The URL can be used to link to this page

Browse Search

Home My WebLink About20071693.tiff RESOLUTION RE: APPROVE FIVE NOTIFICATION OF FINANCIAL ASSISTANCE AWARDS FOR MENTAL HEALTH 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 five Notification of Financial Assistance Awards for Mental HealthServices 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. Barry Lindstrom, Ph.D., LLC 2. Victor Cordero 3. Jack Gardner, Psychologist- Greeley Counseling Center 4. Transitions Psychology Group 5. Individual and Group Therapy Services 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 five Notification of Financial Assistance Awards for Mental Health 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. 2007-1693 SS0034 FIVE NOTIFICATION OF FINANCIAL ASSISTANCE AWARDS FOR MENTAL HEALTH 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 WEQOUNTY, COLORADO ATTEST: c' David E. Long, Chair Weld County Clerk to th-j' o- lI , 1861` 1, �,%''�� _ 1♦, � H. rk ro'Tem BY: ✓ ��G(`� �v;i_a_s� / � Deputy Clerk to the B U -i omit I �� Wilkm F. Garcia AP' " P)VED AS TO !�" • AV lA Robert D. Masden ounty A orney ougla Rademach r Date of signature: 7- 907 2007-1693 SS0034 WELD COOKERS OMP,, SC, - 11: 53DEPARTMENT OF SOCIAL SERVICES lODI JUN I U P P.O. BOX A VII ' GREELEY, CO. 80632 r' L" '1 "-) Website:www.co.weld.co.us ' ° ; Administration and Public Assistance(970)352-1551 OFax Number(970)353-5215 • COLORADO MEMORANDUM TO: David E. Long, Chair Date: June 14, 2007 Board of County Commissioners / FR: Judy A. Griego, Director, Social Services 4,teLL`(��II II�,�1,gp RE: Notification of Financial Assistance Awa ds with Various Contractors— Mental Health Services Enclosed for your approval are Notification of Financial Assistance Awards with Various Contractors for Mental Health Services. The Department and the Families, Youth, and Children (FYC) Commission are recommending approval of these Awards. These Awards were reviewed at the Board's work session of June 6, 2007. 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 Core Services or Child Welfare Administration. 3. The Contractors will provide mental health services for adults,youth, and children involved in the child welfare system. 4. The Contractors include: A. Barry Lindstrom, Ph.D., LLC $300 hourly rate psychological examination $150 hourly rate family counseling $125 hourly rate individual counseling $150 hourly rate court facilitation staffings $175 per hour court testimony B. Victor H. Cordero $1,200 per episode psychological examination $600 per episode assessment $75 per episode other services $1,200 per episode parent/child interactional $100 hourly rate individual counseling $100 hourly rate family counseling $120 hourly rate court testimony 2007-1693 MEMORANDUM Page 2 David E. Long, Chair, Board of County Commissioners June 14, 2007 C. Jack J. Gardner $1,800 per episode after-care low—training $1.339 per episode psychological examination $927.00 per episode standard treatment $1,648 per episode treatment package low $1,450 per episode treatment package moderate $1,450 per episode treatment package high $600 per episode diagnostic services $120 hourly rate care coordination $120 hourly rate individual counseling $135.00 hourly rate crisis intervention $115 hourly rate after care moderate $103 hourly rate parent/child interactions $135 hourly rate therapeutic visitations $125 hourly rate multi-family therapy $115 hourly rate treatment package high $113 hourly rate after care high $175 hourly rate court testimony $110 hourly rate for other services D. Transitions Psychology $1,320 per episode psychological examination Group $1,020 per episode treatment package $1,100 per episode parent/child interactions $440 per episode treatment of additional adult $220 per episode treatment of additional child $220 hourly rate treatment moderate $100 hourly rate family counseling $150.00 hourly rate court testimony E. Individual & Group Therapy $39.44 hourly rate treatment package Services $100.00 hourly rate court testimony If you have any questions,please telephone me at extension 6510. Weld County Department of Social Services Notification of Financial Assistance Award for Core Funds Type of Action Contract Award No. X Initial Award 07-CORE-55 Revision (RFP-FYC-006-00;002-MH-07) Contract Award Period Name and Address of Contractor Beginning 06/01/2007 and Barry Lindstrom,Ph. D.,LLC Ending 05/31/2008 Mental Health Services 3211 20 Street,#D Greeley,CO 80634 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Assistance Program provides diagnostic services to assist in the Award is based upon your Request for Proposal(RFP). development of the Department's family services The RFP specifies the scope of services and conditions of plans,and to assess family communication, award. Except where it is in conflict with this NOFAA in functioning and relationships.Monthly average which case the NOFAA governs,the RFP upon which this capacity is 5 evaluation reports, 10 open evaluations, award is based is an integral part of the action. and 1-2 treatment cases. All evaluations and Special conditions treatment will be conducted in English.MMPI-2 is 1) Reimbursement for the Unit of Services will be based on an available in Spanish for bilingual clients. hourly rate per child or per family. Culturallethnic needs considered in evaluation 2) The hourly rate will be paid for only direct face to face process and in making treatment recommendations; contact with the child and/or family,as evidenced by client- South Weld County access. Available for visitations signed verification form,and as specified in the unit of cost at DSS Del Camino or Fort Lupton offices. computation. 