instruments, documents, studies or reports given to or prepared or assembled by the Sponsoring Agency under this Agreement; 4. Acknowledge that in receiving, storing, processing or otherwise dealing with any confidential information, it will safeguard and not redisclose the information, except as otherwise provided in this Agreement; 5. Comply with the DPS JCPC Policy and North Carolina Administrative Code procedures; 6. Secure local match, if applicable, pursuant to 14B NCAC 11 B.0105, for the approved DPS funds; 7. Create and adopt individualized written agency guidelines specific to the funded program, while also adhering to DPS JCPC Policy for the specific funded program type; 8. Ensure that state funds received are spent in accordance with the approved Program Agreement, or most recently approved Program Agreement Revision, and be accountable for the legal and appropriate expenditure of those state funds; 9. Maintain reports, records, and other information to properly document services rendered and outcomes; also maintain an ability to send and receive electronic communication; 10. Have the capacity to use the DPS electronic, internet-based system for tracking clients served; also maintain an ability to electronically sign required DPS documents; 11. Use generally accepted accounting procedures that guarantee the integrity of the expenditure of funds, and maintain reports, records, and other information to properly account for the expenditure of all State funds provided to the Sponsoring Agency; 12. When refunds are requested from the North Carolina Department of Revenue for sales and/or use taxes paid by the agency in the performance of the Program Agreement, or most recently approved Program Agreement Revision, as allowed by NCGS § 105-164.14(c), the agency shall exclude all refundable sales and use taxes from reportable expenditures submitted to the County and DPS; 13. Submit Program Agreement Revisions, Third Quarter Accounting, Final Accounting, and annual detailed expenditures through NCALLIES. These reports must be in accordance with the submission process as outlined in the DPS JCPC Policy and with the due dates established by DPS; 14. Make personnel, reports, records and other information available to DPS, the County, the JCPC, and/or the State Form structure last revised 12/20/2013 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 Auditor for oversight, monitoring and evaluation purposes; 15. Submit any other information requested by DPS, the County, the JCPC, and/or the State Auditor; 16. Be responsible for the performance of all subcontractors as described in the Program Agreement or most recently approved Program Agreement Revision; 17. Indemnify, defend, and hold harmless DPS, the State of North Carolina, the County, the JCPC and any of their officers, agents and employees, from any claims of third parties arising out of any act or omission of the Sponsoring Agency in connection with the performance of the Program Agreement or most recently approved Program Agreement Revision; 18. Receive written permission and budgetary approval from DPS prior to using the Program Agreement, or most recently approved Program Agreement Revision, as a part of any news release or commercial advertising, and acknowledge DPS funding in partnership with the County; 19. Comply with DPS JCPC Policy 6: Operations: Program Eligibility for Funding regarding any trainings and requirements for the United States Department of Justice national standards to prevent, detect, and respond to prison rape under the Prison Rape Elimination Act (PREA) and any additional requirements in 14B NCAC 11 C 20. Be deemed an independent contractor in the performance of services described in the Program Agreement, or most recently approved Program Agreement Revision, and as such shall be wholly responsible for the services to be performed and for the supervision of its employees, interns, volunteers and subcontractors; and 21. Represent that it has, or shall secure at its own expense, all personnel required in performing the services as described in the Program Agreement, or most recently approved Program Agreement Revision. Such personnel shall not be employees of or have any individual contractual relationship with DPS. Sponsoring Agency and Use of Contractor(s)/Subcontractors The Sponsoring Agency may engage with independent contractors as needed to perform services or support services described in line item 190 the Program Agreement, or most recently approved Program Agreement Revision. When independent contractors are providing services the Sponsoring Agency must: 22. Upload a signed Contract for Professional Services (Form JCPC/PO 001 Contract for Professional Services Template) into NCALLIES once the Program Agreement or Program Agreement Revision is approved by DPS; 23. Be responsible for the performance of all contractors or subcontractors as described in the Program Agreement, or most recently approved Program Agreement Revision; 24. Hold any contractor or subcontractor to which the Sponsoring Agency provides State funds accountable for the legal and appropriate expenditure of State funds and require compliance with all applicable laws and DPS JCPC Policy; and 25. Ensure that all contractors or subcontractors provide all information necessary to comply with the standards set forth in the Program Agreement, or most recently approved Program Agreement Revision. The JCPC shall: Form structure last revised 12/20/2013 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 1. Ensure the Sponsoring Agency uses JCPC funds only for the purposes approved by DPS in the JCPC Program Agreement or most recently approved JCPC Program Agreement Revision; 2. Comply with the DPS JCPC Policy, the North Carolina Administrative Code procedures (14B NCAC 11 B), and N.C.G.S. §§ 14313-845 to 851; 3. Review and locally approve Program Agreements, Program Agreement Revision(s), and Third Quarter Accounting and submit information to the County in a timely manner to meet due dates established by DPS; 4. Submit any other information requested by the County or DPS; and 