HomeMy WebLinkAbout20071747.tiff Weld County Department of Social Services
Notification of Financial Assistance Award
for Core Funds
Type of Action Contract Award No.
X Initial Award PY 07-08-CORE-92
Revision (RFP-FYC-07007; 003-SAT-07)
Contract Award Period Name and Address of Contractor
Beginning 06/01/2007 and Individual&Group Therapy Services
Ending 05/31/2008 Sex Abuse Treatment
1020 8th Street
Greeley, CO 80631
Computation of Awards Description
Unit of Service The issuance of the Notification of Financial
Services are provided by utilizing a non- Assistance Award is based upon your Request for
medical,cognitive behavioral model, focusing Proposal(RFP). The RFP specifies the scope of
primarily on the treatment of juveniles and services and conditions of award. Except where it is
adults with a variety of issues, including sexual in conflict with this NOFAA in which case the
offending, domestic violence, anger NOFAA governs,the RFP upon which this award is
management and general mental health. Program based is an integral part of the action.
is geared toward providing specialized Special conditions
outpatient services that meet the needs of male 1) Reimbursement for the Unit of Services will be based
and female clients.Adolescent groups focus on on an hourly rate per child or per family.
youth ages 12-18.Family units coincide with 2) The hourly rate will be paid for only direct face to
number of youth in program. Program provides face contact with the child and/or family, as
education,treatment, support to ensure a safe evidenced by client-signed verification form,and as
and successful integration with family and specified in the unit of cost computation.
community.. Monthly maximum capacity to12 3) Unit of service costs cannot exceed the hourly and
youth and their families, with average capacity yearly cost per child and/or family.
of 10.Duration of program is an average of 42 4) Payment will only be remitted on cases open with,and
weeks,average hours per week is approximately referrals made by the Weld County Department of
2.5 hours per week, average groups per week is Social Services.
one. Bilingual services are being pursued. South 5) Requests for payment must be an original submitted to
Weld Services are available. the Weld County Department of Social Services by the
Cost Per Unit of Service end of the 25th calendar day following the end of the
Hourly Rate month of service.The provider must submit requests
Treatment Package $42.58 for payment on forms approved by Weld County
Court Testimony $100.00 Department of Social Services.Requests for payments
Enclosures: submitted 90 days from the date of service,and
X Signed RFP: Exhibit A thereafter,will not be paid.
X Supplemental Narrative to RFP: Exhibit B 6) The Contractor will notify the Department of any
X Recommendation(s) changes in staff at the time of the change.
X Conditions of Approval
Approv�IS�- Progr Official:
By ` By �c ( {
David E. Long, Chair Judy, .Grieg Direct 9J —
Board of Weld Count Co sioners Weld l ounty Departme of Social Services
Date: JUN 1 8 Zwi Date:_4(11
l}1
2007-1747
EXHIBIT A
SIGNED RFP
003-SAT-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 Sfr
(ft r receipt of order) BID MUST BE SIGNED IN INK
Program Area: Sept E b uS& Kt wt RR k y L a J
m Di vi built G "up copy TYPED OR PRINTED SIGNATURE
VENDOR S�✓t CCU `'c)Th Q—
(Name) Handwritten Signature By Authorized
Officer or Agent of Vendor
ADDRESS 1O 2O 8TH Snre�r TITLE'
G e-N"i r yc Co 8o(031 DATE O-) 3U4C-1-
PHONE# (9Zo) 353-El'J/
The above bid is subject to Terms and Conditions as attached hereto and incorporated.
Page 1
Request for Proposal
Colorado Family Preservation Act
Sexual Abuse Treatment Program
Individual and Group Therapy Services
I. ABSTRACT
Individual and Group Therapy Services (IGTS) will utilize a non-medical, cognitive
behavioral model,focusing primarily on the treatment of juveniles and adults with a variety of issues,
including sexual offending, domestic violence, anger management and general mental health.
This program will be geared toward providing specialized outpatient services that meet the needs
of male and female clients. Adolescent groups will focus on youth between the ages of 12 to 18
years old. The program will provide education, treatment, and support to ensure a safe and
successful integration with the family and community.
This mission of the IGTS outpatient program for sexually reactive youth is to reduce
recidivism rates by:
• Providing a structured environment for the safety of the client, family and
community.
• Increasing awareness and empathy for the victim and the impact of the offense on the
victims and family members.
• Fostering a family environment to effect positive change.
• Developing the use of appropriate social/sexual skills and expressions through
recognition of situations and stimuli that trigger sexually aggressive behavior.
• Assisting family members to develop the skills necessary to recognize and
understand the sexual behavior oft heir family member for the purpose of providing
support while the client progresses through treatment.
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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 8
4. Workload Standards 9
5. Staff Qualifications 9
6. Program Capacity per month 10
7. Internal Tracking and Billing Process 10
8. Literature Citations 10
9. Confidentiality and Participant Protection/Human Subjects 12
A. Protecting Clients and Staff from Potential Risks 12
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
G. Risk Benefit Discussion 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 IGTS outpatient program for sexually reactive youth will treat:
• Male and female youth twelve (12) to eighteen (18) years of age.
• Youth with current sexual offense adjudications or youth who have admitted guilt
and will provide a written letter from a parent or attorney stating they plan to plead
guilty.
• Youth with both regular intelligence and developmental delays.
Guidelines for conducting offense-specific groups indicate that the ideal number of clients
should be approximately nine youth, with a maximum group of twelve. As mentioned previously,
clients for the offense-specific groups will include youth between the ages of 12 to 18. Family units
will coincide with the number of youth in the offense-specific program. Bilingual services are not
available at this agency for Spanish-speaking clients.
Offense-specific services, including individual, group, couples, and family therapy,will be
provided at IGTS in Greeley. Additional services can be offered in the South Weld County area, if
a minimum of five clients and their families need services. All eligible Weld County families will
have to arrange transportation to the group location. Emergency services are available nights and
weekends for all clients or families in crisis.
Monthly maximum capacity will be limited to 12 youth and their families, with monthly
average capacity expected at 10. Due to the intensity of the program,youth are expected to complete
the program in an average of 42 weeks. Average hours per week in the program are expected at
approximately 2.5 hours per week for adolescents. Average groups per week will be one group.
III. PROJECT NARRATIVE/SUPPORTING DOCUMENTATION
A. Type of Services To Be Provided
Program services for clients include:
• Psychosexual testing and evaluation
• Polygraph administration
• Offense-specific group therapy
• Individual, couples and/or family therapy
• Informed Supervision groups -youth (1.5 hours/month)
• Relationship and interpersonal social skills
• Sex education
• Interdisciplinary team meetings (monthly or as needed)
• Victim empathy and awareness
• Anger management/impulse control skills
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•
• Cognitive behavioral modification
• Self-esteem building
• Values clarification and examination
• Relapse prevention plan
• Aftercare services
Before clients can be accepted into the program, a psychosexual assessment is necessary to
determine the level of risk and what placement option is appropriate for the youth. Assessment will
examine six areas:
• The client's potential to reoffend
• Amenability for treatment
• Recommended treatment setting
• Type of treatment needed
• Risk factors/monitoring/potential new victims
• Psychiatric/substance abuse/individual/family needs
• Mental health concerns
Assessment will include:
• A structured clinical interview.
• Collateral information from schools, caseworkers, probation/parole officers,
therapists, doctors, courts, police reports or other relevant sources
Other assessments tools may include(depending on the age of the offender and circumstances
of the case):
• Minnesota Multiphasic Personality Inventory-Adolescents (measures personality
traits)
• Jessness Inventory(measures criminal thinking)
• Multiphasic Sex Inventory-Adolescents (measures sexual knowledge, behaviors,
attitudes, and beliefs)
• Wilson Sex Fantasy Questionnaire (measures frequency of fantasies to various
stimuli)
• SASSI-III Drug and Alcohol Inventory-Adolescents (measures substance use and
abuse)
• Millon Adolescent Clinical Inventory(measures personality traits)
• Shipley Institute of Living Scale (measures intelligence)
• State Trait Anger Inventory-II (measures level/control over anger)
• Juvenile Sex Offender Risk Protocol (JSOAP)
• Penile Plethysmograph(measures deviant and non-deviant arousal)
Assessments may reveal the need for additional treatment,such as medication evaluation and
monitoring of substance abuse, and/or substance abuse treatment. Referrals will be made to the
appropriate agencies to address these treatment needs. Results of the initial assessment will indicate
what treatment goals will need to be addressed. Measurable treatment goals will be developed and
monitored on a monthly basis.
Page 5
Therapy for adolescents consists of a cognitive behavioral,"carefrontational"model. Studies
have shown that caring confrontation (pointing out client errors in thinking and behavior while
treating the client with respect) is the most effective way of motivating the client to make changes.
This model also focuses on the various types of abuse that clients have committed in addition to
their deviant sexual behavior, including physical, emotional, verbal and psychological.
Understanding of when sexual behavior is abusive will be taught by helping clients understand the
concept of consent and the SAFE formula(Secret, Abusive, Feelings, and Empty).
An integral part of assessment will include a polygraph during portions of the program, as
well as shortly before discharge from the program. The purpose of the polygraph includes:
• Encouragement of more disclosure of additional victims or other deviant sexual
behavior.
• Monitoring for honesty of client to assess progress in treatment.
Clients will also be introduced to the sexual abuse cycle. The cycle will be used throughout
group therapy to help youth understand their personal abuse cycle, and develop ways they can make
their behavioral patterns more functional. Part of the abuse cycle will include how defense
mechanisms and cognitive distortions contribute to the continuation of the cycle. Clients will learn
Rational Emotive Therapy, which will help them understand how their thoughts and feelings
contribute to their behavior, to assist in changing faulty behavior patterns.
Sexual abuse issues will be discussed in group therapy. Clients will learn to describe the
sexual abuse cycle in detail, and identify each step of the cycle as it pertains to their own abuse.
Clients will also be able to explain cognitive distortions and thinking errors in relation to the sexual
abuse cycle. Empathy training will include teaching clients to accurately read cues from others,
interpret cues from others, and check for understanding by validating cues. Clients will learn to
experience empathic interactions from others and will develop the ability to understand in advance
how their actions affect others. To assist in controlling deviant fantasies, clients will be taught
arousal management, which will assist them in extinguishing deviant thoughts and replacing them
with positive, caring sexual thoughts. Finally, clients will address their own abuse, and learn how
their abuse led to their choice to abuse others. Progress will be measured by successful completion
of assignments, increasingly appropriate contributions in groups, completion of non-deceptive
polygraphs as scheduled, and reports from family members, school, therapists, and the multi
disciplinary team.
An important part of group therapy will be addressing victim empathy. Clients will learn to
read cues from others,interpret them accurately,and validate what they have heard from others. The
goal is for clients to identify an empathic experience or interaction,and eventually develop empathic
foresight on how their behavior affects others. An essential part of developing empathy includes
addressing the client's own victimization, if applicable, and how it affected their own choices.
Since the ultimate goal of offense-specific treatment is to prevent recidivism, clients will
focus on developing a comprehensive relapse prevention plan,which will provide them with their
own individual guidelines to prevent further deviant sexual behavior. Clients will review their
Page 6
relapse prevention plan during group with therapists and group members who are familiar with the
client's offense to assist in developing a plan that will minimize the possibility for reoffense.
Informed supervision is essential to help the adolescent remain safe at home and in the
community. Informed supervision groups provide two essential elements:
• Improve parental understanding of the pattern of sexual abuse.
• Develop a support group with other parents to gain acknowledgment fromothers
about their experiences as parents of sexually reactive youth.
Family therapy will focus on the situations at home that may have contributed to past abuse,
and what interventions would be necessary in order to provide a safe home environment for all
family members. This may include sorting out feelings for each family member about the abuse,
reunifying family members, and assessing how families can contribute to improving safety in the
home. Family members will also learn how to support the client while he/she completes the therapy
process. Parenting education and conflict resolution for family members will also be addressed.
Clarification and reunification is provided in cases where sexually abusive youth are
returning to the family. family therapy when the client has progressed to the point where they are
considered to be safe and the victim is ready to have contact.
Aftercare will be provided for clients who have successfully completed an offense specific
treatment program. Adolescent clients will begin attending groups weekly,then drop to bi-weekly,
with the plan of releasing the client from aftercare treatment within six months. Aftercare will focus
on providing the client with healthy and non-deviant ways of experiencing their sexuality.
B. Measurable Outcomes
According to the Colorado Sex Offender Management Board Standards and Guidelines,upon
completion of the program (minimum 32 to 52 weeks), clients should be able to demonstrate the
following behaviors:
• Consistently defines all types of abuse (self, others, property)
• Acknowledges risk by demonstrating foresight and using safety planning
• Consistently recognizes/interrupts sexual abuse cycle
• Demonstrates new coping skills and develops stress management techniques
• Demonstrates victim empathy and understands how his/her behavior effects the
victim, family, community, etc.
• Displays accurate attributions of responsibility for offending behavior
• Able to manage frustration and unfavorable events
• Rejects sexually abusive thoughts as dissonant with self image
• Demonstrates pro-social relationship skills
• Projects positive self image
• Demonstrates ability to resolve conflicts and make decisions
• Celebrates appropriate behavior and experiences pro-social pleasure
• Works/struggles to achieve delayed gratification
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• Able to communicate assertively
• Develops family and/or community support systems
• Has an adaptive sense of purpose and future
Tracking progress through the program will take place in the following manner:
• Upon acceptance into group,clients will receive an individualized treatment plan that
will outline what the client needs to accomplish in order to complete treatment.
