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Home My WebLink About20071688.tiff RESOLUTION RE: APPROVE SEVEN NOTIFICATION OF FINANCIAL ASSISTANCE AWARDS FOR HOME STUDIES, UPDATES, AND RELINQUISHMENT COUNSELING SERVICES WITH VARIOUS PROVIDERS AND AUTHORIZE CHAIR TO SIGN WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS,the Board has been presented with seven Notification of Financial Assistance Awards for Home Studies, Updates,and Relinquishment Counseling Services, between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Social Services, and various providers, listed below, commencing June 1, 2007, and ending May 31, 2008, with further terms and conditions being as stated in said awards: 1. Ackerman and Associates, P.C. 2. Blythe Johnson, Private Practice 3. Julie Box, Private Practice 4. Patricia Chase, Private Practice 5. Transitions Psychology Group, LLC 6. Keith Wawrzyniak, Private Practice 7. Helene Wurth, Private Practice WHEREAS, after review, the Board deems it advisable to approve said awards, copies of which are attached hereto and incorporated herein by reference. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, ex-officio Board of Social Services, that the seven Notification of Financial Assistance Awards for Home Studies, Updates,and Relinquishment Counseling Services between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Social Services, and various providers, listed above be, and hereby is, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said awards. 2007-1688 Op SsSS0034 07-/a -- o7 SEVEN NOTIFICATION OF FINANCIAL ASSISTANCE AWARDS FOR HOME STUDIES, UPDATES, AND RELINQUISHMENT COUNSELING SERVICES PAGE 2 The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 18th day of June, A.D., 2007, nunc pro tunc June 1, 2007. BOARD OF COUNTY COMMISSIONERS WE.. . OUNTY, COLOR DO ATTEST: ;: E. Long, Chair Weld County Clerk to the Board (:6i ---s SS9 G'�e9�i H. e ,e ro Tem Deputy Clerk to the Board ( F. Garcia APP ED AS TOs- �' ) Robert D. Masden ounty A orney ` Douglas demacher Date of signature: 77-0 7 2007-1688 SS0034 a WELD COUNTY gS CQ +1S51QNEBLPARTMENT OF SOCIAL SERVICES 101 JUN I2 P 4: 51 P.O. BOX A ' GREELEY, CO. 80632 Website:www.co.weld.co.us R E C 6 V E D Administration and Public Assistance(970)3524551 OFax Number(970)353-5215 • COLORADO MEMORANDUM TO: David E. Long, Chair Date: June 8, 2007 Board of County Commissioners �y FR: Judy A. Griego, Director, Social Services�%1..(„� �J� RE: Notification of Financial Assistance Awards with ariou Contractors— Home Studies, Updates and Relinquishment Counseling Enclosed for your approval is a Notification of Financial Assistance Awards with Various Contractors for Home Studies, Updates and Relinquishment Counseling. These Awards were reviewed at the June 6, 2007, Work Session. The major provisions of these Awards are as follows: 1. The Award period is June 1, 2007 through May 31, 2008. 2. The source of funding is Child Welfare Administration. 3. The Contractors will provide home studies, updates and relinquishment counseling under the child welfare system. 4. The Contractors include: Contractor Hourly Rate/Home Study Cost A. Ackerman and Associates $120 hourly rate relinquishment counseling $75 hourly rate court testimony $1,045 full home study $570 updated home study B. Blythe Johnson $75 hourly rate court testimony $950 full home study with background check $1,050 full home study with 3 +additional adults $450 updated home study $250 relinquishment counseling C. Julie Box, Private Practice $103.89 hourly rate relinquishment counseling $75 hourly rate court testimony $950 full home study with background check $850 full home study without background check $225 full home study cancellation after 3.5 hours $250 per additional adults full home study $425 updated home study 2007-1688 MEMORANDUM Page 2 Board of County Commissioners June 11, 2007 D. Pat Chase, Private Practice $103.89 hourly rate relinquishment counseling $75 hourly rate travel time $75 hourly rate court testimony $.34 mileage four court testimony $.34 travel outside of Weld County $950 full home study with background check $1,050 full home study with 3 additional adults $450 updated home study $250 relinquishment counseling $31.66 hourly rate home study in excess of 30 hours E. Transitions Psychology Group, LLC $1,200 full home study with background check$780 update home study $120.70 hourly rate home study or update $120.70 hourly rate relinquishment counseling$150 hourly rate court testimony F. Keith Wawrzyniak, Private Practice $46.52 hourly rate SAFE home study with background check $46.52 hourly rate home study update $46.52 hourly rate terminated(by DSS)home study $95.29hourly rate relinquishment counseling, $75 hourly rate court testimony $930.55 SAFE home study with background check $465.28 SAFE home study update $200 for each additional adult in household G. Helene Wurth, Private Practice $75 hourly rate court testimony $75 hourly rate relinquishment counseling $75 hourly rate interpreter services $950 full home study with background check $450 updated home study If you have any questions, please telephone me. Weld County Department of Social Services Notification of Financial Assistance Award for Child Welfare Regular Administration Funding Type of Action Contract Award No. X Initial Award 07/08HS/0030 Revision (RFP-006-00B; 001-HS-07) Contract Award Period Name and Address of Contractor Beginning 06/01/2007 and Ackerman and Associates,P.C. Ending 05/31/2008 Home Studies,Updates, Relinquishment Counseling 1750 25th Avenue, Suite 101 Greeley,CO 80634 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Home study format is based on 20 hours of Assistance Award is based upon your Request for work, 11 hours of direct professional services as Proposal(RFP). The RFP specifies the scope of well as required background checks.Updates are services and conditions of award. Except where it is based on a format of six hours. Relinquishment in conflict with this NOFAA in which case the counseling is a maximum of two hours per NOFAA governs,the RFP upon which this award is parent,billed in one hour increments. Program based is an integral part of the action. capacity is 24 home studies or updates, and a Special conditions total of 48 hours of relinquishment counseling 1) Reimbursement for the Unit of Service will be based per year.The average stay is expected to be two on an episode rate per home study; home study months for a home study,and two weeks for update, and an hourly rate for relinquishment each parent in relinquishment counseling,with counseling sessions. up to two one-hour sessions of individual 2) Reimbursement requests must be an original with an counseling per parent.Bilingual-bicultural original signature from the provider and/or designee. services are available through current staff. 3) Reimbursements requests must include the date the home study,update, or relinquishment counseling was Cost Per Unit of Service completed.The request must reflect the referral Hourly Rate per number assigned to each home study, the amount Relinquishment Counseling $120.00 billed for each home study,and the month the service Court Testimony $75.00 was provided. Rate per Study 4) Payment will only be remitted on referrals made by Full Home Study $1.045.00 the Weld County Department of Social Services. Updated Home Study $570.00 5) Requests for payment must be an original submitted to the Weld County Department of Social Services by Enclosures: the end of the 25th calendar day following the end of X Signed RFP:Exhibit A the month of service.The provider must submit X Supplemental Narrative to RFP: Exhibit B requests for payment on forms approved by Weld X Recommendation(s) County Department of Social Services.Requests for payments submitted 90 days from the date of service, Conditions of Approval and thereafter,will not be paid. 6) The Contractor will notify the Department of any changes in staff at the time of the change. ,..),_ Approva sC Program Official: By C BY ,.iia David E. Long„ Chair Judyirecto ` Board of Weld County Commissi ners Weldartment of Social Services Date: JUN 18 2007 Date: L7 di097-/688 EXHIBIT A SIGNED RFP _- i - N `: - 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 Presen-ation Act—Core Sen-ices 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.RS. 26-5.5-101)and Emergency Assistance for Families with Children at Imminent Risk of Out-of-Home Placement Act (C.RS. 26-5.3-101). The Families,Youth and Children Commission wishes to approve services targeted to run from June 1, 2007,through May 31, 2008, at specific rates for different types of service,the County will authorize approved providers and rates for services only. This program announcement consists of the following documents, as follows: • Invitation to Bid • Main Request for Proposal (All program areas) • Addendum A—Program Improvement Plan Requirements(by program area) • Addendum B—Scope of Services(by program area) • Core Budget Form (A -Cc' Delivery Date ; 3 -rr (After receipt of order) BID MUST BE SIGNED IN INK Program Area: (11�A�yk `( 1 P&\1\'1(4€ \tkt E 1rY ED OR PRINTED SIGNATURE �l p VENDOR tHi1 \ hY6- >( 1(3.\00' C�� t\-e*14�s NN\ak rnxt)-? (Name) H ' en Signature By Authorized Officer or Agent of Vendor pp ADDRESS i ' v& TITLE \l��(�� ((yyl fvi yl)� i . 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A home study program for new or existing cases where a family study is needed to certify that a proposed adoption placement is in the best interest of the specified potential adoptee and the adoptive family. A new home study is referred to in the proposal simply as a home study. 2. A home study that is for an existing case, where an appropriate home study has been completed previously and where new information is required is termed a home study update. 3. The home study program would be required of new foster parent homes. 4. Relinquishment counseling is designed to assure that each parent relinquishing the child is fully aware of, in agreement with and capable of making a decision related to relinquishment. We propose to provide up to two hours of relinquishment counseling as specified by Colorado and Weld County. Such services will be referred individually for each parent relinquishing their rights and giving their child permanently to another family in an adoption process. We will provide these programs primarily through services in the home of the family intending to adopt, the new foster parent home or in our offices. Services will consist of: 1. A home study format of twenty hours of work based on eleven of direct professional services as well as required background checks. Work performed will meet the state criteria for an appropriate home study as illustrated by the fictional case study appended to this bid. 2. A home study update format based on six hours of direct professional services to update an appropriate home study. The update will meet the state criteria for an appropriate home study. 3. Two hours of relinquishment counseling services for each parent billed in one hour increments. The billing format is designed to recognize that the parents may be estranged or one may be unavailable for the process. A maximum of two hours per referral is needed in this process. The relinquishment counseling report will document the criteria set forth by the WCDSS and the Colorado relinquishment guidelines for relinquishment for each parent 1 Table of contents : page 2 Abstract page 1 Overview page 2 Number of clients served page 3 Distribution of clients page 3 Families served and limitation of catchment area page 3 Bilingual services limitations page 3 Accessibility of services page 3 Maximum per month page 4 Monthly average capacity page 4 Average stay page 4 Types of services provided page 4 Home study description page 4 Home study update description page 4 Relinquishment counseling page 5 Measurable outcomes page 5 Service objectives page 5 workload standards page 6 Staff Qualifications page 7 Evidence standards page 7 Confidentiality standards and informed consent page 8 Unit rate of service (fixed rate) page 9 PIP Plan adherence page 9 Standards of responsibility page 9 Evaluation of process page 9 Evaluation of outcome page 10 Budget page 11 Overview: A primary strength of this proposal is the experience of the licensed psychologist Joyce Ackerman, Ed. D. who is also a certified state vendor of these services with several years of direct experience working with WCDSS in adoption studies and trained in the SAFE model. Our purpose is to: 1. assure that a placement is in the best interest of the adoptee and the family intending to adopt. 2. recommend for or against the placement with clear explanation for those recommendations. 3. recommend activities and work needed to improve or enhance the adoptive process and outcomes for the adoptive child. 2 4. assure that relinquishment process is fully understood within the context of the Weld County and Colorado requirements. Target/Eligibility Populations A. Total number of clients to be served in a twelve-month program has been calculated as follows. Up to two home studies, either as complete home studies or home study updates, per month for a maximum of 24 per year is the anticipated capacity of our program. B. Distribution of clients.We anticipate that about 1/3 of the studies will be for new foster parents. About one third will be for kinship placements and the remaining third for adoption outside the kinship system. This assumes a maximum of approximately 48 hours of counseling services for relinquishment across 24 cases of relinquishment. C. Families Served and limitation to the catchment area . We anticipate serving 24 family units for home study of either type and 24 mothers and 24 fathers for relinquishment counseling.. We will limit provision of services in home studies to an area within 15 miles of Greeley, Colorado and therefore, do not anticipate serving families based in South Weld County. D. Sub total who will receive bicultural/bilingual services.We anticipate we will not be able to meet the needs of families who need these services in Spanish. Although the staff has staff extensive cross cultural experience with Hispanic clients, sufficient language skill is not present without the addition of a translator (which has not been budgeted in this proposal)for the provision of home studies. Bilingual services for a home study are not intended to be provided under this proposal. If for some reason Ackerman and Associates is requested to provide such bilingual services, the cost of translation services would need to be paid separately by the department to a translator. As we would desire to use a court certified counselor, these costs appear to be prohibitive. We have a Hispanic subcontractor, Emily Jaramillo, M.A., L.P.C. who is fluent in Spanish, however, we do not anticipate that she will be available for home study services, but only for relinquishment counseling. Joyce Ackerman, Ed..D. has spent several years working in American Indian reservation populations and with Hispanic mental health in Greeley. She has practiced in Greeley since 1981. The practice has been recognized for supporting diversity through an award by Greeley Chamber of Commerce. E. Accessibility. On weekdays, all providers of Ackerman and Associates are accessible through our office secretary and through cell phones. After hours, we maintain a 24 hour answering service and cell phone contact 3 system. On weekends, the 24 hour access reaches the provider on call who is always a licensed Mental Health provider. F. Maximum per month. The program maximum is estimated at a maximum of two home studies of any type and four hours of relinquishment counseling per month. G. The monthly average capacity is anticipated to be one home study of any type and two hours of relinquishment counseling per month. H. The average stay in the program is expected to be two months for a home study of either type and two weeks for each parent in relinquishment counseling. Types of Services Provided Home study: The home study will consist of the following procedures (11 hours) 1. Each parent will complete a detailed questionnaire designed to assist the interview process and return it prior to the first appointment. 2. Each parent will complete the required activities for a background check. 3. An initial meeting in the home with both parents desiring to adopt or to be certified as foster parents. (2 hours) 4. One or two additional interviews and observation of family in the home setting, including age appropriate interviews with children, as needed. (4 hours) 5. Data review as needed (2 hours) 6. Home study report and recommendations. (2 hours) 7. Meeting with parents in office. (1 hour) A sample home study report is attached. Home study update: (6 hours) 1. Each parent will complete a detailed questionnaire designed to assist the interview process and return it prior to the next appointment. 2. Review of previous report. (lhour) 4 3. A meeting at with each parent desiring to adopt or to be certified as foster parents. (2 hours). 4. Additional interviews and observation of family members in the home setting. (2 hours) 5. Home study report. (1 hour) Relinquishment counseling: 1. Relinquishment counseling will consist of focused discussion based on the required WCDSS outline for provision of relinquishment services and the State of Colorado guidelines for relinquishment counseling 2. We also assure WCDSS, as we have in the past, that no individual working with Ackerman and Associates and providing therapy or having any other relationship with clients being served will provide relinquishment counseling, thus avoiding any conflict of interest. 3. Up to two hours per referral (per parent) will be provided under relinquishment counseling services. Measurable Outcomes are specified as : 1. Acceptability of Home Study reports to WCDSS. Our goal is for 100% of our home study reports to be acceptable to WCDSS foster parent and adoptive services. Home study reports will be based on the SAFE model. All reports turned in the last grant period have met this standard. 2. Timeliness of reports: Our goal is that 70% of reports will be completed within one month of referral for those whose background checks are processed within this period and that 100% of reports (i.e. the remaining ten percent)will be completed within eight weeks of referral. By adhering to these standards during the past year, we have demonstrated a good faith and a successful effort in this process. These procedures should assist the department in obtaining expedient placements. Service Obiectives We stipulate to the provisions of the required background checks and relinquishment counseling standards as stated in the proposal, • One aspect of all home studies will be to assess parental competency We expect that all reports will comment on strengths and weakness of the potential adoptive home consistent with the requirements of the SAFE protocol. Very serious weaknesses that rise to a clinical potential for injury to the adoptive 5 child may disqualify a family as prospective adopters in the judgment of WCDSS. However it is expected that reports will suggest strategies for improvement where areas of deficiency are noted where these deficiencies in themselves do not negate the potential of the home to serve an adoptive role for the specified child. Some of the areas may include: Improvement of parental competency The ability of the family to access resources Application of parental competencies in daily activities. After a full assessment of the family and home recommendations, are made in each of these areas. The attached study report data forms show the type of material that is collected in the SAFE protocol. The SAFE model will be utilized for all home studies. Workload Standards The program has an annual capacity of 24 home studies of either type and relinquishment counseling for twenty four mothers and twenty four fathers. There is one provider—Joyce Ackerman Ed. D. for home studies and relinquishment counseling. One additional provider is available for home studies only— Susan Bromley, Psy. D. and one additional provider is available for relinquishment counseling only- Emily Montoya, L.P.C. The maximum caseload a maximum of two home studies of either type and 4 hours of relinquishment counseling is projected per month. The modality of treatment is face to face assessment and background checks by written format. A questionnaire and other formats have been developed by the state SAFE program and will be followed to standardize the content of the home study. Hours/month a maximum of two home studies of either type and 4 hours of relinquishment counseling is projected per month. The maximum face to face hours would thus be 26 hours Staff There are 3 individual providers supported by one administrative professional in the practice as well as contracted staff for billing and accounting. Two additional licensed mental health providers support this project through our on call coverage system if an incident occurs outside of normal hours. Supervisor This contact would be supervised by Joyce Shohet Ackerman, Ed. D., who would monitor the project for compliance. Providers are 6 individually licensed and do not require clinical supervision. The maximum caseload per supervisor is 24 families per year. Insurance All providers carry one million/three million liability policy Ackerman and Associates carries an additional one million/three million liability policy on the group and a general liability policy, which meets the required criteria for this application. Co-listing of the state of Colorado on our Ackerman and Associates insurance for professional liability is required by the procedures of the State vendor list. Evidence standards: The Colorado Home study program is based upon the SAFE format, a validated instrument adopted by the Colorado State adoption program and required for certifying vendors in the home study process. The interview techniques used are based upon Dr Ackerman's professional training as a licensed psychologist and her 25 years of experience. Her interview style are consistent with an approach to clients that is based on cognitive behavioral therapy. Staff Qualifications Staff Qualifications Three staff are available for the project. They exceed the minimum qualifications specified as documented below. The staff members are: Joyce Shohet Ackerman, Ed. D., Licensed Psychologist; Emily Jaramillo M.A., L.P.C., and Susan Bromley Psy. D., M.S.W. Drs. Ackerman and Bromley are listed as vendors for home studies by the state of Colorado. Dr. Ackerman has conducted or supervised home studies using the current protocol for three years. Training The staff has extensive training in family therapy and short term therapy as documented by their extensive work experience in their resumes. All listed providers are vendors on the state list for home study providers. Continuing education As a part of their work in the private sector, all providers in this group maintain continuing education programs more than the minimum eight hours required. They participate in workshops and other activities. This proposal's continuing education requirements coincide with the requirements of other contractual arrangements and are being met on an ongoing basis by members of the group. Dr. Ackerman has recently completed several steps in certification toward life coaching under her continuing education. Supervision All of the providers are independently licensed and not required to have clinical supervision. All the staff have advanced skills in family therapy and in individual and family assessment. The contract supervisor will monitor the specifications made in this proposal. They are not caseworkers and so they do not have training associated with that role as mandated for caseworkers in Colorado. 7 Supervisor continuing education The supervisor of the project is involved in ongoing training to keep current with her profession through advanced workshops and seminars. Ackerman and Associates, P.C., of which the supervisor is the president, has more than ten years contracting experience with WCDSS. Dr. Ackerman has done extensive evaluation work in child custody, Special Advocate and Child and Family Investigator cases. Dr. Ackerman manages all contracts for Ackerman and Associates, P.C. Confidentiality protection and Informed consent: ( this section answers the questions listed in the corresponding instruction sections of the proposal application packet) Ackerman and associates is fully HIPAA compliant and maintains strict standards of confidentiality as mandated by the American Psychological Association and by federal and state law. Fair selection of patients is not an issue in this proposal as only the referred families seeking adoption related services will be evaluated. Absence of coercion is also not an issue as the program is required for the county to certify an adoption, The process is voluntary and no coercion is present. Participants can end their participation at any time if they decide to not continue with an adoption process. Data collection will be on the mandated data collection form a computer ized instrument—the SAFE document a hard copy of which is attached in Appendix 2 that also meets all the requirements of appendix b of this proposal.. Privacy - Data collected will be stored in locked files at Ackerman and Associates P.C. with access only to HIPAA compliant members of the staff of our professional corporation. Data will not be separately coded from the participant's name as there is no intent in this project to report only statistical information about the subjects. Consent - Participation is voluntary to the extent the participant can leave at any time and refuse to further participate in the process without any recourse from Ackerman and Associates P.C. Documentation of consent complies with the sate of Colorado Legal standards for the practice of psychology. Risks to participation in an adoption evaluation are limited to whether or not the family qualifies for the adoption and the psychological effects such outcome may have on their view of themselves and to any extent such an altered view relate to their future behavior.. Similar risks exist in relation to relinquishment counseling. 8 Ackerman and Associates will report perceived psychological risk to WCDSS , will intervene in the unlikely event if there is immanent danger. We will not be further monitoring the participants for consequences of such risks and perceive the requirement for such monitoring to be the responsibility of the WCDSS, who renders the final decision as to eligibility for the adoption. Our consent process is based on the requirements of Colorado for the provision of psychological services. For those unable to read, the form will be read to them. The very young or the very old will not be those giving consent to the adoption process in this contract. We also have the form available in Spanish but do not expect monolingual Spanish speakers will be referred into this proposed contract based on our stated limited bilingual capacity to serve their needs. A copy of the English language version of the consent is included along with other documents used to obtain consent. Risk benefit is such that the risk is low and the desired benefit of obtaining approval for the adoption the family is seeking is high. The risk benefit ratio is therefore judged to be very much more beneficial that a risk to the participants. Unit of service rate computation For home study professional time outlined above we are requesting a fixed rate of$1045 for a full home study and $570 for a home study update. For relinquishment counseling, we will bill up to two hours at $120 per hour. Direct and indirect costs and how these relate to overall expenses of the corporation are shown on the required bid sheet. PIP plan Addendum A: Ackerman and Associates stipulates that the PIP plan sections A-F and associated descriptions will be maintained in the performance of home studies and relinquishment counseling. Standards of responsibility for 2007 bids Ackerman and Associates, P.C. is a type S professional corporation and not a 501.c.3. In 2006, Ackerman and Associates had a net loss of one half of one percent on its revenue compared to expenses, generating no profit Ackerman and associates stipulates to requirements as stated in Appendix C of the proposal package. Evaluation—Process components: After each home study is completed we will compare the timeline of anticipated completion with actual completion. Deviations that occur in the planned schedule usually result from delays in obtaining background information or in scheduling conflicts for home visits. Such deviations 9 may make timeliness difficult but this has not been a problem since our previous evaluations in earlier programs led us to eliminate an underperforming state vendor licensed subcontractor from this type of work at Ackerman and Associates. As to the who , what, where and when aspects of process analysis, usually Joyce Ackerman Ed..D. will provide home study services to clients referred by WCDSS using the SAFE protocol at the documented cost of this proposal. This will be the benchmark against which process components will be measured. Evaluation—outcomes 1. What is the effect of the intervention?—either adoption will be approved by WCDSS or it will be denied. 2. What program/contextual factors were associated with the outcome?. Findings of the home study were either positive or negative along each measured parameter of the assessment tool such that the conclusions reached by the evaluator were developed through the analysis of the psychological and social information provided. Her judgment is based on her training as a licensed psychologist with more than 25 years of experience. Most relinquishment counseling, we have been told, is done by caseworkers from within the department. When it is not, and we are asked to do such counseling by referral we will use the state form for relinquishment counseling located on the state website. 3. What individual factors are associated with the outcome of the adoption study? The SAFE form details the individual parameters to be assessed. 4. How durable are the effects?: The full adoption is intended to be permanent. A foster home placement is intended to be temporary the durability depends on the context. The relinquishment process is designed to achieve separation on a permanent basis, consistent with the context of the case. 5. Does the outcome align with the PIP?— It is expected it will do so. Comparison would be made between the PIP and the plan outcome to determine this question. Internal Tracking and Billing process: All clients seen at Ackerman and Associates are recorded on a day sheet by the provider. Client appointments are kept in a central appointment registry for each provider which we can use as a cross check. All patients are given reminder cards, for their next appointment, that we keep a copy of. All data is recorded in patient charts and financial data is also recorded in patient accounts. Social services clients also sign time sheets. All social services billing and associated forms and reports are due in to the office by the fifth of the month. These are then logged in a computer program by Cindy Brogden , public accountant and the billing prepared by her for Joyce Ackerman's to sign. . Signed bills are transmitted usually in person to WCDSS where the originals are signed as received by social services and by the representative of Ackerman and Associates and we then obtain copies of the received forms. 10 We then track payment by social services by monitoring deposits, obtain verification of cases paid and record the payment against the account when received. We maintain separate levels of control between contact with patients, provision of services, and billing preparation and authorization to bill as an internal fiscal control procedure. Budget: Note that the data from budget calculation sheets used by the WCDSS produces a number higher as rate per hour than what we are requesting in our bid. We believe this results from a number of factors we would be happy to discuss if there are questions. Principle among these is difficulty in estimating overhead to be assigned in terms of secretarial and accounting services time and over how long a period the Ackerman and Associates data base should be ( we have 15 years experience in these bids) for use in these calculations as the rate of work from WCDSS is very variable from year to year. We have made our best estimates in the calculations. Specific issues are identified in footnotes on the budget pages at the front of the application. Also note that the bids are for fixed rates for home studies based on past application practices, not at an hourly rate. Please contact us if there is any issue in this regard. Court testimony was not specified in this bid but would be a separate fee of$130 per hour with a two hour minimum, Time in excess of two hours would be billed at 32.50 per 15 minute interval. 11 Data collection forms SAFE QUESTIONNAIRE I Instructions • Please answer the following questions as they apply to you. • Check all the choices that apply. Most of the questions have more than one answer. PRINT NAME: DATE: 1. Who primarily raised you? ❑Mother and Father 0 Stepmother 0 Older Sibling(s) ❑ Father 0 Stepfather 0 Adoptive Parent(s) ❑ Mother 0 Maternal Grandparent(s) 0 Foster Parent(s) ❑ Mother and Stepparent 0 Paternal Grandparent(s) 0 Institutional Caretaker(s) ❑ Father and Stepparent 0 Aunt(s) and/or Uncle(s) 0 Legal Guardian(s) 0 Other. 2. Were you separated from either or both of your parents during your childhood for any of the following reasons? ❑ No separations 0 Abandoned by parents(s) ❑Removed from your home by ❑ Parents separated ❑Parent(s)long-term hospitalization police or social services 0 Parents divorced 0 Parent(s) in military ❑ Other: ❑Death of parent(s) 0 Parent(s) in prison 3. How old were you when you moved away from your parent(s)or primary caretaker(s)home? ❑ years of age ❑ I currently live with my parent(s)or primary caretaker(s) 4. What were the circumstances that led you to leave home? 5. Among the children in your family,what is your position? ❑ Only child ❑ Number of children 6. Check the boxes that best characterize your childhood relationship with your mother. ❑ No relationship ❑ Friendly 0 Affectionate ❑Took care of mother 0 Abusive ❑Warm 0 Anxious ❑Afraid of mother ❑ Idolized ❑ Gentle 0 Consistent 0 Unpredictable 0 Neglectful 0 Smothering ❑Distant/Uninvolved 0 Full of conflict ❑ Caring 0 Demonstrative ❑ Superficial ❑ Relaxed ❑ Supportive ❑Over protective ❑ Strained 0 Loving ❑ Fun 0 Respectful 0 Close 0 Other: SAFE QUESTIONNAIRE I 7. Check the boxes that best characterize your childhood relationship with your father: O No relationship O Friendly ❑Affectionate ❑Took care of father ❑ Abusive O Warm O Anxious O Afraid of father ❑Idolized O Gentle ❑Consistent O Unpredictable ❑ Neglectful ❑Smothering O Distant/Uninvolved O Full of conflict ❑ Caring O Demonstrative ❑ Superficial ❑ Relaxed ❑Supportive O Over protective O Strained O Loving ❑ Fun ❑ Respectful O Close O Other. 8. If you were not primarily raised by your mother and/or father,which of the following best describes your relationship with your primary caretaker(s)? ❑ Non-Applicable O Friendly O Affectionate O Predictable ❑ Abusive ❑Warm ❑ Anxious O Educational ❑ Idolized O Gentle O Consistent O Unpredictable ❑ Neglectful O Smothering O Distant/Uninvolved O Full of conflict ❑ Caring ❑Crazy making ❑ Superficial ❑ Relaxed ❑ Supportive O Over protective O Strained ❑ Loving ❑ Fun O Respectful O Close ❑Other. 9. Check the boxes that best describe what your childhood experience was like: ❑Painful O Stable ❑Traumatic ❑Happy O Confusing O Spoiled ❑ Fun O Frightening O Enjoyable ❑ Wonderful ❑ Chaotic O Sad ❑ Exciting ❑ Lonely O Stimulating ❑ Unhappy O Secure O Difficult to remember ❑ Carefree O Sickly ❑Other 10. Check the boxes that best describe your parents'/primary caretakers'relationship with each other when you were a child: ❑ No relationship O Cold O Committed ❑ Divorced O Loving O Hostile ❑Separated O Violent O On again/off again ❑Close O Fulfilling O Supportive ❑Happy O Full of Conflict O Relaxed ❑ Fun and playful ❑Domineering/Submissive O Affected by alcohol/drug abuse ❑Distrustful and suspicious ❑Tense ❑Other , SAFE QUESTIONNAIRE I 11. How would you rate your parents'/primary caretakers'ability to manage their lives? Mother or Primary Caretaker Father or Primary Caretaker ❑ Very good ❑Very good ❑Good ❑ Good ❑ Fair ❑ Fair ❑Poor ❑Poor ❑ Unknown O Unknown 12. Check the boxes that best describe the personal characteristics of your mother or primary caretaker when you were a child: ❑ Not applicable ❑Active O Moody O Easy going ❑ Loving O Outgoing O Overly critical O Kind ❑Perfectionist O Generous ❑Hardworking O Self centered ❑ Domineering O Aggressive ❑ Flexible ❑ Unforgiving ❑ Isolated O Shy O Content O Stubborn ❑Happy O Irresponsible ❑Serious O Irrational ❑ Optimistic ❑Pessimistic/Worrier O Compassionate O Manipulative/Controlling ❑Calm ❑Temperamental O Friendly/Social O Passive ❑Violent O Understanding O Warm O Prejudiced ❑ Substance Abuser O Nervous/Anxious ❑ Supportive ❑ Emotional ❑ Preoccupied O Fun/Playful O Dramatic ❑ Reassuring ❑ Self-confident O Rigid O Irritable ❑ Other. 