ࡱ> EGD#` b%bjbj5G5G .2W-W-|4hhhhhhh8<>De\`$h9hhhhhhh la50e h, eD|hhhhhh  DIVISION OF MENTAL HEALTH SERVICES ANNEX A INFORMATION SHEET  AGENCY NAME:  FORMTEXT       CONTRACT NUMBER:  FORMTEXT       CONTRACT TERM:  FORMTEXT       TO  FORMTEXT       PROGRAM NAME:  FORMTEXT      PROGRAM ELEMENT CODE:  FORMTEXT      CHECK ONEOTHER TARGET GROUPSPROGRAM OPERATIONS DAY/EVENING HOURS Monday  FORMTEXT      - FORMTEXT       Tuesday  FORMTEXT      - FORMTEXT       Wednesday  FORMTEXT      - FORMTEXT       Thursday  FORMTEXT      - FORMTEXT       Friday  FORMTEXT      - FORMTEXT       Saturday  FORMTEXT      - FORMTEXT       Sunday  FORMTEXT      - FORMTEXT        FORMCHECKBOX  Youth Only (under 18)  FORMCHECKBOX  AduF    2 L P R f h j t v x ~ ޷ɥޓɥށɥs_s&jh7N@h7N@5CJUaJjh7N@5CJUaJ#jvh7N@h7N@CJUaJ#jh7N@h7N@CJUaJ"jh"LCJUaJmHnHu#jh7N@h7N@CJUaJjh7N@CJUaJh7N@5CJaJh7N@CJaJh"L56CJaJh7N@56CJaJh7N@%JZ\ $Ifgkd$$Ifl'8( t0644 la $$Ifa$ $`%    0 2 4 > @ D       ( * > @ T ָָ֩ֈָyָjָjh7N@CJUaJjth7N@CJUaJj\h7N@CJUaJ"jh"LCJUaJmHnHujh7N@CJUaJjh7N@CJUaJh7N@5CJaJh7N@6CJaJh7N@CJaJjh7N@5CJUaJ%jh"L5CJUaJmHnHu(  B $Ifgkd^$$Ifl'8( t0644 laB D X , . |||sss|||||| $$Ifa$$If|kd$$Ifl]0d'h  t0644 la T V X b d f h | ~ " $ . 0 2 4 H J L V X l n ʻʬʝʎpjh7N@CJUaJjh7N@CJUaJj0h7N@CJUaJjh7N@CJUaJjDh7N@CJUaJjh7N@CJUaJh7N@CJaJ"jh"LCJUaJmHnHujh7N@CJUaJj\h7N@CJUaJ, Z \ " "fkd $$Ifl4JF d'h h `h  t06    44 laf4$If      2 4 H J L V X Z \ p r t ~ ڼڭڞڏ}#j h"Lh"LCJUaJjj h7N@CJUaJj h7N@CJUaJj~ h7N@CJUaJj h7N@CJUaJjh7N@CJUaJh7N@CJaJjh7N@CJUaJ"jh"LCJUaJmHnHu- """:"<">"f"h"""""""""""###>#@#\#^#`########ٳ١ُ}n\"jh"LCJUaJmHnHujh7N@CJUaJ#j]h"Lh"LCJUaJ#j h"Lh"LCJUaJ#ju h"Lh"LCJUaJ#j h"Lh"LCJUaJ#j h"Lh"LCJUaJUh7N@CJaJjh7N@CJUaJ#j h"Lh"LCJUaJ$lt Only (18+)  FORMCHECKBOX  Elderly Only (65+)  FORMCHECKBOX  Youth and Adults  FORMCHECKBOX  Other Age ( )  FORMCHECKBOX  Family Members of MI  FORMCHECKBOX  N/A (C&E, TA, etc.) FORMTEXT      PROGRAM LOCATIONS:  FORMTEXT      PROGRAM DIRECTOR:  FORMTEXT      TITLE:  FORMTEXT      BRIEF DESCRIPTION OF PROGRAMS:  FORMTEXT           3/07 Page 1 of 1 Filename: INFO SHEET "f""">######$$fkdE$$Ifl4F d'h h  h t06    44 laf4$If ########$$$($,$.