How to Apply

STEP 1: ATTEND INFORMATIONAL WEBINAR

Applicants are encouraged to participate in an Informational Webinar on August 4, 2021, at 12:00 PM–1:00 PM (PT) to hear a detailed description of the program and ask questions.

Register here!

STEP 2: APPLY ONLINE

Your proposal and budget must be submitted through the Application Submission Form below by Tuesday, August 17, 2021 at 5pm.

Applications should include the following:

  1. Application Narrative: Download narrative questions.
  2. Budget Template: Download budget template.
  3. Tax Status Documentation
  4. Letter of Leadership Support from the chief medical officer, chief operating officer, or chief executive officer: refer to “Participant Expectations” in the application.

Download RFA as PDF

Advancing Behavioral Health Equity- Application Submission Form 

Upload and submit all application materials via this form by Tuesday, August 17th at 5pm. 
Decisions will be made and announced by September 20th, 2021. 

Please reach out to Juliane Tomlin, [email protected] with any questions. 


Applicant Organization Information









                     






Financial Information


Fiscal Sponsor Information









Application Components




Organization and Team Contacts
CEO Contact 




Grant Manager Contact 







The core team should be comprised of four to six dedicated individuals with primary care and behavioral health representatives. The core team should include the following roles: 
  • Project Lead
  • Behavioral Health Care Provider/Leader 
  • Physical Health Care Provider/ Leader 
  • Frontline Staff Member (e.g., Medical Assistant, Care Manager, Care Coordinator)
  • Other core team members could include those with expertise in data, systems management/ electronic health record, etc.
For more detailed information regarding the core team roles and expectations, please refer back to "Participant Expectations" in the Request for Applications. 
Project Team Lead






Team Member 2





Team Member 3





Team Member 4






One to two individuals are required to be committed members of the extended program team. Extended team members may include the following roles: 
  • Senior Administrative Leader Sponsor (e.g., Chief Executive Officer, Executive Director, Chief Operating Officer)
  • Clinical Leader (e.g., Medical Director, CMO)
  • Clinical front-line champions and staff 
  • Recommended if available: Family Specialist, Navigator, Peer Support Specialist, Community Health Worker, Patient, or Family Advisors(s)
For more detailed information regarding the extended team roles and expectations, please refer back to "Participant Expectations" in the Request for Applications.
Senior Administrative Leader / Sponsor




Other Extended Team Member (Optional)