5. Monitor the Sponsoring Agency's currently funded JCPC program(s) in accordance with DPS JCPC Policy 3. Operations: Program Oversight and Monitoring. Reference: 14B NCAC 118.0202 and DPS JCPC Policy (policies 1, 3, 7, 8, 9, 10 and 11). The Countv shall: 1. Ensure the Sponsoring Agency is appropriately licensed when applicable, and either a local public agency, a 501(c)3 nonprofit corporation or local housing authority (applicable only to the JCPC funding process); 2. Use funds only for the purposes approved by DPS in the Program Agreement, or most recently approved Program Agreement Revision; 3. Disburse funds monthly and oversee funds to the Sponsoring Agency in accordance with 14B NCAC 11 B.0108; 4. Comply with the DPS JCPC Policy and North Carolina Administrative Code procedures (14B NCAC 11 B); 5. Review and locally approve Program Agreement Revisions received from the Sponsoring Agency for final approval from DPS; and 6. Review and locally approve Third Quarter and Final Accounting forms for the JCPC and all funded programs according to the procedures and due dates established by DPS. Reference: 14B NCAC 11 B.0108; DPS JCPC Policy (policies 8 and 9). Headings: The Section and Paragraph headings in these General Terms and Conditions are not material parts of the agreement and should not be used to construe the meaning thereof. Choice of Law: The validity of this Program Agreement and any of its terms or provisions, as well as the rights and duties of the parties to this Program Agreement, are governed by the laws of North Carolina, including the relevant provisions of G.S. Chapter 143B, Article 13, Part 3, Subpart F, and the Rules of 14B NCAC Chapter 11. The parties, by signing this Program Agreement, agree and submit, solely for matters concerning this Program Agreement, to the exclusive jurisdiction of the courts of North Carolina and agree, solely for such purpose, that the exclusive venue for any legal proceedings shall be Wake County, North Carolina. The place of this Program Agreement and all transactions and agreements relating to it, and their situs and forum, shall be Wake County, North Carolina, where all Form structure last revised 12/20/2013 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 matters, whether sounding in Program Agreement or tort, relating to the validity, construction, interpretation, and enforcement shall be determined. Assignment: No assignment of the Sponsoring Agency's obligations or the Sponsoring Agency's right to receive payment hereunder shall be permitted. However, upon written request approved by the issuing purchasing authority, DPS may: (a) Forward the Sponsoring Agency's payment check(s) directly to any person or entity designated by the Program Manager, or (b) Include any person or entity designated by the Sponsoring Agency as a joint payee on the Sponsoring Agency's payment check(s). In no event shall such approval and action obligate DPS or County Government to anyone other than the Sponsoring Agency, and the Sponsoring Agency shall remain responsible for fulfillment of all Program Agreement, or the most recently approved Program Agreement Revision, obligations. Beneficiaries: Except as herein specifically provided otherwise, this Program Agreement shall inure to the benefit of and be binding upon the parties hereto and their respective successors. It is expressly understood and agreed that the enforcement of the terms and conditions of this Program Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to DPS, the County Government, and the Sponsoring Agency. Nothing contained in this document shall give or allow any claim or right of action whatsoever by any third person. It is the express intention of DPS and County Government that any such person or entity, other than DPS or the County Government or the Sponsoring Agency receiving services or benefits under this Program Agreement shall be deemed an incidental beneficiary only. Property Rights Intellectual Property: All deliverable items produced pursuant to this Program Agreement are the exclusive property of DPS. The Sponsoring Agency shall not assert a claim of copyright or other property interest in such deliverables. Physical Property: The Sponsoring Agency agrees that it shall be responsible for the proper custody and care of any property purchased for or furnished to it for use in connection with the performance of this Program Agreement, or the most recently approved Program Agreement Revision, and will reimburse DPS for loss of, or damage to, such property. At the termination of this Program Agreement, the Sponsoring Agency, County Government, and JCPC shall follow the guidelines for disposition of property set forth in the North Carolina Administrative Code and DPS JCPC Policy 1. Operations: JCPC Operations. Reference: 14B NCAC 11 B. 0110. Disbursements and Internal Controls Reversion of Unexpended Funds Any remaining unexpended funds disbursed by DPS to the County for the Sponsoring Agency must be refunded/ reverted back to DPS at the close of the fiscal year or upon termination of this Agreement. Accountability for Funds Form structure last revised 12/20/2013 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 Audit Requirement - Local Government or Public Authority Requirements Local Government or Public Authorities in accordance with N.C.G.S. § 159-34 must have an audit performed in conformity with generally accepted auditing standards. The audit shall evaluate the performance of a unit of local government or public authority regarding compliance with all applicable Federal and State agency regulations. This audit, combined with the audit of financial accounts, shall be deemed to be the single audit described by the "Federal Single Audit Act of 1984". Audit Requirement — Non -Governmental Entities An audit, when required by law, or requested by the County or DPS shall be performed in conformity with generally accepted auditing standards and audits of non-governmental entities, both for-profit and not-for-profit, and must meet the requirements of OMB Circular A-133. At a minimum, the required report