Therapists will be checking on the progress each client is making on their treatment
plan. Changes and updates will be made on treatment plans as needed.
• Group notes will be compiled by clients after each group. The therapist will evaluate
whether the client is understanding the concepts presented during groups. Feedback
will be provided at the start of the next group to help the client obtain maximum
benefit from groups.
• Polygraphs will be conducted periodically to determine whether clients are being
truthful regarding their referring offense, their current and continued safety in the
community, and their sexual history.
• The multi-disciplinary team will meet monthly to discuss client's progress in the
program. Any major concerns that arise prior to the monthly meeting will be
discussed with the case worker, probation or parole officer within 48 hours.
C. Service Objectives
The primary objective of IGTS will be to provide safety for the victim and the community,
decrease recidivism, and help clients develop healthy sexuality. Successful completion of this
objective requires addressing issues in the following areas:
• Improve parental competency- Parents will initially be assessed to determine their
level of parenting skills. Parents will be referred to parenting education to increase
their skill level. Parents of adolescent offenders will be monitored weekly in family
therapy to check on behaviors occurring at home, and help parents understand "red
flags"that indicate potential problem areas regarding safety in the home. Informed
supervision groups will offer educational information on the "nuts and bolts" of
sexual abuse(e.g.,polygraphs,the legal process of adjudication,thinking errors,etc.)
Parents will also be encouraged to talk about their experiences and share support and
information with each other. Progress will be measured by verbal demonstration of
understanding of the concepts,successful completion of homework assignments,and
participation in groups.
• Improve family conflict management-Families will learn to talk about the underlying
feelings resulting in anger and conflict at home. Family culture will be explored,and
family members will learn to develop family meetings, 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 and at home.
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• Improve personal and individual competencies-Upon acceptance into the program,
clients will be assessed to determine deficiency areas. Problems that are not
specifically limited to sexually inappropriate behavior, but may affect the client's
ability to be successful in class, will be addressed in individual therapy
• Improve ability to access resources-An essential part of the psychosexual evaluation
includes assessing what resources clients and their families need to have a successful
transition back to the community. Recommendations will be made as a part of the
assessment process and will assist clients and their families in locating these
resources as they are identified. Progress will be measured by successful follow
through by clients or non-offending partners.
• 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.
D. Workload Standards
A. Number of hours per day/week/month
Day- maximum of two hours per day
Week-maximum of four hours per week
Month-16 hours per month
B. Number of individuals providing treatment
2 - Group therapists
1 - Individual/family therapists
C. Maximum caseload per worker= 12
D. Modality of treatment will be cognitive/behavioral format, including group,
individual, couples and family therapy
E. See A above
F. Total number of individuals providing services = 3
G. Maximum caseload per supervisor= 12
H. See D above
I. See enclosed insurance agreement
E. Staff Qualifications
1. The IGTS adolescent and adult program for sexual offenders will meet or exceed the
minimum qualifications in education and experience. Services will be provided by
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three 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. These therapists are Licensed Professional
Counselors for the State of Colorado.
2. Total staff available for the project=4
3. Three therapists are SOMB approved to provide adolescent treatment. Two
therapists are SOMB approved to provide adolescent, developmentally delayed
offenders, and adult treatment, evaluations, and plethysmography. Therapists who
are not fully approved in these areas are directly supervised by fully approved SOMB
providers. IGTS follows all SOMB rules and regulations for adults and adolescents.
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 Per Month
Minimum capacity: 1 Maximum capacity: 24
G. Internal Tracking and Billing Process
Billing occurs once per month. Bills are generated at the beginning of each month and sent
out to each individual agency by the fifth day of each month. The billing program generates the
payments and sessions for each month, with past balances included. Each bill is counter checked
with the funding form to ensure the appropriate sessions are being billing and the total fund approved
matches the sessions being billed. A copy is made for the agency.
H. Literature Citations
Association for the Treatment of Sexual Abusers (2000). Position on the Effective Legal
Management of Juvenile Sexual Offenders.Beaverton,OR:Association for the Treatment of Sexual
Abusers.
Bagley&Shewehuk-Dann(1991),Miner,Siekart,&Ackland(1997),and Morenz&Becker(1995)
as cited in Righthand, S.,&Welch,C. (2001)Juveniles who have Sexually Offended: A Review of
the Professional Literature, Office of Juvenile Justice and Delinquency Prevention.
Barbaree,H.E. &Cortini,F.A.(1993). Treatment of the Juvenile Sex Offender within the Criminal
Justice and Mental Health Systems. The Juvenile Sex Offender,H.E. Barbaree,W.L.,Marshall, &
S.M. Hudson (Eds.). New York: Guilgord Press, PP 243-263.
Page 10
Becker, J.V., 7 Hunter, J.A. (1997). Understanding and Treating Child and Adolescent Sexual
Offender. Advances in Clinical Child Psychology:Vol 19,T.H. Ollendick&R.J.Prinz(Eds.)New
York: Plenum Press pp 177-197.
Becker,J.V.(1998). What we know about the characteristics and treatment of adolescents who have
committed sexual offenses. Child Maltreatment, 3 (4), 317-329.
Bernet, W., Dulcan, M.K. (1999_ Paractice Parameters for the Assessment and Treatment of
Children and Adolescents who are Sexually Abusive of Others. Journal of the American Academy
of Child and Adolescent Psychiatry, 38(12), 55S-76S.
Bischof, G.P., Stith, S.M., Whitney, M.L. (1995). Family of Environments of Adolescent Sex
Offenders and Other Juvenile Delinquents. Adolescence, 30(117).
Bourduin, C.M., Henggeler, S.W., Blaske, D.M., Stein, R.J. (1990). Multisystemic Treatment of
Adolescent Sexual Offenders. International Journal of Offender Therapy & Comparative
Criminology, 34(2).
Cortoni, F., & Marshall, W.L. (2001). Sex as a Coping Strategy and its Relationship to Juvenile
Sexual History and Intimacy in Sexual Offenders. Sexual Abuse: A journal of research and
Treatment. 13(1).
English, K. (1998). The Containment Approach: An Aggressive Strategy for the Community
Management of Adult Sex Offenders. Psychology, Public Policy, and Law, 4 (1/2), 218-235.
Hagen,M.P.&Gist-Brey,K.L. (2000). A Ten-Year Longitudinal Study of Adolescent Perpetrators
of Sexual Assault Against Children. Journal of Offender Rehabilitation, 12(1/2),
117-126.
Hanson, K.R., Harris, A. (1998-2001). Dynamic Predictors of Sexual Recidivism. Department fo
the Solicitor General Canada. ,
Kahn,T.J. & Chambers, H.J. (1991). Assessing Re-Offense Risk with Juvenile Sexual Offenders.
Child Welfare, Vol. LXX (3).
Langstrom, N. & Grann, M. (200). Risk for Criminal Recidivism Among Young Sex Offenders.
Journal of Interpersonal Violence, 15(8).
Marshall,W.L.(1999). Current Status of North American Assessment and Treatment Programs for
Sexual Offenders. Journal of Interpersonal Violence. 14(3), 221-239.
Marshall, W.L., & Barbaree, H.E. (1990). Outcome of Comprehensive Cognitive-Behavioral
Treatment Programs. Handbook of Sexual Assault: Issues,Theories &Treatment of the Offender,
W.L.Marshall,D.R.Laws,H.E.Barbaree(eds)New York,New Yourk:Plenum Press,pp 363-385.
Page 11
McGrath, R.J., Cumming, G., Holt, J. (2002). Collaboration Among Sex Offender Treatment
Providers and Probation and Parole Officers: The Beliefs and Behaviors of Treatment Providers,
Sexual Abuse: A Journal of Research and Treatment, 14(1).
Miner, M.H., & Crimmins, C.L. (1997). Adolescent Sex Offenders—Issues of Etiology and Risk
Factors. The Sex Offender:New Insights,Treatment Innovations, and Legal Developments Vol II,
B.K. Schwartz & H.R. Cellini (Eds.) Kingston, New Jersey: Civic Research Institute.
National Adolescent Perpetrator Network(1993). The Revised Report from the National Task force
on Juvenile Sex Offending. Juvenile and Family Court Journal, 44(4).
National Task Force on Juvenile Sexual Offending, 1993.
The National Task Force on Juvenile Sexual Offending(1993_as cited in Hunter,J.A.,&Figueredo,
A.J. (1999). Factors Associated with Treatment Compliance in a Population of Juvenile Sexual
Offenders. Sexual Abuse: A Journal of Research and Treatment, 11(1).
Prentky,R.,Harris,B.,Frizzell,K.,and Righthand,S.(2000). An acturarial procedure for assessing
risk in juvenile sex offenders. Sexual Abuse: A Journal of Research and Treatment, 12 (2), 71-93.
Quinsey,V.L.,Harris,G.T.,Rice,M.E.,Cormier,C.A. (1998). Violent Offenders: Appraising and
Managing Risk. American Psychological Association, 55-72.
Ryan, G.D., & Lane, S.L. (1997). Juvenile Sexual Offending. San Francisco: Josey-Bass.
Sirles,E.A.,Araji,S.K.,Bosek,R.L.(1997). Redirection Children's Sexually Abusive and Sexually
Aggressive Behaviors: Programs & Practices. Sexually Aggressive Children, S.K. Araji (ed).
Thousand Oaks: Sage. pp 161-192.
Weinrott, M.R. (1996). Juvenile Sexual Aggression: A Critical Review. (Center Paper 005).
Boulder, CO: Center for the Study and prevention of violence.
Worling, J.R. (2000). Adolescent Sexual Offender Recidivism: 10-year Treatment Follow-Up of
Specialized Treatment & Implications for Risk Prediction. Paper presented at the 15'h Annual
Conference of the National Adolescent Perpetration Network, Denver, CO. Feb., 2000.
I. Confidentiality and Participant Protection/Human Subjects:
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 sexual offending. However,IGTS is required
to suspend confidentiality in some cases, such as imminent danger to self or others. Clients
attending sexual offense specific therapy are required to sign an Acknowledgment of Non-
Confidentiality and Waiver. This document indicates that in cases where new victims are revealed,
Page 12
Social Services will be contacted regarding the identity of the new victim, if known. The purpose
of the waiver is to make clear to all clients that the rights of victims will be recognized over their
right of confidentiality.
B. Fair Selection of Participants:
As mentioned previously,the target population consists of male and female between the ages
of 12 to 18. Clients that exceed the required age range may be referred to adult groups,while clients
beneath the cut off age may receive individual services. Services are available to all racial and ethnic
populations.
Participants will be selected based on the results of their psychosexual evaluation and their
willingness to participate in treatment. Since most sexual offenders are initially resistive to therapy,
this will not be a deterrent for acceptance into the program.
C. Absence of Coercion:
Participation in sex offense specific treatment is often required by court order. Research
indicates that clients who are court ordered are more likely to be successful in treatment. However,
clients who wish to participate on a voluntary basis are also accepted.
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.
F. Adequate Consent Procedures:
As mentioned previously,most clients are referred by court order. However, no client can
be forced to participate in therapy. Research indicates clients that refuse to participate in sexual
offender treatment pose a greater threat to the community. These clients are referred back to the
legal system.
Page 13
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 client before signatures are obtained.
G. Risk/Denefit 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.
Page 14
APPENDIX A
RESUMES FOR KEY STAFF MEMBERS
Kim R. Ruybal,MA, LPC, NCAC II
Executive Director/Owner
Individual& Group Therapy Services
1020 8`h 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 (BOMB) 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,
to the present.
Page 15
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
served included chronically mentally ill,bi-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.
American Counseling Association (ACA). Member# 06084761. July 2001 to Present.
Page 16
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
staffings 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 with
team members, associates and others.
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
Page 21
Offender Management Board, 5-29-01 Associate, 11-25-03 Full Operating.
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,
CO-ATSA
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:
Page 27
Adult history of suicide:
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 8th 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 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.
Page 30
'This cohsent 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 fith Street
Greeley, Colorado 80631
Phone 970-353-8171 Fax 970-353-0371
Our staff credentials are as follows:
Kim R. Ruvbal M.S. Community Counseling, 1996
M.A. Agency Counseling, 1998 Summa Cum Laude
Summa Cum Laude Mankato State University
LPC# 2647 LPC# 4409
DVOMB Approved Domestic Violence Jodie M. Goter
Evaluator&Treatment Provider M.A. Counseling Psychology, 1998
SOMB Approved Evaluator, Treatment Leslie University
Provider,Plethysmoghrapher: LPC # 3138
Adult/Juvenile SOMB Evaluator, Treatment Provider
National Certified Drug& Alcohol Counselor Plethysmograph Clinician:
Adults/Juveniles
Julie Nelson
M.A. Agency Counseling, 1994 Paul Hooten
Summa Cum Laude (Intern)
University of Northern Colorado Masters Candidate,UNC
LPC# 1512 B.A. Psychology,2003
SOMB Approved Treatment provider: Point Loma Nazarene University, San Diego
Juveniles
Kristen Jernigan
Bobbie Feather (Intern)
(Contract Therapist) M.A Community Counseling, 2000
M.S.C.P. Counseling sychology,1994 University of Denver
Chaminade University of Honolulu LPC# 3487
Shelly Cox
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,ifknown,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 3rd 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.