$B$D$F$P$R$T$^$d$f$z$|$~$$$$$$$$$$$$$$$$%%% % %%^%|hdhTKjhTKUh7N@6CJaJjh7N@CJUaJjh7N@CJUaJj/h7N@CJUaJ"jh"LCJUaJmHnHujh7N@CJUaJjh7N@CJUaJh7N@5CJaJh7N@CJaJ/$$,$T$d$$yyyy$Ifkdr$$Ifl40d' h  t0644 laf4$$$$||$If|kd$$Ifl_0d'h  t0644 la$$$$$%%% %%%\%^%`%b%$a$ikd5$$Ifl '8( t0644 la^%`%b%h7N@6CJaJh7N@,1h/ =!"#$% $$If!vh58(#v8(:V l t0658(/ vD@Text24vD@Text25tD@Text1tD@Text2$$If!vh58(#v8(:V l t0658(/ tDText3tDText4$$If!vh55h #v#vh :V l] t0655h / tDText6tDText7tDText8tDText9vDText10vDText11vDText12vDText13vDText14vDText15vDText16vDText17vDText18vDText19$$If!vh5h 5h 5h #vh :V l4J t06+5h / / / f4tDeCheck1tDeCheck2tDeCheck3tDeCheck4tDeCheck5tDeCheck6tDeCheck7tDText5$$If!vh5h 5h 5h #vh :V l4 t06+5h / / f4vDText20$$If!vh55h #v#vh :V l4 t06+55h / / f4vDText21vDText22$$If!vh55h #v#vh :V l_ t0655h / vDText23$$If!vh58(#v8(:V l t0658(/ @@@ NormalOJQJ_HmH sH tH DAD Default Paragraph FontVi@V  Table Normal :V 44 la (k(No List POP OmniPage #3d1$7$8$H$ CJ^JaJ4@4 Header  !4 @"4 Footer  !2 z%-.@ABCef !",@STfg-.^_3Vx*2FGfz{`'v:`'s`'s`'s`'s`'s`'s`'s`'s`'s`'s`'sA ss s sW s s s s s s s s s s s s s s s s s s s s2 s s s s s s s s ssMss s s\`'s`'s"`'s`'v:%-.@ABCef !",@STfg-.^_3Vx*2FGfz{|0000000000000000000000000000000000000 0 0 0 0 0 0 0 0 0 0 0 0000000000$ 3336 T #^%b%  B "$$$b% `% Q]cx nz%+6BHJV\htz|3CVfx"(2>DfrxFFFFFFFFFFFFFFFFFFFFG$G$G$G$G$G$G$FFFFF Text24Text25Text1Text2Text3Text4Text6Text7Text8Text9Text10Text11Text12Text13Text14Text15Text16Text17Text18Text19Check1Check2Check3Check4Check5Check6Check7Text5Text20Text21Text22Text23Ryo7Ki}4Wy3g d ,I]{Dg)Ey||%Qdx   "STfn,6IJ]_h{|)*12EGfy|7N@TK"Ld9AB!",@*FGz{@vO4PP P P"UnknownGz Times New Roman5Symbol3& z Arial"hiBiBWݸ!r4dzz3HX)?7N@2'DIVISION OF MENTAL HEALTH AND HOSPITALS Bobbie HalljdecolaOh+'0< LX x   (DIVISION OF MENTAL HEALTH AND HOSPITALS Bobbie Hall,Annex%20A%20-%20Info%20Sheet.dot?attach=1jdecola2Microsoft Office Word@@@fɏa@fɏa՜.+,0( hp  CPC Behavioral Healthcarez (DIVISION OF MENTAL HEALTH AND HOSPITALS Title  !"#%&'()*+,-./012356789:;=>?@ABCFRoot Entry FbnaHData 1Table$WordDocument.2SummaryInformation(4DocumentSummaryInformation8<CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q