shall include the financial statements prepared in accordance with generally accepted accounting principles, all disclosures in the public interest required by law, and the auditor's opinion and comments relating to financial statements. The audit report must be submitted to the State Auditor's office as required by law, to the County, and DPS, and to other recipients as appropriate within nine (9) months after the end of the program's fiscal year. Oversight Access to Persons and Records The State Auditor shall have access to persons and records related to all Program Agreements entered into by State agencies or political subdivisions in accordance with N.C.G.S. § 147-64.7. Additionally, as the State funding authority, DPS shall have access to persons and records related to all Program Agreements entered into by State agencies or political subdivisions. Record Retention Records shall not be destroyed, purged, or disposed of without the express written consent of DPS. State basic records retention policy requires all records to be retained for a minimum of five (5) years or until all audit exceptions have been resolved, whichever is longer. If the Program Agreement is subject to Federal policy and regulations, record retention may be longer than five (5) years since records must be retained for a period of three (3) years following submission of the final Federal Financial Status Report, if applicable, or three (3) years following the submission of a revised final Federal Financial Status Report. Also, if any litigation, claim, negotiation, audit, disallowance action, or other action involving this Program Agreement has been started before expiration of the five- year retention period described above, the records must be retained until completion of the action and resolution of all issues which arise from it, or until the end of the regular five-year period described above, whichever is later. No Overdue Tax Debt Not for profit organizations ONLY must comply with this section. This form must be uploaded in NCALLIES when submitting a Program Agreement. The Sponsoring Agency shall be responsible for the payment of all State, local, and Federal taxes. Consistent with N.C.G.S. § 143C -6-23(c), not for profit organizations shall file with DPS and the County a written statement completed by that Sponsoring Agency's Board of Directors or other governing body, stating whether or not the Sponsoring Agency has any overdue tax debts, as defined by N.C.G.S. § 105-243.1, at the Federal, State, or local level. This written statement, No Overdue Tax Debts, shall be completed by the Sponsoring Agency to certify when there are no overdue taxes. If the agency has overdue taxes, the Sponsoring Agency must notify DPS at the time a Program Agreement is submitted. Conflict of Interest Not for profit organizations ONLY must comply with this section. This form must be uploaded in NCALLIES when submitting a Program Agreement. Form structure last revised 12/20/2013 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 Consistent with the N.C.G.S. § 143C -6-23(b), not for profit organizations shall file with DPS and the County, a copy of that Sponsoring Agency's policy addressing conflicts of interest that may arise involving the Sponsoring Agency's management employees and the members of its Board of Directors or other governing body. The policy shall address situations in which any of these individuals may directly or indirectly benefit, except as the Sponsoring Agency's employees or members of its Board or other governing body, from the Sponsoring Agency's disbursing of State funds and shall include actions to be taken by the Sponsoring Agency or the individual, or both to avoid conflicts of interest and the appearance of impropriety. The policy shall be filed before the County or DPS will disburse any funds. The Sponsoring Agency shall also complete the DPS Conflict of Interest Policy Statement (Form DPS 13 001) and upload the statement in NCALLIES along with and the Sponsoring Agency's policy addressing conflicts of interests. Proof of 501(c)(3) Not for profit organizations ONLY must comply with this section. This form must be uploaded in NCALLIES when submitting a Program Agreement. Not for profit organizations must upload proof of the agency's 501(c)(3) status when submitting a program agreement in NCALLIES. Amendment: This Agreement may not be amended orally or by performance. Any amendment must be requested by the Sponsoring Agency through submission of a Program Agreement Revision and executed by duly authorized representatives of DPS, the County Government, JCPC, and Sponsoring Agency. Severability: In the event that a court of competent jurisdiction holds that a provision or requirement of this Program Agreement violates any applicable law, each such provision or requirement shall continue to be enforced to the extent it is not in violation of law or is not otherwise unenforceable and all other provisions and requirements of this Program Agreement shall remain in full force and effect. Termination for Cause: If, through any cause, the Sponsoring Agency shall fail to fulfill its obligations under this Program Agreement in a timely and proper manner, DPS shall have the right to terminate this Program Agreement by giving written notice to the Sponsoring Agency and specifying the effective date thereof. In that event, all finished or unfinished deliverable items prepared by the Sponsoring Agency under this Program Agreement shall, at the option of DPS, become its property and the Sponsoring Agency shall be entitled to receive just and equitable compensation for any satisfactory work completed on such materials, minus any payment or compensation previously made. Notwithstanding the foregoing provision, the Sponsoring Agency shall not be relieved of liability to DPS for damages sustained by DPS by virtue of the Sponsoring Agency's breach of this agreement, and DPS may withhold any payment due the Sponsoring Agency for the purpose of setoff until such time as the exact amount of damages due DPS from such breach can be determined. The filing of