HomeMy WebLinkAbout20071749.tiff Weld County Department of Social Services
Notification of Financial Assistance Award
Core Funds
Type of Action Contract Award No.
X Initial Award 07-CORE-58
Revision (RFP-FYC-006-00; 004-MH-07)
Contract Award Period Name and Address of Contractor
Beginning 06/01/2007 and Individual& Group Therapy Services
Ending 05/31/2008 Mental Health Services
1020 8th Street
Greeley, CO 80631
Computation of Awards Description
Unit of Service The issuance of the Notification of Financial
Program provides mental health evaluations, Assistance Award is based upon your Request for
couples and family therapy, domestic violence Proposal(RFP). The RFP specifies the scope of
evaluation&treatment, evaluation&treatment services and conditions of award. Except where it is
of youth in conflict, and therapy for those in conflict with this NOFAA in which case the
involved in dependency&neglect cases. Ability NOFAA governs, the RFP upon which this award is
to evaluate and treat individuals with high levels based is an integral part of the action.
of anti-social traits, as well as anger Special conditions
management problems. Services for Domestic 1) Reimbursement for the Unit of Services will be based
Violence Offender Management Board approved on an hourly rate per child or per family.
clientele, victims of sexual abuse, victims of 2) The hourly rate will be paid for only direct face to
domestic violence, children and extended family face contact with the child and/or family, as
members who are secondary victims of crimes, evidenced by client-signed verification form, and as
including mental health, domestic violence specified in the unit of cost computation.
evaluations, and psychosexual evaluations. 3) Unit of service costs cannot exceed the hourly and
Average stay in program varies, i.e., domestic yearly cost per child and/or family.
violence treatment, 36 weeks; general mental 4) Payment will only be remitted on cases open with,and
health services, 12 weeks,youth-in-conflict, 12 referrals made by the Weld County Department of
weeks. Average monthly capacity is 12. Services Social Services.
in Ft. Lupton, Greeley, Del Camino, the 5) Requests for payment must be an original submitted to
Department of Corrections and County the Weld County Department of Social Services by the
Correctional facilities, when needed. end of the 2511 calendar day following the end of the
Cost Per Unit of Service month of service.The provider must submit requests
Hourly Rate for payment on forms approved by Weld County
Treatment Package Intensive $39.44 Department of Social Services. Requests for
Court Testimony $100.00 payments submitted 90 days from the date of service,
Enclosures: and thereafter, will not be paid.
X Signed RFP: Exhibit A 6) The Contractor will notify the Department of any
X Supplemental Narrative to RFP: Exhibit B changes in staff at the time of the change.
X Recommendation(s)
X itions of Approval
BA�provals:� (� PBy graffici
David E. Long, Chair Judy.q(. 3riego3 irector t'
Board of Weld County Commiss ners Weld County Department o Social Services
Date: 07 Date: O/f 'f p
2007-1749
EXHIBIT A
SIGNED RFP
■
807-MH-07 _
INVITATION TO BID
BID 001-07
DATE: February 28, 2007
BID NO: 001-07
RETURN BID TO: Monica Mika, Director of Administrative Services
915 10th Street, P.O. Box 758, Greeley, CO 80632
Third floor, Centennial Building, Purchasing Department
SUMMARY
Request for Proposal for: Colorado Family Preservation Act—Core Services Program
Deadline: Friday, March 30, 2007, 10:00 a.m. (MST)
The Families,Youth and Children Commission, an advisory commission to Social Services, announces
that competing applications will be accepted for approved providers pursuant to the Board of Weld
County Commissioners' authority under the Colorado Family Preservation Act (C.R.S. 26-5.5-101) and
Emergency Assistance for Families with Children at Imminent Risk of Out-of-Home Placement Act
(C.R.S. 26-5.3-101). The Families, Youth and Children Commission wishes to approve services targeted
to run from June 1, 2007, through May 31, 2008, at specific rates for different types of service, the
County will authorize approved providers and rates for services only. This program announcement
consists of the following documents, as follows:
• Invitation to Bid
• Main Request for Proposal (All program areas)
• Addendum A—Program Improvement Plan Requirements(by program area)
• Addendum B—Scope of Services (by program area)
• Core Budget Form
Delivery Date '5130 01'
(After receipt of order) BID MUST BE SIGNED IN INK
Program Area: M e ill.I liia 14-L i/l m P
" TYPED OR PRINTED SIGNATURE
VENDOR 1'`I,1V i Out_ k e(OU,DjkGfQry
(Name) 'S2 coLes_ Handwritten Signature By Authorized
Officer or Agent of Vendor
ADDRESS joao $ g• TITLEcpSre(t(
e7 feLk•EC+ t Co gM0 3 / DATE 3/3O1O7
PHONE# (q7O ) 3S_: - ?I71
The above bid is subject to Terms and Conditions as attached hereto and incorporated.
Page 1
RFP-FYC-006-00
MENTAL HEALTH SERVICES BID PROPOSAL
INDIVIDUAL & GROUP THERAPY SERVICES OUTPATIENT TREATMENT
PROGRAM
L ABSTRACT
Individual&Group Therapy Services(IGTS)will utilize a non-medical,cognitive behavioral
model, focusing primarily on the treatment on individuals with mental health concerns. This
program will include mental health evaluations, couples and family therapy, domestic violence
evaluation and treatment, evaluation and treatment of youth in conflict, and therapy for those
involved in dependency and neglect cases. This program will provide services in Ft. Lupton,
Greeley, Del Camino, the Department of Corrections, and County Correctional Facilities when
needed.
Individual & Group Therapy Services has the ability to evaluate and treat individuals with
high levels of antisocial traits, as well as anger management problems. In addition, this program
would provide services for Domestic Violence Offender Management Board approved clientele,
victims of sexual abuse, victims of domestic violence, as well as children and extended family
members who are secondary victims of crime. This program includes performing mental health
evaluations, domestic violence evaluations, and psychosexual evaluations.
The mission of Individual & Group Therapy Services is to continue to offer services which
reflect our care and interest in our clients, and to provide useful services to the community. By
doing so we will:
• Provide a structured program and environment for the safety of the client,family,and
community.
• Decrease levels of anxiety,depression,anger and violence and increase coping skills.
• Foster a family environment to effect positive change.
• Develop the use of appropriate cognitive, social, communication, and sexual skills
to reduce reactive and concerning behaviors.
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TABLE OF CONTENTS:
I. ABSTRACT
1. Introduction 2
2. Expectations 2
II. TARGET/ELIGIBILITY POPULATIONS
1. Guidelines 4
III. PROJECT NARRATIVE/SUPPORTING DOCUMENTATION
1. Type of services to be provided 4
2. Measurable Outcomes 7
3. Service Objectives 9
4. Workload Standards 10
5. Staff Qualifications 11
6. Program Capacity per month 11
7. Internal Tracking and Billing Process 11
8. Literature Citations 12
9. Confidentiality and Participant Protection/Human Subjects 13
A. Protecting Clients and Staff from Potential Risks 13
B. Fair Selection of Participants 13
C. Absence of Coercion 13
D. Data Collection 13
E. Privacy and Confidential Information 13
F. Adequate Consent Procedures 13
IV. APPENDIX A
1. Resumes for Key Staff Members 15
V. APPENDIX B
1. Data Collection Instruments/protocols 23
2. Intake Assessment Outline 23
VI. APPENDIX C
1. Sample Consent Forms
2. Consent for the Release of Information 30
3. Disclosure Statement 32
4. Contract of Agreement 35
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II. TARGET/ELIGIBILITY POPULATIONS
The total number of clients to be served is estimated to be thirty. Total family units are
estimated to be a maximum of thirty during the fiscal year.