Page 33
' Client's Signature Date
Client's Printed Name
Therapist's Signature Date
Page 34
INDIVIDUAL & GROUP THERAPY SERVICES
1020 8th 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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" AMERICAN ECONOMY INSURANCE COMPANY PAGE 1
41/4 ca insurance
SEATTLE, WASHINGTON
ULTRA OFFICE POLICY
NAMED PERKLEN ENTERPRISES, INC RENEWAL DECLARATIONS
INSURED DBA IND & GROUP THERAPY
MMD
MLING SERVICES POLICY NUMBER 02-BO-901136-7
MAILING
ADDRESS 1020 8TH ST RENEWAL OF 02-BO-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.
05-83511 (970) 353-2020
FORM OF
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
BP7059(0105) COMMERCIAL FINE ARTS COV FORM BP8136(0702) EQUIPMENT BREAKDOWN ENDORSEMEN
BP0523(1102) CAP ON LOSSES CERTIFIED ACTS 0 C4359(0405) NOTICE TO POLICYHOLDERS
_ IL7201 (0392) COMPANY COMMON POL CONDITIONS BP8068(0702) EXCLUSION -ASBESTOS
BP8029(0702) AMENDMENT-AGGREGATE LIMITS OF BP0455(0702) BUSINESS LIABILITY COV-TENANT:
BP0576(1102) FUNGI OR BACTERIA EXCLUSION (p BP0441 (0702) BUSINESS INCOME CHANGES
MEM BP0417(0702) EMPLOYMENT RELATED PRACT. EXCL BP0181 (0702) COLORADO CHANGES
MEE BP8128(0502) EMPLOYMENT PRACTICES LIABILITY
EXHIBIT B
SUPPLEMENTAL NARRATIVE TO RFP
Individual & Group Therapy Services
1O2O8th Street,Greeley,Colorado 80631 •Pk:970-353-8171 • Fax:970-353-0371
O
May 21, 2007
Weld Corinty Department of Social Services
Ms. Tolt4dVegter
P.O. Boxr,A
GreeleyO 80632
Re: R04-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 (PIPI: 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
Family • Couples • Adolescents • Victim Services • Mental Health Assessments
Domestic Violence Evaluation and Treatment • 50M5 Evaluation,Treatment and Plethysmography
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
DEPARTMENT OF SOCIAL SERVICES
P.O. BOX A
IGREELEY, CO. 80632
WI p Website:www.co.weld.co.us
Administration and Public Assistance(970)352-1551
OFax Number(970)353-5215
•
COLORADO May 11, 2007
Kim R. Ruybal M.A., LPC,NCAC II
Individual &Group Therapy Services
1020 8th 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 recommendation 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.
Condition: 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 by Bidders
Concerning FYC Commission Recommendations:
You are requested to review the FYC Commission recommendations 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
Weld County Department of Social Services
Notification of Financial Assistance Award
for Core Funds
Type of Action Contract Award No.
X Initial Award PY 07-08-CORE-91
Revision (RFP-FYC-07007; 004-SAT-07)
Contract Award Period Name and Address of Contractor
Beginning 06/01/2007 and Shiloh Home
Ending 05/31/2008 Sex Abuse Treatment
6400 W Coal Mine Avenue
Littleton,CO 80123
Computation of Awards Description
Unit of Service The issuance of the Notification of Financial Assistance
Services provide outpatient offense specific treatment for Award is based upon your Request for Proposal(RFP). The
up to 10 youth, ages 12-18 years and their families. RFP specifies the scope of services and conditions of award.
Youth served will have an IQ greater than 70, and will Except where it is in conflict with this NOFAA in which case
be able to function in a reality-based manner. Clients the NOFAA governs, the RFP upon which this award is based
must have a current offense-specific evaluation. is an integral part of the action.
Outpatient therapy will incorporate perpetrator, Special conditions
victimization and mental health needs. English speaking 1) Reimbursement for the Unit of Services will be based
services. Efforts will be made to work in conjunction on an hourly rate per child or per family.
with other resources to provide interpreter services when 2) The hourly rate will be paid for only direct face to
no family members speak English. The interpreter will face contact with the child and/or family, as
be involved in the ongoing treatment and planning for evidenced by client-signed verification form, and as
client/family. Three hours per week will be provided to specified in the unit of cost computation.
each client and family as deemed needed in the 3) Unit of service costs cannot exceed the hourly and
referral/assessment process. Services are provided at the yearly cost per child and/or family.
Longmont facility. 4) Payment will only be remitted on cases open with, and
Cost Per Unit of Service referrals made by the Weld County Department of
Hourly Rate Social Services.
Individual Counseling(Individual Therapy) $75.00 5) Requests for payment must be an original submitted to
Family Therapy(Family Counseling) $75.00 the Weld County Department of Social Services by the
Group Therapy $45.00 end of the 25th calendar day following the end of the
Multi-Family Therapy $45.00 month of service.The provider must submit requests
Treatment Package Moderate for payment on forms approved by Weld County
(Staffings/Professional Meetings) $75.00 Department of Social Services. Requests for payments
Treatment Package(Court Testimony) $75.00 submitted 90 days from the date of service, and
Enclosures: 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)
Conditions of Approval
Approva `p Progra Offcialr'�
d BY Zt ‘ BY V`
David E. Long, Chair Judy . Grie o, Direc r
Board of Weld County Commis oners Weld ounty epartment of Social Services
Date: JUN 18 2007 Date: (C J I I Jul
a)Er 1797
EXHIBIT A
SIGNED RFP
03/20/2007 ITT 10:22 FAA 9703467662 004-SAT-07 002/002
Program Area Supervisor/Provider Meeting
Verification/Comment Form
Date of Meeting: 3/4 el/0 7
Program Area: SQ->c 4t4 S,e 1 1C Sit; /0vl `trees
Comments(to be completed by Program Area Supervisor):
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•
Signal ofProgrnm Supervisor
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.RS. 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 3 13 a ( 6
(After receipt of order) BID MUST BE SIGNED IN INK
Program Area: e K fA"FOCAse 71---e& e
TYED,OR PRINTED SJE'rNATURE
•
VENDOR Ivk e , J . 21/x;A., mfr+ i,2zz..
(Name) Handwritten Signature By Authorized
Officer or Agent of Vendor
ADDRESS L Lt W . Coal ()Acne hoe - TITLE CpL>r
a C6 80(2."' DATE k t4d(/ ,
PHONE# 305 °ea- - 4lS`1'�t
The above bid is subject to Terms and Conditions as attached hereto and incorporated.
.
Shiloh Home, Inc. Page 2
Sex Abuse Treatment
Target/Eligibility Population
Shiloh Home will provide outpatient offense specific treatment for up to 10 youth ages 12
to 18 years and their families. Youth served by the program will have an IQ greater than
70, and can function in a reality-based manner. Clients must have a current offense-
specific evaluation. The outpatient therapy will incorporate perpetrator, victimization
and mental health needs.
The Utilization Committee reviews the referral information to determine appropriateness
of treatment. Considerations include, but are not limited to: history of violence;
treatment amenability; level of risk to family, victim, and community; typology of
offending history; level of denial; age; intellectual functioning; and mental
health/secondary diagnostic features.
Clients must be English speaking. In situations where a family member does not s peak
English, efforts will be made to provide an interpreter of the language in questions.
Shiloh is continually searching to hire a bilingual clinician or treatment staff. In the event
that there is not a bilingual staff at Shiloh, efforts will be made to work in conjunction
with another resource. The interpreter will be involved in the on-going treatment and
planning of the client and family.
• e
Shiloh Home, Inc. Page 3
Request For Proposal
Table of Contents
Invitation for Bid Page 1
Overview of Day Treatment Program Page 2
Table of Contents Page 3
Target/Eligibility Page 4-5
Types of Services Provided Pages 6
Measurable Outcomes Pages 7
Service Objectives Page 7
Workload/Staff Qualifications Pages 8
Internal Tracking/Billing Process Pages 8-9
Confidentiality/Ethical Practices Pages 9-10
Appendix 1 (staff resumes) Pages 11-17
Appendix 2 (data collection) Pages 18
Juvenile Sex Offender Assessment Page 19-47
Appendix 3 (sample consent form) Page 48
Treatment Consent Form Page 49
Notice of Privacy Practices Pages 50-53
Disclosure Statement Page 54
Request for Information Form Page 55
Research Policy Page 56
501 C 3 Pages 57-61
Budget Page 62
' T
Shiloh Home, Inc. Page 4
Overview of Offense Specific Outpatient Services
Mission Statement
Shiloh Home, Inc. offers a nurturing, therapeutic and educational environment to those
lives impacted by abuse, neglect and trauma. It is through guidance, clinical intervention
and advocacy that Shiloh Home strives to meet the needs of the individual, while
respecting the diversity of youth and families.
Shiloh Home will provide outpatient offense specific treatment at the Longmont facility
located on 745 Highway 119, Longmont CO, 80501. Shiloh is aware of the shortage of
in-county treatment options, specifically the South County region. This has a negative
impact on the community through increased costs of managing placements and treatment
options outside of the county, as well as increasing the challenges of successfully
maintaining youth at home with their families. In today's current climate of child
welfare, the State, Counties and Providers are especially concerned with issues around
the State's Program Improvement Plan (PIP). The opportunity for youth and families to
be provided services within their community is a benefit to achieving such outcomes.
Shiloh Home recently opened a residential program and day treatment program serving
Weld county youth and their families in their county. This project will allow us to
broaden our community-based services to Weld County. These proposed outpatient
services may be accessed by clients entering the system, in hope of maintaining
placement with the family or other community-based resources, as well as accessed by
clients stepping down from higher levels of care, whether from Shiloh's residential and
day treatment, or that of another provider. If a Shiloh client is able to transfer to
outpatient services at Shiloh upon residential discharge, it is believed that this will benefit
the client's success due to the familiarity with the agency, providers and treatment
program in the transition process. A continuum of care leads to efficiency and continuity
for the clients.
A partnership between Weld County and Shiloh within an outpatient model can move
toward success with the designated outcomes in the PIP. Shiloh strives to achieve the
outcomes of protecting children from abuse and neglect; maintaining children safely in
their homes when possible and appropriate; upholding permanency and stability in the
children's living situations; preserving continuity of family relationships and
connections; enhancing families' capacity to provide for their children's needs; accessing
appropriate educational services for children; and receiving adequate mental health
needs. Through the use of the outpatient offense specific program, it is hoped that the
PIP outcomes can be achieved, especially as the program focuses on family connections
and preserving safety. When appropriate for all parties(that of the victim and the youth
who offended,) maintaining youth in home can lead to overall success for the developing
child, elimination of abuse and long-term outcomes.
Shiloh Home, In. Page 5
Project Overview
Shiloh practices the best standards of care and emphasizes implementation of evidenced-
based treatment practices. Shiloh's programs adhere to the SOMB Guidelines and
Standards. Risk assessment will be addressed through the JSOAP, updated tools,
ongoing team and family collaboration, treatment progress and team members' input
behavioral observation within all arenas of the child's life(home, school,job, social,
community activities.) Adjunct referral to polygraphs, arousal measurements,
psychological services and psychiatric services may also be part of risk assessment and
the ongoing treatment.
Data management and outcomes measures will also be available to evaluate program
effectiveness. Date collection also allows for open discussion of potential modifications
to treatment plan and services. It is the hope that Shiloh and Weld County can partner to
track post-discharge data, especially as it relates to recidivism.
This proposed project is designed to benefit the youth and families of Weld County by
supporting the client and family, prioritizing victim and community safety, fostering
active family participation, accurately assessing service plan needs, involving the youth
and family with appropriate community resources, addressing mental health treatment,
increasing overall health, and working within the community.
•
Shiloh Home, Inc. Page 6
Project Narrative
➢ Types of Service Provided:
Treatment sessions utilize the following evidence-based treatments: Cognitive-
Behavioral Therapy (correcting thinking errors; linking thoughts, feelings and
behaviors;teaching new, healthy, empathic and reality-based way of thinking) and
Behavioral Therapy (teaching and rehearsing healthy ways to behave when
overwhelmed by feelings and perceived needs). Therapy will also address trauma
work when indicated. Psycho-education and Family Systems Theory is utilized.
Therapy will also address stabilization of the client's mental health diagnosis.
Individual , Family and Group Therapy will be offered by either a licensed clinician
or a Master's-level clinician supervised by a Licensed clinician. The clinicians and
supervisor will be listed with the SOMB. The frequency of these therapies will be
determined at the time of referral and assessment with Weld County caseworker. On
average, each therapy modality is offered weekly. Victim clarification, community
restoration and family reunification may be addressed if deemed appropriate by the
team.
Individual sessions address increased safety, correction of abusive behavior, mental
health stabilization, decrease in risk, increase in health. Victim impact and
community safety are addressed throughout the treatment process. There is also a
focus on fine-tuning and individualizing the youth's plan for how to respond with
coping "tools" in difficult family, school and community situations. Such tools
include: rehearsal of corrected cognitions, behavior management and self-control,
and safety and relapse prevention plans. Focus on improved self-esteem, increased
pro-social behaviors and stabilization of mental health symptoms are addressed.
Sessions will be offered throughout the day, including late afternoon and early
evening for working families. Therapy adheres to the Colorado Sex Offender
Management Board's Standards and Guidelines for the Evaluation, Assessment,
Treatment and Supervision of Juveniles Who Have Committed Sexual Offenses.
