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Home My WebLink About20071748.tiff Weld County Department of Social Services Notification of Financial Assistance Award for Core Funding Type of Action Contract Award No. X Initial Award 07-CORE-56 Revision (RFP-FYC-006-00; 003-MH-07) Contract Award Period Name and Address of Contractor Beginning 06/01/2006 and Jack J. Gardner, Psychologist-Greeley Counseling Center Ending 05/31/2007 Mental Health Services 1228 8th Street Greeley,CO 80631 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Assistance Program provides screening, evaluations,and other Award is based upon your Request for Proposal(RFP). The assessment services intended to provide information RFP specifies the scope of services and conditions of award. needed by Social Services staff. Capacity is 8-12 Except where it is in conflict with this NOFAA in which case evaluations per month, and five to ten individuals or the NOFAA governs,the RFP upon which this award is families per month. Provider does not offer bilingual based is an integral part of the action. services. Bicultural and South County services.. Special conditions Cost Per Unit of Service 1) Reimbursement for the Unit of Services will be based Episode Rate Per on an hourly or episode rate per child or per family. After Care Low(Training) $1,800.00 2) The hourly rate will be paid for only direct face to Psychological Exam(Adult Psychological face contact with the child and/or family, as Evaluations) $1,339.00 evidenced by client-signed verification form, and as Treatment Package (Adult Psychological Evaluations, specified in the unit of cost computation. Standard in office-additional parties) $927.00 3) Unit of service costs cannot exceed the hourly and Treatment Package Low (Adolescent/adult yearly cost per child and/or family. Psychological Evaluations, Sexual-specific- 4) Payment will only be remitted on cases open with,and One party) $1,648.00 referrals made by the Weld County Department of Treatment Package Moderate (Adolescent/adult Social Services. Psychological Evaluations 5) Requests for payment must be an original submitted to in Correctional Facilities $1,450.00 the Weld County Department of Social Services by the Treatment Package High(Adolescent/adult end of the 251h calendar day following the end of the Psychological Evaluations in Other Settings (i.e.,group month of service. The provider must submit requests home,foster home) $1,450.00 for payment on forms approved by Weld County Diagnostic Services (Parental Fitness Department of Social Services. Requests for payments Evaluations) $600.00 submitted 90 days from the date of service,and Hourly Rate Per thereafter, will not be Care Coordination(Consultation/DSS) $120.00 paid. Individual Counseling(Individual&Family 6) The Contractor will notify the Department of any Therapy) $120.00 changes in staff at the time of the change. Family Counseling (Individual&Family Therapy in-home, 1s`hour) $135.00 Crisis Intervention Services (Emergency- after hours) $160.00 After Care Moderate(Formal Consultations) $115.00 Parent-Child Interactions (Parent-Child 2007-1748 Page 1 of 2 Type of Action Contract Award No. X Initial Award 07-CORE-56 Revision (RFP-FYC-006-00; 003-MH-07) Contract Award Period Name and Address of Contractor Beginning 06/01/2006 and Jack J. Gardner, Psychologist-Greeley Counseling Center Ending 05/31/2007 Mental Health Services 1228 8th Street Greeley, CO 80631 Interactional Evaluation-DSS Greeley) $103.00 Therapeutic Visitations [Parent-Child Inter- actional Evaluations(at DSS Fort Lupton, or more than 30 miles,l"hour)] $135.00 Multi-family Therapy[Parent-Child Interactional Evaluations(at DSS Ft. Lupton, or more than 30 miles) 2nd hour] $125.00 Treatment Package High[Parent-Child Interactional Evaluations(at DSS-Ft. Lupton, or more than 30 miles) 3r°hour] $115.00 After Care High Interactional Evaluations (local home visits) $113.00 Court Testimony $175.00 Other Services Court Facilitation, Mediation, or Staffing $110.00 Enclosures: X Signed RFP: Exhibit A X Supplemental Narrative to RFP: Exhibit B X Recommendation(s) X Co ' ions of Approval Approvals: Program fficial: n, By C . \ By /l�►I David E. Long, Chair Judy riego, irector Board of,Weld County Commissio rs Weld qty artmen of Social Services Date: JUN 1 8 2007 Date: o' Page 2 of 2 ,Roo -/244) EXHIBIT A SIGNED RFP '603-MH-07 ■ ■ INVITATION TO BID BID 001-07 -------------- DATE: February 28,2007 BID NO: 001-07 RETURN BID TO: Monica Mika, Director of Administrative Services 915 10th Street,P.O.Box 758,Greeley,CO 80632 Third floor,Centennial Building. Purchasing Department ------------- SUMMARY Request for Proposal for: Colorado Family Preservation Act—Core Services Program Deadline: Friday,March 30, 2007. 10:00 a.m. (MST) The Families, Youth and Children Commission, an advisory commission to Social Services,announces that competing applications will be accepted for approved providers pursuant to the Board of Weld County Commissioners' authority under the Colorado Family Preservation Act(C.R.S. 26-5.5-101)and Emergency Assistance for Families with Children at Imminent Risk of Out-of-Home Placement Act (C.R.S. 26-5.3-101). The Families, Youth and Children Commission wishes to approve services targeted to run from June 1, 2007,through May 31, 2008, at specific rates for different types of service,the County will authorize approved providers and rates for services only.This program announcement consists of the following documents,as follows: • Invitation to Bid • Main Request for Proposal(All program areas) • Addendum A—Program Improvement Plan Requirements (by program area) • Addendum B—Scope of Services (by program area) • Core Budget Form Delivery Date (After receipt of order) BID MUST BE SIGNED IN INK Program Area: M.ey '�k/ #ec//t �,nrtn&a Sc�k '. u "rG/t [✓ t -s �• TYPED OR PRINTED SIGNATURE VENDOR Tack T C-c..rcfn-ev.,i4y,t4 . (Name) an�Signature By Authorized / Officer or Agent of Vendor ADDRESS �l.-.e.¢/-r&J&a,.r s-e/, &J 4- TITLE / 'cam �+ c1 ,3y c/r,ee� .•s1 /Rr� St� •� L r7 a� � Qr1iDATE 3 2 6 'oT PHONE# 3576—BV B'z The above bid is subject to Terms and Conditions as attached hereto and incorporated. GREELEY GC : S UNSEEING ,.t �� LATER, P.C. .,�`3.L;'.. 'Y ...., . _ Oar'+.9andnan, 73y 7) ' 1228 8th Street, &canted 74yc%lopal ria Greeley, Colorado 80631 .V;.970-356-8482 F; .9704564646 I Bid Proposal: Weld DSS March 2007 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist Table of Contents I. ABSTRACT 3 II. TARGET/ELIGIBILITY POPULATIONS 4 1 . Total Number of Clients to be served 4 2. Total Family Units 4 3. Sub-total of individuals who will receive bicultural/bilingual services 4 4. Sub-total of individuals who will receive services in South Weld County 4 5. The monthly program capacity per group 4 6. The monthly average capacity per group 4 7. Average stay in the program (weeks) 4 8. Average groups per week in the program 5 III. PROJECT NARRATIVE/SUPPORTING DOCUMENTATION 1. Types of Services Provided 6 2. Measurable Outcomes 8 3. Service Objectives 8 4. Workload Standards 9 5. Staff Qualifications 9 6. Program Capacity per Month 9 7. Internal Tracking and Billing Process 9 V. BUDGET 10 VI. APENDICES 1 through 5 11 1 . Appendix 1: Resume for Dr. Gardner 12 2. Appendix 2: Data Collection Instruments/Protocols 17 "Parental Fitness Evaluation" (Sample) 18 3. Appendix 3: Sample Consent Forms 39 a. Evaluation Disclosure 39-A b. Therapy Disclosure 40 4. Appendix 4: Evaluation Mockup 42 5. Appendix 4: Proof Of Insurance 59 Page 2 of 58 • Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist Abstract I own and operate The Greeley Counseling Center. For several years I have provided a variety of psychological services to the department in a variety of modalities. I maintain that whenever possible children should be raised by their biological parents, if the parents can be made whole enough to do the task. I believe that the short-term and long-term physical, emotional and sexual safety of the child is the number one priority in assessment and treatment of the child, the parents, or the family unit. If children are placed outside the home I believe siblings should be together whenever possible. The following services are offered with these beliefs in mind: • Adult Psychological Evaluations, in office (Standard, 1 party) • Adult Psychological Evaluations, in office (Standard, additional parties) • Adolescent/Adult Psychological Evaluations (Sexual Specific, 1 party) • Adolescent/Adult Psychological Evaluations in Correctional Facilities • Adolescent/Adult Psychological Evaluations in Other Settings (i.e., group home, foster home). • Interactional Evaluations (at DSS-Greeley) • Interactional Evaluations (at DSS-Ft. Lupton) • Interactional Evaluations (Home Visits) • Court Testimony • Court Preparation • Consultation • Training • Child/Adolescent/ Adult Individual Therapy, in office • Family Therapy, in office • Family Therapy, in home or foster home • Court Facilitation, Mediation, or Staffing • No Shows (Client Terminated after 2 no shows). Page 3 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist II TARGET/ELIGIBILITY POPULATIONS 1. Total Number of Clients to be Served: ➢ I complete between 55 and 100 evaluations per year. My weekly evaluation capacity is between two and three completed reports per week depending on the complexity of the cases and the timely attendance of the clients. ➢ I see from 1 to S clients in therapy per week. ➢ I usually complete 2 trainings per year. ➢ I attend approximately 25 mediation sessions per year. ➢ I consult with the department on cases approximately 5 times per year. D. I testify in court approximately 20 times per year. ➢ The total number of clients is the number of evaluations completed, plus a few added family members. ➢ The children's ages are between newborn and eighteen years old. 2. Total number of Family Units ➢ The number of Family Units evaluated is somewhat less than the total number of total evaluations as I sometimes see both mother and father, ➢ I have capacity to see two families per week in therapy. 3. Sub-total of individuals who will receive bilingual/ bicultural services ➢ I do not provide bilingual services. I am bicultural (Hispanic culture). I do not keep records of the number of arsons who _ coma tame who are of a specific ethnicity, but the vast majority have English as a primary language. 4. Sub-total of individuals who will receive services in South Weld County ➢ During the last year I have been asked to see more clients from south county than ever before. I estimate I see 5% of the total number of evaluations from south county and anticipate this number will increase. 5. The Monthly Program capacity per group ➢ I do not offer any group based services. 6. The monthly average capacity per group ➢ N/A 7. Average stay in the program (weeks) ➢ Psychological evaluations often take 6 to 8 weeks from beginning to end, depending on the client's cooperativeness. ➢ Psychological evaluations in correctional institutions are usually completed in one or two, four to five hour visits. ➢ Family and individual work ranges from a few visits to many years (i.e., I currently provide therapy on an every other week or every third week basis for some developmentally delayed sex offenders. This treatment is very long term.) Most therapy is completed in twelve to fifteen sessions over the course of five or six months. The duration of therapy is determined by the success in reaching goals; the increase in desired behaviors, Page 4 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist healthy attitudes and emotional capacities; and the decrease in negative behaviors and attitudes. In some cases therapy may span more than a year. Often I meet with the family or client several consecutive times to began the change process. Then I begin to titrate the frequency of visits to the level that will allow forward change to continue and prevent regression to previous maladaptive states (backsliding). This avoids the "Flight into health" or "honeymoon syndrome" that is often mistaken for actual therapeutic change. As true change is a very gradual process, I have found spaced therapy visits over a prolonged period to be far superior to a few clustered visits. This level of care is very reassuring to the client and encourages them to grow between sessions. Clients are encouraged to titrate their own therapeutic schedule and use services only as needed to advance an issue or solve a problem. ➢ I do not provide 24 hour access to any clients. > When necessary I ask clients to sign a release of information to allow me to contact other treatment professionals who have provided services. I have the client sign a ROI to allow the evaluation to go to the Department of Social Services and usually to their attorney. 8. Average groups per week in the program ➢ N/A Page 5 of 58 Bid Proposal 3/27/07 Jack 1.Gardner,Psy.D. Licensed Psychologist III. PROJECT NARRATIVE/SUPPORTING DOCUMENTATION 1 . TYPES OF SERVICES TO BE PROVIDED This bid is for the production of psychological and/or interactional evaluations, relevant conversations with Department of Social Services Personnel, provision of court testimony regarding evaluations, case consultation, training, and individual or family therapy. Evaluations I request caseworkers discuss cases with me PRIOR to making a referral to insure I am the best provider for the specific needs of the case. After a referral has been made, please have the client contact my Appointment Secretary, April, at 381- 1474. My experience has been that the rate of "No Shows" is dramatically reduced when the client takes responsibility to initiate the first appointment. The client may place the call from the caseworker's office or their attorney's office. They must leave a valid phone number or message phone. If a client "No Shows" two times during the course of an evaluation, the procedure will be discontinued and either a letter or a partial report will be sent to the caseworker. If a client is more than fifteen minutes late to an evaluation it is considered a "No Show." Evaluations are conducted following generally accepted standards and are designed to produce useful responses to specific referral questions which should be designed by the evaluator and caseworker. The written report follows a general outline. Reports are extensive (i.e., between twelve to forty pages) and are provided to the department worker for dissemination to relevant parties. The caseworker usually reviews the report with the client. The client can contact this psychologist to discuss the report or add relevant information. If new information will alter the responses to the referral questions, an addendum will be issued. A mockup of an evaluation is in Appendix 4. Names and pertinent data have been altered or omitted to protect the client's confidentiality. Parental Fitness Evaluation I recently developed and put into use a structured interview to be completed by this examiner and the caseworker supervisor. The caseworker observes the interview and completes the rating scale. The interview utilizes a "Job Testing" assessment approach to help determine a parent's knowledge and skills. A mockup evaluation is in Appendix 2. Consultation I am available to meet with caseworkers or other's involved with a client to discuss clinical issues, appropriate therapy steps, expected outcomes and other relevant issues. I am available to the Department to consult regarding development of programs or treatment strategies. The fee will be $120.00 per hour. Page 6 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist Training I can provide training on a wide variety of issues. The fee is $1800.00 per day of training. Fees will be prorated for partial days of training. Therapy I provide individual or family therapy but do not use books or manuals to guide my therapy. I abandoned the managed care model of therapy more than a decade ago as I am absolutely clear that it detracts significantly from the client's care and degrades the client/therapist relationship. I do not obtain formal baseline data nor accumulate exit data. I do not generally use pre and post therapy assessment devices. However in some cases I will use tools to measure anxiety, depression, ADHD, or other symptom clusters. Most of my clients demonstrate significant progress, and when progress is not being made, therapy is stopped, postponed, or a referral to another provider is offered. I seek consultation from other professionals when needed. I generally follow a humanistic/cognitive/behavioral model in which I work with the client to determine treatment needs and desired outcomes to improve and stabilize functioning. Therapy may focus on understanding and improving the bond/attachment between caregivers and children, or aiding in reunification of children and parents, grandparents or other caregivers. Occasionally therapy is primarily structured to maintain children in a certain living situation by furnishing education, support and behavioral strategies to both the children and the caregivers. To help the client achieve his/her goals I use a variety of techniques (biblio- therapy; relaxation therapy; hypnosis; journaling; self-monitoring; homework to be done between sessions; open and honest communication; referral to medical practitioners as needed; goal setting; clarification; empathy; installation of hope; development and nurturance of a therapeutic relationship; drug testing when needed; various educational strategies regarding child development and forms of health and illness; use of various behavioral strategies to alter behavior; instruction in self-soothing, self-reinforcement; self care; and encouragement and support). I am willing to write progress letters and to have communication with the caseworker (with signed permission by the client). The fee for individual and family therapy is $120.00 per hour in the office and $135.00 per hour in the home or other setting. Family sessions are usually two to three hours for the initial intake and 1.5 hours for subsequent sessions. Individual sessions are usually two hours for the initial intake and 1.0 hour for subsequent sessions. No additional charge is levied for brief periodic written reports, letters or phone conversations with the client or caseworker (with the exception of emergency after hours phone calls). Emergency and after hours calls are billed at $160.00 per hour. Formal consultations are billed at $1 15.00 an hour. Page 7 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 2. MEASUABLE OUTCOMES Regarding psychological evaluations, I do not use quantitative measures. I rarely know the outcome of my evaluations as I rarely have contact with the clients or caseworkers when an evaluation is complete. I seek informal feedback from caseworkers, but have no formal method for garnering information. For psychotherapy I usually adopt a humanistic/cognitive/behavioral model that facilitates changes in frequency, duration and magnitude of both positive and negative behaviors. I rely on the subjective reports of the client and family as well as the reports of the caseworker to determine if the client is changing. Occasionally I utilize brief scales (such as the Beck Depression Scale, the Revised Children's Manifest Anxiety Scale, or the Brown Attention Deficit Disorder Scale) to determine treatment needs or response to therapy or medication. I do not anticipate there will be much of a change in the time it takes to complete evaluations from start to finish. I obviously do them as quickly as possible as my livelihood is directly tied to completion of each evaluation. Each piece of work must be of top notch quality and internally consistent to withstand the rigors of court review and review by second opinions. Each report must be valuable to the caseworker for treatment planning. There will be no change in availability of services. I try to answer all calls the day they are received and usually within 24 hours. The frequency of contacts between the Department and the Psychologist depends on the complexity of the case. We call each other as much as necessary. I discuss my therapeutic interventions regularly in the few instances when I have been asked to do therapy. I also communicate via letters and written reports. As noted elsewhere, I do not provide 24 hour emergency service. I will respond to caseworker's calls as soon as possible and usually within 24 hours. 3. SERVICE OBJECTIVES Evaluations attempt to provide practical information regarding the client's personality structure, risk profiles, diagnosis, strengths, and weaknesses for the caseworker to use in planning needed interventions and assessing progress. I make many recommendations to improve the clients mental and emotional functioning with the goal of reunification of the family. I recommend different kinds of therapy but only occasionally provide the therapy myself. I often provide the court and attorney's with information to plan for the child's placement. I do not primarily address ways parents can find or utilize community resources. My evaluations have been well received by the courts in the past several years. I continue on-going training to provide the best reports and care possible. I also know the limits of my competency and refer the case workers and/or clients to other practitioners as needed. Page 8 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 4. WORKLOAD STANDARDS This section does not seem to apply to the solo practitioner like myself, but rather to an agency. I work 40+ hours a week. I am the only one providing the evaluations and/or therapy. I sometimes work with specific individuals and families who have behavioral or sexual dysfunctions, as I have specialized training in these areas. I complete six to twelve evaluations per month depending on the complexity of the cases. I have a 1/3 million dollar malpractice insurance policy. A copy of the current certificate is attached. The new certificate should arrive soon and can be forwarded to the department. 5. STAFF QUALIFICATIONS I have a Psy.D. I am a licensed psychologist. I do not have a supervisor, nor do I provide supervision. I have knowledge of risk assessment in the areas of homicide, suicide, violent behavior, sexual assault/abuse, self-injury, and likelihood to benefit from treatment. I have provided therapy, evaluations, consultation and training for 36 years. 6. PROGRAM CAPATICY PER MONTH I complete 8 to 12 evaluations per month and see between 5 and 10 individuals or families per month. 7. INTERNAL TRACKING AND BILLING PROCESS I will follow the procedures already in place to submit billings at the time each evaluation is completed. Therapy billing will follow a similar procedure for billing with the additional inclusion of the treatment plan, goals, and progress made in therapy. Page 9 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist IV. BUDGET As in years past I will use a flat fee scale rather than a budget analysis. Fees are as follows: • Adult Psychological Evaluations,in office(Standard,1 party) $1339.00 • Adult Psychological Evaluations,in office(Standard,additional parties) $927.00 Each • Adolescent/Adult Psychological Evaluations(Sexual Specific, 1 party) $1648.00 • Adolescent/Adult Psychological Evaluations in Correctional Facilities $1450.00 • Adolescent/Adult Psychological Evaluations in Other Settings (i.e.,group home,foster home). $1450.00 • Interactional Evaluations(at DSS-Greeley) $103.00/hr • Interactional Evaluations(at DSS-Ft.Lupton or more than 30 miles) $135.00/hr(P` hour) $125.00/hr(2nd hour) $115.00/hr(3rd hour) • Interactional Evaluations(Local Home Visits) $113.00/hr • Court Testimony $175.00/hr • Consultation $115.00/hr • Training $1800.00/day • Child/Adolescent/Adult Individual Therapy,in office $120.00/hr • Family Therapy,in office $120.00/hr • Family Therapy,in home or foster home $135.00/hr(1st hour) $125.00/hr(2nd hour) • Court Facilitation,Mediation,or Staffing $110.00/hr • Parental Fitness Evaluations $600.00 Page 10 of 58 • Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist V. SUPPORTING DOCUMENTS APENDICES 1 through 3 Page t t of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist Appendix I: Resume for Dr. Gardner Jack J. Gardner, Psy.D. Licensed Psychologist 1228 8th Street Greeley,CO 80631 V: (970)356-8482;F: (970)356-9646 Education 7/89 Licensed as Psychologist in Colorado-#1326 9/82-12/86 Psy.D. Counseling Psychology. The University of Northern Colorado,Greeley,Colorado. 1/75-5/78 M.A. Guidance and Counseling. The University of New Mexico, Albuquerque,New Mexico. 1/73-7/73 B.A. Psychology. The University of New Mexico,Albuquerque, New Mexico. 8/72-12/72 Lubbock Christian College,Lubbock,Texas. 8/69-8/72 New Mexico Highlands University,Las Vegas,New Mexico. Undergraduate Major: Psychology; Minor: Public Speaking Employment and Experiences 3/07 Board Member,Colorado Chapter,Association of Family and Conciliation Courts. 3/06 Committee to Establish Colorado AFCC Chapter. 8/94-6/96 Consultant:Judicial Department,State of Colorado. Sex Offender Trainer for Probation Officers. Program consultant to devise model sex offender treatment program. 10/94-6/96 Consultant: Sex Offender Treatment Board;assisted in development of assessment standards for sex offenders. 7/92- 7/02 Consultant:Island Grove Alcohol Treatment Facility;Domestic Violence Program and Sex Offender Tx Program. 7/91 Intensive Supervised Probation Board Weld County,CO. 7/91- Trainer National Institute of Corrections:Treatment of Adolescent Sex Offenders 7/89- Private Practice. Greeley,Colorado. 10/88-8/92 Consultant Psychologist. District 6 Schools. 10/88 State Wide Task Force. "Forensic Mental Health in Rural Colorado." Denver,Colorado. 9/88-5/01 Adjunct Faculty. University of Northern Colorado,Greeley,Colorado. Page 12 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 5/88-9/90 Therapist. Weld Mental Health Center,Greeley,Colorado. 9/87-4/88 Clinical Psychologist II. New Mexico State Hospital,Las Vegas,New Mexico. Psychologist on multidisciplinary team. 10/86-9/87 Clinical Psychologist II. New Mexico Boys School,Springer,New Mexico. Coordinator of Sexual Offender Treatment Program. 10/85-10/86 Doctoral Psychology Internship. Federal Correctional Institution,Lexington, Kentucky. Evaluation and Treatment of female offenders. 9/85 Consultant. Federal Correctional Institution,Lexington,Kentucky. Drug and Alcohol Counseling groups. 1/84-8/85 Private Practice(part-time). Greeley,Colorado. Individuals,step-families,couples, sexual disorders,peer review,and consultation. 3/83-7/85 Employee Assistance Counselor. PAR Programs Inc., Denver,Colorado. Assessment of drug and alcohol problems,marital and family counseling,stress management training, corporate supervisory training. 10/83-5/84 Consultant. Alpha House,a community corrections program for adult male offenders, Denver,Colorado. Group counseling with convicts and staff consultation. 5/84-8/85 Advisory Boards. "Developing a Needs Assessment for the Implementation of a Children's Center at the Weld County Jail" and "Familial Attitudes of the Incarcerated Parent." Department of Vocational Teacher Education,University of Northern Colorado. Spring 83 Planning and Budget Committee. College of Education, University of Northern Colorado. 1/81-9/83 Task Force: "To Establish a Secure Residential Treatment Facility for the Violent Juvenile Offender." Albuquerque,NM. 12/80-8/82 Clinical Psychologist II. New Mexico Boy's School,Springer,New Mexico. Court and parole board ordered evaluations,expert witness,group treatment with adolescent sex offenders,psychological testing,research,individual and group counseling,staff consultation,design,implementation/supervision,and placement of mentally disordered offenders. 10/79-12/80 Clinical Psychologist I. New Mexico Boy'School. Duties same as above. 7/80& 11/80 Guest Lecturer. New Mexico Highlands University. "Treatment of the Mentally Ill Juvenile Delinquent." 1/79-10/79 Clinical Psychologist I. New Mexico State Hospital. Individual and group treatment of mentally retarded(50%time)and chronic schizophrenic(40%time),Teacher/Trainer for attendants and psychiatric technicians in use of behavioral techniques. Design and implement ward milieu treatment programs. Expert witness in commitment hearings. 7/79-8/79 Teacher/Consultant. Luna Vocational-Technical School. Taught Psychiatric Technician Course: "Behavioral Techniques with the Mentally Retarded." Supervised on-site student practicum at New Mexico State Hospital. Page 13 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 10/76-1/79 Social Worker III. New Mexico State Hospital,Children's Psychiatric Unit. Design and implementation of token economy system,group and individual treatment,social histories. 12/73-10/76 Caseworker. Bemalillo County Mental Health center,Inpatient Unit,Albuquerque,New Mexico. Treatment team leader,group treatment,assessment and diagnosis. 3/73-8/73 Attendant I. New Mexico State Hospital. Custodial care of female patients on a locked ward token economy. Specialized Training I have attended approximately 1500 hours of seminars and training in • Attachment Disorder • Effects of Domestic Violence on Children • Hypnosis • Family therapy • Divorce/custody evaluations • Alternative Dispute Resolution • Forensic psychology • Attention Deficit Disorder • Brief psychotherapy • Sex offender treatment • Treatment of Sexual Assault Surviors • Psychopharmacology • Brain damage • Emergency medical treatment. I attend two major conferences a year and two one-day trainings per year. Scholarships and Honors 1984 Doctoral Fellowship,University of Northern Colorado. 1982 Doctoral Fellowship,University of Northern Colorado. 