If a facility is made available in the South Weld county area, the number of individuals
who will receive services in that area include a minimum of five (5) individuals. Services will
include individual, group or family services. There will be no bilingual services available for this
bidding year due to the resignation of the bilingual therapist.
The monthly and average maximum program capacity is 12. Average stay in the program
varies, depending on the specific entity involved in the individual treatment plan. For
individuals referred for domestic violence treatment, the minimum number of weeks in the
program would be thirty six (36), as mandated by the Colorado Domestic Violence Offense
Management Board. Regarding general mental health services, an individual may attend
anywhere from one therapy session to an unlimited amount of therapy services, with an average
length in the program of 12 weeks. Clients will need to attend an average of one to two hours per
week. The program for youth in conflict would be similar, and would include a treatment plan to
involve anywhere from one to an unlimited number of treatment sessions, with the average
length in the program of 12 weeks.
Emergency services will be available to all clients nights and weekends for clients in
crisis. An on-call counselor is available after hours or on weekends to assist clients in dealing
with a crisis.
III. PROJECT NARRATIVE/SUPPORTING DOCUMENTATION
A. TYPE OF SERVICES PROVIDED:
1. Psychological Evaluations:
This service is not applicable to this request for funding, as the psychological evaluation
and report is to be conducted by a licensed psychologist. Because there is no one meeting these
credentials associated with Individual & Group Therapy Services, this section is not being
applied for at this time.
2. Family/Child/Adolescent Assessment Services
To begin a mental health evaluation, an initial appointment is scheduled between the
client and the evaluator. In most cases at least one comprehensive clinical/diagnostic interview
will occur; however, occasionally two or three sessions will be necessary to accomplish all
requirements for a mental health evaluation.
The next step of the evaluation process includes a question and answer format designed to
gather basic identifying information, mental status examination, the client's mental health issues,
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mental health history, family and medical history, substance abuse history, inpatient and
outpatient history and current social situation. At times, a DSM-IV-T R diagnosis would be
applicable and utilized. In addition, treatment recommendations may occur and if so, this
recommendation will be in written format at the conclusion of the mental health evaluation.
The next stage includes gathering collateral information from agencies noted by the client
and/or supervising agency. At times, requests of the supervising agency will be made to assist in
gathering collateral data.
The last phase of the mental health evaluation includes psychometric testing, which may
include any number of the following psychometric instruments:
• HARE PCL-R (utilized in cases where psychopathy is to be assessed)
• Minnesota Multiphasic Personality Inventory-II(measures personality traits)
• Jesness Inventory(measures criminal thinking)
• Multiphasic Sex Inventory(measures sexual knowledge, behaviors, attitudes, and
beliefs)
• Wilson Sex Fantasy Questionnaire (measures frequency of fantasies to various
stimuli)
• SASSI-III drug and alcohol inventory
• Millon Clinical Multiaxial Inventory-III (measures personality traits)
• Shipley Institute of Living Scales (measures intelligence)
• State Trait Angry Inventory-II (measures level/control over anger)
• Violence risk assessment guide (measures level of risk)
After all phases of the mental health evaluation have been completed, the evaluator then
combines all of the information from the clinical interview, collateral data, and testing
summaries in order to ascertain the client's amenability for treatment. A written report is
submitted to the appropriate caseworker outlining recommendations for treatment.
Individual counseling includes one client and one therapist. Group counseling would
include one therapist and two or more clients. It is a policy of Individual & Group Therapy
Services to limit the ratio to one therapist per eight clients in most group scenarios, with the
exception of educational settings. Family counseling will include at least one therapist, and at
times may include a second therapist. In addition, at least one client and one or more family
members will attend a family counseling session.
All therapists establish a treatment plan, either at the conclusion of the evaluation
process, or at the conclusion at the intake session. A standard treatment plan with Individual &
Group Therapy Services will include:
• Short or long term goals.
• Measurable objectives relating to the achievement of the established goals.
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• Type and frequency of services the client will be receiving.
• Specific criteria for treatment completion.
• Anticipated time frame.
• Follow up services.
The therapist will document treatment plan reviews which will occur approximately every
30 days that will include the continued date for treatment. Monthly progress reports will be
provided to the referring agency to inform caseworkers on clients' progress.
At the conclusion of services received by a client of Individual & Group Therapy
Services, a discharge summary will be submitted within fifteen (15) days of treatment
termination. A standard discharge summary will include the reason the client is being
discharged, treatment history with Individual & Group Therapy Services, progress or lack of
progress following the care of Individual & Group Therapy Services, and any recommendations
made for future care. In the case of clients of domestic violence, risk to the community will also
be included. The discharge summary will clearly delineate the client's status at discharge, which
may include a successful, administrative, or negative discharge.
Results of the evaluation will be provided to the client, if requested,by scheduling an
appointment with the evaluator. This appointment is free of charge, and will consist of
reviewing the results of the evaluation with the client.
The Individual & Group Therapy Services outpatient treatment program will treat:
• Male and female clients, ages twelve(12) and older.
• Individuals with power and control, domestic violence and mental health
concerns.
• Individuals with developmentally delayed features and those with above average
functioning.
Program Services for targeted population include:
• Mental health sex offense specific testing and evaluation, domestic violence
offender management board offense specific evaluation, mental health evaluation
• Group and/or individual anger management, and cognitive restructuring
• Individual and or family therapy for general mental health concerns
• Family education/support groups, general mental health concerns
• Victims education of support groups (Pro Bono)
• Victim empathy and awareness, general mental health concerns
• Anger Management/Impulse control skills
• Cognitive behavioral modification
• Self esteem building
• Values clarification and examination.
• Relapse prevention plan for domestic violence clients
• After care services for domestic violence and general mental health clients
• Relationship and interpersonal social skills for general mental health clients
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Guidelines for conducting general mental health and offense specific groups, as mandated
by the Colorado Domestic Violence Offender Management Board, indicates the ideal number of
clients should be approximately eight(8) individuals with one facilitator, and up to twelve (12)
individuals with co-facilitation. Clients for Individual & Group Therapy Services outpatient
treatment program include male and female clients twelve(12) years of age and up.
Non-offending partner group therapy is offered weekly for victims of domestic violence
free of charge. The children's program, offered in conjunction with the victims' services,
education and support programs, range from infancy to the age of twelve (12). This program is
co-facilitated by staff members of the Child Advocacy Resource and Education center(CARE),
and is offered pro bono.
All of the services provided by Individual & Group Therapy Services will include
individual, group, and family therapy. With the exception of any services conducted in south
Weld County, the services provided will take place at 1020 8`h Street, Greeley, Colorado. All
eligible Weld County families will need to arrange transportation to the facility.
3. Consultation with Caseworkers:
Clinical consultation will include an individual or group session with the Department of
Social Services to discuss mental health supervision issues for the purpose of aiding and
identification of offender problems and treatment issues. This may include a review of pre-
sentence reports, prior psychological reports, and other existing information to identify the need
for continued mental health services. When applicable, a written report will be submitted, which
will include the mental status of the client, diagnostic impression, current psycho-social stressors,
and obvious indicators of decompensation, recommended treatment activities, and report or
records analysis. Evaluations and recommendations will take the overall plan for Social Services
into consideration.
Clients who are identified as suicidal or homicidal will be released to Northern Colorado
Medical Center in Greeley, Colorado for further assessment of their safety in the community.
Appropriate social services personnel will be notified of any concerns regarding client safety.