3) Unit of service costs cannot exceed the hourly and yearly Cost Per Unit of Service cost per child and/or family. Hourly Rate Per: 4) Payment will only be remitted on cases open with,and Psychological Evaluations $300.00 referrals made by the Weld County Department of Social Family Counseling $150.00 Services. Individual Counseling $125.00 5) Requests for payment must be an original submitted to the Court Testimony(2 hour minimum) $175.00 Weld County Department of Social Services by the end of Court Facilitation Stagings $150.00 the 25th calendar day following the end of the month of service.The provider must submit requests for payment on Enclosures: forms approved by Weld County Department of Social X Signed RFP:Exhibit A Services.Requests for payments submitted 90 days from the X Supplemental Narrative to RFP: Exhibit B date of service,and thereafter,will not be paid. X Recommendation(s) 6) The Contractor will notify the Department of any changes in Conditions of Approval staff at the time of the change. Approvals:Program C ffici.1: By �� < < By David E.Long,Chair Judy . riegot irector Board#1V eld?in?ommissi ers Weld ty Department o Social Services Date: (ii) .1 Date: Dl97-493 EXHIBIT A SIGNED RFP L _ t02-MH-07 0 INVITATION TO BID BID 001-07 DATE: February 28, 2007 BID NO: 001-07 RETURN BID TO: Monica Mika, Director of Administrative Services 915 10th Street, P.O. Box 758, Greeley, CO 80632 Third floor, Centennial Building, Purchasing Department • SUMMARY Request for Proposal for: Colorado Family Preservation Act—Core Services Program Deadline: Friday, March 30, 2007, 10:00 a.m. (MST) The Families, Youth and Children Commission, an advisory commission to Social Services, announces that competing applications will be accepted for approved providers pursuant to the Board of Weld County Commissioners' authority under the Colorado Family Preservation Act (C.R.S. 26-5.5-101) and Emergency Assistance for Families with Children at Imminent Risk of Out-of-Home Placement Act (C.R.S. 26-5.3-101). The Families, Youth and Children Commission wishes to approve services targeted to run from June 1, 2007, through May 31, 2008, at specific rates for different types of service,the County will authorize approved providers and rates for services only. This program announcement consists of the following documents, as follows: • Invitation to Bid • Main Request for Proposal (All program areas) • Addendum A—Program Improvement Plan Requirements (by program area) • Addendum B— Scope of Services (by program area) • Core Budget Form Delivery Date j?qo7 (A rept of order) BID MUST BE SIGNED IN INK Program Area: fMt/VIt /� 79i2ay O L//nlofrwzcni TYPED OR P ED SIGNAT RE OA VENDOR -01'/ R Aw4-i'v /4c ac (Name) Handwritten Signature By Authorized Officer or Agent of Vendor BARRY LINDSTROM, Ph.D., L.L.C. Q ADDRESS LICENSED CLINICAL PSYCHOLOGIST TITLE / ig zaQ/l,_ GREELEY, CO 80634 DATE 3l?p�o7 PHONE # The above bid is subject to Terms and Conditions as attached hereto and incorporated. March 3O', 2007 Program Area: Mental Health Services Page 2 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D.. LLC I ABSTRACT The proposed project will provide diagnostic services to assist in the development of the Department's family services plans, and to assess family communication, functioning and relationships. This project will provide mental health assessments and psychological evaluations for individuals (children, adolescents, and adults) and families (interactional and attachment assessments) as requested by Weld County Department of Social Services (WCDSS) and ordered by Weld County Courts. The goal will be to provide diagnostic information to the Department and Courts for to facilitate the development of the family services plan and the move of the child to a permanent placement. Clients will be informed of the nature, scope and procedures of evaluation at the outset and their informed consent obtained in writing. Releases of information will be signed to obtain records from and allow consultation with the Department and all collateral sources and contacts. Psychological Evaluations will include clinical interviews, psychological testing, review of case records and consultation with collateral contacts (other involved professionals). Evaluations will be responsive to the context of the referral in the phase of the family's involvement with the