a petition for bankruptcy by the Sponsoring Agency shall be an act of default under this Program Agreement. Termination without Cause: DPS, the County Government, or the Sponsoring Agency may terminate this Agreement at any time and without cause by giving at least thirty (30) days advance written notice to the other parties. If this Program Agreement is terminated by DPS as provided herein, the Sponsoring Agency shall be reimbursed on a pro rata basis for services satisfactorily provided to DPS under this Program Agreement, or the most recently approved Program Agreement Revision, prior to Program Agreement termination. Waiver of Default: Waiver by DPS of any default or breach in compliance with the terms of this Program Agreement, or the most recently approved Program Agreement Revision, by the Sponsoring Agency shall not be deemed a waiver of any subsequent default or breach and shall not be construed to be modification of the terms of this Program Agreement unless stated to be such in writing, signed by an authorized representative of DPS, County Government, the JCPC, and the Sponsoring Agency. Force Majeure: Neither party shall be deemed to be in default of its obligations hereunder if and so long as it is Form structure last revised 12/20/2013 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 prevented from performing such obligations as a result of events beyond its reasonable control, including, without limitation, fire, power failures, any act of war, hostile foreign action, nuclear explosion, riot, strikes, civil insurrection, earthquake, hurricane, tornado, or other catastrophic natural event, pandemic, or act of God. Survival of Promises: All promises, requirements, terms, conditions, provisions, representations, guarantees, and warranties contained herein shall survive the Program Agreement expiration or termination date unless specifically provided otherwise herein, or unless superseded by applicable Federal or State statutes of limitation. Entire Agreement: This Program Agreement (including any documents mutually incorporated specifically herein) represents the entire agreement between the parties and supersedes all prior oral or written statements or agreements. END OF SECTION V — Terms of Agreement Form structure last revised 12/20/2013 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION VI: BUDGET NARRATIVE Youth Empowerment Services Fiscal Year FY 23-24 Item # Justification Expense In Kind Expense 120 Director .05 FTE, LCT Supervisor .4 FTE, CSR Prog Assist 1 FTE, CJS Supp Svcs Coord .25 FTE, Admin Sup Spec .25 FTE, Admin Sup Tech .10 FTE $0 $118,188 120 All programs staff salary and wages $338,174 Licensed Clinical Therapist-LCSW.75 FTE Annual In-kind Salary 64,799 180 FICA and standard county benefits for in-kind salaried staff YES Manager .4 FTE Annual Salary 81,043 $46,466 180 FICA and standard county benefits for salaried staff $149,688 190 Clinical supervision for Licensed Clinical Staff $1,760 CJS Administrative Support Technician .10 FTE Annual Salary 51,388 190 Clinical Services Contract $21,840 220 CSR food for youth during activities $400 $15,200 230 Education/Med Supplies $2,930 Licensed Clinical Therapist -Supervisor .4 FTE Annual Salary 95,071 260 General office supplies $700 $338,1741 290 Other supplies (CSR Youth Community Service supplies and equipment) $200 310 Travel, lodging and meals for training/conferences $2,820 320 Communication (cell phone stipend and postage) $1,863 390 Professional Training $2,890 390 CSR restitution bank $5,400 TOTAL $528,6651$164,654 Job Title Annual Expense Wages Annual In Kind Wages CJS Support Services Coordinator .20 FTE Annual Salary 71,486 $14,297 Licensed Clinical Therapist -LPA .75 FTE Annual In-kind Salary 85,662 $64,246 CSR Program Assistant .70 FTE Annual Salary 40,177 $0 $28,124 CSR Program Assistant 1.00 FTE $55,284 Licensed Clinical Therapist-LCSW.75 FTE Annual In-kind Salary 64,799 $48,599 YES Manager .4 FTE Annual Salary 81,043 $32,417 CSR Program Assistant 1.00 FTE $40,177 CSR Program Coordinator 1.00 FTE $51,851 CJS Administrative Support Technician .10 FTE Annual Salary 51,388 $5,138 CJS Administrative Support Specialist .20 FTE Annual Salary 54,454 $10,891 Licensed Clinical Therapist-LCSW .60 FTE .20 In-kind Annual Salary 76,000 $45,600 $15,200 Director .05 FTE Annual Salary 130,194 $6,510 Licensed Clinical Therapist -Supervisor .4 FTE Annual Salary 95,071 $38,028 TOTAL $338,1741 $118,188 Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION VII: BUDGET NARRATIVE LINE ITEM SUMMARY Program: Youth Empowerment Services Fiscal Year: FY 23-24 Number of Months: 12 Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 12/31/2012 Department of Public Safety Cash In Kind Total I. Personnel Services $511,462 $164,654 $676,116 120 Salaries & Wages $338,174 $118,188 $456,362 180 Fringe Benefits $149,688 $46,466 $196,154 190 Professional Services' $23,600 $23,600 *Contracts MUST be attached II. Supplies & Materials $4,230 $4,230 210 Household & Cleaning $0 220 Food & Provisions $400 $400 230 Education & Medical $2,930 $2,930 240 Construction & Repair $0 250 Vehicle Supplies & Materials $0 260 Office Supplies and Materials $700 $700 280 Heating & Utility Supplies $0 290 Other Supplies and Materials $200 $200 III. Current Obligations & Services $12,973 $12,973 310 Travel & Transportation $2,820 $2,820 320 Communications $1,863 $1,863 330 Utilities $0 340 Printing & Binding $0 350 Repairs & Maintenance $0 370 Advertising $0 380 Data Processing $0 390 Other Services $8,290 $8,290 IV. Fixed Charges & Other Expenses $0 410 Rental or Real Property $0 430 Equipment Rental $0 440 Service and Maint. Contracts $0 450 Insurance & Bonding $0 490 Other Fixed Charges $0 V. Capital Outlay $0 [This Section Requires Cash Match] 510 Office Furniture & Equipment $0 530 Educational Equipment $0 540 Motor Vehicle $0 550 Other Equipment $0 580 Buildings, Structure & Improv. $0 Total $528,665 $164,654 $693,319 Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SECTION VIII: SOURCES OF PROGRAM REVENUE (ALL SOURCES) FY 23-24 New Hanover County Funding ID: 965-XXXX Sponsoring Agency: Justice Services, Youth Empowerment Services Program:mpowerment ENHommunity Services $406,345 DPS/JCPC Funds * This is the amount approved in your application 20% Local Match Rate Is the Local Match Rate 10%, 20% or 30%? $122,320 County Cash New Hanover County (Specify Source) Local Cash (Specify Source) Local Cash (Specify Source) $164,654 Local In -Kind New Hanover County (Specify Source) Other (Specify Source) Other (Specify Source) Other (Specify Source) Other (Specify Source) $693,319 TOTAL $81,269 $286,974 Required Local Match Match Provided -DocuSigned by: �798FE7A4BD9F419_. 