1969-1970 Speech Activity Award,New Mexico Highlands University. NMHU Deans List three quarters. UNM Deans List one semester. NMHU inter-collegiate debate team for three quarters. Two speech awards: Extemporaneous Speaking and Oratory. Professional Organizations Past Member Psi Chi National Registry of Health Service Providers in Psychology American Psychological Association Colorado Psychological Association Current Member Association of Family and Conciliation Courts Page 14 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist Voluntary Organizations Committee to establish Colorado Chapter of AFCC Attention Deficit Disorder Advocacy Group: Professional Advisor for local Attention Deficit Disorder Support Group Publications "Attitudes About Rape Among Inmates and Correctional Officers," Doctoral Dissertation. "Alcohol Use Patterns of Incarcerated Delinquent Adolescents." Unpublished paper,September 1984. "Gardner Structured Forensic Interview": Unpublished instrument, June, 1990. "Gardner Sex Offender Discharge Criteria: Unpublished Instrument, October 1990" "Parental Competency Evaluation": Unpublished Instrument March 2006. Presentations 10/95- "Treatment of Sex Offenders," Week-long workshop for Probation Officers and Treatment Providers,Colorado Judicial System. 6/95- "Treatment of Sex Offenders," All day workshops for several groups of Probation Officers and Treatment Providers,Colorado Judicial System. 1/93 - "Treatment of Sex Offenders," All day workshops for several groups of Probation Officers and Treatment Providers,Colorado Judicial System. 7/19/91 "Ethical obligations to Adult Respondents in Child Custody Evaluations," 25th Annual Emotional Crisis Workshop,University of Northem Colorado,Summer 1991. 7/14/91 "Treatment of Adolescent Sex Offenders," National Institute of Corrections,Boulder, Colorado 11/90 "Anxiety Disorders," Public Lectures for Centennial Peaks Psychiatric Hospital. 11/87 "Issues of Adolescence," New Mexico Corrections Academy. 11/86 "The Mentally 111 Offender," Federal Correctional Institution. 12/83 "Treating the Re-Married Family," in service for clinical staff of PAR Programs,Denver, Colorado. 10/83 "Understanding and Treating the Re-Married Family," Community Consultation Workshop,University of Northern Colorado. 3/81 "Relaxation Techniques,"New Mexico Corrections Academy,Santa Fe,New Mexico. 8/80 "Mental Status Examination," an eight week seminar for classification officers and psychological counselors at New Mexico Boy's School,Springer,New Mexico. Page 15 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist References available on request. Page 16 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist Appendix Data Collection Instruments/Protocols Page 17 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist Parental Fitness Evaluation Jack J. Gardner, Psy.D. Licensed Psychologist The Greeley Counseling Center DATE: Evaluator: JACK J. GARDNER.Psy.D.. Licensed Psychologist Evaluator: GOAL: To determine if (Parent's Name) has the skills, knowledge, and psychological sophistication/knowledge to care for any or all of his children safely and with nurturance. This examination also focuses specifically on Mr. M's sexual attitudes, values, relationships and behaviors. The evaluation aims to determine Mr. M's risk to his children emotionally, behaviorally, physically or sexually. This includes exposure to material, behavior, attitudes, or values which would harm the children or delay their developmental progress. METHODOLOGY: Apply a series of sexual value and parenting skill related questions and scenarios in a video taped interview format by two interviewers. Ask Mr. M to role play certain situations. Compare scores between examiners and external raters. Record Mr. M's responses and rate them from minus 2 to positive 2. Minus scores indicate responses that are lacking in knowledge, are very concrete, lack psychological sophistication, or are clearly detrimental or dangerous. 7ero scores indicate an area of no knowledge and no negative attitudes or ideals. Positive scores indicate the presence of knowledge, ideals, well thought out answers, more abstract answers, psychological sophistication, or behaviors helpful to the task of raising children. ❑ 0 ❑ O O - 2 -1 0 +1 +2 DISCLOSURE: You will be asked a number of questions across a wide range of areas regarding your capacity to provide appropriate and healthy care for the child(ren) considered for placement in your home. You may be asked to role play certain scenarios. You will be asked a number of questions regarding your sexual knowledge, values, and attitudes. These procedures do not meet psychometric standards of reliability and validity. Scores on each item are for heuristic purposes only. Page 18 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist You may ask the interviewers for their qualifications, credentials, or expertise. You may stop the interview at any time. The interview will be video taped so your attorney, the child's attorney, or other clinicians or department personnel may review the process. You have a right to file a grievance with the State Board of Regulatory Agencies at: Mental Health Grievance Board, 1560 Broadway, Suite 880, Denver, Colorado 80202; phone 303-894-7800. By signing below you agree you have read and understand the above statements and agree to participate. Name Date Name Date This information may be released to the COURT deciding this issue and the following persons, agencies, or institutions: By signing below you agree you to release any written notes or reports from the interview, any verbal conversations, and/or any video or audio recordings to the above listed persons. Name Date Name Date Page 19 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist Parental Fitness Evaluation Jack J. Gardner, Psy.D. Licensed Psychologist The Greeley Counseling Center DATE: Evaluator: JACK J. GARDNER. Psy.D., Licensed Psychologist Evaluator: Parent's Name(s): J M Child's Name(s) and age(s): 1 General Concept Areas to Evaluate 2 1. Knowledge of Sexual Abuse 3 4 A. Describe what you have learned about sexual abuse during the time you have been 5 involved with the Department of Social Services. 6 7 8 9 10 11 12 13 14 0 0 0 0 0 15 -2 -1 0 +1 +2 16 17 18 B. Have your children been abused,and if so,by whom? 19 20 21 22 23 24 0 0 0 0 0 25 -2 -1 o +1 +2 26 Page 20 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 1 2 C. Define Grooming. 3 4 5 6 7 8 9 ❑ 0 0 0 0 10 -2 -1 0 +1 +2 11 12 13 D. What would you do if you thought someone was grooming one of the children? 14 15 16 17 18 19 20 21 22 0 0 0 0 0 23 -2 -I 0 +1 +2 24 25 26 E. How would you protect the children from others you perceived to be dangerous to 27 them(for sexual assault,physical assault,drug/alcohol use,negative peer influences, 28 pornography use,etc.) 29 30 31 32 33 34 35 36 0 0 0 0 0 37 -2 -1 0 +1 +2 38 39 40 F. Describe what perpetrators might do to a child. 41 42 43 44 45 46 0 0 0 0 0 47 -2 -I 0 +1 +2 48 Page 21 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 1 G. What are the signs and symptoms of sexual or physical abuse in a child? 2 3 4 5 6 7 8 9 ❑ 0 0 0 0 10 -2 -1 0 +1 +2 11 12 13 H. If you believe the children were abused,what was your role in their abuse? 14 15 16 17 18 19 20 21 22 0 0 0 0 0 23 -2 -1 0 +1 +2 24 25 26 I. Describe the effects of abuse on a child. 27 28 29 30 31 32 33 34 35 ❑ 0 0 0 0 36 -2 -1 0 +1 +2 37 38 39 J. Who will you allow as visitors to your home and who will you exclude? 40 41 42 43 44 ❑ 0 0 0 0 45 -2 -1 0 +1 +2 46 47 Page 22 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 1 K. How can you find out if someone might be a known offender? 2 3 4 5 6 7 ❑ 0 0 0 0 8 -2 -1 0 +1 +2 9 10 11 12 L . What, if anything , would you have done 13 differently to prevent the children from being 14 abused ? 15 16 17 18 ❑ 0 0 0 0 19 -2 -I 0 +1 +2 20 21 M. How will you recognize a child might be afraid? 22 23 24 25 26 27 28 0 0 0 0 0 29 -2 -1 0 +I +2 30 31 32 33 N. What can you do to insure the children are not further victimized? 34 35 36 37 38 ❑ 0 0 0 0 39 -2 -1 0 +1 +2 40 41 42 O. Are you currently married,in a committed relationship or seeing any one on a regular 43 basis? 44 45 46 0 0 0 0 0 47 -2 -1 0 +1 +2 48 Page 23 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 1 2 P. Describe your current sexual habits. 3 4 5 6 7 8 ❑ 0 0 0 0 9 -2 -I 0 +1 +2 10 11 12 Q. Describe the effects of video or in-vivo pornography,graphic sexuality,graphic violence, 13 or a combination of these types of events on children. 14 15 16 17 18 19 20 21 0 0 0 ❑ 0 22 -2 -1 0 +1 +2 23 24 25 26 2.Dealing with Children's Sexual Behavior 27 28 Describe the types of sexual behavior you might see from the child. 29 30 31 32 33 34 35 36 ❑ 0 0 0 ❑ 37 -2 -1 0 +1 +2 38 39 40 What would you do or say when you 41 i. find your child masturbating 42 43 44 Ii. playing sexually with someone else 45 46 47 III. touching you inappropriately 48 49 50 Iv. playing with an animal sexually Page 24 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 1 2 v. peeping on someone 3 4 5 vi. looking at pornography 6 7 8 vii. using sexually graphic language 9 10 11 viii. Dressing in clothes of the opposite sex? 12 13 14 15 16 0 0 0 ❑ 0 17 -2 -1 0 +l +2 18 19 20 21 3. Dealing with Children's Aberrant or Difficult Behavior 22 Describe the types of aberrant or difficult behavior you might see from the child. 23 24 25 26 27 28 0 0 0 0 0 29 -2 -1 0 +1 +2 30 31 32 33 B. What would you do or say when you 34 i. find your child starting a fire 35 36 37 ii. urinating or defecating in an inappropriate place or manner 38 39 40 iii. destroying his/her property 41 42 43 iv. destroying your property 44 45 46 v. being cruel to an animal 47 48 Page 25 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 1 vi. physically hurting you or someone else 2 3 vii. being extremely hyperactive 4 5 6 viii. stealin 7 8 9 ix. lying 10 11 12 x. running away from home 13 14 15 xi. being oppositional 16 17 18 xii. self injuring? 19 20 21 22 23 ❑ ❑ ❑ ❑ ❑ 24 -2 -1 0 +1 +2 25 26 27 28 4. Providing Healthy Structure for the Child's Growth and Development 29 30 How much structure does each of your children need? 31 32 33 34 35 36 ❑ ❑ ❑ ❑ ❑ 37 -2 -1 0 +1 +2 38 39 40 41 B. Describe how you would structure the child's day. 42 43 44 45 ❑ ❑ ❑ ❑ ❑ 46 -2 -I 0 +1 +2 47 Page 26 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 1 C. Describe how you would approach meals,homework,chores,and/or bedtime. 2 3 4 5 6 7 ❑ 0 0 0 0 8 -2 -I 0 +I +2 9 10 11 12 5. Time Management to Deal with Child's Needs 13 14 A. How will having a child in your home change your own 15 daily schedule? 16 17 18 19 20 21 22 0 0 ❑ 0 ❑ 23 -2 -1 0 +1 +2 24 25 26 c. Do you have 27 I. a car 28 29 II. a driver's license 30 31 III. current insurance 32 33 iv. current registration 34 35 36 0 0 0 0 0 37 -2 -1 0 +1 +2 38 39 c. Who will take the child 40 I. to school 41 42 43 ii. to the doctor 44 45 46 iii. to therapy 47 48 49 iv. to the visit friends Page 27 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 1 2 3 v. to visit relatives 4 5 6 vi. to teacher conferences? 7 8 9 10 ❑ ❑ ❑ ❑ ❑ 11 -2 -I 0 +1 +2 12 13 14 D. How will caring for a child effect your ability to work and earn a living? 15 16 17 18 19 20 21 22 ❑ ❑ ❑ ❑ ❑ 23 -2 -1 0 +I +2 24 25 26 E. What is your obligation to keep in contact with the Department of Social Services? 27 28 29 30 31 32 33 34 35 36 37 38 39 ❑ ❑ ❑ ❑ ❑ 40 -2 -1 0 +1 +2 41 Page 28 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 1 6. Dealing with the Child's Parents or other Significant Others 2 3 A. Describe how you will deal with the child's parents or significant others. 4 5 6 7 8 ❑ ❑ ❑ ❑ ❑ 9 -2 -1 0 +1 +2 10 11 12 13 7. Knowledge of Behavioral Principles, Reinforcement Strategies, Consequences, 14 Discipline, and Criticism and Punishment. 15 16 A. Have you ever used a behavioral program with children? If so,please describe it. 17 18 19 20 21 22 23 24 25 26 ❑ ❑ ❑ ❑ ❑ 27 -2 -1 0 +1 +2 28 29 30 B. Does a child learn best by 31 I. Punishment 32 33 34 ii. Discipline 35 36 37 iii. Consequences 38 39 40 iv. Reinforcement 41 42 43 v. Criticism 44 45 46 vi. Being left alone 47 48 ❑ ❑ ❑ ❑ ❑ 49 -2 -1 0 +1 +2 50 Page 29 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 1 8. Attitudes and Expectations about Therapy and Training 2 3 A. Does the child need to be in therapy? If so,what kind and for how long? 4 5 6 7 8 9 ❑ 0 0 0 0 10 -2 -1 0 +1 +2 11 12 13 B. Do you need to be in therapy? If so,what kind and for how long? What goals do you have 14 for therapy? 15 16 17 18 19 0 0 0 0 0 20 -2 -1 0 +1 +2 21 22 23 C. Does the child need in specific therapy or learning interventions? 24 25 26 27 28 0 0 0 0 0 29 -2 -1 0 +1 +2 30 31 32 D. Do you need any specific therapy or learning interventions? 33 34 35 36 37 ❑ 0 0 0 0 38 -2 -1 0 +1 +2 39 40 41 42 9. Knowledge and Attitudes Regarding Child's Medications 43 44 Does the child need medication? If so,what do you expect the medicine to do? 45 46 47 0 0 ❑ 0 ❑ 48 -2 -1 0 +1 +2 49 Page 30 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 1 Do you think the medicine the child is using is more harmful or helpful to the child? 2 3 4 5 6 7 8 9 10 0 0 0 0 0 11 -2 -1 0 +1 +2 12 13 14 How long will the child need medication? 15 16 17 18 19 0 0 0 0 0 20 -2 -1 0 +1 +2 21 22 23 24 How will you determine if the medication is helping? 25 26 27 28 29 30 31 ❑ 0 0 0 0 32 -2 -1 0 +1 +2 33 34 35 36 10. Ability to meet the Child's Nutritional Needs 37 38 A. Does the child have any specific nutritional needs? 39 40 41 42 43 44 45 0 0 0 0 0 46 -2 -1 0 +1 +2 47 Page 31 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 1 Make a menu for seven days 2 Sunday 3 4 5 6 7 8 9 Monday 10 11 12 13 Tuesday 14 15 16 17 18 Wednesday 19 20 21 22 23 Thursday 24 25 26 27 28 Friday 29 30 31 32 33 Saturday 34 35 36 37 38 39 ❑ ❑ ❑ ❑ ❑ 40 -2 -1 0 +1 +2 41 42 43 44 B. What kind of"treats"do you like to give the child? 45 46 47 48 49 50 51 52 ❑ ❑ ❑ ❑ ❑ 53 -2 -1 0 +1 +2 54 55 56 Page 32 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 1 11. Capacity and Likelihood to Hear and Respect the child's desires.needs,and fears;to react to 2 various affective reactions are to express various emotions 3 4 O. What emotions do you most like to see/hear from 5 the child ? 6 7 8 9 10 11 12 0 0 0 0 0 13 -2 -1 0 +1 +2 14 15 16 P. What emotions are most difficult to see/hear from 17 the child ? 18 19 20 21 22 23 24 0 0 ❑ 0 0 25 -2 -1 0 +1 +2 26 27 28 Q. How will you react if the child 29 i.Cries 30 31 32 ii.Laughs 33 34 35 iii.Pouts 36 37 38 iv.Yells 39 40 41 v.Withdraws 42 43 44 vi.Rejects you("I hate you." "I want to go to my mom/dad's or another foster home") 45 46 47 vii.ls proud 48 49 50 viil.ls discouraged 51 52 ix.Makes negative self-statements 53 0 0 0 0 0 54 -2 -1 0 +1 +2 55 Page 33 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 1 D. How is trust established? 2 3 4 5 6 ❑ ❑ ❑ ❑ ❑ 7 -2 -1 0 +1 +2 8 9 10 E. How does a child learn self-confidence? 11 12 13 14 15 ❑ ❑ ❑ ❑ ❑ 16 -2 -I 0 +1 +2 17 18 19 20 12. Parent's Expectations regarding the long-term care of his children 21 22 A. What level of involvement will you have in your children's lives during the next fifteen 23 years? 24 25 26 27 28 29 30 31 ❑ ❑ ❑ ❑ ❑ 32 -2 -1 0 +1 +2 33 34 35 36 13. Parents Long-Term Future Goals and Plans 37 38 A. How old are you? 39 B. How is your health? 40 C. What are your long-term goals and plans? 41 42 43 D. How will having a child effect your goals and plans? 44 45 46 ❑ ❑ ❑ ❑ ❑ 47 -2 -1 0 +1 +2 48 Page 34 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 1 14. What obstacles,concerns. fears,and/or hopes do you have at this point? 2 3 4 5 6 7 8 9 ❑ ❑ 0 0 0 10 -2 -1 0 +1 +2 11 12 13 14. Assessment of Values and Ideas Supportive of Sexual Abuse 14 A. Please complete this brief scale (Burt Rape Myth Scale) 15 B. What role does the victim play in abuse? 16 17 18 19 20 21 0 0 0 0 0 22 -2 -1 0 +1 +2 23 24 25 C. When is a victim responsible for their own abuse? 26 27 28 29 30 0 0 0 0 0 31 -2 -1 0 +1 +2 32 33 34 D. Do you have values,attitudes and beliefs which will undermine your children's sexual 35 development? If so,what are they? 36 37 38 39 40 41 42 0 ❑ 0 ❑ ❑ 43 -2 -1 0 +1 +2 44 45 Have you used pornography in the past? If so,what type,with whom,with what frequency,and for 46 what purpose? 47 48 49 0 0 0 0 ❑ 50 -2 -1 0 +1 +2 51 Page 35 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 1 2 E. Do you currently use pornography? If so,what type,with whom,with what frequency,and 3 for what purpose? 4 5 6 7 8 9 ❑ 0 0 0 0 10 -2 -1 0 +1 +2 11 12 13 F. You apparently made a sexually insulting statement to a therapist recently. What did you 14 say? 15 16 17 18 19 0 0 0 0 ❑ 20 -2 -t 0 +1 +2 21 22 23 G. What,if anything,was insulting about what you said? 24 25 26 27 28 29 0 0 0 0 0 30 -2 -I 0 +1 +2 31 32 33 H. Did you notice any discomfort from the therapist following your statements? 34 35 36 37 38 ❑ 0 0 0 ❑ 39 -2 -1 0 +1 +2 40 41 When was the last time your children saw their mother? 42 43 44 ❑ ❑ ❑ ❑ 0 45 -2 -1 0 +1 +2 46 47 Page 36 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 1 When was the last time the children visited your home on 8" Street? 2 3 4 ❑ 0 0 0 0 5 -2 -1 0 +1 +2 6 7 8 When was the last time you spoke with J? 9 10 11 ❑ 0 0 ❑ 0 12 -2 -I 0 +1 +2 13 14 15 What will you do if you happen to run into J during a visit? 16 17 18 19 20 21 ❑ ❑ 0 0 0 22 -2 -I 0 +1 +2 23 24 25 26 27 Do you agree with the recommendations that the children are not to visit you at the 28 home on 8th Street? 29 30 31 32 0 0 0 0 0 33 -2 -1 0 +1 +2 34 35 36 Page 37 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist OTHER COMMENTS OR QUESTIONS Bid Proposal Page 38 of58 3/27/07 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist Appendix 3: Sample Consent Forms Evaluation Disclosure Bid Proposal Page 39 of58 3/27/07 • y 5Y4 �.. Greeley Counseling • I Center P C Jae.ggardna3 Psy-D. Lkaued Psytkologirt Mandatory Disclosure For Psychological Evaluation FEES: The fee for this evaluation is I The fee will be paid by . If I am responsible for the fee I agree to pay half at the beginning of the evaluation and the remainder before the evaluatdon is released. I agree appointments not canceled at least 24 hours in advance will be billed to me at one-half the cost per session. { The practice of both licensed and unlicensed poisons in the practice of psychological evaluation is regulated by the State of Colorado, Board of Regulatory Agenies. If you have a complaint you may contact the State Board of Regulatory Agencies at Mental Health Grievance Board, 1560 Broadway, Suite 1340, Denver, Colorado 80202. The phone number is (303) 894-776 . In a professional relationship, sexual intimacy is never appropriate and should be reported to the Mental,Health Grievance Board- l You are entitled to receive information about m4ntal health therapy, my credentials, the duration of evaluation,' and the fee structure.` You may seek a second ()pinion from another psychotherapist (at your expense)• and you may terminate the evaluation at any time. - - I understand the purpose of the evaluation is to $nswer the following questions: Information revealed in the course of this evaluation will be released to BILLING: I understand that if I am notified my account is past due, my account may be turned over to a collection agency. I understand, if I request the Greeley Counseling Center, P.C., not send mail to my address, am responsible for my account and forfeit the ngtification of a past due account I understand my account may be turned over to a collection agency after sixty days of no payment I further understand, should t owe any amount on my balance which remains unpaid fir longer than 60 days from the date of service, interest in the amount of 18% (1:5 percent monthly) shalt accrue on the unpaid balance until paid in full I understand time involved in court appearances by the evaluator. Whether by my request or by lawful subpoena, will be billed to my account .- CONSENT: I consent to psychological evlauation and release the results to the person(s) or agency(ies) listed above I understand the above, and indicate my agreement by the signature below. Client Signature Date Responsible Party Signature Date Relationship For Client Name Client Name 1221 S+k Sr a7 Greeley,CO 80631•(970)356-8482 • Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist Therapy Disclosure Bid Proposal Page 40 of58 3/27/07 Greeley Counseling Center P.C. • (Ott Jack J. Gardner, Psy. D. Licensed Psychologist Mandatory Disclosure FEES:FEES_ Individual psycholhera ndvihour, emergencypy $120.00 per hour couple therapy - $120.00 per hour,r, familtherapy.._ $12unscheduled 0per timer, e after hour calls or visas - $150:00 pay psychotherapy fees;betweenthe 0me of m and 8.00 A M., Monday thin FridayPwe kendser hour. ,"After holidays. means any personal psychotherapy other or cask at y session. Payment may be made by y In gottagree to e I understand the Greeley Counseling Center will submit my company when I insurance company. by negotiable provide a signed insurance form. I- agree. appointments not advance will be billed to'me bills to my insurance at one-half the cost per session canceled at least 24 hoursin The practice of both licensed and unlicensed of Colorado, Board of Reguaatnd Persons in the practice of psychotherapy oservioes, I would Agencies_ If you have a complaint regarding the practice of . is regulated by the State not ices I w appreciate the opportunity to discuss::the compliant with satisfactory, you may contactthe-State Board ofn'� tai- hem�;; 1 o Broadway, Regulatory' you. (f resolution of ri the complaint is y, Suite 134Q Denver, Colorado The h -nt Mental Health GrievanceBoard, professional relationship, sexual intimacy is 80202. - G professional a Bo never a phone- number is (303) 8 Mental In a and. appropriate should be reported.to the Mental Health You are entitled to receive information about mental health there known, and the fee structure. You may seek a second opinion from,.nother psych my otherapist the 'duration(at of therapy, and you may terminate therapy at any time. A terminating session is suggested. aPy if - psychotherapist (at your expense), Information revealed by a person in the course of therm The only a exceptions are: ,1) if the client e becomes dangerous is legally confidential in the case of must be released to collect an unpaid account or 3) throbs to others orby self, 2) if attendant'syinform ton as otherwise required law.BILLING: I understand that if 1-am notified m account may be turned to a collection agency.account is past due, or after sixty days of no payment g n I agree sen costs tocollection including spoon ible my account m, if I request ue the over Greeley ecti a ncyter, P.C., notto send costs of m my,account and forfeit the notification of-a past due my aclancecount which remains it the unpaid for longer than 60 days from my address, I e nyponsiu t for account I further ate of and, e, interest n Lowe any amount on f 18% (1:5 percent`monthly) shall accrue on the unpaid oY the date of service, in�the amount. in court appearances by the therapist, whether by m balance until in,y request or b lawul'subpoena,l. Iwill be billed rstand ttomy account: in TREATMENT_ by 1 consent to psychotherapy Y account and treatment as recommended by the Greeley Counseling Center I understand the above, and indicate my agreement by the signature below. For Agreement• - -.Client Signature Client Signature Date Responsible Party Signature Date Relationship Date For. Client Name Client Name 122 g gilt STn1£7--Greeley,CO 80691 '(970) 356'84132 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist Appendix 4: Evaluation Mockup Bid Proposal Page 41 of58 3/27/07 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist PSYCHOLOGICAL AND INTERACTIONAL EVALUATION Jane Doe DOB - -/ - - / 80 CONCERNING: Paul Junior Doe - Shaffer DOB -/--/01 Justin Doe DOB -/--/O2 Ruth Doe DOB --/--/03 Saul Doe DOB -/--/05 CONFIDENTIAL FOR PROFESSIONAL USE ONLY Fvaluated by: Jack J. Gardner, Psy.D. Licensed Psychologist Date of Report: -/-/07 GREELEY COUNSELING CENTER, P.C. 1228 8th Street Greeley, Colorado 80631 (970) 356-8482 NOTICE TO WHOM INFORMATION IS GIVEN: The information disclosed in this document is confidential and protected by Federal Law. Federal regulations prohibit unauthorized use of this information, or the further disclosure of this report without the specific written consent of the person(s) to whom it pertains. Bid Proposal Page 42 of58 3/27/07 Psychological Evaluation 2 Confidential for Professional Use Only 3 4 5 NAME: Jane Doe MARITAL STATUS: Married 6 DOB: --/--/80 EDUCATION: High School 7 RACE: Caucasian EVALUATED BY: Jack J. Gardner, Psy.D. 8 Licensed Psychologist 9 Date of Report: -/-/07 EVALUATION DATES: --/--/06; --/--/06; & -/--/07, 10 -/--/07 (Home Visit), 11 -/--/07(Home Visit), 12 -/-/07(Home Visit). 13 14 15 REASONS FOR REFERRAL AND DISCLOSURE 16 Jane Doe was referred by her Weld County Department of Social Services caseworker, F. R., in 17 MONTH 2006. Ms. R noted that Jane had been diagnosed with a common childhood Disorder in 18 the past and had been given a trial of MEDICATION. The current evaluation attempted to more 19 definitively diagnose ADD or ADHD. Additionally, the current evaluation was to focus on Ms. 20 Doe's learning styles to help determine which teaching methods might be most effective with 21 her. Ms. R's initial phone call on --/--/06 indicated that Jane had admitted that she had the 22 potential to hurt her children. Ms. Doe denied she had ever made such statements. 23 24 Jane entered the current case with the Department of Social Services on a voluntary basis 25 following her four year old son, Justin, becoming violent and out of control. Social services 26 workers observed him hitting Jane. He appeared to be suffering from SERIOUS EMOTIONAL OR 27 DEVELOPMENTAL DELAYS. Ms. R reported his speech improved significantly after being placed 28 in foster care. 29 30 Jane was asked what caused her recent involvement with the Department of Social Services. 31 She stated that when she stopped at Social Services At that time, the Department 32 intervened and placed Justin in foster care. She reported, "He's doing better. He's not even in 33 therapy anymore. He does have speech therapy." She did not think Justin was taking any 34 medication and was not in favor of him using any medication. 35 36 Ms. Doe understood the purpose of the current evaluation and agreed to participate. She 37 understood the following questions would be considered: 38 39 1 . Does Jane have a disease of mind, a defect of mind, or an 40 emotional condition that will deleteriously effect her capacity to 41 parent her children? 42 2. Describe Jane's personality. What is her diagnosis? 43 3. What risks, if any, does Jane pose to her children? 44 4. What recommendations are forthcoming from this evaluation? 45 5. If changes are needed, can they be made in a reasonable amount of 46 time for the children's best interests? 47 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 1 Ms. Doe signed a release of information to allow this report to be sent to the Weld County 2 Department of Social Services and her attorney, 3 4 Following the initial testing and interviews, this examiner did request that the Department 5 broaden the evaluation to include an interactional component. This was based on Ms. Doe's 6 significant past history with the Department, apparent malingering on tests, and her extreme 7 unwillingness to be forthcoming with the examiner during interviews. 8 9 COLLATERAL REFERENCES 10 • Review of extensive Social Services records. 11 • Conversations with F R - Weld County Department of Social Services. 12 • Review of Dr. 's psychological evaluation - 200-. 13 14 PROCEDURES 15 Standardized psychological measures: 16 • Minnesota Multiphasic Personality Inventory (MMPI). 17 • Million Clinical Multiaxial Inventory (MCMI-III). 18 • Personality Assessment Inventory (PAI). 19 • Wide Range Achievement Test (WRAT-3). 20 • Weschler Adult Intelligence Scale - Third Edition (WAIS-III). 21 • Brown Attention Deficit Disorder Scale for Adults. 22 • Inventory for Client and Agency Planning. 23 24 Non-standardized procedures: 25 • Life History Questionnaire (LHQ). 26 • Children's History Forms for all four children - completed by Jane. 27 • Review of Extensive Records. 28 • Two Extensive Clinical Interviews. 29 • Three in home observations of Jane with her children. 30 31 REVIEW OF COLLATERAL REFERENCES 32 33 THE REVIEW OF COLLATERAL MATERIAL WAS MORE THAN THREE PAGES 34 35 36 RELEVANT BACKGROUND INFORMATION 37 When Jane was seen on -/-/07 she was prompt for her interview. BEHAVIORAL DESCRIPTIONS 38 FOLLOW. 39 40 Family Information 41 Jane stated that she is the FIRST of three children born to ___ and ___. Her parents divorced 42 before she was born. FOLLOWING ARE SEVERAL PARAGRAPHS ABOUT HER PARENTS AND 43 EARLY LIFE HISTORY Bid Proposal Greeley Counseling Center 3/27/07 Page 44 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 1 2 Childhood History 3 Jane stated that her parents' rights were terminated when she was years old because 4 . Jane was placed in foster care with 5 6 To describe the atmosphere in her home during her childhood, Jane wrote, "Very good' 7 " She stated she was disciplined by both foster parents who took privileges away. 8 CHILDHOOD BEHAVIORAL PROBLEMS WERE DESCRIBED. 9 10 Jane stated she was closest to ____ while growing up. DESCRIPTION OF RELATIONSHIP WITH 11 FOSTER PARENTS. 12 13 Jane wrote that she was loved most as a child by " 14 15 School History & Work History 16 Jane began the first grade in and was held back in the first grade. 17 18 DEATAILED WORK HISTORY 19 20 Relationshio History 21 Jane circle of friends. During childhood, ____. Asked about local friends she stated 22 23 24 Jane began to date 25 26 At age nineteen, Jane began to date 27 HISTORY OF MARRIAGE, SEXUAL PARTNERS, AND CHILDREN FOLLOWS. 28 29 Medical And Mental Health History 30 MEDICAL HISTORY 31 32 Regarding mental health counseling, Jane wrote, " 33 34 Jane stated that through high school she was given PSYCHOTOPHIC AND ALLOPATHIC 35 MEDICATIONS. 