Department and court process (initial D&N, progress in treatment, or review of permanency plans and goals) and address all questions outlined in the caseworker's referral (e.g., treatment planning and recommendations, placement and permanency questions). Where appropriate, evaluations will be brief, focused and time limited Mental Health Assessments, screening for mental health issues and the need for further evaluation. This project does not provide psychosexual evaluations. Individual evaluations will assess and summarize individual psychosocial functioning and diagnostic questions raised in the referral, in particular as it relates to issues (child or parent) that support or interfere with parenting or reunificication. Family evaluations will assess and summarize individual child and parent functioning and the attachment relationship and family interaction between family members that support or interfere with parenting or reunificication. This will include sibling evaluations to provide diagnostic information about needs and placement. All evaluations will be documented in and completed by a written report outlining: the referral questions; brief case history and context; evaluation procedures and findings; and conclusions and recommendations. Evaluation reports will address both strengths or protective factors, and risk factors or problems. Evaluations will completed and documented in a manner that will support expert testimony in court as needed. Evaluations will be completed in a timely and professional manner following all state, federal and professional (American Psychological Association, APA) regulations and standards regarding confidentiality, record keeping, and professional standards for evaluations and treatment. Problem Focused individual and family therapy will also he offered on a limited basis to assist in the resolution of the issues that led to departmental involvement in support of the treatment goals of safety and maintaining or preserving a child's placement and reunification with or permanency in a family. Treatment efforts will be directed to: Addressing specific referral issues; improving the clients' ability to access resources; improving household management and competency, and improving family conflict management. March 36,, 2007 Program Area: Mental Health Services Page 3 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D., LLC II TABLE OF CONTENTS Page Invitation to Bid 1 Abstract 2 Table of Contents 3 III Target Eligibility Populations 4 IV Project Narrative A. Types of Services Provided 5 1. Assessment a. Mental Health Assessment 5 b. Individual Psychological Evaluation 5 c. Family Interactional Evaluation 6 2. Individual and Family Treatment Services 8 3. Consultation with Caseworkers 10 4. Court Testimony and Staffings 10 B. Measurable Outcomes 11 C. Service Objectives 13 D. Workload Standards 14 E. Staff Qualifications 15 F. Program Capacity per Month 15 G. Internal Tracking and Billing Process 16 Supporting Documentation H. Literature Citations 17 I. Confidentiality and Participant Participation Protection/Human Subjects 19 J. Supervisor/ Provider Meeting 21 K. Insurance Documentation Malpractice Insurance 22 Automobile Insurance 23 Liability Insurance 24 V Budget Unit of Service Rate Calculation 25 Program Budgets 26 Direct Service Costs 27 Administrative Costs Non Face to Face 28 Overhead Costs and Profits 29 VI Appendix 1: Resume for Dr. Barry R. Lindstrom, PhD 30 VII Appendix 2: Data Collection Instruments/Protocols Categories of Evaluation (Budd et al 2006) 34 Evaluation Outline: Clinical Interview / Mental Status (proprietary) 35 KEMPE Family Stress Inventory (Korfmacher. 2000) 40 Family Assessment Outline (Humber & Moss. 2005) 41 Evaluation Tracking (proprietary) 42 Evaluation Summary statistics 44 VIII Appendix 3: Sample Consent Forms Informed Consent 45 Release of Information 46 Professional Disclosure 47 Murch 30, 2007 Program Area: Mental Health Services Page 4 BID 001-07 Vendor: Barry R. Lindstrom. Ph.D., LLC III TARGET ELIGIBILTY POPULATIONS A. Up to sixty (60) assessment/evaluation or treatment cases can be completed within the fiscal year depending on the needs of the Department. Family evaluations can be for any size family and include members of all ages. Individual evaluations can be for children, adolescents and adults of any age. B. All evaluations and treatment will be conducted in English. The MMPI-2 is available in Spanish for bilingual clients. Clients' cultural/ethnic background and needs will be considered in the evaluation process and in making relevant treatment recommendations. C. South Weld County residents can access services through my office. I can be available to observe family interaction / visitations at the WCDSS Del Camino or Ft. Lupton offices. D. All clients and Department personnel have access to after hours' answering service. Evaluations and treatment will be conducted during office hours (8am to 5pm, Mon-Fri). I can also be available to attend evening appointments or Saturday