Shiloh will assist youth and families in getting linked to community services that may
be beneficial that Shiloh does not provide. An aftercare plan will be provided
outlining ongoing services to ensure the youth is maintained successfully in the
family home.
Clients must be English speaking. In situations where a family member does not
speak English, efforts will be made to provide an interpreter of the language in
question. The interpreter will be involved in the ongoing treatment and planning of
the client and family.
,
Shiloh Home, Inc. Page 7
Project Narrative
An initial treatment plan is completed for each client and their family and is reviewed
on an ongoing basis modifying as appropriate.
➢ Measurable Outcomes:
1). No more sexual offenses
2). Completion of SOMB standards(outcomes 3.150 and 3.151)
3). Increased parenting competency with Shiloh's pre and post-test
4). Parent compliance with Informed Supervision criteria
5). Successful completion of victim clarification if appropriate, measured in
conjunction with victim therapist
6). Maintenance in the community(home,job, public school)
➢ Service Objectives: The focus of treatment is the maintenance of safety towards self
and others, honestly/accountability for behavior and education around abuse-specific
issues.
Objectives of offense-specific treatment:
1). Completion of a comprehensive intake assessment
2). Ongoing assessment of functioning evident in client, family and therapist
feedback
3). An initial treatment plan developed with family, caseworker and Shiloh.
4). Ongoing review and modification of treatment plan as necessary
5). Consistent participation in scheduled individual, family and group sessions
6). Functional change in family that does not tolerate abusive behavior
7). Evidenced of abuse-free functioning evident in consistently appropriate and
pro-social behavior in sessions and with family at home
8). Recognition of harm done to victim(s)
9). Implementation of relapse prevention plan
10). Acceptance of responsibility for abusive behavior without blame or
externalizing
11). Overview of interventions/progress/ongoing needs
12). Recommendations of completion of treatment
Goals of offense-specific treatment:
1). Full disclosure of all abusive behavior
2). Full disclosure of own victimization
3). Ability to understand personal cycle of abuse, as well as ways to avoid
maladaptive thoughts, feelings and behavior
4). Behavioral stability evident in consistent display of safety towards self, safety
towards others and respect towards property
Shiloh Home, Inc. Page 8
Project Narrative
5). Development of a parent-child relationship and home environment that
supports abuse-free functioning and does not tolerate abusive behavior
6). Development and display of greater repertoire of adaptive coping skills
7). Development of a relapse-prevention plan that matches abusive behavior
8). Recommendations upon completion of treatment to include ongoing needs
and supports to increase likelihood of success to ensure youth maintains in
home
➢ Workload Standards/Staff Qualifications:
Referral process includes review of client's offense specific evaluation and
recommendations; police reports and victim statements; updated mental health
evaluations; and other treatment summaries if applicable. A psychosocial assessment
will be completed at intake. 3 hours per week will be provided to each client and the
family, as deemed needed in the referral and assessment process. This may include
individual, family, groups and multi-family groups. The type of therapy and the
frequency will be determined at intake with Shiloh and Weld county caseworker.
Clinician caseloads are approximately 10 clients and staff employed at Shiloh Home
meet or exceed the standard for minimum qualifications in education and experience.
Master's-level mental health clinicians supervised by licensed professionals, or
licensed mental health professionals who are listed by the SOMB will provide the
treatment.
Staff include the following:
• Chief of Direct Service, Treatment Supervisor/LCSW, Full Operating SOMB
Provider
• Clinical Manager/LPC, in listing with the SOMB
• Master-level mental health clinician
• Chief Administrative Officer, BS
Shiloh will hire additional staff as needed.
➢ Internal Tracking and Billing Process:
The Financial Services Department generates monthly reports(balance sheet and
income statement)by the 15th of the month. These are submitted to the Chief
Operating Officer for review. The following are the procedures regarding
maintenance of payment:
Shiloh Home, Inc. Page 9
Project Narrative
• Payment information comes from different funding sources and is separately
billed
• Billing is compared with the agency rosters indicating clients and the counties
from where they were referred
• The net term for billing is approximately 45 days
• Depending on the specific type of billing and from where it originates,
billings/invoices are submitted either via mail or electronically and subsequently
confirmations of receipt of payment are received either through electronic deposit
or through general mail
• Once monthly figures have been determined, they are listed on the Estimated
Income sheet. As payments are received and/or verified, they are removed from
the Estimated Income sheet
• In the event that a payment from a specific funding stream is not received within
the net term, the CFO will contact the specific entity to obtain payment
• In the event of over payment,the CFO will notify the specific entity to inform of
the overpayment
Shiloh has internal accounting controls and are reviewed and evaluated annually by the
CPA firm and the Board of Directors. Shiloh has a formal audit annually. Each facility
or department is individually examined and is presented separately within the audit and
the agency budget. Each department maintains its own budget and is submitted monthly
to the CFO. The CFO and COO with the consultation of the CPA closely monitors
revenues and expenses. All revenues and expenses are reflected with the audit.
➢ Confidentiality/Ethical Practice, Rights and Responsibilities:
Shiloh Home has policies and procedures addressing the ethical practices and
respecting the rights and clients and their families who Shiloh provides services. All
clients/families are provided with written information regarding their rights at intake
and staff receive training during their orientation. The eligibility criteria is described
in the admissions policies and Shiloh ensures all clients/families understand this
criteria at intake and the services that Shiloh provides. All clients and families are
informed of Shiloh's grievance procedure and sign a statement at intake that they
have received the information and understand the process. Grievances are reviewed
by the appointed grievance representative with 72 hours of the grievance being
submitted and a response is given back to the client/family.
Shiloh protects the confidential information on all clients/families and has policies
and procedures that all staff are trained on during orientation training and are in daily
practice. All staff sign a confidentiality statement that is filed in their personnel file.
In addition to Shiloh's policies and procedures, ITEPPA manual is maintained and
Shiloh Home, Inc. Page 10
Project Narrative
client/family is given HIPPA disclosure at intake. Client case records are stored in a
locked area.
Shiloh accepts youth ages 12 to 18 from any racial/ethnic background. Clients must
be English speaking. Once a youth is referred by Weld County Human Services, the
Utilization Review Committee reviews the specific case in order to determine the
appropriateness for treatment. Considerations include, but are not limited to: history
of violence;treatment amenability; level of risk to family, victim, and community;
typology of offending history; level of denial; intellectual functioning; and mental
health/secondary diagnostic features.
Shiloh considers clients/families who demonstrate some willingness to receive
treatment and a commitment to community safety and completion of treatment.
Intake information is requested. An updated offense specific evaluation, as per
SOMB Guidelines and Standards, is requested at referral. Releases of information are
signed by parent/guardian and a copy filed in client's case record. Outcomes
measures are utilized by the agency to inform and provide feedback on the quality of
treatment.
Shiloh Home, Inc. Page 11
Project Narrative
Appendix 1 (Staff Resumes)
Page
Pamela L. Hricik, MSSW, LCSW
EDUCATION
1994 to 1996 Columbia University School of Social Work,New York,NY
Masters of Science in Social Work,Received May 1996
Clinical Social Work Major
1989 to 1993 Miami University,Oxford,OH
Bachelors of Arts,Received May 1993
Psychology Major,Family Studies Minor
Honors:Dean's List;Psi Chi(Psychology National Honor Society)
PROFESSIONAL
EXPERIENCE
January 2004 to Chief of Direct Services
Present Shiloh Home, Inc. Child Welfare Agency,Littleton,CO
Responsible for direct supervision of Administrator of Education,and Clinical Directors/Managers.
Supervised Administrator of Residential Services(2004-2005.)Management and facilitation of direct
clinical services.Oversight of offense specific therapy and Colorado's SOMB therapy and program
requirements. Responsible for agency-wide program development. Assist in implementation of
accreditation policies and procedures. Organize and implement strategic and business plans. Develop
contracts with county social services.
February 1999 to Clinical Director
January,2004 Shiloh Home, Inc. Child Welfare Agency,Littleton,CO
Supervised team of master level clinicians,tracking unit,clinical office manager,day treatment staff and a
CAC III. Responsible for the development and oversight of day treatment program. Responsible for
facilitation of all clinical services,as well as,offense specific evaluations and assessments.Organized,and
implemented multi-family and outpatient offense specific groups. Served as an agency liaison with outside
entities and provided input on a variety of treatment committees addressing local and national issues.
Facilitated direct clinical services. Evaluated and developed programs. Responsible for staff training.
July 1996 to Clinician
February 1999 Shiloh Home, Inc. Child Welfare Agency,Littleton,CO
Provided individual,group,family and multi-family therapy to a 12 to 18 client caseload. Responsible for
administering assessments,treatment and case management planning,and monthly staffmgs.Specialization
emphasized with clientele in need of offense specific services. Supervised on-line staff and case manager.
September 1995 to Social Work Intern
May 1996 Green Chimneys Children's Services Residential Treatment Center,Brewster,NY
Worked on a multi-disciplinary treatment team as a primary therapist and case manager. Conducted
individual and family treatment with emotionally and psychiatrically disturbed male adolescents.
Facilitation of residential and day treatment groups.
Summer 1995 Instructional Aide
Greenwich Public School System,Summer Special Education Program,Greenwich,CT
Facilitated the integration of children with autism in an inclusive preschool program. Utilized Applied
Behavior Analysis,which involved behavioral assessment,continuous evaluation and the teaching of social
skills
September 1994 to Social Work Intern
May 1995 Pediatric-Primary Care Center,Yale-New Haven Hospital,New Haven,CT
Provided case management and acute crisis intervention services for high risk families. Co-organized and
facilitated a parents' psychoeducational support group. Collaborated with school,state child welfare
systems,as well as,with community resources.
Pale 13
Pamela L. Hricik, MSSW, LCSW
August 1993 to Educational Instructor
August 1994 Cooperative Educational Services,Fairfield,CT
Instructed children with developmental delays and severe behavioral problems. Implemented behavior
management programs and participated in the preparation of Individualized Education Plans and Placement
Team Meetings.
TRAINING AND
CERTIFICATIONS
July 2003,current SOMB Full Operating Level Treatment Provider
May 2000,current LCSW Licensure,#992424
State of Colorado
Licensed Clinical Social Worker
March 2000 Certification
Behavioral Technologies,Inc., Salt Lake City, Utah
Certified Clinical Interpreter for penile plethysmograph.
PROFESSIONAL COMMITTEES
Colorado Sex Offender Management Board—participation in several sub-committees
CAFCA(Colorado Association of Family&Children's Agencies/CAFCA,Inc.)
SAFE JeftCO(Sexual and Abuse Free Environment,Jefferson County)
PROFESSIONAL TRAININGS
PRESENTATIONS
See attached
OTHER National Association of Social Workers
Member 1994-2001
Member of the following networks and organizations:Colorado Continuum Network; Safe JeffCo;
Colorado SOMB work groups
REFERENCES Provided upon request
0120/05 17:04 ID:U A T MFD FAX:3033750066 PAGE 2 Pas e i4
KIMBERLY A. STYLES, LCBW
1h20 Rediail Court
Longmont, Colorado 90501
(:103) 774-9283
OBJECTIVE
90 provide nervier,^ to individuals and families no improve their
quality of life.
NUCA'1'I ON/LICRNS0SE
I,C0W 4 992988
UNIVERSITY OF DENVER, DENVER, COLORADO
Master of Social Work received June 1997
fIN I:VFIR:1TY OF MASSACHUSETTS, AMHERST, MASSACHUSETTS
Bachelor of Arta - Psychology received May 1993
EXPERIENCE
TRINITY CHILDREN AND FAMILY SERVICES
Colorado Director.
Westminster, Colorado 9/00 to 12/04
Developed new foster care Child Placement Agoncy in Colorado.
Prepared and compiled all noni::ssary policies for licensing and
operation. Responsible, for recruitment, training, and certification of
lo.Yter parents, training and supc:rv.i siou of master's Iovol clinical
staff, billing, administration, developing donation resources, public
relations with service contractors, and community relation:.
Supervising Soriol Worker
V.iciorv.il]e, California 0/99 to 9/00
Provided both individual and group clinical and administrative
marry/Sion to a team of foster Care Social Workers. A.nsirated Director
in daily operations of office. OLher r .sponsihili ties included public
relation:, assessment and certification of new homes, ntatf
do icing, and interface with licensing analysts and continuing rinse
management . Trained staff and families in c111 and First. Aid.
Foster Care Social Worker
Vi.ct.orvi lles California 7/99 - 8/99
Mini l ored carsalcad of foster children and their foster Tamil i ea.
Developed individualized treatment plans, provided parenting training
( including First Aid and CPR) , acted as a liaison between the placing
agency and the foster family, coordinated and supervised natural
Family visits, attended court hearings, ans.isted with permanency
planning.
Pay- 15
0120/05 17:04 ID:U A F MFD FAX:3033750066 PAGE 3•
g
OASIS COUNSELING (:ENTER:/ Contract Therapist
Hu r:stnw, Cali firm is 12/99 to 8/00
Serve as independent contractor, providing .initial assessments and
counseling for childron, adolescents and their tamilior,, Assisted in
reel rlcluring of services Lo better nerve the el iunt. population and
reterral sources.
Cl EO WALLACE CENTER, WESTMINSTER, COLORADO
Residential Clinician 9/96 - 6/98
Conducted individual, family, and group therapy with ohi Idt on and
adolescents, managing a variety of local and out-ni-state contracts.