36 37 Criminal History 38 39 40 Substance Abuse History 41 Jane stated she began nicotine use at age 42 43 Jane began caffeine consumption at age ___ 44 Bid Proposal Greeley Counseling Center 3/27/07 Page 45 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 1 Alcohol use began at age . Jane stated she last drank ____. 2 3 MENTAL STATUS EXAMINATION & BEHAVIORAL OBSERVATIONS 4 Present for testing and interview was a ____ year old Anglo female who stated she was five 5 feet one inch tall and weighed one hundred and eighty pounds. This obviously overweight 6 woman stated that she does take various kinds of over-the-counter diet pills. When seen on 7 , 2006 Jane was fifteen minutes late. She had called several times to make sure she 8 was coming to the correct location. misplaced her Life History Form and Children's 9 History Forms. Jane had obvious pressure of speech. She frequently spoke rapidly, 10 and apparently impulsively. 11 12 When seen on --/--/06, Jane had significant halitosis. When seen on --/--/06 she had 13 significant foul odor about her person. FUTHER PHYSICAL DESCRIPTION. 14 15 DESCRIPTION OF EARLY LEARNING HISTORY AND PRIMARY LANGUAGE. 16 17 DESCRIPTION OF ERRORS IN THINKING AND MEMORY GAPS 18 19 SUICIDAL IDEATION/EATING DISORERS 20 21 SLEEP PATTERNS/NIGHTMARES 22 23 FEARS/PHOBIAS 24 25 HALLUCINATIONS/THOUGHT DISORDER 26 27 SOCIOPATHIC PERSONALITY MARKERS 28 29 Jane stated that her most common mood is "happy." 30 31 PSYCHOLOGICAL TEST RESULTS 32 Jane Doe was given tests to assess personality and behavioral functioning. These tests provide 33 hypotheses (which have a substantial likelihood of accuracy) to describe the clients' thoughts, 34 feelings, and behaviors. Personality tests are not indicators of absolute fact, as many 35 interpretive principles are highly inferential and/or actuarially based. Predictions about 36 personality style and potential behavioral manifestations should only be derived by looking at 37 the test results and consistent historical information. When information is consistent across 38 tests and with known facts about the patient, there is a substantial degree of validity to the 39 hypotheses. 40 41 Jane was given the Wechsler Adult Intelligence Scale (WAIS-III) to provide an estimate of her 42 intellectual functioning. On this instrument, Jane achieved a Full Scale IQ of __, a Verbal IQ of 43 __, a Performance IQ of , a Verbal Comprehension Index of and a Perceptual 44 Organizational Index of . Scores between 70-79 are in the Borderline range of intellectual Bid Proposal Greeley Counseling Center 3/27/07 Page 46 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 1 ability. Scores of 69 and lower are considered to be in the Developmentally Disabled range. 2 Jane's Full Scale IQ is at the very bottom of the Borderline Range of intellectual capacity. 3 4 Jane achieved the following subtest scores: 5 6 Vocabulary _ Picture Arrangement _ 7 Similarities _ Picture Completion _ 8 Information _ Block Design _ 9 Comprehension _ Matrix Reasoning _ 10 Arithmetic _ Coding _ 11 Digit Span _ 12 13 On this instrument, subtest scores between 7 and 13 are average and scores below 7 14 reveal significant weakness. Scores between 4-7 are one standard deviation below 15 average, whereas scores below 4 are two standard deviations below average. In the 16 Verbal arena, Jane was highest on a test measuring 17 Jane was only slightly stronger in her ability to understand and to complete 18 arithmetic problems. It seems very likely that Jane does not have enough skills to 19 manage money. 20 21 In the Performance arena, Jane was well below average on all subtests except for She 22 literally does not see many details in life. This would explain why her capacity to clean her 23 person, her children or her house is very limited. She literally does not perceive the dirt, clutter, 24 and mess that other persons see in her home. Of even more concern, is the likelihood that this 25 will impair her capacity to care for her children. She very literally will not see many behavioral 26 cues that her children may give her regarding their needs for relationship, food, care, or 27 nurturing. She will miss their noises, behaviors, attitudes, and emotions, not because she is ill 28 meaning, but simply because she does not perceive or register these features of her 29 environment. Thus, Jane is at high risk to neglect her children. 30 31 Overall, this test suggests that Jane is very likely to have difficulty forming and executing 32 comprehensive and effective parenting strategies and plans. She is very likely to have difficulty 33 remembering what has been taught to her and implementing it. This test suggests that she is 34 not likely to take new knowledge and generalize it to new situations. 35 36 Jane was given the Wide Range Achievement Test (WRAT 3) to verify her current capacities for 37 Reading, Spelling, and Arithmetic were sufficient for taking projective written tests. This test 38 indicated that Jane is Reading at the grade level, Spelling at the grade level, 39 and computing Arithmetic at the grade level. may have been 40 malingering when taking the IQ test to drive her score lower.. 41 42 Jane was asked to complete the MMPI. The MMPI is a five hundred and sixty-six true and false 43 item test that is a well know test of personality and is useful in helping the examiner to 44 understand the client's feelings about herself and relationships with others. This test was valid Bid Proposal Greeley Counseling Center 3/27/07 Page 47 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 1 and suggested Motivation to change may be a 2 problem. 3 4 Jane also took the MCMI-III. This one hundred and seventy-seven-item test helps to understand 5 personality dynamics with special emphasis on the possibility of personality disorders. 6 7 8 Jane completed the Personality Assessment Inventory (PAI). This 344 item instrument is a 9 newer assessment of personality functioning. This scale was valid. 10 11 This examiner attempted to complete the Brown Attention Deficit Disorder Scale with Jane 12 13 14 The Inventory for Client and Agency Planning (ICAP) is a comprehensive, structured instrument 15 designed to assess the status, adaptive functioning, and service needs of the client. The 16 primary purpose of the instrument is to aid in screening, monitoring, managing, planning, and 17 evaluating services for handicapped, disabled, and elderly people. The ICAP was completed by 18 the examiner and the caseworker, F R, in conjunction with Jane. Jane has serious developmental 19 lags in three of four areas: 20 21 Motor Skill functioning is at the __ year old level; 22 Social and Communication S ills are at the __ year _ month level; 23 Personal Living Skills are at the __ year _ month level; 24 Community Living Skills are at the __ year __ month level. 25 26 Her Broad Independence Score is at the __ year _ month level. These scores are generally 27 consistent with her intellectual testing and in part with prior functioning. These scores are 28 consistent with past behavior while working with the Department during the last ____ years. 29 She has made little gain and does not maintain training. This instrument suggests that Jane 30 requires regular supervision and is capable of only limited personal care. 31 32 The ICAP produces instructional ranges in age equivalent values. Jane's projected ability to 33 learn new information suggests she will easily learn at the lower end of the ranges below and will 34 struggle to learn information presented at the top end of the range: 35 36 Motor Skill - __ year _ month to __ year _ month; 37 Social and Communication . kik - _ year _ month to __ year __ month; 38 Personal Living Skills - year _ month to __ year _ month; 39 Community Living Skills - _ year _ month to __ year _ month; 40 Broad Independence - year _ month to __ year __ month. 41 42 The ICAP produces a Maladaptive Behavior Index comprised of four scales. Jane's scores 43 suggested functioning ranging from Serious to Normal: 44 45 internalized (Self-harm; withdrawal; Repetitive Habits) - NORMAL Bid Proposal Greeley Counseling Center 3/27/07 Page 48 of 58 ' Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 1 Asocial (Outwardly directed unpleasant, uncooperative behavior) - MODERATELY 2 SERIOUS 3 Externalized (Outwardly Aggressive Behavior) - MARGINALLY SERIOUS 4 General (Overall Measure of Problem Behavior) - MODERATELY SERIOUS. 5 6 These findings are generally consistent with past history. Jane is not currently self injurious. 7 However, she does have problems with general life functioning. 8 9 CHILDREN'S INFORMATION 10 Jane was asked about attachment between herself and her children. She remarked that all of 11 her children are more attached to their father than to her. She stated 12 13 Jane stated that she is being seen in her home twice per week for one and a half hours per 14 session by . Asked the purpose for the visits she stated, "We work on safety 15 stuff and meal things. I really don't need any help. We work on bathing. She says everything's 16 perfect. says we're doing just fine." At the time of the evaluation, Jane was having 17 unsupervised visits with Justin on Saturdays for several hours. 18 19 Jane was asked to list her strengths and weaknesses as a parent. She began with strengths by 20 saying: 21 • " 22 23 She then listed weaknesses: 24 • " 25 • " 11 26 26 27 28 29 Information regarding Jane's children was obtained using the Children's History Form. 30 31 Paul Junior 32 Paul Jr. was born -, 2001 following a pregnancy in which Jane gained approximately 33 pounds. Labor lasted approximately hours and the child was born in a normal 34 head first vaginal delivery. He was full term and weighed pounds and ounces at 35 birth. Jane stated she breastfed Paul for ____ months. 36 37 Jane reported no unusual problems with Paul during his early infancy. Motor milestones as 38 remembered by mother were , frequent ear infections in the past, but none 39 currently. He has had tubes placed in his ears. His tonsils were removed when he was two 40 years old. 41 42 Jane reported that both she and Paul Sr. discipline with 43 44 Justin Bid Proposal Greeley Counseling Center 3/27/07 Page 49 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 1 Justin was born --, 2002. Jane reported that her pregnancy with Justin was without 2 event. She could not remember her weight gain during this pregnancy. had gained 3 twenty-five to thirty pounds labor lasted approximately hours. 4 Justin was born in a standard head first vaginal delivery. He was full term and weighed eight 5 pounds at birth. Jane stated she breastfed this baby for a couple of months. She stated she 6 stopped because . DESCRIPTION OF DEVELOPMENTAL DELAYS 7 8 requent ear infections and had tubes implanted. MEDICAL ISSUES 9 10 MEDICATIONS AND THERAPIES 11 12 Ruth 13 Ruth was born --, 2003. Jane's pregnancy with this child was uneventful and she 14 reported a weight gain of approximately thirty-five pounds. a very long labor 15 ( hours). She was ultimately born in a standard head first vaginal delivery. Jane noted 16 that Ruth was blue at birth but did cry quickly. Jane believed that this child was about five days 17 early. She weighed seven pounds, fourteen ounces. Jane breastfed this child for about six 18 months. 19 20 Ruth had no unusual difficulties during her infancy. Ruth's language is delayed and Jane believed 21 . Toilet training has not yet been completed. This child does have significant 22 . Ruth also suffered frequent ear infections and had tubes placed. 23 24 Sul 25 Saul was born --, 2005. Jane's pregnancy with this child was complicated by problems 26 with the . Jane believed that she gained only nine to ten pounds during this 27 pregnancy because she kept losing weight. Labor lasted approximately fifteen hours. Saul was 28 born in a standard head first vaginal delivery. EARLY DIFFICULTIES AND PHYSICAL ANOMALIES 29 Jane stated this child has had two sets of tubes placed in his ears. 30 31 This baby was hospitalized on a few occasions. She remarked that he is 32 "always sick." She is currently giving him 33 34 OBSERVATIONS 35 The examiner completed three planned home visits. During the second visit only Justin 36 was present. Underlined words are areas of concern. Italics indicate positive 37 observations. 38 39 Jane Doe 40 Home Visit 41 42 On -/--/07 this examiner observed Jane and Paul with their four children in their home in 43 Greeley. Jane refused to allow the examiner to observe unless the caseworker Bid Proposal Greeley Counseling Center 3/27/07 Page 50 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 1 was present. F R was present and spent the majority of her time on the living room 2 sofa. DESCRIPTION OF HOME AND ACTIVITY LEVEL. 3 4 5 5:22 6 Jane turned off the music. She made a bottle for Saul and water. 7 FOLLOWING BEHAVIORAL DESCRIPITIONS OCCUPY THREE PAGES. 8 9 Home Visit 10 -/--/07 11 12 10:00 13 Justin, Jane, FATHER, and F are at the home. F asks FATHER to leave so Jane can be 14 observed with Justin. He leaves. 15 16 FOLLOWING BEHAVIORAL DESCRIPITIONS OCCUPY TWO PAGES. 17 18 Home Visit 19 -/-/07 20 21 5:00 P.M. 22 Jr., Ruth, Saul and Paul, Sr. are in the home. Justin is not present as the foster parent 23 had sick children. 24 25 FOLLOWING BEHAVIORAL DESCRIPITIONS OCCUPY TWO PAGES. 26 27 28 SUMMARY 29 Jane Doe is a year old Anglo female functioning in the range of intellectual 30 ability. Current IQ tests may slightly under represent her actual 31 capacity. She may have been malingering to suppress her scores. 32 Current testing suggests 33 34 FOLLOWING SUMMARY OCCUPY ONE PAGE. 35 36 37 38 RESPONSES TO REFERRAL QUESTIONS 39 40 1 . Does Jane have a disease of mind, a defect of mind, or an emotional 41 condition that will deleteriously effect her capacity to parent her 42 children? 43 Bid Proposal Greeley Counseling Center 3/27/07 Page 51 of 58 Bid Proposal 3/27/07 Jack 1.Gardner,Psy.D. Licensed Psychologist 1 Yes. Jane has limited intellectual capacity with specific lack of competence in areas 2 required for personal living skills, communication, community living, and discerning 3 details. These features are likely to lead to general poor functioning 4 and poor communication with social agencies. Thus, her children are at high risk of 5 6 7 transient psychotic episodes in the past. 8 9 2. Describe Jane's personality. What is her diagnosis? 10 11 Jane's personality is 12 13 Her diagnoses are as follows: 14 15 Axis I: 16 17 Axis II: 18 19 . 20 21 Axis III: 22 23 Axis IV: 24 25 26 Axis V: --. 27 28 3. What risks, if any, does Jane pose to her children? 29 30 A. Jane cannot provide a safe, healthy, nurturing, sanitary environment for her 31 children. 32 B. ignores her children much of the time. 33 C. limited repertoire of coping skills to deal with Ruth, Justin, or Saul. 34 strong concerns that Jane may pose a risk of physical harm to 35 her when frustrated. In the absence of anger, Jane is likely to excessively withdraw 36 from Ruth and her other children. 37 D. to have poor bonding with him. No discernible bond was noted with 38 him during current observations. 39 E. serious developmental lags effecting her social and communication 40 skills, her personal living skills, and her community living skills. These lags have 41 significant serious implications for her ability to parent her children in an effective 42 manner. Bid Proposal Greeley Counseling Center 3/27/07 Page 52 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 1 F. no ability to maintain consistent employment. not 2 likely to be able to sustain meaningful, gainful employment. She will not 3 independently be able to provide sustenance or shelter for her children. 4 G. In the home Jane was 5 H. Jane can not multitask or focus on more than one thing at a time. 6 I. Jane lacks the capacity to self-soothe and to help her children calm and soothe. 7 This is consistent with a hypothesis that Jane has the residual effects of poor 8 bonding and attachment. Jane has a very low and unhealthy frequency of 9 spontaneous, nurturing touch to her children. She is very likely to have significant 10 bonding deficits with her children. 11 12 4. What recommendations are forthcoming from this evaluation? 13 14 A. Jane should be evaluated by a competent psychiatrist 15 B. More thorough understanding of FATHER's capacities as a parent is 16 needed. 17 C. The three younger children should be placed in a 18 permanent setting where adequate nutrition, nurturance, bonding and developmental 19 support are available. Jr. may be stable enough to remain at home. This should be 20 further assessed to confirm he is developmentally, academically, socially and 21 emotionally on track for his age and culture. 22 23 5. If changes are needed, can they be made in a reasonable amount of 24 time for the children's best interests? 25 26 Prediction of behavior is difficult and imprecise. However, past behavior is generally the 27 best predictor of future behavior, given no significant change. Additionally, the 28 presence of certain factors (i.e., diminished intellectual capacity; organic brain syndrome; 29 limited or no change with training, therapy or medication; lack or discomfort or 30 dissonance with current behavior; lack of motivation to change; or concomitant 31 substance abuse) can be used to predict behavior. Testing and history clearly suggest 32 that Jane will struggle . Sadly, this examiner does not believe 33 that Jane will be much different if tested or examined a year in the future. 34 35 Jane has been resistant to cooperative treatment with some service providers in the 36 past and did not understand basic developmental needs of her children. She currently 37 does not perceive the need for treatment or intervention, thinks everything in her home 38 is "perfect", and eschews the notion of medication to improve her functioning. She does 39 not understand the developmental capacities of her children. These features bode ill for 40 successful change in a reasonable time period, if ever. 41 42 Jane's consistent pattern of denial followed by minimization, rationalization or 43 justification renders her self report to be highly questionable much of the time. This is 44 not likely to change over time. Her propensity for prevarication is automatic and well 45 practiced. It is likely to remain stable over time. Bid Proposal Greeley Counseling Center 3/27/07 Page 53 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist I 2 3 4 I trust these opinions are of assistance. Should you have any questions please do not hesitate 5 to contact me. 6 7 8 9 10 Jack J. Gardner, Psy.D. 11 Licensed Psychologist Bid Proposal Greeley Counseling Center 3/27/07 Page 54 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 1 APPENDIX A 2 3 CONCEPTS REGARDING "MINIMALLY COMPETENT PARENT" 4 5 • Legal standards dictate that children may be removed from parents if the 6 parents do not demonstrate minimal competency as parents. This concept is 7 poorly defined. The following continuum suggests that parenting behaviors, 8 attitudes and emotions which are conductive to the healthy development of a 9 child are on a continuum and may vacillate greatly depending on a number of 10 intrinsic individual factors coinciding with environmental conditions. Parental 11 competency will vary as an interaction between the individual's capacities and 12 the environmental demands. 13 14 • Clearly there are impermissible Situations (see below). 15 16 • Minimally competent parents are not necessarily providing the healthiest 17 environment for the child, but one in which a child may develop, depending on 18 the child's capacities and resilience. Sturdy children often grow up in difficult 19 situations and prosper. 20 21 • There are many factors which may or may not be altered to help a parent bridge 22 the gap between Incompetent and Minimally Competent. 23 24 25 A THEORETICAL PARENTING CONTINUM 26 27 »» »» »» »» »» »» »» »» »» »» »» »» 28 29 Impermissible Situations Minimally Competent Maximally Competent 30 Catastrophic Major (Legally Permissible but 31 BRIDGE minimally healthy) 32 FACTORS 33 34 35 IMPERMISSIBLE SITUATIONS 36 There are some conditions which are clearly impermissible and the occurrence of which would 37 clearly warrant the removal of the child from the home and very likely termination of parental Bid Proposal Greeley Counseling Center 3/27/07 Page 55 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 1 rights. These impermissible behaviors can be divided into two categories: Catastrophic and 2 Major. 3 4 A. Catastrophic Impermissible behaviors include (but may not be limited to): 5 1 .) Repeated and/or severe physical, emotional, or sexual violence from 6 an adult toward a child; 7 8 2.) Repeated severe violence between adults; 9 10 3.) Inability to bond or attach with a child; 11 12 4.) Characterological, intellectual, and/or organic incapacity to change 13 within a reasonable amount of time for the best interest of the child; 14 15 5.) The fostering of an inhumane or dangerous environment for the child 16 due to lack of food, clothing, shelter, appropriate medical care or the 17 ongoing presence of noxious chemicals and pollutants (i.e., second hand 18 smoke, methamphetamines), animals, or persons (i.e., cohabiting with a 19 person who is manufacturing methamphetamines and who is violent and 20 antisocial in nature). 21 22 6.) Repeated changes of caregivers resulting in the lack of a consistent, 23 nurturing primary caregiver. 24 25 B. Major Impermissible behaviors include (but may not be limited to): 26 1 .) Limited, non-violent physical, sexual, or emotional abuse from an adult 27 to a child; 28 29 2.) High conflict divorce which is ongoing and without remission in a 30 normal amount of time; 31 32 3.) Continuous severe drug/alcohol use which degrades capacity to 33 parent; 34 35 4.) Inability to maintain employment or income; 36 37 5.) Inability to provide consistent or adequate food, medical care, 38 intellectual/academic support, shelter, clothing, or peer interaction; 39 40 6.) Significant medical, mental, or emotional limitations or conditions 41 which endanger the child's physical or emotional development; 42 43 7.) Presence of moderate to severe character disorder which threatens 44 to, or does impair parent/child relationships; Bid Proposal Greeley Counseling Center 3/27/07 Page 56 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 1 8.) Consistent exposure of the child to harmful, violent, or antisocial 2 others or situations; 3 4 9.) Presence of significantly diminished cognitive capacity due to physical 5 limitations, low innate intellectual ability, or organic brain syndrome which 6 impair the adult's functioning to the degree that the child is neglected or 7 harmed. 8 9 10 MINIMALLY COMPETENT PARENT 11 12 A Minimally Competent Parent can demonstrate: 13 1.the ability, without harming the child, to be willing and able to create an 14 environment which will keep the child alive; and 15 2.which may or may not allow the child to reach his or her maximum 16 potential. 17 3.Parents who are minimally competent have some understanding of the 18 child's developmental needs and capacities; 19 4. are able to communicate with the child on a developmentally 20 appropriate level; 21 5. are able to form and maintain a rudimentary bond with the child; 22 6.provide some nurturing, appropriate structure; 23 7.and provide a rudimentary level of cognitive simulation (i.e., books, toys, 24 creative experiences). 25 26 27 MAXMALLY COMPETENT PARENT 28 29 A Maximally Competent Parent might be one who, without harming the child, is 30 1.) able and willing to create and maintain a safe and enriched 31 environment, commensurate with his/her means, which will keep 32 the child alive and proactively stimulate the child's physical, 33 emotional, social, spiritual, and moral growth. This environment 34 will strongly encourage the child to develop to his or her maximum 35 capacity. 36 37 BRIDGE FACTORS 38 This examiner does not believe that the law requires parents to be maximally competent 39 to have their children returned or reunited with them. They must be minimally 40 competent. The factors between the impermissible and the minimally competent can be 41 considered to be bridge factors. These are characteristics which need to be present, 42 or instilled, in any individual parent to allow her/him to retreat from the parameters of 43 the impermissible and enter the basic domain of minimally competent parent. 44 Bid Proposal Greeley Counseling Center 3/27/07 Page 57 of 58 Bid Proposal 3/27/07 Jack J.Gardner,Psy.D. Licensed Psychologist 1 It is necessary to estimate the likelihood that the parent is likely to achieve such status 2 in a reasonable amount of time for the best interest of the child (ren) and maintain 3 adequate and healthy behavior for a long enough period of time for the child (ren) to 4 grow and develop past the parent's vulnerabilities. The following bridge factors are 5 necessary but may not be all inclusive: 6 1.) The minimally competent parent must have enough intellectual 7 capacity to form some insights and to engage in cause and effect 8 reasoning. 9 10 2.) This parent must have the capacity to develop, maintain, and support 11 a limited understanding of th hild' d v lopm n al n d . 12 13 3.) This parent must have the motivation and capacity to work with 14 external caregivers and participate meaningfully in their theranies. These 15 therapies may be behavioral, psychological, physical, pharmacological, or 16 focused on substance abuse or domestic issues. In these therapies, the 17 individual must demonstrate the capacity to make significant changes and 18 must demonstrate that significant changes have been made so that 19 conditions which resulted in removal of the child are ameliorated and are 20 likely to recur with very low frequency or not at all. 21 22 4.) This parent must have adequate external support systems which will 23 help them facilitate and maintain changes. Such support system could be 24 in the form of extended family, church or spiritual group, self-help 25 organization, or pressure from legal or social agencies. 26 27 5.) This parent must have the ability to consistently remain abstinent of 28 illegal mood or behavioral altering substances if this has been a prior issue 29 of concern. 30 31 6.) This parent must have the presence of core features in the 32 personality which are generally adaptive and prosocial. These variables 33 include the ability to make good moral judgments; the capacity to discern 34 right from wrong following generally accepted social standards; the 35 presence of honesty, empathy, and a sense of fairness and fair play; the 36 capacity and willingness to share of themselves emotionally with their 37 children and others; and the capacity to form and maintain trusting 38 relationships at least at a rudimentary level. 39 40 7.) This parent must be able to demonstrate snontaneous emotional 41 affection and be emotionally available to the child on a relatively 42 consistent basis. 43 44 Bid Proposal Greeley Counseling Center 3/27/07 Page 58 of 58 03/28/2007 11 : 32: 15 American Prof Agency --> 9703569646 P.001/002 AMERICAN PROFESSIONAL AGENCY, INC. 95 Broadway • Amityville, New York 11701 (881) 691-6400 s (800) 421-6694 Certificate of Insurance request. TO: GREELEY COUNSELING FROM: Laverne DATE: 03/28/07 TIME: 11:31:48 PAGES: 002 03/28/2007 11 : 32:45 American Prof Agency --> 9703569646 P.OUG/UUL Adcdunt Number: CO GREE 6310 Date: 3/28/07 Initials: KB DARWIN NATIONAL ASSURANCE COMPANY C/O: American Professional Agency, Inc. 95 Broadway, Amityville, NY 11701 This is to certify that the insurance policies specified below have been leaned by the company indicated above to the insured named herein and that, subject to their provisions and conditions, such policies afford the coverages indicated insofar as such coverages apply to the occupation or business of the Based insureds) as stated. THTS r.FRTTFTCATF CIF TNSIRANCF NFTTHFR AFFTRMATTVFI Y NfYt NFC.ATTVFI Y ANFNHS, FXTFNCIs (Y2 ALTERS THE COVERAGE(S) AFFORDED BY THE POLICY(IES) LISTED ON THIS CERTIFICATE. Name and Address of Insured: Additional Named Insureds: GREELEY COUNSELING JACK J. GARDNER, PSY.D. CENTER, P.C. 1228 8TH STREET GREELEY CO 80631 Type of Work Covered: PROFESSIONAL PSYCHOLOGIST Location of Operations: N/A (If different than address listed above) Claim History: Policy Effective Expiration Limits of Coverages Number Date Date Liability PROFESSIONAL/ 1,000,000 LIABILITY 5011-2674 4/01/07 4/01/08 3,000,000 NOTICE OF CANCELLATION WILL ONLY BE GIVEN TO THE FIRST NAMED INSURED ON THIS POLICY AND HE OR SHE SHALL ACT ON BEHALF OF ALL INSUREDS WITH RESPECT TO GIVING OR RECEIVING NOTICE OF CANCELLATION. Comments: T64c rn,*4F4rneo TecumA ton- GREELEY COUNSELING CENTER, P.C. Address: 1228 8TH STREET Au orized Representative GREELEY CO 80631 EXHIBIT B SUPPLEMENTAL NARRATIVE TO RFP GREELEY UNSELlNG :' km C r., 4 SEWER, F.C. q 3'Striker, 71y 7 1228 8th Street, o Greeley, Colorado 80631 -- ._V: 970.356-44@2;: I: 070-3664646 . WELD DSS BID PROPOSAL ADDENDUM 5/17/07 1. I have more than 300 volumes in my professional library. Two that I often look at regarding evaluations include: Groth - Marnat, G. (1997). Handbook of Psychological Assessment (3rd ed.). New York: Wiley. Sattler, J. M. (1998). Clinical and forensic interviewing of children and familiet . San Diego, Author. I get the journal published by the Association of Family and Conciliation Courts and peruse pertinent articles when time permits. 2. Section 5, "Confidentiality and Participant Protection/Human Subjects" does not apply to my bid. I perform court ordered psychological evaluations, not research. Regards the evaluations, I provide the client with disclosure of limited confidentiality and the purpose of the evaluation. A copy of the disclosure was appended to the original application. 