4. Court Testimony:
The staff of Individual & Group Therapy Services are qualified and experienced in court
testimony. When given proper notification, Individual & Group Therapy Services is available for
court testimony regarding clients with open and/or closed cases.
B. MEASURABLE OUTCOMES
Clients referred from Social Services will be scheduled for the appropriate assessment as
soon as collateral information is sent. The collateral information is essential to help clinicians
determine the appropriate service objective. As soon as the evaluation is completed, the
appropriate caseworker will be notified about recommendations regarding treatment.
Recommendations will clearly delineate the type and length of treatment needed for court
Page 7
purposes.
At a minimum, contacts will be made at least monthly in regard to client progress.
However, caseworkers will be notified immediately if any situation exists that affects the
progress of the client, such as absences or failure to progress.
For emergency consultations, a therapist is available by pager if a client needs after hours
services. The client can be scheduled for an emergency appointment with their therapist, or if
their therapist is unavailable, with the on-call therapist.
Upon completion of a mental health program, clients should be able to demonstrate the
following behaviors:
• Consistently defined all the abuse all the time to themself, to others, and property.
• Acknowledges risk in the future, and demonstrates the ability for safety planning.
• Consistently recognizes and interrupts their domestic violence cycle, anger
management cycle, and general recidivism cycle.
• The interruptions will take place no later than the first thought of an abusive
solution.
• Demonstrates new coping skills.
• Demonstrates empathy and views the cues of others and responds.
• Displays accurate attribution of responsibility and does not try to control the
behaviors of others.
• Able to manage frustration and unfavorable events in reference to anger
management and self protection.
• Rejects abusive thoughts as dissident and incongruent with self image.
• Demonstrates pro-social relationship skills, such as closeness, trust, and
trustworthiness.
• Projects positive self image.
• Demonstrates the ability to resolve conflict and make decisions through assertive
communication, tolerance, forgiveness, cooperation, and is able to negotiate and
compromise.
• Celebrates good, experiences pleasure, and is able to relax and socialize.
• Works toward achieving delayed gratification and is persistent in the pursuit of
goals and submissive to reasonable authority.
• Able to think and communicate effectively through rational cognitive processing,
demonstrate adequate verbal skills, and is able to concentrate.
• Has developed a family and or community support system.
• Adapts a sense of purpose and future.
Tracking progress through the program will take place in the following manner:
• Clients attending group therapy will receive feedback weekly from their therapist
in the form of a"group note." The purpose of the group note is to monitor
progress on treatment goals. Group notes will be compiled by the therapist after
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each group. The therapist will evaluate whether the client is learning during
group sessions. Feedback will be provided to help the individual obtain
maximum benefit from their treatment modality.
• Staff will also discuss the progress of the individual and indicate whether or not
he or she is on track.
• A compilation of these reports will be available to the Department of Social
Services on a monthly basis, or as requested.
• Progress in a computerized system will be made upon each contact with this
agency by any one on the multi-disciplinary team, Department of Social Services
caseworker, the client, or those who have been granted permission to associate
with Individual & Group Therapy Services from the client.
• For family therapy sessions, those of authority will be asked to report on the
child's progress in the home.
• Parents and therapists will evaluate the youth's progress on a monthly basis by
verbally testing to see if they understand the concepts being taught, and can
demonstrate the use of concepts learned in their home environment.
• When appropriate, schools, employment sites, and additional family members can
be contacted on a regular basis to monitor behavior in those environments.
• With regard to general mental health issues, the caseworker will be contacted any
time a team meeting involving the client is needed. These meetings should take
place in the therapeutic environment most comfortable for the client.
• Clients will be required to complete therapy assignments in group or individual
treatment. These assignments will be part of the requirements to complete therapy
successfully.
• In many of the programs, clients are required to complete a relapse prevention
plan designed to illustrate how they plan to avoid this situation in the future.
Aftercare services are available for all clients. If a client has successfully completed
treatment, they are encouraged to return to or continue with groups if they feel the need for
continued support. Fees for these clients are significantly reduced. In addition, clients are often
stepped down from treatment by gradually decreasing the frequency of visits to allow continued
support at a lower level. Clients will also be referred to community support programs as needed.
Mental health clients with Medicaid coverage will be referred to Nelson, Wolf and
Associates, as they are Medicaid providers. Medicaid will not pay for domestic violence and/or
sex offender treatment.
C. SERVICE OBJECTIVES
The primary objective of Individual & Group Therapy Services is to offer services that
reflect our care and interest in our clients, and to provide useful services to the community. By
doing so we will:
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A. Improve family conflict management: Family members will learn to talk about their
underlying feelings resulting in anger, conflict, and their personal environments, impulse control,
and general feelings of dysphoria. Family culture will be explored, and family members and the
individual will learn to develop a relapse plan, implement constructive discipline, improve
communication, and develop problem solving skills. Progress will be measured by successful
completion of homework assignments, as well as the ability to demonstrate the concepts learned
in therapy in the home.
B. Improve Household Management Competency: With regard to youth specifically,
parents will initially be assessed to determine their level of parenting skills. Parents will be
offered parent education to increase their skill level. In addition, parents will be monitored
weekly in family therapy to check on behaviors occurring at home, and help parents to
understand"red flags," which will indicate potential problem areas regarding safety in the home.
Where appropriate, a referral will be made for parenting classes if the parenting issues cannot be
resolved in this format. Progress will be measured by verbal demonstration of understanding of
the concepts, successful completion of homework assignments, and participation in family
discussion.
C. Improve ability to access resources: Part of treatment will include what resources an
individual will need to have successful transition from the therapeutic environment into a self
managed environment. Therapists, family members, the Department of Social Services
caseworker, and other involved parties will assess what resources are needed and will assist
family members and individuals in locating the resources as they are identified. Progress will be
measured by successful follow through by the individual.
D. Specific Referral Issues: IGTS uses solution-focused therapy as its primary treatment
modality. Clients will focus on issues as directed by the Department of Social Services.
E. Improve Outcomes in the Performance Improvement Plan (PIP): Evaluations will
focus on recommendations that will assist in keeping families together or developing
recommendations that will minimize the time children need to be out of the home. Treatment
plans and therapy will focus specifically on intervention designed to improve relationships and
communication in the family, as well as parenting skills, limit setting, and any other therapy
options that will assist in supporting families to stay together or minimize separation from
families. Progress will be measured by family attendance in treatment and demonstrated ability
to follow through with therapy assignments in the home.
D. WORKLOAD STANDARDS
A. Number of hours per day/week/month:
Day maximum of two hours
Week maximum four hours
Month maximum 16 hours
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B. Number of individuals providing treatment:
Seven group/individual /family therapists, all qualified to facilitate in these areas.
C. Maximum case load per worker: twenty(20).
D. Modality of treatment will be cognitive behavioral and will include group,
individual, and family therapy.
E. See A above
F. Total number of individuals providing services: seven (7)
G. Maximum case load per supervisor: twenty five (25) Total of two supervisors.
H. Total completed assessments per month: 10
I. See enclosed insurance agreement
E. STAFF QUALIFICATIONS
Individual & Group Therapy Services mental health outpatient treatment program will
meet or exceed the minimal qualifications in education and experience. Services will be
provided by six Masters level counselors who have met the standards of practice to perform
mental health intake assessments and reports, as established by the State of Colorado Department
of Regulatory Agencies. Three therapists are Licensed Professional Counselors for the State of
Colorado. In addition, one therapist have completed the requirements to provide domestic
violence treatment by the Colorado Domestic Violence Offender Management Board and three
therapists have completed credentials to provide treatment through by Colorado Sex Offender
Management Board. The remaining therapists have completed all course work requirements and
are under the direct supervision of a licensed Masters level psychotherapist, Kim R. Ruybal, MA,
LPC, NCAC II. All practitioners who are not licensed with the state of Colorado are listed with
the Department of Regulatory Agencies in the non-licensed data base. Total staff available for
the project= six, including two supervisors.