Re:;pons.ibi ii Li on included case management , treatment planning, cu-
facil.ilalion of the ::ex offender and substance abuse prevention groupn,
ongoing treatment and utilization rnvi ews, eoordimation ot out-et-Stale
visitation and therapy, clinical on-call, and provision ot care on
residential., Inpatient, and day treatment levels. Held position as
Clinical Intern and por diem therapist. from 9/96 Lu 1/97.
ARAPAHOE ROUSE, /NC., THORNTON, COLORADO
Adolescent Llnit. Family Therapist. 7/97 - 9/9'1
Treated adolescents recovering from :rubstduoe abuse and addiction,
while including the family i.n the rehabilitation and recovery prnecu..;.
Redeveloped and implemented the family therapy program, increasing it
to an NU% participation rate. Facilitated weekly parent support and
education groups, anti conducted family assessments and therapy
sessions.
U RNVFH PUBLIC SCHOOLS, DENVER, COIC)RA UO
School Social Worker - Clinical Tntorn 9/9h - 6/96
Provided case management and counseling Lo high school students
regarding individual, educational , and family Issues, co-facilitated
group therapy, aSsisLed with Attendance filings and special eduction
starting, made referral, le community resources, and attended area
meetings.
ARC OF SOMERSET COUNTY, SOMERVTiLN, NEW JERSEY
Alternate Living Program Manager 11/94 - B/9h
Coordinated and nupervised all daily operations and activities of
Supported living apartments, including development of individualized
Habitation Plan:;, scheduling and training of staff, budget maintenance
and community involvement.
Group Home Assistant Manager 12/93 • 11/94
Ansi.sled manager with daily operations. Managed group home finances and
coordinated appoilLment.n and year Ly 111P's. Encouraged and coardinatr,i.
I
01/20/05 17:05 ID:U A P MFD FAX:3033750066 PAGE 4 Pa9 t
p,irt.ici patien in community activities, including the New Jersey Special
olympicr;.
Residential Counselor 7/93 - 12/9:4
Nruvided personal care, structured weekly activities, and living skill:;
training her residents in a supported living environment.
alih1fMENCEF
Furnished upon request.
.age (l
J.Carol Cummings M.A.,N.C....
JCC@QSoftLLC.eo•
(970)532-0789
Education: M.A.Calamity Caureiag with Fay and Marringe,2116
University of Northern Colorado-Greeley,CO
Medial A-- ' t,1989
Colorado College—Denver, CO
B.A.Hearth,Edmeaasa,and Wanes,1906 Geddes 3 years ie ESN program)
Loretto Heights College-Darner,CO
Calla me Claud 7ieaalit ova(Milieu ad Outmodes°
Mental Health Center of Denver—Denver, CO (8/05—present)
Worked closely with severely nary it ad eatieus'y Laarbed eiikast ad adolescents in day
treatment setting,as well as ouipatiest ciSi+ea ad Milks midi*iJiviid,grasp,ad frailly
away,as wea r play therapy lo kids ages 7-14 yeas;intake meeseme a s;assisted with milieu
maintained ad activities;fa than with eat/STAR;managed caseload as care coordinator,collaboration
with team aarmbers,psychiatrists ad outside apnea Saw age Mater p-a development
experience with and assaed therapy-,worked ado FEMA gat to provide alas corseting to Katria
evacuees.
Wes Gawp Mir ad Coma
Cherde oldie Soatlwat-Lain,CO (9/➢3-9/914)
Worked dsaely with group of wanes at their ladies at with same abase,repeals domestic abase,
Moo,and crisis situations
it igistated Dad Amidaat/Meiicd Spada (6/99-6/03)
Health First Jonathan W.Sanger, D.O.—Greenwood Village CO
Worked closely with physician performing hood deans,ere,sciadaling terms,pat eieanoa,ad
appointments,ad tracking accosts receivable. Also assisted with pap smears,swegral ad acaseetwe
CNA pima Mat Aide)c owes Cansindam Ma Sanfaa Sawa (7/14-5/95)
Edendiaare—Whe iridge,CO
Professional Ha Health Care, I .-Deaver.CO
Colorado Comprehensive Care,lac.-Lakewood CO
Haase halt care management;coordination of staff visits,emapmcies,and clients after boas;Provided
educational Sservices to staff,extensive work with elderly ad chided.
P'-' --. 3 Ukases*of Nrtlreem Caivada:
Inducted into Chi Sigma Iota(aiernationd(Counseling Honor Society),RHO Epsilon
Chapter
Lea Inter Caw
Who's Whoa American Colleges ad Universities, 1926
Alpha Cr National Honor Society
'—a-Class Tara
First gradate of the Heals,Eihcaiann,ad Wellness Program
Mead Huh Center of Denver(bey treatment ad outpatreet child and faun')
Ridge Home(employee evahrahon&set np Wetness Resource Ca)
Vaiener Work
Women's Group trader at Church of the Southwest
Lutheran Medial Caner
Sea Sports Medicine Clinic
Outreach to elderly(shut-ir ad musing homes)
A tions; Member in good standing of APA,Colorado Licensed Professional Counsekss(CLPCA) and ACA
Active member of National Association of Allied Hahh Professionals(NAAHP)
Active member of International Critical Incident Stress Management Foundation,Inc.(ICISMF)
Bond member of Critical Incident Stress Management Tam(CISM)at Denver Seminary
Active member of Chi Sigma Iota lnternaional(RHO Epsilon Chapter)
Refonsess: Upon request
Shiloh Home, Inc. Page 18
Project Narrative
Appendix 2 (Date Collection Instrument/Protocols)
Pine
JUVENILE SEX OFFENDER ASSESSMENT
PROTOCOL
MANUAL
Robert Prentky, Ph.D. & Sue Righthand, Ph.D.
Faye ao
Section I
Static Risk Assessment
Scale I
Sexual Drive /Preoccupation Items
Item I: Prior legally charged sex offenses
Description:
Item 1 is simply the total number of prior charged sexual offenses that
involved physical contact. Conviction is not necessary. Do not count
the current, governing, or index sexual offense(s).
Scoring:
0 = None.
1 = 1 Offense.
2 = More than 1 Offense.
10
Pas e Gat
Item 2: Duration of sex offense history
Description:
This item looks at the total amount of time that the individual has been
known to commit sexual contact offenses [i.e., from the first known
sexual contact offense to the current (governing or index) sexual
contact offense]. In making this judgment, include all credible reports
and self-report. Do not limit scoring to legally charged offenses.
Scoring:
0 = Only 1 known sexual offense and no other history of sexual
aggression (i.e., the governing or index offense is the only known
sexual offense).
1 = There are multiple sex offenses within a brief time period [6
months or less]. The multiple sex offenses may involve multiple
assaults on the same victim or multiple victims.
2 = There are multiple sex offenses that extend over a period greater
than 6 months, whether one victim or multiple victims.
11
P9 as
Item 3 Evidence of sexual preoccupation/obsessions
Description:
This item assesses the juvenile's preoccupation with sexual fantasies
and gratification of sexual needs; consider any credible evidence, self-
reported or documented in the records, of unusually high sexual
drive/high total sexual outlet. Evidence may include reports of
frequent uncontrollable sexual urges; excessive sexualized language,
gestures, or behaviors; multiple paraphilias (such as exposing, peeping,
cross-dressing, fetishes); compulsive masturbation; excessive use of
pornography; cruising; and/or stalking.
Scoring:
0 = No.
1 = There is some evidence suggesting sexual preoccupation or
obsessions but the evidence is too sketchy, vague, or simply
insufficient to merit a score of 2. Examples may be instances
when the individual has exposed himself once but apparently has
not repeated this behavior or when there is an isolated report of
extensive pornography use without independent corroboration.
2 = Yes. Sexual preoccupation or obsessions are clearly present as
indicated by credible report or multiple observations.
12
Pact'. 23
Item 4 Degree of planning in sexual offense/s
Description:
This item looks at the degree of forethought, planning, and
premeditation that took place prior to the sexual assaults. It concerns
the juvenile's modus operandi (MO); everything the juvenile did to
commit the offense. In general, the more detail and forethought
involved in planning an offense, the more complex the MO. With
highly impulsive, opportunistic offenses, the MO will be negligible.
When there are multiple known sexual assaults, score for the assault
that reflects the greatest degree of planning.
Scoring:
0 = Minimal planning. All known sexual offenses appear to have
been impulsive, opportunistic, sudden, and without any apparent
planning.
1 = Moderate degree of planning. There must be clear evidence that
the individual thought about or fantasized about the sexual
offense. Grooming or "setting up" the victim typically reflects
moderate planning.
2 = Detailed planning. There must be a clear modus operandi. The
offenses may appear "scripted," with a particular victim and
crime location targeted. A rape "kit" or paraphernalia may
have been brought to an offense, including weapon and/or
restraints].
13
Pet ye a
Item 5 Gratuitous/extreme sexual exploitation of victim
Description:
This item is intended to capture extreme sexual exploitation of the
victim, as evidenced by the offender forcing the victim to participate in
pornography, videotaping or photographing the victim unclothed,
prostituting the victim or forcing the victim into a sex ring, subjecting
the victim to repeated sexual assaults during protracted confinement,
or performing sadistic acts.
Scoring:
0 = No.
1 = Somewhat. Present but minimal or occasional.
2 = Yes. Clearly present and observed on multiple occasions.
14
Pa9 Q as
Scale 2
Impulsive /Antisocial Behavior Items
Item 6 Caregiver consistency
Description:
This item measures the consistency and stability of caregivers in the
life of the juvenile up to the age of 16. Multiple changes in caregivers
or changes in living situations with different caregivers and the number
of different caregivers are critical. A "change" must last for at least
six months to be considered (for example, if the individual spends a
month living with his aunt and uncle, it would not be considered a
change of caregivers).
Scoring:
0 - Has lived with biological parents until his current age or age 16 if
older than 16.
1 - Has lived with only one biological parent or has lived with one
stepfamily, one foster family, or one adoptive family until his
current age or the age of 16. Score 1 for one change in
caregivers (e.g., from biological parents to step or foster parents).
2 - Two or more changes in caregivers up to his current age or age
16.
15
Pa9 a�.
Item 7 History of problems with expressed anger
Description:
This item includes repeated instances of verbal aggression, angry
outbursts, threatening and intimidating behavior, and nonsexual
physical assaults. Expressed anger also may be reflected in destruction
to property, suspensions or expulsions from school due to anger and
loss of jobs due to anger, and cruelty to animals. The essential point is
that the behavior must reflect anger. Destruction of property, for
example, does not necessarily result from anger.
Scoring:
0 - None/Minimal.
1 - Moderate (1 or 2 different criteria present).
2 - Strong (3 or more different criteria present).
16
(A)ate a�
Item 8 School behavior problems
Description:
Score this item for kindergarten through eighth grade only. School
behavior problems include school failure not due to cognitive
difficulties such as chronic truancy, fighting with peers and/or teachers
or other evidence of serious behavioral problems at school that require
corrective intervention.
Scoring:
0 - None/Minimal.
1 - Moderate (Problems evidenced on 1 or 2 different occasions).
2 - Strong (3 or more different occasions).
p43, ae
Item 9 School suspensions or expulsions
Description:
Score suspensions and expulsions for kindergarten through eighth
grade only. Omit in-school suspensions, if specified. Include both self-
report and documented incidents.
Scoring:
0 = No.
1 = Once.
2 = More than once.
18
2a3 t_ al
Item 10 History of conduct disorder before age 10
Description:
Score this item for behavior before the age of 10. Score for a
persistent pattern of behavioral disturbance characterized by repeated
failure to obey rules, violating the basic rights of others, and engaging
in destructive and aggressive conduct at school, home, and/or in the
community.
Scoring:
0 - None/Minimal.
1 - Moderate (1 or 2 different criteria present).
2 - Strong (3 or more different criteria present).
19
3-e 36
Item 11 Juvenile antisocial behavior [Age 10-17/
Description:
Score this item for behavior between the ages of 10 and 17. Score for
delinquent behavior including non-sexual, victimless crimes, vandalism
and destruction to property, other non-assaultive offenses, fighting and
physical violence, owning or carrying a weapon (other than for sport
and hunting), or other serious rule violations.
ScorinE:
0 - None/Minimal.
1 - Moderate (1 or 2 different criteria present).
2 - Strong (3 or more different criteria present).
20
Past 31
Item 12 Ever arrested before the axe of 16
Description:
Score current offenses as well as proious sexual and non-sexual
offenses. The juvenile must have been charged and/or arrested;
conviction is not necessary.
Scoring:
0 = No.
1 = Once.
2 = More than once.
21
PG�c 3a
Item 13 Multiple types of offenses
Description:
Scoring for this item is not limited to legally charged offenses. Include
self-report as well as other credible reports. Check as many different
types of offense categories as apply and score according to the total
number of categories checked.