13. Check the boxes that best describe the personal characteristics of your father or other primary caretaker when you were a child: ❑ Not applicable O Active O Moody O Easy going ❑ Loving ❑Outgoing O Overly critical O Kind ❑ Perfectionist ❑Generous O Hardworking ❑Self centered ❑Domineering ❑Aggressive O Flexible O Unforgiving ❑ Isolated ❑ Shy ❑Content O Stubborn ❑Happy O Irresponsible O Serious O Irrational ❑Optimistic ❑ Pessimistic/Worrier O Compassionate O Manipulative/Controlling ❑Calm ❑Temperamental O Friendly/Social O Passive ❑Violent O Understanding O Warm O Prejudiced ❑ Substance abuser O Nervous/Anxious O Supportive O Emotional ❑ Preoccupied O Fun/Playful O Dramatic O Reassuring O Self-confident O Rigid O Irritable O Other: SAFE QUESTIONNAIRE I 14. Who primarily disciplined you during your childhood? ❑ Both parents equally O Maternal grandparent(s) ❑Mother ❑Paternal grandparent(s) ❑ Father ❑ Aunt and/or unde O Stepmother ❑ Foster parent(s) ❑ Stepfather ❑ Legal guardian(s) ❑ Older sibling(s) O Primary caretaker(s) O Other 15. Check the boxes that best describe the way your parent(s)/primary caretaker(s)disciplined you during your childhood: Mother or Primary Caretaker Father or Primary Caretaker ❑ Not applicable ❑Praised positive behaviors ❑Not applicable O Praised positive behaviors O Consistently O Shamed O Consistently O Shamed ❑ Fairly ❑ Grounded ❑ Fairly ❑ Grounded ❑ Strictly O Removed privileges ❑ Strictly O Removed privileges ❑ Leniently ❑ Logical consequences O Leniently ❑ Logical consequences ❑ Made idle threats ❑Withheld food ❑Made idle threats ❑Withheld food ❑ Lectured ❑ Sent me to my room ❑ Lectured ❑Sent me to my room ❑ Used time outs El Ignored misbehaviors ❑ Used time outs ❑ Ignored misbehaviors ❑ Reasoned with me ❑ Used phvsicil restraints ❑ Reasoned with me ❑ Used physical restraints (e.g.,tied to bed) (e.g.,Get to bed) ❑ Spanked O Spanked ❑Physically punished [Other: O Physically punished❑ Other. (other than spanking) (other than spanking) 16. Check the boxes that represent the personal values held by your parents/primary caretakers: Mother or Primary Caretaker Father or Primary Caretaker ❑ Not applicable O Honesty O Not applicable O Honesty ❑ Religious beliefs O Family closeness O Religious beliefs O Family closeness ❑ Compassion O Family support ❑ Compassion O Family support ❑ Social conscience ❑ Social status O Social conscience ❑ Social status ❑ Strong work ethic ❑ Education O Strong work ethic O Education O Being responsible ❑ Self Respect ❑ Being responsible ❑ Self Respect ❑ Freedom of expression ❑ Independence O Freedom of expression ❑Independence ❑ Leading a balanced life ❑ Making money O Leading a balanced life ❑ Making money ❑ Being a parent O Fidelity ❑ Being a parent ❑ Fidelity ❑ Patriotism ❑Healthy Life Style O Patriotism ❑ Healthy Life Style O Other. O Other: SAFE QUESTIONNAIRE I 17. How do your own personal values compare to those of your parents/primary caretakers? ❑ Basically share the same values ❑ Share most of their values O Share some of their values ❑ Do not share any of their values ❑ Don't know 18. Check the boxes that best describe your parents'/primary caretakers'attitudes about sexuality when you were a child Mother or Primary Caretaker Father or Primary Caretaker ❑ Unknown O Awkward discussing ❑ Unknown ❑ Awkward discussing ❑ Open about sexuality O Believed sex was sinful O Open about sexuality O Believed sex was sinful ❑ Comfortable discussing O Liberal sexual attitudes O Comfortable discussing O Liberal sexual attitudes ❑ Old fashioned O Conservative attitudes O Old fashioned O Conservative attitudes ❑ Never discussed sex O Sexually repressed ❑ Never discussed sex O Sexually repressed ❑ No sex before marriage O Sexually irresponsible O No sex before marriage O Sexually irresponsible ❑ Condemned homosexuality O Knowledgeable O Condemned homosexuality O Knowledgeable ❑ Supported sex education O Other: O Supported sex education O Other: 19. Check the boxes that best describe what you were like as a child(pre-teenage years): ❑Happy O Awkward O Responsible O Rebellious O Shy ❑Temperamental O Self-confident O Sad O Disobedient O Curious ❑ Stubborn O Friendly O Irresponsible O Outgoing O Compliant ❑ Unhappy ❑Calm O Anxious/Nervous O Sickly ❑Thoughtful ❑ Aggressive O Serious O Active ❑ Insecure ❑ Quiet ❑ Fearful ❑ Hyperactive O Funny O Obedient ❑ Other: 20. Check the boxes that best describe what you were like as a teenager. ❑Happy O Awkward O Responsible O Rebellious O Shy ❑ Temperamental ❑Self-confident O Sad O Disobedient O Curious ❑ Stubborn ❑ Friendly O Irresponsible ❑Outgoing ❑Compliant ❑ Unhappy O Calm O Anxious/Nervous O Sickly O Thoughtful ❑ Aggressive ❑ Serious ❑Active O Insecure ❑ Quiet ❑ Fearful O Hyperactive O Funny O Obedient O Other: SAFE QUESTIONNAIRE I 2L When you were a child,with whom would you confide? ❑ Mother El Aunt(s)/Uncle(s) ❑ Counselor(s)/Teacher(s) ❑ Father 0 Stepparent 0 Psychiatrist(s)/Psychologist(s)/Social Worker(s) ❑ Sibling(s) El Primary Caretaker(s) 0 Clergy 0 Grandparent(s) 0 Cousins(s) El Others: 22. When you were a child or adolescent, did you require counseling or psychiatric care? ❑ No ❑ Yes 23. Are there issues, traumatic incidents or accidents from your childhood that currently cause you distress? ❑ No 0 Yes 24. Check the boxes that best describe your early dating experiences: ❑Didn't date 0 Traumatic 0 Extensive 0 Frightening ❑ Fun ❑Too much too soon 0 Unusual ❑ Exciting 0 Unremarkable ❑Dull El Pressured ❑ Limited 0 Other. 25. Check the boxes that best describe your early sexual experiences: ❑ Limited 0 Unremarkable 0 Frightening El Pleasurable ❑Traumatic ❑ Unusual ❑ Confusing ❑ Abusive 0 Awkward ❑ Romantic El Shameful ❑Pressured ❑ Exciting ❑ Regretful ❑Amusing ❑ Other: 26. If you were married previously,how did your marriage(s)end? ❑ Not Applicable El Divorce ❑Death of spouse(s) El Annulment 27. If you were previously ins domestic partnership(s),how did your partnership(s)end? ❑ Not Applicable ❑Terminated partnership without legal agreement(s) El Terminated partnership with legal agreement(s) SAFE QUESTIONNAIRE I 28. If you went through a divorce or terminated a domestic partnership,check the boxes that best describe what the experience was like for you: ❑Not Applicable ❑Painful O Crazy O A relief ❑ Easy ❑ Unfair O Frustrating O Long and drawn out ❑ Expensive O Bitter O Fair O Depressing ❑ Frightening O Amicable O Devastating O Othher. 29. Have you ever been in a custody dispute? ❑ No ❑Yes 30. How long did you know your current spouse/partner before you were married or established a domestic partner relationship? ❑ Not Applicable O 1 to 2 years O 8 to 12 years ❑ Less than 6 months ❑ 3 to 4 years O 13 or more years ❑ Less than a year ❑ 5 to 7 years 31. Check the boxes that best describe the characteristics of your current spouse/partner. ❑Not Applicable ❑Playful ❑ Unhappy O Smart ❑ Religious O Distant O Argumentative O Social ❑ Uncaring O Thoughtful ❑ Competitive O Happy ❑Appreciative O Athletic O Sarcastic ❑ Unforgiving ❑Affectionate O Workaholic O Faultfinding O Understanding ❑ Compassionate O Prejudiced O Flexible O Honest ❑Dogmatic O Careful O Abusive O Romantic ❑ Introvert O Outgoing O Moody O Generous ❑ Emotional ❑ Quick tempered O stubborn ❑Dependable ❑ Friendly O Worrier O Depressed O Impulsive ❑ Rigid O Domineering ❑Tolerant D Good sense of humor ❑ Self-centered O Supportive O Communicative O Kind ❑ Gentle O Predictable ❑Clear thinking O Energetic ❑ Good listener O Considerate O Anxious O Other: SAFE QUESTIONNAIRE I 32. Check the boxes that best describe the various roles you and your spouse/partner play in the relationship: Roles you play in relationship Roles spouse/partner plays in relationship O Not Applicable O Wage earner O Not Applicable ❑Wage earner ❑Head of household O Decision maker O Head of household O Decision maker ❑ Leader ❑ Rational one ❑ Leader ❑ Rational one ❑ Emotional one O Organizer O Emotional one O Organizer ❑ Social planner O Compromiser O Social planner El Compromiser ❑ Initiator O Caregiver O Initiator O Caregiver ❑Peacemaker ❑ Follower ❑Peacemaker O Follower ❑Comforter O Negotiator O Comforter O Negotiator ❑Risk taker ❑Manager El Risk taker O Manager ❑ Money manager O Homemaker O Money manager ❑Homemaker ❑ Other: O Other. 3.3. How often do you and spouse/partner argue? O Not Applicable O Once or twice a year ❑Almost daily O Never O Once or twice a month O Once a day ❑ Rarely O Once or twice a week O Several times a day 34. Check the boxes that best describe the major areas of conflict between you and your spouse/partner? O Not Applicable ❑Personal habits ❑Sexual relations O Personal expectations ❑ Discipline of children O Household chores O Politics O Friends O Religion ❑Work O Values ❑ Leisure time ❑ Alcohol/Drugs O Infidelity O Separate activities O Shared activities ❑ Emotional closeness O Emotional separateness ❑Time apart O Time together O Family involvement O Money ❑Travel O Other 35. Check the boxes that best describe the way you typically react when you have a major disagreement with your spouse/partner: O Not Applicable O Agree to disagree El Reach agreement through mutual give and take O Sometimes yell and shout ❑Take time to think things over before discussing O Leave the house to cool off ❑ Give in and attempt to smooth things over ❑ Become silent ❑ Seek outside help such as a counselor/clergy person O Try to outwit spouse/partner ❑Sometimes pound or break things O Things get physical (pushing,shoving,hitting) O Change the topic ❑ Other. SAFE QUESTIONNAIRE I 36. How sexually compatible are you and your spouse/partner? O Not Applicable O Compatible O Not very compatible ❑ Very compatible O Somewhat compatible O Incompatible 37. Have you and your spouse/partner ever gone through a difficult period that threatened your relationship? ❑No O Yes O Not Applicable 38. Have you and your spouse/partner ever separated? O No O Yes ❑ Not Applicable 39. Check the boxes that best describe your current relationship with your mother and father. Relationship with Mother Relationship with Father ❑ Mother deceased O Dependent ❑ Father deceased ❑ Dependent 9 No contact ❑ Loving ❑ No contact ❑ Loving ❑ Strained El Very close O Strained ❑ Very close El Distant ❑ Comfortable O Distant O Comfortable ❑ Caring El Over involved El Caring O Over involved ❑ Emotionally intense O Not involved enough O Emotionally intense❑ Not involved enough ❑ flexible O On again,off again O flexible ❑On again,off again ❑ Hostile O Problematic ❑Hostile ❑Problematic ❑ Understanding O Enjoyable ❑ Understanding ❑ Enjoyable El Argumentative O Improving O Argumentative ❑ Improving ❑Manipulative O Gratifying ❑ Manipulative ❑ Gratifying ❑Positive O I am caretaker for El Positive ❑I am caretaker for O Supportive O Other: O Supportive El Other. 40. How helpful and supportive do you feel members of your extended family are/will be to you as a parent? Your side of die family Spouse/Partner's side of the family El All family members are helpful and supportive ❑ Not Applicable El Most family members are helpful and supportive El All family members are helpful and supportive ❑About half are helpful and supportive ❑ Most family members are helpful and supportive ❑ Few are helpful and supportive El About half are helpful and supportive 9 No family members are helpful and supportive El Few are helpful and supportive 9 No family members are helpful and supportive SAFE QUESTIONNAIRE I 41. In some families, different viewpoints concerning such things as life-styles, personal values, religion, socio/economic status, sexual orientation, politics, etc., interfere with family relationships. To what degree is that the case in your family? ❑ Issues such as these do not interfere with relationships within my family ❑ Issues such as these seldom interfere with relationships within my family El Occasionally issues such as these interfere with relationships within my family ❑ Frequently issues such as these interfere with relationships within my family 42. How comfortable are members of your extended family when it comes to being around and relating to children? Your side of the family Spouse/Partner's side of the family ❑ All family members are comfortable ❑ Not Applicable ❑ Most family members are comfortable O All family members are comfortable ❑ About half are comfortable ❑Most family members are comfortable ❑ Few are comfortable ❑About half are comfortable ❑ No family members are comfortable ❑ Few are comfortable ❑ No family members are comfortable 43. List your siblings according to how close or distant your relationship is with them: ❑ I don't have any brothers or sisters ❑ I am very dose to: ❑ I am somewhat close to: ❑ I am distant funk ❑ I am in conflict with: 44. How many members of your immediate and extended family are ready, willing and able to fully accept an unrelated child into the family? ❑ All family members are ready,willing and able to fully accept ❑Most family members are ready,willing and able to fully accept ❑ About half are ready,willing and able to fully accept ❑ Few are ready,willing and able to fully accept ❑ No fa'lily member is ready,willing and able to fully accept SAFE QUESTIONNAIRE I 45. How many people in your life,outside of your family,are ready,willing and able to provide you support as a parent? ❑There are numerous people who are ready,willing and able to be supportive ❑ There are several people who are ready,willing and able to be supportive El There are a few select people who are ready,willing and able to be supportive ❑ There is one person who is ready,willing and able to be supportive ❑There is nobody who is ready,willing and able to be supportive 46. How many people in your life cause you serious conflict and stress? ❑There are numerous people who cause me serious conflict and stress El There are several people who cause me serious conflict and stress El There are a few select people who cause me serious conflict and stress ❑ There is one person who causes me serious conflict and stress ❑There is nobody who causes me serious conflict and stress 47. Check the boxes that best describe your community involvement ❑Have no friends that I socialize with ❑ Active in politics ❑ Have a few friends that I socialize with ❑ Regular attendance at religious services ❑ Have many friends that I socialize with 0 Occasional attendance at religious services ❑ Regular involvement in social organizations 0 Rarely/Never attend religious services ❑ Occasional involvement in social organizations ❑Active in community organizations ❑ Rarely get involved in social organizations ❑ Occasional involvement in community organizations ❑ Other: 0 No involvement in community organizations 48. If you are employed outside of the home,how many hours per week do you work? ❑ Non-Applicable ❑ 20-30 hours ❑ 41- 50 hours ❑ Less than 20 hours ❑ 31 -40 hours El More than 50 hours 49. If you are employed outside of the home,how long have you worked at your current job? ❑ Non-Applicable ❑ years and months 50. Whether you work inside or outside the home,do you enjoy your work? ❑ No ❑ Most of the time ❑ Some of the time ❑ All of the time 51. Have you ever been fired? ❑No ❑Yes 52. Do you plan any career or job changes in the near future? 0No 0Yes SAFE QUESTIONNAIRE I 53. How do/will you discipline a child in your care? ❑ Spanking 0 Physical punishment other than spanking ❑ Lecturing 0 Use"time outs" ❑ Rational discussion ❑ Raise my voice ❑ Consistently use reasonable consequences ❑Have my spouse/partner handle the discipline ❑ Ignore the child's misbehavior ❑ Tell child they are grounded 0 Discipline according to how I feel at the lime ❑Tell child he/she should be ashamed ❑ Physical restraint,e.g.,strap down in crib 0 Threaten punishment in the future ❑ Make rules and consequences dear in advance 0 Tell child how angry he/she makes me 0 Take away privileges ❑ Send child to their room ❑ Other. 54. What is the overall condition of your health? 0 Excellent 0 Good 0 Fair 0 Poor 55. Have you ever been hospitalized or had surgery? ❑ No ❑Yes 56. Are you currently taking any medication(s)? ❑ No 0 Yes 57. Have you or any of the family members listed below had any of the following conditions? Indicate which family member by using the following code, place the appropriate number in front of the condition: 1= Self 2= Parent(s) 3 = Sibling(s) 4 = Children 5 = Spouse/Partner Diabetes Arthritis Seizures High blood pressure Cancer Frequent headaches Ulcers Colitis Asthma Hearing loss Impaired sight Allergies Kidney disease Insomnia Sickle cell anemia Heart condition High cholesterol Tuberculosis Thyroid condition Mental retardation Alcoholism Drug Addiction Eating Disorder Anxiety/Panic attacks Depression Bipolar Illness Schizophrenia Attention Deficit Disorder Infertility/Sterility Sexually transmitted disease Other condition(s) not listed: I affirm that the information given in this questionnaire is correct to the best of my ability. Signature Date To dick hi! hum up Iilc, plc..III':Lill kcc:and dm{,thislini SAFE QUESTIONNAIRE II Name Date 1. Have you or your spouse/partner ever experienced any of the following?(Cheek All that apply) SELF SPOUSE OR PARTNER N/A(No spouse/partner) ❑ Incarceration ❑ ❑ Military combat ❑ ❑ Bankruptcy ❑ ❑ Miscarriage 0 0 Infertility ❑ El Debilitating injury or illness 0 El Psychiatric hospitalization or outpatient treatment 0 0 Fired ftom a job 0 ❑ Death of a child or spouse/domestic partner El El Had a child adopted El ❑ Had a child abducted or kidnapped El ❑ Put under a court restraining order 0 El Domestic Violence 0 ❑ None of the above El ❑ 2. Have any of the issues listed below ever presented a problem for you or your spouse/partner? (Check all that apply) SELF SPOUSE OR PARTNER N/A(No spouse/partner) ❑ Gambling El ❑ Money management ❑ ❑ Food 0 ❑ Sex ❑ El Controlling temper ❑ ❑ Smoking ❑ 0 Work ❑ 0 Education ❑ ❑ Pornography 0 El None of the above 0 0 3. Who in your family has used illegal drugs or abused legal drugs?(a.ca,all that apply) ❑ Self ❑Mother ❑ Brother(s) ❑ Aunt(s) ❑ Cousin(s) O Spouse or Partner 0 Father 0 Sister(s) ❑ Uncle(s) ❑ In law(s) ❑ Son(s) ❑ Stepmother ❑ Grandmother El Nieces(s) ❑ No family member has ❑Daughter(s) ❑ Stepfather ❑ Grandfather ❑ Nephew(s) 0 Other(s): Stn¢mred Analmis Family Rvahutinn/SA FF.)—nnralionnnire IT Version-07111-2015- 1 SAFE QUESTIONNAIRE II 4. Who in your family has ever had a problem with alcohol abuse?(Check all that apply) ❑ Self ❑ Mother 0 Brother(s) 0 Aunt(s) ❑ Cousin(s) ❑Spouse or Partner 0 Father ❑ Sister(s) ❑ Uncle(s) 0 In law(s) ❑ Son(s) ❑ Stepmother 0 Grandmother 0 Nieces(s) ❑ No family member has ❑ Daughter(s) 0 Stepfather ❑ Grandfather 0 Nephew(s) ❑ Other(s): 5. What is the average frequency and amount of alcohol that you and your spouse/partner drink? SELF SPOUSE OR PARTNER N/A (No spouse/partner) ❑ • Daily,one or two drinks ❑ ❑ Daily,three or more drinks ❑ El Several times a week,one or two drinks 0 ❑ Several times a week,three or more drinks ❑ 0 Several times a month,one or two drinks ❑ 0 Several times a month,three or more drinks ❑ ❑ Several times a year,one or two drinks ❑ ❑ Several times a year,three or more drinks ❑ ❑ Never drink alcohol ❑ ❑ 6. Do you and/or your spouse/partner ever drink alcohol in the morning? 0 Yes,myself 0 Yes,my spouse or partner ❑ No 7. Was there ever a time when you and/or your spouse/partner were drinking too much alcohol? ❑Yes,myself ❑Yes,my spouse or partner ❑No 8. As a direct or indirect result of alcohol use, have you or your spouse/partner experienced any of the following?(Check all that apply) SELF SPOUSE OR PARTNER N/A (No spouse/partner) ❑ Legal difficulty ❑ ❑ Attt,sted or cited for driving under the influence ❑ 0 Absence from work ❑ ❑ Accidents ❑ ❑ Loss of a job 0 0 Health problems ❑ ❑ Violent behavior ❑ ❑ Arguments with family or friends 0 ❑ Inpatient and/or outpatient alcohol treatment program ❑ ❑ None of the above 0 ❑ Structured Analysis Family Evaluation(SAM—Ourstionnaim 11 Version—08-1$-2005- SAFE QUESTIONNAIRE II 9. Which of the following have you or your spouse/partner used? (Check all that apply) SELF SPOUSE OR PARTNER N/A(No spouse/partner) ❑ Barbiturates/Sleeping Pills O O Methamphetamines/Amphetamines/Speed ❑ ❑ Over the counter diet pills/other stimulants O O Hallucinogens/LSD/Psiloybin/Mescaline ❑ ❑ Inhalants/Glue/Solvents O ❑ Quaaludes O O Methadone O O Heroin/Morphine/Opium O ❑ Cocaine/Crack O ❑ Marijuana/Hashish O O Tranquilizers O ❑ Pain Pills ❑ O PCP ❑ ❑ Club Drugs/Ecstacy/GHB/Rohypnol/Ketamine ❑ ❑ None of the above O O 10. As a direct or indirect result of legal or illegal drug use,have you and/or your spouse/partner experienced any of the following?(Check all that apply) SELF SPOUSE OR PARTNER N/A(No spouse/partner) ❑ Legal difficulties ❑ O Absence from work O ❑ Accidents O O Loss of a job ❑ O Health problems ❑ ❑ Violence O ❑ Arguments with family or friends O O Arrested for driving under the influence of drugs O O Outpatient and/or inpatient drug treatment program O ❑ None of the above O O Smvmrenl Analysis Family Realization(SAM—Onestinnnaire II Version—08-18-2005- 2 SAFE QUESTIONNAIRE II 11. When you were a child or teenager,did any person (adult, teen or child)ever force, trick or coerce you into having any kind of sexual contact with them? O Yes O No ❑ I don't know if this ever happened to me 12. When you were a child or teenager,did any person (adult, teen or child)every hit,push,whip,bite, punch, slap or burn you in a way that resulted in injuries being left on your body? ❑ Yes ❑ No O I don't know if this ever happened to me 13. As an adult,have you ever been sexually abused,assaulted or molested? O Yes O No 14. As an adult,have you ever been physically abused,assaulted or battered? O Yes O No 15. Who in your family has been sexually abused,assaulted or molested as an adult,teenager or child? ((heck all that apply) ❑ I am not sure O Mother ❑Brother(s) ❑ Aunt(s) O Cousin(s) ❑ Spouse or Partner D Father O Sister(s) O Uncle(s) ❑ In law(s) ❑ Son(s) O Stepmother O Grandmother O Nieces(s) O No family member has ❑ Daughter(s) O Stepfather O Grandfather O Nephew(s) ❑ Other(s): 16. Who in your family has been emotionally abused and/or physically assaulted or battered as an adult, teenager or child? PK&as that apply) ❑ I am not sure O Mother O Brother(s) O Aunt(s) O Cousin(s) O Spouse or Partner O Father O Sister(s) ❑ Uncle(s) O In law(s) ❑ Son(s) ❑ Stepmother O Grandmother O Nieces(s) O No family member has ❑Daughter(s) O Stepfather O Grandfather O Nephew(s) ❑ Other(s): 17. Have you or anyone in your family ever been suspected of,investigated for,charged with,or convicted of physical,emotional or sexual child abuse?(cheek all that apply) ❑ Self O Mother O Brother(s) O Aunt(s) O Cousin(s) O Spouse or Partner O Father O Sister(s) O Uncle(s) O In law(s) O Son(s) O Stepmother O Grandmother O Nieces(s) ❑ No ❑ Daughter(s) O Stepfather ❑ Grandfather ❑ Nephew(s) ❑ Other(s): 18. Have you or anyone in your family ever been suspected of,investigated for,charged with,or convicted of activities involving child pornography?(mess as that apply) ❑ Self O Mother ❑ Brother(s) O Aunt(s) O Cousin(s) ❑ Spouse or Partner O Father O Sister(s) ❑ Uncle(s) O In law(s) ❑ Son(s) O Stepmother ❑ Grandmother O Nieces(s) O No ❑Daughter(s) O Stepfather ❑Grandfather O Nephew(s) O Other(s): Structured Analysis Family Evaluation!SAM—Oitestionnain,II Version—05-I8-21105- A SAFE QUESTIONNAIRE II 19. Have you or anyone in your family ever been suspected of,investigated for,charged with,or convicted of child neglect?(Cheek an that apply) ❑Self O Mother O Brother(s) ❑ Aunt(s) ❑ Cousin(s) O Spouse or Partner O Father O Sister(s) O Uncle(s) O In law(s) ❑Son(s) O Stepmother O Grandmother O Nieces(s) O No ❑Daughter(s) O Stepfather O Grandfather O Nephew(s) O Other(s): 20. Have you or anyone in your family ever been arrested for or convicted of a criminal offense? (Check an that apply) ❑ Self O Mother O Brother(s) ❑ Aunt(s) O Cousin(s) ❑ Spouse or Partner O Father ❑ Sister(s) O Uncle(s) O In law(s) ❑ Son(s) O Stepmother O Grandmother O Nieces(s) O No ❑ Daughter(s) O Stepfather ❑ Grandfather O Nephew(s) O Other(s): 21. Have you or anyone in your household ever been struck by anyone living in the home? ❑Yes O No 22. Has your spouse/partner ever hurt you physically by actions such as pushing,slapping,kicking, punching,biting,choking,throwing objects or cutting? ❑N/A ❑Never ❑ Once O Twice O Several Times O Frequently 23. Has your spouse/partner ever physically forced you to have sexual contact against your will? ❑ N/A O Never O Once ❑ Twice O Several Times O Frequently 24. As an adult,teenager or child,have you or your spouse/partner ever gone for counseling or psychotherapy? O Yes,self O Yes,spouse or partner O No 25. Do you or anyone in your family have a history of mental illness or suicidal behavior?(tom all that apply) ❑Self O Mother O Brother(s) ❑ Aunt(s) O Cousin(s) ❑Spouse or Partner O Father O Sister(s) O Uncle(s) O In law(s) ❑ Son(s) O Stepmother O Grandmother O Nieces(s) O No ❑Daughter(s) O Stepfather O Grandfather O Nephew(s) O Other(s): I affirm that the information given in this questionnaire is correct to the best of my ability. Signature Date To check for farm updates.press the ctrl key and click this lisle Structured Analysis Family Rvahution(SAFE' -Chuestinnnain-IT Version-OR-to-200S- 6 REFERENCE FORM To: Enter name and address Date: lle Enter name and address Enter name and address REFERENCE CONCERNING: (Applicant # 1) Me (Applicant#2) — My name is Dr Joyce Ackerman and I am a psychologist with Ackerman and Associates,P.C.. I am currently in the process of accomplishing a home study for the individuals named above who have applied to adoptive parents. Your name has been given to us as a reference. My task is to determine if families are ready,willing and able to become viable resources for children in need of adoptive placement. Parenting such children can be a very challenging as well as rewarding experience. In making these determinations, it is very helpful to have information from individuals who know the applicants well. We would appreciate it if you would answer the following questions and return the completed form to us by lea If you have questions about this request or prefer to speak with me directly, I can be reached at the phone number listed at the bottom of this form. 1. How long have you known the applicant(s) and in what capacity? 2. Of the following characteristics,which ones best describe the applicant(s)? (Check all that apply) ://7 ❑ Outgoing O Shy ❑ Outgoing ❑ Shy O Aggressive ❑ Active O Aggressive ❑ Active ❑ Honest ❑ Happy ❑ Honest ❑ Happy ❑ Friendly ❑ Emotional ❑ Friendly ❑ Emotional ❑ Responsible O Nervous ❑ Responsible O Nervous ❑ Serious ❑ Stubborn ❑ Serious O Stubborn ❑ Supportive ❑ Rigid ❑ Supportive ❑ Rigid ❑ Hardworking ❑ Calm ❑ Hardworking ❑ Calm ❑ Moody ❑ Involved ❑ Moody ❑ Involved ❑ Confident ❑ Flexible O Confident ❑ flexible ❑ Compassionate ❑ Fun ❑ Compassionate ❑ Fun ❑ Compulsive ❑ Assertive ❑ Compulsive ❑ Assertive ❑ Impulsive O Careful ❑ Impulsive ❑ Careful O Other. O Other. REFERENCE FORM 3. What kind of experience has each applicant had with children? 4. The applicant(s)is/are capable of providing love and security to a child. (Check one for each person) rte! ❑ Strongly agree ❑ Strongly agree ❑ Agree ❑ Agree ❑ Somewhat agree O Somewhat agree ❑ Disagree ❑ Disagree ❑ Strongly disagree O Strongly disagree 5. To your knowledge,has/have the applicant(s)engaged in activities,or do you believe the applicant(s) might engage in activities, that are incompatible with responsible parenting? ❑ Yes O No If Yes,please name: 6. Have any of the problem behaviors or conditions listed below been a problem for the applicant(s)? 'SINS ❑ Excessive use of alcohol ❑ Excessive use of alcohol ❑ Poor work history ❑ Poor work history ❑ Child abuse or neglect O Child abuse or neglect O Drug abuse O Drug abuse ❑ Violent behavior O Violent behavior ❑ Poor money management O Poor money management ❑ Compulsive gambling O Compulsive gambling ❑ Inappropriate sexual behavior ❑ Inappropriate sexual behavior ❑ Mental illness ❑ Mental illness ❑ Criminal activities ❑ Criminal activities ❑ Depression and/or Suicidal tendencies O Depression and/or Suicidal tendencies ❑ Pornography O Pornography ❑ Other. O Other. 7. If you checked any of the problem behaviors listed in question#6,please elaborate on the nature of the and how it was dealt with: s i 2 REFERENCE FORM 8. This is a compatible couple with a strong, loving and stable relationship. (Please check one) ❑ N/A ❑ Strongly agree ❑ Agree ❑ Somewhat agree ❑ Disagree ❑ Strongly disagree 9. Which of the following statements best describe the level of support the applicant(s) derive(s) from their friends,family, community and religious institutions? (Please check one) ❑ High level of support ❑ Moderate level of support ❑ Low level of support ❑ Virtually no support 10. Would you feel comfortable allowing the applicant(s) to care for your child permanently if you were unable to do so? ❑ Very comfortable 0 Comfortable 0 Uncomfortable 0 Very uncomfortable 11. Is there anything that we have not covered in this questionnaire that you believe would be important for us to know about the applicant(s)? ❑ Yes ❑ No If Yes,please explain: 12. It would be helpful to us to know whether you plan to discuss the contents of your reply with the applicant(s). ❑ I plan to discuss the content of my reply. ❑ I have discussed the content of my reply. ❑ I do not plan to discuss the content of my reply. 13. Please provide a phone number for us to contact you if we have any further questions. Day phone# Evening phone# Cell phone# Signature Date Thank you for your time in completing this questionnaire. Dr.Joyce Ackerman Telephone No. 970-353-3373 1750 25°Avenue Greeley,Colorado 80634 ,:I,h i. Afl ri<<- 3 1:. ,.I a ! 'nr•„ 3 Psychosochil Inventory Name(#1): Interview with: on on Name(#2): on--- 00--- Evaluator: on Evoked*b In the purposed: (Meek o0 that apply) ❑ Adoption Home Study j O Relative Placement O Foster Care Home Study ----.--- --_-.! O Reunification Services Plan O Consolidated Adoption/Foster Care Home Study ❑ Family Maintenance Services { ❑ Foster Care Licensure Renewal i O Other. • Consider and rate all the psychosocial factors on this Inventory after each face-to-face contact with the person(s)being evaluated. • Using the general definitions of the numbered ratings found below and the operational definitions provided in the Psychosocial Inventory Desk Guide,mark the number to the right of the factor being evaluated which best reflects your judgment • Use a different marking to make your ratings each time you complete this form. Computer markings can be color-coded. For handwritten '., markings,the following code is recommended: • 1°Interview-Use a line slanted right(/)to mark through the rating numbers chosen • 2nd Interview-Use a line slanted left(\)to mark through the rating numbers chosen. • 3"'Interview-Use a diagonal line(-)to mark through the rating numbers chosen. • 4m Interview-Circle the numbered ratings chosen. • 5th Interview-Use a filled in circle over the numbered ratings chosen • If a factor continues to receive the same numbered rating after each completion of the Inventory,the handwritten markings described above would be superimposed over each other on that number. Discretionary notes can be added at the end of the document to clarify or expand upon significant issues- • All factors rated as an issue of concern(rating of 3,4 or 5),at any point in time,will require full narration in the psychosocial evaluation report in order to provide the basis for the rating and describe how the issue was addressed. • All factors that received a final rating of I will require full narration in the psychosocial evaluation report in order to provide the basis for the rating and acknowledge the exceptional strength. • The Overall Evaluation of Section ratings determine the integrity of each section. The Overall Evaluation of Section ratings are not made until the final ratings we established during the final completion of the Inventory. • For the History Section only,the influence that any factor receiving a final rating of 3,4 or 5 will have on the Overall Evaluation of Section rating depends upon the effect childhood/adult historical issues of concern have on current functioning. • For the remaining Inventory sections,the influence that any factor receiving a final rating of 3,4 or 5 has on the Overall Evaluation of Section rating will depend upon the need and prognosis for positive change. DEFINITION OF NUMBERED RATINGS —— 1 EXCEPTIONAL STRENGTH Represents exceptional strengths that positively influence safe and/or healthy family functioning and parenting. 2 ,; STRENGTH Represents strengths that positively influence safe and/or healthy family functioning and parenting 3 ISSUE OF CONCERN Represents an issue that could or would impede safe and/or healthy family functioning and parenting. 4 MAJOR ISSUE OF CONCERN Represents a more serious issue that could or would impede safe and/or healthy family functioning and parenting. 5 ' VERY SERIOUS PROBLEM Represents an extremely problematic issue that could or would severely impede safe and/or healthy family functioning and parenting. Psychosocial Inventory-Page 2 FA. HISTORY Person# 1 Person#2 A-1. Childhood Family Adaptability 1 2 3 4 5 1 2 3 4 5 A-2. Childhood Family Cohesion 1 2 3 4 5 1 2 3 4 5 A-3. Childhood History of Deprivation/Trauma 1 2 3 4 5 1 2 3 4 5 A-4. Childhood History of Victimization 1 2 3 4 5 1 2 3 4 5 A-5. Adult History of Victimization/Trauma 1 2 3 4 5 1 2 3 4 5 A-6. History of Child Abuse/Neglect 1 2 3 4 5 1 2 3 4 5 A-7. History of Alcohol/Drug Use 1 2 3 4 5 1 2 3 4 5 A-8. History of Crime/Allegations/Violence 1 2 3 4 5 1 2 3 4 5 A-9. Psychiatric History 1 2 3 4 5 1 2 3 4 5 A-10. Occupational History 1 2 3 4 5 1 2 3 4 5 A-11. Marriage/Domestic Partner History 1 2 3 4 5 1 2 3 4 5 OVERALL EVALUATION OF SECTION: 1 2 3 4 5 1 2 3 4 5 B PERSONAL CHARACTERISTICS Person # 1 Person#2 8-1. Communication 1 2 3 4 5 1 2 3 4 5 B-2. Commitment/Responsibility 1 2 3 4 5 1 2 3 4 5 B-3. Problem Solving 1 2 3 4 5 1 2 3 4 5 B-4. Interpersonal Relations 1 2 3 4 5 1 2 3 4 5 B-5. Health/Physical Stamina 1 2 3 4 5 1 2 3 4 5 B-6. Self-esteem 1 2 3 4 5 1 2 3 4 5 B-7. Acceptance of Differences 1 2 3 4 5 1 2 3 4 5 B-8. Coping Skills 1 2 3 4 5 1 2 3 4 5 B-9. Impulse Control 1 2 3 4 5 1 2 3 4 5 B-10. Mood 1 2 3 4 5 1 2 3 4 5 B-11. Anger Management/Resolution 1 2 3 4 5 1 2 3 4 5 B-12. Judgment 1 2 3 4 5 1 2 3 4 5 B-13. Adaptability 1 2 3 4 5 1 2 3 4 5 OVERALL EVALUATION OF SECTION: 1 2 3 4 5 1 2 3 4 5 C. MARITAIJDOMESTIC PARTNER RELATIONSHIP C-1. Conflict Resolution 1 2 3 4 5 C-2. Emotional Support 1 2 3 4 5 C-3. Attitude Toward Spouse/Partner 1 2 3 4 5 C-4. Communication Between Couple 1 2 3 4 5 C-5 Balance of Power 1 2 3 4 5 C-6. Stability of the Marriage/Partnership 1 2 3 4 5 C-7. Sexual Compatibility 1 2 3 4 5 OVERALL EVALUATION OF SECTION: 1 2 3 4 5 Structured Analysis Family Evaluation(SAFE)Questionnaire I Copyright,2005,Consortium for Children,All Rights Reserved Psychosocial Inventory—Page Three D. SONS/DAUGHTERS/OTHERS RESIDING OR FREQUENTLY IN THE HOME .. D-1. Minor Sons/Daughters Name: 1 2 3 4 5 Name: 1 2 3 4 5 Name: 1 2 3 4 5 Name 1 2 3 4 5 Name: 1 2 3 4 5 Name: 1 2 3 4 5 D-2. Other Minors Residing or Frequently in the Home Name: 1 2 3 4 5 Name: 1 2 3 4 5 Name: 1 2 3 4 5 D-3. Adult Sons/Daughters Name: 1 2 3 4 5 Name: 1 2 3 4 5 Name: 1 2 3 4 5 D-4. Adults Residing or Frequently in the Home Name: 1 2 3 4 5 Name: 1 2 3 4 5 Name: 1 2 3 4 5 OVERALL EVALUATION OF SECTION: 1 2 3 4 5 E EXTENDED FAMILY RELATIONSHIPS Person#1 Person#2 E-1. Extended Family Cohesion 1 2 3 4 5 1 2 3 4 5 E-2. Extended Family Adaptability 1 2 3 4 5 1 2 3 4 5 E-3. Relationship with own Extended Family 1 2 3 4 5 1 2 3 4 5 E-4. Relationship with Spouse's/Partner's Family 1 2 3 4 5 1 2 3 4 5 OVERALL EVALUATION OF SECTION: 1 2 3 4 5 1 2 3 4 5 F. PHYSICAL/SOCIAL ENVIRONMENT F-1 Cleanliness/Orderliness/Maintenance 1 2 3 4 5 F-2. Safety 1 2 3 4 5 F-3. Furnishings 1 2 3 4 5 F-4. Play Area/Equipment/Clothing 1 2 3 4 5 F-5 Finances 1 2 3 4 5 F-6. Support System 1 2 3 4 5 F-7. Household Pets 1 2 3 4 5 OVERALL EVALUATION OF SECTION: 1 2 3 4 5 Structured Analysis Family Evaluation(SAFE)Questionnaire I Copyright,2005,Consortium for Children,All Rights Reserved Psychosocial Inventory—Page Four G.GENERAL PARENtING Person#1 Person#2 G-1. Child Development 1 2 3 4 5 1 2 3 4 5 G2. Parenting Style 1 2 3 4 5 1 2 3 4 5 G-3. Disciplinary Methods 1 2 3 4 5 1 2 3 4 5 G4. Child Supervision 1 2 3 4 5 1 2 3 4 5 G-5. Learning Experiences 1 2 3 4 5 1 2 3 4 5 G6. Parental Role 1 2 3 4 5 1 2 3 4 5 G7. Child Interactions 1 2 3 4 5 1 2 3 4 5 G8. Communication with Child 1 2 3 4 5 1 2 3 4 5 G9. Basic Care 1 2 3 4 5 1 2 3 4 5 G-10. Child's Play 1 2 3 4 5 1 2 3 4 5 OVERALL EVALUATION OF SECTION: 1 2 3 4 5 1 2 3 4 5 H. SPECIALIZED PAIRENTDIG Person# 1 Person #2 H-1. Expectations 1 2 3 4 5 1 2 3 4 5 Effects of Abuse/Neglect 1 2 3 4 5 1 2 3 4 5 H-3. Effects of Sexual Abuse 1 2 3 4 5 1 2 3 4 5 H-4. Effects of Separation/Loss 1 2 3 4 5 1 2 3 4 5 H-5. Structure 1 2 3 4 5 12 3 4 5 H-6. Therapeutic/Educational Resources 1 2 3 4 5 1 2 3 4 5 Birth Sibling Relationships 1 2 3 4 5 1 2 3 4 5 H-8. Child Background Information 1 2 3 4 5 1 2 3 4 5 H-9. Birth Parent Issues 1 2 3 4 5 1 2 3 4 5 OVERALL EVALUATION OF SECTION: 1 2 3 4 5 1 2 3 4 5 ' L ADOPTION ISSUES Person# 1 Person#2 I1. Infertility 1 2 3 4 5 1 2 3 4 5 I-2. Telling Child About Adoption 1 2 3 4 5 1 2 3 4 5 I-3. Openness in Adoption 1 2 3 4 5 1 2 3 4 5 I-4. Adoptive Parent Status 1 2 3 4 5 1 2 3 4 5 OVERALL EVALUATION OF SECTION: 1 2 3 4 5 1 2 3 4 5 Structured Analysis Family Evaluation(SAFE)Questionnaire I Copyright,2005,Consortium for Children,All Rights Reserved Psychosocial Inventory—Page 5 Notes: History: Personal Characteristics: Martial/Domestic Partner Relationship: Sons/Daughters/Others Residing or Frequently In The Home: Extended Family Relationships: Physical/Social Environment: General Parenting: Specialized Parenting: Adoption Issues: 1n check Ibr loan a pd:ar.. r<s.th< trI Lcv and click Ihi,Lnl. Structured Analysis Family Evaluation(SAFE)Questionnaire I Copyright,2005,Consortium for Children,All Rights Reserved MATCHING INVENTORY Name of Child: Prospective Parent(# 1): DOB:___ Prospective Parent(#2): Child's Social Worker: Home Study Social Worker: Social Worker Phone#: ( ) Social Worker Phone#: ( ) Social Worker Email: Social Worker Email: INSTRUCTIONS FOR CHILD WORKER • Rate each child need or issue that applies in accordance to the definitions below by inserting the appropriate number in the box to the left of the selected child need or issue. • Include narration at the end of each section to clarify or expand upon all selected factors. DEFINITION OF NUMBERED RATINGS FOR CHILD NEEDS/ISSUES 1 CRITICAL CHILD NEED OR EXTREMELY CHALLENGING CHILD ISSUE: Use this rating for a critical child need that absolutely must be met or an extremely challenging child characteristic or behavior. 2 SIGNIFICANT CHILD NEED OR CHALLENGING CHILD ISSUE: Use this rating for a significant child need that should be met or a challenging child characteristic or behavior. 3 DESIRABLE PLACEMENT CONSIDERATION OR CHILD ISSUE OF MODERATE SEVERITY: Use this rating for a child issue that is desirable but not nerescary or a child characteristic or behavior that is of moderate severity and relatively easy to manage. 4 HIGHLY PROBABLE FUTURE NEED OR CHALLENGING ISSUE: Use this rating for a child need or challenging child characteristic or behavior that in all likelihood will have to be dealt with in the future. INSTRUCTIONS FOR HOME STUDY SOCIAL WORKER • Rate each prospective parent's level of competency to address the child issues checked on this Inventory. • If necessary, use the space provided on page#6 to provide the basis for your ratings. DEFINITION OF NUMBERED RATINGS FOR PROSPECTIVE PARENT(S) 1 VERY COMPETENT: The prospective parent is ready, willing and have an exceptional ability to meet this child need or manage this child characteristic or behavior. 2 COMPETENT: The prospective parent is ready, willing and able to meet this child need or manage this child characteristic or behavior. 3 PROVISIONAL COMPETENCE: The prospective parent is ready, willing and able to meet this child need or manage this child characteristic or behavior provided needed support and guidance is available. 4 INCOMPETENT: At this point in time, the prospective parent is not ready, willing and/or able to meet this child need or manage this child characteristic or behavior. More preparation and education is needed. 5 UNABLE/UNWILLING: The prospective parent is not able and/or willing to meet this child need or parent a child with this behavior or characteristic. 1 Child SPECIAL NEEDS OR CONSIDERATIONS Prospective P.#1 Prospective P.#2 Maintain connections with birth family, e.g. mother, siblings, 1 2 3 4 5 1 2 3 4 5 etc. Maintain connections with significant non-family individual(s) 1 2 3 4 5 1 2 3 4 5 Placement with sibling(s) 1 2 3 4 5 1 2 3 4 5 Placement in current community 1 2 3 4 5 1 2 3 4 5 Placement inproximity to specific needed resource(s) 1 2 3 4 5 1 2 3 4 5 Placement where there is a stay-at-home parent 1 2 3 4 5 1 2 3 4 5 Placement with a single parent 1 2 3 4 5 1 2 3 4 5 Placement in a two parent home 1 2 3 4 5 1 2 3 4 5 Special accommodations for a physical disability 1 2 3 4 5 1 2 3 4 5 Counseling/Therapy/Special medical attention 1 2 3 4 5 1 2 3 4 5 Acceptance of behaviors associated with gender confusion 1 2 3 4 5 1 2 3 4 5 Acceptance of homosexuality 1 2 3 4 5 1 2 3 4 5 Retain ties with his/her culture and/or religion 1 2 3 4 5 1 2 3 4 5 Specific requirement(s) regarding other children in the home 1 2 3 4 5 1 2 3 4 5 Special diet 1 2 3 4 5 1 2 3 4 5 Special sleeping accommodations 1 2 3 4 5 1 2 3 4 5 Specialized school 1 2 3 4 5 1 2 3 4 5 Parent(s)who can cultivate a special child interest or talent 1 2 3 4 5 1 2 3 4 5 Child falls under the Indian Child Welfare Act 1 2 3 4 5 1 2 3 4 5 Parent(s)who speak the child's language 1 2 3 4 5 1 2 3 4 5 Other needs: or considerations: 1 2 3 4 5 1 2 3 4 5 SECTION SUMMARY: (Describe each child need or consideration checked) Child CHILD TEMPERAMENT CHARACTERISTICS Prospective P.#1 Prospective P.#2 Atypical reaction to newness 1 2 3 4 5 1 2 3 4 5 Unusual hunger/eating patterns 1 2 3 4 5 1 2 3 4 5 Unusual sleep patterns 1 2 3 4 5 1 2 3 4 5 Extreme persistence 1 2 3 4 5 1 2 3 4 5 Not easily distracted 1 2 3 4 5 1 2 3 4 5 Irritable 1 2 3 4 5 1 2 3 4 5 Moody 1 2 3 4 5 1 2 3 4 5 Uncooperative 1 2 3 4 5 1 2 3 4 5 Inflexible 1 2 3 4 5 1 2 3 4 5 Extreme high or low activity level 1 2 3 4 5 1 2 3 4 5 High impulsivity 1 2 3 4 5 1 2 3 4 5 Extreme introvert or extrovert 1 2 3 4 5 1 2 3 4 5 Other characteristics: 1 2 3 4 5 1 2 3 4 5 SECTION SUMMARY: (Describe each child issue checked) Child CHALLENGING CHILD BEHAVIORS Prospective P. #1 Prospective P.