Individual and Group Therapy Service employees are not required to attend mandated
new caseworker training. All therapists at Individual and Group Therapy Services have received
extensive risk assessment training through various workshops provided by the Colorado
Domestic Violence and Sex Offender Boards.
F. PROGRAM CAPACITY BY MONTH
Minimum capacity: 1 Maximum capacity: 30
G. INTERNAL TRACKING AND BILLING PROCESS:
Billing occurs once a month. Bills are generated at the beginning of each month, with the
bills being sent out to each individual agency by the 5th day of each month. The billing program
generates the payments and session for each month, with past balances included. Each bill is
counter checked with the funding form to ensure the appropriate sessions are being billed for and
the total funds approved matches the sessions being billed. A copy is made for the agency. The
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•
enclosed sample billing illustrates the process.
H. LITERATURE CITATIONS:
Cognitive Therapy is a type of psychotherapy develop by psychiatrist Aaron Beck in the
1960s. Beck came to the conclusion that the way in which his clients perceived, interpreted, and
attributed meaning in their daily lives was a key to therapy. Albert Ellis was key in developing
his Rational Emotive Behavior Therapy, which is a primary focus of therapy at IGTS. He
developed a list of thinking errors that he proposed could cause or maintain mental health issues.
Cognitive therapy seeks to identify and change distorted or unrealistic ways of thinking, and
therefore to influence emotion and behavior. Cognitive therapy has been shown to be useful with
clients suffering with depression, anxiety, delinquency, anger, and a variety of other mental
health issues.
Alberti, R.E. and Emmons, M.E. (1982) Your Perfect Right, 4`h Edition. San Luis Obispo, CA:
Impact.
Amerian Psychiatric Association (1987)Diagnostic and Statistical Manual of Mental Disorder-
III(Revised). Washington: American Psychiatric Press.
Argyle, M. And Trower, P. (1979)Person to Person. London: Harper& Row.
Beck A>T> (1970) "The Core Problems in Depression: The Cognitive Triad", in J. Masserman
(ed),Depression: Theories and Therapies. New York: Grune & Stratton
Beck A.T. (1976) Cognitive Therapy and the Emotional Disorders. New York: New American
Library.
Beck, A.T. (1985) "Theoretical and Clinical Aspects", in A.T. Beck and G. Emery,Anxiety
Disorders and Phobias:A Cognitive Perspective. New York: Basic Books.
Burns, D.D. (1980)Feeling Good: The New Mood Therapy. New York: William Morrow.
Dryden, W. (1984)Rational-Emotive Therapy: Fundamentals and Innovations. Beckenham,
Kent: Croom Helm.
Ellis, A. (1977) 'The Basic Clinical Therory of Rational Emotive Therapy', in A. Ellis and R.
Grieger(eds), Handbook of Rational-Emotive Therapy. New York, Springer.
Pennebaker, J.W. (1997) Opening Up: The Healing Power of Expressing Emotion. New York:
Guilford.
Spiraldi, G.R., and S.L. Brown. (2001) "Primary Prevention for Mental Health: Results of an
Exploratory Cognitive-Behavioral College Course.: The Journal for Primary Prevention: 22(1).
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•
I. CONFIDENTIALITY AND PARTICIPANT PROTECTION:
A. Protecting Clients and Staff from Potential Risks:
IGTS recognizes that protecting the confidentiality of clients is of the upmost importance,
particularly when working with the sensitive subject of mental health. However, IGTS is
required to suspend confidentiality in some cases, such as imminent danger to self or others. In
addition, helping professionals are required to report child abuse or neglect to Social Services
within 24 hours.
B. Fair Selection of Participants:
As mentioned previously, the target population consists of males and females, ages 12
and up. Services are available to all racial and ethnic populations.
Participants will be selected based on the results of their mental health or psychological
evaluation and their willingness to participate in treatment. Since many persons are initially
resistive to therapy, this will not be a deterrent for acceptance into the program. However, no
one will be forced to continue with therapy.
C. Absence of Coercion:
Clients will be accepted based on their willingness to participate in treatment. Although
many of the clients in this population may be referred by social services, no client will be
required to attend treatment and may abandon treatment at any time. Clients who abandon
treatment will be referred back to the Department of Social Services.
D. Data Collection:
Information of clients is gathered through a variety of sources, including police reports,
social service records, psychological assessments, family members, personal observation, and
client self report.
E. Privacy and Confidentiality:
Confidentiality is protected by the Release of Information. No information is released
regarding any client for any reason without a signed release. Children will be required to have
parental signatures on releases. Clients may revoke consent previously given at any time.
Data will be collected by employees of IGTS. All have been trained on the rules of
confidentiality and are bound by these rules. Data is stored in locked filing cabinets in an area
that is not accessible to clients. Access to data is only available to employees of IGTS. In
addition, client privacy is protected by the use of client numbers.
Clients must sign a contract of agreement in order to participate in therapy at IGTS. Part
of the contract stipulates that clients must not reveal the names or any information regarding
another client. Failure to follow this stipulation will result in immediate dismissal from
treatment.
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F. Adequate Consent Procedures:
New clients attend an intake process. During the intake, the release of information,
disclosure statement, contract of agreement, treatment plan and contract for participation in
therapy is reviewed verbally with the parents and/or client before signatures are obtained. Clients
can revoke consent at any time by signing a revocation of consent form at the IGTS office.
G. Risk/Benefit Discussion:
Although there is always risk involved in attending therapy, clients most often indicate
they benefit from individual, couple, group and/or family therapy. Failure to provide any
services for individuals or families will likely result in continued problems.
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APPENDIX A
RESUMES FOR KEY STAFF MEMBERS
Kim R. Ruybal,MA, LPC,NCAC II
Executive Director/Owner
Individual& Group Therapy Services
1020 8th Street
Greeley, Colorado 80631
(970) 353-8171 Fax- (970) 353-0371
VITAE
EDUCATIONAL AND PROFESSIONAL CREDENTIALS
Masters of Arts. Professional Psychology: Agency Counseling. Summa Cum Laude. University of
Northern Colorado. August, 1998.
Bachelors of Arts. Psychology. Cum Laude. University of Northern Colorado. December, 1994.
Licensed Professional Counselor (LPC) with the State of Colorado, Department of Regulatory
Agencies, Division of Registrations, #2647. October, 2000, to present.
Nationally Certified Addiction Counselor, Level II. March 2003
Sex Offender Management Board(SOMB) Full Operating Level Supervisor, Treatment Provider,
Evaluator and Plethysmograph Examiner: Adults. January, 1998, to the present.
SOMB Full Operating Level Supervisor, Evaluator, Treatment Provider, and Plethysmograph
Examiner for Juveniles Who Have Committed Sexual Offenses. November, 2003, to the present.
SOMB Full Operating Level Supervisor, Evaluator, Treatment Provider, and Plethysmograph
Examiner for Developmentally Delayed Sexual Offenders. September 2004, to the present.
Domestic Violence Offender Management Board(DVOMB) Supervisor, Treatment Provider and
Evaluator. June, 1997, to the present.
DVOMB Approved Evaluator and Treatment Provider for Gay and Lesbian Domestic Violence
Offenders.