visitations at DSS, CARE, etc. E. Multiple evaluations can be occurring simultaneously within any given month. The monthly average capacity is ten open evaluations. F. Each evaluation takes between one and three months from referral to report depending on the clients' availability and willingness. Each evaluation averages two hours per week of direct contact. March 30, 2007 Program Area: Mental Health Services Page 5 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D., LLC IV PROJECT NARRATIVE / SUPPORTING DOCUMENTATION A. TYPE OF SERVICES TO BE PROVIDED 1. Mental Health Assessment & Psychological Evaluation Services All evaluations will be conducted as efficiently as possible with no unnecessary intrusion, but with an emphasis on gathering sufficient and appropriate information and clinical data to answer referral questions and adhere to Court and professional (APA) standards for psychological evaluations. This includes a "Multi-trait. Multi-method" of data gathering including information from interview, observation, testing, reviews of records and collateral contacts. The length of the evaluation is dependent on the number and complexity of the referral questions, the context of the Department and Court involvement (e.g., neglect or abuse), the phase of involvement with the Department and Court (e.g., initial assessment and treatment planning vs. reasons for treatment failure or noncompliance, or changes in permanency planning) and the client(s) themselves (e.g., cooperative and stable vs. uncooperative or unstable). The relative number of individual or family evaluations is dependent upon the needs of the Department. 1 a. Mental Health Assessments provide basic screening for mental health problems that need to be addressed as part of the treatment plan for reunification at the initial stages of a case. A brief written report will provide recommendations for treatment. medication evaluations or further psychological evaluation as clinically indicated. Assessment will include a review of WCDSS social history and family services plan. but minimal collateral information. Psychological screening instruments, but no formal Psychological testing will be included. Typically requires an average of 2 hours. Individual Clinical Interviews to obtain relevant psychosocial history and mental status evaluation (I to 2 hours; for child and adolescent clients this will include interview with current caretakers); Psychological Screening: Adults: Beck Depression Inventory, Beck Anxiety Inventory, Penn Inventory for PTSD, and Stressful Life Events Questionnaire, Rotter Incomplete Sentences (other screening instruments as needed). Children and Adolescents: Behavioral Assessment System for Children (BASC) standardized behavioral assessment for each child, completed by the child (as age appropriate), parents foster parents, and teachers. Other non-standardized behavioral assessment and developmental history forms completed by parents, foster parents, and teachers as clinically indicated. 1 b Individual Psychological Evaluations require an average 6 hours and include some or all of the following to address referral questions regarding personality and intellectual functioning as clinically indicated to address referral questions: Individual Clinical Interviews to obtain relevant psychosocial history and mental status evaluation (2 to 3 hours over several sessions; for child and adolescent clients this will include interview with current caretakers); March 30', 2007 Program Area: Mental Health Services Page 6 BID 001-07 Vendor: Barry R. Lindstrom. Ph.D., LLC Psychological Testing: Adults: Minnesota Multiphasic Personality Inventory-2 (MMPI-2; also available in Spanish and spoken language administrations), Millon Clinical Multiaxial Inventory-Ill (MCMI-III) Wechsler Abbreviated Scale of Intelligence (WASI), Bender Gestalt Visual Motor Test (BGVMT), Thematic Apperception Test (TAT), Projective Drawings, Rorschach Test, Beck Depression Inventory, Beck Anxiety Inventory, Penn Inventory for PTSD, and Stressful Life Events Questionnaire, Rotter Incomplete Sentences (2 to 3 hours each evaluation); Children and Adolescents: Minnesota Multiphasic Personality Inventory for Adolescents (MMPI-A: also available in spoken language administrations), Millon Adolescent or Pre- Adolescent Clinical Inventory, (MAC', M-PACI). Thematic Apperception Test (TAT) or Children's Apperception Test (CAT). Projective Drawings. Rorschach Test, Stressful Life Events Questionnaire, Behavioral Assessment System for Children (BASC) standardized behavioral assessment for each child, completed by the child (as age appropriate), parents, foster parents, and teachers. Other non-standardized behavioral assessment and developmental history forms completed by parents, foster parents, and teachers as clinically indicated. lc. Family (Interactional) Evaluations evaluate the child, the caregiver and the interaction between them (see Lindstrom, 1999) across two or more sessions. Family evaluations require an average of eight