#2 Frequent temper tantrums 1 2 3 4 5 1 2 3 4 5 Overly aggressive behavior 1 2 3 4 5 1 2 3 4 5 Vandalizing or destroying property 1 2 3 4 5 1 2 3 4 5 Talks back 1 2 3 4 5 1 2 3 4 5 Uses profanity 1 2 3 4 5 1 2 3 4 5 Untruthfulness 1 2 3 4 5 1 2 3 4 5 Cruel treatment of animals 1 2 3 4 5 1 2 3 4 5 Disobedience 1 2 3 4 5 1 2 3 4 5 Smokes 1 2 3 4 5 1 2 3 4 5 Drugs 1 2 3 4 5 1 2 3 4 5 Fire setting 1 2 3 4 5 1 2 3 4 5 Stealing 1 2 3 4 5 1 2 3 4 5 Highly argumentative 1 2 3 4 5 1 2 3 4 5 Intrusive 1 2 3 4 5 1 2 3 4 5 Disrespectful 1 2 3 4 5 1 2 3 4 5 Manipulative 1 2 3 4 5 1 2 3 4 5 Abuses animals 1 2 3 4 5 1 2 3 4 5 Other behaviors: 1 2 3 4 5 1 2 3 4 5 SECTION SUMMARY: (Describe each child issue checked) Child ATTACHMENT ISSUES Prospective P. #1 Prospective P.#2 Highly ambivalent attachment to birthmother/birthfather 1 2 3 4 5 1 2 3 4 5 Indiscriminate affection with relatively unfamiliar adults 1 2 3 4 5 1 2 3 4 5 Lack of comfort seeking when frightened, hurt of ill 1 2 3 4 5 . 1 2 3 4 5 Excessive dependence on attachment figure 1 2 3 4 5 1 2 3 4 5 Unable to seek or use supportive presence of attachment 1 2 3 4 5 1 2 3 4 5 figure Compulsive compliance with caregiver requests 1 2 3 4 5 1 2 3 4 5 Lack of compliance with caregiver request 1 2 3 4 5 1 2 3 4 5 Failure to check back with caretaker in unfamiliar settings 1 2 3 4 5 1 2 3 4 5 Lack of warm and affectionate interchanges 1 2 3 4 5 1 2 3 4 5 Over solicitous and inappropriate care giving behavior 1 2 3 4 5 1 2 3 4 5 Excessively bossy and controlling 1 2 3 4 5 1 2 3 4 5 Intense anger 1 2 3 4 5 1 2 3 4 5 Other attachment issues: 1 2 3 4 5 1 2 3 4 5 3 SECTION SUMMARY: (Describe each child issue checked) Child STRESS RELATED BEHAVIOR Prospective P.#1 Prospective P.#2 Hoards food 1 1 3 4 5 1 2 3 4 5 Fearful 1 2 3 4 5 1 1 3 4 5 Eating Disorder, e.g. Anorexia/Bulimia 1 2 3 4 5 1 2 3 4 5 Stool smearing 1 2 3 4 5 1 2 3 4 5 Frequent nightmares 1 2 3 4 5 1 2 3 4 5 Sleepwalking 1 2 3 4 5 1 2 3 4 5 Excessive or too little sleep 1 2 3 4 5 1 2 3 4 5 Head banging 1 2 3 4 5 1 2 3 4 5 Daytime or nighttime wetting(ages 5-18) 1 2 3 4 5 1 2 3 4 5 Daytime or nighttime soiling(ages 5-18) 1 2 3 4 5 1 2 3 4 5 Depressed 1 2 3 4 5 1 2 3 4 5 Hyperactivity 1 2 3 4 5 1 2 3 4 5 Other: 1 2 3 4 5 1 2 3 4 5 SECTION SUMMARY (Describe each child issue checked) Child MEDICAL/EMOTIONAL CONDITIONS Prospective P. #1 Prospective P. #2 Allergies/asthma/nebulizer 1 2 3 4 5 1 2 3 4 5 Diabetes 1 2 3 4 5 1 2 3 4 5 Hearing impaired and/or requires signing 1 2 3 4 5 1 2 3 4 5 Visually impaired and/or needs Braille 1 2 3 4 5 1 2 3 4 5 Feeding tubes 1 2 3 4 5 1 2 3 4 5 Limited life span 1 2 3 4 5 1 2 3 4 5 Needs leg braces, prosthesis, wheelchair 1 2 3 4 5 1 2 3 4 5 Para or Quadriplegic 1 2 3 4 5 1 2 3 4 5 Seizure disorder 1 2 3 4 5 1 2 3 4 5 FAS or FAE 1 2 3 4 5 1 2 3 4 5 Attention Deficit Disorder 1 2 3 4 5 1 2 3 4 5 Effects of pre-natal drug exposure 1 2 3 4 5 1 2 3 4 5 Developmental disability 1 2 3 4 5 1 2 3 4 5 Mental retardation 1 2 3 4 5 1 2 3 4 5 Medically Fragile Infant 1 2 3 4 5 1 2 3 4 5 Other: 1 2 3 4 5 1 2 3 4 5 4 SECTION SUMMARY: (Describe each child issue checked) Child LEARNING/SCHOOL ISSUES Prospective P.#1 Prospective P. #2 Disruptive in class 1 2 3 4 5 1 2 3 4 5 Disrespectful to teachers 1 1 3 4 5 1 2 3 4 5 Low motivation for learning and school 1 2 3 4 5 1 2 3 4 5 Learning disability 1 1 3 4 5 1 2 3 4 5 Gifted 1 2 3 4 5 1 2 3 4 5 Requires special education program 1 2 3 4 5 1 2 3 4 5 Truancy 1 2 3 4 5 1 2 3 4 5 School Phobia 1 2 3 4 5 1 2 3 4 5 Other school issues: 1 2 3 4 5 1 2 3 4 5 SECTION SUMMARY.• (Describe each child issue checked) Child CHILD SEXUAL BEHAVIORS Prospective P. #1 Prospective P. #2 Compulsive or public masturbation 1 2 3 4 5 1 2 3 4 5 Sexually seductive 1 2 3 4 5 1 2 3 4 5 Sexual victimization of other children 1 2 3 4 5 1 2 3 4 5 Sexually precocious 1 2 3 4 5 1 2 3 4 5 Explicit sexual language 1 2 3 4 5 1 2 3 4 5 Early sexual experimentation 1 2 3 4 5 1 2 3 4 5 Unusual knowledge of or interest in sex 1 2 3 4 5 1 2 3 4 5 Other sexual behaviors: 1 2 3 4 5 1 2 3 4 5 SECTION SUMMARY: (Describe each child issue checked) Child OTHER CONSIDERATIONS Prospective P.#1 Prospective P.#2 Nothing known about mother and/or father 1 2 3 4 5 1 2 3 4 5 Nothing known about siblings 1 2 3 4 5 1 2 3 4 5 Conceived through incest 1 2 3 4 5 1 2 3 4 5 Conceived through rape 1 2 3 4 5 1 2 3 4 5 Genetic predisposition for psychiatric disorder: 1 2 3 4 5 1 2 3 4 5 Genetic predisposition for medical disorder: 1 2 3 4 5 1 2 3 4 5 5 ( Other: I 1 2 3 4 5 I 1 2 3 4 5 SECTION SUMMARY: (Describe each child issue checked) FAMILY SOCIAL WORKER'S OPTIONAL RATING COMMENTS CHILD NEEDS DIFFICULT CHILD TEMPERAMENT CHARACTERISTICS CHIT D BEHAVIORS ATTACHMENT ISSUES STRESS RELATED BEHAVIORS MEDICAL/EMOTIONAL CONDITION LEARNING/SCHOOL ISSUES 6 CHILD SEXUAL BEHAVIORS O IHkR CONSIDERATIONS 11 heel. I i tom ujd.nc,_pic th,_nI Lc and tli,k n link 7 SAFE Multi Purpose Home Study Report This home study was completed 1w Name of Public/Private Agency solely for use in foster care placement end/or adoption by and for United States licensed/authorized agencies unless otherwise specified. Name of Family: Address: City: _ State: Postal Code: 00000-000(1 Home Phone: "Cell Phone: APPLICATION DISPOSITION Select One on: Home Study Application received on: The Applicants have applied to accept placement of a child between the ages of The Applicants Select One open to placement of a sibling group. The Applicants are primarily interested in becoming Select One. APPLICANT INFORMATION Applicant's Full Name Applicant's Full Name Date of Birth: ; ; Date of Birth: Birthplace: i Birthplace: Gender: { Gender: i Religion- - Occupation_ I Occupation: i j.anguage(s): Lansuage(s): Education: Education: L IL Height: Height: q Weight: Weight: Hair. Hair: Eyes: — ----- Ev es: Date of health questionnaire/report: ! I Date of health questionnaire/report: ] i MARITAL INFORMATION Date of Marriage: Marriage Verification:On File Place of Marriage: DATES OF CONTACT Date Individual/Couple Location Structured Analysis Family Evaluation(SAFE)*Colorado Couple Multipurpose Home Study Report -Version 05-06-2006 Copyright,2005,Consortium for Children,All Rights Reserved MOTIVATION Indicate both Applicants'stated reasons for wanting to become a foster parent, an adoptive parent, a foster adoptive parent or resource family. HOME ENVIRONMENT Type of residence House,Apt, Condo, Etc Square Footage Bedrooms: Bathrooms Length of Time in current residence: Describe general characteristics of the Applicants'home and neighborhood. Indicate the type of residence(house, apartment, condo,etc.)and square footage. Describe the floor plan including the number of bedrooms and bathrooms. Describe the yard space and indicate if there is a pool,pond/fountain,etc. Describe the sleeping arrangements and also indicate whether or not there are guns or pets in the home. The interior and exterior of the home was inspected for health and safety hazards. The inspection was completed on FAMILY Applicant#1: Applicant's Full Name Describe how the applicant presents him/her self. Also indicate any special interests,hobbies, expertise or talents the applicant possesses. Identify parents, siblings,their location and circumstances plus type and frequency of contact. Indicate name(s)and length of time of previous marriages and/or domestic partnerships. Include how relationships were terminated,e.g.,death,divorce,annulment,breakup. Identify any children born of these unions and describe their current situation. Applicant#2: Applicant's Full Name Describe how the applicant presents him/her self. Also indicate any special interests,hobbies, expertise or talents the applicant possesses. Identify parents, siblings,their location and circumstances plus type and frequency of contact. Indicate name(s)and length of time of previous marriages and/or domestic partnerships. Include how relationships were terminated,e.g.,death,divorce,annulment,breakup. Identify any children born of these unions and describe their current situation. Applicants' Sons and Daughters Indicate"None"or provide name(s), DOB and gender. Describe their personality, interests, school or occupational situation, general health and living situation. Other children living or frequently in the home Indicate"None"or provide name(s), DOB,gender. Provide description of their personality, interests, school report information if any,general health. Indicate nature of relationship to Applicants,and living situation. Other adults residing or frequently in the home Indicate name of any adult who is living in the home or who is in the home on a regular basis. Describe the amount and type of contact they would have with a child. Indicate each individual's occupation,general health and the nature of their relationship to the Applicant. Structured Analysis Family Evaluation(SAFE)C Colorado Couple Multipurpose Home Study Report -Version 05.06-2006 Copyright,2005,Consortium for Children,Al Rights Reserved Family Lifestyle Describe current and proposed child care arrangements and work and non-work day routines and rituals. What are the basic household rules and expectations? Who does what in terms of chores,cooking,bill paying, home maintenance,transportation, etc.?Describe how the family deals with privacy and nudity in the home. What kind of recreational, social and religious activities does the family engage in? Does the family celebrate holidays;which ones and how are they spent? Previous adoptions or foster care experience Indicate"None"or discuss the circumstances and the adjustment of the child or children to the family. FINANCES Combined annual gross earned income: $ Sources of additional income: Explain, if any CRIMINAL/CHILD ABUSE RECORD The required criminal record and Child Abuse Index checks were completed for Applicant's Full Name and Applicant's Full Name. Indicate the name(s)of any other individuals who were screened. State automated system,CBI,ICON/Co Courts,and FBI(if applicable)Clearance Findings: Indicate the findings for each individual screened. Other findings: Indicate who was screened for each of the following and the findings for each person: DMV (optional), local law enforcement(optional)and CPS service records. EMERGENCY CARE PLAN In case of an incapacitating illness or death of the Applicants,indicate whom the designated caretaker(s)will be and the nature of their relationship to the Applicants. Indicate if these arrangements have been discussed with the designated caretaker(s),how willing they are to assume this responsibility and whether arrangements have been formalized in a will or trust. CONTACT WITH FAMILY OF ORIGIN AND SIGNIFICANT OTHERS Describe the type of relationship and contact the Applicants are willing to have with the birth parents and other significant connections such as siblings,grandparents, foster parents,etc. Describe any written post-adoption contact agreement(s). REFERENCES References received: Select One FAMILY TRAINING Identify and describe agency family training. Include Applicants'statements regarding their participation and benefits derived from these activities. LEGAL/FINANCIAL RIGHTS AND RESPONSIBILITIES Applicant's Full Name and Applicant's Full Name have been provided with information concerning the different roles, responsibilities, legal and financial rights and benefits of relative/child specific kin caregivers,foster parents, legal guardians and adoptive parents. Also, should they file a petition to adopt,Applicant's Full Name and Applicant's Full Name understand that they will be accepting full legal and financial parental responsibility once an adoption is finalized. The agency's grievance procedures Select One explained to the Applicants. Structured Analysis Family Evaluation(SAFE)O Colorado Couple Multipurpose Home Study Report -Version 05-08.2006 Copyright,2005,Consortium for Chidren,Al Rights Reserved It is recommended that Applicant's Full Name be Select One as an Select One for the placement of Names) of Child(ren)/Youth(s). Caseworker Supervisor Title Title Date: Date: Additional Attachments Indicate"None"or list additional attachments. REVIEW-OF COPY OF HOME STUDY REPORT By signing below I acknowledge that I read a copy of this report. Applicant's Full Name Date: h••I:I,•I I .11)1 q•Ld •.I•m..'Ii.•:ul kt v Alp 'I:El".Iwl. Structured Analysis Family Evaluation(SAFE)Colorado Single Child Specific Home Study Report-Version 05-1 5-2006 Copyright,2005,Consortium for Children,All Rights Reserved PSYCHOSOCIAL INVENTORY RESULTS NOTE: Below is a list of the psychosocial factors found on the SAFE Psychosocial Inventory. Using the Psychosocial Inventory,each factor was considered and rated several times by the social worker during the course of this home study. The ratings below represent the final ratings.The ratings are defined as follows: 1 =an exceptional strength, 2=a strength, 3=an issue of concern,4=a major issue of concern and 5=very serious problem. The OVERALL EVALUATION OF SECTION ratings reflect the degree to which all issues of concern identified in the section were either resolved, mitigated or the prognosis for change. #1 #2 HISTORY #1 #2 EXTENDED FAMILY RELATIONSHIPS 2 2 Childhood Family Adaptability 2 2 Extended Family Cohesion 2 2 Childhood Family Cohesion 2 2 Extended Family Adaptability 2 2 Childhood History of Deprivation/Trauma 2 2 Relationship with own Extended Family 2 2 Childhood History of Victimization 2 2 Relationship with Spouse's/Partner's Family 2 2 Adult History of Victimization/Trauma 2 2 OVERALL EVALUATION OF SECTION 2 2 History of Child Abuse/Neglect 2 2 History of AlcoholDrug Use PHYSICAL/SOCIAL ENVIRONMENT 2 2 History of Crime/Auest/AllegationsNiolence 2 Cleanliness/Orderliness/Maintenance 2 2 Psychiatric History 2 Safety 2 2 Occupational History 2 Furnishings 2 2 Marriage/Domestic Partner History 2 Play Area/Equipment/Clothing 2 2 OVERALL EVALUATION OF SECTION 2 Finances 2 Support System #1 #2 PERSONAL CHARACTERISTICS 2 Household Pets 2 2 Communication 2 OVERALL EVALUATION OF SECTION 2 2 Commitment and Responsibility 2 2 Problem Solving #1 #2 GENERAL PARENTING 2 2 Interpersonal Relations 2 2 Child Development 2 2 Health and Physical Stamina 2 2 Parenting Style 2 2 Self-esteem 2 2 Disciplinary Methods 2 2 Acceptance of Differences 2 2 Child Supervision 2 2 Coping Skills 2 2 Learning Experiences 2 2 Impulse Control 2 2 Parental Role 2 2 Mood 2 2 Child Interactions 2 2 Anger Management and Resolution 2 2 Communication with Child 2 2 Judgment 2 2 Basic Care 2 2 Adaptability 2 2 Child's Play 2 2 OVERALL EVALUATION OF SECTION 2 2 OVERALL EVALUATION OF SECTION MARITAL/DOMESTIC PARTNER #1 #2 SPECIALIZED PARENTING RELATIONSHIP 2 2 Expectations 2 Conflict Resolution 2 2 Effects of Abuse/Neglect 2 Emotional Support 2 2 Effects of Sexual Abuse 2 Attitude toward Spouse/Partner 2 2 Effects of Separation and Loss 2 Communication between Couple 2 2 Structure 2 Balance of Power 2 2 Therapeutic/Educational Resources 2 Stability of the Marriage or Partnership 2 2 Birth Sibling Relationships 2 Sexual Compatibility 2 2 Child Background Information 2 OVERALL EVALUATION OF SECTION 2 2 Birth Parent Issues 2 2 OVERALL EVALUATION OF SECTION SONS/DAUGHTERS/OTHERS RESIDING OR FREQUENTLY IN HOME #1 #2 ADOPTION ISSUES 2 Minor Sons and Daughters 2 2 Infertility 2 Minors Residing or Frequently in the Home 2 2 Telling Child about Adoption 2 Adult Sons and Daughters 2 2 Openness in Adoption 2 Adults Residing or Frequently in the Home 2 2 Adoptive Parent Status 2 OVERALL EVALUATION OF SECTION 2 2 OVERALL EVALUATION OF SECTION Structured Analysis Family Evaluation(SAFE)O Colorado Couple Multipurpose Home Study Report -Version 05-06-2006 Copyright,2005,Consortium for ChNdren,AN Rights Reserved PSYCHOSOCIAL EVALUATION REPORT HISTORY Describe the basis for ratings of 1 (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3, 4&5 (concerns)to include how the concern was addressed, severity, mitigating factors and degree of resolution. PERSONAL CHARACTERISTICS Describe the basis for ratings of 1 (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3, 4&5 (concerns)to include how the concern was addressed,severity, mitigating factors and the prognosis for change. MARITAL/DOMESTIC PARTNER RELATIONSHIP Describe the basis for ratings of 1 (exceptional strengths). Briefly summarize ratings of 2(strengths). Fully narrate ratings of 3,4&5 (concerns)to include how the concern was addressed, severity, mitigating factors and the prognosis for change. SONS/DAUGHTERS/OTHERS RESIDING OR FREQUENTLY IN THE HOME For each person identified in this section,provide full narration that relates to each of the Desk Guide examples for the rating given. EXTENDED FAMILY RELATIONSHIPS Describe the basis for ratings of 1 (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3,4&5 (concerns)to include how the concern was addressed, severity,mitigating factors and the prognosis for change. PHYSICAL/SOCIAL ENVIRONMENT Describe the basis for ratings of 1 (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3,4&5(concerns)to include how the concern was addressed,severity,mitigating factors and the prognosis for change. GENERAL PARENTING Describe the basis for ratings of 1 (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3, 4&5(concerns)to include how the concern was addressed,severity,mitigating factors and the prognosis for change. SPECIALIZED PARENTING Describe the basis for ratings of 1 (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3, 4&5 (concerns)to include how the concern was addressed,severity, mitigating factors and the prognosis for change. ADOPTION ISSUES Describe the basis for ratings of 1 (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3,4&5 (concerns)to include how the concern was addressed,severity, mitigating factors and the prognosis for change. PSYCHOSOCIAL EVALUATION CONCLUSIONS Provide your conclusions regarding the Applicants'committment,ability and readiness to parent. Highlight the strengths in any section given a rating of 1 and describe the effect any section rated as 3,4 or 5 will have on parenting. CHILDREN THE FAMILY CAN BEST SERVE Indicate the age range,gender and number of children the Applicants are ready to accept. Structured Analysis Family Evaluation(SAFE)O Colorado Couple Multipurpose Home Study Report -Version 05-08-2006 Copyright 2005,Consortium for Chadren,AN Rights Reserved Discuss the Applicants'ability to meet a child's special needs or considerations and level of competency to manage the characteristics, behaviors, conditions and issues of the children being considered for placement with them. Specify any child's special needs,considerations, characteristics, behaviors,conditions or issues that the Applicants are uniquely qualified to address. Also indicate what they are unable and/or unwilling to consider. RECOMMENDATION It is recommended that Applicant) Full Name and Applicant 2 Full Name be Select One for Select One. Caseworker Supervisor V4 Title Title Date: Date: Additional Attachments Indicate "None"or list additional attachments. REVIEW OF HOME STUDY REPORT By signing below I acknowledge that I have read a copy of this report. Applicant's Full Name Applicant's Full Name Date: Date: Ta c k for fo ms tr F ss rh ri key y� chick th Structured Analysis Family Evaluation(SAFE)©Colorado Couple Mukipurpose Home Study Report -Version 05-08-2006 Copyright,2005,Consortium for Children,A9 Rights Reserved SAFE Kinship Non-Certified Child Placement Family Evaluation Name of Family: Address: City: I State: Postal Code: 00000-0000 ' Home Phone: _ ; Cell Phone: APPLICANT INFORMATION Applicant's Full Name T-Applicant's Full Name Date of Birth: Date of Birth: t Birthplace: - Birthplace: i- Gender: ------- , --------------------------- ---- ----------- --- ------- -------------- I . Gender: Language: ! Language: Education: Education: Religion: i Religion: Hmployer: + — Emplocer - ... Occupation: _Occupation: !Work hours: _ _ ( Work hours: lk Length of Employment: Length of Employment: — -- Monthly Salary: tMonthly Salary: Drivers License: I Drivers License: I Car Insurance: Car Insurance: _I CHILDOR YOUTH BEING CONSIDERED FOR PLACEMENT Name: DHS custody: O Yes O No DOB: Ethnicity: Relationship: Religious Preference: Current Whereabouts: Date of Placement: Education: Visitation Plan if appropriate: Child Special Needs: Other: Name: DHS custody: O Yes 0 No DOB: Ethnicity: Relationship: Religious Preference: Current Whereabouts: Date of Placement: Education: Visitation Plan if appropriate: Child Special Needs: Other: Name: DHS custody: O Yes O No DOB: Ethnicity: Relationship: Religious Prcfare i ce: Current Whereabouts: Date of Placement: Education: Visitation Plan if appropriate: Child Special Needs: Other: Structured Analysis Family Evaluation(SAFE)0 Colorado Placement Evaluation—Revision 05-15-2006 Copyright,2005,Consortium for Children,AN Rights Reserved CHILD OR YOUTH BEING CONSIDERED FOR PLACEMENT(continued) Name: DHS custody: ❑Yes ❑No DOB: Ethnicity: Relationship: Religious Preference: Current Whereabouts: Date of Placement: Education: Visitation Plan if appropriate: Child Special Needs: Other: MOTIVATION Provide the Applicants'stated reasons for wanting the child(rent)placed with them. HOME ENVIRONMENT Number of Bedrooms: Bathrooms Finished Basement: 0 Yes 0 No Adequate Furnishings: Adequate Cleanliness: Where will the children sleep? Smoke Detectors: Any Safety Hazards? Weapons in home? 0 Yes 0 No Stored Safely? 0 Yes 0 No Description of neighborhood: Pets: Fenced Yard? How does your pet adapt to other children? School Plan: FAMILY Applicant#1: Applicant's Full Name Describe how the applicant presents him/her self. Also indicate any special interests,hobbies,expertise or talents the applicant possesses. Identify parents, siblings,their location and circumstances plus type and frequency of contact. Indicate name(s)and length of time of previous marriages and/or domestic partnerships. Include how relationships were terminated,e.g.,death,divorce, annulment,breakup. Identify any children born of these unions and describe their current situation. Applicant#2:Applicants Full Name Describe how the applicant presents him/her self. Also indicate any special interests,hobbies,expertise or talents the applicant possesses. Identify parents,siblings,their location and circumstances plus type and frequency of contact. Indicate name(s)and length of time of previous marriages and/or domestic partnerships. Include how relationships were terminated,e.g.,death,divorce,annulment,breakup. Identify any children born of these unions and describe their current situation. Applicants' Sons and Daughters Indicate"None"or provide name(s),DOB and gender. Describe their personality,interests, school or occupational situation, general health and living situation. Other children living or frequently in the home Indicate"None"or provide name(s), DOB,gender. Provide description of their personality, interests, school report information if any,general health. Indicate nature of relationship to Applicants,and living situation. Structured Analysis Family Evaluation(SAFE)O Colorado Placement Evaluation—Revision 05-15-2008 Copyright 2005,Consortium for Chldren,Al Rights Reserved Other adults residing or frequently in the home Indicate name of any adult who is living in the home or who is in the home on a regular basis. Describe the amount and type of contact they would have with a child. Indicate each individual's occupation,general health and the nature of their relationship to the Applicant. Family Lifestyle Describe current and proposed child care arrangements and work and non-work day routines and rituals. What are the basic household rules and expectations? Who does what in terms of chores,cooking,bill paying, home maintenance,transportation,etc.?Describe how the family deals with privacy and nudity in the home. What kind of recreational,social and religious activities does the family engage in? Does the family celebrate holidays; which ones and how are they spent? CRIMINAL/CHILD ABUSE RECORD Name of Adult: CBI In-House Checks Trails Out-of-State checks Lexis Nexis Denver Courts Provide any additional comments regarding the background check here. Home Assessment Process explained? ❑Yes ❑ No Concerns: Indicate whether or not the applicants are willing to cooperate with contacts by other professionals who may need to see the children in the home. Structured Analysis Family Evaluation(SAFE)*Colorado Placement Evaluation--Revision 05-15-2006 Copyright,2006,Consortium for Children,Al Rights Reserved PSYCHOSOCIAL INVENTORY RESULTS NOTE: The following is a list of the Psychosocial Inventory sections and the factors evaluated within each section. All final Psychosocial Inventor ratings of 1 (exceptional strength)and 3.4.and 5(issues of concern)are to be recorded along side the factor so rated. All boxes are marked at 2. Using your mouse please use the pull down boxes for each section(as applicable) should you want to modify the appropriate Inventory areas. #1 #2 HISTORY #1 #2 EXTENDED FAMILY RELATIONSHIPS 2 2 Childhood Family Adaptability 2 2 Extended Family Cohesion 2 2 Childhood Family Cohesion 2 2 Extended Family Adaptability 2 2 Childhood History of Deprivation/Trauma 2 2 Relationship with own Extended Family 2 2 Childhood History of Victimization 2 2 Relationship with Spouse's/Partner's Family 2 2 Adult Histon of Victimization/Trauma 2 2 OVERALL EVALUATION OF SECTION 2 2 History of Child Abuse/Neglect 2 2 History of Alcohol/Drug Use PHYSICAL/SOCIAL ENVIRONMENT 2 2 History of Crime/Arrest/Allegations/Violence 2 Cleanliness/Orderliness/Maintenance 2 2 Psychiatric Histor 2 Safety 2 2 Occupational History 2 Furnishings 2 2 Marriage/Domestic Partner History 2 Play Area/Equipment/Clothing 2 2 OVERALL EVALUATION OF SECTION 2 Finances 2 Support System #1 #2 PERSONAL CHARACTERISTICS 2 Household Pets 2 2 Communication 2 OVERALL EVALUATION OF SECTION 2 2 Commitment and Responsibility 2 2 Problem Solving #1 #2 GENERAL,PARENTING 2 2 Interpersonal Relations 2 2 Child Development 2 2 Health and Physical Stamina 2 2 Parenting Style 2 2 Self-esteem 2 2 Disciplinary Methods 2 2 Acceptance of Differences 2 2 Child Supervision 2 2 Coping Skills 2 2 Learning Experiences 2 2 Impulse Control 2 2 Parental Role 2 2 Mood 2 2 Child Interactions 2 2 Anger Management and Resolution 2 2 Communication with Child 2 2 Judgment 2 2 Basic Care 2 2 Adaptability 2 2 Child's Play 2 2 OVERALL EVALUATION OF SECTION 2 2 OVERALL EVALUATION OF SECTION MARITAL/DOMESTIC PARTNER #1 #2 SPECIALIZED PARENTING RELATIONSHIP 2 2 Expectations 2 Conflict Resolution 2 2 Effects of Abuse/Neglect 2 Emotional Support 2 2 Effects of Sexual Abuse 2 Attitude toward Spouse/Partner 2 2 Effects of Separation and Loss 2 Communication between Couple 2 2 Structure 2 Balance of Power 2 2 Therapeutic/Educational Resources 2 Stability of the Marriage or Partnership 2 2 Birth Sibling Relationships 2 Sexual Compatibility 2 2 Child Background Information 2 OVERALL EVALUATION OF SECTION 2 2 Birth Parent Issues 2 2 OVERALL EVALUATION OF SECTION SONS/DAUGHTERS/OTHERS RESIDING OR FREQUENTLY IN HOME 2 Minor Sons and Daughters 2 Minors Residing or Frequently in the Home 2 Adult Sons and Daughters 2 Adults Residing or Frequently in the Home 2 OVERALL EVALUATION OF SECTION Structured Analysis Family Evaluation(SAFE)0 Colorado Placement Evaluation—Revision 05-15-2006 Copyright,2005,Consortium for Children,Al Rights Reserved PSYCHOSOCIAL EVALUATION REPORT HISTORY Describe the basis for ratings of I (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3,4&5(concerns)to include how the concern was addressed, severity,mitigating factors and degree of resolution. PERSONAL CHARACTERISTICS Describe the basis for ratings of 1 (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3,4 &5(concerns)to include how the concern was addressed,severity,mitigating factors and the prognosis for change. MARITAL/DOMESTIC PARTNER RELATIONSHIP Describe the basis for ratings of 1 (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3, 4&5 (concerns)to include how the concern was addressed,severity, mitigating factors and the prognosis for change. SONS/DAUGHTERS/OTHERS RESIDING OR FREQUENTLY IN THE HOME For each person identified in this section,provide full narration that relates to each of the Desk Guide examples for the rating given. EXTENDED FAMILY RELATIONSHIPS Describe the basis for ratings of 1 (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3, 4&5 (concerns)to include how the concern was addressed,severity, mitigating factors and the prognosis for change. PHYSICAL/SOCIAL ENVIRONMENT Describe the basis for ratings of 1 (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3, 4&5 (concerns)to include how the concern was addressed,severity, mitigating factors and the prognosis for change. GENERAL PARENTING Describe the basis for ratings of 1 (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3,4&5 (concerns)to include how the concern was addressed,severity, mitigating factors and the prognosis for change. SPECIALIZED PARENTING Describe the basis for ratings of 1 (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3,4&5 (concerns)to include how the concern was addressed, severity,mitigating factors and the prognosis for change. PSYCHOSOCIAL EVALUATION CONCLUSIONS Based on your Psychosocial Evaluation determinations, draw your conclusions about the Applicants'commitment, ability and readiness to parent. Cleary explain how a section with an Overall Evaluation of Section rating of 3,4, or 5 will affect parenting. PLACEMENT COMPATABILITY Discuss each child's or youth's goodness of fit with this family in the context of the applicants'competency to address each of the child/youth needs, special considerations and issues as identified and described on the SAFE Matching Inventory. Illuminate any special needs,considerations,characteristics,behaviors,conditions or issues of the child(ren)or youth(s)that the Applicants are uniquely qualified to address or unable to manage. RECOMMENDATION structured Analysis Family Evaluation(SAFE)0 Colorado Placement Evaluation—Revision 05-15-2006 Copyright,2005,Consortium for Children,Al Rights Reserved It is recommended that Applicants Full Name and Applicant2 Full Name be Select One for the placement of Name(s) of Child(ren)/Youth(s). Caseworker Supervisor Title Title Date: Date: I 0rhea I q I im :li,k Ili', link Structured Analysis Family Evaluation(SAFE)©Colorado Placement Evaluation—Revision 05-15-2006 Copyright,2005,Consortium for Children,All Rights Reserved SAFE Child Specific Home Study Report This home study was completed by Name of Public/Private Agency to consider the placement of a specific child or specific children with the applicant for the purpose of either relative or foster care placement and/or adoption. Name of Family: Address: — City: - State: yPostal Code: 00000-0000 Home Phone: Cell Phone: APPLICATION DISPOSITION The Applicant applied specifically to be considered for the placement of Name(s)of Child(ren). Forward for consideration by Agency Approval Team on: Home Study Application received on: APPLICANT INFORMATION Applicant's Full Name Date of Birth: [Birthplace: { — — --Gender: Religion: Occupation: Language(s): Education: FHeight: Weight: I Hair: I Eyes: IL Date of health questionnaire/report: DATES OF CONTACT Date Person Interviewed Location Structured Analysis Family Evaluation(SAFE)Colorado Single Child Specific Home Study Report-Version 05-15-2006 Copyright,2005, Consortium for Children,All Rights Reserved CHILD OR YOUTH BEING CONSIDERED FOR PLACEMENT Provide the Name(s), DOB, gender, reason for protective custody and legal status of the child(ren) or youth(s) being considered, e.g., reunification, reunification terminated,TPR hearing pending, freed for adoption, etc. If the child(ren)or youth(s)is/are currently placed in the home,disniss their adjustment since placement. If not currently placed with the applicant,discuss the nature and character of the applicant's relationship with the child(ren)or youth(s). Describe the strengths,personality, interests and emotional/physical development of each child or youth being considered. Discuss the level of understanding each child/youth has about such issues as reunification,maintaining connections, adoption,etc. Identify and take into account the special considerations noted on the SAFE Matching inventory, e.g. placement with siblings, special diet, accomodations for a physical disability, maintain connections with birth family, needs a stay-at-home parent,etc. Describe the challenging child/youth issues identified on the SAFE Matching Inventory,e.g.,difficult temperament,problematic behaviors,attachment issues,etc. Indicate whether or not therapeutic services are being used or are needed. MOTIVATION Provide the Applicant's stated reasons for wanting the child(ren)placed with him/her and the parenting responsibilities he/she is willing to assume, e.g.,temporary caregiver,resource family, fost/adopt family, guardianship,adoptive parent,etc. HOME ENVIRONMENT Type of residence House,Apt, Condo,Etc Square Footage Bedrooms: Bathrooms Length of Time in current residence: Describe general characteristics of the Applicant's home and neighborhood. Indicate the type of residence(house, apartment, condo,etc.)and square footage. Describe the floor plan including the number of bedrooms and bathrooms. Describe the yard space and indicate if there is a pool, pond/fountain,etc. Describe the sleeping arrangements and also indicate whether or not there are guns or pets in the home. FAMILY Applicant-Applicant's Full Name Describe how the applicant presents him/her self. Also indicate any special interests,hobbies,expertise or talents the applicant possesses. Identify parents, siblings,their location and circumstances plus type and frequency of contact. Indicate name(s)and length of time of previous marriages and/or domestic partnerships. Include how relationships were terminated,e.g.,death,divorce,annulment,breakup. Applicant's Sons and Daughters Indicate"None"or provide name(s), DOB and gender. Describe their personality, interests, school or occupational situation,general health and living situation. Other children living or frequently in the home Structured Analysis Family Evaluation(SAFE)Colorado Single Chad Specific Home Study Report-Version 05-15-2006 Copyright,2005, Consortium for Children,All Rights Reserved Indicate"None"or provide name(s), DOB,gender. Provide description of their personality, interests, school report information if any,general health. Indicate nature of relationship to the Applicant, and living situation. Other adults residing or frequently in the home Indicate name of any adult who is living in the home or who is in the home on a regular basis. Describe the amount and type of contact they would have with a child. Indicate each individual's occupation,general health and the nature of their relationship to the Applicant. Family Lifestyle: Describe current and proposed child care arrangements and work and non-work day routines and rituals. What are the basic household rules and expectations? Who does what in terms of chores, cooking,bill paying, home maintenance,transportation, etc.? Describe how the family deals with privacy and nudity in the home. What kind of recreational, social and religious activities does the family engage in? Does the family celebrate holidays, which ones and how are they spent? Previous adoptions or foster care experience: Indicate"None"or discuss the circumstances and the adjustment of the child or children to the family. FINANCES Combined annual gross earned income: $ Sources of additional income: Explain, if any CRIMINAL/CHILD ABUSE RECORD The required criminal record and Child Abuse Index checks were completed for Applicant's Full Name. Indicate the name(s)of any other individuals who were screened. State automated system,CBI,ICON/Co Courts,and FBI(if applicable)Clearance Findings: Indicate the findings for each individual screened. Other findings: Indicate who was screened for each of the following and the findings for each person: DMV (optional), local law enforcement(optional)and CPS service records. EMERGENCY CARE PLAN In case of an incapacitating illness or death of the Applicant,indicate whom the designated caretaker(s)will be and the nature of their relationship to the Applicant. Indicate if these arrangements have been discussed with the designated caretaker(s),how willing they are to assume this responsbibility and whether arrangements have been formalized in a will or trust. CONTACT WITH FAMILY OF ORIGIN AND SIGNIFICANT OTHERS Describe the type of relationship and contact the Applicant is willing to have with the birth parents and other significant connections such as siblings,grandparents, foster parents,etc. Describe any written post adoption contact agreement(s). REFERENCES References received: Select One FAMILY TRAINING Identify and describe agency family training. Include Applicants'statements regarding their participation and benefits derived from these activities. LEGAL/FINACIAL RIGHTS AND RESPONSIBILITIES Structured Analysis Family Evaluation(SAFE)Colorado Single Child Specific Home Study Report-Version 05-15-2006 Copyright, 2005, Consortium for Children,All Rights Reserved Applicant's Full Name has been provided with information concerning the different roles, responsibilities, legal and financial rights and benefits of relative/child specific kin caregivers,foster parents, Legal Guardians and adoptive parents. Also, should he/she file a petition to adopt,Applicant's Full Name understand that he/she will be accepting full legal and financial parental responsibility for Name(s)of Child(ren)once an adoption is finalized. The agency's grievance procedures Select One explained to the Applicant. Structured Analysis Family Evaluation(SAFE)Colorado Single Child Specific Home Study Report-Version 05-15-2006 Copyright, 2005, Consortium for Children,All Rights Reserved PSYCHOSOCIAL INVENTORY RESULTS NOTE: Below is a list of the psychosocial factors found on the SAFE Psychosocial Inventory. Using the Psychosocial Inventor. each factor was considered and rated several times by the social worker during the course of this home study. The ratings below represent the final ratings. The rating are defined as follows: 1 =an exceptional strength. 2=a strength. 3 =an issue of concern. 