Approved Treatment Provider for the Colorado Department of Corrections (DOC). August, 1996,
Page 15
to the present.
Approved Treatment Provider for the United States District Courts. July 2003 to the present.
Court Recognized Expert Witness for Domestic Violence and Sexual Offenders
EMPLOYMENT HISTORY
Executive Director/Owner-Individual&Group Therapy Services, Greeley,Colorado(February 01,
2001 -Present). In addition to the description which follows,direct the daily activities of a staff of
nine.
Clinical Supervisor: Turning Point, Ft. Collins, Colorado (May 2005 to the June 2006). Provide
supervision to the staff and one therapist at a juvenile residential treatment facility for youth who
have sexually offended.
Psychotherapist-Individual&Group Therapy Services, Greeley,Colorado(April, 1996-Present).
Provide individual, and group therapy services to adults, adolescents,males, females, and families.
In addition, provided are psychometric testing, and psychological evaluations, in the areas of
domestic violence, sexual violence, victim's issues, and general mental health.
Counselor:Externship-North Colorado Medical Center,Psych Care/Family Recovery Center, and
Youth Passages, Greeley,Colorado. (January, 1998-July, 1998). Facilitated family,individual,and
group counseling sessions for adults and adolescents in inpatient and outpatient settings. Populations
sewed included chronically mentally ill,N-polar,chemically dependent,sexual abuse survivors and
offenders, and conduct disordered individuals. Groups facilitated include
Psychodrama/experiential groups, anger management groups, life skills groups, process groups,
stress management, grief and loss groups, and psycho-educational groups. Also facilitated were
multi-family groups for adult alcohol dependency, and adolescent adjustment issues.
Crisis Counselor - A Woman's Place, Greeley, Colorado. (May, 1994 - September, 1995).
Facilitated individual and group counseling sessions. Maintained a twenty-four(24)hour crisis line.
Collaborated with local authorities for the safety and security of women and children who were
battered and seeking safe, temporary shelter.
Legal Advocate: Intern - A Woman's Place, Greeley, Colorado. (January, 1994 - May, 1994).
Assisted women who were battered in filing restraining orders, provided assistance with court
procedures, and counseled throughout the legal process.
PROFESSIONAL AFFILIATIONS
Colorado Organization for Victim's Assistance(COVA). Member# 36. 1997 to Present.
Association for the Treatment of Sexual Abusers (ATSA). January, 2000 to Present.
Page 16
American Counseling Association (ACA). Member# 06084761. July 2001 to Present.
STATE AND LOCAL COMMUNITY ACTIVITIES
Executive Board Member for the Colorado Chapter of the Association of Sexual Abusers (CO-
ATSA). (March 2003, to present.)
Domestic Violence Offender Management Board Committee Member. (June 2003 to January
2004.)
Co-Chair of the Weld County Coalition Against Domestic Violence. (January, 2000, to January
2002.)
Executive Board Member for A Woman's Place. A shelter for women and children who are
being battered. (January, 1999, to December 2002).
Co-Chair of the Potpourri/General Interest Workshop Track for the 2000 COVA Conference
Committee. Co-Chair with Anpeytu Raben. June through November 2000.
Victim Empact Panel: Committee Member and Trained Facilitator. May, 1998, to present.
First PAGE for Primary Prevention(Professional Assistance and Greeley Educators). Committee
member. First PAGE advocates awareness and provides primary prevention and education for
victims issues throughout the community. May, 1997, to December 1998.
AWARDS AND RECOGNITIONS
V-Day Warrior:A Community Service Award: Acknowledgment for outstanding achievement in
the area of community safety, victim safety, and offender containment. Vagina Monologues:
February 13, 2004.
Faye Honey-Knopp Memorial Award (first annual). A full scholarship for attending the
Association for the Treatment of Sexual Abusers (ATSA) conference was granted. Spoke at a
reception in honor of Faye Honey-Knopp at ATSA on the merits of working with both offenders of
violent crimes and victims of violent crimes. November, 1995.
Sunshine Peace Award Nominee. National Coalition Against Domestic Violence (1998).
State Personnel Employees Executive Counsel(SPEEC)Employee of the Month: University
of Northern Colorado. September, 1995.
Page 17
...._......
Julie E.Nelson, MA, LPC
Psychotherapist
Individual and Group Therapy Services
1020 8th Street
Greeley, Colorado 80631
(970) 353-8171 Fax (970) 353-0371
VITAE
EDUCATIONAL AND PROFESSIONAL CREDENTIALS
Master of Arts. Professional Psychology: Agency Counseling, Summa Cum Laude. University
of Northern Colorado, August, 1996.
Bachelors of Science. Business. Cum Laude. Colorado State University, August, 1979.
Licensed Professional Counselor(LPC) with the State of Colorado, Department of Regulatory
Agencies, Division of Registrations, #1512, September, 1996 to present.
Sex Offender Management Board (SOMB) Full Operating Treatment Provider: Juveniles.
Court Recognized Expert Witness for Sexual Offenders
EMPLOYMENT HISTORY
Psychotherapist-Individual and Group Therapy Services, Greeley, Colorado (February, 2004-
Present). Provide individual and group therapy services to adults, adolescents, males, females,
and families. Provide psychometric testing and generate mental health evaluation in the areas of
domestic violence, sexual violence, victim's issues and general mental health. Conduct intakes
for new clients.
Psychotherapist-Youth Emancipation and Services, Greeley, Colorado (June, 2005-Present).
Provide in home family therapy to at risk youth and their families. Generate monthly reports for
social service and probation agencies regarding progress. Communicate closely with
caseworkers and probation officers regarding youth and family progress. Provide training for
employees. Conduct intakes for new clients.
Psychotherapist-Alternative Homes for Youth, Greeley, Colorado (June, 1997 to January, 2004).
Provided individual, group and family therapy for youth in out of home placement. Generated
monthly reports for social service and probation agencies regarding progress. Coordinated
staffing's for juveniles monthly. Conducted intakes with new clients. Developed juvenile sex
offender program.
Page 18
Psychotherapist-Centennial Mental Health, Sterling, Colorado (August, 1996 to June, 1997).
Provided general mental health therapy for individuals and couples. Provided therapy for clients
with employee assistance plans for various companies. Conducted intakes for new clients.
Counselor:Externship-Ft. Collins Mental Heath, Ft. Collins, Colorado (August, 1995 to June,
1996). Provided individual and couples mental heath therapy, including chronically mentally ill
clients. Counseled sexual abuse victims. Completed appropriate paperwork, as needed.
Page 19
Jodie Margeline Goter
PO Box 17764
Boulder, Colorado 80304
303-579-4965
FORMAL EDUCATION:
University of Colorado at Boulder
Degree: BA, Psychology
Conferred: May 1995
Leslie College
Degree: MA, Counseling Psychology
Conferred: November 1999
LICENSE: Licensed Professional Counselor/Colorado License # 3138
PROFESSIONAL EXPERIENCE:
Jodie M.Goter,Licensed Professional Counselor,Offense Specific Therapy and
General Psychotherapy,Boulder and Ft.Collins,Colorado,August 2003-to present. Therapist for
sexual offenders and juveniles who commit sexual offenses. Population served also includes
individuals with chronic mental illness or a developmental disability. Responsibilities include
facilitating groups, individual, couples and family therapy; facilitate partners, family and friends
psycho educational program, conduct mental status evaluations and conduct mental health sex
offense specific evaluations as needed, participate in agency and team staffing 's with probation
officers,parole officers,polygraphers,victims therapists, Case managers and DHS case managers;
engage in community liaison work with team members, associates and others.