6/12/2023 Authorizing Official, Department of Public Safety Date The following signature certifies that this program agreement has been locally approved by the Board of County Commissioners. —DocuSigned by: f"& W' C6B88CFC5D1A4B5_. 6/9/2023 Chair, County Board of Commissioners or County Finance Director Date The following signature certifies that this program agreement has been locally approved by the Juvenile Crime Prevention Council. —DocuSigned by: �3DD8F15... D4A2540C 6/6/2023 Chair, Juvenile Crime Prevention Council Date -DocuSigned by: �c�wtt,S �A'Id77RFAFdFRdRG 6/6/2023 Program Manager Date Form JCPC/PA 001 JCPC Program Agreement Form structure last revised 12/31/2012 Department of Public Safety DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 Contract for Professional Services Template This Contract for Professional Services is entered into by and between New Hanover County Community Justice Services, Youth Empowerment Services Division, (hereinafter referred to as the Agency), and Mark Basquill, (hereinafter referred to as the Contractor). The Agency and the Contractor do mutually agree as follows: 1. Term of Agreement. This agreement shall become effective July 1, 2023 and shall terminate June 30, 2024. This contract may be terminated by either party by providing thirty days written notice to the other party. with a copy of the notice submitted to the JCPC Chairperson, and the DPS Area Consultant. 2. Payment to Contractor. Agency and Contractor agree upon these rates as reimbursed fees: the services will be delivered at the rate of $ 110 per hour (16 hours per year) not to exceed $1,760 for the term of this contract. The Contractor must submit a signed monthly request for reimbursement to the Agency documenting the actual time worked or the units of service provided. 3. Funding. All terms and conditions of this Contract are dependent upon and subject to the allocation of funds for the purpose set forth in this Contract, and this Contract shall automatically terminate if funds cease to be available. The terms of the contract are limited to the availability of the JCPC funds which have been allocated for that purpose. 4. Taxes. The Contractor shall be considered an independent Contractor and as such shall be responsible of all taxes. 5. DPS JCPC and Community Programs Section -Funded Programs Minimum Standards Policy. The Contractor shall adhere to all DPS JCPC standards, policies, and procedures related to the provision of the program's service type. 6. Responsibilities of Contractor. The Contractor hereby agrees to provide the following services in a manner satisfactory to the Agency, within the stated time frames. A. Provide clinical supervision and consultation services for clinical staff and as required by the NC Psychology Board for Licensed Psychological Associates. 7. Juvenile Files/Records. Juvenile files and records created during the term of the contract are the property of the funded sponsoring agency. These files/records must be available at all times to the Agency, JCPC and DPS, and must be submitted to the Agency as juveniles are terminated from services or upon the end of the contract. 8. Referral and Initial Appointment. The maximum length of time between receiving the referral and initial appointment shall not exceed N/A business days. Program Manager or Authorized Akent Name and Title: Chris Preston (Agency) New Hanover Couni ) , Community Justice Services Mailing Address: 320 Cl1estnqjl;$,Obuttc 518 Wilmington, NC 28101 Signature: 4 _ Date: j Contractor Name: Marklobasa uill, PhD, PC (Contractor) 313 Walnut Street, Wilmin on. NC 28401 Mailing Address: M-'-</— /--V 1 Date: Form JCPC/PO 001 Contract for Professional Services Template Form structure last revised July 2022 NC Department of Public Safety Page 1 of l DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 STATE OF NORTH CAROLINA COUNTY OF New Hanover 1, Mark Basquill behalfof himself AFFIDAVIT of COMPLIANCE with N.C. E -Verify Statutes (hereinafter the "Affiant"), duly authorized by and on (hereinafter the "Employer") after being first duly sworn deposes and says as follows: 1. I am the affiant _ (President, Manager, CEO, etc.) of the Employer and possess the full authority to speak for and on behalf of the Employer identified above. 2. Employer understands that "E -Verify" means the federal E -Verify program operated by the United States Dept. of Homeland Security and other federal agencies, or any successor or equivalent program used to verify the work authorization of newly hired employees pursuant to federal law. 3. No Employer employs 25 or more employees in the State of North Carolina, and is in compliance with the provisions of N.C. Gen. Stat. §64-26. Employer has verified the work authorization of its employees through E -Verify and shall retain the records of verification for a period of at least one year. Yes Employer employs fewer than 25 Employees and is therefore not subject to the provisions of N.C. Gen. Stat. §64-26. 4. All subcontractors engaged by or to be engaged by Employer have or will have likewise complied with the provisions of N.C. Gen. Stat. §64-26. 