4=a major issue of concern and 5=very serious problem. The OVERALL EVALUATION OF SECTION ratings reflect the degree to which all issues of concern identified in the section were either resolved, mitigated or the prognosis for change. HISTORY PHYSICAL/SOCIAL ENVIRONMENT 2 Childhood Family Adaptability 2 Cleanliness/Orderliness/Maintenance 2 Childhood Family Cohesion 2 Safety- 2 Childhood History of Deprivation/Trauma 2 Furnishings 2 Childhood History of Victimization 2 Play Area/Equipment/Clothing 2 Adult History of Victimization/Trauma 2 Finances 2 History of Child Abuse/Neglect 2 Support System 2 History of Alcohol/Drug Use 2 Household Pets 2 History-of Crime/Arrest/AllegationsNiolence 2 OVERALL EVALUATION OF SECTION 2 Psychiatric History- ') Occupational History GENERAL PARENTING 2 Marriage/Domestic Partner History 2 Child Development 2 OVERALL EVALUATION OF SECTION 2 Parenting Style 2 Disciplinary Methods PERSONAL CHARACTERISTICS 2 Child Supervision 2 Communication 2 Learning Experiences 2 Commitment and Responsibility 2 Parental Role 2 Problem Solving 2 Child Interactions 2 Interpersonal Relations 2 Communication with Child 2 Health and Physical Stamina 2 Basic Care 2 Self-esteem 2 Child's Play 2 Acceptance of Differences 2 OVERALL EVALUATION OF SECTION 2 Coping Skills 2 Impulse Control SPECIALIZED PARENTING 2 Mood 2 Expectations 2 Anger Management and Resolution 2 Effects of Abuse/Neglect 2 Judgment 2 Effects of Sexual Abuse 2 Adaptability 2 Effects of Separation and Loss 2 OVERALL EVALUATION OF SECTION 2 Structure 2 Therapeutic/Educational Resources SONS/DAUGHTERS/OTHERS RESIDING 2 Birth Sibling Relationships OR FREQUENTLY IN HOME 2 Child Background Information 2 Minor Sons and Daughters 2 Birth Parent Issues 2 Minors Residing or Frequently in the Home 2 OVERALL EVALUATION OF SECTION 2 Adult Sons and Daughters 2 Adults Residing or Frequently in the Home ADOPTION ISSUES 2 OVERALL EVALUATION OF SECTION 2 Infertility 2 Telling Child about Adoption EXTENDED FAMILY RELATIONSHIPS 2 Openness in Adoption 2 Extended Family Cohesion 2 Adoptive Parent Status 2 Extended Family Adaptability 2 OVERALL EVALUATION OF SECTION 2 Relationship with own Extended Family 2 Relationship with Spouse's/Partner's Family 2 OVERALL EVALUATION OF SECTION Structured Analysis Family Evaluation(SAFE)Colorado Single Child Specific Home Study Report-Version 05-15-2006 Copyright,2005, Consortium for Children,All Rights Reserved PSYCHOSOCIAL EVALUATION REPORT HISTORY Describe the basis for ratings of I (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3, 4 & 5 (concerns)to include how the concern was addressed, severity, mitigating factors and degree of resolution. PERSONAL CHARACTERISTICS Describe the basis for ratings of 1 (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3, 4 & 5 (concerns) to include how the concern was addressed, severity, mitigating factors and the prognosis for change. SONS/DAUGHTERS/OTHERS RESIDING OR FREQUENTLY IN THE HOME For each person identified in this section,provide full narration that relates to each of the Desk Guide examples for the rating given. EXTENDED FAMILY RELATIONSHIPS Describe the basis for ratings of I (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3, 4 & 5 (concerns) to include how the concern was addressed, severity, mitigating factors and the prognosis for change. PHYSICAL/SOCIAL ENVIRONMENT Describe the basis for ratings of 1 (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3, 4 & 5 (concerns) to include how the concern was addressed, severity, mitigating factors and the prognosis for change. GENERAL PARENTING Describe the basis for ratings of I (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3, 4 & 5 (concerns) to include how the concern was addressed, severity, mitigating factors and the prognosis for change. SPECIALIZED PARENTING Describe the basis for ratings of I (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3, 4 & 5 (concerns) to include how the concern was addressed, severity, mitigating factors and the prognosis for change. ADOPTION ISSUES Describe the basis for ratings of I (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3, 4 & 5 (concerns) to include how the concern was addressed, severity, mitigating factors and the prognosis for change. PSYCHOSOCIAL EVALUATION CONCLUSIONS Based on your Psychosocial Evaluation determinations, draw your conclusions about the Applicant's commitment, ability and readiness to parent. Cleary explain how a section with an Overall Evaluation of Section rating of 3, 4, or 5 will effect parenting. PLACEMENT COMPATABILITY Discuss each child's or youth's goodness of fit with this family in the context of the applicant's competency to address each of the child/youth needs, special considerations and issues as identified and described on the SAFE Matching Inventory. Illuminate any special needs, considerations, characteristics, behaviors, conditions or issues of the child(ren) or youth(s)that the Applicant is uniquely qualified to address or unable to manage. RECOMMENDATION Shuctured Analysis Family Evaluation(SAFE)Colorado Single Child Specific Home Study Report-Version 05-15-2006 Copyright,2005, Consortium for Children,All Rights Reserved structured Analysis family evaluation - Google Search Page 1 of 3 Sign in Web Images Video News Maps more » Google structured Analysis familyevaluation Search Advanced Search Preferences Web Results 1 - 10 of about 1,290,000 for structured Analysis family evalual Book results for structured Analysis family evaluation shi Research Methods In Family Therapy - by Sprenkle. Douglas H.. Fred P. Piercy - 473 pages Evaluating Family-Based Services - by Peter J. Pecora Journal of Family Therapy - by Association for Family Therapy IPon COLORADO DEPARTMENT OF HUMAN SERVICES 1575 SHERMAN ST. , DENVER ... File Format: PDF/Adobe Acrobat - View as HTML To convey to individuals who complete Structured Analysis Family Evaluation (SAFE) home. studies information about key elements of the SAFE structure, ... stateboard.cdhs.state.co.usiagency/CW0607P.pdf - Similar pages IPDn COLORADO DEPARTMENT OF HUMAN SERVICES 1575 SHERMAN ST. , DENVER ... File Format: PDF/Adobe Acrobat - View as HTML Using the SAFE (Structured Analysis Family Evaluation) home study format and its. requirements. • Foster care and kinship. Background: ... stateboard.cdhs.state.co.usiagency/CW06051.pdf - Similar pages SAFE overview It provides home study practitioners with a structured method to process, ... The psychosocial evaluation is not merely a description of the family. ... www.safehomestudy.org/overview/index.cfm - 5k - Cached - Similar pages NRCFCPPP: Teleconferences Keeping Children SAFE: Structured Analysis Family Evaluation - September 13, 2006. The Adam Walsh Child Protection And Safety Act - November 15, 2006 ... www.hunter.cuny.edu/socwork/nrcfcpp/teleconferences/index.html - 49k - Cached - Similar pages http://www.google.com/search?hl=en&q=structured+Analysis+family+evaluation&btnG=... 3/28/2007 structured Analysis family evaluation -Google Search Page 2 of 3 [PEW] Overview File Format: PDF/Adobe Acrobat - View as HTML The Structured Analysis Family Evaluation (SAFE) is a home study methodology that. provides a suite of comprehensive home study tools and practices for the ... www.hunter.cuny.edu/socwork/nrcfcpp/downloads/ teleconferences/Structured_Analysis_Family_Evaluation.pdf - Similar pages Wisconsin PEP Display Detail The attached document, Structured Analysis Family Evaluation (SAFE), is a home study methodology that California Department of Social Services designed to ... dhfs.wisconsin.gov/cwreview/PEP-Team/Bulletinboard/PEPlnitdetail.asp? PEP_Initiative_Id=67 - 11k - Cached - Similar pages The Adoption Home Study Process Listen to audio files and view handouts from a teleconference on the Structured Analysis Family Evaluation (SAFE) presented to State adoption and foster ... www.childwelfare.gov/adoption/adoptive/homestudy.cfm - 25k - Cached - Similar pages Toward formalizing structured analysis Real-time extensions to structured analysis (SA/RT) are popular in industrial practice. ... The article allows for the evaluation of formal definitions by ... portal.acm.org/citation.cfm?id=268429&coll=portal&dI=ACM - Similar pages [PDF] Toward Formalizing Structured Analysis File Format: PDF/Adobe Acrobat article suggests a new approach toward the formalization of structured. analysis, which leads to the formalization of a family of interpretations to ... portal.acm.org/citation.cfm?doid=268411 .268429 - Similar pages An evaluation of three statistics of structured exploratory data ... 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Help us improve Google Home - - Business Solutions - About Google ©2007 Google http://www.google.com/search?h1=en&q=structured+Analysis+family+evaluation&btncc=... 3/28/2007 References and Sample consent forms ACKERMAN & ASSOCIATES, P.C. 1750 25th Avenue, Suite 101 Greeley, Colorado 80634 Phone: (970) 353-3373 Fax: (970) 353-3374 Social Services Programs Disclosure Ackerman and Associates works with the Weld County Department of Social Services(WCDSS)on several programs. All of these programs require a referral from Social Services or from the court. Information regarding your family is recorded and used to help set goals and in obtaining those goals. Together, you and the therapist will set these goals and monitor your progress. Our contractual agreements with WCDSS allow our program staff to exchange information with WCDSS and require us to send WCDSS a summary upon termination of our counseling with your family. Confidentiality is limited by these considerations. The cost of these services is covered by funds through Weld County for preserving families. A description of the appropriate program will be given to you at the time of the first session. Please ask the providers any questions. Ackerman and Associates have several providers. They are: Joyce Shohet Ackerman, Ed.D., Licensed Psychologist Joyce is licensed by the State of Colorado to practice psychology. She has a Bachelor of Science in Special Education, a Master of Science in Special Education,and a Doctorate of Education in Psychology, Counseling, and Guidance from the University of Northern Colorado,which she received in 1981. She is listed in the National Register for Health Service Providers in Psychology. Susan Bromley, Psy.D., L.L.C., Licensed Psychologist Susan is licensed by the State of Colorado to practice psychology. She received her Doctorate in Clinical Psychology from the University of Denver in August of 1983. She received her Master's in Social Work from Case Western University of Cleveland, Ohio, in 1968. Laurence P. Kerrigan, Ph.D., Licensed Psychologist Larry is licensed by the State of Colorado to practice psychology. He received his Doctorate of Clinical Psychology from the California School of Professional Psychology in August of 1974. Emily Montoya, M.A., L.P.C., Licensed Professional Counselor Emily graduated from the University of Northern Colorado in 1996 with a Master's degree in Agency Counseling. She is licensed by the State of Colorado to practice psychotherapy. Tom Pappas, MS.W, L.C.S W., Licensed Clinical Social Worker Tom received his Master's degree in Social Work in 1986 and his Post Graduate Certificate in Advanced Psychotherapy with Children and Adolescents in 1993. He is licensed in Clinical Social Work by the state of Colorado. You are entitled to have therapeutic methods and techniques explained to you and have an estimate of how long your therapy may take. You are free to seek another opinion or to end therapy at any time. The Colorado Department of Regulatory Agencies has the general responsibility of regulating the practice of both licensed and unlicensed persons in the field of psychotherapy. You can report complaints to Mental Health Occupations Grievance Board, 1560 Broadway, Suite 1340, Denver, Colorado, 80202, or phone(303) 894-7766. Colorado law requires that you know it is never appropriate for psychologists(or any psychotherapists) and their clients to engage in sexual intimacies and these incidents should be reported to the Mental Health Grievance Board. What you say during sessions is confidential with certain legal exceptions. Among these are: suspected child abuse or neglect,threats of harm to yourself and others, and in some cases,custody matters. Persons 15 years of age or older have a right to confidentiality. In the event you will not be able to keep an appointment,PLEASE contact us as soon as you know you will be unable to attend your scheduled session. This may allow us to provide services to someone else during that time period if you can give us as much notice as possible. By signing below,you are stating that you understand and agree to these conditions and have been informed of our degrees, credentials,and fees. Client Child(if 15 years of age or older) Date (Parent for a minor child) Provider Date Ackerman and Associates, P.C. 1750 25th., Suite 101 Greeley, CO 80634 Phone: (970) 353-3373 Fax: (970) 353-3374 Email: counseling@ackermanandassociates.com AUTHORIZATION TO RELEASE/OBTAIN INFORMATION I authorize to RELEASE and/or OBTAIN information concerning: Name: Date of Birth: Name: Date of Birth: TO/FROM/WITH: Name: Phone/Fax: Address: Type of information to be released(circle yes or no to each): YES NO Treatment information to include history, attendance, diagnosis,treatment progress,treatment approaches/plans/goals,prognosis, medication, intervention,prescriptions and discharge summary YES NO Psychological evaluation and testing summaries YES NO Clinical evaluation and testing summaries YES NO Alcohol/drug treatment information YES NO Physical exam, lab studies, diagnostic evaluation,EKG, EEG YES NO Other (specify): For the purpose of treatment planning, service coordination and(as specified): I understand that my records are protected under the Federal and State confidentiality regulations. I understand that if I have authorized the release of drug abuse and/or alcohol abuse information that the confidentiality of this information is protected by Federal Law 42CFR, Part 2. This information cannot be disclosed without my written consent, unless otherwise specifically provided for in the regulations. I understand 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 sent to the agencies and persons identified above. Client (15 and older) or Guardian Signature Date Printed Name Relationship Date of Birth Witness This consent expires and cannot be used for more than one year from the date of signing. Ackerman and Associates, P.C. 1750 25th Avenue, Suite 101 Greeley, Colorado 80634 (970)353-3373 fax(970)353-3374 Information About Our Providers Joyce Shohet Ackerman, Ed.D., Licensed Psychologist: Dr. Ackerman is licensed by the State of Colorado to practice psychology. She has a Bachelor of Science in Special Education, a Master of Science in Special Education and a Doctorate of Education in Psychology, Counseling, and Guidance from the University of Northern Colorado,which she received in 1981. Dr. Ackerman is listed in the National Register for Health Service Providers in Psychology, which means her training corresponds to that of programs accredited by the American Psychological Association. Susan Plock Bromley, Psy.D., Licensed Psychologist: Dr. Bromley is licensed by the State of Colorado to practice psychology. She received her Doctorate in Clinical Psychology from the University of Denver in August 1983. She received her Master's in Social Work from Case Western Reserve University of Cleveland, Ohio, in 1968. Laurence P. Kerrigan, Ph.D., Licensed Psychologist: Dr. Kerrigan is licensed by the State of Colorado to practice ps, hology. He received a Doctorate in Clinical Psychology from the California School of Professional Psychology in August of 1974. Tom Pappas, M.S.W., L.C.S.W.,Licensed Clinical Social Worker Tom received his Master's degree in Social Work in 1986 and his Post Graduate Certificate in Advanced Psychotherapy with Children and Adolescents in 1993. He is licensed in Clinical Social Work by the state of Colorado. Disclosure 1 PSYCHOTHERAPIST-CLIENT AGREEMENT Welcome to Ackerman and Associates'practice. This document(the Agreement)contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act(HIPAA), a new federal law that provides new privacy protections and new client rights with regard to the use and disclosure of your Protected Health Information (PHI)used for the purpose of treatment,payment and health care operations. The Notice, which is attached to this agreement,explains HIPAA and its applications to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information before our first session. Although these documents are long and sometimes complex,it is very important that you read them carefully before our first session. We can discuss any questions you have about the procedures at that time. When you sign this document,it will also represent an agreement between us. You may revoke this Agreement at any time. The revocation will be binding on me unless I have taken action in reliance on it;if there are obligations imposed on me by your health insurer in order to process or substantiate claims under your policy;or if you have not satisfied any financial obligations you have incurred. PSYCHOLOGICAL AND COUNSELING SERVICES Psychotherapy is not easily described in general statements. It varies depending on the personalities of the therapist and client and the particular problems you are experiencing. There are many different methods I may use to deal with problems that you hope to address. Therapy calls for a very active effort on your part. In order for therapy to be most successful,you may have to work on things we talk about during our sessions. Therapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life,you may experience uncomfortable feelings like sadness,guilt,anger,frustration,loneliness,and helplessness. On the other hand, therapy has also been shown to have many benefits. Therapy often leads to better relationships,solutions to problems,and reductions in feelings of distress. But there are no guarantees of what you will experience. Our first session will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Therapy involves a commitment of time,money, and energy,so you should be very careful about the therapist you select. If you have questions about my procedures, feel free to discuss them whenever they arise. If your doubt persists,I will be happy to help you set up a meeting with another mental health professional. MEETINGS I normally conduct an evaluation that will last from 1 to 2 sessions. During this time,we can both decided if I am the best person to provide the services you need in order to meet your treatment goals. If therapy is begun, I will usually schedule one session (one appointment hour of approximately 50 minutes duration)per week at a time we agree on,although some sessions may be longer or more frequent. Once an appointment hour is scheduled,you will be expected to pay 50% of the regular hourly fee if you do not provide 24 hours advance notice of cancellation ]unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that most insurance companies flo not provide reimbursement for cancelled sessions PROFESSIONAL FEES The hourly fee is SI20 for doctoral level providers and S90 for master's level providers. In addition to weekly appointments, you will be charged this amount for other professional services you may need,though I will break down the hourly cost if I work for periods of less than one hour. Please note that the first session may be billed at one and a half hours. Other services include report writing,telephone conversations lasting longer than five minutes,consulting with other professionals with your permission,preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation,you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Doctoral level therapists charge$130 per hour for preparation and for attendance at any legal proceeding. Master's level therapists charge$100 for preparation and for attendance at any legal proceeding. If travel is required for legal proceedings, this is included in preparation time. If,in the future,we find it necessary to increase our rates,you will be notified in a timely manner. CONTACTING ME Due to my work schedule I am often not immediately available by telephone While the office is usually open between 9 AM and 5PM, I will not take a call when I am with a client. When I am unavailable, my telephone is answered by an answering service or by my secretary. I will make every effort to return your call on the same day you make it,with the exception of Disclosure 2 • weekends and holidays. If it is difficult to reach you, please inform me of times when you will be available. If you are unable to reach me and feel that you can't wait for me to return your call, contact the person on call for Ackerman and Associates,your family physician or the nearest emergency room and ask for the therapist on call. if I will be unavailable for an extended time,I will provide you with the name of a colleague to contact, if necessary. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. The protection of confidentiality of communications with counselors who are not psychologists follow some different rules in Colorado. In most situations,I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written advance consent. Your signature on this Agreement provides consent for those activities,as follows: • I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation,I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep the information confidential. If you don't object, I will not tell you about these consultations unless I feel that it is important in our work together. 1 will note all consultations in your Clinical Record(which is called "PHI"in my Notice of Psychologist's Policies and Practices to Protect the Privacy of Your Health Information). • Please be aware that I practice with other mental health professionals and that I employ administrative staff. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling,billing,and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. • I also have contracts with an accountant,a billing service,your insurance company, and on occasion a collection agency. As required by HIPAA,i have a formal business associate contract with these businesses in which they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you with the names of these organizations and/or a blank copy of this contract. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • If a client threatens to harm himself/herself or others, I may be obligated to seek hospitalization for him/her,or to contact family members or others who can help provide protection. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning my professional services, such information is protected by the psychologist-client privilege law. I cannot provide any information without your written authorization,or a court order. A counselor who is not a psychologist may have to provide such information. If you are involved in a legal situation or contemplating litigation,you should consult with.your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities,lam required to provide it for them. • If a client files a complaint or lawsuit against me,i may disclose relevant information regarding that client in order to defend myself. • If a client files a worker's compensation claim,lam required to submit a report to the Worker's Compensation Division. There are some situations in which I am legally obligated to take actions,which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a client's treatment. These situations are unusual in my practice. • If I have reasonable cause to know or suspect that a child has been subjected to abuse or neglect or if I have observed a child being subjected to circumstances or conditions which would reasonably result in abuse or neglect,the law requires that I file a report with the appropriate governmental agency. Once such a report is filed, I may he required to provide additional information. • If I have reasonable cause to believe that an at-risk adult has been or is at imminent risk of being mistreated, self-neglected, or financially exploited, the law requires that I file a report with the appropriate governmental agency. Once such a report is filed, I may be required to provide additional information. Disclosure 3 ' • if a client communicates a serious threat if imminent physical violence against a specific person or persons,I must make an effort to notify such pa-sons; and/or notify an appropriate law enforcement agency;and/or take other appropriate action including seeking hospitalization of the client. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you have now or in the future. The laws governing confidentiality can be quite complex,and I am not an attorney. In situations where specific advice is required,formal legal advice may be needed. Please note that I will be thanking my professional colleagues(e.g.physicians,attorneys, and/or counselors)for referring you unless you request that I DO NOT do so. PROFESSIONAL RECORDS I keep Protected Health Information about you in a professional record which constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis,the goals that we set for treatment,your progress toward those goals,your medical and social history, your treatment history, any past treatment records that I receive from other providers,reports of any professional consultations, your pilling records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself and others,you may examine and/or receive a copy of your Clinical Record,if you request it in writing. in most situations, I am allowed to charge a copying fee of S.50 per page(and for certain other expenses). If I refuse your request for access to your Clinical Record,you have a right of review, which I will discuss with you upon request. CLIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of Protected Health Information. These rights include requesting that I amend your record;requesting restrictions on what information from your Clinical Record is disclosed to others,requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized;determining the location to--rich protected information disclosures are sent;having any complaints you make about my policies and procedures recorued in your records;and the right to a paper copy of this agreement,the attached Notice form,and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS&PARENTS Clients under 15 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child's treatment records,unless I decide that such access is likely to injure the child. Because privacy in therapy is often crucial to successful progress,particularly with teenagers, it is sometimes my policy to request an agreement from parents that they consent to give up their access to their child's records. If they agree,during treatment, I will provide them only with general information about the progress of the child's treatment,and his/her attendance at scheduled sessions. I will also provide parents with a summary of their child's treatment when it is complete. Any other communication will require the child's Authorization,unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information,I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held,unless we agree otherwise or unless you have insurance coverage that requires another arrangement and you have been pre-approved by our insurance and billing office. Payment schedules for other professionally services will be agreed to when they are requested. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. if your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency(or going through small claims court)which will require me to disclose otherwise confidential information. In most collection situations,the only information I release regarding a client's treatment in his/her name,the nature of services provided, and the amount due. if such legal action is necessary, its costs will be included in the claim. PLEASE NOTE THAT THE PERSON WHO COMES TO OUR OFFICE (PARENT,IF A MINOR IS INVOLVED)IS RESPONSIBLE FOR PAYMENT. WE WILL SEND BILLS TO INDIVIDUALS WHO HAVE COME TO THE OFFICE Disclosure 4 FOR SERVICES. If you are a student and expect your parents to be financially responsible,you will need to get a special form signed by them. Otherwise, you will be responsible for payment.Please inform the secretary,and she will give you this form. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities,it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy,it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled;however,you(not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services you insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage,call your plan administrator. Of course, I will provide you with whatever information you receive from your insurance company. If it is necessary to clear confusion,I will be willing to call the company on your behalf. Due to the rising costs of health care,insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. "Managed Health Care"plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person's usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some clients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your therapy. You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries,or copies of your Clinical Record. In such situations, i will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, .`ive no control over what they do with it once it is in their hands. in some cases,they may share the information with a national medical information databank. I will provide you with a copy of any report I submit,if you request it. By signing this Agreement,you agree that I can provide requested information to your carrier. Once we have all of the information about your insurance coverage,we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above unless prohibited by contract. SPECIAL SITUATIONS if you share custody of your children with a former partner,it is your responsibility 0.1000 hinl/ber.utformed about your child's psychotherapy.if it is indicated,your former partner may need to be involved in your child's•therapy,and under certain conditions,your partner may be asked to sign a consent farm for treatment.It may he necessary forynu to assist and encourage this process' With regard to group or family therapy,Colorado law provides that nopers who ohs participated#rtany psychfllogrcat therapy be questioned in emit_ concerting the lunowicdge gained during the course of therapy unless all participants'consent: In other words,if you have been in farmly therapy=or in group therapy,you are not allowed to talk about what was said unless the other participants agree.You need to be aware of these restrictions upon your comments Ackerman and Associates, P.C. 1750 25th Avenue, Suite 101 Greeley, Colorado 80634 (970)353-3373 fax(970)353-3374 YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE RECEIVED WRITTEN NOTICE OF THE FOLLOWING: 1. INFORMATION ON YOUR THERAPIST'S DEGREE AND LICENSES 2. A NOTICE OF THE PRIVACY PRACTICES Client (or parent for a minor) Date Provider Date Resumes JOYCE SHOHET ACKERMAN, Ed.D. 1750 25th Avenue,Suite 101 Greeley, Colorado 80634 RESUME PERSONAL DATA Date of Birth: August 3,1950 Health: Excellent Married;two children CERTIFICATION - LICENSURE Licensed Clinical Psychologist,State of Colorado since 1984 Listed in National Register of Health Service Providers in Psychology since 1986 Staff Privileges, North Colorado Medical Center, Greeley, Colorado since 1985 PROFESSIONAL MEMBERSHIP American Psychological Association Colorado Psychological Association (elected board member 1986-1989) HONORS President's Award - Colorado Psychological Association, 1989 EDUCATION 1978 - 1981 Ed.D. in Counseling Psychology, University of Northern Colorado, December 1981 graduate 1972- 1974 M.S. in Education(E.D./L.D.) Lesley College,Cambridge, Massachusetts, August graduate 1968 - 1971 B.S. in Special Education and Elementary Education with a minor in psychology Boston University, Boston, MA, December 1971 graduate PROFESSIONAL EXPERIENCE 1981 - present Clinical Director in group practice in Greeley,CO. Among responsibilities are: Diagnosis,therapeutic intervention and referral for adults,families,children and groups. Primary areas are: mediation, alternative conflict resolution,stress reduction. Also developing, organizing and presenting workshops and consultative programs to community,schools,organizations and agencies. 1986- present Consulting psychologist on interdisciplinary team for in-patient rehabilitation program. Progressive Care Rehabilitation Center,Greeley, CO. Medical Director Dr.Judith Vaughan,Neurologist. Adults with traumatic injuries- primary problems are: psychological aspects of physical rehabilitation,grief counseling,and brief group counseling using cognitive-behavioral goal oriented therapy. 1989- 1992 Consulting psychologist for Head Injury Treatment Team North Colorado Medical Center,Greeley CO Team coordinator-Dr.John McVicker,neurosurgeon. 1986- 1989 Consulting psychologist for Family Recovery Center(in-patient substance abuse/chemical dependency program), North Colorado Medical Center,Greeley CO Coordinator Ruth Wick,R.N. 1986- 1989 Provider and Coordinator for Mental Health Services in Northern Colorado for Peak Health Care(HMO). Peak mental health services utilized a three-session model for initial services followed by referral. Activities included coordination of Psychological and Psychiatric Services for approximately the last two years of the Contract. Peak supervisor- Elaine Taylor 1983 - 1986 Psychologist subcontractor for a Vietnam Veteran's Counseling Program funded by the Veteran's Administration. Principal Contract Dr. Robert Stewart. 1980- 1987 Part time faculty member with responsibilities for classes,workshops and community programs in parenting skills. Family/Life Education Program,Aims Community College,Greeley CO August 1980- August 1981 -Clinical internship on Children's Team of Community Mental Health Center. Responsibilities included:consultation to schools and community programs; therapy for children and families;and assessment of diverse mental health programs. Assistant program evaluator - developed evaluation tools to determine cross-cultural perceptions of expectations and satisfaction with services. Supervisors- Dr.Joan Gillespie and Dr. Laurence P. Kerrigan. APA National Convention in Toronto,Canada"Psychology and National Health Reform: "National Health Insurance: Policy Considerations. Benefit Designs. and Economic Realities",and"Marketing: Psychology's Key to National Health Reform. 1993 Disaster Relief Training. Alan Keck through Colorado Psychological Association,Denver CO 1992-Fall Short Term Therapy,Bernard Bloom;University of Northern Colorado, Greeley CO 1990-Fall National Cognitive Rehabilitation Conference, Richmond VA 1990-summer Postgraduate training: 1. Adult Neuropsychological Method based on Lezak Neuropsychological assessment,1983. 2. Child Neuropsychology,Dr.Hynd. 3. Child Neuropsychological Methods 1988 Cognitive Rehabilitation Training Program,Dr.Sena,Ph.D., Colorado Springs CO 1988- present Psychologist-Head Injury Treatment Team at North Colorado Medical Center,Greeley CO 1987 Halstead Reitan Neuropsychological Assessment Training. Ralph Reitan,Ph.D., Washington DC Summer 1986 Albert Einstein School of Medicine,Workshop on Adolescent Therapy, Cape Cod MA 1985 to present North Colorado Interdisciplinary Team of Child Custody Member and participant Fall 1985 Interdisciplinary Workshop on Child Custody, Keystone CO Summer 1984 Workshop in Clinical Use of Hypnosis, Boston MA Winter 1983 Workshop on In-patient Programs for Service Related Disorders, Cheyenne Veterans Administration Hospital. Fall 1983 Veteran's Administration Workshop on Post Traumatic Stress Syndrome, Denver Veteran's Center. Fall 1981-Winter 1984 Post-Doctoral Supervised Candidate for Licensure(psychology) under Gale R.Giebler,Ph.D.Licensed Psychologist and Susan Spilman, Ph.D., Licensed Psychologist 1980- 1981 Intern-Weld County Sexual Abuse Team,Greeley CO Weld Mental Health Center,Greeley CO adults,adolescents, families. Primary areas anxiety disorders,mood disorders and adjustment disorders. Typical problems included: trauma, physical abuse substance abuse,job stress. Orientation used - primarily cognitive-behavioral therapy. 1980 Group Facilitator-Regional and National Conferences in cross-cultural community needs. Flagstaff, AZ-Colorado Springs CO August 1975-July 1978 Chairperson of the Department of Education and Behavioral Science at an accredited,Indian controlled community college on the Navajo Reservation. Administration responsibilities included: Supervision and evaluation of faculty;budget preparation and management;curriculum development and integration of Navajo culture; personnel recruitment and selection;class scheduling and program development. Also faculty member with academic responsibilities for instruction in Psychology, Child Development and Counseling courses,advising and counseling students. Navajo Community College,Tsaile AZ September 1974- August 1975 Education Specialist and counselor at an Indian controlled primary and secondary school on the Navajo Reservation. Coordinated community resource program,which included: counseling,student assessment,prescriptive programming,staff development and curriculum. Also,adjunct faculty for the University of New Mexico and for Navajo Community College at the Rough Rock Demonstration school,Rough Rock, AZ September 1972-June 1974 Designed and coordinated Learning Center Program for Dedham Public Schools. A program and crisis intervention center for emotionally disturbed children. Responsibilities included: Diagnostic prescriptive programming,counseling,supervision and training of aides, tutors and volunteers,and consultation with regular classrooms teachers. Also organized group and individual meetings with parents. Adjunct faculty for Curry College assisting with in-service instruction for Dedham School System employees. Dedham Public Schools, Dedham MA WORKSHOPS AND SPECIAL TRAINING 1996 Biodyne training workshop adolescent treatment in short term therapy, Tom Kalous, Ph.D. 1995 Biodyne Training Workshops in short term therapy Julian Ang, Ph.D. 1994 Certification in family mediation,CDR Associates, Boulder CO 1993 Disaster Relief Training. Alan Keck,through Colorado Psychological Association, Denver CO 1993 August Hospital Practice for Psychologists Summer 1981 Independent Study of Child Sexual Abuse, University of Northern Colorado Spring 1981 Interdisciplinary Workshop on Assessment of Sexual Assault, Boulder Social Services Summer 1979 Biofeedback Training related to labor and delivery. Summer 1974 Participant in Institute on Obstacles to Learning. Joint Symposium between McLean psychiatric hospital, Harvard University and Lesley Graduate School,Cambridge MA • Summer 1973 Kennedy Memorial Hospital, Boston MA. Participant,Summer Aphasia Institute. PUBLICATIONS Ackerman A., Ackerman,J.S., Kelley K. Hale K. Family Planning Attitudes of Traditional and Acculturated Navajo Indians. Key Issues in Population and Food Policy. University Press of America, pp.178-171 (1979) Ackerman,J.S.,Client Expectations and Satisfaction with Community Mental Health Center Services: A Cross-Cultural Analysis Between Hispanics and Anglos. Published Doctor Dissertation,University of North Colorado. Copyright 1981. El ACE American Insurance Company Psychologists' ❑ ACE Insurance Company of Illinois ❑ Atlantic Employers Insurance Company Professional Liability Claims Made Insurance Policy Declarations (This Policy is issued by the stock insurance company listed above. Herein called "Company") BRANCH B/A PRODUCER NUMBER DATE OF ISSUE PRIOR CERTIFICATE NUMBER 273865 03/17/2006 PSYCHOLOGISTS PROFESSIONAL LIABILITY CLAIMS-MADE INSURANCE POLICY NOTICE: THIS IS A CLAIMS-MADE POLICY, PLEASE READ THE POLICY CAREFULLY PURCHASING GROUP POLICY NUMBER: 45-0002000 Item DECLARATIONS CERTIFICATE NUMBER: 58G22307137 1. Ackerman and Associates PC Named Insured 175025th Ave ADDRESS Greeley, CO 80634-4943 Number&Street,Town,County,State&Zip No.) 2. Policy Period: 12:01 A.M.Standard Time At From:05/01/2006 To: 05/01/2007 Location of Designated Premises 3. COVERAGE LIMITS OF LIABILITY PREMIUM Professional Liability $ 1,000,000 each incident $3,000,000 aggregate $ 1,437.00 4. BUSINESS OF THE NAMED INSURED: Psychology 5. The Named Insured is: 0 Sole Proprietor (including independent contractor) 0 Partnership C Corporation 0 Other: 6. This policy shall only apply to incidents which happen on or after: a) the policy effective date shown on the Declarations: or b) the effective date of the earliest claims-made policy issued by the Company to which this policy is a renewal; or c) the date specified in any endorsement hereto. 05/01/1992 7. This policy is made and accepted subject to the printed conditions in this policy together with the provisions, stipulations and agreements contained in the following form(s) or endorsement(s). 815polcov , PF-15215(03/04), PF-15217(03/04), CC-1K11d(04/02), PF-15238(03/04), PF-15230(03/04), PF-15241 (03/04), PF-15242(03/04), PF-15225(03/04), PF-15253(06/04), PF-15742 (06/04), PF-17914 Notice of Claim should be sent to: All other notices should be sent to: Claims Vice President Underwriting Vice President ACE USA ACE USA 140 Broadway, 401h Floor 140 Broadway, 41st Floor New York, NY 10005 New York, NY 10005 _ REPRESENTATIVE: Agent or broker: Potomac Risk Management Services, Inc. 181 W Madison St Ste 2900 Office address: Chicago, IL 60602-4643 City, State, Zip: PF-15215(03/041 TOM PAPPAS, LCSW 1624 Kirkwood Drive Ft. Collins, Colorado 80525 970-472-1315 EDUCATION 6/86 Masters Degree in Clinical Social Work, Simmons College School of Social Work,Boston,Massachusetts. 