_a. Sexual Offenses [such as rape, indecent assault, gross sexual
assault, unlawful sexual contact, open and gross lewdness]
_b. Person Offenses — Non-sexual [such as assault, assault and
battery, assault causing bodily harm, robbery, kidnapping, attempted
murder, manslaughter, murder, terrorizing]
_c. Property Offenses [such as theft, burglary, possessing burglary
tools, larceny, breaking and entering, criminal trespass, malicious
destruction of property, arson, receiving/possessing stolen property,
embezzlement, extortion of property]
_d. Fraudulent Offenses [such as fraud, forgery, passing bad checks,
using stolen credit cards, impersonation, identity fraud, counterfeiting]
_e. Drug Offenses [such as possession of drugs, drug trafficking]
_f. Serious Motor Vehicle Offenses [such as operating to endanger,
operating under the influence, reckless driving, chronic speeding,
leaving the scene of an accident, vehicular homicide]
22
Pc 5e 33
_g. Conduct Offenses [such as disorderly conduct, running away,
vagrancy, malicious mischief, possession of alcohol, resisting arrest,
habitual truant, habitual offender]
_h. Other Rule Breaking Offenses [there is no clear victim but the
law has been broken, such as escape from legal custody, failure to
appear, conspiracy, accessory before or after the fact, possession of a
firearm without a permit, obstruction of justice, violation of conditions
of probation or other release, violation of a protection/ restraining
order, prostitution]
Scoring:
0 = 1 type.
1 = 2 types.
2 = 3 or more types.
23
cbie 34
Item 14 Impulsivity
Description:
This item assesses evidence of a highly impulsive lifestyle as suggested
by a persistent pattern of hasty and rash decision-making without
adequate consideration of the consequences. Behaviors may include
spur-of-the moment truancy and absenteeism, unplanned running
away, a history of escapes, fighting and assaultive behavior, unstable
work history, numerous, brief relationships, reckless driving, driving to
endanger, and joyriding.
Scoring:
0 - None/Minimal.
1 - Moderate (1 or 2 different criteria present).
2 - Strong (3 or more different criteria present).
24
Pale 35-
Item 15 History of substance abuse
Description:
Score this item for a history of problems associated with substance
abuse such as driving violations; physical illness; assaultive behavior;
and school, work. family, or legal problems associated with substance
abuse.
Scoring:
0 - No problems or minimal problems associated with abuse.
1 - Some problems associated with abuse.
2 - Multiple problems associated with abuse.
25
Pacy 310
Item 16 History of parental/caregiver substance abuse
Description:
Score this item for a history of problems associated with substance
abuse in one or both parents or long-term caregivers. Problems
include driving violations; physical illness; assaultive behavior; and
work, family, or legal problems associated with substance abuse.
Scoring:
0 - No problems or minimal problems associated with abuse.
1 - Some problems associated with abuse.
2 - Multiple problems associated with abuse.
26
( ge 31
Section II
DYNAMIC RISK ASSESSMENT
Scale 3
Intervention Items
/
Item 17 Accepts responsibility for sexual offense/s
Description:
Accepting full responsibility for one's sexual offenses/s means no
redirecting or assigning some or all of the responsibility for the offenses
to others (i.e., the individual does not attribute some of the
responsibility to the victim, to friends or other kids, to society, to the
police or the courts, or others). Any statements suggesting other than
full responsibility should be coded as 1 or 2.
Scoring:
0 = Accepts full responsibility for offenses and there is no evidence of
minimizing.
1 = Accepts some (but not total) responsibility. Although occasional
minimizing may be present, individual does not deny offending.
2 = Accepts no responsibility or there is full denial. Otherwise, there
is partial denial and/or significant or frequent minimizing.
27
Pei t 3E
Item 18 Internal motivation for change
Description:
The focus of this item is the extent to which the individual truly
experiences sexual offending as out of character and appears to have a
genuine desire to change his behaviors to avoid any recurrences.
Scoring:
0 = Distressed by his sexual offenses and appears to have a genuine
desire to change behavior.
1 = There is some degree of internal conflict and distress, mixed with
a clear desire to avoid the "consequences" of re-offending.
2 = No internal motivation for change. Does not perceive a need to
change. He may feel hopeless and resigned about life in general
or may deny ever committing a sex offense and therefore
maintains he does not need sex offender treatment. Also score 2
if motivation for treatment is solely external (e.g., to avoid arrest,
incarceration or residential placement).
28
Poi t 39
Item 19 Understands risk factors and applies risk
management strategies
Description:
This item concerns the individual's knowledge and understanding of
factors and situations associated with his sexual offending and the
individual's awareness of risk management strategies and utilization of
such strategies.
Scoring:
0 = Good understanding and demonstration of knowledge of risk
factors and risk management strategies. Knows triggers, his
cognitive (thinking errors), and high-risk situations. Knows and
uses risk management strategies.
1 = Incomplete or partial understanding of risk factors and risk
management strategies. Demonstration of knowledge may be
present, but inconsistent.
2 = Poor or inadequate understanding of risk factors and risk
management strategies. Cannot identify triggers, cognitive
(thinking) errors and offense-justifying attitudes, risk situations,
or risk management strategies.
29
Paee `t0
Item 20 Evidence of empathy, remorse, and Quilt
Description:
This item assesses the extent to which the individual expresses
thoughts, feelings, and sentiments that reflect remorse for sex offense
related behavior and empathy for the victim/s of such behavior. An
attempt should be made to distinguish between statements that appear
to reflect genuine feelings and statements that are primarily cognitive
and reflect attitudes (e.g., socially desirable responses or genuinely held
but strictly intellectual statements about "feeling bad" or beliefs about
the propriety of expressing remorse).
Scoring:
0 = Appears to have genuine remorse for his victims and can
generalize to other victims. Importantly, remorse appears to be
internalized at an affective (emotional) level.
1 = There is some degree of remorse or guilt, however there are
possible egocentric motives (e.g., shame or embarrassment).
Score 1 when the remorse appears to be internalized at a strictly
cognitive (thinking) level.
2 = There is little or no evidence of remorse or empathy for victims.
30
Page I
Item 21 Absence of cognitive distortions (thinking
errors)
Description:
This item assesses the relative presence (or absence) of distorted ideas,
beliefs, or attitudes that justify the sex offense/s and that disown
responsibility for the offenses. Although these attitudes invariably
sound like denial, they serve the specific purpose of excusing the
behavior or disowning responsibility for the behavior.
Scoring:
0 = Expresses no thoughts, attitudes, or statements that disown
responsibility for the offenses or that minimize, distort, or justify
sex offending.
1 = Occasional comments, attitudes or statements that disown
responsibility for the offenses or minimize, distort, or justify sex
offending.
2 = Frequent comments, attitudes or statements that disown
responsibility for the offenses or minimize, distort, or justify sex
offending.
31
Ngye `I?-
•
'Scale 4
Community Stability /Adjustment Factor
SCORE THE REMAINING FIVE ITEMS FOR THE PAST 6 MONTHS.
OMIT THIS SECTION IF THE YOUTH IS INCARCERATED EN A
CORRECTIONAL FACILITY OR A SECURE RESIDENTIAL
TREATMENT PROGRAM.
During the past 6 months:
If a youth has recently been discharged from a correctional facility or
residential treatment program and is now being assessed in the
community,he must have been in the community for at least three
l; months in order to score these 5 items.
If the youth has been incarcerated or has been placed in a residential
treatment program, he must have been in the community for at least
two months prior to incarceration in order to score these 5 items.
32
Page_ 143
•
Item 22 Evidence of poorly managed anger in the
community
Description:
This item includes verbal aggression, angry outbursts, threatening and
intimidating behavior, and non-sexual physical assaults that have
occurred within the past 6 months. Expressed anger also may be
reflected in destruction to property, suspensions or expulsions from
school due to anger and loss of jobs due to anger, and cruelty to
animals. As with Item #7, the key point is poorly controlled anger.
Scoring:
0 - None/minimal.
1 - Moderate (1 or 2 incidents).
2 - Strong (3 or more incidents).
33
page_ Lq
Item 23 Stability of current living situation
Description:
This item assesses the stability (or instability) of the living situation
where the youth is residing at the time of the assessment. Instability
may be evidenced by household members (caregivers, their partners,
or the juvenile's siblings) engaging in: substance abuse, frequent
changes in sexual partners, poor boundaries, use of pornography,
family violence and/or child neglect, having a known criminal history,
or frequently relocating the family's home. Instability may also be
indicated by frequent changes in individual's living situation, or when
the individual is in a high-risk living situation (such as a shelter) or lives
in a high-risk location (i.e., near a bar or a playground).
Scoring:
0 - Stable (presence of no more than 1).
1 - Unstable (presence of 2 or 3).
2 - Highly unstable (presence of 4 or more).
34
Pere_ 4c
Item 24 Stability of school
Description:
This item assesses the stability (or instability) of the youth's behavior in
school. Instability would be evidenced by truancy, repeatedly coming
to school late, fighting with peers or teachers, suspensions or
expulsions, carrying weapons at school, and use of alcohol or drugs at
school. If the youth is not in school, score this item for the stability of
his day, for example, the stability of the youth's behavior at work. For
the most part, the exemplars of instability are consistent across
settings. For example, in the work setting, instability may be evident
by failing to come to work, coming to work late, or being fired.
Scoring:
0 - Stable (no evidence of any of the above).
1 - Unstable (presence of 1 or 2 of the above).
2 - Highly Unstable (presence of 3 or more of the above).
35
pay e y
Item 25 Evidence of positive support systems in the
community
Description:
This item considers the relative presence or absence of support systems
that the youth has available to him in the community and that he uses
for positive support. Support systems may include apparently
supportive family members, extended families, foster families, friends
or significant others such as therapists and juvenile probation officers
and caseworkers. Positive supports also may be indicated by
participation in organized after-school sports and activities and
involvement in church and church-related functions.
Scoring:
0 - Considerable support systems (2 or more of the above apply).
1 - Some support systems (1 of the above applies).
2 - No known support systems/only negative support systems (such
as delinquent peers).
36
Item 26 Quality of peer relationships
Description:
This item assesses the nature and quality of the juvenile's social life,
the extent to which his time is occupied by healthy, non-delinquent
social activity, and the extent to which the individuals that he spends
his time with are age appropriate and non-delinquent.
Scoring:
0 - Socially active, peer-oriented and rarely alone; often with friends
in structured and unstructured social and/or sports activities;
friends are non-delinquent.
1 - A few casual (non-delinquent) friends, some involvement in
structured or unstructured activities, occasional social life.
2 — Is, for-the-most-part, withdrawn from peer contact and socially
isolated; no "good" friends, just "acquaintances" or all peers are
part of a delinquent group.
37
Shiloh Home, Inc. Page 48
Project Narrative
Appendix 3 (Sample Consent Forms)
Pay_ 45
SHILOH HOME, INC.
6400 West Coal Mine Avenue
Littleton, Colorado 80123
Phone: (303) 932-9599 TREATMENT CONSENT FORM
g:\admissio\CCC
I, (We)
certify that I(we) give and grant my(our) consent for my/our child
to participate in and receive treatment(individual, family, group, milieu therapies)within a
Shiloh Home, Inc. program.
It is understood that will be expected to participate fully in
the therapeutic program outlined by the Treatment Team. In addition, I (we) agree to assist the
Treatment Team to the fullest extent possible in achieving the goals established for my/our child
during his placement at SHILOH HOME, INC. It is understood that refusal to participate in
treatment may result in termination from the program.
Signature of(Parent) or Guardian/Date
Signature of(Parent) or Guardian/Date
Witness/Date
Signature of Client/Date
blase So
Notice of Privacy Practices
Shiloh Home Inc.
Effective Date: 4/14/2003
THIS NOTICE DESCRIBES HOW MEDICAL/MENTAL HEALTH INFORMATION ABOUT YOU
MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION. PLEASE REVIEW IT CAREFULLY.
If you have any questions about this notice, please contact the Privacy Official, Maureen Grey, by
dialing 303-932-9599 x308.
During a client's stay at Shiloh Home, a record of care is maintained. Typically, this record
contains information regarding behavioral/emotional symptoms, a client's reported thoughts and
feelings, results of assessments at Shiloh Home, diagnostic information, information about
treatment, educational information, a plan for future care or treatment, and billing-related
information. Information about a client's family members may also be contained in the record, as
such information pertains to the client's treatment. This notice applies to all of the records of your
care generated by Shiloh Home, whether made by Shiloh Home staff, your Shiloh Home clinician
or any Shiloh Home employee.
Our Responsibilities
We are required by law to maintain the privacy of your health information and provide you a
description of our privacy practices. We will abide by the terms of this notice and notify you if we
cannot agree to a requested restriction. We will accommodate reasonable requests you may
have to communicate health information by alternative means or at alternative locations.
Uses and Disclosures
How we may use and disclose Medical/Mental Health Information about you.
The following categories describe examples of the way we use and disclose medical information:
For Treatment: We may use medical/mental health information about you in the provision of
treatment or services. We may disclose medical/mental health information about you to treatment
counselors, clinicians, administrators and teachers who are involved in your care and are Shiloh
Home employees. For example: treatment counselor staff may need to know information about
behavioral and/or emotional information about you in order to determine the amount of
freedoms/privileges while you are living in a Shiloh Home residence. This would be done to that
an appropriate amount of structure and supervision could be in-place to better ensure your safety
and that of other clients and staff.
We may also provide other mental health providers, department of human services
representatives, probation officers and the courts with copies of various reports that should assist
these people in their work with you. Please understand that such releases of information are only
with informed consent allowing for the sharing of information. Exceptions to obtaining informed
consent would be in case of medical/mental health emergency, the commission of criminal
behavior on the part of the client or by court order. In addition, the department of human services
has the right to review records for the purposes of licensing.
For Payment: We may use and disclose medical/mental health information about your treatment
and services to bill and collect payment from you,your insurance company or a third party payer.
For example,we may need to give your insurance company information about your care so they
will pay us or reimburse you for your treatment at Shiloh Home.