3. Program Improvement Plan In my psychological evaluations and interactional evaluations I include recommendations for placement and/or remediation of s '11s deficits. Page 53 of the original proposal contains recommendations rearding placement' from a sample psychological evaluation. I am often asked to assess the attachment/bond between parents and children. I make recommendations .,- for placement of the children based on observed behavior and prior history., . It is my personal belief, which is concordant with Colorado law and current practices in psychology, that whenever possible the best placement for a , child is with biological parents. This is always the preeminent goal in my wor6 , when the child's safety and physical, emotional, and mental well-being can be-4 assured. 4. Meeting with Program Area Supervisor Sheet I met with Robin Overmeyer and Andrea Shay on 3/6/07. (See attached form.) ck J. Gardner, Psy.D. Licensed Psychologist "3 . a W , 0 2 Greeley Counseling Center Program Area Supervisor/Provider Meeting Verification/Comment Form f Date of Meeting: 31_) CD i u `1 Program Area: s: \\.c°�, ' N Comments (to be completed by Program Area Supervisor): \-i'..3\.S.,,( r,C` i ' '-_f .,, , a • �� y ' f.,, j.,>a:' , ti ICI, e. ( 1K ?(\ DvJC 7r� 6 QTh ) O35 )0 -. c,6 C ,r .�.�* oV, _n�� F V , i 9 „..)„,.c.2 9 \:. O cc Q*,\,,,� o r'a pit) ,,. 1 c.)(--- �v e. bk. > Q St `)s, ( , .tom,-.,0 _ C,-}- .C-x1,1 tisz�'� ,,\\ \, \L l J ri U. -\+ , C3 cry 4 vc�Q c>r "iT->C _ ic C-ITh C..s ;U, �� ,�ynAU1 , l41 k i; Signature of Program Area Supervi rs DEPARTMENT OF SOCIAL SERVICES P.O. BOX A WWebsIlDGREELEY, CO. 80632 ite:www.co.weld.co.us Administration and Public Assistance(970)352-1551 OFax Number(970)353-5215 • COLORADO May 11,2007 Jack J. Gardner, Psychologist. Greeley Counseling Center 1228 8 Street Greeley, CO 80631 Re: Bid 003-MH-07 (RFP 001-07)Mental Health Services Dear Dr. Gardner: 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 Through the 2007-2008 bid evaluation process,the Families,Youth and Children(FYC) Commission recommended approval of your Bid#003-MH-07 (RFP 001-07),Mental Health,for inclusion on our vendor list, attaching the following conditions. Conditions: Greeley Counseling Center must provide information not addressed in the submitted bid,including; 1. Literature citations, 2. Confidentiality and Participant Protection/Human Subjects, 3. Program Improvement Plan, 4. Meeting with Program Area Supervisor Signature Sheet. B. Required Response by FYC Bidders Concerning FYC Commission and Conditions: 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 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. Page 2 Gardner/Results of RFP Process for 2007-2008 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, Weld County Department of Social Services,P.O. Box A, Greeley, CO, 80632, by Monday, 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 at 352.1551,extension 6392. Sincerely, y A. riego, • -ctor I cc Juan Lopez, Chair, FYC Commission Tobi Vegter, Core Services Coordinator Gloria Romansik, Social Services Administrator Weld County Department of Social Services Notification of Financial Assistance Award for Core Funding Type of Action Contract Award No. X Initial Award 07-CORE-59 Revision (RFP-FYC-006-00;006MH07) Contract Award Period Name and Address of Contractor Beginning 06/01/2007 and Transitions Psychology Group Ending 05/31/2008 Mental Health Services 804 11th Avenue Greeley,CO 80631 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Assistance Award is Provides comprehensive psychological services to facilitate based upon your Request for Proposal(RFP). The RFP specifies the service planning and expedite permanency planning for scope of services and conditions of award. Except where it is in children. Services include psychological evaluations, conflict with this NOFAA in which case the NOFAA governs,the interactional assessments,mental health evaluation/dual RFP upon which this award is based is an integral part of the action. diagnoses evaluation,therapy for individuals,couples,and Special conditions families,and consultation with caseworkers.Bicultural and 1) Reimbursement for the Unit of Services will be based on an South County services(Del Camino&Greeley office)are hourly rate per child or per family. available. Capacity to serve a total of 90 clients,total family 2) The hourly rate will be paid for only direct face to face units 70,children ages 2-18,average stay in the program is six contact with the child and/or family,as evidenced by client- weeks,average hours per week is two. signed verification form,and as specified in the unit of cost Cost Per Unit of Service computation. Episode Rate per 3) Unit of service costs cannot exceed the hourly and yearly Psychological Exam(Assessment) $1,320.00 cost per child and/or family. Treatment Package(Psychological Evaluation 4) Payment will only be remitted on cases open with,and following Mental Health Evaluation) $1,020.00 referrals made by the Weld County Department of Social Parent-Child Interactions(up to four Services. family members) $1,100.00 5) Requests for payment must be an original submitted to the Treatment Package-Intensive Weld County Department of Social Services by the end of (Each Additional Adult) $440.00 the 25`h calendar day following the end of the month of Treatment Package-High service.The provider must submit requests for payment on (Each Additional Child) $220.00 forms approved by Weld County Department of Social Treatment Package-Low Services.Requests for payments submitted 90 days (Mental Health Evaluation) $300.00 from the date of service, and thereafter,will not be Hourly Rate per paid. Treatment Package-Moderate 6) The Contractor will notify the Department of any changes in (Parent-Child Interactions) $220.00 staff at the time of the change. Family Counseling(Individual,Couple, Family) $100.00 Court Testimony $150.00 Enclosures: X Signed RFP: Exhibit A X Supplemental Narrative to RFP:Exhibit B X Recommendation(s) X Conditions of Approval Approvals:C. Pro Official: By (3 �� By„ fob David E. Long,Chair Judy Grieg , irector Board q(,} el�GptFp;y, ommissi ere Wel unty Dartment of ocial Services Date: JIJN Zj LU0 Date: r EXHIBIT A SIGNED RFP • 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 StreetLP.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 (After receipt of order) BID MUST BE IGNED IN INK Program Area: IA P 171 TYPE OR PRINTED SIGNATURE VENDOR Transitions 1syclw!o9 y Gp. u.G (Name) Handwritten Signature By Authorized ff Officer or Agent of Vendor ADDRESS I 1 AVei. TITLE CO-- Cl Y Y &reele T CO Dlo3I DATE '}jI /01- J Q PHONE# (9-4-o)3300- I I a'3 The above bid is subject to Terms and Conditions as attached hereto and incorporated. Program Area Supervisor/Provider Meeting Verification/Comment Form Date of Meeting: 3 %t brt Program Area: '(moo)-k- \\ stc�SL C . Comments (to be completed by Program Area Supervisor): rr W YI C' 9 C gn oj. \\ n 6Y��--t n SL., 4 k. -D fT a- U r:, Cu t Y C L.33 l--R\rte c r‘ O CR 3 0 �s{` Qun r>4 J 1 w (7 \flarw2 . rk c{S . o C\L) S. CAS rases ��QYt5l � �(\C2\„._? Nod rs' c 32_ I\ A}- *\o 1cC krs .. ._J�?iJv�1 C� T�i�VOi . A> c;A�Gi U ,‘ ac-1 Sere of ram Area Sys ism ORIGINAL a_ via Mental Health Services, 2007-08 w ^ ea Mos Transitions PSYCHOLOGY 611UHP. LL[ ABSTRACT Transitions Psychology Group, LLC (Transitions) is a team of counseling, consulting and assessment professionals working together to provide innovative, effective behavioral health services to children, adults and families. The agency attracts creative, experienced professionals who are inspired to help others fulfill their potential, improve their relationships and strengthen their connection to their community and their world. The mission of the Mental Health Services program offered by Transitions is to provide comprehensive assessment services to facilitate service planning and expedite permanency planning for children. The overall goal of the program is to offer a variety of assessment options to clarify family issues and assist with treatment planning in order to expedite reunification. Transitions will utilize the team approach that is the hallmark of the agency in order to provide the highest quality assessments possible. Psychological Assessment services will serve a variety of clients from children to adults. Assessments will be comprehensive, addressing a multitude of referral concerns and issues. Assessment can be done in any combination of the following areas: cognitive, personality, attention/memory/concentration, achievement/educational and adaptive behavior. Interactional Assessments involve examining the quality of the parent-child relationship and offering suggestions and strategies about ways to enhance the bonding and attachment of parents and their children. Mental Health Evaluations will serve adolescent and adult clients. These brief evaluations are intended to provide a preliminary diagnosis and preliminary recommendations, including dual diagnoses when substance abuse and mental health concerns are both present. Transitions team of mental health professionals have been a trusted resource individual, couple's and family therapy in the community for eight years. Our experienced therapists are available to provide counseling interventions for social services clients to address issues identified in their service plans. TABLE OF CONTENTS I. Target/Eligibility Populations... ...... ............... ......... ............ ..........3 II. Project Narrative/Supportive Documentation.. .3 A. Types of Services Provided. .3 B. Measurable Objectives. .5 C. Service Objectives. .7 D. Workload Standards......... ............ ......... ...............................7 E. Staff Qualifications... ... ............ .............................. ... ... ... ......8 F. Program Capacity by Month............... ............... .....................8 G. Internal Tracking and Billing Process .9 H. Literature Citations. .10 I. Confidentiality and Participant Protection... ......... ...... ...... ... ......11 III. Budget.. .11 IV. Appendices.................. ... .............................. ...... ... ............ ...11 A Appendix 1: Resumes B. Appendix 2: Data Collection Instruments/Protocols C. Appendix 3: Sample Consent Forms TARGET/ELIGIBILITY POPULATIONS > Total number of clients to be served: 90; children's ages: 2-18; total family units: 70 ➢ Sub-total of individuals who will receive bicultural/bilingual services: 30. The monthly maximum program capacity per group: 5 individuals for Psychological Assessments, 12 individuals for Mental Health Evaluations, 5 families for Interactional Assessments and 30 individual or family units for Therapy; the monthly average capacity is 2, 4, 2 and 5 respectively. ➢ Average stay in the program (weeks): 6; Average hours per week in the program: 2 > Cultural/ethnically specific services: 30; services to South Weld County clients: 30. Bicultural services are available in all Mental Health program categories. Psychological Assessments are available in English only. Mental Health Evaluations, Interactional Assessments and Therapy are available in English and Spanish. Transitions is located in Greeley, CO. However, all services can be provided in the Ft. Lupton or Del Camino social services offices, or in the client's South Weld County homes as appropriate. PROJECT NARRATIVE/SUPPORTING DOCUMENTATION A. Types of Services Provided 1. Screening, evaluation and other assessment services intended to provide information needed by the staff of Social Services. a. Psychological Evaluation Data collection, clinical interviews and testing instruments will be utilized to increase the understanding of a client's functioning and provide information needed by the staff of social services for service planning. Evaluations will be conducted by licensed eligible psychologists who have an earned doctorate (PhD) in the field of psychology and are under the constant supervision of a licensed psychologist. The PhD will determine the appropriate assessment instruments and use these instruments to address the referral questions. The instruments will allow the practitioner to address issues including, but not limited to the following: abilities, mental health impairments, parent's ability to recognize and provide a safe environment for children, ability to learn new strategies, most effective way to learn information, ability to adapt and assimilate to one's community, and an individual's ability to concentrate and recall specific information. Assessments will also identify any learning disabilities, mental health diagnoses and/or other cognitive impairments. Substance abuse and use will also be assessed. A variety of available tests will be considered to evaluate the subject in areas relevant to the referral questions, such as cognitive (Wechsler Adult Intelligence Scale- Third Edition, Wechsler Intelligence Scale for Children- Fourth Edition, Universal Nonverbal Intelligence Test); personality (Minnesota Multiphasic Personality Inventory[MMPI], Minnesota Multiphasic Personality Inventory for Adolescents [MMPI-A], TAT, CAT, Children's Personality Inventory, Trauma Symptom Scale, Draw-A-Person Screening Procedure for Emotional Disturbance, HTP, Kinetic Family Drawing); attention/ memory/ concentration (Wechsler Memory Scale, Cognitive Assessment System, Behavior Assessment System for Children, NEPSY); achievement/ educational (Woodcock-Johnson Tests of Achievement, Wechsler Individual Achievement Test); and adaptive behavior (Vineland, Gilliam Autism Rating Scale (GARS), Gilliam Asperger's Disorder Scale (GADS). b. Interactional Assessment An interactional assessment evaluates the quality of the interaction and bonding between parents and their children. Transitions utilizes the Dyadic Parent Child Interaction Coding System (DPICS); this system allows the practioner a standardized means to quantify the interactions between the parents and the child. Also, a functional analysis of behavior will be utilized to determine the purpose of any maladaptive behaviors which may be displayed. When appropriate, the interactional assessment will take place in or two settings: Transitions office, family home, and/or community venues. The structured portion of the interactional will be videotaped and staffed with a team of professionals to provide a wealth of information and a balanced perspective on the family. c. Mental Health Evaluation/Dual Diagnoses Evaluation The Mental Health Evaluation (MHE) is a clinical interview for adolescents and adults designed to provide preliminary DSM-IV diagnoses and directions for treatment. A structured intake protocol is utilized. The Addiction Severity Index (ASI) is utilized for clients when substance use and abuse is also a concern. d. Therapy (Individual. Couple and Family) Individual, couple and family therapies work with different segments of the family unit to address issues identified in the assessments or to meet the requirements of the service plan. Individual therapy is geared toward resolving issues that interfere with the parents' ability to provide a safe, nurturing home for their children. Couples and family therapy is focused on family strengths and ability to find solutions to their own problems so that reunification can occur. 3. Consultation with caseworkers Transitions consults with caseworkers throughout the assessment process for all mental health programs. When a referral is received, Transitions contacts the referring caseworkers to clarify the caseworker's concerns and specify questions that they would like addressed by the assessment. Transitions communicates information gathered in the assessment throughout the evaluation process. We will promptly notify the caseworker of any suicidal ideations, homicidal ideations and any other forms of gross mental impairment exhibited by the client. Transitions will work with the caseworker to seek appropriate and immediate interventions. Transitions will be available to respond to caseworker questions and requests within 24 hours by phone or e-mail. Transitions also hosts a monthly case consultation meeting at social services; all caseworkers are invited to attend and various Transitions staff members are present to consult on referrals. After the assessment is completed, written reports will be made available to caseworkers and other professionals, as dictated by state laws and APA/ACA ethical guidelines, to delineate services provided and the results of the assessment. Transitions will also provide information to collateral contacts as permitted within these guidelines. Transitions will work directly with caseworkers to integrate assessment information into the care plans for children, adolescents and families. Transitions will work with other clinicians and agencies regarding rationale of recommendations and to determine appropriate level of care. Court testimony is also available regarding all assessment services with proper notice and following APA/ACA guidelines. FYC resources will not supplant existing available services in the community. Transitions will provide a variety of assessment and treatment options to complement services currently available in the community. These services will not supplant existing services in the community, as they will be based on social services referrals for services that are not funded by mental health capitation services, ADAD or other funding. B. Measurable Outcomes 1. Transitions' Mental Health services are designed to shorten the time required to obtain evaluation results following a social services referral. Practitioners have designated appointment times reserved for intakes each week so that referred clients can begin their assessments promptly. Transitions maintains phone contact with clients throughout the assessment process to schedule and confirm appointments. Reports are written promptly after the assessments are completed. Transitions will track the date of the referral and the date that the report is submitted. No more than 45 days will transpire for psychological and interactional assessments; no more than 30 days will transpire for mental health evaluations. 2. Mental Health practitioners are accessible to social services staff in order to answer questions about implementation of the evaluation results. A current e-mail and cell phone list for all practitioners will be provided to caseworkers. Practitioners will respond to all phone and email correspondence no later than the next business day and record the contacts in the client's chart. Transitions hosts a monthly case consultation meeting at the Department; various practitioners from the agency attend and all caseworkers and supervisors are invited to discuss referrals. 3. The contacts between the evaluation practitioner and social services staff occur at a high frequency. Transitions initiates contacts with the referring caseworker before, during and after each assessment. The practitioner responds promptly, within one business day, to contacts initiated by the caseworker. This will be documented in the client's chart. 4. Transitions outpatient programs follow the same guidelines, responding to caseworker inquiries within one business day. Practitioners reserve appointment times each week for new clients, allowing for prompt scheduling, typically within two days of the receipt of the referral. Transitions will track the date of the referral and the date of the client's first appointment. 5. Transitions coordinates therapeutic interventions with social services staff by obtaining a signed release of information from the client at the outset of services; this will be kept in the client's chart. The practitioner reviews the care plan and discusses concerns and treatment goals with the caseworker. Monthly written progress reports are provided to the referring caseworker. More pressing concerns are promptly communicated by phone or email and documented in the chart. 6. Transition has a team of mental health professionals who each reserve intake sessions each week to accommodate emergency consultations within 24-hours of the request. These appointment slots can be accessed immediately by the caseworker by calling the agency or via on on-line scheduling program. Transitions provides psychological evaluations by a license eligible psychologist who is supervised by a Licensed Psychologist. This PhD has seven years of experience providing assessments using widely accepted, standardized instruments. The PhD has experience providing court testimony and has been certified as an • expert in court. All assessment recommendations are developed by the primary practitioner and a supervisor to ensure that the recommendations are clear and defensible in court. The supervisor co-signs the report to certify that this review has been completed. C. Service Objectives 1. Improve family conflict management-Transitions assessment services will provide vital diagnostic information to identify the source of problems that lead to child maltreatment and other status offenses and assist in effective service planning. This will be measured by the inclusion of diagnostic information in the results and recommendations section of the reports and documented consultations with caseworkers. The Therapy program will directly address conflicts and disagreements between parents and their children; these interventions will be documented in the monthly report. 2. Improve household management competencies-Transitions will assist caseworkers in evaluating the capacity of parents to provide a safe and stable home environment for their children, including the determination of any gross impairments, suicidal ideation or homicidal ideation. Transitions will discuss parent competencies with the caseworker and document them in the reports. 3. Improve ability to access resources-Transitions will provide comprehensive assessment services that will determine a client's functioning in a variety of areas. The recommendations in the report will identify applicable resources that are available for the client. In some cases, the resulting diagnoses may qualify clients for new services that the client has not previously been able to access (e.g. social security). 4. Address Specific Referral Issues-Transitions will be in contact with the caseworker at the beginning of the referral to clarify all referral questions. Transitions will provide specific recommendations to address each referral question; these recommendations will be reviewed by the supervisor and the supervisor will sign the report, certifying that this has been completed. 5. Improve Outcomes in the Performance Improvement Plan (PIP) — Transitions will recommend interventions geared to prevent out-of-home placements and the re-entry of children into the foster care system. In addition, the results will be useful in creating realistic and timely permanency and treatment plans. Transitions will provide written recommendations regarding how to maintain children in their current placements, or how a change in placement would help to move the child closer to his permanency goal. When a child is free for adoption, the practitioner will include specific recommendations for how to facilitate an adoptive placement or, alternately, identify that adoption is not an appropriate goal for the child. D. Workload Standards > Number of hours per month: 6 for psychological and interactional assessments, 2 for mental health evaluations and 4 for therapy. > Number of individuals providing the services: 1 for psychological assessments; 4 for other program areas. > Maximum caseload per worker: 5 family units. > Modality of treatment: Mental health services are individual, couple or family, depending on the service requested. Services are primarily delivered it the Transitions offices for this program area, but some services will be in the South Weld County social services offices, client's homes, or other community settings as needed. > Total number of hours per day/week/month: 25 per month. > Total number of individuals providing the services: 5. Transitions has one licensed-eligible psychologist and four licensed professional counselors providing direct mental health program services. > Maximum caseload per supervisor 30 family units > The number of assessments completed per month: 7. > Insurance: Transitions co-directors and employees are insured through Healthcare Providers Service Organization Purchasing Group (HPSO). The limits of liability are$1,000,000 per occurrence and$6,000,000 aggregate. Contract counselors maintain their own policies, each with a minimum of$1 M/$3M liability. Current contracted counselors are insured through HPSO and the Philadelphia Indemnity Insurance Company. E. Staff Qualifications 1. Minimum Qualifications: All counselors and supervisors providing direct services will meet minimum qualifications in education and experience as defined in Staff Manual Volume VII, Section 7.303.17, and Section 7.0006 Q, Colorado Department of Human Services. All staff and supervisors contracting with Transitions have a minimum of a bachelor's degree in a human services related field and two years of related experience. Therapeutic visitation providers have at least a Master's degree in a human service field and the majority is licensed professional counselors. 2. Staff available for the project: 6. Transitions has one licensed eligible psychologist, four licensed professional counselors and one Licensed Psychologist supervisor for the project. 3. Mandated New Caseworker Training: One full-time Transitions counselor has received mandated new caseworker training. Other counselors will not receive this training. F. Program Capacity per Month Transitions utilizes a combination of full-time employees and contracted therapists to address fluctuations in referrals to the program. The maximum program capacity per month is 4 referrals for Interactional Assessments and Psychological Assessments. The maximum program capacity for Mental Health Evaluations and Therapy is 10 per month. The minimum number of referrals necessary to sustain the program is 1 per month. G. Internal Tracking and Billing Process 1. Transitions receives new referrals via email from the CORE services coordinator. Once a new referral is received, Transitions emails the CORE coordinator and the primary caseworker to confirm that the referral has been received. Transitions' administrative assistant records the referral, including the dates of approval. The referral is then assigned to a primary by a co-director; the primary practitioner records the hours of service on the verification form and has the client sign after each face-to- face contact. The administrative assistant tracks the number of hours utilized each month and to date for each referral monthly and records this information on the billing form. 2. Transitions follows a structured billing process in order to maintain prompt billing for services. Transtions staff are required to submit all signed and dated verification forms for Mental Health services by the 1st workday of the month following the month services were provided. All documentation, including original signed monthly reports for coaching and for therapeutic visitation are due by the 5th workday of the month. The administrative assistant reviews all verification forms and completes all invoices, Authorization Forms, and Core Service Forms by the 5th workday of the month. The forms are audited by a co-director for accuracy and signed. The billing, which includes all signed documentation and the final report, is then hand delivered to the Department of Social Services H. Literature Citations Bell, S., & Eyberg, S.M. (2002). Parent-child interaction therapy. In L. VandeCreek, S. Knapp, & T.L. Jackson (Eds.). Innovations in Clinical Practice: A Source Book(Vol. 20; pp. 57-74). Sarasota, FL: Professional Resource Press. Borrego, J., Jr., Urquiza, A.J., Rasmussen, R.A., Zebell, N. (1999). Parent-child interaction therapy with a family at high risk for physical abuse. Child Maltreatment, 4, 331-342. 1. Wechsler Adult Intelligence Scale-Third Edition 2. Wechsler Intelligence Scale for Children- Fourth Edition 3. Universal Nonverbal Intelligence Test 4. Minnesota Multiphasic Personality Inventory-2, 5. Minnesota Multiphasic Personality Inventory for Adolescents [MMPI-A], 6. TAT (Thematic Aptitude Test) 7. CAT (Children's Apperception Test) 8. Children's Personality Inventory 9. Trauma Symptom Scale 10.Draw-A-Person Screening Procedure for Emotional Disturbance, 11.HTP (House Tree Person) 12.Kinetic Family Drawing (KFD) 13.Wechsler Memory Scale 14.Cognitive Assessment System 15.Addiction Severity Index 16.Behavior Assessment System for Children 17.Woodcock-Johnson Tests of Achievement - Ill, 18.Vineland, 19.Gilliam Autism Rating Scale (GARS) 20.Gilliam Asperger's Disorder Scale (GADS). I. Confidentiality and Participant Protection 1. Protect Clients and Staff from Potential Risks Transitions counselors explain privacy rights in the State of Colorado and give informed consent to all client participants in our programs (see Appendix 2). The forms are signed by the clients. In order to protect confidentiality, a release of information is always requested and signed by clients (see Appendix 2). There are no foreseeable physical, medical, psychological, social or legal risks that would be caused by the program. It is possible that the evaluation or assessment would identify mental illness, substance abuse or interactional deficits, which could have legal and psychological implications. In the best interests and protection of children, there are times when family reunification is not possible. To mitigate the effects of this, families are informed in the intake that they are being evaluated and that these evaluations will be shared with social services and may affect treatment planning and court decisions. Families are also routinely advised to seek legal advice when they have question of a legal matter. Furthermore, the results of the evaluations are reviewed with parents and when necessary, risk assessment and appropriate referrals for counseling and other services are made by the counselor. 