5/80 Bachelor of Arts Degree in Psychology and Secondary Education University of Lowell,Lowell,Massachusetts. EMPLOYMENT 10/04- Psychotherapist. Group practice with Ackerman and Associates, P.C. Individual, marital and family therapy. 3/94-10/04 Clinical Social Worker. Montrose Memorial Hospital Care Center Inpatient/Outpatient Services,Montrose, Colorado. Individual, family,marital and group therapy; discharge planning services. Co-therapist for geriatric partial-hospitalization program; supervisor for Masters Level student. 3/90-3/94 Senior Clinician. Justice Resource Center/The Butler Center, Westboro,Massachusetts. Individual, family and group therapy specializing in sexual offender treatment to adjudicated adolescent males in secure treatment facility. 11/864/89 Clinical Social Worker. New Bedford Area For Human Services, Inc., Children Services Unit. Individual, family and group therapy in outpatient setting. Co-therapist for latency-age girls' sexual abuse groups. 9/85-6/86 Social Work Intern. Beaverbrook Guidance Center,Waltham, Massachusetts. Individual, family and group therapy with children in outpatient setting. 9/84-5/85 Social Work Intern. Children's Hospital,Boston,Massachusetts. Individual, family and group therapy in pediatric out-patient setting. 12/81-5/84 Mental Health Counselor. Marlboro Hospital Mental Health Unit, Marlboro,Massachusetts. Individual, family and group therapy with adolescents and adults in inpatient psychiatric setting. 5/80-5/81 Mental Health Counselor. Littleton Girls House,Littleton, Massachusetts. Counseling to adjudicated adolescent females in secure treatment facility. TRAINING 2/01 Certificate in Level II EMDR Training. 5/91 Postgraduate Certificate in Advanced Psychotherapy With Children and Adolescents,Boston University,Boston,Massachusetts. REFERENCES AVAILBLE UPON REQUEST CNA HEALTHCARE PROVIDERS SERVICE ORGANIZATION PURCHASING GROUP CERTIFICATE POLICY OF LI FORM • aDD�9 12:e41AM Pro ' • 4Tktle :1� +1 I7 1624Pannasood Dr 150 Ea County vs Oggaa8an e Road Fort �Collins, CO 80525-2017 Hatboro, PA 19040-1216 3odd Code*72B60C��- 1►�•`` A. PROFESSIONAL LIABILITY Professional Liability(PL) $ 1,000,000 each claim $ 3,000,000 aggregate Good Samaritan Liebily included above Personal�ury Uabtlty Included above nelpiacentent Liability Included above B. COVERAGE EXTENSIONS: License Protection $ 25 000 Defendant Expense Benefit 10,000 aggregate tar ep per an 33 5,000 epprapate Assault 10,000 Per oddest $ 26,000 aggregate Medical F 2"000 100 000 _First Aid z� —Nigro➢ Damage to Property of Others 500 per inddent $ 10,000 aggregate C. YMORIWLACE LABILITY Comore pat C.Wanda UMW do..not rata Cannes part D.Game US It minds pat dais Color. Workplace Included In A.PL Int shown above Fire Wader Lie Included in A PL Yrr thown above urbjact to$150,000 sub-lima ,000,000 aggregate D. GENERAL LIABILITY Ccwre pad D.O m•miLU does nd slyly Menage pan D. :SatL nr.modspmeSt.poky. General t.iabiity(GL) none none iiWed Me&Wort OwnedArdo none Flre a Water Legal LIMN none none -ensonal UabNty vane Taal Premium: 288.00 • -• 'Z CALL: 14009024401 G-121500-C G-121503-C G-121501-C G-145184-A G-147292-A G-144872-A G-123846-005 Master Policy 1108711433 Keep this dammed in ssS penalised pout or paving arose ms d your rnaaNns..e ae. Chairman of the Board g y G-141241-A(07/2001) Coverage Change Date: Endorsement Change Date: Emily Montoya, M.A. Licensed Professional Counselor 1851 13th Avenue, Greeley,Colorado 80631 Home (970) 353-9361 * Cell (970) 545-0928*Office (970) 353-3373 Email: emilymontoya2003@yahoo.com EDUCATION • Master of Arts, Counseling University of Northern Colorado, Greeley, Colorado • Graduate Fellowship Study, Criminology Rutgers State University of New Jersey, Newark, New Jersey • Bachelor of Arts, Sociology/Criminology with emphasis in Psychology University of Northern Colorado, Greeley, Colorado PROFESSIONAL EXPERIENCE 2003-Present, Marriage Education Independent Consultant, Greeley, CO Deliver marriage education with the Prevention and Relationship Enhancement Program (PREP) to a Hispanic population nationwide that includes both faith and non-faith-based populations. Delivery of marriage education(PREP) and consultation services in high Hispanic populations (Los Angeles, CA, Orlando, Florida and Philadelphia,PA.) Provide consultation to national Hispanic serving organizations on strengthening Hispanic families and marriages. Deliver PREP curriculum as a master trainer candidate (New York Puerto Rican Institute). Provide marriage education program development and oversight to Saint Patrick Presbyterian Church, Greeley, CO. 1998-Present, Licensed Professional Counselor, self-employed,Ackerman I Associates, Greeley, CO. Provide intensive home-based family therapy to families involved in the Child-Welfare System with the Weld County Department of Social Services (WCDSS) and those families voluntarily seeking assistance from WCDSS. Provide foster parent training and consultation to foster families and children in Weld County placed in WCDSS foster care. Provide psychotherapy to children placed in the Weld County foster care system. Provide therapy to children and foster parent consultation to private foster care agencies (Lutheran Family Services). Provide therapy to clients under EAP, insurance, and private-pay sectors. Areas of expertise: Marriage and Family; families in transition, and Latino cultural issues. March 1996 - February 1999, Director, Ronald E. McNair Post-baccalaureate Achievement Program, University of Northern Colorado, Greeley, CO. Directed all efforts to ensure efficient administration of the McNair federal TRIO grant. The grant's targeted population was minority, low-income, first-generation college students. Received funding for the U.S. Department of Education McNair grant. Compiled, analyzed, and submitted annual performance reports to the U.S. Department of Education. Monitored McNair's near million-dollar budget over the program's four year funding. Supervised and trained staff members. Developed and directed all student scholar activities. Collaborated with campus departments in order to exceed program objectives. Directed the publishing of the "The McNair Scholars Journal." Identified, recruited, and selected program scholars. Ensured the completion of scholar's academic research projects. Provided academic advising and guidance to the scholars. Directed the academic year research seminar series, the residential Summer Research Internship, and other scholarly activities that prepared scholars for doctoral study. Coordinated research and scholarly actives between faculty mentors and McNair scholars. Lobbied in Washington,D.C. on continued funding for TRIO programs. Counseled scholars academically and personally. September 1995 -March 1996,Assistant Director, Ronald E. McNair Post-baccalaureate Achievement Program, University of Northern Colorado. Assisted in the implementation of the McNair Scholars Program. Facilitated the recruitment and selection of program scholars. Compiled and submitted federal reports. Informed and collaborated with campus offices and departments. Implemented an academic workshop series based on student needs. Provided academic advisement and guidance to scholars. January 1995 - September 1995, Assistant Coordinator of Academic Advising, Student Support Services, University of Northern Colorado. Provided academic advisement and guidance to federal TRIO Student Support Service students. Maintained student record database. Assisted with the compilation of federal student outcome reports. Served as liaison to the athletic department and the financial aid office. Assisted in the supervision of peer advisors. Provided technological assistance within the program. August 1994 - December 1994, Assistant Coordinator of Technology, Student Support Services, University of Northern Colorado. Supervised, evaluated and trained technology lab students. Provided technical assistance and advisement to federal TRIO Student support Service participants in a learning environment. RELATED EXPERIENCE 1985 — 1988,Admissions Office Assistant, University of Northern Colorado. Assisted in the daily operation of the UNC Admissions Office. Received and reviewed applications and distributed accordingly. Filed, typed, and performed data-entry on all incoming, transfer, re-entry, and non-traditional students. Trained and supervised work-study employees on office procedures, FERPA, and the CCHE Index system. Provided general information to incoming students and parents. 1995, Co-Instructor, Student Support Services, University of Northern Colorado. CSPA 359: Paraprofessionals in Student Affairs, Academic Peer Advisors. Co-facilitated the instruction of training of peer advisors who advised Student Support Service participants at the Center for Human Enrichment. Coordinated curriculum and instruction for pre-service and on-going training for a staff of fifteen peer advisors. January 1996-July 1996, Counselor Intern, North Colorado Medical Center, Greeley, CO. Facilitated psychotherapy counseling groups and individual counseling for chemically dependent and eating disordered patients. Performed case management from admission to discharge. Presented psychoeducational information to patients, family members, and staff. Designed a portfolio brochure distributed to health care and managed care providers. September 1994-February 1995, Clinical Care Assistant, Weld Mental Health Center, Greeley, CO. Monitored and supervised the daily activities of chronically mentally ill patients in a learning/self- development environment. Facilitated group and individual counseling sessions. Coordinated patient recreation activities. Prepared written and oral reports. PRESENTATIONS Participant: Hispanic Healthy Marriage Research Meeting, Washington, D.C. Panelist: Marriage Forum, Colorado Springs, Successful Marriage Education Programs Presenter: Esperanza USA, The Prevention and Relationship Enhancement Program, Philadelphia, PA, Orlando, FL, Los Angeles, CA. Saint Patrick Presbyterian, The Prevention and Relationship Enhancement Program, Greeley, CO. Puerto Rican Family Institute, The Prevention and Relationship Enhancement Program, New York City, NY. Moderator: University of Northern Colorado, "Research and Policy Affecting the Education of the Mexican Child in the 21st Century." Panelist: Colorado State University "Minority Students in Graduate School." Presenter: Ackerman Sr Associates, "Perspectives on Treating Cultural Diverse Populations." Instructor: Centennial Area Health Education Center, Greeley, CO, "Children of Divorce/Stepchildren: Feelings, Thoughts, Behaviors, and Interventions for Children and Adults of Divorce and Stepfamilies." Instructor: Centennial Area Health Education Center, Greeley, CO, "Children of Divorce: Helping Stepfamilies Succeed." Presenter: University of Northern Colorado: Cultural Sensitivity and Awareness Hispanic Women in Higher Education Communicating Across Cultures Financing a Graduate Education How to Help Someone with an Eating Disorder, National Eating Disorders Week Presenter: North Colorado Medical Center Cultural Sensitivity and Awareness Communicating Across Cultures Conflict Resolution and Communication Skills Setting Limits and Boundaries Family Dynamics in Substance Abuse An Overview of Eating Disorders Presenter: Weld County Foster Parent Program The Terrific Twos! Prenatal Insults and Long-Term Effects Social, Emotional and Sexual Development: Infancy through Adulthood Cognitive and Physical Development: Infancy through Adulthood Parenting with Love and Logic An Overview of Eating Disorders Officer/Member Board Member, Strong Marriages Northern Colorado Board Member, The Redeemer Project Mentor, Escalante At-Risk Youth Program Weld County Mental Health/Substance Abuse Coalition Professional and Administrative Staff Council, UNC Co-chair,Student Advisory Committee,Cesar Chavez Cultural Center, UNC Undergraduate Research Council,UNC Cesar Chavez Cultural Center Advisory Council, UNC Relations with UNC Board of Trustees Committee, UNC Salary Equity Committee, UNC Exempt Staff Evaluation and Performance Committee,UNC Team UNC Fund Raising Committee Academic Excellence Week Task Force, UNC Continuing Education/Training Prevention & Relationship Enhancement Program (PREP) Love Without Hurt: Compassion Power The Relationship Enhancement Program Premarital Inventories: A User's Guide Imago: Couplehood as a Spiritual Path Remarriage Preparation Divided Selves: Children of Divorce Designing Stepfamilies Play Therapy and Therapeutic Care Reaching Children Through Play Therapy Advanced Play Therapy Internship Family Preservation Basic & Advanced Dialectical Behavioral Therapy Jurisprudence for Psychotherapists Grant Writing and Evaluation Diverse Learners Academy Fire Starters Training and Prevention Counseling At-Risk Students Parent/Child Hispanic Leadership Supervised Practicum in Family Preservation Cultural Diversity Conference Yours, Mine, and Ours: Stepfamily Finances Honors/Awards Featured in New York Times: Stepfamilies (2004) Featured in Redbook Magazine: Spiritual Marriage (Print Date: December 2005) Hispanic Leader of the Year, Cesar Chavez Cultural Center, University of Northern Colorado Keynote Speaker, Latina Youth Leadership Conference, University of Northern Colorado Distinguished Alumni, Department of Sociology, University of Northern Colorado Fellowship, Graduate Study, Rutgers State University of New Jersey , 1993 Scholarship, National Hispanic Scholarship Fund Scholarship, Candelaria Scholarship PERSONAL- DATA SHEET Identifying Information: Name : Laurence "Larry" P. Kerrigan , Ph . D . Address : 1706 19th Avenue Greeley , CO 80631 DOB : 9/20/32 Phone : L3.Q-31353-3373 - business Degrees : BSC - Business Economics , from Creighton University , 1954 . MS - Economics , from St . Louis University , St . Louis , Mo . , 1963 . MA - Theology , from St . Mary ' s University , Regis College Campus , Toronto , Ontario , Canada, 1967 . Ph . L . - Philosophy , St . Louis University, St . Louis , Mo . 1960 , ( Ecclesial Degree ) . Ph . D. - California School of Professional Psychology , Berkeley/Alameda Campus , 1974 , Clinical Psychology. Currently a licensed psychologist in the state of Colorado . Educational Background : 1950-54 Creighton University , Business economics , 1954-56 Marquette University, Milwaukee , WI . , Classical studies and ascetical theology, 1956-57 Springhill College , Grand Coteau LA. Campus , Classical studies , 1957-60 St . Louis University , Philosophy and Economics , 1963-67 St . Mary ' s University, Toronto Campus , Theology, 1971 -74 California School of Professional Psychology , clinical psychology , Berkeley/Alameda Campus Positions Held : 1969-71 Member of Board of Directors , Campion College , Prairie du Chien, WI . 1968-71 Director, Department of Psychology , Campion College . 1971-74 Director of Student Counseling Center , Long Mountain College . 1975-80 Director of Short-term Children and Family Team, Weld Mental Health Center , Greeley , CO . 1975-'87 Clinical Psychologist , Child and Family Team , Weld Mental Health Center , Greeley , CO . r 1975-88 Co-founder of Weld County Child Protection Team, 1987-88 Member of Executive Board, Weld Mental Health Center , Greeley, CO . Honors Received : 1968-69 and Teacher of the year, Campion College . 1970-71 1972-73 Class Representative to Campus Executive Committee , and California School of Professional Psychology 1973-74 Work and Experiential Background : 1959-60 Counselor at Dismas Halfway House for ex-convicts , St . Louis , Missouri , 1960-63 Teacher-counselor-coach, Marquette Prep High School , Milwaukee , WI . 1964-67 Counselor-therapist at Street Haven and Sancta Maria Halfway Houses for women and at the Don ( metro ) Jail in Toronto , Canada. 1967-68 Teacher and Campus Counselor at Creighton University , Omaha, NB. 1968-71 Teacher at Campion College , Prairie du Chien , WI . , Director of Psychology Department , Department chairman . 1970- 71 Director and Staff member of a total environment for Inter-city boys , late grade school age from Milwaukee , WI . 1971-73 Director of Student Counseling , Lone Mountain College , San Francisco , CA. Teacher at the Lone Mountain College , San Francisco , California. 1973-74 Psychologist Trainee at San Francisco Mental Health Center , Richmond District , Outpatient Care . 1974-75 Private Practice , So . Bay Human Services Center, San Diego , CA. Part-time instructor at/California School of Professional Psychology , San Diego , CA . r a 1,975-80 Director , Short-Term Therapy Team , Children and Family Unit , Weld Mental ❑ealth Center , Greeley , CO . • 1980-87 Member of Children and Family Therapy Team , Weld Mental Health Center , Greeley , CO . 1987- present Full time private practice with Joyce Shohet Ackerman , Ed , D . , Licensed Psychologist , Greeley , CO . Part time practice at Weld Mental Health Center , Greeley , CO . Publication : Kerrigan , Laurence P . - The Relationship Between Therapist and Client ' s Perceptions of One Therapy Session . Published Doctoral Dissertation , University of California School of Professional Psychology . Copyright , 1974 . Worksl,o arnL _ peci.al __'fraifring: Since 1974 , I have attended an average of• about three workshops per year . Most of these workshops have presented specialized training in the following areas : Neuro-linguistic training , Autogenic and relaxation training , Visualization-Imagery- Hypnosis , Cognitive-Behavioral Therapy , Ericksonian approaches to hypnotherapy and psychotherapy, Family therapy, Strategic family therapy , Sexual abuse , dynamics and applied treatment , Paradoxical intention psychotherapy , and other related areas . In the last fifteen years , I have taught classes and conducted workshops in the following subjects : The Psychology of Dreams Emotional and Physical Health through Visualization and Imagery Western Psychotherapies and Eastern Ways of Liberation Cognitive and Behavioral Therapy Hypnosis in Pain and Habit Control The Psychology of Consciousness and Meditation r gqDARWIN NATIONAL ASSURANCE COMPANY 12/01/06 - A PSyChTHIS 7S A CLAIMS MADE POL CY PLEASE Liability Policy NOTICE: A LOWER LIMIT OF LIABILITY APPLIES TO JUDGMENTS OR SETTLEMENTS WHEN THERE ARE ALLEGATIONS OF SEXUAL MISCONDUCT(SEE THE SPECIAL PROVISION"SEXUAL MISCONDUCT"IN THE POLICY). DECLARATIONS POLICY NO: 501-0006485 ACCOUNT NO: CO-KERL175-0 0099745C ITEM 1. (a)NAME AND ADDRESS OF INSURED: ITEM 1. (b)ADDITIONAL NAMED INSUREDS: LAURENCE P. KERRIGAN, PH.D. 1750 25TH AVE. • SUITE #101 GREELEY, CO 80634 • TYPE OF ORG: INDIVIDUAL ITEM 2. ADDITIONAL INSUREDS: ITEM 3. POLICY PERIOD: FROM: 12/01/06 TO: 12/01/07 12:01A.M.STANDARD TIME AT THE ADDRESS OF THE INSURED AS STATED HEREIN: ITEM 4. LIMITS OF LIABILITY: (a)$ EACH WRONGFUL ACT OR SERIES OF CONTINUOUS,REPEATED 1, 000, 000 OR INTERRELATED WRONGFUL ACTS OR OCCURRENCE • (b)$ 5, 00 0 COSTS RELATED TO ANY SINGLE PROCEEDING (c)$ 3 , 000, 00 0 AGGREGATE,FOR ALL CLAIMS AND ALL PROCEEDINGS ITEM 5. PREMIUM SCHEDULE: -NiJMBER - RATE ANNUAL,PREMIUM CLASSIFICATION 1ST PSYCHOLOGIST 1 1191. 00 1, 191 . 00 DEFENSE LIMIT . 00 ITEM 6. RETROACTIVE DATE: 12/01/91 TOTAL PREMIUM: 1, 191. 00 ITEM 7. EXTENDED REPORTING PERIOD ADDITIONAL PREMIUM(if exercised):$ 2 , 084 . 00 NO DISCOUNT INCLUDED ITEM 8. POLICY FORMS AND ENDORSEMENTS ATTACHED TO THIS POLICY PRGE2000 (3/2006) PRGe1070 (1/2006) THIS IS NOT A BILL.PREMIUM HAS BEEN PAID. AU RIZED COMPANY REPRESENTATIVE PRGE2005(3/2006) Americ rofessional Agency 95 Broadway,Amityville,NY 11701 FACULTY N ITA May,2006 NAME: BROMLEY,Susan Plock SOCIAL SECURITY NUMBER: 483-50-9243 POSITION: Associate Professor of Psychology Department of Psychology College of Arts and Sciences University of Northern Colorado Greeley,CO 80639 HOME ADDRESS: 1621 13th Avenue Greeley,CO 80631 TELEPHONE: Office:(303)351-2236 Home: (303)352-8750 EMAIL:sbromley@earlhliek•net EDUCATION: Area of Study Year(sl Institutes 1983 PsyD University of Denver Clinical Psychology School of Professional Psychology Denver,Colorado 1968 MSSA Case Western Reserve University Casework (MSW) School of Applied Social Sciences Cleveland,Ohio 1965 BA Mt Holyoke College Economics/Sociology South Hadley,Massachusetts WORK EXPERIENCE—Professional Academic Years) Institution/Oraanintion Mika! Responsibilities 1996-Pres University of Northern Colorado Assoc.Professor Psychology Teaching/Research 1985-96 University of Northern Colorado Asst Professor Psychology Teaching/Research 1983-84 University of Northern Colorado Asst.Professor Psychology Teaching WORK EXPERIENCE—Professional Non-Academic: Year(s) Institution/Organization Position Responsibilities I996-present Ackerman and Associates Psychologist Clinical 1984-85 Kaiser Permanente Psychotherapist Clinical Lakewood,Colorado 1979-80 Bethesda Mental Health Center Psychology Intern Clinical/ Denver,Colorado Administrative 1968-79 Denver General Hospital Clinical Social Worker/ Clinical/ Denver,Colorado Supervisor Administrative AREA OF SPECIALIZATION: Behavioral Medicine/Pain Management/Clinical Hypnosis/EMDR RESEARCH AREAS/INTERESTS: Hypnosis/Pain Assessment and Management/Women's Issues/Teaching Methods 1 PROFESSIONAL ACTIVITIES: Colorado Licensure: Psychology License#1086 PUBLICATIONS—Professional/Juried: and sttbstarce Musgrave-Marquart,D.,Bromley,S.P.&Dailey,M.B.(1997).'Personality,academicn attribution, nty. abuse as predictors of academic achievement in college students'. 501-511. Karlin,N.J.and Bromley,S.P.(1996).Differences in caregivers of demented and lucid chronically ill family members. American Journal of Alzheimer's Disease 11(5)3945. Retr1aff,P.and Bromley,S.(1994).Counseling personality disorders.in Ronch,I.L.,VanOrnum,W.&Stillwell, N.C. (Eds)The counseling sourcebook:A practical reference gp contenlporary issues. New York:Crossroad Publishing group.pp.466-474. Bromley,S.and Hewitt,P.(1992). Fatal attraction:The sinister side of women's conflict about career and family. Journal of Popular Culture.26(31 pp. 17-24. Retzlaff,P.and Bromley,S.(1991). "A Multi-Test Alcoholic Taxonomy:Canonical Coefficient Clusters". Journal of Clinical Psychology.47(21,pp.299-309. Bromley,S.P.(1985). "Treatment of Pain:Theory and Research"in Zabourek,IL(Ed.).Clinical nfid Therapeutic Suggestion. New York:Gnme and Stratton. Reprinted in Zahourek,R(Ed.)(1990). New York:Bruler/Mazel,Inc.,pp.77-98.. PROFESSIONAL PRESENTATIONS—Jrrie& Touchton,M.A.&Bromley,S.P.(2000).Complementary/alternative medical use among undergraduates at the University of Northern Colorado. Poster session presented at the Rocky Mountain Psychological Association,Tucson, AZ.(April). Nickisson,J.W.and Bromley,S.P.(1999)'Hypnosis:Attitudes,knowledge and experience among psychology and nursing students".Paper presentation et the American Psychological Association Convention,Boston.(August) Bromley,S.(1998)Hypnosis,psychology and managed care.In S.Bromley(Chair)Complanwtary,nontraditional and indigenous healing practices. Symposium conducted at the combined meetings of the Western and Rocky Mountain Psychological Associations,Albuquerque.(April) Bromley,S.(1998).Complementary healing methods:A psychological and artistic exploration.in L.Wickerlgren (Chair).Interdisciplinary courses involving psychology:A sampler. Symposium conducted at the combined meetings of the Western and Rocky Mountain Psychological Associations,Albuquerque.(April) Campbell,J.S.,Titus,J.and Bromley S.P.(1998).'Neuroanatomy teaching technique for introductory psychology students. Poster presented at the joint WPA/RMPA convention,Albuquerque,NM.(April) Bromley,S.(1997)(Chair)"Linking through honors programs:The cross-discipline course).Paper presentation as part of a symposium titled"Creating links between psychology and other disciplines".,American Psychological Association Convention,Chicago.(August) Bromley,S.,Gilliam 11,&Johnson,T. (1995). 'Assessment of student created tests as an evaluation method'. Poster presented at the American Psychological Association Convention,New York City.(August) Bromley,S.(1994). "Student created tests as an evaluation method". Poster presented at 16th Annual National Institute on the Teaching of Psychology,St.Petersburg,Florida. Karlin,N.and Bromley. S.(1992).'Similarities and differences for caregivers of demented and lucid chronically ill'. Poster presented at the Rocky Mountain Psychology Association Convention,Boise,Idaho.(April) Montoya,K.J.and Bromley,S.(Chair)(1992).'Changes in undergraduate counseling styles in an introductory 2 counseling theories course". Paper presented at the Rocky Moulin Psychology Association Convention,Boise, Idaho(April) Bromley,S.(1992)."Connected learning methods to faciliate research understanding". Paper presentation as put of panel titled,'Teaching techniques in the social sciences',Western Social Science Association Convention,Denver, Colorado.(April) Bromley,S.,Ramirez,S.,and McCoy,J.(1991)."Impact of a health psychology course on student health beliefs". Poster presented at the Rocky Mountain Psychology Association Convention,Denver,Colorado.(April) Karlin,N.and Bromley,S.(1991)."Support,burden and affect among caregiver of dementia and nondementia patients". Poster presented at the American Psychology Association,San Francisco,California.(August) Bosley,G.and Bromley,S.(1990). Post death ritual in a Colorado community. Paper presentation at the American Psychology Association,San Francisco,California.(August) Bromley,S.(1990). "Husbands at Childbirth:Who Does It Help?"Paper presentation at Far West Popular Culture Association,Las Vegas,Nevada(January). Hewitt,P.and Bromley S.(1989). "Images of Work and Intimacy in'Turning Point'and'Fatal Attraction"'. Paper presentation National Convention of Popular Culture Association and American Culture Association,St.Louis, Missouri.(Session Char) Itetzlaf P.and Bromley,S.(1989). "The Basic Personality inventory:Alcoh Sub-Group Identification". Poster session at the Joint Convention of the Rock Mountain Psychological Association and Western Psychological Association,Reno, Nevada. Bromley,S.(1988). "Our Culture Affects Our Pain."Paper presentation,National Convention of Popular Culture Association and American Culture Association,New Orleans,LA.(March). Bromley,S.(1987). "Husband-Assisted Autohypnosis for Labor and Delivery: A Clinical Model". Paper presented at Rocky Mountain Psychological Association,Albuquerque,New Mexico(April). Bromley,S.and Loy,P.(1987). "Politics of PMS". Paper presentation Association of Women Psychologists,Denver, Colorado(March). PROFESSIONAL PRESENTATIONS—Invited• Bromley,S.P.&Caoales,G.(2000).Issues in presenting information on bisotircally underrepresented groups in the classroom.Symposium conducted at the Rocky Mountain Psychological Association,Tucson.(April). Strongin,D.&Bromley,S.(1999).Student and faculty reactions to the introduction of a graduate ethics course. in Miller,R.(Chair)Ethics in college teaching. Symposium conducted at the Rocky Mountain Psychological Association,Ft Collins,CO(April) Bromley,S.(1999).Issues of religion and spirituality with therapists and clients.In S.Bromley(Chair)Religion and spirituality hi research,practice and the classroom.Symposium conducted at the Rocky Mountain Psychological Association,Ft Collins,Co(April) Handelsman,M.M.,Bromley,S.P.&Davis,S.F.(1995).'Clinical Psychologist,Counseling Psychologist,Clinical Social Workder,or Psychology Professor.Which Degree is Right for Me?Psi Chi invited panel presentation,Rocky Mountain Psychological Association,Boulder,CO(April). Bromley,S.(Co-Chair),Seibert,P.(Co-Chair),Knuckey,D.,Bohlin,M.,Zaweski,C.,Watson,D.,Hammon,D., West,K.&Robins,J.(1994). "Training the Teaching Assistant'Invited Panel Presentation,Rocky Mountain Psychological Association,Las Vegas,Nevada(April) Bromley,S.(1993). "Hypnosis in Dentistry."Presentation at Monthly Meeting of Weld County Dentistry Association,Greeley,Colorado(February). 3 Bromley,S.(1993). "Learning about the author as a way to understand research." Presentation at"Teaching Take Out",CTUP Special Event. WPA/RMPA Convention,Phoenix,Arizona(April). Allen,M.and Bromley,S.(1993). Co-Chairs Two CTUP Special Event Sessions, ke Out Experiences in Collaborative Learning",Western Psychological Association/Rocky tion Convention,Phoenix,Arizona(April). Bromley,S.(1993). Chair,Invited Symposium,"Psychological and Social Perspectives on Male Violence Against Women",Western Psychological Association/Rocky Mountain Psychological Association Convention,Phoenix, Arizona(April). Bromley,S.(1992).•Enhancement of student research and writing skills in any course". CTUP Workshop presented at the Rocky Mountain Psychology Association Convention,Boise,Idaho.(April) Bromley,S.and Karlin,N.(1992). 'General and health locus of control of adult caregivers". Poster session at the UNC Research Forum,Greeley,Colorado. Bromley,S.(1992). Panel member in Mental Health Symposia for Victim Compensation Convention as part of the Colorado Organization for Victim Assistance Conference.(Estes Park/October) Bolocofski,Bromley,Foster and Mean(1988). "Hypnosis:Research and Clinical Perspectives,"symposium presentation,Colorado Psychological Association,Greeley(March). Bromley,S.(1986). "Pain:A Psychological Event". Presenter-20th Annual Emotional Crisis Workshop,University of Northern Colorado,Greeley,Colorado(July). LECTURES--Invited: Bromley,S.(1998)'Psychological methods of pain control'Invited lecture for the annual meeting of the Weld County Arthritis Society. Bromley,S.(1998). `Hypnosis for pain control of arthritis"Invited lecture for"Brown Bag'lunch series sponsored by the Greeley Medical Clinic. Bromley,S.(1998)"Headache Control-Psychological Methods". Invited lecture as part of a seminar titled"Coping with headache". Sponsored by the Greeley Medical Clinic. Bromley,S.&Ackerman J.(1998)."What to do to handle burnout'A workshop conducted for foster parents working with Weld County Social Services. Bromley,S.(1995).Keynote speaker for Golden Key Honor Society Induction Ceremony,University of Colorado, Boulder,Co.(November) Bromley,S.(1992). Keynote speaker for Sophomore Honor Society Induction Ceremony. Bromley,S.(1991)Featured speaker. UNC Acadmic Honors Convocation.(April) Bromley,S.(1991)..Banquet speaker Emotional Crisis Workshop,Greeley,Colorado.(July) GRANTS: Bromley,S( 1994)Honors Grant($500)to attend research training at the Society for Clinical Hypnosis meeting,San Francisco(October) Bromley, S.(1994). Research and Publications award of$1500.00. "Assessment protocols to measure the efficacy of hypnotic treatment for injured workers. Karlin,N.and Bromley,S.(1990). Research and Publications award of 52,4440.00."Control,support,burden and 4 affect differences among dementia and non-dementia caregivers'. BOOK/GRANT REVIEWS: of Education(1995) Grant review for Boise State Deparmtent Review of Santrock,J.(1991). The science of mind and behavior. W.C.Brown aownnBenclunark. o Colorado Press. Review of McKee,P.&Thiem,J.(1993).Real life:Ten stories of aging.University PROFESSIONAL CONSULTATION/PRACTICE: Bag Institution/Organization Clinical Psychologist 1988 preset Bonerman and Associates Pain Management Consultant and Trainer 1988 Bonnet Good DentaSamal Carean Center Consultant in Pain Management 1984-85 Denver Metropolitan waAssociation Dental e i al Therapists Hypnosis for Pain Management Consultant 1984 Iowa of Registered Physical And Teacher ROFESSIONAL ASSOCIATION PARTICIPATION: 198 present Rocky Mountain Psychological Association 1988-present American Psychological Association(Divisions 2,30,35) 1989-96 Greeley Area Mental Health Network 1987-88 Association of Women in Psychology 1980-89 Colorado Psychological Association 1988 CPA Program Committee Member for Spring Meeting--Greeley Coordinator SERVICE: EXTERNAL' NATIONAL SERVICE: 1994-2003 Rocky Mountain Coordinator-American Psychological Association,Division 2-Teaching of Psychology 1992-94 Co-Chair,Rocky Mountain Region Council of Teachers of Undergraduate Psychology(CIUP)• 1991-94 Mountain States Regional Academic Coordinator,Golden Key National Honor Society REGIONAL/STATE SERVICE: 2000-Moderator for G.Stanley Hall Lecturer-Dweck,C.(2000).Motivation and the self. Presented at the Rocky Mountain Psychological Association Convention,Tucson.(April) themes 1999•Moderator for G.Stanley Hall Lecturer Unifying-Viney,W.(1999).A larger canopy for psychology: fyntB and pragmatic empiricism.Presented at the Rocky Mountain Psychological Association Convention,Ft. Collins,CO(April) 1989-present Rocky Mountain Psychology Association 1998-pram Ex-Officio Board Member As Division 2 Coordinator 1992-1998 Board Member 1995-1998 Elected Chair,Groups Under-Represented in Psychology Committee 1992-94 Co-Chair,Groups Under-Represented in Psychology Committee 1991 Coordinator of Student Volunteers,RMPA Convention,Denver,Colorado. 1995 Psychology Chair-CCHE Faculty to Faculty Conference(October) COMMUNITY SERVICE: 2005-Preset Member Weld County Centennial Critical Incident Stress Management Team 2003-presets Board Member Weld County Area Agency on Aging 1999-present Member Weld Senior Wellness Program Evaluation Committee 1999-2000 Member,Weld County Area Agency on Aging,Grandparenting Committee 1998-present Member,Weld County Medical Society Commitee on Alternative and Complementary Healing 1997-1998 UNC Loaned Executive-United Way of Weld County 1997 Mental Health Pro Bono Workshop,'Commtmication in the Workforce" 1991- 1996 Board Member, 19th Judicial District Victim Compensation Board 1995-96 Chair 5 1990.93 Board Member,Weld County Area Agency on Aging 1992-93 Chair 1991-92 Vice-Chair and Liability Underwriters/Insurance Institute Exam Supervisor-American Institute for Property of America 1987-present Clinical Psychologist-pro-bono work with individual clients and commtmity training DITERNAL: DEPARTMENTAL: 1993-present Member,Department Executive Committee 2000-present Advisor Psi Chi National Honor Society 1995-1999 Co-Advisor Psi Chi National Honor Society into clinicaUcotmselingguad programs. 1996-present Guest lecturer for Psi Chi Grad Night on getting 1989-91,93, 1995-1998 Department Representative,CCHE Faculty to Faculty Conference 1987-94 Department Representative to graduation ceremonies 198644 Library Representative 1983,86 89, 90-93,97,98 Member,Faculty Search and Screen Committee au Committee(Chair 1992) 1990-92 Member,Psychology Department 1987-88 Co-Coordinator Semester Conversion Cotmnittee COLLEGE: 1992,93,96,97 Member of faculty invited to teach in the Cluster Program 1990-93 Graduation Marshall,Arts&Sciences 1988-89 Member,Arts and Sciences Teacher Education Committee or in the College 1986-89 Chair,Interdisciplinary Committee to develop and revise Human Development Major of Arts and Sciences and Psychology Department • UNIVERSITY: 1992-94 1996-99 Member-Research and Publications Board 1993-94 Chair-Elect 1988-99 Founding Co-Advisor,Golden Key Honor Society 1992-95 Member-UNC Women's Commission 1992-94 Co-Chair-Assessment Task Force 1989-90 Faculty Representative,Student Fee Allocation Committee 1986-89 Member,Faculty Senate 1988-89 Secretary 1987-88 Vice-Chair 1986-87 At-Large Member,Executive Committee 1986-89 Member,Academic Policies Committee 1986-87 Member,Elections Committee 1988 Representative,Western States Faculty Leadership Conference,Reno, 1988 Senate Representative,Statewide Commission Advisory Committee 1988 Advisor,In-Touch Helpline 1985-86 Volunteer Therapist,UNC Counseling Center GRADUATE STUDENT COMMITTEES—Doctoral: 1998-99 Committee Member,Shu-Shin Lu,Professional Psychology,'Using Metaphor in Child Counseling in Taiwan' 1997-00 Committee Member,Christine Rogers,Professional Psychology,'A Qualitative study of the experiences of pastor's wives. 1995-1997 Committee Member,Lisa Ing,Special Education 1994-pres Committee Member,Marla Gallagher,Educational Psychology 1993 Committee Member,Hsiu-Lan Ma,Science Ed.-Oral Comprehensives 1993 Committee Member, Jerry Buford,School Psychology,'Treatment of depressive symptoms of 6 early adolescents'. of attitudes and practices of 1993-1998Canmittee Member,Pat Flanagan,CSPA,Orals,"A comparison teaching faculty regarding student academic dishonesty at a two year and four year institution". 1991 Committee Member,Mike Propriano,School Psychology 1990-94 Committee Member,Paul Jana,School Psychology, 1989 Committee Member,Mike Peters,Vocational Rehabffiation,'The Effectiveness of Vocational Evaluation for Various Disabling Conditions of Free Association in Virginia 1987 Committee Member,Ane Marie Kajenckii,English,'The Concept Woolf s The Waves" 1986 Committee Member,Fuming Liao,Mechanical Kinesiology,'Development and Validation of a Method for Providing Immediate Feedback information on Speed and Angle of Release in Shotpntting" GRADUATE STUDENT COMMITTEES—Masters: 2001 Jeremy Ehmke,Chair 1999-00 Jennifer Lawrence,Committee Member 1998-99 Vanessa Ewing,Committee Member 1997 Stephanie Blasi,Committee Member 1997 John Nickisson,Chair 1994 David Watson,Committee Member 1994 Tiernan Mcllwaine,Committee Member 1994 Jerrod McCoy,Committee Member 1993 Sheldine Runyan,Committee Member Goals of Selected Male and Female College 1993 Sue Cole,Committee Chair, Influences on Occupational Students'. 1990 Jerry Benner,Committee Member of Pre-Employment and Random 1990 Kurds Armstrong,Committee Member,'Attitudinal Consequences Employee Drug Testing" 1989 Michelle Honor,Committee Member 1989 Anne Schmittgnnd,Committee Chair,"Age and Electrothermal Biofeedback Training". 1988 Cheni Hockett,Committee Member,"The Effects of Turnover on Those Who Remain in an Organization" 1988 Tony Ambrosio,Committee Member,"The Belief in a lust-World and the AIDS Epidemic: Predictors of Attitudes Towards individuals with AIDS" 1988 Steve Foster,Committee Chair,"Hypnotic Susceptibility As a Function of Locus of Control and Director Indirect Inductional Deepening and Suggestion Style" 1988 Lisa Dillon,Committee Chair,"Cognitive-Behavioral Approach to the Treatment of Elderly Rheumatoid Arthritis Subjects" 1987 Deanna Holmes,Committee Member 1987 Darlene Nold,Committee Member,"Reading and Writing Assessment Tests as Predictors of Success in the Basic Peace officer Academy at Aims Community College" 1987 Dan May,Committee Member 1986 Jeff Schiels,Committee Member,"The Reformulated Hypothesis:Is its dominator of Learned Helplessness Literature Justifiable? 1986 Linda Coulthard-Morris,Committee Member,"Biofeedback of Cortical Slow Wave Potentials, Hand Temperature and Muscle Tension in Normal and Attention Deficit Disorder with Hyperactivity Children" TEACHING: Honors Activities; 2000-pAnna Cornier,Jennifer Donnelly 2000-prsntl7nesis Co-coordinator,Stephanie Price,Allison Osag, 2000-prsntThesis Co-advisor,Shansi Pepper,'Hindsight bias and prejudice against homosexuals' 2000-prsntThesis Advisor,Angela Hanson,'Effects of aromatherapy on attention' 2000 Thesis Coordinator,Cindy Mitchell,Christin Hillyer,Angela Hanson 1999 Thesis Advisor,Melissa Touchton"Complementary/alternative medical use among undergraduates at the University of Northern Colorado'. 1999 Thesis Advisor,Sarah Painton.'Early parent loss in terms of maintaining a connection with the deceased. 1999 UNC Research Day, Faculty Panel Coordinator,'Complementary Healing Methods" 7 1999 Thesis Coordinator-Kristin Pietryzick,Jennifer Kimberling,Cristine Dickey 1997 Thesis Co-Advisor Kelly Kinser."An evaluation of the city of Greeley community outreach program". 1997 Honors Connection Course development-Alternative Healing Methods 1996-pros Honors Co-Coordinator,Psychology Department 1989-94 Honors Coordinator,Psychology Department Personality Traits,Alcohol,Caffeine, 1994 Thesis Co-Advisor, Diane Musgrave,'The Relationships Among and Nicotine Consumption,and Academic Performance in College Students" 1994 UNC Remark Day,Faculty Panel Coordinator,"Hypnosis:Theory and Research" Serving Women and 1993 UNC Research Day,Faculty Panel Coordinator,"Non-traditional Theories of Therapy Minorities". 