5. Employer shall keep New Hanover County informed of any change in its status pursuant to Article 2 of Chapter 64 of the North Carolina General Statutes. Further this affiant sayeth not. This the r day of�G� '200-3. Affiant STATE OF NORTH q4ROLfNA COUNTY OF 0 voB1hf$ y� Sworn to and subscribed before me, this the _q____ day of 200-- 2 r� pTA,9k W [SEAL] S Nota lic da 'O�►BL��: My commission expires: c�iD ''•�'♦i,�Hoy � Go" t�NIP, r DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SUBCONTRACTOR'S WAIVER OF WORKERS' COMPENSATION COVERAGE I do hereby release New Hanover County, its officers and employees from all responsibility or liability of any nature whatsoever for any injury or aggravation of a pre-existing condition as a result of my being a sole proprietorship, should l become injured while working for New Hanover County. I further agree to indemnity and hold harmless New Hanover County, its officers and employees from any and all claims which might be brought and which are in any way connected with New Hanover County. This agreement shall be effective and binding upon my heirs, agents, personal representatives and assigns. I am aware that by signing this waiver, I assume all risks and waive and release rights that I may have or possess. This the l Witness: day of k4l a v',"` 20� 12.JI Contractor (SoleProprietorship) and DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 Contract for Professional Services Template This Contract for Professional Services is entered into by and between New Hanover County Community Justice Services, Youth Empowerment Services Division, (hereinafter referred to as the Agency), and Lisa Bentz, (hereinafter referred to as the Contractor). The Agency and the Contractor do mutually agree as follows: 1. Term of Agreement. This agreement shall become effective July 1, 2023 and shall terminate June 30, 2024. This contract may be terminated by either party by providing thirty days written notice to the other party. with a copy of the notice submitted to the JCPC Chairperson, and the DPS Area Consultant. 2. Payment to Contractor. Agency and Contractor agree upon these rates as reimbursed fees: the services will be delivered at the rate of $ 60 per hour (7 hours per week x 52 weeks) not to exceed $21,840 for the term of this contract. The Contractor must submit a signed monthly request for reimbursement to the Agency documenting the actual time worked or the units of service provided. 3. Funding. All terms and conditions of this Contract are dependent upon and subject to the allocation of funds for the purpose set forth in this Contract, and this Contract shall automatically terminate if funds cease to be available. The terms of the contract are limited to the availability of the JCPC funds which have been allocated for that purpose. 4. Taxes. The Contractor shall be considered an independent Contractor and as such shall be responsible of all taxes. 5. DPS JCPC and Community Programs Section -Funded Programs Minimum Standards Policy. The Contractor shall adhere to all DPS JCPC standards, policies, and procedures related to the provision of the program's service type. 6. Responsibilities of Contractor. The Contractor hereby agrees to provide the following services in a manner satisfactory to the Agency, within the stated time frames. A. Outpatient individual/family substance use therapy on a weekly basis for DPS referred youth. B. Completion of Comprehensive Clinical Assessments/Substance Use Assessments upon request. C. Coordination of services with DPS Court Counselors and CJS staff to include but not limited to monthly treatment team meetings, phone consultations, and thirty -day program report updates. Client/individual case consultation related to ASAM criteria, coordination of higher level of care requests, differential diagnosis and updates related to current trends in adolescent substance use may be included. 7. Juvenile Files/Records. Juvenile files and records created during the term of the contract are the property of the funded sponsoring agency. These files/records must be available at all times to the Agency, JCPC and DPS, and must be submitted to the Agency as juveniles are terminated from services or upon the end of the contract. 8. Referral and Initial Appointment. The maximum length of time between receiving the referral and initial appointment shall not exceed N/A business days. Program Manager or Authorized Agent Name and Title: Chris Preston (Agency) New Hanover County, Community. Justice Services Mailing Address: 320 Chestnut St, Suite 518 Wilmin ■ton 'vC 28401 Date: Contractor Name: Form JCPC/PO 001 Contract for Professional Services Template Form structure last revised July 2022 NC Department of Public Safety Page 1 of 2 DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 _ Contract for Professional Services Template (Contractor) , 201 North Front Street Suite 713 Mail ins -Address. Wilm'n ton NC 28401 Sivriature: ! r r4 Date: Form JCPC/PO 001 Contract for Professional Services Template Form structure last revised July 2022 NC Department of Public Safety Page 2 of 2 DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 STATE OF NORTH CAROLINA COUNTY OF New Hanover I, Lisa Bentz behalf of h e rs e l f sworn deposes and says as follows: AFFIDAVIT of COMPLIANCE with N.C. E -Verify Statutes (hereinafter the "Affiant"), duly authorized by and on (hereinafter the "Employer") after being first duly I am the affi a nt (president, Manager, CEO, etc.) of the Employer and possess the full authority to speak for and on behalf of the Employer identified above. 2. Employer understands that "E -Verify" means the federal E -Verify program operated by the United States Dept. of Homeland Security and other federal agencies, or any successor or equivalent program used to verify the work authorization of newly hired employees pursuant to federal law. 3. No Employer employs 25 or more employees in the State of North Carolina, and is in compliance with the provisions of N.C. Gen. Stat. §64-26. Employer has verified the work authorization of its employees through E -Verify and shall retain the records of verification for a period of at least one year. Yes Employer employs fewer than 25 Employees and is therefore not subject to the provisions of N.C. Gen. Stat. §64-26. 4. All subcontractors engaged by or to be engaged by Employer have or will have likewise complied with the provisions of N.C. Gen. Stat. §64-26. 