Individual & Group Therapy Services, Offense Specific Therapy and General
Psychotherapy, Greeley, Colorado, October 2003 to present. Therapist, co therapist, Penile
plethysmographer, clinician for adult sex offenders and juvenile's who commit sex offenses.
Populations served also includes incarcerated individuals with chronic mental illness or a
developmental disability. Responsibilities include;facilitate groups,individual,couples and family
therapy, facilitate chaperone psycho educational program; coordinate the chronically mentally ill
program and facilitate therapy groups,conduct mental status evaluations and conduct mental health
sex offense specific evaluations as needed;conduct Penile plethysmograph evaluations,interpret and
review results with client; participate in agency and team staffing's with probation officers, parole
officers, polygraphers, victims therapists, Case managers and DHS case managers; engage in
community liaison work with team members, associates and others.
Larimer County Department of Human Services,Contracted Treatment Provider,Ft.
Collins, Colorado, December 2003-present. Therapist and evaluator for individuals 10 to 18 years
of age who commit sexual offenses or emit sexually abusive behaviors. Therapist for victims of
Page 20
sexual and physical violence, ages 10 to 18 years old. Population also served includes includes
incarcerated individuals with chronic mental illness or a developmental disability. Responsibilities
include; facilitate groups, individual, couples and family therapy, facilitate chaperone psycho
educational program; coordinate the chronically mentally ill program and facilitate therapy groups,
conduct mental status evaluations and conduct mental health sex offense specific evaluations as
needed; conduct Penile plethysmograph evaluations, interpret and review results with client;
participate in agency and team staffing's with probation officers, parole officers, polygraphers,
victims therapists,Case managers and DHS case managers;engage in community liaison work with
team members, associates and others.
Dr. Pamela J.S. Rodden, PhD & Associates, Offense Specific Therapy and General
Psyhotherapy,Ft.Collins,Colorado,January 2001 to August 2003. Therapist,Co-Therapist,penile
plethysmoghrapher,Clinician and case manager fo adult sexual offenders and juveniles who commit
sexual offenses. incarcerated individuals with chronic mental illness or a developmental disability.
Responsibilities include; facilitate groups, individual, couples and family therapy, facilitate
chaperone psycho educational program;coordinate the chronically mentally ill program and facilitate
therapy groups, conduct mental status evaluations and conduct mental health sex offense specific
evaluations as needed;conduct Penile plethysmograph evaluations,interpret and review results with
client;participate in agency and team staffing's with probation officers,parole officers,polygraphers,
victims therapists,Case managers and DHS case managers;engage in community liaison work with
team members, associates and others.
Dr.Pamela J.S.Rodden,PhD&Associates,Ft.Collins,Colorado,January 2001 to August
2003, Facilitator of Chaperone Supervision Training Program for both adult and juvenile's who
commit sexual offenses to have supervised visits with a particular child. Responsibilities include
Program development using updated statistical data; administrative duties; general sexual offense
and victim education; friends,couples and family therapy continued contract with the chaperone to
assess safety and ability to supervise and coordinate treatment planning with multi disciplinary team.
Garza&Associates,Offense Specific Therapy,Longmont,Colorado,September 1998 to
2000. Ft. Morgan, Colorado, July 2003 to present. Therapist, co therapist and case manager.
Responsibilities include; facilitate groups, individual, couples and family therapy, facilitate
chaperone psycho educational program;coordinate the chronically mentally ill program and facilitate
therapy groups, conduct mental status evaluations and conduct mental health sex offense specific
evaluations as needed;conduct Penile plethysmograph evaluations,interpret and review results with
client;participate in agency and team staffing's with probation officers,parole officers,polygraphers,
victims therapists, Case managers and DHS case managers; engage in community liaison work.
OTHER PROFESSIONAL QUALIFICATIONS:
Penile Plethysmograph Technician/Clinician,The Monarch System, Alliance Programs.
A division of Behavioral Technologies, Inc., Salt Lake City, Utah.
Listed Full Operating Level Treatment Provider,Developmental Disability Specialty
and Penile Plethysmograph Technician/Clinican,Adult and Jevenile. The Colorado Sex
Offender Management Board, 5-29-01 Associate, 11-25-03 Full Operating.
Page 21
Clinically Certified Forensic Counselor, American College of Certified Forensic
Counselors.
Twentieth Judicial District Special Advocate
PROFESSIONAL MEMBERSHIPS:
Board Member at Large- The Colorado Association for the Treatment of Sexual Abusers
Clinical member of the American Counseling Association
Page 22
APPENDIX B
DATA COLLECTION INSTRUMENT/PROTOCOLS
Individual and Group Therapy Services
Intake Assessment Outline
1. Name:
Date:
DOB/AGE: /
Gender: Male Female Race/Ethnicity:
Current Legal Status: Probation Intervention
Parole Unsupervised
Current Case Number Restraining Order(s)
County where charges filed:
2. Current Offense:
Current charge:
Plea bargains taken:
Sentence:
Time in jail:
Detailed Description of Offense:
Page 23
Severity of Offense:
Use of weapons/homicidal or suicidal threats:
Children present:
Who called police:
Residential status of victim/offense:
Previous Offense Specific Treatment(DV?):
Criminal History(Misdemeanor or Felony):
3. Psycho-Social History:
Family/childhood history:
Family dynamics (genogram of family of origin):
Page 24
Multiple primary caretakers (divorce or single parent upbringing):
Frequency of residence change:
Sibling violence:
Parental loss:
History of victimization, abuse, neglect or abandonment as child/adult:
Witnessing of DV in family:
Childhood Problems:
Health problems:
School problems/discipline:
Peer violence:
Arrests as a juvenile:
Suicide attempts as a child:
Childhood/Adolescent Drug/Alcohol abuse:
Page 25
Educational/Employment history:
Employment, Residential, and Financial Stability/Instability:
History of violent, abusive, or neglectful behavior toward partners, children, animals (including sexual):
Intimate Relationship History:
Relationships:
Accusations of infidelity, drug abuse, etc.
Restraining orders:
Relationship patterns:
4. Medical History:
Current conditions and medications:
Page 26
Head injuries:
5. Substance Abuse and Addiction Assessment:
Alcohol/drug use history:
Substance use in family of origin:
Use patterns and attitudes:
Criminal History related to use:
Use of Substance at time of offense:
Other addictions:
6. Mental Health Evaluation:
History of mental health treatment/diagnosis/current medications:
Family mental health history:
Adult history of suicide:
Page 27
Current suicidal and homicidal ideation/risk:
Current obsessive/compulsive thoughts regarding victim:
Assessment of Axis I disorders:
Personality functioning:
Mental health status exam/clinical impressions:
7. Assessment for treatment amenability:
Attitude toward treatment:
Learning styles:
Previous response to treatment:
Disabilities and special needs:
8. Assessment of risk of re-offending:
Risk factors:
Page 28
9. Other factors for consideration:
Sexual orientation/gender identity:
Language/cultural issues:
High level offender resistance:
Transportation barriers:
10. Strengths:
Other Pertinent Information:
Page 29
APPENDIX C
SAMPLE CONSENT FORMS
INDIVIDUAL & GROUP THERAPY SERVICES
1020 8`h Street
Greeley, Colorado 80631
PH 970-353-8171 FAX 970-353-0371
CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION
I, D/Birth:
understand I am being asked to disclose my mental health records which includes the following
information for the purpose of service coordination, collaboration, continuity of care and case
management activity.