1993 Thesis Co-Advisor,Linda Norton',"Clozapine and Event Related Brain Potentials in Schizophrenics" 1992 Thesis Advisor,Deborah Knuckey,"The Effect of Touch on AffectAmong Strangers Under Mildly Stressful Conditions' 1992 UNC Research Day, Faculty Panel Coordinator 1992 UNC Research Day, Faculty Panel Coordinator(2 student panels)'Sex Roles and Psychology", The Power of Social Influence 1989 Thesis Advisor,Geri Bosley,"Post Death Ritual in a Small Colorado Cotntntmity" 1988 Thesis Advisor,Pam Clasen,"The Use of Relaxation and Imagery Techniques in Pain Management" 1989&97 Honors Connection Course Development Courses Taught:(1-4 Scale with 1 as Highest)('1-5 Scale with 5 as highest) HRS ENR AVG.RATING DATE COURSE TITLE W 198 8 PSY 101 IntroSeminar Psychology 1 43 — W 1987 PSY 101 InhoSeminar Psychology 1 16 1.12 W 1986 PSY 101 IntroSeminar Psychology 1 32 1.24 F 1997 PSY 120 Principles of Psychology 4 107 3.76 F 1996 PSY 120 Principles of Psychology 4 139 F 1993 PSY 120 Principles of Psychology 4 119 1.64 F 1991 PSY 120 Principles of Psychology 4 161 1.67 F 1983 PSY 120 General Psychology 3 42 -- Sp 1984 PSY 121 Intro to Psychology I 4 40 --- Sum 1988 PSY 230 Human Growth &Development 5 60 55 -- Sp 1988 PSY 230 Human Growth &Development 1.58 W 1988 PSY 230 Human Growth &Development 5 90 1.38 F 1987 PSY 230 Human Growth &Development 5 45 1.54 W 1987 PSY 230 Human Growth &Development 5 75 1.54 Sp 1987 PSY 230 Human Growth &Development 5 90 — Sum 1986 PSY 230 Human Growth &Development 5 47 F 1986 PSY 230 Human Growth &Development 5 80 1.36 W 1986 PSY 230 Human Growth &Development 5 80 I A2 W 1986 PSY 230 Human Growth &Development 5 52 1.27 F 1985 PSY 230 Human Growth &Development 5 56 1.53 F 1985 PSY 230 Human Growth &Development 585 1.56 26 Sp 1984 PSY 265 Social Psychology 3 23 -- 3 47 -- W 1984 PSY 265 Social Psychology F 2000 Pay 323 Health Psychology 4.23 3 46 F 1999 PSY 323 Health Psychology 3 40 3.3.99 Sp 1998 PSY 323 Health Psychology 3 39 4.08(SRC 4.08) 1 F 1998 PSY 323 Health Psychology Sp 1997 PSY 323 Health Psychology 3 44 4.37 F 1995 PSY 323 Health Psychology 3 47 Sp 1994 PSY 323 Health Psychology 3 41 1.69 F 1992 PSY 323 Health Psychology 3 49 Sp 1992 PSY 423 Health Psychology 3 42 1.69 F 1990 PSY 423 Health Psychology 3 1.66 F 1988 PSY 423 Health Psychology 3 35 1.36 Sp 1986 PSY 330 Child&Adolescent Psych 3 27 1.4 8 Sp 1993 PSY 331 Maturity&Aging 3 40 Sp 1991 PSY 331 Maturity &Aging 3 46 1.62 F 1989 PSY 331 Maturity &Aging 3 23 1.45 F 1988 PSY 331 Maturity &Aging 3 27 1.40 Sp 1988 PSY 430 Maturity&Aging 3 44 1.58 Sp 1987 PSY 430 Maturity&Aging 3 34 — Sp 1986 PSY 430 Maturity&Aging 3 36 1.52 F 2000 PSY 455 Abnormal Psychology 3 52 4.47 Su 2000 PSY 455 Abnormal Psychology 3 21 4.16 Sp 2000 PSY 455 Abnormal Psychology 3 52 4.06 Su 1999 PSY 455 Abnormal Psychology 3 4.72 F 1999 PSY 455 Abnormal Psychology 3 45 3.83 Sp 1999 PSY 455 Abnormal Psychology 3 4.17 F 1998 PSY 455 Abnormal Psychology 3 49 4.27 Sp 1997 PSY 455 Abnormal Psychology 3 49 4.03 Sp 1996 PSY 455 Abnormal Psychology 3 4.43 F 1995 PSY 455 Abnormal Psychology 3 32 Sp 1993 PSY 355 Abnormal Psychology 3 37 Sp 1992 PSY 355 Abnormal Psychology 3 42 1.26 Sp 1991 PSY 355 Abnormal Psychology 3 37 137 F 1990 PSY 355 Abnormal Psychology 3 1.46 Su 1990 PSY 355 Abnormal Psychology 3 31 Sp 1990 PSY 355 Abnormal Psychology 3 37 138 Sp 1990 PSY 355 Abnormal Psychology 3 42 1.53 Sp 1989 PSY 355 Abnormal Psychology 3 78 1.51 Sp 1986 PSY 358 Abnormal Psychology 3 41 1.54 W 1984 PSY 358 Abnormal Psychology 3 31 Su 1998 PSY 350 Theories of Personality 3 20 4.10 Su 1990 PSY 357 Theories of Personality 3 21 1.45 W 1988 PSY 357 Theories of Personality 3 40 1.57 F 1987 PSY 357 Theories of Personality 3 55 138 W 1987 PSY 357 Theories of Personality 3 37 1.33 F 1986 PSY 357 Theories of Personality 3 54 -- F 1983 PSY 357 Theories of Personality 3 51 F 2000 PSY 407 Intro to Counseling Theories 3 18 4.88 Sp 2000 PSY 407 Intro to Counseling Theories 3 25 4.8 F 1999 PSY 407 Intro to Counseling Theories 3 15 4.37 Sp 1999 PSY 407 Intro to Counseling Theories 3 4.62(SRC 4.59) F 1998 PSY 407 Intro to Counseling Theories 3 20 4.31 (SRC 4.66) Sp 1998 PSY 407 Intro to Counseling Theories 3 20 4.42 F 1997 PSY 407 Intro to Counseling Theories 3 15 4.71 F 1996 PSY 407 Intro to Counseling Theories 3 19 Sp 1996 PSY 407 Intro to Counseling Theories 3 4.61 F 1995 PSY 407 Intro to Counseling Theories 3 19 Sp 1994 PSY 407 Intro to Counseling Theories 3 F 1993 PSY 407 Intro to Counseling Theories 3 24 1.32 Sp 1993 PSY 407 Intro to Counseling Theories 3 22 F 1992 PSY 407 Intro to Counseling Theories 3 25 1.18 Sp 1992 PSY 407 Intro to Counseling Theories 3 22 1.21 F 1991 PSY 407 Intro to Counseling Theories 3 44 1.26 Sp 1991 PSY 407 Intro to Counseling Theories 3 33 1.21 F 1990 PSY 407 Intro to Counseling Theories 3 Sp 1990 PSY 407 Intro to Counseling Theories 3 16 1.12 F 1989 PSY 407 Intro to Counseling Theories 3 24 1.20 Sp 1989 PSY 407 Intro to Counseling Theories 3 18 1.31 F 1987 PSY 407 Intro to Counseling Theories 3 26 1.21 F 1986 PSY 407 Intro to Counseling Theories 3 41 1.57 9 Sum 1987 PSY 499 Psychology of Sex Roles 3 16 1.18 Sum 2000 PSY 508 Health Psychology and Healing 2 17 4.57 Sum 1989 PSY 508 Emotional Crisis Workshop 1-2 39 *** `Frontiers of Mental Health And Education" Sum 1988 PSY 508 Emotional Crisis Workshop 2-3 63 "Mind/Body Interactions" Sum 1987 PSY 508 Emotional Crisis Workshop 2-3 106 "Relationships" Sum 1991 PSY 595 Health Psychology 3 15 Sp 2000 PSY 620 Assessment&Interviewing 2 15 4.06 Sp 1999 PSY 620 Assessment&Interviewing 2 4.61 Sp 1998 PSY 620 Assessment&Interviewing 2 9 4.31 F 1992 PSY 620 Assessment&Interviewing 2 12 1.66 F 1990 PSY 620 Assessment&Interviewing 2 1.02 F 1988 PSY 620 Issues in Behavioral Medicine 3 5 2.08 F 1997 PSY 621 Practicum College Teaching 2 10 4.77 F 1996 PSY 621 Practicum College Teaching 2 10 F 1993 PSY 621 Practicum College Teaching 2 13 1.45 F 1992 PSY 621 Practicum College Teaching 2 13 W 1984 PPSY 670 Tests and Measurements 3 20 -- Sp 1997 HON 200 Honors Connections Seminar: Alternative Healing Methods 2 20 3.67 of 4 Sp 1989 HON 200 Honors Connection Seminar II: 2 9 *** "Love" Sum 1986 Elderhostel "Dream On" NC (25) Sum 1987 Elderhostel "Mind/Body Interactions" NC 19 *** Courses Developed: 2000 PSY/PPSY 508,Health Psychology and Healing 1997 HON 200,Alternative Healing Methods 1991- PSY 595,Issues in Health Psychology,Summer 1989- 23rd Annual Emotional Crisis Workshop,Frontiers of Mental Health and Education,Summer 1988- PSY 620,Assessment in Behavioral Medicine,Fall(Revised Spring 1998) 1988- PSY 423,Health Psychology,Fall 1988- 22nd Annual Emotional Crisis Workshop,Mind/Body Interactions,Summer 1987- 21st Annual Emotional Criss Workshop;Relationships,Summer 1987- Mind/Body Interactions-Elderhostel Program,Summer 1987- PSY 499,Psychology of Sex Roles-Summer 1986- Dream On-Elderhostel,Summer Directed Studies: Graduate: 1995- Cynthia Holley,Hypnosis 1994- Tara Johnson,Hypnosis Theory and Practice 1994- Marla Gallagher, Sociometric Processes 1994- Marla Gallagher,Cluster Development in Intro Psychology Classes 1992- Bruce Holoman,Hypnosis Research and Practice 1988- Paul Jantz,Hypnosis for Pain With Children 1988- Lori Kochevar,Women as Leaders 1988- Jerri Israel,Alan Shaw,Issues in Health Psychology 1988- Steve Foster,Michele Hozer,Teaching Apprenticeship 1987- Tony Ambrosio,Hypnosis Models 1986- Candy Disch,Psychological Testing Undergraduate: 2000- Lynell Rice - Crosscultural attitudes towards healing methods 10 2000- Andrea Hagedorn-Attitudes towards counseling(in lieu of honors thesis) 2000- Laura Bell-Psychology of childbirth 1999❑ Lynell Rice-Healing Methods 1999- Stefan Stecker-Student's perceptions of parent-child sex communication(in lieu of honors thesis 1998 Jennifer Altman-Exercise and Psychology 1996 El Kindra Sanchez-Biracial Identity 1996- Jenna Weatherbee-Pain Coping Styles 1995- Allison Ellis-Psychological Theories in Business Management 1995- Holli Elrick,Counseling and the Hearing-Impaired Child 1994- Lewis Garza,Etiology of Schizophrenia 1994- Suzanne Bodetko,Autogenic Training 1994- Rebecca Furstenberg,Impact of Alzheimer's Disease on Families 1994- Bonnie Sarton,Hypervigilence in Youth(Hon 351) 1993 - Mary Jo Hamilton,Hypnosis Theory 1994- Greg Schooley,Forgiveness as a Therapy Tool 1993 - Jason DeBueno,Youth Advocacy 1993- Kelley Ferguson-Women in Psychology 1993- David Rosenberg-Offender Programs 1992- Robin Trostel,Analysis of Learning Styles 1992- Robin Trostel,Health Locus of Control 1992- Roberta Inman,Family Violence and Lesbians(Hon 351) 1991 - Mark ICahl,Back Pain 1991 - Tracy Moulton,Treatment of Sexual Abuse 1991 - Alice McPherson,African American Women and Higher Education 1991 - Jody Hunter,Hypnosis:Theory and Practice 1990- Jimmie Berg,Women's Learning Styles 1989- Elary Violett,Cognition and Pain Management 1989- Geri Bosley,Chris Snodgrass,Bev Foster,Elary Violett,Issues in Personality 1989- Penny Vaughn,Female Pioneers in Social Work 1989- Lori Peterson,Pain and the Elderly 1988- Peer Training for Hotline Service 1987- Tracy Boh,Issues in Child Abuse 1987- Julie Stoddard,Grief and Divorce 1987- Eric Bouch,Hypnosis Models 1987 - Mike Lesser,Assessment in Sport Psychology 1986- Lynne Sheffield,Childhood and Loss 1986 - Jennifer March,Adolescence Practica 2000- Rebecca Kuhn-Aromatherapy research 2000- Ackerman and Associates-Berkely Holston 1999❑ Melissa Touchton-Applied statistics 1998- Andrea Lamb-Hypnosis and golf performance 1998- Rebecca Varoula-Women's Place 1998: Greeley Medical Clinic-Gay Lemons,Renae Smith 1998❑ Ackerman and Associates-Amy Minute],Kristin Pietrzyk,Jennifer Kimberling,Greg Pedersen 1997- Greeley Medical Clinic-Lori Darst,Barbara Glode,Ann Marie McCullen,Jeff Titus 1993 - Greg Schooley,Breavement Research 1993 - Di Smice,Women's Commission 1992 - Mary Jo Hamilton,Hypnosis Research 1992- Carol Sexton,Psychology Testing 1992- Lisa Schlott,Learning Styles PROFESSIONAL DEVELOPMENT ACTIVITIES: Workshops,Clinics, Symposia,Conferences:(Excluding Conferences as a Presentor) 2005 Structured Analysis Family Evaluation Training(SAFE)— 16 hours 2005 International Critical Incident Stress Foundation 11 Group Crisis Intervention(August 21-22—14) Individual Crisis Intervention and Peer Support(August 18-19) 2001 EMDR Training and Level II certification 1999- Cognitive Behavioral Therapy Training Program,Institute for Behavioral Healthcare 19990 EMDR training and Level I certification 1998 Qualitative research lecture series-UNC 1998- Lewis M.Terman Western Regional Teacher's Conference sponsored by APA Division2 in conjunction with the WPA/RMPA joint convention. 1998- "Spirituality and health in counseling",CAHEC Workshop,Greeley 1998- 'Divorce Busting;Solution oriented brief therapy with couples",Colorado Assoc.Marriage and Family 1997- Health Maintenance-Legal and Ethical Issues 1997- Body and Soul:Healing in the 90's 19960 Celebrating our Essence:Women's Health and Spirituality 1995- International Society for Clinical and Experimental Hypnosis-Research Workshop,San Francisco,CA (30 more hours toward certification) 1989- "Minding the Body,Mending the Mind",CAHEC Workshop,Ft. Collins 1988- "Demystifying Publishing",CAHEC Workshop,NCMC,Greeley 1985- "Attentional Deficit Disorders in Children",Meichenbaum,Denver 1980- International Society for Clinical and Experimental Hypnosis-30 certification hours,Denver Numerous other workshops on Parent Loss,Child Abuse,Grantsmanship,Short-Term Treatment,Supervision,Pain Management,Medical Terminology,Depression,Personality Disorders Courses Taken Credit: 1994- EPRE 603-Analysis of Variance Audit: 1993- EPRE 602-Elements of Statistics 1990- EPRE 700-Advanced Research Methods Continuing Education Credit: 1976- C.U.Medical School-Medical Ethics 1972- C.U.School of Nursing-Hypnosis(10 weeks) 1969- University of Chicago-Kubler-Ross,Death and Dying HONORS AND AWARDS: 2000- "Wonderful Outstanding Woman"Award 1998- Distinguished Service Award-Rocky Mountain Psychological Association 1998- Arts and Sciences Teacher of the Year Award 1998- "Wonderful Outstanding Woman"Award-Highlighted in October newsletter-Women's Resource Center 1993 - Commencement Banner Carrier,Arts and Sciences 1993,91,89,88-Mortar Board Favorite Professor 1992- Sudent Representative Council University Professor of the Year 1992- Student Representative Council University Advisor of the Year 1989- Arts and Sciences Achievement Award 1988- Honors Advisor of the Year 1984 - Psi Chi,University of Northern Colorado Chapter 1982-83- Writing Associateship-Rocky Mountain Women's Institute 12 El ACE American Insurance Company PM, 0 ACE Insurance Company of Illinois Professional Liability Claims Made Insurance O Atlantic Employers Insurance Company Policy Declarations (This Policy is issued by the stock insurance company listed above.Herein called"Company".) BRANCH BlA PRODUCER NUMBER I DATE OF ISSUE I PRIOR CERTIFICATE NUMBER 273885 03/3012006 PSYCHOLOGISTS PROFESSIONAL LIABILITY CLAIMS-MADE INSURANCE POLICY NOTICE:THIS IS A CLAIMS.MADE POLICY,PLEASE READ THE POLICY CAREFULLY PURCHASING GROUP POLICY NUMBER: 45-0002000 Item DECLARATIONS CERTIFICATE NUMBER: 58622320300 1. Swan Bromley Named Insured 152113tH Ave ADDRESS Greeley,CO 80631-5415 Number&Street,Town,County,Stab&Zp No.) 2. Policy Period: 1201 A.N.Standard Time At From:04/01/2006 TO: 04/01/2007 I Amnion of Waignated Prelate's 3. COVERAGE LIMITS OF LIABILITY PREMIUM Professional Liability $1,000.000 each incident $3,000.000 aggregate $ 1,235.00 4. BUSINESS OF THE NAMED INSURED: Psydwbgy • 5. The Named Insured is: ® Sole Proprietor(including Independent contractor) O Partnership O Corporation O Other. 6. This policy shag only apply to incidents which happen on or after a)the policy effective date shown on the Declarations:or b)the effective date of the eeriest claims-made policy issued by the Company to which this policy is a renewal;or c)the date specified in any endorsement hereto. 04/05/1996 7. This policy is made and accepted subject to the printed conditions in this policy together with the provisions,stipulations and agreements contained in the following form(s)or endorsement(s). 815potcov,PF-15215(03/04),PF-15217(03104),CC-1611d(04/02),PF-15238(03/04),PF-15230(03104),PF-15241 (03/04), PF-15242(03/04), PF-15225(03/04),PF-15253(06/04),PF-15742(06/04).PF-17914 Notice of Claim should be sent to: AN other notices should be sent to: Claims Vice President Underwriting Vice President ACE USA ACE USA 140 Broadway,40" Floor 140 Broadway,414 Floor New York, NY 10005 New York, NY 10005 REPRESENTATIVE: Agent or broker. Potomac Risk Management Services, Inc. 181 W Madison St Ste 2900 Office address: Chicago, IL 60602-4643 City, State, Zip: 1477-637-9700 PF-15215 103/04) EXHIBIT B SUPPLEMENTAL NARRATIVE TO RFP Ackerman and Associates, P.C. 1750 25th Avenue, Suite 101 Greeley, Colorado 80634 (970)353-3373 fax(970)353-3374 May 21, 2007 Judy Griego Weld County Department of Social Services 315 N. 11th Ave Greeley, CO 80631 RE: RFP 001 SAT-07 and RFP 001 1-1507 Dear Ms. Griego, Ackerman and Associates, P.C. acknowledges the receipt of the FYC commission's recommendations on the above referenced bids and accepts those recommendations. We will pursue bilingual interpreters, translators or staff by seeking appropriate individuals in the community to be available on a case by case basis to better serve bilingual or monolingual clients. We will also use appropriate family resources to assist in translation. The home study materials are available in both Spanish and English. However, if no family members or voluntary community resources are available, we can purchase translation services and pass this cost onto Social Services by direct billing for their fees, if this is acceptable to Social Services. Please let me know if you need additional information concerning our acceptance of the FYC recommendations. Respectfully, pp 18LJoyce Shohet Ac k ,m p, �� p an, Ed.D. Licensed Psychologist Clinical Director DEPARTMENT OF SOCIAL SERVICES ('t P.O.BOX A ' GREELEY, CO. 80632 Website:www.co.weld.co.us Administration and Public Assistance(970)352-1551 O _ Fax Number(970)353-5215 • COLORADO May 11, 2007 Joyce Ackerman Ed.D. Ackerman&Associates,P.C. 1750 25th Avenue, Suite 101 Greeley,CO 80631 Re: RFP 001-SAT-07-Sex Abuse Treatment RFP 001-HS-07-Home Studies,Updates,Relinquishment Counseling Dear Ms.Ackerman: The purpose of this letter is to outline the results of the Bid process for PY 2007-2008 and to request written information or 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 Bid#001 SAT07(RFP 07007) Sex Abuse Treatment,and Bid#001-HS-07(RFP 006-00B)Home Studies,Updates,and Relinquishment Counseling. The Families,Youth and Children's Commission attached the recommendation described below to your bids. Recommendation: The approved bidder will pursue bilingual interpreters/translators/staff in order to better serve bilingual and monolingual clients. This may include offering incentives, accommodations, and encouragement to Spanish bilingual interpreters,translators, and staff. B. Required Response by FYC Bidders Concerning FYC Commission Recommendations: You are requested to review the FYC Commission recommendations and to: 1. accept the recommendation(s)as written by the FYC Commission; or 2. request alternatives to the FYC Commission's recommendation(s); or 3. not accept the recommendation(s)of the FYC Commission. Page 2 Ackerman&Associates,P.C./Results of Bid Process for PY 2007-2008 Please provide in writing how you will incorporate the recommendation(s)into your bid. If you do not accept the recommendation,please provide written reasons why.All approved recommendations under the NOFAA will be monitored and evaluated by the FYC Commission. The Weld County Department of Social Services is requesting your written response to the FYC Commission's recommendations. Please respond in writing to Tobi Vegter, Core Coordinator, Weld County Department of Social Services,P.O. Box A,Greeley,CO, 80632,by Monday,May 21,2007,close of business. If you have questions concerning the above,please call Tobi Vegter,970.352.1551, extension 6392. Sincerely, J A. G o,Dir r c 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 Child Welfare Regular Administration Funding Type of Action Contract Award No. X Initial Award PY07-08-HS-0034 _ Revision (RFP-006-00B;002-HS-07) Contract Award Period Name and Address of Contractor Beginning 06/01/2007 and Blythe Johnson,Private Practice. Ending 05/31/2008 Home Studies,Updates,Relinquishment Counseling 20011 MCR T.5 Fort Morgan,CO 80701 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Assistance Award Services provide home studies and home study updates to is based upon your Request for Proposal(RFP). The RFP families who are willing to be foster and adoptive homes specifies the scope of services and conditions of award. Except for children in need of out-of-home placement. Services where it is in conflict with this NOFAA in which case the are also provided to parents who wish to relinquish their NOFAA governs,the RFP upon which this award is based is an legal rights in order that their child(ren)will have a stable integral part of the action. and nurturing environment while achieving permanency of Special conditions adoption.Estimated home study yearly capacity is 17 1) Reimbursement for the Unit of Service will be based on home studies,and 17 relinquishment counseling sessions. an episode rate per home study;home study update,and Average stay for each home study is six weeks from relinquishment counseling. Court testimony will be referral date;relinquishment counseling will be completed billed at an hourly rate. within two weeks of the referral date.Program capacity is 2) Reimbursement requests must be an original with an two family units for home studies and two family units for original signature from the provider and/or designee. relinquishment counseling per month.Bilingual services 3) Reimbursement requests must include the date the through an interpreter. home study,update,or relinquishment counseling was Cost per Unit of Service completed.The request must reflect the amount billed Hourly Rate per for each home study,and the month the service was Court Testimony $75.00 provided.Requests for services submitted 90 days Episode Rate per from the date of service,and thereafter,will not be Full Home Study with Background Check $950.00 paid. Full Home Study with 3 or more additional adults in the 4) Payment will only be remitted on referrals made by home,or outside of a 50-mile radius from Greeley the Weld County Department of Social Services. (includes Background Check) $1,050.00 5) Requests for payment must be an original submitted to Updated Home Study $450.00 the Weld County Department of Social Services by the Relinquishment Counseling $250.00 end of the 25th calendar day following the end of the Enclosures: month of service.The provider must submit requests for X Signed RFP:Exhibit A payment on forms approved by Weld County X Supplemental Narrative to RFP:Exhibit B Department of Social Services.Requests for payments X Recommendation(s) submitted 90 days from the date of service,and thereafter,will not be paid. Conditions of Approval 6) The Contractor will notify the Department of any changes in staff at the time of the change. Approva . Progr O cia1: ' By B David E. ng,Chair Ju . Grieg Directo Boar JUN 8 2007elCounty Commissio ers Wed ounty) artmen of Soci 1 Services Date: Date: 1r/� L07 4OO'/-/e6SW EXHIBIT A SIGNED RFP C . l _ /-JS 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,though 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 31 a A I O1 (After receipt of order) BID MUST BE SIGNED IN INK Program Area: -time urli left, rl}uskAehut ` �, 1- v\S-L r, �D OR SIGNATURE VENDOR -j\y+1\f' 70\-1nson 1�11� e Johnson (Name) Handwritten Signature By Authorized Officer or Agent of Vendor ADDRESS a,GU11 \NiCR T,S TITLE \v\c'1/4.e_P,c, ?MU I(VP r 1=orE- Ction3&Cn eo kolnl DATE ?429 \ nci PHONE# C-t-1 U - l 04,- 5 CI K a The above bid is subject to Terms and Conditions as attached hereto and incorporated. ABSTRACT: As an independent provider, the mission is to approve and complete quality home studies and relinquishment counseling for adults in order to allow children to obtain permanency. Results of this proposal show the provider to be in compliance with all guidelines of Volume 7 requirements, the Colorado Children's Code; objectives include helping to meet the goals that the Colorado Administrative Review Division has set with the Program Improvement Plan. By completing quality home studies, children in need of out-of-home placement will have homes available to them that are able to meet the child's needs and keep them in a safe environment while working to reunify with their families, follow their case plan, and achieve the permanency goal of"return home." Completing adoptive home studies for applicants in the Weld County area will allow the provider to ensure that the children who have a permanency goal of adoption are able to achieve this goal by having adoptive homes available to them. This will also allow children to have permanency and follow their case plan devised by the Weld County Department of Social Services. Providing relinquishment counseling services for families wishing to relinquish their parental rights will allow the provider to determine and ensure that the family is relinquishing their rights for the best interest of their child or children. This is a necessary step for children who are unable to return to their parents care--to have and follow the goal in the Family Services Plan and remain in a placement on a permanent basis. By providing these services and ensuring that the foster and adoptive applicants have a clear understanding of what being a foster and/or adoptive home entails, this will in turn reduce the number of placements for a child. The foster home can assist and support the child or children when reuniting with their families or transitioning to a permanent home. By providing the services for relinquishment counseling, the provider will ensure that the family is aware of the permanence of their decision, knows all the options they have in regard to keeping their parental rights, and have completed the relinquishment counseling on their own free will. The Core Service Program focuses on family strengths by directing intensive and time-limited services to families to protect children, prevent placement, and reunify children and their families. By completing the home study process with the applicants, the applicants will be able to continue to serve children in need for out-of-home placement. Approved foster homes will allow children who have been placed in a restrictive level of care to move to a less restrictive out-of-home placement while working on reunification and permanency. Once the family is approved as a foster and/or adoptive home, they will have continued support through the Weld County Department of Social Services. Achieving quality of life for children is of utmost importance. Children deserve to live in a safe, nurturing environment on a permanent basis. Approving and completing quality home studies and relinquishment counseling for adults will help attain that objective. Instead of"for now" placement, the child/children can think in terms of"forever." 2 TABLE OF CONTENTS Invitation to Bid 1 Abstract 2 Table of Contents 3 Target/Eligibility Populations 4 Project Narrative/Supporting Documentation 5-9 Types of Services 5 Measurable Outcomes 5 Service Objectives 6-7 Workload Standards 7 Staff Qualifications 7-8 Program Capacity per Month ..8 Internal Tracking and Billing Process ...8 Budget attachment Appendices 1-3 9-11 Appendix 1-Resume 9-10 Appendix 2-Data Collection Instruments/Protocols attachment Appendix 3-Sample Consent Form 11 OTHER ATTACHMENTS: Sample Home Study Verification of Supervisor Meeting Proof of Personal Liability Insurance 3 TARGET/ELIGABILITY POPULATION This target population is unique and different from that served by agencies. Specific families are the target population. These families must be willing to help children achieve permanency. They will complete a home study process with a qualified individual (home studies provider) who is keenly observant and aware of real situations and practices of these families and how they fit with the child's needs. Because services will be provided by an individual rather than an agency, and due to the special populations targeted, terminology such as "monthly program capacity" and "average groups per week" may vary from traditional meaning and may or may not be applicable. The target populations are families who are willing to be foster and adoptive homes for children in need of out-of-home placement. These families must be willing to complete the home study process so they are able to provide temporary care for children who have a permanency goal of"return home". These families will also be informed about children who are identified as expedited permanency planning. Expedited Permanency Planning is also known as EPP cases. EPP cases are designed for children five years of age and under with the expectation that they will achieve permanency within six months of being placed outside the home. These families may also wish to be an adoptive placement for children who are in the custody of the Weld County Department of Social Services. Being an approved adoptive home would allow children to have the permanency goal of adoption which would also allow these children to follow their case plan to achieve permanency. The home study provider will also work with parents who request to relinquish their parental rights so their child is able to have a stable and nurturing environment while achieving permanency of adoption. When working with home study applicants the provider will be able to communicate with the families the importance of following the child's case plan. All home study applicants will need to support independent living programs for the adolescent to successfully emancipate. Home study applicants will need to maintain the children's cultural and racial connections along with maintaining monthly face-to-face visits with their caseworker. The home study process will address the importance of setting up medical and dental appointments as required. The provider will be able to address, with the foster and adoptive homes, the issue of making appropriate appointments for the children to maintain good health while achieving permanency. This will include physicals within two weeks of the child's placement in their home and dental appointments within eight weeks for children over the age of three. The home study will address the applicants' willingness to work with other professionals outside of the Weld County Department of Social Services to meet the emotional, medical and educational needs of all children in their care. The proposed independent provider can provide services for a total of four per month—two home studies and two relinquishment counseling services. The provider will be able to serve any English-speaking family referred in the Weld County area. (Provider is not bilingual.) The average stay for each home study referral in the program will be six weeks from the time the referral is made. (This is the time frame that is set by Weld County Department of Social Services.) The relinquishment counseling services will be completed within two weeks of the referral date. 4 PROJECT NARRATIVE/SUPPORTING DOCUMENTATION Types of Services Provided: A family assessment, using the Structured Analysis Family Evaluation (SAFE) instrument to determine the character and suitability of the applicant(s), appropriateness of the home, and childcare practices, must be completed (7.500.2). The types of services that I will be providing are home studies for families who wish to provide for children in need of out-of-home placement. These services will include adoption, foster care, and expedited permanency planning home studies. The home studies will be completed in the SAFE home study format. By utilizing the SAFE format it will address the social history of the family, adult general functioning, parenting styles, methods of discipline, the family system, past and present marital relationships, family support, and most importantly how these families are going to provide a safe, stable and nurturing environment for the children while they are achieving permanency. If the child meets the target group requirements of Program Area 4, 5, or 6, county departments shall ensure that relinquishment counseling services are provided to parents considering relinquishment, to the child when twelve years of age or older(if appropriate) and when it is court ordered (7.308). By providing these services, it will allow the children to follow their case plan. As an independent provider providing relinquishment counseling for individuals who are involved with Weld County Department of Social Services, I understand that the relinquishment counseling is provided in accordance with Section 19-5-103, C.R.S. As an independent provider the way I will ensure that resources will not supplant existing services will be to communicate with the referring working on what services I will be providing and discuss what services the applicants or clients are getting. I will only provide the services that are requested by Weld County. That maybe to update a home study, provide relinquishment counseling or to complete a foster/adoptive home study. Measurable Outcomes: How to measure and evaluate the outcomes of the services being provided will determine if there is an increased number of placements in an expedited permanency planning case, increased placement stability for children, and fewer disrupted adoptions. By providing quality home studies and following the Program Improvement Plan, along with utilizing the SAFE instrument, this will allow children to have more expedited and fewer placements. By using the SAFE instrument, the home study process can be used and will be familiar with other counties and across state lines. 5 Service Objectives: As a home study provide with Weld County, I will provide quality home studies and updates by using the knowledge and skills learned by the SAFE Home Study training. I will provide quality service for relinquishment counseling, Adoptive, Foster Parents and Social Services clients. During the home study process I will conduct a minimum of three joint interviews with a couple, one individual interview with each adult member in the household and an age/developmentally appropriate interview with all children residing in the home. For single applicants I will complete a minimum of three interviews, as required. At least one of the three interviews will be conducted in the applicant's home. The interviews will not be more then seven consecutive days apart. Background checks will be completed for all individuals living in Colorado. The background checks will include fingerprint results by CBI. The results that are sent from Weld County will be returned directly to Weld County. I, as the provider, will distribute, collect and submit the fingerprint cards. I will pay for the CBI processing fee. If the applicant has lived in the state less than two years, an FBI search will be requested. Background checks will also include the Department of Motor Vehicles, Local County DSS search for an open case, reference questionnaires to be sent out and returned to me along with the SASE, local police search, and central registry check. All of the original background check information will be forwarded to the Weld County Social Services with the completed home study. I will complete the home study within six weeks of initiation. This time frame is subject to timely submissions by family being studied, including fingerprints, Central Registry check, application and reference information. Completing the home study requests in a timely manner and providing quality work on the home studies will allow Weld County Department of Social Services to meet the goals of the Program Improvement Plan set by the Federal Government. This will address placement changes. As a home study provider, I will focus upon the permanency needs of children in out-of-home placement. Other than imminent danger defined by the Colorado Department of Human Services "Risk Assessment Chart", the removal of a child is a decision make by the Placement Review Team and Caseworker of the Department. At no time will I advise or give permission for a child to be removed from a placement. As a home study provider, I will be able to explain independent living programs so the out-of-home providers know what to expect and know they will need to cooperate with an adolescent's case plan for the adolescent to successfully emancipate from the system, as well as contribute to the plan through daily life skills. It will be important as a home study provider to provide assistance to applicants for maintaining the cultural and racial identity of the child. They will understand and be open to cultural resources, holidays, community connections and spiritual needs: All of these aspects will be considered during the home study process. The applicants will understand the importance of monthly face-to-face visits with the caseworker and know that this will better facilitate communication between foster parents and the Department regarding the permanency of the children. Visits with the caseworker and the child in custody of the Department will occur in spite of schedule changes, illness, vacations and 6 whatever else may be occurring. Foster parents will be trained to be proactive in regard to contacting the caseworker, supervisor and other professionals involved in the case. I will address with the applicants the importance of setting up medical and dental appointments at the time of placement. Lists of medical providers will be available. The out-of-home placement will have two weeks to arrange a medical appointment and eight weeks for a dental appointment for children who are over three years of age. The child will need to continue with a yearly physical, dental check-up every six months, and a yearly eye exam. When conducting a home study, I will be focused upon these objectives, particularly toward the retention of children in their placement. By providing timely relinquishment counseling services, this will allow the child or children to be free for adoption, which will follow their permanency goal of adoption, thus allowing permanency for the child. The relinquishment counseling will be completed within two weeks of the initial contact and will be held in Weld County. Workload Standards: As an independent provider, I will be able to complete and be assigned up to two home studies per month. This will be approximately 15 hours per week. Being an independent provider, I will be the only individual providing this service. I will provide services to any Weld County home. I have professional personal liability insurance through Healthcare Provider Services Organization (HPSO). The insurance policy is in effect through March 5, 2008. I will also be able to provide up to two relinquishment counseling sessions per month. This will be approximately 10 hours per week, depending on when services are needed. I also have insurance that will cover the relinquishment counseling services. I am willing to comply with all requests made by the program supervisor in Weld County and attend any and all meetings that are required. I will also have myself available for court appearances if necessary. Staff Qualifications: I will be the only staff providing home study and relinquishment counseling services under this proposal because I am an independent provider. The State requirements (Volume VII, 7.000.6Q) state the County Departments shall ensure that all personnel who supervise or provide professional services in child welfare services need a bachelor's degree with a major in a human behavioral science field and one year of professional caseworker experience acquired after the degree in a public or private social services agency. I have met the qualifications to be placed on the Colorado Department of Human Services vendor list. To be placed on the vendor list I had to show proof of education that I have my Bachelors Degree in Social Work from Chadron State College, proof of insurance, and experience of 5 years working in child welfare as an ongoing caseworker who also conducts home studies and provides relinquishment counseling services for Morgan County Department of Human Services. I am currently a senior level ongoing caseworker. I have completed all CORE trainings and all new caseworker trainings that are mandated by the State of Colorado to continue casework services. I have also completed the SAFE home study training and have been writing home studies 7 under the SAFE format since October 2005 when I completed the training. As an ongoing caseworker, I am familiar with the risk assessment tools as I am determining safety in risk in homes on a daily basis. Program Capacity per Month: As an independent provider I am able to serve two families per month by completing home studies and two families per month by completing relinquishment counseling services. I am willing to work with families throughout the entire Weld County area. I can accept a maximum caseload of four. Limiting this maximum caseload will ensure quality work while reaching objectives; I can conduct home studies and relinquishment counseling in a timely manner, which allows for children to reach permanency and follow their case plan. Internal Tracking and Billing Process: As an independent provider I will be responsible for all program costs, background processing fees, travel expenses and supplies. For home studies that are in the Greeley area and have two adults in the home, I will charge a rate of$950.00 per home study. For home studies that are a 50-mile radius outside of Greeley and/or have three or more adults in the home, I will charge a rate of$1050.00 per study. This is due to background processing fees for every adult residing in the home and/or travel. Relinquishment counseling services will be charged a rate of$250.00 per counseling service, a home study update will be a rate of$450.00. 