For Health Care Operations: Shiloh Home staff may use information in your health record to
assess the care and outcomes in your case and others like it. The results will then be used to
Mage CI
• •
• , •
continually improve the quality of care for all clients we serve. For example,we may combine
information about many clients to evaluate the need for new services or treatment.We may
disclose information to outside entities educational purposes. The disclosure of such information
will not identify any clients. We may combine medical/mental health information we have with
that of other treatment providers to see where we can make improvements. We may remove
information that identifies you from this set of medical information to protect your privacy.
We may also use and disclose medical/mental health information:
To business associates we have contracted with to perform the agreed upon service and
billing for it;
To assess your satisfaction with our services;
To tell you about possible treatment alternatives;
As part of fund raising efforts;
For Population based activities relating to improving program outcomes or reducing
treatment costs; and
For conducting training programs or reviewing competence of mental health care
professionals.
Business Associates: There are some services provided in our organization through contracts
with business associates. Examples include our accrediting body,which serves to support Shiloh
Home in maintaining high standards of care.When Shiloh Home works with its accrediting body,
we may disclose your health information to our business associates so that they can perform the
job we've asked them to do. To protect your health information, however, we require the business
associate to appropriately safeguard your information.
Individuals Involved in Your Care or Payment for Your Care: We may release
medical/mental health information about you to a parent, county caseworker, guardian ad litem
and/or probation officer who is involved in your treatment. In addition, we may disclose medical
information about you to an entity assisting in an emergency situation so that your family can be
notified about your condition, status and location. Such disclosures, except in cases of
emergency, court order, or where existing laws mandate disclosure, are only done with
appropriate consent.
Research:We may disclose information to researchers when an institutional review board that
has reviewed the research proposal and established protocols to ensure the privacy of your
health information has approved their research.
Organized Health Care Arrangement: This practice is presenting you this document as a
notice. Information will be shared as necessary to carry out treatment, payment and health care
operations. Physicians and caregivers may have access to protected health information in their
offices to assist in reviewing past treatment as it may affect treatment at the time. Affiliated
Covered Entity: Caregivers at other facilities or practices may have access to protected health
information at their locations to assist in reviewing past treatment information as it may affect
treatment at this time. Please contact the facility or practice Privacy Official for further information
on the specific sites included in this affiliated covered entity.
As required by law,we may also use and disclose health information for the following types of
entities, including but not limited to:
Food and Drug Administration
Public Health or Legal Authorities charged with preventing or controlling disease, injury or
disability
Law Enforcement Officials
Thal e_ S
State and County Departments of Human Services
The Courts
Health Oversight Agencies
Law Enforcement/Legal Proceedings: We may disclose health information for law enforcement
purposes as required by law or in response to a valid subpoena.
State-Specific Requirements: Colorado Department of Human Services requires access to all
records as part of its role in oversight of day treatment and residential treatment centers.
Your Health Information Rights
Although your client record is the physical property of Shiloh Home that compiled it,you have the
Right to:
Inspect and Copy: You have the right to inspect and copy information that may be used
to make decisions about your care. Usually,this is certain mental health and billing
records, but does not include psychotherapy notes or other notes which we are legally
forbidden to disclose. We may deny your request to inspect and copy in certain very
limited circumstances. If you are denied access to mental health information,you may
request that the denial be reviewed. Another mental health care professional chosen by
Shiloh Home will review your request and the denial. The person conducting the review
will not be the person who denied your request. We will comply with the outcome of the
review.
Amend: If you feel that mental health/medical information we have about you is incorrect
or incomplete, you may ask us to amend the information. You have the right to request
an amendment for as long as the information is kept by or for Shiloh Home.
We may deny your request for an amendment and if this occurs, you will be notified of
the reason for the denial.
An Accounting of Disclosures: You have the right to request an accounting of
disclosures. This is a list of the disclosures we make of medical information about you.
Request Restrictions: You have the right to request a restriction or limitation on the
mental health/medical information we use or disclose about you for treatment, payment
or health care operations. You also have the right to request a limit on the mental
health/medical information we disclose about you to someone who is involved in your
care or the payment for your care, like a family member or friend. For example, you could
request that information shared about family members not be shared with those family
members.
We are not required to agree to your request. If we do agree,we will comply with your
request unless the information is needed to provide you emergency treatment.
Request Confidential Communications: You have the right to request that we
communicate with you about mental health/medical matters in a certain way or at a
certain location. We will agree to the request to the extent that it is reasonable for us to
do so. For example, you can ask that we not leave messages on an answering machine,
or that notices of treatment staffings be mailed to an alternative location.
A Paper Copy of This Notice: You have the right to a paper copy of this notice. You
may ask us to give you a copy of this notice at any time. Even if you have agreed to
receive this notice electronically, you are still entitled to a paper copy of this notice.
To exercise any of your rights, please obtain the required forms from the Privacy Official and
submit your request in writing.
-Pa'c 63
CHANGES TO THIS NOTICE
We reserve the right to change this notice and the revised or changed notice will be effective for
information we already have about you as well as any information we receive in the future. The
current notice will be posted on the practice's website and include the effective date. In addition,
each time you visit the practice for treatment or health care services, we will have available a
copy of the current notice in effect.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with Shiloh Home
by contacting the main number and asking for Shiloh Home's Privacy Official or with the
Secretary of the Department of Health and Human Services. To file a complaint with Shiloh
Home, contact the Privacy Official. All complaints must be submitted in writing.
You will not be penalized for filing a complaint.
OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of medical information not covered by this notice or the laws that
apply to us will be made only with your written permission. If you provide us permission to use or
disclose medical information about you, you may revoke that permission, in writing, at any time. If
you revoke your permission,we will no longer use or disclose medical information about you for
the reasons covered by your written authorization. You understand that we are unable to take
back any disclosures we have already made with your permission, and that we are required to
retain our records of the care that we provided to you.
PRIVACY OFFICIAL
Name: Maureen Grey
Telephone Number: 303-932-9599 X308
Address:
6400 W. Coal Mine Ave.
Littleton, CO 80123
k�a�e S4
•
•
DISCLOSURE STATEMENT
Shiloh Home,Inc.
6400 West Coal Mine Avenue
Littleton,Colorado 80123
2. Shiloh employs licensed and unlicensed psychotherapists to do therapeutic work with clients,individually,in groups and in family
therapy.
3. The Colorado Department of Regulatory Agencies has the general responsibility of regulating the practice of licensed
psychologists,licensed clinical social workers,licensed professional counselors,licensed marriage and family therapists,certified
school psychologists,and unlicensed individuals who practice psychotherapy.
The agency within the Department that has responsibility specifically for licensed and unlicensed psychotherapists is the State
Grievance Board, 1560 Broadway,Suite#1340,Denver,Colorado 80202,(303)894-7766.
4. Client Rights and Important Information:
a. You are entitled to receive information regarding methods of therapy,the techniques used,the duration of your therapy
(if it can be determined),and the fee structure. Please ask if you would like to receive this information.
b. You can seek a second opinion from another therapist to terminate therapy at any time.
c. In a professional relationship,sexual intimacy between a therapist and a client is never appropriate. If sexual intimacy
occurs,it should be reported to the State Grievance Board.
(FOR LICENSED PSYCHOTHERAPISTS OR UNLICENSED PSYCHOTHERAPISTS PRACTICING UNDER
SUPERVISION—see state Grievance Board Rule 12(e).)
Generally speaking,the information provided by and to client during therapy sessions is legally confidential if the
therapist is a certified school psychologist,a licensed clinical social worker,a licensed marriage and family therapist,a
licensed professional counselor,a licensed psychologist,or an unlicensed psychotherapist practicing under the
supervision of a licensed psychotherapist. If the information is legally confidential,the therapist cannot be forced to
disclose the information without the client's consent. Information disclosed to an unlicensed psychotherapist not
practicing under the supervision of a licensed psychotherapist is not legally confidential.
There are exceptions to the general rule of legal confidentially. These exceptions are listed in the Colorado Statues(see
Section 12-43-218,C.R.S.,in particular). You should be aware that,except in the case of information given to a
licensed psychologist,legal confidentiality does not apply in a criminal or delinquency proceeding. There are other
exceptions that I will identify to you as the situations arise during therapy.
5. If you have any questions or would like additional information,please feel free to ask.
I have read the preceding information and understand my rights as a client/patient.
Client/Resident/Date
Parent/Guardian/Date
Therapist/Date
g:\admissioklisclose
5g
SHILOH HOME,INC.
6400 West Coal Mine Avenue
Littleton, Colorado 80123 AUTHORIZATION TO RELEASE/
Phone: (303) 932-9599 Fax: (303) 973-1269 REQUEST FOR INFORMATION
G:/Admission/Release
I, authorize staff member of Shiloh Home, Inc., 6400 West
Coal Mine Avenue,Littleton, Colorado 80123,to obtain from,and share information with:
Name:
Address:
Phone#:
Regarding:
Client's name Client's DOB Parent/Guardian Signature Date
Information may include:
Social History Dental
Psychological Evaluation immunizations
Hosnitalization Note/Summaries Medical Records
Progress Notes Other
Court Renorts/Investigative Renorts Treatment Summary
Academic Records Offense Specific
Placement History
Information to be used for:
Assessment Leaving School D.
Service Planning Entering the School D.
Continuity of Care College Admission
Other
I understand that I may revoke this authorization to release/request information at any time by giving written notice
to Shiloh Home,Inc. Without such revocation,this authorization shall expire on / / (date). (If left
blank,ninety(90)days from the date of my signature). I also herewith release Shiloh Home,Inc., from all liability
for releasing such information.
NOTICE TO WHOM THIS INFORMATION IS GIVEN: This information has been disclosed to you from
records whose confidentiality is protected by Federal Law. Federal regulations prohibit you from making further
disclosure of this information without the specific written consent of the person to whom it pertains.
I hereby revoke this Authorization to Release/Request for Information:
SIGN HERE ONLY IF REVOKING THIS RELEASE
Client: Date: Witness: Date:
A copy of this Authorization is as valid as the original.
SHILOH HOME,INC. RESEARCH POLICY
REV:5/15/06
Research will receive Board, CEO, and parent/guardian approval and adhere to the
following guidelines:
1) The consent of participation in the research is voluntary and informed, without any
implied deprivation or penalty for refusal to participate, and with due regard for
participant's privacy and dignity.
2) The participants will be protected from unwarranted physical or mental discomfort,
distress, harm, danger or deprivation.
3) The evaluation of services or cases will only be discussed with persons directly and
professionally concerned with the information.
4) All information about the participants in the research will be treated strictly
confidential.
�aq e 57
Internal Revenue Service
Department of the Treasury
P. O. Box 2508
Date: May 12, 2004 Cincinnati, OH 45201
Person to Contact:
Shiloh Home, Inc. Steve Brown 31-07422
6400 W. Coal Mine Ave Customer Service Representative
Littleton, CO 80123 Toll Free Telephone Number:
8:00 a.m.to 6:30 p.m.EST
877-829-5500
Fax Number:
513-263-3756
Federal Identification Number:
84-0978992
Dear Sir or Madam:
This is in response to your request of May 12, 2004, regarding your organization's tax-exempt status.
In October 1985 we issued a determination letter that recognized your organization as exempt from federal
income tax. Our records indicate that your organization is currently exempt under section 501(c)(3) of the
Internal Revenue Code.
Based on information subsequently submitted, we classified your organization as one that is not a private
foundation within the meaning of section 509(a) of the Code because it is an organization described in
sections 509(a)(1) and 170(b)(1)(A)(vi).
This classification was based on the assumption that your organization's operations would continue as stated
in the application. If your organization's sources of support, or its character, method of operations, or purposes
have changed, please let us know so we can consider the effect of the change on the exempt status and
foundation status of your organization.
Your organization is required to file Form 990, Return of Organization Exempt from Income Tax, only if its
gross receipts each year are normally more than $25,000. If a return is required, it must be filed by the 15th
day of the fifth month after the end of the organization's annual accounting period. The law imposes a penalty
of$20 a day, up to a maximum of$10,000, when a return is filed late, unless there is reasonable cause for the
delay.
All exempt organizations (unless specifically excluded) are liable for taxes under the Federal Insurance
Contributions Act (social security taxes) on remuneration of$100 or more paid to each employee during a
calendar year. Your organization is not liable for the tax imposed under the Federal Unemployment Tax Act
(FUTA).
Organizations that are not private foundations are not subject to the excise taxes under Chapter 42 of the
Code. However, these organizations are not automatically exempt from other federal excise taxes.
Donors may deduct contributions to your organization as provided in section 170 of the Code. Bequests,
legacies, devises, transfers, or gifts to your organization or for its use are deductible for federal estate and gift
tax purposes if they meet the applicable provisions of sections 2055, 2106, and 2522 of the Code.
Pale_ Sir
-2-
Shiloh Home, Inc.
84-0978992
Your organization is not required to file federal income tax returns unless it is subject to the tax on unrelated
business income under section 511 of the Code. If your organization is subject to this tax, it must file an
income tax return on the Form 990-T, Exempt Organization Business Income Tax Return, In this letter, we are
not determining whether any of your organization's present or proposed activities are unrelated trade or
business as defined in section 513 of the Code.