5. Employer shall keep New Hanover County informed of any change in its status pursuant to Article 2 of Chapter 64 of the North Carolina General Statutes. Further this affiant sayeth not. This the CIAOL day of , 20,�3. A 'ant STATE OF NORTH CAROLINA COUNTY OF IA.0 %)Z" Sworn to and subscribed before me, this thea day of [SEAL] Notary PYW My commission expires:.y �fN1ifN�� • �i ' 20 �,pT,1gy tin oVER 01180111100 DocuSign Envelope ID: 592CE858-7A1C-4298-9F5F-4A77F55C4D51 SUBCONTRACTOR'S WAIVER OF WORKERS' COMPENSATION COVERAGE I do hereby release New Hanover County, its officers and employees from all responsibility or liability of any nature whatsoever for any injury or aggravation of a pre-existing condition as a result of my being a sole proprietorship, should I become injured while working for New Hanover County. I further agree to indemnity and hold harmless New Hanover County, its officers and employees from any and all claims which might be brought and which are in any way connected with New Hanover County. This agreement shall be effective and binding upon my heirs, agents, personal representatives and assigns. I am aware that by signing this waiver, I assume all risks and waive and release rights that I may have or possess. This the day of__MW 120 �C Contractor (Sale Proprietorship) Witness: and Certificate Of Completion Envelope Id: 592CE8587A1C42989F5F4A77F55C4D51 Subject: DPS eSignature Request for New Hanover 965-10752 Youth Empowerment Services Source Envelope: Document Pages: 51 Signatures: 4 Certificate Pages: 5 Initials: 0 AutoNav: Enabled Envelopeld Stamping: Enabled Time Zone: (UTC -05:00) Eastern Time (US & Canada) Record Tracking Status: Original 6/6/2023 1:16:12 PM Signer Events James Roten jroten@nhcgov.com Security Level: Email, Account Authentication (None) Electronic Record and Signature Disclosure: Accepted: 6/6/2023 2:03:31 PM ID:6a487e4f-0247-4c6e-b140-Oae21452ad63 J H Corpening II julius.h.corpening@nccourts.org Security Level: Email, Account Authentication (None) Electronic Record and Signature Disclosure: Accepted: 6/6/2023 3:03:44 PM ID:aea7dc27-dae9-4e74-87d8-ea0d23d5477f Eric Credle ecredle@nhcgov.com Security Level: Email, Account Authentication (None) Electronic Record and Signature Disclosure: Accepted: 6/9/2023 4:30:15 PM ID: e02edcl1-64d1-4a8e-b054-29d51350b1a4 Cindy Porterfield cindy.porterfield@ncdps.gov Director of Juvenile Community Programs NC Dept of Public Safety Security Level: Email, Account Authentication (None) Electronic Record and Signature Disclosure: Not Offered via DocuSign Holder: DPS-DJJ Community Programs djjdp.applicationsupport@ncdps.gov Signature UD11U Sig "Itl by: A143266AF4F646A... Signature Adoption: Pre -selected Style Using IP Address: 152.31.193.130 CDocuSi,netl by: R CbVpt,ln,t" 3DD8E15D4A2540C... Signature Adoption: Pre -selected Style Using IP Address: 204.152.2.232 &DSi,n1dby: G Cktj B88CFC5D1A4B5... Signature Adoption: Pre -selected Style Using IP Address: 152.31.193.130 DocuSignetl by: 798FE7A4BD9F419... Signature Adoption: Pre -selected Style Using IP Address: 199.90.60.4 DocuSign Status: Completed Envelope Originator: DPS-DJJ Community Programs 3040 Hammond Business PI Raleigh, NC 27603 djjdp.applicationsupport@ncdps.gov IP Address: 207.4.107.7 Location: DocuSign Timestamp Sent: 6/6/2023 1:16:14 PM Viewed: 6/6/2023 2:03:31 PM Signed: 6/6/2023 2:03:47 PM Sent: 6/6/2023 2:03:48 PM Viewed: 6/6/2023 3:03:44 PM Signed: 6/6/2023 3:03:53 PM Sent: 6/6/2023 3:03:55 PM Viewed: 6/9/2023 4:26:44 PM Signed: 6/9/2023 4:31:10 PM Sent: 6/9/2023 4:31:12 PM Viewed: 6/12/2023 11:11:35 AM Signed: 6/12/2023 11:11:41 AM In Person Signer Events Signature Timestamp Editor Delivery Events Status Timestamp Agent Delivery Events Status Timestamp Intermediary Delivery Events Status Timestamp Certified Delivery Events Status Timestamp Carbon Copy Events Status Timestamp Witness Events Signature Timestamp Notary Events Signature Timestamp Envelope Summary Events Status Timestamps Envelope Sent Hashed/Encrypted 6/6/2023 1:16:14 PM Certified Delivered Security Checked 6/12/2023 11:11:35 AM Signing Complete Security Checked 6/12/2023 11:11:41 AM Completed Security Checked 6/12/2023 11:11:41 AM Payment Events Status Timestamps Electronic Record and Signature Disclosure Electronic Record and Signature Disclosure created on: 4/3/2018 2:57:43 PM Parties agreed to: James Roten, J H Corpening II, Eric Credle CONSUMER DISCLOSURE From time to time, NC Dept of Public Safety (we, us or Company) may be required by law to provide to you certain written notices or disclosures. Described below are the terms and conditions for providing to you such notices and disclosures electronically through the DocuSign, Inc. (DocuSign) electronic signing system. Please read the information below carefully and thoroughly, and if you can access this information electronically to your satisfaction and agree to these terms and conditions, please confirm your agreement by clicking the a€ -T agreea€TM button at the bottom of this document. Getting paper copies At any time, you may request from us a paper copy of any record provided or made available electronically to you by us. You will have the ability to download and print documents we send to you through the DocuSign system during and immediately after signing session and, if you elect to create a DocuSign signer account, you may access them for a limited period of time (usually 30 days) after such documents are first sent to you. After such time, if you wish for us to send you paper copies of any such documents from our office to you, you will be charged a $0.00 per -page fee. You may request delivery of such paper copies from us by following the procedure described below. Withdrawing your consent If you decide to receive notices and disclosures from us electronically, you may at any time change your mind and tell us that thereafter you want to receive required notices and disclosures only in paper format. How you must inform us of your decision to receive future notices and disclosure in paper format and withdraw your consent to receive notices and disclosures electronically is described