(Circle YES or NO)
YES NO Treatment information to include history,diagnosis,progress in treatment,prognosis,
treatment approaches/plan/goals,medication intervention and prescriptions, status at discharge.
YES NO Treatment attendance.
YES NO Psychological Evaluation and Testing Summaries.
YES NO Clinical Evaluation/Assessment Summaries.
YES NO Alcohol and Drug Treatment Information.
YES NO Verbal Communication.
YES NO Financial Information.
YES NO OTHER:
Regarding myself and/or the following persons:
Name: D/Birth:
Name: D/Birth:
Name: D/Birth:
List no more than five(5)agencies/individuals:
To: Name of agency/person:
To: Name of agency/person:
To:Name of agency/person:
To: Name of agency/person:
To: Name of agency/person:
I also authorize the above listed entities to release the information identified above regarding myself
and/or the persons listed above to Individual and Group Therapy Services, for the purpose of service
coordination, collaboration, continuity of care, and case management activity. I understand that my
records and/or those of any individual listed above are protected under Federal and State confidentiality
Page 30
regulations. This information cannot be disclosed without my written consent, unless otherwise
specifically provided for in the regulations. I understand that I may revoke this in writing at any time
except to the extent that action has been taken based on this authorization. I understand that any
disclosure of information carries with it the potential for re-disclosure and once the information is
disclosed, it may no longer be protected by federal HIPAA confidentiality rules. All attempts will be
made to keep this information confidential. Copies of this form may be used in lieu of the original. I
understand and agree that this release form may be sent to the entities identified above.
This consent expires on , 20 (365 days maximum).
Executed this day of , 20
(Client's Signature) (Print Client's Name)
Parent/Guardian Signature) (Witness Signature)
(Minor Signature) (Printed Name of Witness)
This Authorization reflects the requirements of HIPAA,45 C.F.R. § 164.508.
Page 31
Disclosure Statement
Individual & Group Therapy Services
1020 8th Street
Greeley, Colorado 80631
Phone 970-353-8171 Fax 970-353-0371
Our staff credentials are as follows:
Kim R.Ruybal Shelly Cox
M.A. Agency Counseling, 1998 M.S. Community Counseling, 1996
Summa Cum Laude Summa Cum Laude
LPC # 2647 Mankato State University
DVOMB Approved Domestic Violence LPC# 4409
Evaluator&Treatment Provider Jodie M. Goter
SOMB Approved Evaluator, Treatment M.A. Counseling Psychology, 1998
Provider, Plethysmoghrapher: Leslie University
Adult/Juvenile LPC# 3138
National Certified Drug&Alcohol Counselor SOMB Evaluator,Treatment Provider
Plethysmograph Clinician:
Julie Nelson Adults/Juveniles
M.A. Agency Counseling, 1994
Summa Cum Laude Paul Hooten
University of Northern Colorado (Intern)
LPC# 1512 Masters Candidate,UNC
SOMB Approved Treatment provider: B.A. Psychology, 2003
Juveniles Point Loma Nazarene University, San Diego
Bobbie Feather Kristen Jernigan
(Contract Therapist) (Intern)
M.S.C.P. Counseling sychology,1994 M.A Community Counseling, 2000
Chaminade University of Honolulu University of Denver
LPC# 3487
Page 32
The practice of both licensed and unlicensed persons in the field of psychotherapy is regulated by the
Colorado State Department of Regulatory agencies. Any questions,concerns,or complaints regarding the practice
of mental health may be directed to the State Governing Board listed below.
Colorado State Grievance Board
1560 Broadway, Suite# 1370
Denver,CO 80202
303-894-7766
You are entitled to receive information regarding the methods of Therapy,the techniques used,the duration
of therapy,if known,and the fee structure.You may seek a second opinion from another therapist or may terminate
therapy at any time. It is important for you to know that in a professional relationship, sexual intimacy is never
appropriate and should be reported to the Grievance Board. Please understand that information provided by you
during therapy is legally confidential in the case of supervised unlicensed and licensed psychotherapists. Legal
confidentiality does not apply in criminal or delinquency proceedings. There are other exceptions which can be
discussed and will be identified should any such situations arise during therapy.
SUPERVISION
Services delivered to clients of IGTS may be supervised by a variety of staff members. Supervision
provides a source of knowledge,expertise,and more advanced skills to the person being supervised. Those staff
members who provide supervision are bound by the rule of confidentiality mentioned above. For cases involving
sexual assault,domestic violence, cases involving reimbursement from 3'd party payer,and any other counseling
situations not mentioned above.
Supervision for IGTS staff is provided by:
Kim R.Ruybal,M.A.,LPC,NCAC II
Shelly Cox,MS,LPC
Supervision for Kim and Shelly provided by:
Rabbi Dr. Larry Denmark
Clinical Supervisor
Licensed Psychologist
I have read the preceding information and understand my rights as a client.
Client's Signature Date
Client's Printed Name
Therapist's Signature Date
Page 33
Page 34
• INDIVIDUAL & GROUP THERAPY SERVICES
1020 81b Street
Greeley, Colorado 80631
PH 970-353-8171 FAX 970-353-0371
CONTRACT OF AGREEMENT
TREATMENT:
I consent to be assessed to determine appropriateness for treatment services as recommended by my therapist at
Individual and Group Therapy Services(IGTS). I understand it is not appropriate to be under the influence of alcohol or illicit
drugs eight(8)hours prior to attending treatment services at IGTS. Any letters required to be written to the criminal justice
system about your treatment require a two (2)week advance written notice to your therapist.
RELEASE FOR REVIEW:
I understand my records may be reviewed by Associates of IGTS for supervision and case management. I understand
that all Associates are bound to protect my confidentiality. Data obtained may be used for research purposes. Rules of
confidentiality apply.
FINANCIAL AGREEMENT:
I understand the service provided by IGTS carries an hourly rate of$65.00 and a group fee of$35.00 per session.
An assessment requires a separate payment of$ . In some cases additional psychological testing may be requested.
I understand any additional testing will be at my expense. I agree to be responsible for payment in full at the time services
are rendered.Insurance may be billed,but clients remain responsible for payment at the time services are received. Insurance
will be used to reimburse the client as stipulated on their insurance policy. Fees are subject to change with reasonable notice.
BILLING:
I understand if my account is past due, my account may be turned over to a collection agency unless I contact
my therapist at IGTS to negotiate a solution to the problem. I understand I will be billed one-half(1/2)of my service fee,if
I miss a scheduled appointment or group, and do not cancel twenty-four (24) hours in advance. I understand any time
involved in court appearances will be billed at one hundred dollars($100.00)per hour. Any emergency contact will also be
billed at the hourly rate. Any unpaid balances beyond thirty (30) days are subject to a monthly charge of 1.75%. Any
Account sent to collections will be assessed a fifty percent(50%) surcharge of the total account balance.
I have read and understand the above and indicate my agreement by the signature(s)below:
Page 35
'FOR AGREEMENT:
Client Signature: Date:
Client Printed Name:
Client's Address: Client's Phone #:
SSN: Driver's Lic.#or ID#:
Therapist Signature: Date:
Therapist Printed Name:
For client under age of consent:
Parent/Guardian Name: Date:
Parent/Guardian Address: Phone#:
Page 36
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Program Area: � 4.