Section 6104 of the Internal Revenue Code requires you to make your organization's annual return available
for public inspection without charge for three years after the due date of the return. The law also requires
organizations that received recognition of exemption on July 15, 1987, or later, to make available for public
inspection a copy of the exemption application, any supporting documents and the exemption letter to any
individual who requests such documents in person or in writing. Organizations that received recognition of
exemption before July 15, 1987, and had a copy of their exemption application on July 15, 1987, are also
required to make available for public inspection a copy of the exemption application, any supporting documents
and the exemption letter to any individual who requests such documents in person or in writing.
For additional information on disclosure requirements, please refer to Internal Revenue Bulletin 1999 - 17.
Because this letter could help resolve any questions about your organization's exempt status and foundation
status, you should keep it with the organization's permanent records.
If you have any questions, please call us at the telephone number shown in the heading of this letter.
Sinnc-Q-cerely, ,l,
tl r-0-
)
Janna K. Skufca, Director, TE/GE
Customer Account Services
0gye 59
Internal Revenue Service Department of the Treasury
District Director
FFN: 750109595
Date: Employer Identification Number:
MAR 17 1988 84-0978992
v Case Number:
757322050E0
Person to Contact:
ED Technical Assistor
Shiloh Homes , Inc . Contact Telephone Number:
6884 S. Marshall St . , Suite 9 (214) 767-3526 EO: 7213:4913:JS
Littleton, CO 80123 Our Letter Dated:
October 16, 1985
Caveat Applies:
N/A
Dear Sir or Madam:
This modifies our letter of the above date in which we stated that you would be
treated as an organization that is not a private foundation until the expiration. of your
advance ruling period.
Based on the information you submitted, we have determined that you are not a private
foundation within the meaning of section 509(a) of the Internal Revenue Code because you
are an organization of the type described in section 170(b) (1) (A) (vi) 6 . Your exempt
status under Code section 501(c) (3) is still in effect. 509(a) (1)
Grantors and contributors may rely on this determination until the Internal Revenue
Service publishes notice to the contrary. However, if you lose your section
509(a) (1) status, a grantor or contributor may not rely on this determination if
he or she was in part responsible for, or was aware of, the act or failure to act that
resulted in your loss of such status, or acquired knowledge that the Internal Revenue
Service had given notice that you would be removed from classification as a section
509(a) (1) organization.
If—the heading- at` this letcwr indicates- that--a caveat- s he caveat-below-or-on-- -
the enclosure is an integral part of this letter.
Because this letter could help resolve any questions about your private foundation
status, please keep it in your permanent records.
If you have any questions, please contact the person whose name and telephone number
are shown above.
Sincerely yours,
G Cagle Glenn Cagle
l e ,(,
T 7 �'
District Director
District Director, Dallas District Letter 1050(00) (Rev. 3-86)
3/41 e tea
. .
Internal Revenue Service Department of the Treasury
District Director
Date: ryr r 1 A 1985 Employer Identification Number.
lllJll.. 84-09 7899 2
Accounting Period Ending:
September 30
Foundation Status Classification:
170(b) (1) (A) (vi) and 509(a) (1)
p Shiloh Home , Inc. Advance Ruling Period Ends:
7201 S . Sheridan Court September 30, 1987
Littleton, CO 80123 PersontoContad:
EO Technical Assistor
Contact Telephone Number.
(214) 767-3526
EO: 7213:4913:DAL:JS
Dear Applicant :
Based on information supplied, and assuming your operations will be as stated
in your application for recognition of exemption, we have determined you are exempt
from Federal income tax under section 501(c) (3) of the Internal Revenue Code.
Because you are a newly created organization, we are not now making a final
determination of your foundation status under section 509(a) of the Code. However,
we have determined that you can reasonably be expected to be a publicly supported
organization described in section 170(b) (1) (A) (vi) and 509(a}(1) .
Accordingly, you will be treated as a publicly supported organization, and not
as a private foundation, during an advance ruling period. This advance ruling period
begins on the date of your inception and ends on the date shown above.
Within 90 days after the end of your advance ruling period, you must submit to
us information needed to determine whether you have met the requirements of the
applicable support test during the advance ruling period. If you establish that you
have been a publicly supported organization, you will be classifiedasa section
509 (a) (1) or 509 (a) (2) organization as long as you continue to meet the requirements
of the applicable support test. If you do not meet the public support requirements
during the advance ruling period, you will be classified as a private foundation
for future periods. Also, if you are classified as a private foundation, you will
be treated as a private foundation from the date of your inception for purposes of
sections 507(d) and 4940.
Grantors and donors may rely on the determination that you are not a private
foundation until 90 days after the end of your advance ruling period. If you submit
the required information within the 90 days, grantors and donors may continue to
rely on the advance determination until the Service makes a final determination of
your foundation status. However, if notice that you will no longer be treated as a
section 509(a) (1) organization is published in the Internal Revenue
Bulletin, grantors and donors may not rely on this determination after the date of
such publication. Also, a grantor or donor may not rely on this determination if he
or she was in part responsible for, or was aware of, the act or failure to act that
resulted in your loss of section 509(a) (1) status, or acquired knowledge
that the Internal Revenue Service had given notice that you would be removed from
classification as a section 509(a) (1) organization.
(over)
hcle (et
, If ,sources of support, or your purposes, character, or method of operation
change, please let us know so we can consider the effect of the change on your
exempt status and foundation status. Also, you should inform us of all changes in
your name or address.
As of January 1, 1984, you are liable for taxes under the Federal Insurance
Contributions Act (social security taxes) on remuneration of $100 or more you pay
to each of your employees during a calendar year. You are not liable for the tax
imposed under the Federal Unemployment Tax Act (FUTA) ,
Organizations that are not private foundations are not subject to the excise
taxes under Chapter 42 of the Code. However, you are not automatically exempt from
other Federal excise taxes. If you have any questions about excise, employment, or
other Federal taxes, please let us know.
Donors may deduct contributions to you as provided in section 170 of the Code.
Bequests, legacies, devises, transfers, or gifts to you or for your use are
deductible for Federal estate and gift tax purposes if they meet the applicable
provisions of sections 2055, 2106, and 2522 of the Code.
You are required to file Form 990, Return of Organization Exempt from Income
Tax, only if your gross receipts each year are normally more than $25,000. If a
return is required, it must be filed by the 15th day of the fifth month after the
end of your annual accounting period. The law imposes a penalty of $10 a day, up to
a maximum of $5,000, when a return is filed late, unless there is reasonable cause
for the delay.
You are not required to file Federal income tax returns unless you are subject
to the tax on unrelated business income under section 511 of the Code. If you are
subject to this tax, you must file an income tax return on Form 990—T, Exempt
Organization Business Income Tax Return. In this letter, we are not determining
whether any of your present or proposed activities are unrelated trade or business
as defined in section 513 of the Code.
You need an employer identification number even if you have no employees. If
an employer identification number was not entered on your application, a number
will be assigned to you and you will be advised of it. Please use that number on
all returns you file and in all correspondence with the Internal Revenue Service.
-
Because this letter could help resolve any questions about your exempt status
and foundation status, you should keep it in your permanent records.
If you have any questions, please contact the person whose name and telephone
number are shown in the heading of this letter.
Sincerely yours,
Glenn Cagle
District Director
Letter1045(D0) (Rev. 10-83)
Shiloh Home, Inc. Page 62
Request For Proposal
Budget
Offense Specific (Sex Abuse) Treatment
Individual Therapy $ 75.00
Family Therapy 75.00
Group Therapy 45.00
Multi-Family Therapy 45.00
Additional costs will be negotiated with Weld County at intake as well as the type of
therapy and length of treatment for each youth and family. Additional costs may include
but are not limited to case management, tracking services, court testimony, and
polygraph.
•
EXHIBIT B
SUPPLEMENTAL NARRATIVE TO RFP
Shiloh Home, Inc.
6400 S. Coal Mine Ave
Littleton, Co 80123
FYC Commission Recommendations
> Evidenced-Based Practice/Service
Shiloh practices the best standards of care and emphasizes implementation of
evidenced-based treatment practices. Shiloh adhere to the SOMB (Sexual Offender
Mangagement Board) Guidelines and Standards. Risk assessment will be addressed
through the JSOAP (Juvenile Sexual Offender Assessment),updated tools, ongoing
team and family collaboration,treatment progress and team members' input,
behavioral observation within all arenas of the child's life(home, school,job, social,
community activities). Adjunct referral to polygraphs, arousal measurements,
psychological services and psychiatric services may also be part of risk assessment
and the ongoing treatment.
Treatment sessions utilize the following evidence-based treatments:
• Cognitive-Behavioral Therapy(correcting thinking errors; linking thoughts,
feelings and behaviors; teaching new,healthy, empathic and reality-based way of
thinking).
• Behavioral Therapy(teaching and rehearsing healthy ways to behave when
overwhelmed by feelings and perceived needs).
• Psycho-education and Family System Theory is utilized
> Program Improvement Plan
Shiloh's priority is the opportunity for youth and families to be provided services
within their community is a benefit to achieving such outcomes. Shiloh strives to
achieve the following:
• Protecting children from abuse and neglect
• Maintaining children safely in their homes when possible and appropriate
• Upholding permanency and stability in the children's living situations
• Preserving continuity of family relationships and connections
• Enhancing families' capacity to provided for their children's needs
• Accessing appropriate educational services for children
• Receiving adequate mental health and medical needs
Tobi Vegter
From: Maureen Grey[maureengrey735@hotmail.com]
Sent: Wednesday, May 23, 2007 2:50 PM
To: Tobi Vegter
Subject: RFP response
Attachments: Weld FYC Report.doc
Ela
Weld FYC
Report.doc(25 KB)
Tobi,
Attached is the final part of the response. Please let me know if you need
additional information.
Thank You,
Maureen E. Grey
Director of Licensing and Operations
Shiloh Home, Inc.
303-932-9599 ext. 308
1
Through the use of the outpatient offense specific program/Day Treatment Program,
it is hoped that the PIP outcomes can be achieved, especially as the programs will
focus on family connections and preserving safety. When appropriate for all parties
maintaining the youth in home can lead to overall success for the developing child,
elimination of abuse and long-term outcomes.
➢ Evaluation
Evaluation of the clients and families progress is completed throughout treatment.
Shiloh tracks progress through monthly staffings to include county worker, client and
family. Client assessments and evaluations are conducted by a variety of disciplines.
The client is initially assessed for appropriateness of admission and a complete
assessment is completed on each client upon admission to include the following:
• Identifying information
• The needs and services for all family members
• Emergency health needs
• Emergency contacts
• Imminent danger or risk of future harm
• Guardianship status
• History of treatment and effectiveness
• Mental health screening
• Clients/families strengths and weaknesses
• Psychiatric issues
• Legal status
Outcomes measures are utilized by the agency to inform and provide feedback on the
quality of treatment and in meeting PIP requirements. The ultimate goal of outcome
measures is to help ensure that high quality standards are implemented that will
ensure interventions success. Outcomes are assessed at various identified key points
in the treatment process. Outcomes monitored by Shiloh Home include the
following:
• Family participation as measured by family member's attendance in monthly
staffings and level of participation.
• Client improvement in clinical/behavioral functioning is measured at admission
and again at discharge using the CCAR(Colorado Client Assessment Record).
• Client improvement in academics is measured at admission and at discharge using
the WRAT(Wide Range Achievement Test).
DEPARTMENT OF SOCIAL SERVICES
P.O. BOX A
I'DGREELEY, CO. 80632
Website:www.co.weld.co.us
WI Administration and Public Assistance(970)352-1551-
OFax Number(970)353-5215
May 11,2007
COLORADO
Steven Rameriz,CEO
Shiloh Home, Inc.
6400 W.Coal Mine Avenue
Littleton, CO 80123
Re: Bid#003-DT-07(RFP 07006)Day Treatment
Bid#004-SAT-07(RFP 07007) Sex Abuse Treatment
Dear Mr. Ramirez:
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 appreciate 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(FYC)Commission recommended approval of your Bid#
003-DT-07, (REP 07006)Day Treatment, for inclusion on our vendor list. The FYC
Commission attached the following recommendation and conditions to your bid.
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.
Conditions: Bidder must submit information that was not addressed or submitted with the
original bid submission,including;
1. Provide information relating to groups under the Target Eligibility section,
2. Address medical eligibility,
3. Provide a statement related to how Bilingual services are being addressed,
4. Describe specific service objectives,including the methods the bidder will use to
measure, evaluate,and monitor services.
5. Provide information as required relating to evidenced-based services,
6. Provide the educational background of staff under Staff Qualifications,
7. Provide the program rate under Budget Information.
-
Page 2
Shiloh Home of RFP Practice 2007-2008
• The Families,Youth and Children(FYC)Commission recommended approval of your Bid#
004-SAT-07,(RFP 07007) Sex Abuse Treatment, for inclusion on our vendor list. The FYC
Commission attached the following recommendation to your bid.
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.
B. Required Response by FYC Bidders
Concerning FYC Commission Recommendations:
You are requested to review the FYC Commission recommendations 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.
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 accepts your mitigating circumstances. If you do not accept the conditions,
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 recommendations and conditions.Please respond in writing to Tobi Vegter, Core Services
Coordinator,Weld County Department of Social Services,P.O.Box A,Greeley, CO, 80632,by Monday,
May 21, 2007,close of business.
If you have questions concerning the above,please call Tobi Vegter,352.1551, extension 6392.
Sincerely,
dy A. G ego, Dir r
cc: Juan Lopez, Chair,FYC Commission
Tobi Vegter, Core Services Coordinator
Gloria Romansik, Social Services Administrator
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