Funding Provided by
Ma Dept. of Mental Health
Section 5
Community-based Perinatal Support Model™ (CPSM) Request for Proposal Application
*Please note that we are accepting communities at varying levels of community readiness and if you do
not know the answer to any of the following questions by the time of submission please include possible
suggestions of next steps you would take.
Organization
Information
Organization Name
Mailing Address (PO Box or
Street)
City, State, ZIP Code
County
Phone
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
Funding Provided by
Ma Dept. of Mental Health
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
BASIC PROJET 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
Describe the population/community you are applying for.
Funding Provided by
Ma Dept. of Mental Health
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
EFFORTS
Community efforts to address perinatal depression to date
What resources are currently available to mothers with perinatal depression within the community?
Describe any known screening protocol for perinatal depression in the community.
Are there any existing interventions/grants/programs to address perinatal depression in the community?
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, etc (if applicable).
Describe strengths and challenges experienced providing services related to perinatal depression.
COMMUNITY CLIMATE
Justification
Explain the impact of perinatal depression in your community.
Identify unique barriers to care for mother experiencing perinatal depression within the community.
Funding Provided by
Ma Dept. of Mental Health
Describe how the CPSM will benefit your community.
Project/Program Goals
List 3 main goals for your community that you hope to accomplish by implementing the CPSM.
How do you plan to collaborate with diverse community partners?
How do you envision the CPSM assisting in expanding resources that address perinatal depression in your
community?
COMMUNITY KNOWLEDGE OF PERINATAL DEPRESSION
Are community members aware of the impact of perinatal depression on mothers, families and communities?
What members of the community seem most concerned about perinatal mental health? (i.e. moms, OB, pediatricians,
social services)
What members of the community could benefit from knowing more about perinatal depression?
COMMUNITY KNOWLEDGE OF EFFORTS
Are community members aware of existing efforts to address perinatal mental health?
How do you plan to reach out to community members to make them aware of your efforts to implement the CPSM?
Funding Provided by
Ma Dept. of Mental Health
LEADERSHIP
Collaboration
Describe proposed partnerships and include hospital commitment (if applicable).
Describe resources that may be contributed by proposed partners (e.g. time, use of facility, etc.).
How do you plan to build on your existing list of proposed partners?
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?
List proposed partners that will participate in the leadership team.
Which providers, agencies or individuals (e.g. medical, mental health, social services, community organizations) are
missing from the proposed leadership team and what role would they fulfill?
How do you propose addressing the gaps in the leadership team?
Implementing Support Groups
Support groups may be successfully implemented as a partnership between collaborating partners or may be
implemented by lead agency or other entity within the community.
What agencies/organizations will be involved in implementing a support group?
What will the community approach to implementing support groups be (e.g. location, language, target population
etc.)?
Funding Provided by
Ma Dept. of Mental Health
List identified leaders to attend MotherWoman Group Facilitator Training© (Ideally would represent diverse
backgrounds, language and lived experience)
RESOURCES
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 begin a
coalition
1
2
3
4
5
3. Have the resources to implement 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
Sustainability
1
2
3
4
5
Describe your vision of how the project will result in lasting change regarding care for mothers with perinatal
depression in your area.
COMMITMENT TO CPSM ACTIVITIES
Confirmation of Participation in all CPSM and Support Group Activities:
Do you believe you have the capacity to recruit community leaders and providers to attend the CPSM Community
Training (about 30 participants)?
Propose possible recruitment strategies you would employ for this training?
Do you have the capacity to identify a location for trainings to be held (i.e. conveniently located, able to
accommodate a minimum of 30 participants).
Funding Provided by
Ma Dept. of Mental Health
Preferred Date for CPSM Community Training©
Please select your top 3 dates for participating in the CPSM Community Training session.
Training sessions may be held on: Oct. 6th, Oct 8th, Oct 13th, Oct 15th, Nov. 10th and Nov 12th. By each date
selection please put whether you prefer 9am – 12pm or 1pm – 4pm.
Preference:
DATE
1.
2.
3.
TIME
Commitment to MotherWoman Group Facilitator Training© - Date to be Confirmed
Provide names of two or more possible attendees (include email address and area of expertise). If unavailable, how
do you plan to recruit attendees?
Attendees must submit the MotherWoman Facilitator Training Addendum clearly stating their intention to implement a
support group and commitment to participating in coalition activities.
1.
2.
Commitment to CPSM Leadership Team Training – Date to be Confirmed
Provide list of names of five possible attendees and include their area of expertise. If unavailable at time of
submission, how do you plan to recruit attendees?
1.
2.
3.
4.
5.