2. Fair Selection of Participants Participants for the project are not selected by Transitions. We accept referrals from DSS and do not discriminate for age, gender, racial/ethnic background or other reasons. 3. Absence of Coercion Often referrals are made for Transitions' social service programs as a result of a court order. In these cases, clients are essentially being required to participate in order to complete their service plan and reunify their families. Transitions counselors recognize this dynamic and try to encourage open interaction with the clients and help clients to feel motivated to make positive changes in their lives. Clients are informed that they may seek a second opinion from another counselor, request an alternate referral from their caseworker or may terminate services at any time. Transitions is always willing to refer to other counselors and agencies as needed. Furthermore, Transitions discusses treatment alternatives with the referring caseworker. Nevertheless, Transitions recognizes our duty to help protect the well-being of children and to consider child safety when making recommendations for treatment. 4. Data Collection Data is collected directly from families, from the referring agency, and from other corroborative sources as necessary to provide Life Skills services. A release of information from the client is always requested and signed prior to obtaining data. Transitions collects data from the families directly during Life Skills sessions through direct contact, observations and assessments. The forms include the Life Skills intake and Parental Stress Inventory. 5. Privacy and Confidentiality Transitions adheres to privacy and confidentiality laws and statutes in Colorado and the APA (American Psychological Association) and/or ACA (American Counseling Association) code of ethics. All data collected is used for the compilation of the home study report, update or relinquishment counseling report. The data is stored in a password protected database with a backup system and/or physical charts which are secured and maintained for seven years. 6. Adequate Consent Procedures Informed consent (see Appendix 2) is used according to the ACA code of ethics. The program is not a research project and does not require assent forms for youth. It is sufficient and ethical to have parents agree to consent and to sign release forms. 7. Risk/benefit Discussion Participating in Life Skills services is recommended by the caseworker and sometimes ordered by the court when they endorse the Family Service Plan. The parents have a choice whether or not to complete the Family Service Plan, but often are required to participate in mental health services in order to successfully complete their Family Service Plan and end social services involvement with their family. Considering the well- being and safety of children as the primary benefit, it is worth some risk to require parents to participate in services. BUDGET See attached form. Costs for services: • Psychological Assessment (Adult or Child) $1320 • Psychological Evaluation following a Mental Health Evaluation $1020 • Parent-Child Interactional (up to 4 family members) $1100 $440 (for additional adult) e4a 4.4 ilLin— #�"l el9—va 80411"Avenue b, Greeley, CO 80631 ®ate mom' Phone (970)336-1123 Fax(970)351-0182 Q Consent/Release Transitions Y x L Y 6Y0Y1, L .. I authorize Transitions to release the infatuation indcated to the agency or persons listed below for the purpose of service coorcination of care,and case management. Circle YES NO. I authorize Transitions to obtain the information indcated from the agency or persons listed below for purposes of service,coordnatian,continuity of care,and case management. Circle YES NO. This is the indcated information-circle every item YES or NO YES NO Treatment information to include history,attendance,diagnosis,progress in treatment,prognosis, treatment prognosis,treatment approaches/plan/goals,medcaticn intervention and prescriptions, status at dscharge. YES NO Psychological evaluation and testing summaries. YES NO Clinical evaluatiordassessmert summaries. YES NO Alcohol and drug treatment information. YES NO Physical exam,lab studes,and dagnostic evaluation,EKG,EEG. YES NO Other(specify) The release pertains to:(Please Print) Client Name: Date of Birth: Name: Date of Birth: Name: Date of Birth List complete names of no more than five(5)agencies or individuals iduals regadng this release: Name of Agency or Person Address/Phone 1. 2. 3. 4. 5. I understand that my records and/or those of any individual())listed above are protected under federal and state confidentiality regulations. I understand tha'f I have authorized the release of drug abuse ardor alcohol abuse information that the confidentiality of this intonation is protected by Federal Law(42 CFR,pert 2). This information cannot be dsclosed without my written consent,unless of envise specifically provided for in the regulations. I understand that I may revoke this consent at any time. Copies of this form may be used in feu of the original. I understand and agree that this release form may be sent to the agencies and persons identified above. This consent expires and cannot be used past the following date: (Not more than are year). (Client Signature) (Date) (Parent/Guardan Signature) (Dale) (Witness Signature) (Date) $220 (for additional child) $220 (per hour assessment) • Mental Health Evaluation $300 • Individual/Couple/Family Counseling (per hour) $100 APPENDICES Appendix 1: Resumes for key staff members Appendix 2: Data collection instruments/protocols Appendix 2: Sample consent forms Charles A. Howard, Ph.D. 2186 44th Avenue Greeley, CO 80634 Cell: (970)302-7661 DrChuckHoward@rotmail.com Licenses&Certifications Licensed Psychologist: Colorado#2124,Nebraska#308 Marriage and Family Therapist Supervisor: State of Colorado, LMFT Board Certificate of Professional Qualification(CPQ);Association of State&Provincial Psychology Boards Education M.S. Alliant International University California School of Professional Psychology San Francisco, CA Clinical Psychopharmacology, Post-doctoral degree,2004 Ph.D. Texas A&M University College Station,TX Counseling Psychology, 1991 M.A. University of Northern Colorado Greeley,CO Agency Counseling, 1984 B.S. Sam Houston State University Huntsville,TX Law Enforcement and Police Science, 1981 Clinical Experience North Colorado Medical Center, Behavioral Health Services, Greeley, Colorado. Supervising Psychologist-August,2001 to present Supervise provision of clinical services in outpatient and day treatment programs to children, adolescents and adults. Direct and train professional staff, including, LPCs,LCSWs,MFTs, CACs,RNs and technicians. Co- admitting(treating)Physician for the outpatient unit. Intricately involved in the planning and development of the adolescent and adult day treatment programs,along with the inpatient therapy program. Developed and implemented outcome measurement and satisfaction surveys. Provide evaluations and psychotherapy to outpatient and day treatment clientele. Administer psychological evaluations to children,adolescents,and adults for the hospital,courts, social services, school district, special education providers, and other community agencies. Bariatric presurgical evaluations(ASBS Center of Excellence). Transitions Psychology Group,LLC,Greeley, Colorado. Co-Founder and principal - 1998 to 2003. Clinical Consultant/Supervisor-2003 to present. Developed screening/mentor program for Weld County Department of Social Services clientele. Provide clinical supervision to numerous masters and doctorate level mental health professionals. Perform psychological evaluations (ages 10 to 65),custody evaluations, and parenting evaluations. Supervise home studies of potential foster and adoptive families. Provide short-term psychotherapy to individuals and families. Charles A Howard Page 2 of 3 Larimer Center for Mental Health,Intake/Aduk Unit, Fort Collins, Colorado, Staff Psychologist-April, 2000 to August, 2001 Responsibilities included supervision of new clinicians, patient intake interviews,crisis counseling, individual psychotherapy, and psychological evaluations of adults and children. North Range Behavioral Health, Child&Family Services,Greeley, Colorado. Staff Psychologist-December, 1995 to January, 1999 Program Director-January, 1999 to April, 2000 Managed 16 clinicians in three service units. Responsibilities included program management,budgeting, planning, employee supervision, and administrative oversight. Supervised and trained psychotherapists and psychology doctoral interns. Provided individual therapy and family therapy. Conducted psychological evaluations of adults,adolescents, children, and families. The Family Center, Scottsbluff&Alliance,Nebraska. Founder and principal-August, 1992 to July, 1996 Psychological provider for the Newell Children's Center, Burlington Northern Railroad,West Nebraska Juvenile Services, Human Services Inc.,Nebraska Department of Social Services, Disability Determination Services, Nebraska Department of Education. Provided individual,marital,family and group psychotherapy to children, adolescents, adults, and older adults. Performed psychological evaluations and custody evaluations. Regional West Medical Center,Psychiatric Unit, Scottsbluf Nebraska. Psychology Resident-July, 1991 to January, 1993. Staff Psychologist-January, 1993 to September, 1993 Planned, developed and operated a satellite outpatient office. Provided individual,group, family,and marital therapy and evaluations with adults,elderly,adolescents,and children. Created and coordinated community education workshop series. Ulster County Community Mental Health Services, Kingston,New York. Doctoral Intern-July, 1990 to July, 1991 Clinical psychology internship, filly approved by the American Psychological Association. Provision of outpatient therapy and evaluation/testing services for the Child and Adolescent Unit,as well as services to the Adult and Chronic Adult Units. Completed custody evaluations and parent psychological evaluations for the Ulster County Family Court. Texas A&M University,Athletic Department,College Station,Texas. Graduate Assistant-September, 1987 to March, 1990 Counseled athletes. Conducted educational,vocational,and psychological testing. Provided academic skills education and career counseling. Provided performance enhancement techniques and information. Panhandle Mental Health Center, Scottsbluff,Nebraska. Professional Counselor-February, 1985 to August, 1987 Provided individual,marital, family and group psychotherapy to adults,elderly,children and adolescents. Performed mental health evaluations and consulted with a wide variety of state agencies and local businesses. Texas Department of Corrections,Psychiatric Unit,Huntsville,Texas Graduate Intern-January, 1982 to July, 1982 Contracted and reimbursed position. Provided counseling and assisted with psychological testing. NORMA ALKIRE , MA , LPC , CACIII EDUCATION 1995 -1997 Aims Community College Greeley,Colorado AA Degree,Liberal Arts 1997-1998 University of Northern Colorado Greeley,Colorado Bachelor of Arts Degree,Sociology Major,Psychology Minor 1999-2001 University of Northern Colorado Greeley,Colorado Master ofArts Degree,Rehabilitation Counseling/Vocational Evaluation 2002-2004 University of Northern Colorado Greeley,Colorado Masters of Arts Community Counseling/Marriage&Family Therapy LICENSURES AND CERTIFICATIONS CVE Certified Vocational Evaluator #00058987 Exp.3/31/09 NCC National Certified Counselor #89888 Exp.8/31/10 CAC III Certified Addiction Counselor #ACC6430 Exp.6/30/07 LPC Licensed Professional Counselor #LPC4453 Exp.6/30/07 PROFESSIONAL EXPERIENCE 1999-2000 North Range Behavioral Health Greeley,Colorado Clinical Care Assistant Supervisor,Alice McPherson,MA • Assisted Master's level counselors with the care and treatment of chronic mentally ill adults • Assisted in answering and counseling on a 24-hour crisis line Nov 2001-April 2003 Transitions Psychology Group Greeley,Colorado Mentoring Coordinator Supervisor, Greg Creed,MA,LPC • Mentored TANF clients • Provided encouragement and support to clients re-entering the workplace • Worked with case managers and TANF technicians • Attended staffings and other relevant meetings • Completed monthly progress reports May 2003-April 2004 North Range Behavioral Health—Frontier House Greeley,Colorado Rehabilitation Counselor Supervisor,Jemn+fer Euler,MA • Assisted adults with mental illness in seeking employment • Completed monthly summaries with clubhouse members • Helped clubhouse members in finding community resources • Provided lob coaching • Developed jobs in the community for clubhouse members • Attended daily and weekly meetings 4913 12'"St Rd.Greeley,Co. 80634 PHONE 970-590-9861 • E-MAIL nonnaalldre@hotmaiLCOM Jan 2004-July 2004 NCMC/Psychcare Greeley,Colorado Therapist(Intern) Supervisor, Stacey Blank M4,LPC, CAC III • Facilitated and Co-facilitated adult drug and alcohol groups for both in and out patients • Administered Social Assessments to both mental health and substance abuse adult and adolescent inpatients • Attended staffings and case conferences with psychiatrists,psychologist and therapists • Completed progress notes and other relevant paper work • Facilitated and Co-facilitated family discharge planning meetings • Taught parenting classes • Co-facilitated continuing care group June 2004—September 2005 Island Grove Regional Treatment Center Greeley,Colorado Youth&Family Services Counselor/Research Assistant Supervisors, Rochelle Galey,MSW, CAC III Katherine Bryant,MS CAC H John Wilde,M4,MC • Facilitated adolescent substance abuse and anger management groups • Conducted substance abuse evaluations,intakes,and discharges • Completed all relevant paperwork ie:progress notes,substance abuse evaluations,intakes,discharge summaries,letters,etc. • Case management • Collaborated with other treatment and community agencies to meet the individual needs of clients • Attended staffings • Participated in community meetings • Attended trainings relevant to certification requirements for Certified Addictions Counselor(CAC)and Clinical Trials Network(CTN) • Administered baseline and follow-up assessments for CTN research protocol • Contacted research participants for follow-up appointments September 2005-July 2006 Platte Valley Youth Services Center Greeley,Co.80631 Youth Services Counselor I Supervisor, Gail White,MS • Provide drug and alcohol treatment for adolescent males committed to DYC • Facilitate drug and alcohol groups • Complete all relevant paperwork including TRAILS documentation • Attend staffings,Parole Board hearings,and other relevant meetings • Provide case management and transitional services as needed • Communicate with Parole Officers/Client Manager's,families,and other counselor's with regard to youth's disposition • Facilitate family therapy • Provide(Eye Movement Desensitization and Reprocessing)EMDR therapy for youth with trauma and substance abuse issues • Supervise CSO I and CSO II(security officers)pod staff • Complete PMAP evaluations • Attend(Sex Offender Management Board)SOMB and other trainings relevant to job duties 4913 12th St Rd.Greeley,Co. 80634 PHONE 970-590-9861 • E-MAIL nonnaalkire@hotmaiLCOM F- w 0 q 0 w O U a E F- 0 a 0 10 N m C O a Lo co 2 v- 4 1� m es' c� m m .- co [] ap M as d 4, V! 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LLI Transitions Psychology Group provides an interdsdplinary treatment approach tat utilizes a broad range of expertise and therapeutic modalities. You are encouraged to<iscuss your treatment with your therapist,and you have the right to receive more information regarding the following items: • Your are entitled to receive reformation regarding credentials,professional background and theoretical approach used by the therapist involved in your treatment • You are entitled to receive an estimate of the average treatment duration for issues or concerns similar to yours,even though an exact length of treatment is hard to predict • You will be provided with a general plan that will identify the specific therapeutic goals you chose to accomplish. • You may seek a second opinion from another therapist or may terminate therapy at any time. The Colorado State Department of Regulatory Agencies regulates the practice of both licensed and unlicensed persons in the field of psychotherapy. My questions,concerns,or complaints regrading the practice of mental health may be drected to the State Board listed Below THE STATE DEPARTMENT OF REGULATORY AGENCIES 1580 Broadway,Suite 1340 Denver,Colorado 80202 (303)8947786 In the majority of situations client i fonradon is legally confidential and shall be held in time strictest of confidence and only with written permission of the client or legal guardian will treatment information be dadosed In certain situations, the law requites that information gathered during therapy be revealed without the clients permission: • If you threaten badly ham or death to yourself or other persons • If you reveal information relative to physical abuse,sexual abuse,or neglect of a child • If a court of law issues a legitimate subpoena • If you are in therapy by order of court of law • If you are involved in a criminal or delinquency proceeding Sexual intimacy between therapist and client is illegal and not a part of any recognized therapy. If this occurs it should be reported to the grievance board identified above. I have read and understand the preceding hitomnatloa,including my rights as a client I agree to all the above policies and procedures. I have received a copy of this font CLIENT SIGNATURE DATE TIME SIGNATURE OF THERAPIST DATE 111€ 41 gt, 4i• 804 11th Avenue ti? Greeley, CO 80631 c :®,®'"' 0 Phone (970)338-1123 tix,® Fax(970)351-0182 Consent/Release Transitions ♦ x 0 ♦ OGOOP, L I authorize Transitions to release the information indcated to the agency or persons listed below for the purpose of service coordnation of care,and case management. Circle YES NO. I authorize Transitions to obtain the information indcated from the agency or persons listed below for purposes of service,loordtnallon,continuity of care,and case managernert Circle YES NO. This is the indcated intonation-circle every item YES or NO YES NO Treatment information to include history,attendance,dagnosis,progress in treatment,prognosis, treatment prognosis,treatment approachestpian/goals,medcation intervention and prescriptions, status at dscharge. YES NO Psychological evaluation and testing stennaries. YES NO Clinics evaluation/assessment summaries YES NO Alcohol and drug treatment information YES NO Physical exam,lab Studies,and dagnostic evaluation,EKG,EEG. YES NO 0ther(specify) The release pertains to:(Please Print) Client Name: Dated Birth: Name: Dated Birth: Name: Dated Birth: list complete names of no more than five(5)agencies or indviduals regaling this release: Name of Agency or Person Address/Phone 1. 2 3. 4. 5. I understand that my records andror those of any indnidial(s)listed abode are protected under federal and state confidentiality regulations. I understand that if I have aulhorimd the release of drug arise and alcohol abuse information that the confidentiality of this information is protected by Federal Law(42 CFR,part 2) This information cannot be disclosed without my written consent,unless otherwise specifically provided for in the regulations. I understand that I may revoke this consent at any time. Copies of this form may be used in lieu of the original. I understand and agree that this release form may be senito the agencies and persons identified show. This consent expires and cannot be used past the following date: (Not more than one year). (Client Signature) (Date) (ParenUCwardan Signature) (Date) (Witness Signature) (Date) EXHIBIT B SUPPLEMENTAL NARRATIVE TO RFP 804 11th Avenue t Greeley,CO 80631 * tit ,` Tel.(970)3364123 #; _ i FAX(970)351-0182 1 a Transitions Pitt..L... lO*T. tta t May 18, 2007 Tobi Vegter, Core Services Coordinator Weld County Department of Social Services P.O. Box A, Greeley, CO, 80632 Re: Bid #006-LS-07 (RFP 05005) Lffeskills Bid# 003-FPT-07 (RFP 006-00C) Foster Parent Training Bid #008-HS-07 (006-00B) Home Study, Relinquishment Counseling Bid #006-MH-07 (RFP 006-00) Dear Ms. Vegter. I am writing in response to the award letter dated May 11, 2007 for the 2007 RFP process. We greatly appreciate the awards for our programs and would like to respond to questions on our bids. • Bid#006-LS-07 (RFP#07005), Ldfeskilis. Responses: Recommendation: The approved bidder will pursue bilingual interpretersA`ianslators/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 • Transitions currently has three bilingual providers available for this program. We continually seek out experienced bilingual therapists. In addition, we supply educational materials in Spanish for clients. Conditions: The bidder must clarify and submit information that was not addressed or included with the original bid submission. 1. Provide a copy of insurance. See enclosures. 2. Provide staffing information, including resumes and education levels of staff. See enclosures. 3. Address mandated caseworker training for staff. This was addressed.in Section E, 3; "Mandated New Caseworker Training: One full-time Page 2 Transitions Psychology Group/Results of RFP Process for 2007-2008 Transitions counselor has received mandated new caseworker training. Other counselors will not receive this training.° Additional providers would attend New Caseworker Training if required by the Department. 4. Address bilinguaUbicultural services. Transitions has three Spanish/English bilingual therapists. All master level counselors have had coursework and training in multicultural competencies. 5. Provide rates for levels of service (parent education and therapeutic visitation). We do not have different levels of service on this program. Transitions Lifeskills services are all therapeutic and as such are provided by Master's level clinicians. The rate for services is $100.06 per hour. 6. Address step-down services. Transitions works with an internal consultation team to tailor and adjust the level of service according to the family's needs and progress. We attend Core Review Team meetings monthly to ensure the level of service is appropriate for each case. Transitions regularly refers families to less intensive services after therapeutic services. We transition visits from the more restrictive office environment to the less restrictive home environment when possible. Hours of service are decreased gradually to phase out treatment • Bid#003-FPT-07 (RFP#006-00C), Foster Parent Training. Responses: 1. Bidder must address and darify class size. The evaluating committee requests that the bidder not limit class size. Transitions will not limit class size. Transitions determined class size in order to provide optimal training. We have since understood that class size normally does not exceed 20 participants and that it is critical not to delay certification for funding purposes. 2. Bidder must address whether there is a lead"trainer. Address the consistency and continuity of trainers/training. Dennette Janus, MA, NCC, a therapist and former child protection caseworker, is the designated lead trainer for Transitions. Other profressional staff and consultants will provide training on various topics in order offer additional expertise and maintain the interest of participants. 3. Provide a curriculum as requested in the APP. 'See enclosure. 4. Provide a copy of insurance. See enclosure. • Bid#008-HS-07 (RFP#006-00B), Home Studies, Updates,and Relinquishment Counseling. Repsonses: 1. All staff must attend Core Caseworker Training. All staff attended the required SAFE training and three staff attended an additional training for SAFE supervisors to satisfy the vendor requiremenets. In a discussion with Dave Aldridge, we were told that the Core Caseworker Training requirement is waived for home study providers. 2. The bidder must address the Program Improvement Plan (PIP). The PIP Page 3 Transitions Psychology Group/Results of RFP Process for 2007-2008 was addressed in the bid proposal in the narrative. However, the following summarizes that content: • Placement Changes: Transitions will never advise or give permission for a child to be removed from a placement. Our role is to assess the home and make recommendations that will help establish permanency and help foster parents and relative placements access the supportive services they need in order to preserve placements. • Independent Living: Transitions home study providers will assess the prospective parents capacity to develop independent living skills with children in their care. In addition, the home study makes appropriate recommendations for the education and support of foster parents to development new capacities that will encourage independent living skills in children. • Maintaining Cultural and Racial Connections: Transitions home study providers will assess the family's ability and willingness to maintain the cultural and racial identity of the children in their care. Transitions will help prospective foster care providers access community resources where applicable through recommendations and conditions. • Monthly Face-to-Face Visit with Caseworkers: Transitions home study providers will emphasize to prospective foster famlilies the importance of communication and collaboration with the Department . Home study providerrs will reinforce the requirement of monthly face-to-face contacts between caseworkers and foster children and encourage foster parents to be proactive in maintaining this contact with the Department. • Timely Initial Assessment within Two Weeks of Placement Transitions will assess the potential foster family's ability and willingness to complete medical and dental appointments for each child placed in their care within the alloted time(2 weeks for medical and 8 weeks for dental). • Health Needs Identified and Services Provided: Transitions will assess the potential foster family's awareness and willingness to • communicate with caseworkers in identifying health needs and services of children and adolescents in their care. • Bid #006-MH-07 (RFP#006-00), Mental Health, Responses: 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. 1. Transitions has one bilingual provider available for mental health assessments and interaction assessments. Transitions continues to seek Page 4 Transitions Psychology Group/Results of RFP Process for 2007-2008 out qualified, experienced, bilingual therapists and psychologists. The acquisition of psychological testing materials in another language is difficult due to limited availability and cost. It is not ethical to translate the standardized tests as they have not been normed on multicultural populations. The program has had no referrals for psychological evaluations last year and only two in the previous program year. As the program progresses, this service could be developed. Conditions: The bidder must submit information that was not addressed or submitted with the original bid submission, including: 2. Evidenced-based Practices: Transitions utilizes only norm-referenced psychological tests. All are nationally recognized and have been extensively researched in order to develop the norms required to interpret the tests. Transitions uses Parent-Child Interaction Therapy as an evidenced-based component of the interactional assessments. Transitions uses the Parent Stress Index as an evidence-based component of the mental health assessment. Please see reference section of the bid for additional research information. 3. Bilingual services: Transitions has one bilingual provider, a licensed professional counselor, available for mental health assessments and interactional assessments with Spanish-speaking clients. Psychological Assessments are not available in Spanish for this program year. 4. Program Improvement Plan (PIP), a. placement chancres:Transitions providers are experienced in assessing children and adolescents and will make written recommendations in the reports for psychological evaluations, mental health assessments and interactional assessment to help maintain a child in their placement. Alternately, if this is not appropriate, providers will delineate how a change in placement will advance the child's permanency goals. If a child is free for adoption, providers will include specific recommendations to assist the Department in how to prepare the child for an adoptive home as well as identify when a goal of adoption is not appropriate for a child. 5. Copy of insurance. See enclosures. Sincerely, tab- Gregory S Creed, PhD, LPC Co-Director, Transitions Psychology Group, LLC _ Client#:47194 TRAPS ACORD,. CERTIFICATE OF LIABILITY INSURANCE DATE(M D"Y"`) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Flood&Peterson Ins.Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P.O.Box 578 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 4687 W.18th Street Greeley,CO 80632 INSURERS AFFORDING COVERAGE NAIC V INSURED INSURER Travelers Insurance Company TRANSITIONS PSYCHOLOGY GROUP,LLC INSURER e: Plnnacol Assurance 804 11TH AVE INSURER C: GREELEY,CO 80631 INSURER D. INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO AU.THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. L AUDI. POLICY EFFECTIVE POLICY EXPIRATION LTR NSRC TYPE OF INSURANCE POLICY NUMBER DATE I.MNODD(YYI DATE IMMIOO/YYI MINTS A GENERAL LIABILITY I6804808C710COF07 05/04/07 05/04/08 EACH OCCURRENCE $1.000,000 000,000 X COMMERCIAL LIABLITY " ISESiE,ENToca,,.,,o,l $300.000 CLAIMS MADE El OCCUR MED EXP(Ars'on.PNso..) