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DZVZSZON OF YOUTH ~ERV2CES - CBA <br /> PROGRAM AGREEMENT <br /> <br /> Hame of Program Outpatient Adolescent Substance Abuse <br /> <br /> SpOnSoring Aqency Piedmont Area Menta! aeal~h Center County <br /> <br /> Contact Person (name & address) F~og£am Typo <br /> 3an Autent Director Substance Abuse Services <br /> 657 Lake Concord RD. Funding Period <br /> <br /> _Concord, N. C. 28025 Phone()04) 788-1130 thru <br /> CBA Assigned I.D. ~ <br /> <br />Personnel, Parents, Dept. of Social Services and other <br /> <br /> * Client Capacity - 50 Anticipated average length of stay ~6~ <br /> <br /> (days). Estimated number of youth to be served during funding period <br /> <br /> Date received in regional offi:e <br /> <br /> Please submit 4 copies with original signatures. <br /> <br />*If the funds being requested will be used for more than one program component <br />ptease provide this information for each compOnent on a separate sheet. <br /> <br /> OYS [Rev. 1-87) <br /> <br /> q <br /> <br /> <br />