below. Consequences of changing your mind If you elect to receive required notices and disclosures only in paper format, it will slow the speed at which we can complete certain steps in transactions with you and delivering services to you because we will need first to send the required notices or disclosures to you in paper format, and then wait until we receive back from you your acknowledgment of your receipt of such paper notices or disclosures. To indicate to us that you are changing your mind, you must withdraw your consent using the DocuSign a€ -Withdraw Consenta€TM form on the signing page of a DocuSign envelope instead of signing it. This will indicate to us that you have withdrawn your consent to receive required notices and disclosures electronically from us and you will no longer be able to use the DocuSign system to receive required notices and consents electronically from us or to sign electronically documents from us. All notices and disclosures will be sent to you electronically Unless you tell us otherwise in accordance with the procedures described herein, we will provide electronically to you through the DocuSign system all required notices, disclosures, authorizations, acknowledgements, and other documents that are required to be provided or made available to you during the course of our relationship with you. To reduce the chance of you inadvertently not receiving any notice or disclosure, we prefer to provide all of the required notices and disclosures to you by the same method and to the same address that you have given us. Thus, you can receive all the disclosures and notices electronically or in paper format through the paper mail delivery system. If you do not agree with this process, please let us know as described below. Please also see the paragraph immediately above that describes the consequences of your electing not to receive delivery of the notices and disclosures electronically from us. How to contact NC Dept of Public Safety: You may contact us to let us know of your changes as to how we may contact you electronically, to request paper copies of certain information from us, and to withdraw your prior consent to receive notices and disclosures electronically as follows: To contact us by email send messages to: david.pozun@ncdps.gov To advise NC Dept of Public Safety of your new e-mail address To let us know of a change in your e-mail address where we should send notices and disclosures electronically to you, you must send an email message to us at david.pozun@ncdps.gov and in the body of such request you must state: your previous e-mail address, your new e-mail address. We do not require any other information from you to change your email address.. In addition, you must notify DocuSign, Inc. to arrange for your new email address to be reflected in your DocuSign account by following the process for changing e-mail in the DocuSign system. To request paper copies from NC Dept of Public Safety To request delivery from us of paper copies of the notices and disclosures previously provided by us to you electronically, you must send us an e-mail to david.pozun@ncdps.gov and in the body of such request you must state your e-mail address, full name, US Postal address, and telephone number. We will bill you for any fees at that time, if any. To withdraw your consent with NC Dept of Public Safety To inform us that you no longer want to receive future notices and disclosures in electronic format you may: i. decline to sign a document from within your DocuSign session, and on the subsequent page, select the check -box indicating you wish to withdraw your consent, or you may; ii. send us an e-mail to david.pozun@ncdps.gov and in the body of such request you must state your e-mail, full name, US Postal Address, and telephone number. We do not need any other information from you to withdraw consent.. The consequences of your withdrawing consent for online documents will be that transactions may take a longer time to process.. Required hardware and software Operating Systems: WindowsA@ 2000, WindowsA@ XP, Windows Vist,-A@; Mac OSA@ X Browsers: Final release versions of Internet ExplorerA@ 6.0 or above (Windows only); Mozilla Firefox 2.0 or above (Windows and Mac); Safaria„¢ 3.0 or above (Mac only) PDF Reader: AcrobatA@ or similar software may be required to view and print PDF files Screen Resolution: 800 x 600 minimum Enabled Security Settings: Allow per session cookies ** These minimum requirements are subject to change. If these requirements change, you will be asked to re -accept the disclosure. Pre-release (e.g. beta) versions of operating systems and browsers are not supported. Acknowledging your access and consent to receive materials electronically To confirm to us that you can access this information electronically, which will be similar to other electronic notices and disclosures that we will provide to you, please verify that you were able to read this electronic disclosure and that you also were able to print on paper or electronically save this page for your future reference and access or that you were able to e-mail this disclosure and consent to an address where you will be able to print on paper or save it for your future reference and access. Further, if you consent to receiving notices and disclosures exclusively in electronic format on the terms and conditions described above, please let us know by clicking the a€ -I agreed€TM button below. By checking the d€ -I agreed€TM box, I confirm that: • I can access and read this Electronic CONSENT TO ELECTRONIC RECEIPT OF ELECTRONIC CONSUMER DISCLOSURES document; and • I can print on paper the disclosure or save or send the disclosure to a place where I can print it, for future reference and access; and • Until or unless I notify NC Dept of Public Safety as described above, I consent to receive from exclusively through electronic means all notices, disclosures, authorizations, acknowledgements, and other documents that are required to be provided or made available to me by NC Dept of Public Safety during the course of my relationship with you.