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE 82,000,000 co&M+ORF(GAATTE MIT APPLIES PER: - PRODUCTS-COMP/OP AGG :2,000,000 POLICY f '„ n LOC A AUTOMOBLE LIABILITY BA-62110612-07-SEL 05/04/07 05/04/08 COMBINED SINGLE WIT X ANY AUTO (Es ecddRN) $1,000,000 ALL OWNED AUTOS BODILY SCHEDULED AUTOS WPM W $ X LAMED AUTOS BODILY X NON-OWNED AUTOS (Per occident) PROPERTY rumen (PeroxxMNA) GARAGE LNBIUY AUTO ONLY-EA ACCIDENT S 1 ANY AUTO OTHER THAN EA ACC S AUTO ONLY: AGG $ EXCESS/UMBRELLA UABLITY EACH OCCURRENCE $ 7 OCCUR n CLAIMS MADE AGGREGATE $ 1�I f DEDUCTIBLE $ I RETENTION $ $ B WORKERS COMPENSATION AND 4104451 05/01/07 05/01/08 X ITWCSTMITS I°n EMPLOYERS'UABIUTY ANY PFt0PRIETOR/PARTNERIEXECUTIVE EL EACH ACCIDENT 8100,000 OFFICEWMEMBER EXCLUDED? EL DISEASE-EA EMPLOYEE 8100,000 Ems.aescrbe under SPECIAL PROVISIONS Wow EL DISEASE•POLICY LIMIT $500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER - CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Weld County Department DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL _l0_ DAYS WRITTEN Department of Social Services NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL PO Box A IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Greeley,CO 80632 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ICYO oC T- AE..J«.r'5On! .rA•.It✓r.A././vL , TiNJG, ACORD 25(2001/08)1 of 2 #380507. . VLG fl ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer,and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. • ACORD 25-S(2001108) 2 of 2 #380507 Healthcare Providers Service CNA Organization Purcha►�s�inngg Group �t yy y� ®HPSO i C�1A Plaza, (Certificate rrf 4 ttsu.L C-4ure -------.-- Chicago, --.-- Chicago,IL 60685 OCCURRENCE POLICY FORM Producer Branch Prefix Policy Number Policy Period from: 12:01 AM standard Time on: 12/01/06 018098 970 HPG 272935313-8 to: 12:01 AM Standard Time on: 12/01/07 i Named Insured and Address Program Administrator k Healthcare Providers Service Organization NORMA A ALKIRE 159 East County Line Road 4913 W I2TH STREET RD Hatboro, PA 19040-1218 GREELEY CO 80634-2216 Medical Specialty: Code: — Insurance Provided by Marriage/Family Counselor 72990 American Casualty Co. of Reading, PA 333 Wabash Avenue Chicago, IL 60604 COVERAGE PARTS LIMITS OF LIABILITY A. PROFESSIONAL LIABILITY Professional Liability $1,000,000.00 each claim , $3,000,000.00 aggregate Good Samaritan Liability Included above Personal Injury Liability Included above Malplacement Liability Included above B. Coverage Extensions I License Protection $10,000 .00 per proceeding $25,000.00 aggregate Defendant Expense Benefit $10,000.00 aggregate Deposition Representation $2,500.00 per deposition $5,000.00 aggregate Assault $10,000.00 per incident $25,000.00 aggregate Medical Payments $2,000.00 per person $100,000.00 aggregate First Aid $2,500.00 aggregate Damage to Property of Others $500.00 per incident $10,000.00 aggregate C. WORKPLACE LIABILITY Coverage part C. does not apply if Coverage part D. is made part of this policy. Workplace Liability Included in A. Professional Liability Limit shown above Fire and Water Legal Liability Included above subject to $150,000 sub-limit Personal Liability i $1,000,000.00 aggregate D. GENERAL LIABILITY Coverage part D. does not apply if Coverage part C. is made part of this policy. Workplace Liability None None Hired Auto & Non Owned Auto None Fire & Water Legal Liability None None Personal Liability ' None Total Premium $120.00 Premium reflects employed, full-time rate. Policy forms and endorsements attached at inception QUESTIONS? CALL: 1-800-982-9491 -- - - G-121500-C G-121501-C G-121503-C G-145184-A G-147292-A G-144872=A" G-123846-005- Ilaahheare Providers Service Organizatuul is a division of Affinity inmIama Services.Inc.in NY and Nit AIS Affinity Insurance Agency,in MN and OK,AIS Affinity Insurance Agency,inc.;and in CA.AIS Affinity bunt ance Agency,Inc.dba Aon Direct Insurance Administrators License#0795465. Master Policy: 188711433 (6v Keep this document in a safe place. This and J I v your cancelled check act as proof of coverage. (ICY. Ls..4t. /V Chairman of the Board Secretary 7- Healthcare Providers Service _- ieMA Organization Purchasing Grout II In CNA Plaza, Certificate O1 4nz xraxtce ..-� , �..�- chi�.ga n 60685 OCCURRENCE POLICY FORM Producer Branch Prefix Policy Number Policy Period from: 12:01 AM Standard Time on: 07/04 06 018098 970 HPG 270360326-8 to: 12:01 MI Standard Time on Named Insured and Address Program Administrator Healthcare Providers Service Organization CHRISTINA H HIRATZKA 159 East County Line Road 7205 POUDRE RIVER RD UNIT 3 Hatboro, PA 19040-1218 GREELEY CO 80634-9375 Medical Specialty: Code: Insurance Provided by Clinical Counselor/LPCC 72990 American Casualty Co. of Reading, PA CNA Plaza 26S Chicago, IL 60685 COVERAGE PARTS LIMITS OF LIABILITY .. . A.PROFESSI — Professional Liability $1,000,000.00 each claim $3,000,000.00 aggregate Good Samaritan Liability Included above Personal Injury Liability Included above Malplacement Liability Included above B.Coverage Extensions License Protection $5,000.00 per proceeding $12,500.00 aggregate Defendant Expense Benefit $5,000.00 aggregate Deposition Representation $1,250.00 per deposition $2,500.00 aggregate Assault $5,000.00 per incident $12,500.00 aggregate Medical Payments $1,000.00 per person $50,000.00 aggregate First Aid $1,250.00 aggregate Damage to Property of Others $250.00 per incident $5,000.00 aggregate C. WORKPLACE LIABILITY Coverage part C.does not apply if Coverage pan D. is made part of this policy. Workplace Liability Included in A. Professional Liability Limit shown above Fire and Water Legal Liability Included above subject to $150,000 sub-limit Personal Liability j $500,000.00 aggregate D.GENERAL LIABILITY Coverage part D.does not apply if Coverage part C.is made part of this policy. --Workplace Liability -- -- — - - None` ._ - — None Hired Auto & Non Owned Auto None Eire & Water Legal Liability None - None Personal Liability I None Total Premium $158.00 Policy forms and endorsements attached at inception QUESTIONS? CALL: 1-800-982-9491 G-121500C G-121501C G-121503C G-145184-A G-147292-A G-144872-A G-123846C-05 Man=Providers Service Oapmoation its&vidoa of Affinity human Se vian.bit;in NY=AM Ads Affinity Insurance Agency.in MN and OK.A15 Affinity Inemma Apacy.tot;sad is CA.AM Affinity!manna Meaty,Inc.fibs AoaDien l am+me AdmiaWtsn License 00795465. Master Policy: 188711433 AY14. AJ - your Keep this d ed chec in a sa ep ploofe coThve arse �.t.r[• l�''� your cancelled check act as proof of coverage. Chairman of the Board Secretary Certificate of Insurance(Proof of Coverage) Date Issued:(6/29/2006) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND,OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Insured Name and Mailing Address* Program Administrator _ Name Charles A.Howard Administered By:CPH and Associates Street 804 Eleventh Ave 711 S.Dearborn,Suite 205 Chicago,IL 60605 City Greeley Underwritten By: State CO Philadelphia Indemnity Insurance Company Zip 80631 --_._...*--' ...,�__ t -r = -a- -o- n requested db ,,ividua s — � �. _�.._ �, *Additional insured locations are often by individual business owners who have more than one office. Your coverage is portable,meaning that you are covered at any location for practice under the occupation(s)listed on your policy. Coverage olicy#:PHCP039718 lEf e five Date:(6/18/2006) Expiration Date. HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD DICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH SPELT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES ESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS HOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Limits of Liability ~M Each Occurrence Aggregate (Per individual claim) (Total amount per policy year) Coverage Part $1,000,000.00 $3,000,000-00 1 Professional Liability $1,000,000.00 53,000.000.00 Supplemental Liability Includes: A)Bodily Injury and Property Damage B) Personal Injury Unlimited Unlimited � Defense Expense Coverage $25,000 $25,000 State Licensing Board Investigation Expense Coverage $5,000 $5,000 Assault Coverage $5,000 $15,000 Deposition Expense Benefit $2,500/person S25,000 Medical Expense Coverage 52,500 52,500 I First Aid Coverage Certificate Holder f Cancellation Proof of Coverage Should any of the above described policy be cancelled before the expiration date thereof,the issuing insurer will endeavor to mail 30 days written notice to the certificate holder named to the left,but failure to do so shall impose no obligation or liability of any kind upon the insurer,its agents or representatives. Holder has also been added to the policy as art uthorized Representative additional insured:** _Yes/XN0 .Philip Hodson **If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.A statement on this certificate 1 does not confer rights to the certificate holder in lieu of such I endorsement(s). DISCLAIMER:The Certificate of Insurance does not constitute a contract between the Issuing Insurer(s),authorized representative or producer, and the certificate holder,nor does it affirmatively or negatively amend,extend,or alter the coverage afforded by the policies listed thereon. . Healthcare Providers Service CNAOrganization Purchasing Group ®HPSO CNA Plaza, (Certificate of ;' n urance rt.w...vro.+ae..s..i..o.a«uow.- Chkago,IL 60685 OCCURRENCE POLICY FORM Producer Branch Prefix Policy Number Policy Period from: 12:01 AM Standard Time on: 07/04/07 018098 970 IIPG 270170686-8 to: 12:01 AM Standard Time on: 07/04/08 _ Named Insured and Address Program Administrator Healthcare Providers Service Organization GREGORY S CREED 159 East County Line Road 804 11TH AVE Hatboro, PA 19040-1218 GREELEY CO 80631-3246 Medical Specialty: Code: Insurance Provided by Clinical Counselor/LPCC 72990 American Casualty Co. of Reading, PA 333 Wabash Avenue Chicago, IL 60604 COVERAGE PARTS LIMITS OF LIABILITY A. PROFESSIONAL LIABILITY • Professional Liability $1,000,000.00 each claim $3,000,000.00 aggregate Good Samaritan Liability Included above _Personal Injury Liability Included above Malplacement Liability Included above B. Coverage Extensions License Protection $10,000.00 per proceeding $25,000.00 aggregate Defendant Expense Benefit $10,000.00 aggregate Deposition Representation $2,500.00 per deposition $5,000.00 aggregate Assault $10,000.00 per incident $25,000.00 aggregate Medical Payments $2,000.00 per person $100,000.00 aggregate First Aid $2,500.00 aggregate Damage to Property of Others $500.00 per incident- $10,000.00 aggregate C. WORKPLACE LIABILITY Coverage part C. does not apply if Coverage part D. is made part of this policy. • Workplace Liability Included in A. Professional Liability Limit shown above Fire and Water Legal Liability Included above subject to $150,000 sub-limit I $1,00 Personal Liability 0,000.00. aggregate , D. GENERAL LIABILITY Coverage part D. does not apply if Coverage part C. is made part of this policy. Workplace Liability None - None Hired Auto & Hon Owned Auto None Fire & Water Legal Liability None None personal Liability 1 None Total Premium $317.00 Premium reflects self-employed,full-time rate. _ Policy forms and endorsements attached at inception QUESTIONS? CALL: 1-800-982-9491 G-121500-C G-121501-C G-121503-C G-145184-A G-147292-A G-144872-A G-123846-005 • Healthcare Providers Service Organisation is a division of Affinity Insurance Services.Inc.:in NY and NH,AIS Affinity Insurance Agency,in MN and OK.AIS Affinity Insurance Agency.Inc.;and in CA,MS Affinity Insurance Agency.Inc.dba Aon Direct Insurance Adntinislratmz License 110795465. Master Policy: 188711433 �/�„i � Keep this document in a safe place. This and fiy- t I 2 ( your cancelled check act as proof of coverage......._„_, tilChairman of the Board Secretary , ...,,.._, . r 1 n..1??1.1'.:Z1 f 7 17(1(11 1 - 604 XX 0000066-R 070326 RENHCP4/06 R1M7HIleSE 07085 Healthcare Providers Service CNA ! a Organization yyry of Group r� �HPSO CNA PIar_, Tent- fLcate .Vf l neuran i- •tee_-.tr,a;e.�,s..:.o,:,,,:.;„,- . C17icago,IL 60685 OCCURRENCE POLICY FORM Producer Branch Prefix Policy Number Policy Period from: 12;01 AM Standard Time on: 04/10/07 018098 970 HPG 289232788-8 to: 12:01 AM Standard Time on: 04/10/08 Named Insured and Address Program Administrator Healthcare Providers Service Organization DENETTE JANUS 159 East County Line Road 804 11TH AVE Hatboro, PA 19040-1218 GREELEY CO 80631-3246 Medical Specialty: Code: Insurance Provided by Mental Health Counselor 72990 American Casualty Co. of Reading, PA 333 Wabash Avenue Chicago, IL 60604 COVERAGE PARTS LIMITS OF LIABILITY A. PROFESSIONAL LIABILITY Professional Liability $1,000,000.00 each claim $3,000,000.00 aggregate Good Samaritan Liability Included above Personal Injury Liability Included above Malplacement Liability Included above B. Coverage Extensions License Protection $10,000.00 per proceeding $25,000.00 aggregate Defendant Expense Benefit $10,000.00 aggregate Deposition Representation $2,500.00 per deposition $5,000.00 aggregate Assault $10,000.00 per incident $25,000.00 aggregate Medical Payments $2,000.00 per person $100,000.00 aggregate First Aid $2,500.00 aggregate Damage to Property of Others $500.00 per incident $10,000.00 aggregate C. WORKPLACE LIABILITY Coverage part C. does not apply if Coverage part D. is made part of this policy. Workplace Liability Included in A. Professional Liability Limit shown above Fire and Water Legal Liability Included above subject to $150,000 sub-limit Personal Liability I $1,000,000.00 ag gregate D. GENERAL LIABILITY Coverage part D. does not apply if Coverage part C. is made part of this policy. _ _ _ . Workplace Liability None None Hired Auto & Non Owned Auto • None Fire & Water Legal Liability None None Personal Liability I None Total Premium $120.00 Premium reflects employed,full-time rate. Policy forms and endorsements attached at inception QUESTIONS? CALL: 1-800-982-9491 G-121500-C G-121501-C G-121503-C G-145184-A G-147292-A G-144872-A G-123846-005 Healthcare Providers Service Organizsion is a division of Affinity Insurance Services,Inc.;in NY and HR AIS Affinity Insurance Agency,in MN and OK,AIS Affinity Insurance Agency,Inc.;end in CA AIS Affinity Insurance Agency,Inc.dba Aon Direct Insurance Administrators License#0795465. Master Policy: 188711433 7/ a Keep this document in a safe place. This and /�� j t 1 1/ ' ` your cancelled check act as proof of coverage. .- Chairman of the Board Secretary " G-141241-A ?7/20015 . .604. XX 0000049-R 070102 RENHCP4/06 R1M7HMCSE 07002 Healthcare Providers Service • tom'Organization Yj� YzY of ;Insurance �Groouu+pyyyyrA ®HPSO CNA Plaza, LEzt L4. sate o.l- nsu,l.ance •••�,••,le.wllvno...y.. Chicago,IL 60685 OCCURRENCE POLICY FORM Producer Branch Prefix Policy Number Policy Period from: 12:01 AM Standard Time on: 07/04/07 018098 970 HPG 270170'198-8 to: 12:01 AM Standard Time on: 07/04/08 Named Insured and Address Program Administrator Healthcare Providers Service Organization JAMI MOE HARTMAN 159 East County Line Road 804 11TH AVE Hatboro, PA 19040-1218 GREELEY CO 80631-3246 Medical Specialty: Code: Insurance Provided by Clinical Counselor/LPCC 72990 American Casualty Co. of Reading, PA 333 Wabash Avenue Chicago, IL 60604 COVERAGE PARTS LIMITS OF LIABILITY A. PROFESSIONAL LIABILITY Professional Liability $1,000,000.00 each claim $3,000,000.00 aggregate Good Samaritan Liability Included above Personal Injury Liability Included above Malplacement Liability Included above . B. Coverage Extensions License Protection $10,000.00 per proceeding $25,000.00 aggregate Defendant Expense Benefit $10,000.00 aggregate Deposition Representation $2,500.00 per deposition $5,000.00 aggregate Assault $10,000.00 per incident $25,000.00 aggregate Medical Payments $2,000.00 per person $100,000.00 aggregate First Aid $2,500.00 aggregate Damage to Property of Others $500.00 per incident $10,000.00 aggregate C. WORKPLACE LIABILITY Coverage part C. does not apply if Coverage part D. is made part of this policy. Workplace Liability Included in A. Professional Liability Limit shown above Fire and Water Legal Liability Included above subject to $150,000 sub-limit Personal Liability I $1,000,000.00 aggregate D. GENERAL LIABILITY Coverage part D. does not apply if Coverage part C. is made pan of this policy. Workplace Liability None None Hired Auto & Non Owned Auto None . Fire & Water Legal Liability . None None Personal Liability I None Total Premium $317.00 Premium reflects self-employed,full-time rate. Policy forms and endorsements attached at inception QUESTIONS? CALL: 1-800-982-9491 G-121500-C G-121501-C G-121503-C G-145184-A G-147292-A G-144872-A G-123846-005 Healthcare Providers Service Organization is a division of Affinity Insmenee Services,Inc.:in NY and NIL NS Affinity Insurance Agency,in I&1 and OK.AM Affinity Insurance Agency,Inc.;and in CA A1S Affinity Insurance Agency,Inc.dba Ann Direct Insurance Administrators License#0795465. Master Policy: 188711433 01 J yourKeep this document in a assafe ploce. Ths and A-y(4. 1� your cancelled check act proof of coverage. ke.w til Chairman of the Board Secretary x IA s flit r_A"f9 Y7flf1T\' ' -'d04' 'XX 0000067-R 070326 REHHCP4/06:R1N7HHCSE::0703e Account Number: CO NOBC 2620 Date: 10/04/06 Initials: DMM CERTIFICATE OF INSURANCE AMERICAN HOME ASSURANCE CO. C/O: American Professional Agency, Inc. 95 Broadway, Amityville, NY 11701 This is to certify that the insurance policies specified below have been issued by the company indicated above to the insured named herein and that, subject to their provisions and conditions, such policies afford the coverages indicated insofar as such coverages apply to the occupation or business of the Named insured(s) as stated. THIS CERTIFICATE OF INSURANCE NEITHER AFFIRMATIVELY NOR NEGATIVELY AMENDS, EXTENDS OR ALTERS THE COVERAGE(S) AFFORDED BY THE POLICY(IES) LISTED ON THIS CERTIFICATE. Name and Address of Insured: CAROLE JEAN NOBLITT Additional Named Insureds : 2627 18TH AV GREELEY CO 80631 • Type of Work Covered: PROFESSIONAL SOCIAL WORKER Location of Operations: N/A (If different than address listed above) Claim History: Policy Effective Expiration Limits of Coverages Number Date Date Liability PROFESSIONAL/ 1, 000, 000 / / LIABILITY SWL-0957031 10/01/06 10 Ol 07 3, 000, 000 NOTICE OF CANCELLATION WILL ONLY BE GIVEN TO THE FIRST NAMED INSURED ON THIS POLICY AND HE OR SHE SHALL ACT ON BEHALF OF ALL INSUREDS WITH RESPECT TO GIVING OR RECEIVING NOTICE OF CANCELLATION. Comments: This Certificate Issued to: Name: CAROLE JEAN NOBLITT 2627 18TH AV Address: GREELEY CO 80631 Au orized Representative Certificate of Insu:ance (Proof of Coverage) Date Issued: 1/19/2006 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND,OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Insured Name and Mailing Address* Program Administrator Veronica Rivera Administered By: CTH and Associates 1400 W. Elizabeth St Apt 146 711 S.Dearborn,Suite 205 Fort Collins,CO 80521 Chicago,IL 60605 `Additional insured locations are often requested by individual business owners who have more than one office. Your coverage is Underwritten By: portable,meaning that you are covered at any location for practice Philadelphia Indemnity Insurance Company under the occupation(s)listed on Tour policy. Coverage Policy#: PHCP061477 Effective Date: 01/17/06 Expiration Date: 01/17/07 THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Limits of Liability EACH OCCURRENCE AGGREGATE Coverage Part (Per individµal claim) (Total amount per policy year) $1,000,000 $3,000,000 Professional Liability Supplemental Liability Includes: $1,000,000 $3,000,000 A)Bodily Injury and Property Damage B) Personal Injury - Unlimited Unlimited Defense Expense Coverage $15 000 State Licensing Board $25,000 Investigation Expense Coverage $5,000 $5,000 Assault Coverage $5,000 $15,000 Deposition Expense Benefit $2,500/person $25,000 Medical Expense Coverage $2,500 $2,500 First Aid Coverage Description/Special Provisions: Certificate Holder Cancellation Should any of the above described policy be cancelled before the expiration date thereof,the issuing insurer will endeavor to mail 30 days written notice to the certificate holder named to the left,but failure to do so shall impose no obligation PROOF OF COVERAGE or liability of any kind upon the insurer,its agents or representatives. Holder has also been added to the policy as an Authorized Representative additional insured:** ., _Yes/lNo C f 1 /11461‘ ••If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. A.statement on this certificate does not C. Philip Hodson confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER: The Certificate of Insurance does not constitute a contract between the issuing insurer(s),authorized representative or producer,and the certificate holder,nor does it affirmatively or negatively amend,extend,or alter the coverage afforded by the policies listed thereon. Healthcare Providers Service CNA �-� y Organization yPyurcha`sinngg Group HPSO CNA Plaza, (erttftrate .CTL �4Lzu.Iaucz aW�^ne.w..s..:..aa.:.m.- airbag°,IL 60685 OCCURRENCE POLICY FORM Producer Branch Prefix Policy Number Policy Period from: 12:01 AM Standard Time on: 02/01/06 018098 970 HPG 281668374-8 to: 12:01 AM Standard Time on: 02/01/07 Named Insured and Address Program Administrator Healthcare Providers Service Organization ROSANN M ROSS 159 East County Line Road 3931 PUEBLO ST Hatboro, PA 19040-1218 EVANS CO 80620-3006 Medical Specialty: Code: Insurance Provided by Licensed Professional Counselor 72990 American Casualty Co. of Reading, PA CNA Plaza 26S Chicago, IL 60685 COVERAGE PARTS . LIMITS OF LIABILITY A. PROFESSIONAL LIABILITY professional, Liability 51,000,000.00 each claim 53,000.000 00 aggregate Good Samaritan Liability Included above Personal Injury Liability Included above Malplacement Liability Included above • B. Coverage Extensions License Protection S5 .000.00 per proceeding S12,500.00 aggregate Defendant Expense Benefit $5,000.00 aggregate Deposition Representation $1,250.00 per deposition $2,500.00 aggregate Assault S5,000.00 per incident S12,500.00 aggregate Medical Payments $1,000.00 per person $50,000.00 aggregate First Aid $1,250.00 aggregate Damage to Property of Others S250.00 per incident $5,000.00 aggregate C. WORKPLACE LIABILITY Coverage part C. does not apply if Coverage part D. is made part of this policy. Workplace Liability Included in A. Professional Liability Limit shown above Fire and Water Legal Liability Included above subject to $150,000 sub-limit Personal Liability I $500,000.00 aggregate D. GENERAL LIABILITY Coverage part D. does not apply if Coverage part C. is made part of this policy. Workplace Liability None None Hired Auto & Non-Owned Auto None Fire & Water Legal Liability None None Personal Liability I None Total Premium $100.00 Policy forms and endorsements attached at inception QUESTIONS? CALL: 1-800-982-9491 G-121500C G-121501C G-121503C G-145184-A G-147292-A G-144872-A G-123846C-05 Healthcare Providers Service Organization is a division of Affinity Insurance Services.Inc.;in NY and NH,MS Affinity Insurance Agency,in MN and OK AIS Affinity Insurance Agency,Inc.;and in CA MS Affinity Insurance Agency.Inc.dba Aon Direct Insurance Administrators License#0795465. Master Policy: 188711433 yoKeur this document in a saas e oce. The and ,�J_,�_./� your cancelled check act as proof of coverage. Chairman of the Board Secretary .. _ . .�! ,• �,..,C w nnnnnao_o n54dn7 RP-NHCP5/05 RIN6HM 05371 - gal Inuit PURCHASING GROUP CERTIFICATE OF INSURANCE OCCURRENCE POLICY FORM 018098 970 HPG .- e O.--6-0- : fang 12f01 AM Standard Time on:my- oyes to: 12:01 AM Standard Time on:.: e 1 06 --Carmen Seblierkamp = Healthcare Providers Service Organization Ave 159 East County Line Road Eaton, CO 80615 Hatboro, PA 19040-1218 Medical Specialty: Code: _ - _ Mental Hearth Counselor Student 72990 American Casualty Co. of Readinngg, PA CNA Plaza 26S Chicago, IL 60685 A. PROFESSIONAL LIABILITY Professional Liability(Pt.) $ 1,000,000 each claim $ 3,000,000 aggregate Good Samaritan Liability included above _ - Personal Injury Liability included above i 3 Malpiacement Liability included above B. COVERAGE EXTENSIONS: License Protection $ 0 r t $ 0 ate Defendant Expense Benefit 10,000 aggregate Deposition Representation S per on $ 5,000 aggregate Assault $ 10,000 per incident $ 25,000 aggregate Medical Payments $ 0 Per rson $ 0 aggregate First Aid altOreOate Damage to Property of Others $ 500 per incident] $ 10,000 aggregate C. WORKPLACE LIABILITY coverage pan c.Wed:Owe Liability does not apply if Coverage Part D.General liability is made pad of this policy. Workplace Liability none Fire&Water Legal Liability none Personal Liability .r ` "a° "" '• none D. GENERAL LIABILITY coverage pert o-General liability does not apply it CoveragepenC.Workplace Liabiy is made part etllus policy. 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V Chairman of the Board ryy Secreta G-141241-A(07/2001) Coverage Change Date: Endorsement Change Date: Jami Moe-Hartman, MA, LPC Transitions Psychology Group, LLC 804 11 m Avenue Greeley, CO 80631 (970)336-1123 Licensed Professional Counselor August 1999 to present State of Colorado, License#2296 National Board Certified Counselor April 1999 to present American Counseling Association Member 2002 to present EDUCATION Master of Arts in Community Agency Counseling August 1995 University of North Dakota, Grand Forks, ND • ND Board of Higher Education Tuition Waiver Scholarship • G.P.A.4.0/4.0 Bachelor'of Arts in Psychology May 1991 University of North Dakota, Grand Forks, ND • Minors in Chemical Use/Abuse Awareness and Visual Arts • Phi Beta Kappa PROFESSIONAL EXPERIENCE Counselor/Co-Director October 2001 to present Transitions Psychology Group, LLC, Greeley, CO • Develop and implement agency programs • Conduct assessments of foster and adoptive homes • Provide expert testimony in court • Provide individual and family therapy • Specialize in treatment of children, including play therapy • Provide therapeutic parent training, parenting education and life skills training • Coordinate services with multidisciplinary team and other agencies • Serve on community boards Therapist March 1999 to September 2001 North Range Behavioral Health/Child& Family Services Team, Greeley, CO • Provide individual, group and family therapy, including intensive in-home family therapy and outpatient services • Develop and implement treatment plans • Coordinate services with other agencies • Provide court testimony Substance Abuse Counselor July 1998 to October 1999 ARC Counseling Center, Greeley, CO • Facilitate substance abuse education, anger management and relapse prevention therapy groups for court ordered adults (July 1998 - March 1999) • Substitute as facilitator of relapse prevention groups (March 1999—October 1999) • Provide progress reports to law enforcement and courts. Mental Health Therapist August 1996 - March 1999 North Range Behavioral Health/Children's Acute Treatment Unit, Greeley, CO • Provide intensive individual, group and family therapy to children and adolescents in a residential setting. • Coordinate services with other agencies • Develop and implement treatment plans • Assist in the development and management of the therapeutic milieu • Supervise clinical care assistants Family Advocate February 1995 July 1996 Domestic Violence and Rape Crisis Center, Dickinson, ND • Assist in the development of policies, procedures and program services • Facilitate education/therapy groups for children and adolescents • Recruit, train and supervise children's group volunteers • Conduct public education seminars • Assist with grant writing and the compilation of statistics and reports • Develop, plan and execute fundraising events • Serve as the local coordinator for statewide criminal justice system monitoring project • Represent agency on community boards • Provide case management services to families utilizing the shelter facility • Provide crisis intervention services, information, referrals and advocacy to victims of physical/emotional/sexual abuse Victim Advocate July 1994-February 1995 Community Violence Intervention Center, Grand Forks, ND • Provided individual therapy to victims of physical/sexual/emotional abuse • Facilitated an education/therapy group for victims of domestic violence • Screened and assisted persons applying for protection orders and disorderly conduct restraining orders; provided court advocacy; drafted permanent orders • Conducted public education seminars and assisted in training volunteers CONTINUING EDUCATION Child Family Investigator Training Program, Katz and Loizeaux Forensic Services, LLC, October, 2006,40 hours. Training areas included CFI standards;legal foundations, attachment, child development, divorce research, overnights and relocation, assessment, high conflict and parent alienation, child abuse, domestic violence, substance abuse, adult psychopathology and parenting, developing parenting plans, courts and expert testimony, and ethics. Preserving Connections for Children:How to Develop Effective Visits, Colorado Department of Human Services, September 2005, 14 hours. Training areas included legal, benefits, child development, parenting skills, concurrent planning, abuse, attachment and treatment. Structured Analysis Family Evaluation(SAFE), October, 2005, 14 hours. SAFE Supervisor Training, April, 2006,7 hours. Training on the state mandated instrument for home assessments, including practice values, psychosocial inventory and home study. Supervising other using the SAFE assessment. Juvenile Sex Offenders,The Juvenile Sex Offender Resource Committee/Progressive Therapy Services, April, 2005, 3 hours. The Hard Luck Life: A New Approach to Understanding Bonding and Relationships, Charles Howard, PhD, March 2004, 1.5 hours Annual Play Therapy Conference,Colorado Association for Play Therapy,April 2004, 15 hours. Using Play Therapy for Critical Incident Debriefing with Children and Families, Symbolism and Metaphors in Play Therapy, Release Play Therapy, Gregory S Creed Transitions Psychology Group,LLC 804 11th Avenue, Greeley, CO 80631 Tel(970) 336-1123 FAX(970) 351-0182 Cell(970) 590-1424 e-creed@comcast.net Highlights of Qualifications • Doctoral level marriage and family therapist with over 8 years experience • Licensed Professional Counselor&National Certified Counselor • Professional training in family systems therapy • Proficient in Spanish and Japanese with highly develop cultural competencies. Relevant Experience Sept 1999-Pres Agency Co-Director& Marriage and Family Therapist, Transitions Psychology Group, LLC • Provide high quality marital and family therapy • Supervise counselors on several programs • Perform administrative functions for the agency Jan 99-Aug 99 Counselor/Case Manager,North Range Behavioral Health, 1306 11th Avenue, Greeley, CO 80631 • Provided in-home therapy services for family preservation referrals from DSS and for an interagency collaborative program • Maintained productive working relationships with caseworkers from DSS • Conducted therapy with Spanish speaking families • Produced positive outcomes with families and individuals Jan 98-Dec 98 Internship,North Range Behavioral Health, 1306 11th Avenue, Greeley, CO 80631 • Family,group and individual therapy with children, adolescents,and adults • • Experience with family preservation, HeadStart and outreach • programs • Case consultation with parents,teachers and program directors. 