Section 5
Community-based Perinatal Support Model© Request for Proposal Application
Section 5 is available as a word document to input text directly in boxes below.
Organization
Information
Organization Name
Mailing Address (PO Box
or Street)
City, State, ZIP Code
County
Phone
FAX (if applicable)
Website (if applicable)
Type of Business Entity
(check one)
Mission Statement
Population(s) Served by
the Requesting
Organization
Geographical Area Served
by Requesting
Organization
Programs and Activities
of the Requesting
Organization
Organization Primary
Contact Information:
Prefix
First Name
Middle Name or Initial
_ Non-Profit Organization
_For Profit Organization
_Limited Liability Corporation
_ Partnership
Last Name
Suffix
Title
Email
Office Phone and
Extension
Cellphone
Application Contact
Information:
Prefix
If different from Primary Organization Contact Information
First Name
Middle Name or Initial
Last Name
Suffix
Title
Email
Office Phone and
Extension
Cellphone
Project Information
Please use as much space as needed to complete each section. There is a 10 page limit on the total application.
Target Population to be Served
-Please describe the population/community
-Provide brief definition of the community (i.e. County, town, city, hospital--centered, neighborhood,
community health center catchment area, etc.) to be served --Include: ethnicity, race, languages, economic status, teen pregnancy, and other important factors
Community efforts to address perinatal depression to date
-Known resources available to mothers with perinatal depression within the community
-Screening protocol for perinatal depression
-Known interventions/grants/programs to address perinatal depression
-Active community leaders
-Other
Justification
-Explain impact of perinatal depression in the community and why it should be addressed
-Identify unique barriers to care for mother experiencing perinatal depression within the community
Project/Program Goals
What are your goals in implementing the CPSM in the community?
How will the community benefit from the CPSM?
-How will the CPSM help the community?
-How can the CPSM help collaboration between diverse service providers?
What is the vision of how CPSM can help expand community resources?
Who will be responsible for the project implementation?
The “lead agency” is the applying entity for CPSM implementation.
-Who will be the champion and take the lead role for implementation within the lead agency?
-Who will be part of the leadership team and represent community partners?
-What are the gaps in the leadership team? How will they be addressed?
List of proposed partners for implementing support groups
Support groups may be successful implemented as a partnership between collaborating partners or may be
implemented by lead agency or other entity within the community.
-What will the community approach to implementing support groups be?
-What agencies/organizations will be involved?
Describe current ability to implement support groups:
-Location for support group(s)
-Target population for support group(s)
-Identified leaders to attend MotherWoman Group Facilitator Training© (2) one of whom should have
lived experience with perinatal depression or other relevant experience
-Cultural competence and relevance is a priority.
Outreach Strategies
-Describe how your project will target, recruit and retain support group program participants
-Describe past success with this
-Include the names of organizations with which you may partner to recruit participants
Experience working on issues related to perinatal depression (if applicable)
-Describe your agency’s experience providing perinatal depression services or engaging in perinatal
activities
-Please list the type of services provided, number of staff providing these services, and years of
experience providing these services
-Describe strengths and challenges witnessed during prior experiences providing services related to
perinatal depression
Collaboration
-Description of proposed partnerships: include hospital commitment (if applicable)
-Description of resources contributed by partners (i.e. time, use of facility, etc.)
-How do you plan to build a collaboration of stakeholders?
Sustainability
-Vision of how the project will result in lasting change regarding care for mothers with perinatal
depression in your area once contract is completed
Confirmation of Participation in all CPSM and Support Group Activities:
-Ability to recruit community leaders and providers to attend trainings (30 participants)
-What will the process be to recruit?
-Identify a location for trainings to be held (conveniently located, able to accommodate a minimum of 30
participants)
-If confirmation is not available at time of submission please describe how actions will be met in time for
implementation
Preferred Date for CPSM Community Training©
Please select your top 3 dates for participating in the CPSM Community Training session.
Training sessions will be held Thursdays in May and June from 1:00pm – 4:00pm at a location in the
community (identified above.)
Preference:
1.
2.
3.
Commitment to MotherWoman Group Facilitator Training© held June 4th- 6th, 2014
-Confirm attendance to training of two participants. This should be the same people who will be
implementing the support group(s)
-Provide names of two or more possible attendees If unavailable, how do you plan to recruit attendees?
-Describe credentials of possible attendees including area(s) of expertise?
On a scale of 1 – 5 how would you rate
the following statements regarding
your current situation?
Strongly Disagree ------------------------------ Strongly Agree
1. Have a defined “lead agency”
1
2
3
4
5
2. Have the resources to run a coalition
1
2
3
4
5
3. Have the resources to run a support
group
1
2
3
4
5
4. Have 3-5 committed agencies and/or
organizations
1
2
3
4
5
5. Have hospital or birthing center
commitment
1
2
3
4
5