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O O O p 0 ,3], 8 8 8 8 8 p 8 8 8 p 8 8 8 8 88 p 8 8 8 8 O 8 o 8 p 8 Op < 0 IA OpIVMfl a fl gNphMMNgg „ p u S rc, rr g w w w 462 w o . w w C. 0 000 2 88 0eto 8g2 SE Jw 40 r )W-zzzzzz2zzzzzzzz 2 C F 88 V8 8 N o 8 y _ O u -:441 p f' N 3 N O g 0 0 6_ 6 p 2 0 K w C KKK 0 N y w O w w N 1 t 0 < w c n co 0 K w 0 H O N N F x 0 b >. w 0 • 0 O w 0 0 0 w 449 0 r 0 2 <y u1 0 N O > a > 4000 >Iaz 000 < 0 0 0 Appendix-1 BLYTHE JOHNSON 20011 MCR T.5 Fort Morgan, Co 80701 (970) 768-5982 CAREER OBJECTIVES: To write home studies and complete relinquishment counseling as an independent provider. EDUCATION: Chadron State College, Chadron,NE: Bachelor of Arts Degree Major: Social Work QUALIFICATIONS: • Experience working with peers, co-workers, and clients in a professions setting • Working with computer programs such as Microsoft Office, Word Perfect, MsDos, Internet Explorer, Colorado Trails • Training to complete home studies under the Structured Analysis Family Evaluation(SAFE) format • Placed on the vendor list with the Colorado Department of Human Services • Knowledge with Volume 7 and the Colorado Children's Code • Trainings include but are not limited to; Core 1-4, Legal Issues, Specialized Sexual Abuse, Parents with Mild Cognitive Impairments, NCFAS, Safety and Risk, SAFE EMPLOYMENT HISTORY: Morgan County Department of Human Services. Fort Morgan, Co Senior Level Ongoing Caseworker January 2007 to present Night Time On call Intake Worker,January 2005 to present Journey Level Ongoing Caseworker January 2005 to December 2006 Entry Level Ongoing Caseworker October 2002 to December 2004 • Write Treatment Plans for families involved with child welfare • Assess safety and risk in homes • Attend court appearances including testimony • Help families with community resources • Work with all providers who are caring for children in out-of-home placements (CPA's, Foster Homes, Kinship Homes,TRCCF) • Write home studies (Foster, Kinship and Adoption Studies) • Complete relinquishment counseling services • Work with local law enforcement and other community resources regarding child abuse/neglect. • Conduct sexual abuse interviews 9 Morgan County Department of Human Services,Fort Morgan, Co Child Care Case Manager May 2001 to October 2002 • Determined eligibility for families in need of day care assistance • Data entry for exempt and non-exempt daycare homes. • Conducted interviews • Attended monthly meetings at the Colorado Department of Human Services for the CCAP Program Lutheran Family Services, Scottsbluff,NE Family Support Specialist August 2000 to May 2001 • Teach Parenting • Conduct supervised visitation • Conduct anger management with both adults and children • Work with clients on hygiene issues • Weekly written reports to all parties involved in the case Area 1 Office of Human Development, Chadron, Ne October 1999 to August 2000 • Worked with developmentally disabled adults • Administered medications • Administered programs to improve motor skills • Assisted with hygiene • Supervised contracted employment of clients REFERENCES: Steve Romero, Director, Morgan County Department of Human Services 800 E. Beaver Fort Morgan, Co 80701 (970) 542-3530 Troy Heesacker 17966 MCR W Fort Morgan, Co 80701 (970) 542-9511 (970) 542-3465 ext. 3378 Sharon Armstrong 4339 W. 3`d St Greeley, Co 80634 (970) 227-2733 10 CHECK LIST Children's Names/Ages: Case Name: Caseworker. 'rovider's Name: YES NO Sufficient income to provide for child's short-term needs THE PEOPLE: YES NO Need for additional YES NO Background check clear? funds/benefits such as Medicaid to meet this YES NO Prior relationship with this child's needs long term? child(ren)? YES NO Any objection to applying H M L Motivation:d High for public assistance to help Moderate, Low? meet these children's needs? YES NO If more than one caregiver, does the couple agree? YES NO Agree to refrain from using physical punishment such H M L High y to protect:dera as spanking, hitting, Moderate Low slapping, or mechanically restraining a child as forms YES NO Do kin feel that this child is of discipline? part of the problem that led up to his/her need to be in YES NO Have plan for day care or out of home care? supervision of child? YES NO Do you feel that the parents YES NO Ability to adjust family rules of this child/children need to or routine to meet child's or have accepted needs? responsibility for the reasons that led up to this YES NO Willing to assume legal out of home placement? custod (ardo-they-feet- rpere-camfortabfe-with_th e YES NO Wising to enforce the Dopt. being-the-buffer)? caseworker's or judge's directives in regard to YES NO Willing td take children to contacts with the child's doctor appointments, parents, relatives, or other therapy, school, etc.? significant persons? YES NO Willing to follow child's YES NO Physically able to attend toregimeMof medication or this child's/children's needs therapy? YES NO Any chronic or YES NO Willing to allow communicable health caseworkers, therapists, concerns? GAL etc. to make home visits? (OVER) THE PLACE YES NO Is home clean, neat, and YES NO Is yard free of trash, junk and harmful debris or free of pose anhous imminenthold dangers unsafe play equipment? that an threat to a child's safety? YES NO Is there a reliable automobile and auto YES NO Is there exposed wiring or insurance? broken windows/doors? YES NO Are there two accessible YES NO Are there good car seats, if needed, appropriate to size exits? and age of child? YES NO Is there trash or flammable YES NO Are weapons such as guns, materials near heat sources Ares, apo and arrows, , i.e. wood-burning stove, riflknives cked up roh fireplace, furnace, hot water ock stored p heater, space heaters, etc. separately. YES NO If mobile home, is it YES NO Is fireplace/woodburning permanently secured and stove screened properly. skirted? No open-flame gas or oil stoves, Kere-sun heaters, YES NO Is there adequate sleeping etc. space? (8 x 10 room for 2 children) YES NO Are pets gentle and well- cared fors? Can they be YES NO Does child have own bed? penned separately from YES NO If a roommate, does child children? age 5 or older share bedroom with person of same gender? YES NO Is child's bedroom on same floor as provider? YES NO If child sleeps in a basement or upstairs room, is there a way to escape in case of emergency? What is the plan? YES NO Are there smoke alarms and a fire extinguisher? YES NO Is there a fenced yard for children between 1 and 5 years of age or direct supervision during outdoor play? Sample Consent Form-Appendix 3 The purpose of your participation with the foster and or adoptive home study process is to provide children with a safe, stable and nurturing environment while meeting the permanency goal set for each child.. The goal may include children who are working to reunite with their biological families, children who are in need of adoption and are unable to be successfully reunited with their families, and adolescents who are working on independent living skills to achieve a successful emancipation. The information that will be collected during the home study process will be based on interviews with all household members, questionnaires from the SAFE home study format, and observations in the home. The data collected from the home study process will determine if you are able to be approved to temporarily care for or adopt children who are in the custody of the Weld County Department of Social Services. All information will be kept private and will be strictly confidential. If there are other agencies or individuals I need to speak with during the home study process I will notify you and I will request that you sign a release of information. Because I will complete the home study on behalf of the Weld County Department of Social Services, the completed copy will be kept in their records. You have the right to leave the home study process at any time and this is done on a voluntary basis. Because I am a mandated reporter, if I have concerns or observe abuse or neglect in your home I will have to report this to the Department of Social Services and/or notify local law enforcement. Signature of Home Study Provider Applicant 1 Applicant 2 Additional Household Member 11 SAFE Multi Purpose Home Study Report '', This home study was completed by Morgan County Department of Human Services solely for use in domestic foster care placement and/or adoption by and for United States licensed/authorized agencies unless otherwise specified. fName of Family: John and Jane Doe Address: 18631 CR 34 -_ l -___.__ 11 City: Fort Morgan State Co Postal Code: 80701 0000 Home Phone 970-555-5555 - I Cell Phone 970-555-5555 APPLICATION DISPOSITION Certified: 5/24/2006 Approved: 5/24/2006 The Applicants have applied to accept placement of a child between the ages of 0 to 17 years old. The Applicants are open to placement of a sibling group. The Applicants are primarily interested in becoming a Foster/Adoption Family. APPLICANT INFORMATION D John h Jon Doe Jane Doe D — — Do- = Date of Birth: 02/18/1954 •. Date of Birth: 03/06/1957 i Birthplace: Trinidad Colorado I Birthplace_: ; Holyoke Colorado I.Gender: I Male r Gender Female -- Religion: Assembly of God Religion: hI Assembly of God I Occupation_ Truck Driver,Taxidermist Occupation: County Executive Director Language(s): I English Language(s) i English Education: ' Associates Degree ' Education: 4 High School Diploma - g ' I Height: 61 Height: 53 Weight .4. Weight: 4 285 Hair: — Brown I Hair: 1 Brown Eyes: I Blue F Eyes: I Hazel Date of health questionnaire/report 2/14/2006 1 Date of health questionnaire/report: 1 2/14/06 MARITAL INFORMATION Date of Marriage_ 10/12/1991 i Marriage Verification: On File Place of Marriage: Holoyke Colorado F ' DATES OF CONTACT Date Individual/Couple Location 2/9/2006 Individual (Questionaire I) 18631 CR 34,Fort Morgan, Colorado 2/10/2006 Individual (Questionaire I) 18631 CR 34, Fort Morgan, Colorado 2/14/2006 Couple(Questionaire II) Home evaluation 18634 CR 34, Fort Morgan, Colorado Structured Analysis Family Evaluation(SAFE)©Colorado Couple Multipurpose Home Study Report -Version 09-14-2005 Page 1 of 8 Copyright,2005,Consortium for Children,All Rights Reserved MOTIVATION John and Jane Doe's home were certified as a foster home when Jimmy was placed with them. Jimmy was 3 years old at the time he was placed. At the time he was placed they decided that they would like to adopt Jimmy and provide a permanent home for Jimmy where he can have a stable and loving home environment. John and Jane feel that Jimmy has become a part of their family and they love him. John and Jane want Jimmy to have a permanent family and home. HOME ENVIRONMENT Type of residence: House. Square Footage: 25.00 Square Feet Bedrooms: 4 Bathrooms 3 Length of Time in current residence: 16 months John and Jane Doe own their home and have lived at this residence for fourteen months. When you walk into the front door you enter their living room, dining room and kitchen. All these rooms are spacious. There is a utility room off the kitchen where they keep their washer and dryer. This room leads to their garage. The master bath and bedroom is off of the living room. This is where John and Jane sleep. There is a short hallway off to the other side of the living room. This is where Jimmy's bedroom and bathroom are. There is a staircase located between the living room and kitchen that leads to a finished basement. At the end of the stairs there is a fireplace. To the left of the staircase there is a big open space where Jimmy plays with his toys. On the right of the staircase there is a living area with a couch and TV, a utility room with a door,two empty bedrooms and a bathroom. They have a front yard that is not fenced. They stated that when Jimmy plays in the front yard they supervise him at all times because there is a dirt road that runs in front of the home. There is a large back yard where Jimmy can play. The back yard does not have a fence, but is blocked in by many trees and bushes, which makes it difficult for Jimmy to leave that area. There is a large sliding glass door that leads to the back yard and a window in the kitchen where they are able to view the entire back yard. John and Jane stated that if they are not outside with Jimmy when he is playing in the back yard then they are able to supervise him from the kitchen and dining room. The Doe Family does not have any pets. John is an avid hunter so he does have guns, but has purchased a locked gun cabinet so there are not any safety concerns. The interior and exterior of the home was inspected for health and safety hazards. The inspection was completed on 02/14/2006. FAMILY Applicant#1: John Doe When the worker arrived at the home, John presented himself well. He introduced himself and his wife, Jane. He was dressed appropriately and appeared to have good hygiene. John was very open to the questions that were asked and engaged in conversation. John likes to camp, fish, explore and likes working in taxidermy. • John has two younger brothers and one adopted sister with him being the oldest sibling. Jerry is the second youngest sibling. She lives in Germany. She is married and is a teacher in a college in Germany. John reports that "she is studious, laid back and comfortable." David is John's younger brother. David lives in Alaska. He is not married, but has one daughter. David custom builds windows for new homes. John reports that"David is a hard worker, quick to do things, and hidden when it comes to his private time." Nancy is the youngest sibling. She was adopted when John was a senior in high school. Nancy is not married and does not have children. She lives in Denver. John reports, "she is caring and quiet." John stated that he doesn't know her that well. John father, John Sr., lives in Ault, Colorado. He is seventy years old. He was self-employed business owner and auto parts salesman. His father now works with horses and on race car motors. John states that he has regular contact with Structured Analysis Family Evaluation(SAFE)©Colorado Couple Multipurpose Home Study Report -Version 09-14-2005 Page 2 of 8 Copyright,2005,Consortium for Children,All Rights Reserved his father due to his helping John run his in-home business. John describes his father as"outgoing, a sweet talker, and a type A personality." John's mother, Evelyn, lives in Loveland. She is seventy years old. She helped John's father run his business by doing all the paperwork. She is currently self-employed. John states that he has regular contact with his mother and she"thanks him for being a good son." John describes her as "studious and less of a risk taker then his father is." John was married in 1973 to Ann Day. They lived in St. Francis,Kansas. They have three children together, Chad, April, and Cindy. They divorced in 1981. John stated that his lifestyle working for the railroad was tough on his marriage. He was never home so his wife thought she would be better off without him. John reports that he has a good relationship with his children and they continue to have frequent communication. In 1987, John married Sally McBeth. They lived in Pueblo before they moved to Fort Collins. They have no children together. Sally had a set of twins that lived with them while they were married. John stated that the twins "didn't like him very well even though he tried to be the best father to them as possible." He put Sally through college for two years while they were married. He stated that Sally told him one day that she"got promoted and was going to make$25.00 and hour". She then wanted John to leave in order to allow her to get on with her life. They were divorced in 1990. John continued to work for the railroad in Denver after his divorce. He became a "student of the bible"during that time. John stated that he was broke and living in a barn. He used newspapers to decorate his walls. He stated that he was paying his ex-wife's rent,his rent, and he paid all the costs of the divorce. John met Jane while living and working in Denver. Jane's sister, Heidi, is friends with John and introduced them. They moved to Holyoke in October of 1991 and were married. They have no children together. John entered the police academy in 1995 and worked doing"ride a longs"and was a jail deputy. John worked in this capacity for a little less then two years before returning to school in an effort to obtain a degree in Natural Resources. He reported he didn't like"politics" of the law enforcement culture. John states that the strengths in his and Jane's marriage are that they are committed to one another, love each other and are opposites and"opposites attract". He feels that the weaknesses in their marriage are that they both expect each other to be perfect. Applicant#2: Jane Doe Jane presented herself well. She was dressed appropriately and appeared to have good hygiene. Jane engaged in conversation and was very open to any questions and discussion. Jane took the worker through the home. Jane enjoys camping, fishing, driving around and attending church on Sundays. Jane has four sisters and one brother with her being the third oldest. Heidi is the oldest sister. Heidi lives in Fort Morgan and does finishing work on new homes. She is married and has two children. Jane describes Heidi as "unselfish, loving and a friend." Jody is the second oldest. She lives in Oberlin Kansas and is a stay at home mother. She is married and has two children. Jane describes Jody as"sweet, quiet, and a women who loves her children." Jerilyn Coyne is the next oldest. She lives in Holyoke and works with her husband at the hospital in maintenance and bookkeeping. She has two children. Jane describes Jerilyn as"outgoing, loves horses and an excellent trainer of animals and children." Nick is the second youngest. He lives in Holyoke and works for Highline Electric. He is married and has two children. Jane describes Nick as "fun, likes to tease, good hearted and easy going." Tillie is the youngest sibling. She lives in Holyoke and works for the City of Holyoke. She is married and has no children. Jane describes Tillie as a"great hostess,tidy, good hearted and kind." Jane states that she has a great deal of contact with all of her sisters and brother.They are a very close knit family. Jane stated that is why"she and John moved back to northeast Colorado, to be close to her family."Jane's father,Jack passed away in 1992 at the age of sixty-two. Her father farmed all of his life. Jane states that she had a good relationship with her father. She feels that her father was steady and tried to teach and instill good things into each of his children. Jane describes Jack as "easy going, a hard worker, a man who carried his burden well and steady." Jane's mother, Mildred, lives in Holyoke. She is seventy years of age. She was a stay at home mother all of Jane's life. Their family lived on a farm, but after their father passed away, her mother moved into town. Jane states that she has a very close relationship with her mother. Jane describes Mildred as"good and tenderhearted, and loving." She states that her mother"never showed favoritism to any of the children instead she showed equal love to all of them." Structured Analysis Family Evaluation(SAFE)©Colorado Couple Multipurpose Home Study Report -Version 09-14-2005 Page 3 of 8 Copyright,2005,Consortium for Children,All Rights Reserved ' Jane lived with Tim Tugg for three years. After living together for three years,they got married March 17, 1979. They divorced in 1989. They lived in Gillette, Wyoming. This marriage did not result in children together. She states that he was an alcoholic. She explained the reason for the divorce was that he stole, wrote bad checks and was unfaithful. Jane explained that he could not hold down a job. Jane felt that she was naive with everything that was going on at this time. She described herself as co-dependent and stated she was always trying to make things right in her marriage. Jane met John through her sister, Heidi around 1990. John worked with her brother-in-law on the railroad. They were married October 12, 1991. They have no children together. Jane feels that the strengths in their marriage are faith,trust and love. She feels the weakness in their marriage is communication. She states that they continue to work on this all the time. Applicants' Sons and Daughters John has three grown children from his first marriage, Chad, April and Cindy. Jane has no children from her previous or current marriage. Other children living or frequently in the home None Other adults residing or frequently in the home There are no other adults living in the home besides Jane and John Doe. Family Lifestyle Jimmy attends pre-school at Early Learners three days a week from 8am-lpm. Jimmy also attends Small World daycare if they are unable to be home with Jimmy. John and Jane report that he seldom attends this daycare home, but it is available if they need child care. Some of the basic household rules and expectations are that Jimmy will listen and mind. When he is struggling with the household rules, they feel that communication and talking about why he is having problems is the most helpful. John and Jane feel that Jimmy will challenge Jane more then John. Another rule in the home is that Jimmy will not play in the front yard unless they are there to supervise him at all times due to the road that is in front of their home. If Jimmy would like to play outside he can play in the back yard where they can be outside with him or see him from the kitchen and dining room window. The Doe's celebrate Easter,Thanksgiving, Christmas, Birthday's, Independence Day, etc. They feel that they are pretty traditional in this matter. They engage with their family's to celebrate. The Doe's use to be members of the Assembly of God,but are now members of the 4-Square Church. They feel that they have a lot of support through this church and other members of the church. The Doe's participate in family activities such as fishing, camping, swimming, going to the park,biking, and attending church. Previous adoptions or foster care experience They have not had any previous foster care or adoption experience. FINANCES Combined annual gross earned income: $75,000 Sources of additional income: Retirement funds Structured Analysis Family Evaluation(SAFE)©Colorado Couple Multipurpose Home Study Report -Version 09-14-2005 Page 4 of 8 Copyright,2005,Consortium for Children,All Rights Reserved 'CRIMINAL/CHILD ABUSE RECORD The required criminal record and Child Abuse Index checks were completed for John Doe and Jane Doe. The criminal record was clear. Colorado Criminal CBI,ICON/Co Courts, and FBI(if applicable) Clearance Findings: There are no findings on John and Jane Doe. Records and Reports Findings: There was no record for John and Jane Doe in the Colorado Trails System. Other findings: There are no findings on John and Jane Doe. EMERGENCY CARE PLAN John and Jane have arranged a trust fund for Jimmy through the Assembly of God church so if something were to happen to them there would be some financial support to the family that would care for him. John and Jane have named three families that would be willing to care for Jimmy if needed. John's sister, Heidi,John's daughter and her husband, Cindy and Tom Brink, and family friends, Carol and Vernon Wells. CONTACT WITH FAMILY OF ORIGIN AND SIGNIFICANT OTHERS Continued contact with biological family will not be made. Jimmy will be able to keep in contact with the Coopers, Jimmy's Aunt and Uncle,who where a previous foster family for Jimmy. The Doe's stated that the Coopers may move out of County,but they will continue to send pictures and letters letting them know how Jimmy is doing. REFERENCES Kim Wells-415 Dirt St,Trinidad, Co (719) 555-5555 Ken Kind-410 1740 Rd. Delta Co (970) 555-5555 Vernon Wells-589 Sterling Dr., Monte Vista, Co (719)-555-5555 FAMILY PREPARATION AND TRAINING ACTIVITIES John and Jane Doe's home will be certified for Jimmy Smith, who is four years old. After he has been in their home for six months,they would like to look at adopting him. John and Jane completed Foster Parent Core Training in June 2005. Jane completed her CPR/First Aid in June 2005. John completed his CPR/First Aid in July 2005. John and Jane have read a book called"When Love is not Enough"which discusses parenting children with reactive attachment disorder. John has read some books on parenting. John and Jane completed self-test of stress in the foster home and the need for consistency with children. Further education in child development and parenting will be necessary. John and Jane continue to work on required training to be in compliance with the state requirements. John and Jane are also attending filial therapy with Laura Fourzon dealing with bonding, trauma and attachment issues and this will also teach John and Jane techniques for play therapy. LEGAL/FINANCIAL RIGHTS AND RESPONSIBILITIES John Doe and Jane Doe have been provided with information concerning the different roles,responsibilities, legal and financial rights and benefits of relative/fictive kin caregivers, foster parents, legal guardians and adoptive parents. Should they file a petition to adopt, John Doe and Jane Doe understand that they will be accepting full legal and financial parental responsibility for Jimmy Smith once an adoption is finalized. The agency's grievance review hearing procedures were explained to the Applicants. Structured Analysis Family Evaluation(SAFE)©Colorado Couple Multipurpose Home Study Report -Version 09-14-2005 Page 5 of 8 Copyright,2005,Consortium for Children,All Rights Reserved PSYCHOSOCIAL INVENTORY RESULTS NOTE: Below is a list of the psychosocial factors found on the SAFE Psychosocial Inventory. Using the Psychosocial Inventory, each factor was considered and rated several times by the social worker during the course of this home study. The ratings below represent the final ratings. The ratings are defined as follows: 1 =an exceptional strength, 2 = a strength, 3 = an issue of concern, 4 = a major issue of concern and 5 = very serious problem. The OVERALL EVALUATION OF SECTION ratings reflect the degree to which all issues of concern identified in the section were either resolved,mitigated or the prognosis for change. ^^" +m n tt aTT11:M9 ^,.. r ry Y " - x.. " "�` .tTiONSHII'S" #1 #2 ;HiS�OR .��.,�� °�� .�: .� ... � w.,...3��...: #1 #2 , EXTCNI)ED ,.w„�,...._.�.�._. .,__. .�, 2 2 Childhood Family Adaptability 1 1 Extended Family Cohesion 2 2 Childhood Family Cohesion 1 1 Extended Family Adaptability 2 2 Childhood History of Deprivation/Trauma 1 1 Relationship with own Extended Family 2 2 Childhood History of Victimization 2 2 Relationship with Spouse's/Partner's Family 2 2 Adult History of Victimization/Trauma 2 2 OVERALL EVALUATION OF SECTION 2 2 History of Child Abuse/Neglect 1 1 History of Alcohol/Drug Use EPHYS1Q ,_SbCI41.11 Rb „ j 1 1 History of Crime/Arrest/Allegations/Violence 1 Cleanliness/Orderliness/Maintenance 1 1 Psychiatric History 2 Safety 2 1 Occupational History j 1 Furnishings 3 3 Marriage/Domestic Partner History I Play Area/Equipment/Clothing 2 2 OVERALL EVALUATION OF SECTION 1 Finances #1 #2 iria LG 7 T. 7"�: x. .. 2 Support System a�xi'u , r,;>t: N/A Household Pets .................. 3 3 Communication 2 . OVERALL EVALUATION OF SECTION 2 2 Commitment and Responsibility 2 2 Problem Solving #1 #2 E4it i ,. '5 ,ie. 2 2 Interpersonal Relations 2 2 Child Development 2 2 Health and Physical Stamina 2 2 Parenting Style 2 2 Self-esteem 2 2 Disciplinary Methods 2 2 Acceptance of Differences __. 2 2 Child Supervision 2 2 Coping Skills 2 2 - Learning Experiences 2 2 Impulse Control 1 3 Parental Role 2 2 Mood 1 2 ': Child Interactions 2 2 Anger Management and Resolution 1 2 Communication with Child 2 2 Judgment 1 1 Basic Care 2 2 Adaptability 2 2 Child's Play 2 2 OVERALL EVALUATION OF SECTION 2 2 OVERALL EVALUATION OF SECTION "HABIT - + #I #2 2,SPEC � ' GrF - g ' LAO ALPO S "q° 'r ji .^ *-: 444 rigetn, 2 2 Expectations 3 Conflict Resolution 2 2 Effects of Abuse/Neglect 2 Emotional Support 1 1 Effects of Sexual Abuse 3 Attitude toward Spouse/Partner 2 2 Effects of Separation and Loss 3 Communication between Couple 2 2 ! Structure 2 Balance of Power 1 1 Therapeutic/Educational Resources 2 Stability of the Marriage or Partnership. .. 2 2 Birth Sibling Relationships 2 Sexual Compatibility I 1 Child Background Information 2 OVERALL EVALUATION OF SECTION 2 2 Birth Parent Issues 2 2 OVERALL EVALUATION OF SECTION FSOI SIDA'UGHTE is/OTHERS RESmni r k•.`R'si v. Y 9rv:, ,+ 4 -, yx y "YJ SbnS t i., #1 #2 "r.ADOPTI N IS CJES��3 "" r, r o"' 4�ORFREQ e YINHOME Q �^ N/A Minor Sons and Daughters -, 2 2 Infertility N/A Minors Residing or Frequently in the Home 2 2 Telling Child about Adoption 2 Adult Sons and Daughters 1 1 Openness in Adoption N/A Adults Residing or Frequently in the Home . 2 2 Adoptive Parent Status 2 OVERALL EVALUATION OF SECTION i 2 2 OVERALL EVALUATION OF SECTION Structured Analysis Family Evaluation(SAFE)©Colorado Couple Multipurpose Home Study Report -Version 09-14-2005 Page 6 of 8 Copyright.2005,Consortium for Children,All Rights Reserved PSYCHbSOCIAL EVALUATION REPORT HISTORY John and Jane both scored 2's on their history as a child and family relationships growing up. They scored and exceptional strength on psychiatric history, history of drug/alcohol abuse and history of criminal activity. John nor Jane have a history of drug and/or alcohol abuse. They have a clean criminal background and there is no history of psychiatric problems. PERSONAL CHARACTERISTICS John and Jane scored 2's on all categories. They are able to communicate with John and for the best interest of Jimmy. They are responsible adults with good coping skills when it comes to children. They are able to accept Jimmy's differences and his history with his biological family. Jimmy is a high maintenance child and requires a lot of attention that John and Jane are able to give him. MARITAL/DOMESTIC PARTNER RELATIONSHIP John and Jane scored 2's on emotional support, stability of marriage and sexual compatibility. They seem to be committed to each other and understand the things that need work on in their relationship. Although there are some communication problems,they are aware of them and this is something they work on everyday. At times when there is lack of communication Jane tends to become discouraged with John. John doesn't react with anger. SONS/DAUGHTERS/OTHERS RESIDING OR FREQUENTLY IN THE HOME There are no other adults that are living in the home. Jane doesn't have any children. John has three children, Chad, April and Cindy. John has a positive relationship with his adult children. Cindy is named as someone to possibly care for Jimmy should something happen to John or Jane and result in death. EXTENDED FAMILY RELATIONSHIPS John and Jane moved back to Colorado to be closer to her family. They have a good relationship with one another and feel that family is a big support in their lives. John and Jane both love and accept each other's families. John has a positive relationship with his children. John and Jane rated l's on Extended Family Cohesion,Extended Family Adaptability,Relationship with Own Extended Family and a 2 on Relationship with Spouses Family. PHYSICAL/SOCIAL ENVIRONMENT The Doe's scored high in this area.. There are a few safety issues that will be fixed before the home study is approved. John has purchased a gun cabinet with a lock for his firearms. John and Jane have also put up a screen for the fireplace in the basement. They scored 1's on cleanliness, furnishings, play area and finances. The worker didn't see any problems in these areas. The house was clean and appropriate. Both John and Jane are well groomed and practice good hygiene. GENERAL PARENTING John scored a one on parental role, child interactions, communication with child, and basic care. John has spent more time with Jimmy and Jimmy listens and tends to better follow the rules that are set by John. John scored 2's on the other categories. John demonstrates good general parenting with Jimmy. Jane scored a one on basic care as she will ensure that all of Jimmy's basic needs are met. Jane scored 2's on all other categories except parental role. This is due to John spending more time with Jimmy and he tends to listen to John more then Jane, however,Jane is making those strides by learning different techniques to better help Jimmy. Structured Analysis Family Evaluation(SAFE)©Colorado Couple Multipurpose Home Study Report -Version 09-14-2005 Page 7 of 8 Copyright,2005,Consortium for Children,All Rights Reserved SPECIALIZED PARENTING John and Jane both scored high in this area. They are taking the time to understand and learn ways to best care for Jimmy and his special needs. They are able to have a structured home and are learning how to have a therapeutic home as well. They are aware of Jimmy's background history and are able to help him with any issues that may arise. ADOPTION ISSUES John and Jimmy scored l's and 2's in these categories. They are open about adoption and Jimmy will be aware that they are adopting him. John and Jane show the ability to discuss with Jimmy reasons why they adopted him and under what circumstances while doing this appropriately. PSYCHOSOCIAL EVALUATION CONCLUSIONS John and Jane have many strengths when it comes to providing a safe, stable and nurturing environment for Jimmy. Jimmy requires a lot of attention in which they are willing to give him. John and Jane are committed to providing Jimmy with a family where he is loved and accepted. John and Jane have completed trainings to better help and understand Jimmy and his special needs. There are not any concerns based on the psychosocial evaluation. CHILDREN THE FAMILY CAN BEST SERVE Jimmy is a four-year old male. He is the only child that will reside in their home and is not a part of a sibling group. Jimmy special needs include his speech. John and Jane are willing to accept help and expand their knowledge by attending trainings and working with licensed professionals to better understand how to meet all of Jimmy's needs. RECOMMENDATION It is recommended that John Doe and Jane Doe be approved for Adoption. 3/1/2006 Caseworker Supervisor Title Title Date: Date Additional Attachments Criminal background and reference letters REVIEW OF COPY OF HOME STUDY REPORT By signing below I acknowledge that I have read a copy of this report. John Doe Jane Doe Date: Date To check for form q{nlarrs,press the rid key and(irk this link Structured Analysis Family Evaluation(SAFE)©Colorado Couple Multipurpose Home Study Report -Version 09-14-2005 Page 8 of 8 Copyright,2005,Consortium for Children,All Rights Reserved ks Program Area Supervisor/Provider Meeting Verification/Comment Form Date of Meeting: r3 / ' /o 7 Program Area: Mm e J /vtli Ef /Re-21 y v, J h rte Comments (to be completed by Program Area Supervisor): OScosS/or- . 1 ef jar t coS /e. // (',weir, VI/i#4 Re.1r/ n% v/ s 4 ` cooi r ��rs.� elf-vela niceit f Rc4*!nm // _ pflacesSt 71/".se_ignit e e}�en 71-,..9-7 ,e3/4 es, roc/ el7f- 75,74 St a- y / gnna Serfs 7 et.nra e..74 oPAfrAorl ^f RpVC ,, fvaptgd7 u /0-1 en.es Awl 'Sy gent qua`. rem- /& (nri p -9i9//ae., Air 0 tO/s c v,:s cp /y`l Oni.edener 4AI u `L 14-u P_ Co ay/a,`e40 flntt .S)9FG 7a2,}1 "17 on"in, A- e Age- e 5 4.7 tie K.ad r? / s • arnlifailW Signature of Program Area Supe. Print Date: 03/0 6/0 7 HEALTHCARE PROVIDERS SERVICE ORGANIZATION ANA F CATEN CERT OF INSURANCE OCCURRENCE POLICY FORM Producer*Branch;Prefixi ,Policy:Numberg` Policy';Period` 018098 970 HPG 0296387447 from:12:01 AM Standard Time on:03/05/07 to: 12:01 AM Standard Time on:03/05/08 Named Insured.and_Address:r ,"S1:„ „ ' W;7, :/:4:PriagrarritAdministratot., Blythe E Johnson Healthcare Providers Service Organization 20D11 Mcr T5 159 East County Line Road Fort Morgan, CO 80701 Hatboro, PA 19040-1218 Medical Specialty Code: 'Insurance.Provided;by > Social Worker, Clinical 72990 American Casualty Co. of Reading, PA CNA Plaza 26S Chicago, IL 60685 COVERAGEPARTS 4,7 j , a y�� ; LIMITS:OF'LIABILITY.. A. PROFESSIONAL LIABILITY Professional Liability (PL) $ 1,000,000 each claim $ 3,000,000 aggregate Good Samaritan Liability included above Personal Injury Liability included above I7,-; *: • Mat Malplacement Liability included abovei`, k B. COVERAGE EXTENSIONS: License Protection $ 5 O0 per proceeding$ 12,500 aggregate Defendant Expense Benefit w#P Es I,r=^lr a ilii M: ,,a,! $ 5,000 aggregate Deposition Representation $ 1,250 per deposition $ 2,500 aggregate Assault $ 5,000 per incident $ 12,500 aggregate Medical Payments $ 1,000 per person $ 50,000 aggregate First Aid *< ,r/' r,". $ 1,250 aggregate Damage to Property of Others $ 250 per incident $ 5,000 aggregate C. WORKPLACE LIABILITY Coverage part C.Workplace Liability does not apply if Coverage part D.General Liability is made part of this policy. Workplace Liability included in A. PL limit shown above Fire &Water Legal Liability included in A. PL limit shown above subject to $150,000 sub-limit Personal Liability 45issiregoATOMMANNISAMINO $500,000 aggregate D. GENERAL LIABILITY Coverage part D.General Liability does not apply if Coverage part C.Workplace Liability is made part of this policy. General Liability (GL) none none Hired Auto & Non Owned Auto none .r = s.K , .z. 7 Fire & Water Legal Liability none none Personal Liability ., _ t k, ,` iii none ' Total Premium: $ 144 . 00 QUESTIONS?CALL: 1-800-982-9491 .Policyforinsrand-endorsementsattached";atinceptiona;. G-121500-C G-121503-C G-121501-C G-145184-A - G-147292-A G-144872-A G-123846-005 Master Policy#188711433 Keep this document in a safe place. It and proof of payment are evidence of your insurance coverage. Ca)rjAdti 7k\INZ1- - Chairman of the Board Secretary G-141241-A (07/2001) Coverage Change Date: Endorsement Change Date: EXHIBIT B SUPPLEMENTAL NARRATIVE TO RFP • May 17,2007 Tobi Vegter,Core Services Coordinator Weld County Department of Human Services P.O. Box A Greeley, Co. 80632 Dear Tobi, I have read the recommendation concerning my bid approval,Home Studies,Updates and Adoption Home Studies for inclusion on your vendor list. I am writing to accept the recommendation of the FYC Commission. I estimate that approximately 20%of the clients I will serve through my bid will need bilingual services. I have adjusted my overhead costs to include interpreter services for these clients. This means approximately 3.5 home studies per year will need interpreter services at a rate of$15 per hour, average,times 6 hours per study,for a total overhead cost increase of$315 per year. Sincerely, Blythe Johnson Bid#002-HS-07 (RFP 006-00B)Home Studies 1 it DEPARTMENT OF SOCIAL SERVICES T P.O. BOX A I GREELEY, CO. 80632 Website:www.co.weld.co.us Administration and Public Assistance(970)352-1551 O _ Fax Number(970)353-5215 • COLORADO May 11, 2007 Blythe Johnson 20011 MCR T.S. Fort Morgan, CO 80701 Re: Bid#002-HS-07(RFP 006-00B)Home Studies Dear Ms. Johnson: The purpose of this letter is to outline the results of the Bid process for PY 2007-2008 and to request written confirmation from you by Monday,May 21, 2007. The Families,Youth, and Children Commission appreciate your interest in providing services for families in Weld county. This year, strides were made in structuring an RFP that is clear and concise, and more user friendly, for both prospective bidders and evaluators. It is important to stress the value of following formatting guidelines and addressing the required sections concisely and appropriately. A. Results of the Bid Process for PY 2007-2008 • The Families,Youth and Children(FYC)Commission recommended approval of your Bid# 002-HS-07, (RFP 006-00B)Home Studies,Updates, and Adoption Home Studies for inclusion on our vendor list. The FYC Commission attached the following recommendation to your bid.. Recommendation: The approved bidder will pursue bilingual interpreters/translators/staff in order to better serve bilingual and monolingual clients.This may include offering incentives, accommodations, and encouragement to Spanish bilingual interpreters,translators, and staff. B. Required Response by FYC Bidders Concerning FYC Commission Recommendations: You are requested to review the FYC Commission recommendations and to: 1. accept the recommendation(s) as written by the FYC Commission; or 2. request alternatives to the FYC Commission's recommendation(s); or 3. not accept the recommendation(s)of the FYC Commission. Please provide in writing how you will incorporate the recommendation(s) into your bid. If you do not accept the recommendation,please provide written reasons why. All approved. recommendations under the NOFAA will be monitored and evaluated by the FYC Commission. h Page 2 Blythe Johnson RFP 001-07/2007-2008 The Weld County Department of Social Services is requesting your written response to the FYC Commission's recommendation. 