1996-1998 Program Coordinator, Center for International Education, UNC, 1945 10th Avenue,Greeley, CO 80639 • Coordinate cross-cultural programming campus-wide • Facilitate retention programs for international students • Direct home stay program for Japanese students 1994-1996 Assistant Language Teacher,Kyoto City Board of Education, Oike-Teramachi,Nakagyo-ku,Kyoto 616,Japan • Taught English to high school students in team-teaching format wit Japanese teachers • Encouraged Japanese teachers to be model learners of English and to explore new methods of teaching • Designed teaching materials and teaching plans • Helped team to develop new pilot English course 1990-1996 Owner& Instructor, Gregory's English School,Kyoto,Japan. • Taught 35 sutdents weekly in small groups,parent/child classes and in individual sessions • Helped demystify the learning process for students and helped them to develop a taste for self-guided learning 1989-1990 Spanish Instructor,Aims Community College, Greeley, CO 198-1988 Assistant English Teacher,Japan Exchange and Teaching Program,Kyoto Prefectural Research and Training Center,Nishi- machi,Morinagato,Momoyama,Fushimi-ku,Kyoto,Japan • Presented seminars and training workshops to Japanese educators • Taught English to high school students • Regional representative for Assistant English Teacher Association Education Ph.D.,Counselor Education&Supervision,2006 M.A.,Community Counseling,Marriage&Family Emphasis, University of Northern Colorado, 1999 B.A.,McPherson College,McPherson,Kansas,Business Management& Spanish, 1986 Junior Year Study Abroad,University of Granada, Granadad, Spain, 1983-84 Certification & Licensure Licensed Professional Counselor,#2869 • National Certified Counselor • Presentations A Balancing Act: Strengths&Stressors for Families in Cross-Cultural Transitions,FIGT (Families in Global Transitions)Annual Confence,March 29-30, 2007, Houston, Texas The Mystery of Parenting Teens,Parent Training Seminar, St Mary Catholic Church Fall 2004 and St Peter Catholic Church Fall 2005 International Relocation:Implications for Families,Poster Session,Rocky Mountain ACES annual meeting,Oct 5-7, 1989,Jackson, Wyoming Nicole It Warnygora Transitions Psychology EDUCATION Doctor of Philosophy: School Psychology,2004 University of Northern Colorado,Greeley, Colorado *Graduate Deans Citation for Excellence* Master of Arts: Agency Counseling:Marriage and Family Therapy,August 1997 University of Northern Colorado, Greeley, Colorado Bachelor of Arts: Major: Psychology Minor: Political Science,May, 1993 Augsburg College,Minneapolis,Minnesota EXPERIENCE Licensed Professional Counselor Transitions Psychology Group,Greeley,Colorado(11/03—Present) • Developed a program to provide therapeutic supervised visitation Weld County Department of Social Services using the State of Colorado Program Improvement Plan • Provided therapeutic supervised visitation and documentation of client progress • Conducted comprehensive home studies to evaluate prospective adoptive and foster homes for the State of Colorado • Conducted comprehensive psychological evaluations • Coordinated services with social services agencies across the state of Colorado School Psychologist Poudre School District,Fort Collins, Colorado(08/02—052005) • Conducted comprehensive psychological assessments of students ages preschool through high school • Consulted with parents and teachers to best meet the educational needs of students • Comm-led students with a variety of concerns ♦ Actively participated in Student Teacher Assistant Team • Participated in the Poudre School Districts Multicultural Assessment Team School Psychologist Intern Poudre School District,Fort Collins,Colorado(8/01-08/02) • Assessed students with leaning disabilities,traumatic brain injuries,developmental disabilities and emotional disturbances ranging in age from preschool through high school • Facilitated a social skills group for students with emotional disturbances • Conducted a program evaluation of a twice-exceptional program to determine program efficacy • Participated in the Poudre School District Multicultural Assessment Team Licensed Professional Counselor Poudre Valley Hospital,Fort Collins,Colorado(Summer,2002; Summer,2003; Summer,2004) • Conducted emergency psychiatric assessments to determine if hospitalization was necessary ♦ Provided consumers with resources to acmes mental health services • Responded,assessed,and made appropriate referrals for crisis phone calls Warnygora,Page#2 Licensed Professional Counselor Ackerman and Associates,Greeley,Colorado (5/99-8/01) • Counseled children and families who were involved with Weld County Department of Social Services • Assessed children and families as a part of child custody evaluations • Developed and presented foster parent training workshops • Provided court ordered mediation services to couples and families Mental Health Therapist North Range Behavioral Health, Carson Children's Center/Children's Acute Treatment Unit, Greeley,Colorado(6/97-7/99) • Provided individual therapy to children in day treatment and residential treatment ♦ Evaluated,diagnosed,and created treatment plans for children and families • Facilitated children's groups and parent support groups ♦ Testified as an expnt witness in court Child and Family Therapist Intern North Range Behavioral Health,Greeley,Colorado(1/97-7/97) • Provided individual therapy to children and provided family therapy • Provided services to a diverse population including deaf clients ♦ Counseled clients in crisis Graduate Assistant/Test Supervisor Career Services,University of Northern Colorado, Greeley,Colorado(8/95-6/00) ♦ Coordinated national testing program including administrations of the ACT,SAT,and GRE ♦ Trained hired and supervised testing personnel Habilitation Counselor/Coordinator Paragon Services Incorporated,Duluth,Minnesota(1/94-8/95) ♦Developed programs to assist dual diagnosis clients to achieve independence ♦ Supported families with children with emotional disturbances or developmental delays to remain in their family home ♦ Supervised and trained staff Program Coordinator Nekton Services Incorporated,Duluth,Minnesota(7/93-12/93) ♦ Coordinated the set-up of a group home for three autistic young women ♦ Developed program plans and daily activities ♦ Supervised,scheduled,and trained staff • Designed a training manual and trained staff people in functional American Sign Language PRESENTATIONS/ WORK Suors Davis,A. &Wamygora,N. (2002).Utilizing a comprehensive neuropsychological assessment in the schools. 3P Annual NASP Convention. Davis,A.&Wamygora,N.(2001).Utilizing a comprehensive neuropsychological assessment in the schools. Poster Presentation at 32'd Annual NASP Convention. Wamygora, Page#3 • Ackerman,J.,Jaromillo,E.,&Wamygora,N. (2001).Family group decision-making: Model,Purpose,and Practice.Department of Social Services Training: Greeley,Colorado. Wamygora,N. (2001). Love and Logic Parenting. Presented at Foster Parent Training: Greeley, Colorado. Ackerman,J.,Bromley, S., Wamygora,N.,&Yackley,C. (2000). Team Building: Foster Parents and Caseworkers.Social Worker Training: Greeley, Colorado. Bromley, S. & Wamygora,N. (2000). Grief and loss in children and adults. Foster Parent Workshop: Greeley, Colorado. Ackerman,J.,Warnygora,N.,Yackley,C. &Jaromillo,E.(2000).Behavior modification in preschool children: Creating a safe head start. Weld County Head start Fall Training: Greeley, Colorado Davis,A. &Wamygora,N.(2000).Neuropsychological Assessment for Intervention: A step-by-step approach to integrating a neuropsychological approach into an IEP.Colorado Society of School Psychologists: Breckenridge,Colorado. Ackerman,J. &Wamygora,N.(2000). Discipline strategies that comply with state foster parent regulations. Social Worker Training: Greeley, Colorado. Warnygora,N.(1999).Attention Deficit Hyperactivity Disorder: What it is and what it is not. Foster Parent Training Workshop:Greeley, Colorado. Wamygora,N.(1999).Foster Parent Problem Solving Workshop.Foster Parent Training Workshop: Greeley, Colorado. Wamygora,N.,Palencia,B.,Amato,R.C. (1999). How Neuropsychology can help school psychologists. Colorado Society of School Psychologists: Vail, Colorado. PUBLICATIONS Wamygora,N.R.(2001 In Press).Hemiplegia. In C.R.Reynolds,&E. Fletcher-Janzen(Ft) Diagnostic manual of childhood disorders: Clinical and special education applications.New York,NY: Wiley. Wamygora,Nit,&D'Amato,R.C.(2001 In Press). Chorea.In C.R.Reynolds,&E. Fletcher- Janzen(Eds.)Diagnostic manual of childhood disorders: Clinical and special education applications. New York,NY: Wiley. GRANTS Wamygora,Nicole It (1998).Special Needs Childcare, United Way of Weld County Grant $25,000. TEACHING Teaching Assistant: Practicum in Individual Counseling(Summer 2001) EXPERIENCE Invited Speaker: Learning Disabilities and Traumatic Brain Injuries (Summer 2001) Invited Speaker: Practicum in Personality Assessment(Fall 2000) Teaching Assistant: Learning Disabilities and Traumatic Brain Injuries(Summer 1999) Teaching Assistant: Practicum in Cognitive Assessment(Spring 1999) Invited Speaker: Tests and Measurement(Spring 1999) Wamygora,Page#4 CERTIFICATION/ LICENSES Licensed Professional Counselor, State of Colorado#2304 Nationally Certified Counselor,National Board of Certified Counselors School Psychologist Professional License,Colorado Department of Education NORMA ALKIRE , MA , LPC , _CACIII EDUCATION 1995- 1997 Aims Community College Greeley,Colorado AA Degree, Liberal Arts 1997-1998 University of Northern Colorado Greeley,Colorado Bachelor of Arts Degree, Sociology Major,Psychology Minor 1999-2001 University of Northern Colorado Greeley,Colorado Master of Arts Degree, Rehabilitation Counseling/Vocational Evaluation 2002-2004 University of Northern Colorado Greeley,Colorado Masters of Arts Community Counseling/Marriage&Family Therapy LICENSURES AND CERTIFICATIONS CVE Certified Vocational Evaluator #00058987 Exp.3/31/09 NCC National Certified Counselor #89888 Exp.8/31/10 CAC 111 Certified Addiction Counselor #ACC6430 Exp.6/30/07 LPC Licensed Professional Counselor #LPC4453 Exp.6/30/07 PROFESSIONAL EXPERIENCE 1999-2000 North Range Behavioral Health Greeley,Colorado Clinical Care Assistant Supervisor,Alice McPherson, MA • Assisted Master's level counselors with the care and treatment of chronic mentally ill adults • Assisted in answering and counseling on a 24-hour crisis line Nov 2001-April 2003 Transitions Psychology Group Greeley,Colorado Mentoring Coordinator Supervisor, Greg Creel( MA,LPC • Mentored TANF clients • Provided encouragement and support to clients re-entering the workplace • • Worked with case managers and TANF technicians • Attended staffmgs and other relevant meetings • Completed monthly progress reports May 2003-April 2004 North Range Behavioral Health—Frontier House Greeley,Colorado Rehabilitation Counselor Supervisor,Jennifer Euler, MA • Assisted adults with mental illness in seeking employment • Completed monthly summaries with clubhouse members • Helped clubhouse members in finding community resources • Provided job coaching • Developed jobs in the community for clubhouse members • Attended daily and weekly meetings 4913 12th St Rd.Greeley,Co. 80634 PHONE 970-590-9861 • E-MAIL normaalkire@hotmail.COM Jan 2004-July 2004 NCMC/Psychcare Greeley,Colorado Therapist(Intern) Supervisor,Stacey Blank, MA LPC, CAC III • Facilitated and Co-facilitated adult drug and alcohol groups for both in and out patients • Administered Social Assessments to both mental health and substance abuse adult and adolescent inpatients • Attended staffmgs and case conferences with psychiatrists,psychologist and therapists • Completed progress notes and other relevant paper work • Facilitated and Co-facilitated family discharge planning meetings • Taught parenting classes • Co-facilitated continuing care group June 2004—September 2005 Island Grove Regional Treatment Center Greeley,Colorado Youth&Family Services Counselor/Research Assistant Supervisors, Rochelle Galey, MSW, CAC III Katherine Bryant,M9 CAC II John Wilde, MA,LAC • Facilitated adolescent substance abuse and anger management groups • Conducted substance abuse evaluations,intakes,and discharges • Completed all relevant paperwork ie:progress notes,substance abuse evaluations,intakes,discharge summaries,letters,etc. • (ace management • Collaborated with other treatment and community agencies to meet the individual needs of clients • Attended staffings • Participated in community meetings • Attended trainings relevant to certification requirements for Certified Addictions Counselor(CAC)and Clinical Trials Network(CTN) • Administered baseline and follow-up assessments for CTN research protocol • Contacted research participants for follow-up appointments September 2005-July 2006 Platte Valley Youth Services Center Greeley,Co.80631 Youth Services Counselor I Supervisor, Gail White, MS • Provide drug and alcohol treatment for adolescent males committed to DYC • Facilitate drug and alcohol groups • Complete all relevant paperwork including TRAILS documentation • Attend staffings,Parole Board hearings,and other relevant meetings • Provide case management and transitional services as needed • Communicate with Parole Officers/Client Manager's,families,and other counselor's with regard to youth's disposition • Facilitate family therapy • Provide(Eye Movement Desensitization and Reprocessing)EMDR therapy for youth with trauma and substance abuse issues • Supervise CSO I and CSO II(security officers)pod staff • Complete PMAP evaluations • Attend(Sex Offender Management Board)SOMB and other trainings relevant to job duties 4913 12`"St Rd. Greeley,Co. 80634 PHONE 970-590-9861 • E-MAIL normaalkire@hotmail.COM July 2006—Present Platte Valley Youth Services Center Greeley,Co.80631 Social Work Counselor II Supervisor, Kevin Powell,PhD • Provide drug and alcohol treatment for adolescent males committed to DYC • Facilitate drug and alcohol treatment groups • Complete all relevant paperwork including TRAILS documentation • Attend staffings,Parole Board hearings,Community Review Boards (CAB's),and other relevant meetings • Provide case management and transitional services as needed • Communicate with Parole Officers/Client Manager's, families,and other counselor's with regard to youth's disposition • Facilitate family therapy • Provide EMDR therapy for youth with trauma and substance abuse issues • Monitoring and documentation of youth on suicide watch • Attend SOME and other trainings relevant to job duties • Participate in the hiring process of counseling and other staff • Implement and maintain treatment planning process • Training of staff in utilization of mandated documents • Compliance of audit standards with regard to upkeep and maintenance of clinical records COMMUNITY ACTIVITIES AND AWARDS 2000-2003 University Schools Greeley,Colorado Board of Governors,Board Member • Founding member of the Charter School Board of Governors • Participated in decision making process for new charter school • Member of Public Relations committee • Member of School Advisory committee • Recording Secretary of Board for 1 'A years Recipient of the Weld County Stars of Excellence Award for 2002 in the category of Education PROFESSIONAL REFERENCES Dr.Theresa McDevitt,Professor,UNC McKee 405 Greeley,Colorado 970-351-2621 Dr.Eugene P.Sheehan,Dean,College of Education,UNC McKee 125 Greeley,Colorado 970-351-2817 James Schultz,MA,LPC,Therapist,Psychcare Family Recovery Center Greeley,Colorado 970-691-1112 Rochelle Galey,MSW,CACIII,SWIII,Platte Valley Youth Services Center Greeley,Colorado 970-304-6258 Stacey Blank,MA,LPC,CACIII,Therapist,Psychcare Family Recovery Center Greeley,Colorado 970-352-1056 4913 12th St Rd.Greeley,Co. 80634 PHONE 970-590-9861 • E-MAIL normaalkire@hotmail.COM Charles A. Howard, Ph.D. 2186 44t Avenue Greeley,CO 80634 Cell: (970)302-7661 DrChuckHoward@hotmail.com Licenses&Certifications Licensed Psychologist: Colorado#2124,Nebraska#308 Marriage and Family Therapist Supervisor: State of Colorado,LMFT Board Certificate of Professional Qualification(CPQ);Association of State&Provincial Psychology Boards Education M.S. Alliant International University California School of Professional Psychology San Francisco,CA Clinical Psychopharmacology,Post-doctoral degree,2004 Ph.D. Texas A&M University College Station,TX Counseling Psychology, 1991 M.A. University of Northern Colorado Greeley,CO Agency Counseling, 1984 B.S. Sam Houston State University Huntsville,TX Law Enforcement and Police Science, 1981 Clinical Experience North Colorado Medical Center,Behavioral Health Services,Greeley,Colorado. Supervising Psychologist-August,2001 to present Supervise provision of clinical services in outpatient and day treatment programs to children,adolescents and adults.Direct and train professional staff,including,LPCs,LCSWs,MFTs,CACs,RNs and technicians.Co- admitting(treating)Physician for the outpatient unit. Intricately involved in the planning and development of • the adolescent and adult day treatment programs,along with the inpatient therapy program.Developed and implemented outcome measurement and satisfaction surveys. Provide evaluations and psychotherapy to outpatient and day treatment clientele. Administer psychological evaluations to children,adolescents,and adults for the hospital, courts, social services, school district,special education providers,and other community agencies.Bariatric presurgical evaluations(ASBS Center of Excellence). Transitions Psychology Group,LLC,Greeley,Colorado. Co-Founder and principal- 1998 to 2003. Clinical Consultant/Supervisor-2003 to present. Developed screening/mentor program for Weld County Department of Social Services clientele.Provide clinical supervision to numerous masters and doctorate level mental health professionals.Perform psychological evaluations(ages 10 to 65),custody evaluations,and parenting evaluations. Supervise home studies of potential foster and adoptive families.Provide short-term psychotherapy to individuals and families. Charles A.Howard Page 2 of 3 Larimer Center for Mental Health,Intake/Adult Unit,Fort Collins,Colorado. Staff Psychologist-April,2000 to August,2001 Responsibilities included supervision of new clinicians,patient intake interviews,crisis counseling, individual psychotherapy,and psychological evaluations of adults and children. North Range Behavioral Health,Child&Family Services, Greeley,Colorado. Staff Psychologist-December, 1995 to January, 1999 Program Director-January, 1999 to April,2000 Managed 16 clinicians in three service units. Responsibilities included program management,budgeting, planning,employee supervision,and administrative oversight. Supervised and trained psychotherapists and psychology doctoral interns.Provided individual therapy and family therapy. Conducted psychological evaluations of adults,adolescents,children, and families. The Family Center, Scottsbluff&Alliance,Nebraska. Founder and principal-August, 1992 to July, 1996 Psychological provider for the Newell Children's Center,Burlington Northern Railroad,West Nebraska Juvenile Services,Human Services Inc.,Nebraska Department of Social Services,Disability Determination Services, Nebraska Department of Education.Provided individual,marital,family and group psychotherapy to children, adolescents,adults,and older adults.Performed psychological evaluations and custody evaluations. Regional West Medical Center,Psychiatric Unit,Scottsbluff,Nebraska. Psychology Resident-July, 1991 to January, 1993. Staff Psychologist-January, 1993 to September, 1993 Planned,developed and operated a satellite outpatient office.Provided individual,group,family,and marital therapy and evaluations with adults,elderly,adolescents,and children. Created and coordinated community education workshop series. Ulster County Community Mental Health Services,Kingston,New York. Doctoral Intern-July, 1990 to July, 1991 Clinical psychology internship,fully approved by the American Psychological Association.Provision of outpatient therapy and evaluation/testing services for the Child and Adolescent Unit,as well as services to the Adult and Chronic Adult Units. Completed custody evaluations and parent psychological evaluations for the Ulster County Family Court. Texas A&M University,Athletic Department,College Station,Texas. Graduate Assistant-September, 1987 to March, 1990 Counseled athletes.Conducted educational,vocational,and psychological testing. Provided academic skills education and career counseling.Provided performance enhancement techniques and information. Panhandle Mental Health Center, Scottsbluff,Nebraska. Professional Counselor-February, 1985 to August, 1987 Provided individual,marital, family and group psychotherapy to adults,elderly,children and adolescents. Performed mental health evaluations and consulted with a wide variety of state agencies and local businesses. Texas Department of Corrections,Psychiatric Unit,Huntsville, Texas Graduate Intern-January, 1982 to July, 1982 Contracted and reimbursed position. Provided counseling and assisted with psychological testing. Charles A.Howard Page 3 of 3 Teaching Experience Graduate Chadron State College Theories of Personality Undergraduate The Consortium,Inc.&Nebraska Western College Nebraska Addictions Counselor licensure courses: Counseling Techniques and Theories Group Counseling Nebraska Western College Social Psychology Depression across the Lifespan Understanding Adolescence Attention Deficit Disorder Bipolar Disorder The Psychology of Prejudice Attachment Disorder Stress Management State University of New York,New Paltz Lecturer on topics of adolescent development,family dynamics,and multicultural issues. Professional Presentations (Partial list) Adolescent Development and Child&Adolescent Mental Health Overview. Crisis Intervention Certification; Colorado School Resource Police Officers(2005, 2006,2007) Post Traumatic Stress. Crisis Intervention Certification for Police Officers(2004,2005,2006,2007) Bariatric Expert Panel;Psychologist representative. Bariatric surgery clinic public presentations(2004,2005) Hidden Influences:Neurodevelopment and Genetic Disorders among Behaviorally Disturbed Youth.Colorado Juvenile Council Conference(2002,2005) Suicide. Professional guest appearance;KFKA radio talk show,This Week at NCMC Empty Nest Syndrome and The Role of Fathers.Professional guest TV appearances;Off the Record with Lea Jungle Law: The Role of Trauma and Attachment Issues in Understanding Delinquent Behavior. Colorado Juvenile Council Conference(2000) Understanding Trauma And Helping Victim's Families.2000 Colorado Radiologic Technicians Conference Research and Publications Howard,C.A.(1992).Relationship of anxiety to performance among police cadets in crime scene situations(Doctoral dissertation,Texas A&M University, 1991). Professional Organizations American Psychological Association Society of Clinical Child and Adolescent Psychology American Society for the Advancement of Pharmacology Dennette Janus Education & Certifications Master of Arts, Community Counseling University of Northern Colorado, Greeley, CO May 2003 Bachelor of Science, Human Rehabilitative Services/Psychology Minor University of Northern Colorado, Greeley, CO May 1997 Certified Counselor,National Board of Certified Counselors, August 2003 Bilingual: English& Spanish Professional Experience Caseworker III: Child Protection: Investigations and Ongoing Weld County Department of Social Services, Greeley, CO 2/2004-present • Investigated allegations of all types of child abuse and neglect, including fatalities, made recommendations to the Courts,law enforcement and families • Developed safety plans for acute circumstances and counseled children and families regarding immediate concerns • Provided testimony and evidence at emergency and adjudication hearings, for jury trial,termination hearings and criminal proceedings • Explained the role and process of child protection to families as assigned, educated children and families regarding safe and unsafe practices • Completed initial individual treatment plans and family service plans for the children and parents in cases filed with the Court, ongoing monitoring of treatment plan completion and bather removal for completion • Participated actively in staffings within the Department and between other community agencies. , Drug & Alcohol Evaluator: Social Services Case Manager Island Grove Regional Treatment Center, Greeley, CO 8/2003 -2/2004 • Performed substance abuse evaluations for clients referred by Social Services, primarily on site, at incarceration facility, or at Island Grove Treatment Center • Provided liaison case management between Social Services and Island Grove programs and staff;Documentation and tracking as appropriate to both agencies • Staffing and consultation with staff and supervisors within both agencies • Professional testimony as requested Dennette Janus pg 2 Graduate Internship: Outpatient Counselor Island Grove Regional Treatment Center, Greeley, CO 8/02-5/03 • Co-Facilitated education and therapy groups specific to drug& alcohol abuse and/or domestic violence issues, English and Spanish-speaking • Provided individual counseling sessions and treatment planning/case management • Completed intake interviews,interpretive summaries, and staffing of clients for treatment recommendations • Accountable for documentation to agency and referral sources as needed Therapist/Case Manager North Range Behavioral Health, Greeley, CO 11/99-6/00 • Accepted clients as assigned from agency for individual counseling,primarily related to persistent severe mental illness • Assessed ongoing progress of clients, adjusted treatment plans as necessary. • Advocated for client needs and goals, case management as needed,referrals as indicated, staffing • Submitted appropriate documentation to agency and state regulatory boards Legal Advocate A Woman's Place, Greeley,CO 4/98-9/98 • Provided support/services for victims of domestic violence • Educated regarding legal and emotional aspects of domestic violence • Assisted with paperwork and accompanied client for court proceedings • Performed general shelter duties: crisis line, intake processing,referrals Residential Support/Intensive Case Manager North Range Behavioral Health, Greeley, CO 10/96-12/97 • Provided residential support for clients with severe persistent mental illness • Assisted and encouraged clients in community integration activities • Monitored and assessed medications,activities, interactions,responsibilities • Provided intervention/advocacy with Primary Therapists as needed Volunteer Experience Red Cross Mental Health Professional, Baton Rouge, LA 9/9/05-9/25/05 Provided all aspects of mental health assessment, intervention and support for evacuees/ survivors of Hurricane Katrina Disaster Relief Effort in shelter of approximately 2000 people. Also served as Red Cross staff and military staff debriefing support. Dennette Janus pg 3 Volunteer Experience, continued Crisis Line Advocate,A Woman's Place, Greeley, CO 9/98-2/01 Provided on-call support to victims of domestic violence from contacts through crisis line call or emergency personnel referral. Relayed information to Weld County District Attorney's office for use in prosecution if appropriate. Documentation as necessary. Court Appointed Special Advocate,Greeley, CO 10/99-2/01 Offered bi-weekly interaction with child of Dependency&Neglect case for duration of case (16 months). Reported to all parties involved: Weld County Courts,Dept. of Social Services, family of child, Guardian ad Litem. Assessor and Tutor,Right to Read of Weld County, Greeley, CO 3/92-5/97 Other Work History: Office Management/Dental Treatment Coordinator,Richard Boyes,DMD, Greeley, CO 8/00-8/03 Responsible for all aspects of patient care: initial contact,information management, communicating patient needs/desires to Dr.,treatment planning and presentation, financial arrangements, follow-up and continued care. Fill in regularly for Office Manager and Lead Chairside Assistant. Training and delegation of tasks as needed. Orthodontics Coordinator,Dental Health Centers of America, Greeley, CO 9/98-11/99 Helped initiate an orthodontics specialty within existing practice;provided all aspects of patient care: examinations,treatment planning, case presentation, financial arrangements,insurance, ongoing patient communication. Also performed administrative duties as needed for general dentistry Doctors. Expanded Duties Dental Assistant,James Shaddock, DDS, Greeley, CO 9/93-9/96 Performed chairside duties to assist Dr. with patient care: x-rays, room and supply preparation,patient comfort,procedure assistance. Assisted front-office staff. • Training,certification,and re-certification numerous times in CPR,basic first aid, and medication administration throughout employment history Awards &Recognition Golden Key and Psi Chi Academic Honor Societies Member Grand Achiever, Mary Kay Cosmetics, 1998 JC Penney Golden Rule Volunteer Award Finalist, 1997 Professional and Personal references available Carole Jean Noblitt (Jean) LCSW 262718'"'Avenue Greeley, CO 80631 970-378-9419 Education Masters of Social Work 1996 Colorado State University, Ft. Collins, CO 80523 Post Graduate Course Work-Marriage &Family Therapy Program 1995, 1996, 2000 University of Northern Colorado, Greeley, CO 80639 1996 Bachelor of Science In General Business 1988 University of Northern Colorado, Greeley, CO 80639 Associate of Applied Science in Information Systems 1983 Aims Community College, Greeley, CO 80634 Bachelor Level Course Work—Family& Child Development- 1960-62 Nursing, Kansas State University, Manhattan, KS 66502 Continuing Education How to Help Dying People Attain Dignity and Peace;Douglas Smith, MA, MS, MDiv. EMDR Part 1 Basic Training;EMDR Institute, Inc., July 19-21, 2002, Englewood, CO. Treating Sexual Abuse:From Victim to Surviving to Creating;Carolyn M. Ball, MA;LPC Grief Counseling&Clinical Practice;John R. Jordan, PhD, CMI Education Institute, Inc. Psychopharmacology Made Simple: The Basics&Beyond;John Preston, Psy.D. Domestic Violence Risk Assessment Training;Amend, Alamosa, CO, September 11, 1999 Identification and Intervention in Sexually Abusive Behavior, Gail Ryan, MA, Kempe Center Living Well is the Best Revenge:Moving Beyond the Survivor Identity; Yvonne Dolan, MA Evaluation and Treatment of Child Sex Abuse; Richard A. Gardner, MD. Ethics, Colorado law,and General Standards of Practice for Psychotherapists Why People Don't Heal:Understanding the Intimate Language of Wounds;Carolyn Myss, Exploring Psychology, Spirituality, & Creativity, 15th Annual Common Boundary Conference Paralegal Certificate, University of Northern Colorado, Greeley, CO 1993 Non-Profit Funds Management Certificate Aims Community College, Greeley, CO 1992 RECEIVED O C T �2 �0�2003 BY: .