* indicates a required field

4. 

5. Vernon Township Community Mental Health Board 

   
   

   FY27 Social Services Grant Application

9. General Information

11. Agency Name*
12. Agency Headquarters Address*
14. City*
15. Zip*
19. Chief Executive Officer Name*
20. Title*
22. Phone*
23. Email*
27. Grant Contact Name*
28. Title*
30. Phone*
31. Email*
35. Date Established
36. # of Full Time Employees
38. # of Part Time Employees
39. # of Volunteers
41. Board of Directors/Senior Management

    Please list the names of your Board of Directors and Senior Management and indicate if any are employed by your organization.

43. Is your agency incorporated as a 501(C)(3) Non-Profit organization?*

    1. Yes
    2. No
44. If yes, please provide a copy of your IRS tax-exempt Letter of Determination.
46. Is your agency licensed or registered in the State of Illinois?*

    1. Yes
    2. No
47. Is your agency accredited?*

    1. Yes
    2. No
49. If your agency is accredited, please list your accrediting bodies.
53. Provide information about your Mission Statement, Strategic Plan (if applicable), agency's objectives, and population served.
55. What is your organizations primary service area? Select all that apply. *

    1. Mental Health
    2. Substance Abuse
    3. Disability Services
59. Does your agency have a service location in Vernon Township?*

    1. Yes
    2. No

    If yes, please provide the address of the Vernon Township location first, and then list any other locations.  If no, list all other service office locations.  If you have more than three service office locations, please list the three closest to Vernon Township. 

61. Service Location Address #1
62. City
64. Zip
66. Service Location Address #2
67. City
69. Zip
71. Service Location Address #3
72. City
74. Zip
78. How many Vernon Township clients did you serve in your past fiscal year?*
80. How many Vernon Township clients do you anticipate serving this year?*
82. What is the total number of clients your agency serves?*
84. Do you provide services to all Vernon Township residents without discrimination based on race, religion, gender, sexual orientation, national origin, age, disability, or other protected characteristics?*

    1. Yes
    2. No

86. To check the boundaries of Vernon Township, please click here to see a map.  

90. Grant Amount Requested*

    *Any grant request of more than $100,000 may require a formal presentation to the VTCMHB by an agency board member or senior staff person.  

91. Category for Funding Request*

    1. General Operations
    2. Programming
    3. Capital Improvement/Equipment
93. Summarize the purpose of your request and the services/activities/equipment to be supported with VTCMHB funds.*

97. Budget Information

99. What is your total annual budget?*
100. What are the dates of your fiscal year?*
102. Please upload a copy of your previous fiscal year audit. *
106. Please list your 5 primary sources of funding from greatest to least:
108. Source #1
109. $ Amount
110. % of Total Budget
112. Source #2
113. $ Amount
114. % of Total Budget
116. Source #3
117. $ Amount
118. % of Total Budget
120. Source #4
121. $ Amount
122. % of Total Budget
124. Source #5
125. $ Amount
126. % of Total Budget
128. Do you receive funding from other Townships and/or Mental Health Boards?

     1. Yes
     2. No
130. If you receive funding from other Townships and/or Mental Health Boards, which Township's support your agency? Please provide previous grant amounts and percentage of total budget.
132. Have there been any major changes in your funding sources over the past two years? If so, please describe.
136. Do you charge a fee for your programs/services?*

     1. Yes
     2. No
138. If yes, please indicate how the fee is determined and the dollar amount charged. Please describe your sliding fee schedule if applicable and indicate how the sliding fees are determined.
140. Does your agency accept third party insurance?*

     1. Yes
     2. No
141. If yes, what types of insurance does your agency accept?

     1. Medicare
     2. Medicaid
     3. Private

145. Information on services provided

147. List the primary services provided by your agency.
149. How does your agency's human service outlook and practice serve Vernon Township residents' mental health, substance abuse, and/or developmental disabilities?
151. Describe the primary needs of your population and the existing or proposed programs in place to support those needs.
153. Are the services/activities/other for which the funding request is made modeled after evidence based practices in the field or other measurable outcomes? Explain.
155. If funding is to be used for programming, what are your long term goals, objectives and estimated end date (if applicable)?
157. All clients/participants funded with this award must be Vernon Township residents. Please explain your resident verification process.

161. Thank you for filling out the Vernon Township Community Mental Health Board Grant Application!  A representative from Vernon Township will be in touch soon.  In the meantime, if you have any questions, please contact Barrett Monie at 847-634-4600 or by email at Barrett@VernonTownship.com

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162. 1. Receive an email copy of this form.
163. Email address

     This field is not part of the form submission.

164. Submit

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