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, et J A. Gr ,Direct 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 Child Welfare Regular Administration Funding Type of Action Contract Award No. X Initial Award 07-CPS-31 Revision (RFP-006-00B; 004-HS-07) Contract Award Period Name and Address of Contractor Beginning 06/01/2007 and Julie Box,Private Practice. Ending 05/31/2008 Home Studies,Updates,Relinquishment Counseling 1702 68'"Avenue Greeley,CO 80634 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Home study format is based on 20 hours, Assistance Award is based upon your Request for including 10 hours of direct service and 10 hours Proposal(RFP). The RFP specifies the scope of of indirect service.The average stay is expected services and conditions of award. Except where it is to be 6 weeks for a home study. Estimated home in conflict with this NOFAA in which case the study capacity is five home studies monthly,or NOFAA governs,the RFP upon which this award is 67 home studies and updates yearly. based is an integral part of the action. Relinquishment counseling is estimated at two Special conditions hours of direct service per person,or 24 1) Reimbursement for the Unit of Service will be based individuals per year.The average duration is one on an episode rate per home study; home study week for each person in relinquishment update,and hourly rate for relinquishment counseling counseling. Bilingual-bicultural services are and court testimony. available through subcontract. 2) Reimbursement requests must be an original with an original signature from the provider and/or designee. Cost Per Unit of Service 3) Reimbursement requests must include the date the Hourly Rate per home study,update,or relinquishment counseling was Relinquishment Counseling $103.89 completed.The request must reflect the amount billed Court Testimony $75.00 for each home study, and the month the service was Episode Rate per provided.Requests for services submitted 90 days Full Home Study with Background Check* $950.00 from the date of service, and thereafter,will not be Full Home Study(No Background Check)* $850.00 paid. Updated Home Study $425.00 4) Payment will only be remitted on referrals made by Home Study(3.5 Hour Minimum Direct Face- the Weld County Department of Social Services. to-Face Contact)Cancellation by DSS $225.00 5) Requests for payment must be an original submitted to Additional Fee per Additional Adults in the Weld County Department of Social Services by Household per Home Study* $250.00 the end of the 25th calendar day following the end of Enclosures: the month of service. The provider must submit X Signed RFP:Exhibit A requests for payment on forms approved by Weld Supplemental Narrative to RFP: Exhibit B County Department of Social Services.Requests for _ Recommendation(s) payments submitted 90 days from the date of service, _ Conditions of Approval and thereafter, will not be paid. 6) The Contractor will notify the Department of any changes in staff at thetime time of the change. Approve ls: _ Program ft is : J" q By L `�L� By (l David E. Long, Chair Judy . Grie ,Directoi Board of Weld County Commi Toners Weldbuntunty D part ent of Social Services Date: JUN 1 8 2007 Date: 1 CT7 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 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 Commissioner's 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 ( f� „�� Z L( -J (After receipt of order) BID MUST BE SIGNED IN INK Program Area: Home Studies Hothrte&Relinq,tSait, _Julie Box TYPED OR PRINTED SIGNATURE VENDOR _Julie Box,LCSW (Name) Handwritten Signature By Authorized Offc— ent of Vendor ADDRESS 1702 68th Avenue TITC` E— =% LC Si)/ Greeley, CO 80634 DATE.\ F' ( c t PHONE# _970.302.1471 The above bid is subject to Terms and Conditions as attached hereto and incorporated. 1. June 2007 Bid No: 001-07 Adoption, Foster Care, and Expedited Permanency Planning Home Studies and Relinquishment Counseling Julie Box, LCSW Private Practice ABSTRACT Julie Box(Bidder)is a Licensed Clinical Social Worker offering a wide range of services to children, families and adults. Bidder has been providing mental health and supportive services to the Northern Colorado area since 1986. During the past 21 years,Bidder has provided services as a counselor, a caseworker and a therapist in the field of child welfare. Bidder has provided services to all individuals without consideration of religious beliefs,race,culture, ethnicity, gender, sexual preference,age or economic status. From 2001 through 2004,Bidder provided home studies and relinquishment counseling services to the Weld County Department of Social Services through this Bidder's previous employer, Lutheran Family Services,a non-profit agency. Bidder has been providing these same services for the Weld County Department of Social Services through contractual services as a Private Practitioner since June of 2004. Bidder uses the Structured Analysis Family Evaluation(SAFE) inventory completed by the Consortium for Children in October of 2005. A written,narrative home study will be provided to the Weld County Department of Social Services. Bidder is currently on the state vendor list for adoptive home study providers. Additionally,Bidder has the experience and expertise to provide relinquishment counseling in a timely fashion. Bidder's mission is to provide best practice services to families,youth,children and the Weld County Department of Social Services. Best practice includes the provision of respectful and dignified attempts to focus on family strengths,to protect children,to prevent placement,and to reunify children and their families. 2 TABLE OF CONTENTS A. Invitation to Bid page 1 B. Abstract page 2 C. Table of Contents page 3 D. Target/Eligibility Populations page 4 • Total number of clients to be served • Total family units • Sub-total of individuals who will receive bicultural/bilingual services • Sub-total of individuals who will receive services in South Weld County • Monthly program capacity per group • Average stay in the program (weeks) • Average groups per week in the program E. Project Narrative/Supporting Documentation pages 5-8 • Types of service provided • Measurable outcomes • Service objectives • Workload standards • Staff qualifications • Program capacity per month • Internal tracking and billing process F. Budget page 9 G. Appendices: • Appendix 1: Resume for Julie Box, LCSW pages 10-12 • Appendix 2: Data Collection Instruments/Protocols page 13 • Appendix 3: Sample Consent Forms pages 14-16 3 TARGET/ELIGIBILITY POPULATIONS: The population to be served under this contract includes: families who wish to adopt children from the Weld County Department of Social Services, relinquishment counseling for parents who are considering relinquishing children, applicants for foster care certification and children identified as expedited permanency planning. Bidder has been providing home study services to Weld County for the past six years and has never turned down a referral. At 20 hours per home study, Bidder would be able to complete 5 home studies per month. Home studies are given ten hours of direct service and ten hours indirect service. Bidder is cross-trained to provide a variety of clinical services including therapy, clinical case management, relinquishment counseling or home studies. Note: State Regulations now require that the Department receive the results of the CBI and FBI background checks before the home study can be submitted. The average time CBI and FBI results are received by the Deparbnent is currently two months. Therefore, home studies are now being submitted approximately two months after receipt of the referral. The following numbers reflect a caseload of 5 home studies per month: A. Total Number of Clients to be served: Each home study is'worth'20 hours and will be spread over a six-week period of time. Bidder estimates she could complete 67 home studies per year. Relinquishment counseling will be provided on an hourly basis. Bidder estimates the relinquishment counseling takes an average of two hours of direct service per person. Bidder estimates she could counsel 24 Individuals per year. B. Total family units. Bidder estimates she could complete 67 home studies per year. C. Sub-total of individuals who will receive bicultural/bilingual services Unfortunately, Bidder is not bilingual; however, Bidder would be able to contract with a qualified Spanish speaking clinician to complete home studies as referred. Bidder would not refuse any bicultural services. D. Sub-total of individuals who will receive services in South Weld County. Bidder does not limit her services to specific geographical areas so Bidder will provide services in the Southern part of Weld County as they are referred. E. The monthly program capacity per group. Bidder estimates she could complete 5 home studies every month. F. The monthly average capacity per group. Bidder estimates she can manage the volume of home studies as Bidder has done so the past six years. At the present rate of referral, Bidder would plan to complete 5 home studies per month. G. Average stay in the program (weeks) Bidder's goal is to complete home studies within six weeks of implementation of the home study. Bidder is estimating that relinquishment counseling averages 1 week. H. Average groups per week in the program. Families who are having a home study completed will average 2-3 hours of direct service per week, for 4 weeks. 4 PROJECT NARRATIVE/SUPPORTING DOCUMENTATION ADOPTION, FOSTER CARE AND EXPIDITED PERMANENCY PLANNING A. Types of service provided: Bidder uses the Structured Analysis Family Evaluation (SAFE) protocol developed by the Consortium for Children. This is the format that was taught in state sponsored training that Bidder attended in Greeley, Colorado, on October 10 and 11, 2005. Bidder has also attended the SAFE Supervisor Training on November 16, 2006, and is now certified to supervise other's using the SAFE format. These home studies are'adoptive quality'and meet the state prescribed format. The Psychosocial Inventory aspect of the SAFE format provides quantitative measures as they directly relate to the applicant's abilities to care for traumatized children. There is no difference between adoption, foster care or kinship care home studies. Bidder is currently on the state vendor list for adoptive home study providers. Home study updates will be completed using the SAFE protocol and there will be a reduced fee charged. Bidder will complete the following background checks unless otherwise indicated on the referral: 1 Fingerprints sent to CBI and FBI on Weld County Department of Social Services (WCDSS)fingerprint cards, results will be returned directly by CBI to the WCDSS. Bidder will collect and submit the fingerprint cards to CBI/FBI after the WCDSS has distributed the cards. Prospective foster/adopt families will cover the fee for the submission of these cards. If the applicant(s) has lived in Colorado for less than five years, the applicant(s)will be required to contact any other state Central Registries of Human Services where they have lived over the past five years and procure background checks through these Central Registries. 2 Department of Motor Vehicles(results returned to Bidder). 3 Local county DSS search for open or past cases (results returned to Bidder). 4 Four SAFE reference questionnaires will be sent out (results returned to Bidder). 5 Local police and sheriffs department (results returned to Bidder). 6 TRAILS and LexisNexis CoCourt checks will be completed by the referring caseworker through at the Weld County Department of Social Services. All original background check information will be forwarded to the WCDSS with the written home study. A copy will be retained in Bidder's files, per State Regulations for 7 years. Also included with the final home study will be the SAFE questionnaires one and two, completed by the applicants, the four references and any other original documents submitted to the Bidder by the applicant(s). Bidder has all of the forms and processes in place necessary to complete these background checks. Additionally, Bidder can provide a safety inspection of the home, if requested, at no additional fee to the county. RELINQUISHMENT COUNSELING SERVICES Relinquishment counseling services will be provided to all adult individuals referred for this service by the WCDSS as well as to their children age 12 and older. Services will be provided individually and Bidder will submit a written report and the appropriate affidavits/interrogatories. 5 B. Measurable outcomes: The goal for each home study referral is to complete a quality, comprehensive, written home study within six weeks of initiation of the home study. The outcome will be measured through timely submission of the home study to the referring caseworker, therefore ensuring more expedient placement of children. Bidder will also track the number of home studies referred that Bidder did not accept and the number of home studies referred and subsequently cancelled by the department. The SAFE protocol provides a psychosocial inventory used to measure the risk of the placement in an applicant foster family or adoption of a child in any given home. Bidder will use the psychosocial inventory to measure, evaluate and monitor outcomes of the home assessment. Ultimately, the number of acceptable home studies submitted will define outcomes. Relinquishment counseling referrals will be tracked and measured in the same way as home studies. Bidder uses the state format to interview and assess consumer's intent regarding relinquishment. C. Service obiectives: The service objectives are the same as the measurable outcomes, that is: the completion of quality home studies, updates and relinquishment counseling services in a timely manner. All home studies will be completed using the state endorsed SAFE protocol. Bidder will conduct a minimum of three joint interviews, one individual interview with each adult member in the household and an age/developmentally appropriate interview with all children residing in the home. For single applicants a minimum of three interviews will be completed. At least one interview will be completed in the applicants home. Interviews will be spread out over a period of not less than 7 consecutive days. Bidder focuses upon the permanency needs of the children in out-of-home placement, specifically in preserving the placements of children. Bidder facilitates the efforts of the WCDSS and the providers to contribute to the planning for a child's independent living skills when appropriate. Bidder supports and encourages providers to maintain children's cultural and racial identities. Bidder works with providers to encourage open, honest and consistent communication with the WCDSS. D. Workload standards: Please see the previous section°Target/Eligibility Populations'for a detailed explanation of Bidder's workload standards. In summary, Bidder intends to devote 20 hours per week to completing the home studies referred. Half of Bidder's time will be in Direct Service hours and half in Indirect Service hours. The requested minimum standards for insurance have been met and documentation provided. Bidder encourages providers to comply with the WCDSS requirements of scheduling medical and dental appointments as required by State Regulations (two weeks from time of placement for physicals and eight weeks from time of placement for dental). Bidder emphasizes the importance of providers working as part of a team with the WCDSS caseworkers toward meeting the best interests of the child, stressing the importance of preservation of placements and communication. E. Staff qualifications: Bidder has a bachelor's degree in Psychology(BA),a Masters degree in Social Work(MSW)and is a Licensed Clinical Social Worker(LCSW)since January 21, 2003(license number: 992996). Please see the attached copy of Bidder's license. Bidder has her own private practice and is the only staff available. However, Bidder can provide a qualified professional that can translate for 6 Spanish speaking persons as needed. As an LCSW, Bidder does not have a clinical supervisor. Bidder has not received mandated new caseworker training. Bidder has many years of training and experience in risk assessment. Bidder secures a minimum of 8 hours per year of continuing education training. Bidder agrees to notify the Department immediately of any change in staff at the time of change. F. Program capacity per month: Each home study is'worth' 20 hours and will be spread over a six-week period of time. Bidder estimates she could complete 67 home studies per year. Relinquishment counseling will be provided on an hourly basis. Bidder estimates the relinquishment counseling takes an average of two hours of direct service per person. Bidder estimates she could counsel 24 individuals per year. Bidder estimates a minimum of 3 clients per month to support her program. G. Internal tracking and billing process: Please refer to the attached budget for computation of direct service rate. Home studies: Full home study with background check: $950 Full home study without background check: $850 Updated home study: $425 Additional adults living in the home: $250 per adult. Cancellation fee, if cancelled by WCDSS, after 3.5 hours of direct, face-to-face contact: $225; if cancelled by applicants after 3 hours of direct, face-to-face contact: cost to be arranged with the WCDSS dependent upon the hours Bidder has spent on each case. Relinquishment counseling:$103.89 per hour This fee includes the background check and all necessary interviews for a two-parent family. Bidder bills once the home study has been completed, the WCDSS receives the CBI and FBI background check results and the applicants have read the home study and signed. Bidder submits the bill with the completed home study with all attachments, e.g., SAFE questionnaires one and two, local background checks, the department of motor vehicle checks and four references. Bidder will submit bills using the Weld County CORE Services Program monthly request for reimbursement-PY 2006-2007, home studies, updates, and relinquishment counseling form. Bidder's internal tracking is done through a form recording: receipt of referral's, name of client, referring caseworker, referral type, household and TRAILS numbers, date received, date completed, date submitted and date payment was received. H. Literature citations: NA, Home studies and relinquishment counseling do not require any references to literature. 7 I. Confidentiality and participant protection: • Protect clients and staff from potential risks: Covered by Bidder's Disclosure Statement on pages14-16. • Fair selection of participants: Bidder accepts all referral's from the WCDSS regardless of age, gender, racial/ethnic background, children of substance abusers, foster children, pregnant women, religious preference, sexual preference or disabilities. Bidder does not recruit or select participants, the WCDSS makes such decisions. • Absence of coercion: Covered by Bidder's Disclosure Statement on pages 14-16. • Data collection: Covered by Bidder's Disclosure Statement on pages 14-16. • Privacy and confidentiality: Covered by Bidder's Disclosure Statement on pages 14-16. • Adequate consent procedures: Covered by Bidder's Disclosure Statement on pages 14- 16. • Risk/benefit discussion: Bidder collects information during the course of a home study to assess risk to children, provide expedient placement of children and to provide preservation of placements for children. Risk to the applicants in sharing their personal information is that their application to provide foster/adopt care for children may be denied due to some of the information disclosed. For example, if an applicant shares a history of sexual abuse that currently causes them a great deal of distress their application may be denied until they have addressed this issue. These risks are explained to applicants and therefore reasonable expected benefits to the applicants are that their application would be approved and that they would be able to provide these services to the children, the biological family members and the community. 8 BUDGET Please refer to the attached budget forms and Unit of Rate Computations. APPENDICES 1 THROUGH 3 • Appendix 1: Resume for Bidder • Appendix 2: Data Collection Instruments/Protocols • Appendix 3: Sample Consent Forms 9 APPENDIX 1: RESUME Julie Box, LCSW 1702 68 Avenue Greeley, CO, 80634 970.339.9036 or 970.302.1471 Education: Adams State College;BA in Psychology. Graduated 1984. Colorado State University; MSW; Masters in Social Work. Graduated in 1996. Licensed Clinical Social Worker as of January of 2003; License#992996. Work History: Private Practice: June 01, 2004, to present This clinician currently has a contract with the Weld County Department of Social Services (WCDSS)to complete home studies for individuals applying as foster/adoptive parent(s) in Weld County. Responsibilities include the use of the SAFE, Structured Analysis Family Evaluation, a written,narrative home study provided to the WCDSS,with recommendations,background checks through the Department of Motor Vehicles and local law enforcement, four letters of reference for the applicant parent(s)and SAFE Questionnaires one and two,completed by the applicant parent(s). The WCDSS completes other background checks through the CBI as well as the Colorado Central Registry,on their own. Clinician at Lutheran Family Services May 11, 1998, to January 13, 2006. Program Manager for Family Preservation Program, Home Study Program and Relinquishment Counseling Program for Lutheran Family Services June of 2003 to January of 2004. The rest of the time was a position as clinician. Responsibilities as a clinician include crisis intervention,therapeutic services for foster children dealing with grief and loss issues in LFS homes,case management services for foster children,foster parents,birth parents and county caseworkers, attending and testifying at court hearings,completion of home studies for Lutheran Family Services homes as well as for the Weld County Department of Social Services,completion of all related paperwork including but not limited to monthly reports,ongoing progress notes, interactional assessments,monthly staffing notes and development of treatment plans. Responsibilities as a program manager included responsibility for clinical and administrative oversight of the three programs listed above,assisting in selecting staff,assisting in program development and definition, identifying community resources to supplement program activities and ensure that consistently high quality clinical care and case management services are provided for each program consumer. 10 Social Caseworker III: Child Protection for the Boulder County Department of Social Services August 05, 1996, to May 11, 1998 Responsibilities include family assessments, family and individual therapy,updated written reports on case progress,written court reports, attendance and testimony at court hearings, school stuffing's,therapeutic stuffing's,crisis intervention,written social histories,attending interagency stuffing's, development of treatment plans and general case management. Supervisor for Work Release and Home Detention Inmates for the Weld County Sheriff's Department December of 1994 to July of 1996 Responsibilities include direct supervision of inmates in the work release and home detention programs,daily record keeping of inmate activities,home visits to verify the inmates whereabouts,crisis intervention and counseling of inmates. Counselor II/Assistant Program Directorfor the Weld County Shelter Home and Alternative Homes for Youth November of 1986 to August of 1994 Responsibilities included all financial management, supervision of adjudicated delinquent youth aged twelve to eighteen,counseling youth with a focus on grief and loss issues,development of treatment plans,USDA liaison, supervision of staff,training for all new staff and interns, assumption of the program directors duties when the director was absent,communicating effectively with all other professionals and the upkeep of statistics. Continuing training Family Group Decision Making:November 1998 Understanding Anxiety: October 1999 Play Therapy and Therapeutic Care of Children in Foster Care and Adoption: October 1999 Oppositional Behavior and ODD: 2000 Attachment and Bonding: January 2001 Verbal De-escalation and Personal safety: February 2002 Psychiatric Medications in Children Placed in Foster or Adoptive Care: March 2002 Building Skills in High Risk Families: June 2002 Confirming Safe Environments: September 2002 Foster Family Assessment Training: September 2002 EMDR; Basic Training:November 2002 Attachment and Bonding: February 2003 Understanding and Responding to the Sexual Behavior of Children: May 2003 Advanced Training for Special Advocates: September 2003 Helping Grieving Children and Teens: October 2003 Mediation Course: June 2006 References: Lutheran Family Services Human Resources Department: 1.800.579.9496; 363 S. Harlan, Suite 200,Denver,CO.,80226-3552. 11 Sharon Thomas: Supervisor at LFS from May of 1998 to December of 2003: 970.663.1039; 3733 Lincoln Court, Loveland,CO, 80538. Email: Skt1225@aol.com Diane Baird: LCSW Consultant: Private Practice. 720.217.9352. Maria Baladez: Co-worker at the Boulder County Department of Social Services: 303.250.1484; 640 Gooseberry Drive,#402,Longmont,CO., 80503. Email: mbass@co.boulder.co.us. 12 APPENDIX 2: Data Collection Instruments/Protocol Bidder uses all current SAFE data collection instruments/protocols. Data collection instruments include the following; • SAFE Multi Purpose Home Study Report • SAFE Child Specific Home Study Report • Annual SAFE Update/Renewal/Addendum • SAFE Kinship Non-Certified Child Placement Family Evaluation(specific to couples and individuals) • SAFE Questionnaire's I and H (available in English and Spanish) • SAFE References Forms 13 APPENDIX 3: Sample Consent Form Julie Box, LCSW Private Practice 1702 68th Avenue, Greeley, CO 80634 970.302.1471 Fax: 970.339.9036 Disclosure Statement Colorado law requires the following information be provided to all clients. Julie Box, Licensed Clinical Social Worker: License#: 992996 The Department of Regulatory Agencies regulates the practice of licensed and unlicensed persons in the field of psychotherapy. Concerns or complaints regarding the practice of psychotherapy may be directed to the State Grievance Board at 1560 Broadway, Suite 1370, Denver, Colorado, 80202,or call 303.894.7766. Confidentiality: Generally speaking, information provided by clients during treatment is legally confidential. Exceptions occur when a client is at imminent danger to self or others,when gravely disabled,when there is suspected child abuse or neglect,when the client's case is reviewed in supervision,consultation and training, or when ordered by a court of law. Regarding home studies, families are not"clients"as such and,although Ms.Box cannot discuss family information with individuals not involved with the case,the information gathered in the course of a home study is not confidential. The information gathered in the course of a home study is shared with the Weld County Department of Social Services(WCDSS)case coordinators,various caseworkers interested in placing a child in the home,the courts and, possibly,various attorney's involved in the child's case. Possible psychological, social and legal risks for the home study applicants include the sharing of personal information with strangers that may express some objection to a specific child being placed in or remaining in the applicant's home. Ms.Box attempts to minimize such risks by relating this information to the applicants. Regarding foster parent consultations, including individual, corrective action or group consultations,foster parents are not"clients"and,again,although Ms. Box cannot discuss information shared with individuals not involved with the case,information shared may be passed on to the WCDSS case coordinators and/or the child's caseworker. Ms. Box mitigates any risks to the foster parents by discussing the information to be shared with the foster parents prior to sharing information with the WCDSS case coordinators and/or the child's caseworker. Regarding relinquishment counseling,all information gathered in the course of the relinquishment counseling is recorded in the relinquishment counseling report and is then forwarded to the WCDSS caseworker and then to the courts and various attorneys involved in the child's case. Fair Selection of Participants: Ms.Box does not discriminate in any manner regarding selection of participants. She does not select or recruit participants. The WCDSS refers potential applicants and Ms. Box accepts all referrals from the WCDSS. 14 Absence of Coercion: All participation by the applicant(s)is voluntary. There is no required participation for home studies, relinquishment counseling, individual or group consultation. At any time, participants may withdraw from the process. However,regarding corrective action consultations,the WCDSS requires that identified foster parents participate with individual consultation. If the foster parents refuse to participate in individual consultation under a corrective action request,the WCDSS may revoke the foster parent's license. Foster parents are given the right to seek intervention of these services through the caseworker's supervisor. Collection of Information and Record Keeping: All recorded information, treatment plans,notes and reports are kept in locked filing cabinets at Ms. Box's office and kept on file for seven years. After seven years,the files are destroyed. Ms. Box's office computer and her laptop are password protected. Fee Statement: All Department of Social Services contractual fees are paid by DSS. Families in the process of a home study are required to pay fees for Colorado Bureau of Investigations(CBI)and Federal Bureau of Investigations(FBI)background checks. Private home study fee's are as arranged. Releases of Information: Parents will sign releases of information regarding the treatment of their children. Regarding home studies,consumers will sign any necessary releases of information as discussed with Ms. Box. Gifts: It is inappropriate and unethical for Ms. Box to accept any form of gift so please do not offer gifts. In addition, Ms. Box is required to provide consumers with the following information from the Division of Child Care, Colorado Department of Human Services, 1575 Sherman Street, First Floor, Denver, Colorado, 80203-1714, phone, and 303.866.5958; 1. To review the licensing file of an adoption/child placement agency call: 303.866.5088. 2. To obtain a copy of all licensed adoption/child placement agencies in the state of Colorado call: The Division of Child Welfare, 303.866.3228 or the Division of Child Care at 303.866.5958. I have read through the above disclosure statement with Julie Box and been informed of the proper procedure to file a complaint to the Colorado State Grievance Board. Julie Box explained areas that were unclear to me and I understand clearly all of the preceding information. I have been informed of the degrees,credentials and licenses held by Julie Box. I have read all of the preceding information and understand my rights as a consumer and I have received a copy of this Disclosure Statement. By initialing here,Uwe give consent for Ms.Box to email our completed home study to the referring WCDSS case coordinator/caseworker. 15 Signature of consumer Date Signature of consumer Date Julie Box,LCSW Date 16 ' Account Number: CO BOXJ 1700 Date: 2/20/07 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: Additional Named Insureds : JULIENNE E. BOX 1702 68TH AVE GREELEY CO 80634 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-1919252 2/20/07 2/20/08 1, 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: JULIENNE E. BOX 1702 68TH AVE Address: GREELEY CO 80634 Au orized Representative cTi/le Program Area Supervisor/Provider Meeting Verification/Comment Form Date of Meeting: /8/c 7 J Program Area: Arm ffu/eli 6', /1j'e,I,K/9 v K, I Pk ,71'— Comments(to be completed by Program Area Supervisor): acass/Ott. 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C 4 |, : in X w Pla\el 444n 4% g P 888888888888888888 8 , .q01 | 8 8 | E!t§&2#aea22a.;a#■ & # 7 ; |e ! , n §■■| §| ®-.. |{ | §§ 0000000000000 m§§§ zzzzzzzzzzzzz § a 8888 8 ! ! a |co |§| 6 2 § I § / C | _ | | a ms gLk | tit § f \ | | � | | § \ I ■ k { E | § § § |f || § 2 § 05.17.2007 Julie Box,LCSW 1702 68`"Avenue Greeley, CO, 80634 970.302.1471 Re: Response to recommendations made on: Bid#01-IFT-07(RFP 07008)Mediation and Facilitation under IFT Bid#007-FPC-07(RFP006-00A)Foster Parent Consultation Bidder accepts recommendations made and will meet recommendations in the following fashion: Response to recommendations from Weld County DSS for Mediation: • This bidder offers a bilingual translator for any Spanish speaking clients at no extra charge to the County. This bidder pays a set amount for interpretations as agreed upon by bidder and translator. • This bidder will meet all PIP requirements included in the initial bid from the Weld County DSS. This includes meeting placement changes by focusing on the needs of permanency for children in out-of-home-placement,maintaining cultural and racial connections and encouraging communication between families and the Department caseworkers. Response to recommendations from Weld County DSS for Foster Parent Consultations: • Bidder assures that all Program Improvement Plan requirements under the Foster Parent Consultation program will be met. These PIP requirements include: Placement changes, independent living, maintaining cultural and racial connections,monthly face-to-face visits with caseworkers,timely initial assessment within two weeks of placement and health needs identified and services provided. Please refer to this section addressed in bidder's initial bid for more detail. • Literature citations used with Foster Parent Consultations include Parenting with Love and Logic by Foster Cline and Jim Fay; Adopting the Hurt Child by Keck and Kupecky; Fostering Changes by Richard Delaney as well as bidder's System's Based approach to supporting foster families,the children in their home and the preservation of placements for children placed out of their homes. As stated in the initial bid,bidder has a BA in Psychology, a Master's degree in Social Work and is a Licensed Clinical Social Worker in Colorado. Bidder has 21 years of experience in working with foster families,children in out-of-home placement and birth families. All of this experience is tapped to help support the permanency of placements. Please feel free to contact bidder at the above number to clarify any questions. Sincerely, Julie Box, LCSW • Kit DEPARTMENT OF SOCIAL SERVICES P.O. BOXA I GREELEY, CO. 80632 Website:www.co.weld.co.us Administration and Public Assistance(970)352-1551 O - Fax Number(970)353-5215 COLORADO May 11, 2007 Julie Box,Private Practice 1702 68 Avenue Greeley, CO 80634 Re: Bid#01-IFT-07 (RFP 07008)Mediation&Facilitation under IFT Bid#001-FPT-07 (RFP 006-00C)Foster Parent Training Bid#007-FPC-07 (RFP 006-00A)Foster Parent Consultation Bid#004-HS-07(RFP 006-00B)Home Studies and Relinquishment Counseling Dear Ms. Box: The purpose of this letter is to outline the results of the Bid process for PY 2007-2008 and to request written information or confirmation from you by Monday, May 21,2007. The Families,Youth, and Children Commission appreciates your interest in providing services for families in Weld county. This year, strides were made in structuring an RFP that is clear and concise,and more user friendly, for both prospective bidders and evaluators. It is important to stress the value of following formatting guidelines and addressing the required sections concisely and appropriately. A. Results of the Bid Process for PY 2007-2008 • The Families,Youth and Children(FYC) Commission recommended approval of your Bid# 01-FPT-07,Foster Parent Training program area,and your Bid#004-HS-07, Home Studies, Updates, and Relinquishment Counseling for inclusion on our vendor list. No conditions or recommendations were attached to these bids. • The Families,Youth and Children(FYC) Commission recommended approval of your Bid# 01-IFT-07, Mediation&Facilitation under the Intensive Family Therapy program area with the following recommendations. Recommendations: I. 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. 2. The bidder will provide more information relating to PIP requirements. • The Families,Youth and Children(FYC) Commission recommended approval of your Bid# 007-FPC-07,Foster Parent Consultation program area with the following conditions. Page 2 Julie Box, Private Practice/Results of Bid Process for PY 2007-2008 Conditions: The bidder must clarify and submit information that was not addressed or included with the original bid submission, including; 1. Program Improvement Plan(PIP); 2. Literature citations for evidenced-based practices. B. Required Response by FYC Bidders: Concerning FYC Commission Recommendations: You are requested to review the FYC Commission recommendations and to: 1. accept the recommendation(s)as written by the FYC Commission; or 2. request alternatives to the FYC Commission's recommendation(s); or 3. not accept the recommendation(s)of the FYC Commission. Please provide in writing how you will incorporate the recommendation(s) into your bid. If you do not accept the recommendation, please provide written reasons why.All approved recommendations under the NOFAA will be monitored and evaluated by the FYC Commission. Concerning FYC Commission Conditions: All conditions will be incorporated as part of your Bid and Notification of Financial Assistance Award (NOFAA). If you do not accept the condition(s), you will not be authorized as a vendor unless the FYC Commission and the Weld County Department of Social Services accept your mitigating circumstances. If you do not accept the conditions, you must provide in writing reasons why. A meeting will be arranged to discuss your response. Your response to the above conditions will be incorporated in the Bid and Notification of Financial Assistance Award. The Weld County Department of Social Services is requesting your written response to the FYC Commission's recommendations and conditions. Please respond in writing to Tobi Vegter, Core Services Coordinator, Weld County Department of Social Services, P.O. Box A, Greeley, CO, 80632,by Monday, May 21, 2007,close of business. . If you have questions concerning the above, please call Tobi Vegter, 970.352.1551, extension 6392. Sincerely, J A. Gri o, Di or cc: Juan Lopez,Chair, FYC Commission Tobi Vegter, Core Services Coordinator Gloria Romansik, Social Services Administrator Hello