�7,Jr' 2 1A- Career Experience Adoption Worker Sept. 1999 to Present Adoptions:Advocacy&Alternatives, Ft. Co//ins, CO 80525, 970-493-5868 Work directly under Placement Supervisor and Birth Mother Counselor in private, non-profit agency providing placement services for infants.Family&individual assessments, homestudies, research,public relations, and outreach on a contract basis. Medical Social Worker March 2000 to Jan 2003 Hospice of Northern Colorado, Greeley, CO 80634 970-352-8487 Provide support services to patients and their families in their homes and at the in-patient unit. Psycho/social assessment&care plan development;plan and lead Care Conference; Interdisciplinary Team reports;provide individual grief counseling, education and support; connect patient with community resources,and facilitate groups. Crisis&Support Counselor June 1997 to October 1999 Tu Casa, inc., P.O. Box 473, Alamosa, CO 81101 719-589-5291 Provide individual and group crisis and on going counseling to victims/survivors of domestic violence and/or sexual assault in the San Luis Valley of Southern Colorado. This includes assessment,planning,and follow-through;often working with treatment plans from other area agencies. Clients are predominately adult women;children and teens are also involved with our program. Work closely with area human service agencies and law enforcement. Education Project Director/Outreach Counselor February 1997 to Sept. 1998 Tu Casa, Inc., P.O. Box 473, Alamosa, CO 81101 719-589-5291 Director of San Luis Valley Sexual Assault Prevention Education Project, a "model program" funded by the Colorado Department of Public Health&Environment&the Colorado Coalition Against Sexntl Assault.Designed implemented and taught prevention education programs aimed at students ages 11-19 in the San Luis Valley school districts. Goal:to facilitate understanding of the root rmnces of interpersonal violence and through awareness, develop skills to protect themselves&to promote a violence free environment at home, at school,and with their peers Community Organizer August 1995 to June 1996 Congregations Building Community, 427 Main, Windsor, CO 80550 970-686-0162 Intern in organization of 18 institutional members,representing approximately 20,000 persons. Facilitated grassroots organizing:conducted one-to-one meetings with over 100 persons to listen to concerns and identify potential leaders;promoted assisted with, and led exploratory meetings; formed and trained local organizing committee members;assisted with research actions and public meetings;conducted ongoing evaluations. Care Coordinator January 1996 to May 1996 First Steps of Weld County, 1024 9th Ave., #3, Greeley, CO 80631 970-353-4192 • Intern in small,private, non-profit agency offering no-cost race management services to pregnant • women. Duties included providing information, education, referral, counseling, and support to high risk pregnant women and new mothers. Family Caseworker June 1995 to August 1995 Catholic Charities Northern, Ft. Collins, CO 80521 Case management intent at homeless shelter working with families to prevent reoccurrence of circumstances that caused loss and to establish stable environment for the children. Women's Counselor September 1994 to May 1995 Longmont Coalition for Women in Crisis, P.O. Box 231, Longmont, CO 80502-0231 Intern in nonprofit agency offering outreach services and emergency shelter to battered women &children. Duties:co-facilitated women's groups,crisis line callbacks, client intake and assessment, education and referrals, and shelter work. 303-772-0432 Nobility Carole Jean References Maria Swell, MSW,Former Director Joanne Gallagher, LCSW,Director Tu Casa,Inc.Alamosa Adoptions:Advocacy&Alternatives 3024 Cortez St. 2500 S. College Avenue Ft Collins, CO 80525 Ft Collins, CO 80525 970-282-8679 970-493-5868 Robert Shellenberger,Ph.D.,Retired Mike Kromrey,MSW,Director Dept of Psychology,Alms Community College Metropolitan Organization of People 20627 Catclaw Ct 2517 Birch Johstown, CO 80534 Denver, CO 80207 970-587-2543 303-399-2425 Ann Lundquist,MSW Former Director of Support Services Sandy Brown,MSW,Director Hospice of Northern Colorado Congregations Building Community 2726 West 11th Street Road 1218 W Ash Greeley, CO 80634 Windsor, CO 80550 970-352-8487 970-686-0162 Home: 970-663-9315 *Vote:Ann is leaving Hospice in Greeley for a new position with the hospice in Estes Park effective 10-13-03 VERONICA RIVERA 905 W. Laurel St Apt 116 Fort Collins, CO 8052 vrivera.:ir;larilar.colostate.edu Phone: (970) 492-9122 A certified,bilingual, marriage and family therapist, with skills in areas of child and family therapy,multicultural competence;problem solving, and communication. Seeking for a position in your organization, where my skills can be of value. COMPETENCIES • • Aware of the issues that affect individuals and families. • Strong understanding of the complexities among individual's relationships. • Apply bilingual skills to assist Spanish speaking families. • Promote a safe and pleasant environment for individuals to explore their thoughts and feelings. • Adapt appropriate therapeutic interventions,based on the needs of the client. EDUCATION Colorado State University July 2005 Master in Science in Human Development and Family Studies,Family and Developmental Studies and Marriage and Family Therapy mayor. University of El Salvador, San Salvador, El Salvador. December 2003 Master in Science,Methods and Techniques in Social Research,qualitative research major. Swinburne University. Melbourne,Australia. September 1998 Bachelor of Arts, Sociology and Political Science major. Swinbume University. Melbourne,Australia. December 1995 Associate Degree in Social Sciences, Social Sciences major. PROFESSIONAL DEVELOPMENT Graduate Certificate in Women Studies May 2005 Colorado State University Graduate Diploma in Gender Theory and Human Development March 2001 University of Central America, El Salvador. Graduate Diploma in Victimology and Victims Assistance January 2001 The World Society of Victimology and the University of Central America • RELEVANT AWARDS Harriet Patsy Boyer, awarded a scholarship to continue with my Interest in Human Development and Women Studies. May 2005 Granted with a two year Fuibright scholarship, by The Institute of International Education IIE. August 2003 RELATED EXPERIENCE Internships Psychotherapist intern, Child Safe,Fort Collins, CO. January—July 2005 Supporting with children who have survived different types of abuse_ Psychotherapist intern, The Center for Community Partnership, January--July 2005 Fort Collins, CO. Supporting adolescents in their personal complexities and emotional health. MOST RECENT EXPERIENCE Colorado State University. May 2004—May 2005 Research assistant and facilitator, working in a Study on myths and realities about breast cancer among Hispanic Women. Colorado State University_ August 2003-May 2005 Research and teaching assistant,department of human development and family studies. WORK EXPERIENCE Project Change,Academy for Educational Development(AED), Jan. 2002—Jul. 2003 San Salvador,El Salvador. Researcher and facilitator • Researched on the myths,knowledge, and the practices followed by members of urban neighborhoods in San Salvador,as well as in rural communities, to prevent the dengue fiber that kill people in outbreaks suffered by the country every two years. • Participated as a facilitator in the presentation of preventive programs based on local education through workshops to teachers, public health servants, and state officers. Later the prevention methods and practices were presented to the society through formal education at elementary and secondary schools. Institute for women and children development(ISDEMU), Nov. 1998 --Jul. 2003 San Salvador, El Salvador. Sociologist and counselor • Increased the effectiveness of the intervention programs by assessing the program's goals. • Participated as member of a team developing new prevention programs and interventions. • Counseled and supported battered women. Also worked with abused and neglected children in the shelter of the institution. uaa...4.uwu u� awa iu�air J w tutu out myths, oellavlors, level 01 Knowleage, tack or regional resources, and social risks in urban as well as rural communities. AFILIATIONS Student, American Association of Marriage and Family Therapy May 2003 Member of the Salvadorian Association of Sociology July 2002 • • ROSANN M. ROSS, M.A., L.P.C., N.C.C. BUSINESS: Department of Psychology HOME: 3931 Pueblo Street University of Northern Colorado Evans, Colorado 80620 Greeley, Colorado 80639 (970) 506-4125 (9701 351-2485 • Email: rosann.ross@unco.edu Email: rosieross@earthlink.net EDUCATION: 2002-current Ph.D. Student, Counselor Education & Supervision 25 credit hours completed - 4.0 GPA 1994 Master of Arts, Agency Counseling: Marriage and Family Emphasis University of Northern Colorado 1990 Bachelor of Arts, Psychology University of Northern Colorado CERTIFICATION/ 1994-2005 National Certified Counselor LICENSES National Board for Certified Counselors Certificate #34131 1996 Licensed Professional Counselor; State of Colorado Regulatory Agency License #1436 - current PERSONAL PHILOSOPHY My philosophy of life as it relates to the work environment stems from the family systems therapeutic perspective which holds that all things are interrelated; what affects one member of the system affects all members of the system. Therefore, the system, which can be a family, a group of individuals or an organization, holds the power for change and has the ability to find solutions to any problems that may arise by examining the relationships within that system. Using this framework, I work to maximize the system's power in its ability to change by looking at the unique web woven by these relationships. As each member's contribution to both the problem and the solution, as well as openness for change are assessed, the system can be brought together in such a way where everyone becomes an active member in searching for and finding creative answers for a more permanent change. PROFESSIONAL EXPERIENCE August 1997 - Position: Full Time Lecturer in Psychology present Department of Psychology University of Northern Colorado Primary responsibility: Teaching 15 credit hours each semester. Classes taught: Psy 120 - Introduction to Psychology Psy 265 - Social Psychology Psy 350 - Theories of Personality Psy 344 - Group Roles & Processes Psy 407 - Introduction to Theories of Counseling Psy 455 - Abnormal Psychology Psy 491 - Field Experience HESA 220 - Death & Dying ROSANN M. ROSS, M.A., L.P.C., N.C.C. PROFESSIONAL EXPERIENCE (continued) Additional responsibilities: Minor academic advising of undergraduate psychology majors; promote psychology department to incoming freshmen; providing guidance counseling to graduating seniors regarding graduate school choices; revising & coordinating the undergraduate field experience program (an on-site psychology experience for the student); performing liaison duties with community agencies in placing students at work sites. January 1996 - Position: Mental Health Therapist April 2000 Acute Treatment Unit (ATU) North Range Behavioral Health Greeley, Colorado The ATU is a residential treatment facility for persons with chronic mental illness. Duties included the supervision of three to four clinical care assistants and psychiatric nurses; individual and group therapy sessions; crisis intervention; hospital evaluations; managing emergency phone lines for northeastern Colorado; milieu management and supervision of charting and case management. August 1995 - Position: Part Time Instructor June 1997 Department of Psychology University of Northern Colorado Primary responsibility: Teaching undergraduate courses. Classes taught: Psy 120 - Introduction to Psychology Psy 350 - Theories of Personality Psy 407 - Introduction to Theories of Counseling Psy 455 - Abnormal Psychology July 1994 - Position: Partner in Private Practice December 1996 Counseling Clinic Family Physicians Building 2520 W. 16th Street Greeley, Colorado 80631 • I counseled individuals, couples and families facing emotional difficulty arising from a number of diverse life changes. I focused my practice on working with chronic illness, the aging population, the mind-body connection, the final stages of life, and rief and bereavement, January 1995 - Position: Group Co-Facilitator December 1996 Northern Colorado AIDS Project Fort Collins, Colorado As co-facilitator for a heterosexual couples' group living with full-blown AIDS, I addressed the unique and often forgotten issues that these couples face on a day-to-day basis. 2 ROSANN M. ROSS, M.A., L.P.C., N.C.C. PROFESSIONAL EXPERIENCE (continued) April 1995 - Position: Interim Program Director May 1995 Greeley Transitional House 1202 6th Street Greeley, Colorado 80631 As interim Program Director, my duties included facilitating interpersonal staff relations, intake interviews and crisis intervention with homeless families, liaison with other community agencies on behalf of the families, and managing the daily affairs of the program. October 1993- Position: Intern Therapist August 1994 Weld Mental Health Center 1306 11th Avenue Greeley, Colorado As part of the externship requirement for my Master's Degree, I worked as an intern therapist at the Mental Health Center seeing individuals and couples. When my externship requirement was completed, I worked pro bono for three months. June 1993- Position: Intern Therapist May 1994 North Colorado Medical Center Oncology Floor 1801 16th Street Greeley, Colorado As part of the externship requirement for my Master's Degree, I worked on the Oncology Floor at the hospital. My responsibilities included: in- and outpatient counseling, co- facilitator of the Cancer Support Group, and the development of community outreach services. November 1987 - Position: Administrative Assistant to the Dean July 1992 College of Health and Human Sciences University of Northern Colorado Greeley, Colorado Duties included, but certainly were not limited to: Liaison between Dean and five department chairpersons, problem solving with same, managing student complaints, designing and planning college public relations events, college class scheduling, working with Provost's office in maintaining policy revisions, resource utilization on campus. February 1985 - Position: Administrative Aide November 1987 Office of Academic Affairs University of Northern Colorado Greeley, Colorado Duties included front-line interaction with faculty, deans, and other administrative officers, managing record keeping, intermediary between Provost and students. -3- • ROSANN M. ROSS, M.A., L.P.C., N.C.C. PRESENTATIONS: Spring 1999: Personality and Personal Development: Spirituality in the Classroom Rocky Mountain Psychological Association Fort Collins, Colorado Fall 1998: Guest Lecturer - Psy 407: Theories of Counseling "Family Systems - A Live Role Play" University of Northern Colorado Fall 1998: Guest Lecturer - Psy 240: Maturity and Aging "Stress and Its Effect on Health" University of Northern Colorado October 1996: Guest Lecturer - Psychology 120: Principles of Psychology "Current Views on Death & Dying" University of Northern Colorado October 1995: Guest Lecturer - Psychology 407: Theories of Counseling "Family Systems Perspective" University of Northern Colorado Guest Lecturer - Psychology 450: Abnormal Psychology "The Mind/Body Perspective" University of Northern Colorado • Guest Lecturer - Psychology 433: Health Psychology "AIDS and You" • University of Northern Colorado March 1995: Guest Lecturer - Sociology 221 "Infidelity and Gender Role Differences" University of Northern Colorado April 1995: Guest Lecturer - Sociology 221 "Religious Institutions and Gender Role Differences" University of Northern Colorado November 1994 Business Aspects of Counseling Full- Day Workshop Presented to Division of Professional Psychology Graduate Student Association University of Northern Colorado ADDITIONAL TRAINING/WORKSHOPS: September 2004 Completed 24 hours of continuing education - home study program Academic Year Supervised Individual Thera Therapy practicum; Supervised Group Facilitation Practicum; Practicum in Supervision - Ph.D. Program in Counselor Education and Supervision Academic Year Supervised practicum/Advanced practicum - Ph.D. program in Counselor 2002-2003 Education and Supervision -4- • ROSANN M. ROSS, M.A., L.P.C., N.C.C. ADDITIONAL TRAINING/WORKSHOPS (continued): January 2002 Aggressive & Defiant Behavior: The Latest Assessment and Treatment Strategies Home Study Course: Compact Clinicals Borderline Personality Disorder: The Latest Assessment & Treatment Strategies Home Study Course: Compact Clinicals December, 2001 PTSD: The Latest Assessment & Treatment Strategies Home Study Course: Compact Clinicals Obsessive-Compulsive Disorder: The Latest Assessment & Treatment Strategies Home Study Course: Compact Clinicals April, 1999 Rocky Mountain Psychological Association Regional Conference Fort Collins, Colorado September, 1995 AIDS: The Second Decade Teleconference University of Northern Colorado May, 1995: Alternative Health Care: What is Reasonable? Workshop by Dr. Scott Shannon North Colorado Medical Center Greeley, Colorado April, 1995: Hot Monogamy Workshop by Dr. Patricia Love American Counseling Association National Conference Denver, Colorado April, 1995: American Counseling Association National Conference Denver, Colorado April, 1995: Chronic Fatigue Syndrome Presentation by Dr. Scott Pace Northern Colorado Mental Health Network Greeley, Colorado Feb., 1995: How We Choose Our Mates: A Jungian Perspective Workshop by Dr. Neil Scott Mountain Crest Hospital Fort Collins, Colorado Oct., 1994: Pet Loss and Grief Counseling Mountain Crest Hospital Fort Collins, Colorado 5 ROSANN M. ROSS, M.A., L.P.C., N.C.C. ADDITIONAL TRAINING/WORKSHOPS (continued): February 1994 Marriages from Hell Workshop by Dr. Frank Pittman Mountain Crest Hospital Fort Collins, Colorado April 1993: Colorado Association of Marriage & Family Therapists Conference Denver, Colorado April 1992: Colorado Association of Marriage & Family Therapists Conference Greeley, Colorado SERVICE: Spring, 2004 College of Arts & Sciences - Committee to organize undergraduate internships July, 2004 Discover UNC - meeting incoming freshmen and orienting them to the University and helping them build their class schedules June, 2003 Discover UNC - meeting incoming freshmen and orienting them to the University and helping them build their class schedules May 2003 Reviewed proposed Counseling Theory text for Allyn & Bacon Publishers November 2002 General Education Review for PSY 265, Social Psychology February 2002 Participant in the application and selection process for the National Student Exchange Program July 2002 Discover UNC August 2001 Discover UNC November 2001, Presenter: Women & Spirituality • Celebrating Women Harrison Residential.Hall October 2001 Debriefing in Turner Residential Hall regarding two students' death November 2000 - Committee Member - Community Seminar Planning Committee March 2001 John Fox, Sociology, Chair February 1999 - Faculty Mentor May 2000 McNair Scholarship Program August1998 Faculty Representative May 1999 State Personnel Employees Executive Council University of Northern Colorado -6- • ROSANN M. ROSS, M.A., L.P.C., N.C.C. SERVICE (continued): February 1996 Volunteer Therapist "Tears for the Children" Sexual Abuse Exhibit University of Northern Colorado March 1995- Pro Bono Therapist December 1996 Pro Bono Project of Weld County Greeley, Colorado October 1995 Intake Interviewer National Depression Disorders Screening Day North Colorado Medical Center Greeley, Colorado May 1995 Intake Interviewer National Anxiety Disorders Screening Day North Colorado Medical Center Greeley, Colorado June 1994 - Pro Bono Therapist August 1994 Weld Mental Health 1306 11th Avenue Greeley, Colorado August 1990- Hospice Volunteer May 1994 Hospice of Weld County AWARDS/RECOGNITIONS February 2002 Favorite Professor Distinction - UNC Mortar Board Nominated by Jessica Biel • April, 2001 • Nominated for Women's Recognition Award February, 2001 Favorite Professor Distinction - UNC Mortar Board Nominated by Shanti Pepper February, 2000 Favorite Professor Distinction - UNC Mortar Board Nominated by Amy Barnett April, 1999 Nominated for Women's Recognition Award February, 1999 Favorite Professor Distinction - UNC Mortar Board Nominated by Lexi Rigg February, 1999 Favorite Professor Distinction - UNC Mortar Board Nominated by Gregg Pederson -7- ROSANN M. ROSS, M.A., L.P.C., N.C.C. REFERENCES: Vincent A. Scalia, Ed.O. Thomas Gavin, Ph.D. Tracy Baldo, Ph.D. Associate VP of Academic Affairs Director Professor of Counseling Psychology University of Northern Colorado Institutional Research & Planning Division of Professional Psychology Greeley, Colorado 80639 University of Northern Colorado University of Northern Colorado Greeley, Colorado 80639 Greeley, Colorado 80639 (970) 351-2879 (970) 351-2133 (970) 351-2544 L nda Black Ph.D. Associate Professor of Counseling Psychology Division of Professional Psychology University of Northern Colorado Greeley,Colorado 80639 (970)351-1638 24634 3`" Ave (970) 834-2302 Eaton, CO 80615 Carmen Schlierkamp Objective To secure employment or independent contractor work in the field of counseling psychology to further my experience and knowledge of assessments and counseling, and to expand my horizon by working with a new population. At the same time I hope to utilize my clinical, counseling, and assessment skills. I Experience 2005-2006 Weld County Sheriff's Department Greeley,CO Internship 600 hours(Counseling Department) • Responsible for Full Scale Assessments (Diagnostic Interviews) and treatment planning. • Record keeping(case plans,case notes, narratives,assessments) • Training new officers(research and training on the subjects of ADHD Psychotic Disorders,and Female Offenders) • Individual Psychotherapy (Crisis Intervention, CBT, Brief Therapy, and monitoring of pharmacological treatment progress) • Consultation with the medical team and outside agencies. • Psychoeducational Group Therapy (with co-therapist and independent). Group Therapy topics include substance abuse, anger management,cycle of abuse,and communication. • Deep muscle and imagery relaxation classes. • Populations served:female and male offenders age 18-60 with Hispanic and European American ethnic backgrounds. 2005-2006 Home Instead Senior Care Greeley,CO Home Care Provider(week ends) • Provide assistance with everyday living(cooking, hygiene, medication, and safety). • Provide companionship, utilizing listening skills. 2005(JunelJuly) Medicine Horse Program Boulder, CO Volunteer • Office assistant in a non profit organization maintaining records. • Assist with care of therapy horses. 1997-2003 Guntermania, Inc Pearblossom, CA Management.(Vice President and Secretary) • Responsible for finances, accounting and bookkeeping, sales and marketing. • Designing and overseeing the production of fan products. • Handling all professional correspondence. • Booking and negotiating personal appearances. • Contract negotiations with sponsors and lawyers. • Web design, programming and development of GunterS.net(includes also: designing recipes, writing articles on nutrition and workout information,consulting on supplements, nutrition and training). • Choreographing posing routines, editing music, make up and wardrobe for Gunter at photo shoots, develop workout and nutrition plans for Gunter. 1996-1997 Powerhouse Gym Fairfield, NJ Nutrition Counseling and Personal Trainer • Started behind the counter in memberships. • Teaching Aerobic Classes. • Finished my personal trainer certificate and moved up to nutrition counseling and personal training with some management responsibilities. 1991-1996 Top Sports Buseck Germany Aerobic Instructor • 3-4 courses a week. • Continuing education twice a year. Education 2003—Present Capella University Minneapolis Minnesota • Currently in the last Semester of the Master's Program in Counseling Psychology;4.0 GPA 1991-1996 Justus Liebig University(JLU) Giessen Germany • 1994-1995 B.S.in Nutrition and Dietetics.JLU Giessen Germany. • 1991-1994 Fulfilled the requirements for the B. S. in Biology but did not participate in final exam.JLU Giessen Germany. Certifications • 2005 Equine Assisted Psychotherapy I—Equine Assisted Growth and Learning Association(EAGALA) 1997-1999 Certified Personal Trainer - World Instructor. Training School,Virginia Beach,VA • 1998 Adult CPR American Red Cross. • 1998 Standard First Aid American Red Cross. Interests • Painting, horse back riding, member of the Chamber of Commerce in Greeley with the goal to get more involved with the Greeley community. I am also interested in providing Equine Assisted Psychotherapy for diverse populations. • Well organized. Strengths • Independent learner and self-starter. • Compassionate and spiritual. • Flexible to work in groups or alone. Languages • Fluent in English and German. References If requested reference letters can be produced. • Rosann M. Ross, M.A., L.P.C., N.C.C. Lecturer in Psychology University of Northern Colorado Greeley, Colorado 80639 (970)351-2485 • W.D. Farr Farr WD&Company 1914 14th Ave Greeley,CO 80631 (970)356-1914 • Alice McPherson, MA, L.P.C. Clinical Director Weld County Sheriffs Department 2110 O Street Greeley,CO 80631 (970)356-4015 Ext 3937 amcpherson@comeld.co.us • James Michael Nolan, Ph.D. Director of health&Counseling Services Baldwin-Wallace College 275 Eastland Ave. Berea,Ohio 44017 (440)263-1769 jnolan(dibw.edu • , . Languages • Fluent in English and German. References If requested reference letters can be produced. • Rosann M. Ross, M.A., L.P.C., N.C.C. Lecturer in Psychology University of Northern Colorado Greeley, Colorado 80639 (970)351-2485 • W.D. Farr Fan-WD&Company 1914 14Th Ave Greeley, CO 80631 (970)356-1914 • Alice McPherson, MA, L.P.C. Clinical Director Weld County Sheriffs Department 2110 O Street Greeley,CO 80631 (970)356-4015 Ext.3937 amcpherson@co.weld.co.us • James Michael Nolan, Ph.D. Director of health&Counseling Services Baldwin-Wallace College 275 Eastland Ave. Berea,Ohio 44017 (440)263-1769 jnolanbw.edu a DEPARTMENT OF SOCIAL SERVICES Kist P.O. BOX A GREELEY, CO. 80632 - - - Website:www.co.weld.co.us Administration and Public Assistance(970)352-1551 - OMay 11,2007 Fax Number(970)353-5215 • COLORADO Jami Moe-Hartman,Co-owner Transitions Psychology Group,LLC 804 11 Avenue Greeley,CO 80631 Re: Bid#006-LS-07(RFP 05005)Lifeskills Bid#003-FPT-07(RFP 006-00C)Foster Parent Training Bid#008-HS-07(006-00B)Home Study,Relinquishment Counseling Bid#006-MH-07(RFP 006-00)Mental Health Services Dear Ms.Moe-Hartman: 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 2006-2007 • • The Families,Youth and Children(FYC)Commission recommended approval of your Bid#006-LS-07(RFP#07005),Lifeskills for inclusion on our vendor list.The FYC Commission attached the following recommendations 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:The bidder must clarify and submit information that was not addressed or included with the original bid submission. 1. Provide a copy of insurance, 2. Provide staffing information, including resumes and education levels of staff, 3. Address mandated caseworker training for staff, 4. Address bilingual/bicultural services, 5. Provide rates for levels of service(parent education and therapeutic visitation), 6. Address step-down services. Page 3 Transitions Psychology Group/Results of RFP Process for 2007-2008 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 conditions and recommendations.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, J y A. 'ego,D. tor cc: Juan Lopez, Chair,FYC Commission Gloria Romansik, Social Services Administrator Tobi Vegter, Core Services Coordinator Hello