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AMERICAN ECONOMY INSURANCE COMPANY PAGE 1
maxCO ( � ('� SEATTLE, WASHINGTON
areULTRA OFFICE POLICY
NAMED PERKLEN ENTERPRISES, INC RENEWAL DECLARATIONS
INSURED DBA IND & GROUP THERAPY
AND
MAILING SERVICES POLICY NUMBER 02-BO-901136-7
ADDRESS 1020 8TH ST RENEWAL OF 02-8O-901136-6 02-01
GREELEY, CO 80631
SEE NAMED INSURED EXTENSION AGENT GLEN WALL INSURANCE SERV INC
NAME 1013 37TH AVE CT STE 101
AND
POLICY PERIOD FROM 02-01-07 TO 02-01-08 12:01 AM ADDRESS GREELEY, CO 80634
STANDARD TIME AT YOUR MAILING ADDRESS SHOWN ABOVE.
FORM OF 05-83511 ( 970) 353-2020
BUSINESS: CORPORATION
THE TOTAL PREMIUM DUE FOR THE POLICY TERM IS $500 . 00 .
YOU WILL BE BILLED THROUGH YOUR CUSTOMER ACCOUNT #103-1526-971-01 .
YOU NEED NOT PAY ANY PREMIUM AT THIS TIME. WE WILL SEND A BILLING
STATEMENT IN A SEPARATE MAILING.
IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS Of THIS POLICY, WE AGREE WITH YOU
TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY.
ADDITIONAL INSURED LESSOR LOSS PAYEE
FIRMCO FINANCIAL INC FIRMCO FINANCIAL INC
PREMISES 001 4700 SO STATE STREET PREMISES 001 4700 SO STATE STREET
SALT LAKE CITY, UT 84107 SALT LAKE CITY, UT 84107
21-0 MONARCH 21 MACHINE 21-0 MONARCH 21 MACHINE
THE FOLLOWING FORMS CURRENTLY APPLY TO THIS POLICY:
BP0003(0702) BUSINESSOWNERS SPECIAL COVERAG BP7076(0105) ULTRA PLUS
BP7080(0702) ORDINANCE OR LAW COVERAGE BP1203(0702) LOSS PAYABLE PROVISIONS
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tft BP8029(0702) AMENDMENT-AGGREGATE LIMITS OF BP0455(0702) BUSINESS LIABILITY COV-TENANTS
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EXHIBIT B
SUPPLEMENTAL NARRATIVE TO RFP
•
May 21, 2007
Weld County Department of Social Services
Ms. Toby Vegter
P.O. Box A
Greeley, CO 80632
Re: RFP 004-MH-07: Mental Health Services
RFP 003-SAT-07: Sex Abuse Treatment
Dear Ms. Vegter:
This letter serves as a response to a letter from Judy Griego regarding missing elements in
our bid prosposal. In the letter, there is a condition that specifies the Program Improvement Plan
(PIP)was not submitted in the original proposal. Your recommendation per our phone
conversation today was to verify the page numbers where the information was contained and
repeat the information in the letter.
Regarding the Mental Health Services bid, the PIP was addressed on Page 10. The
following is an exact wording of what was contained in the proposal:
E. Improve Outcomes in the Performance Improvement Plan(PIP): Evaluations will focus on
recommendations that will assist in keeping families together or developing recommendations
that will minimize the time children need to be out of the home. Treatment plans and therapy
will focus specifically on intervention designed to improve relationships and communication in
the family, as well as parenting skills, limit setting, and any other therapy options that will assist
in supporting families to stay together or minimize separation from families. Progress will be
measured by family attendance in treatment and demonstrated ability to follow through with
therapy assignments in the home.
Regarding the Sex Abuse Treatment bid, the PIP was addressed on Page 9. The
following is an exact wording or what was contained in the proposal:
• Program Improvement Plan(PIP)-When at all possible, children will be
maintained in their home environments. Research indicates children who
received parental and family support are more likely to be successful. Offending
children who are located in the same home as the victim are encouraged to be
placed with another family member until completion of treatment. Reunification
is highly encouraged for families when the client has sexually offended on another
family member. This allows for resolution of issues and development of safety
between the offender and other children in the home.
Regarding the recommendation that IGTS pursue bilingual interpreters, it is important to
note that IGTS recently lost the bilingual therapist, and is currently searching for a replacement.
If you have any other questions or concerns, please feel free to contact our agency.
Sincerely,
Kim R. Ruybal, MA, LPC, NCAC II
d
f 3t (t
DEPARTMENT OF SOCIAL SERV
ICES
11.4
P.O. BOX A
GREELEY, CO. 80632
Website:www.c �s
OAdministration and Public Assistance(970)352-1551
pFax Number(970)353-5215
COLORADO May 11, 2007
Kim R. Ruybal M.A.,LPC,NCAC II
Individual&Group Therapy Services
1020 81°Street
Greeley;CO 80631
Re: RFP 004-MH-07: Mental Health Services
RFP 003-SAT-07 Sex Abuse Treatment
Dear Ms.Ruybal:
The purpose of this letter is to outline the results of the Bid process for PY 2007-2008 and to request
written confirmation from you by Monday,May 21,2007.
The Families, Youth, and Children Commission appreciates your interest in providing services for
families in Weld county.This year,strides were made in structuring an RFP that is clear and concise,and
more user friendly, for both prospective bidders and evaluators. It is important to stress the value of
following formatting guidelines and addressing the required sections concisely and appropriately.
A. Results of the Bid Process for PY 2007-2008
• The Families, Youth and Children's Commission attached the reconunendation and condition
below to your bids 004-MH-07 and 003-SAT-07.
Recommendation. The approved bidder will pursue bilingual interpreters/translators/staff in
order to better serve bilingual and monolingual clients.This may include offering incentives,
accommodations,and encouragement to Spanish bilingual interpreters, translators, and staff.
Conn_The bidder must submit an outline of the Program Improvement Plan elements as
defined in the RFP, and not included in the original bid submission.
B. Required Response bo Bidders
Concerning FYC Commission Recomm_ en_ dati�ns
You are requested to review the FYC Commission reconunendations and to:
1. accept the recommendation(s)as written by the FYC Commission; or
2. request alternatives to the FYC Commission's recommendation(s); or
3. not accept the recommendation(s)of the FYC Commission.
•
' : Page 2
Individual&Group Therapy Services/Results of Bid Process 2007-2008
Please provide in writing how you will incorporate the recommendation(s)into your bid. If you
do not accept the recommendation,please provide written reasons why. All approved
recommendations under the NOFAA will be monitored and evaluated by the FYC Commission.
Concerning FYC Commission Conditions:
All conditions will be incorporated as part of your Bid and Notification of Financial Assistance
Award(NOFAA).If you do not accept the condition(s),you will not be authorized as a vendor
unless the FYC Commission and the Weld County Department of Social Services accept your
mitigating circumstances.If you do not accept the condition,you must provide in writing reasons
why.A meeting will be arranged to discuss your response.Your response to the above conditions
will be incorporated in the Bid and Notification of Financial Assistance Award.
The Weld County Department of Social Services is requesting your written response to the FYC
Commission's recommendation and condition.Please respond in writing to Tobi Vegter,Core
Coordinator,Weld County Department of Social Services,P.O.Box A,Greeley,CO, 80632,by Monday,
May 21,2007,close of business.
The Weld County Department of Social Services is requesting your written response to the FYC
Commission's conditions.Please respond in writing to Tobi Vegter, Core Services Coordinator,Greeley,
CO, 80632,by May 21,2007,close of business.You may fax your response to us at 970.346.7662.
If you have questions concerning the above,please call Tobi Vegter, 6292.
Sincerely,
y A. go,D' ctor
cc: Juan Lopez,Chair,FYC Commission
Tobi Vegter,Core Services Coordinator
Gloria Romansik, Social
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