708 Board Application

Please Note: The Stephenson County 708 Board only funds entities providing services to the following individuals or persons with the following conditions:

"Person with a developmental disability" means any person or persons so diagnosed and as defined in the Mental Health and Developmental Disabilities Code. Community mental health boards operating under this Act may in their jurisdiction, by a majority vote, add to the definition of "person with a developmental disability".
"Mental illness" has the meaning ascribed to that term in the Mental Health and Developmental Disabilities Code. Community mental health boards operating under this Act may in their jurisdiction, by a majority vote, add to the definition of "mental illness".
"Substance use disorder" encompasses substance abuse, dependence, and addiction, not inconsistent with federal or State definitions

For more information or to view the State Statute in its entirety please click the link below:

405 ILCS 20 Community Mental Health Act

Today's Date

Agency's Name

Amount Requesting

Current Fiscal Year 708 Funding

Previous Fiscal Year 708 Funding

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Mailing Address (if different)

Primary Contact's First Name

Primary Contact's Last Name

Contact email

Phone number

Website

Agency's FEIN Number

Number of Employees

Agency Mission Statement

CEO First Name

CEO Last Name

CEO Phone Number

CEO Email Address

Program Information

Program Name

Need or Issue Statement – (Describe the need or issue the program/service addresses.) Please address the following as applicable: Clearly define the community need for the program/service Clearly define the community’s benefit from the program/service Submit data (if available) to support the need/benefits identified Show any evidence of community support for the program/service

Program/Service Description (Describe the purpose of the program/services)

Locations of program (include address(es))

*Please explain how the program or service you are requesting funds for meets the requirements of the Community Mental Health Act Statute.

Describe the population to be served by this request:

Explain specifically how 708 funding will be used (include whether the funding will help add new services or supplement funding to maintain current service levels)

Current Total Annual Program Budget

Upload your Program Budget

Provide a detailed budget narrative here

Does this program receive any matching funds?

What is the source of the matching funds?

Is the match expected to be continued into the 2025/2026 allocation year?

What is the ratio of the match (e.g., 2:1 – receive two dollars for every 708 dollar)?

Are there any limits on amount to be received/matched?

What is the limit?

List other current funding sources and amounts for this program

Percent of Services Provided by Ages:

% of Services Provided 0-4 year olds

% of Service provide to youth 5-12 years old

% of Services Provided to youth 13-15 years old

% of services provided to youth 16-18 years old

% of services provided to youth 19-21 years old

UPLOADS

Upload your Agency Budget

Upload your most recent 990

Upload your 501c3 if we do not already have it

Upload your Board of Directors list

Unduplicated Numbers

Provide Total unduplicated numbers served in Stephenson County

Baileyville

Baileyville # Unduplicated Cases

Baileyville # Instances

Baileyville Prior YR Unduplicated

Baileyville Prior YR Instances

Cedarville

Cedarville # Unduplicated

Cedarville # Instances

Cedarville Prior YR Unduplicated

Cedarville Prior YR Instances

Freeport

Number of Unduplicated Cases:

Number of Instances

Prior Year # Unduplicated Cases

Prior Year # of Instances

Lena

Number of Unduplicated Cases

Lena # of Instances

Prior Year Number of Unduplicated Cases:

Prior Year Number of Instances

Dakota

Dakota Number of Unduplicated

Dakota # of Instances

Dakota Prior Year Unduplicated

Dakota Prior Year # Instances

Davis

Davis Unduplicated Cases

Davis Number of Instances

Davis Prior YR Unduplicated

Davis Prior YR # Instances

German Valley

German Valley # Unduplicated

German Valley # Instances

German Valley Prior YR Unduplicated

German Valley Prior YR Instances

McConnell

McConnell # Unduplicated Cases

McConnell # Instances

McConnell Prior YR Unduplicated

McConnell Prior YR Instances

Orangeville

Orangeville Unduplicated Cases

Orangeville # of Instances

Orangeville Prior Year Unduplicated

Orangeville Prior Year Instances

Pearl City

Pearl City # Unduplicated

Pearl City # Instances

Pearl City Prior YR Unduplicated

Pearl City Prior YR Instances

Ridott

Ridott Unduplicated Cases

Ridott # Instances

Ridott Prior YR Unduplicated

Ridott Prior YR Instances

Rock City

Rock City # Unduplicated

Rock City # Instances

Rock City Prior YR Unduplicated

Rock City Prior YR Instances

Winslow

Winslow # Unduplicated

Winslow # Instances

Winslow # Prior YR Unduplicated

Winslow Prior YR # Instances

Provide unduplicated numbers served in areas outside Stephenson County

Goals and Outcomes

Outcome #1 Values and Results

Desired Outcome #1

Strategies or tasks employed to acheive desired outcome #1

Target Value for Current Year

Target Value for Past Fiscal year

Acheived Results for Current Year

Acheived results for Past Fiscal Year

Outcome # 2 Values and Results

Add a second Outcome?

Desired Outcome #2

Strategies or tasks employed to acheive desired outcome #2

Outcome 2 Target Value Current Year

Outcome 2 Target Value for Past Fiscal Year

Outcome 2 Acheived Results for Current Fiscal Year

Outcome 2 Acheived Results for Past Fiscal Year

Indicators

Outcome #3 Values and Results

Add a third Outcome?

Desired Outcome #3

Strategies or tasks employed to acheive desired outcome #3

Outcome 3 Target Value Current Year

Outcome 3 Target Value for Past Fiscal Year

Outcome 3 Acheived Results for Current Fiscal Year_

Outcome 3 Acheived Results for Past Fical Year

Previously Measured Outcomes

List any influencing factors affecting the outcome results

Collaborating Partners

Would you like to add a collaborating partner?

Collaborating Agency Name