hours of direct contact and include the equivalent of an individual Mental Health Assessment of each family member and assessment of interaction between family members. This includes some or all of the following depending on family composition, child's placement and the caseworker's referral questions: Interviews: Individual Clinical Interview(s) with each family member (1 to 2 hours for each member); Conjoint clinical interviews with all family members (including marital, parent-child. and sibling subsystems as clinically indicated: 3 to 5 hours): Conjoint clinical interview / consultation with child and current caregivers (foster parent, relative etc) if child is in out of home placement at the time of evaluation. Psychological Testing: Adults: Millon Clinical Multiaxial Inventory-III (MCMI-III). Beck Depression Inventory, Beck Anxiety Inventory, Penn Inventory for PTSD, and Stressful Life Events Questionnaire (and others as clinically indicated) for each adult. [Additional psychological testing (see complete list above) can be completed as needed to address additional referral questions related to individual psychological functioning]; Children and Adolescents: Behavioral Assessment System for Children (BASC) standardized behavioral assessment for each child. completed by the child (as age appropriate), parents. foster parents, and teachers. Other non-standardized behavioral assessment and developmental history forms completed by parents. foster parents, and teachers as clinically indicated. March 301, 2007 Program Area: Mental Health Services Page 7 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D., LLC All evaluations will include: Collateral Information: Consultation with collateral contacts will be included as part of each evaluation to meet court and professional standards. All evaluations will include: Review of case records, previous evaluations and treatment records (1 to 2 hours); Collaboration with collateral contacts / consultation with caseworker, past or current treatment providers, schools etc (1 to 2 hours); Court Facilitator Staffings as requested (1 to 2 hours, during or after evaluation). Evaluation Reports: A written report for all assessments/evaluations will be provided to the referring caseworker within thirty (30) days of the completion of the evaluation. This report will summarize the referral questions; brief case history; evaluation course; methods and procedures (including psychological testing, records reviewed and collateral contacts): findings: conclusions and recommendations. Evaluation reports will address both strengths and protective factors and risk factors or problems. Recommendations will focus on how to maintain the child in his current placement, or how a change in placement would help to move the child closer to his permanency goal. If the child is legally free for adoption, recommendations will include whether the goal of adoption is appropriate at that time and / or how to move toward getting the child into an adoptive home, and what type of home would best meet the child's needs. Client Feedback: Individuals and families will be offered a final diagnostic feedback session as part of the evaluation process to discuss test results and the findings and recommendations of the evaluation. Copies of the evaluation will be distributed to appropriate parties by the caseworker or psychologist in keeping with privacy laws, client consent and legal and professional standards. March 30', 2007 Program Area: Mental Health Services Page 8 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D., LLC 2. Individual and Family Treatment Services Problem Focused individual and family therapy will also be offered on a limited basis to assist in the resolution of the issues that led to Departmental involvement and in support of the treatment goals of safety and maintaining or preserving a child's placement and reunification with or permanency in a family. Individual Therapy for adults, children or adolescents can be provided to address individual obstacles to reunification related to the client's diagnosis and history. Family Therapy can include family of origin_ foster family. or kinship placement as appropriate. In general, individuals and families seen for psychological evaluation will not subsequently be seen in treatment to minimize any conflict of interest and the clinical differences between the role of evaluation and treatment. Treatment efforts will be directed to: Addressing specific referral issues; Improving the clients' ability to access resources; Improving household management and competency; and Improving family conflict management. Treatment focus and intervention will include developmental, cognitive-behavioral and family systems approaches with an emphasis on a continuum of care and evidence-based practices. Treatment planning will focus on Core services goals and family strengths through treatment services that support and strengthen the family and protect the child. Treatment efforts will be directed toward: Preventing out-of-home placement of the child; Returning children in placement to their own home: or Uniting children with permanent families Providing services that protect the child An initial clinical (interview based) assessment and treatment plan will be completed within 30 days of the client following through on the referral. The assessment will include the presenting problems, brief family history, and an estimate of the client/family's ability to benefit from treatment and meet the goals of reunification or lowered risk of out-of-home placement. The treatment plan will: Recommend appropriate level and modality of treatment (with information on the research base utilized for the therapy when available); Number of recommended sessions of services to be supplied; and Treatment goals and behavioral objectives (symptom reduction). March 30, 2007 Program Area: Mental Health Services Page 9 BID 001-07 Vendor: Barry R. Lindstrom. Ph.D., LLC A monthly client progress report will include: 1) Presenting problem(s) of the client/family: 2) Specific services provided and dates of service; 3) Extent of client(s) participation and commitment to program; 4) Client(s) progress to date and anticipated discharge date: 5) Efforts used to engage resistive clients; 6.) Discharge planning. including: (a) Step-down plans. (e.g., decreased frequency of sessions after a therapeutic working relationship has been established and client/family is in the working through and termination phases of treatment; (b) Transition to ending of services or support services; or (c) Transition to other services/agencies. A discharge summary of treatment outcomes and a practical transition/support plan, including community resource referrals for continued therapy and support and other appropriate resources, will be submitted within 30 days after the completion date of service. March 30, 2007 Program Area: Mental Health Services Page 10 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D., LTC 3. Consultation with Caseworkers Consultation with Caseworkers will occur at the time of initial referral, after the first client contact, prior to the completion of the final report and as needed during the course of evaluation to: Develop referral questions for Evaluation or Treatment, Assess and address any urgent or emergent questions of safety or placement, Gather and share information and findings, Coordinate scheduling of conjoint and child and caregiver interviews, Assist in the preparation of individual and family treatment plans and court updates, Assist in the elaboration and implementation of recommendations, Discuss the clinical rationale for recommendations or decisions, Discuss placement and permanency needs and plans, and As needed or requested by the caseworker or evaluator. 4. Court Testimony Expert testimony will be provided as requested by the county attorney regarding the evaluation process, findings and recommendations or treatment progress and outcomes. This will include preparation, travel and court time out of the office to be billed at the contracted hourly rate. Court facilitator staffings will be attended as requested and billed at the contracted rate. March 30, 2007 Program Area: Mental Health Services Page 11 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D.. LLC B. MEASURABLE OUTCOMES The following targets will monitored for each case and in the aggregate for the contract period (see Appendix 2. pp 41-43). They will also be reviewed during the evaluation process with each caseworker and discussed quarterly with Department supervisors to ensure that the evaluations and reports are meeting Department and Court expectations for content_ clarity and timeliness. Feedback from the Core Services quarterly review will be integrated into the outlined procedures. 1. Mental health assessments can be completed more quickly than complete evaluations. Evaluations will be completed in a timely manner (one to three months) to meet caseworker requests and scheduled court updates and hearings. Appointments may be scheduled for multiple hours in one day to accommodate psychological testing. and multiple or family interviews to expedite and simplify the evaluation process. Any delays in completing the evaluations will be discussed with caseworkers in advance. Any delays due to client non compliance will be discussed and problems resolved with the caseworker. An average of two months from initial referral to completed report is the goal. Individual evaluations can be completed in less time than family evaluations. because of the number of people involved. Where possible. previously scheduled visitations (e.g., Transitions. CARE. WCDSS) will be utilized as a clinical opportunity to observe and assess family interaction in order to facilitate scheduling, minimize disruption to the clients and caregivers and avoid redundancy. At least one conjoint (family) interview in the office is typically necessary for a complete and thorough evaluation. Evaluations conducted at the end of the Court process, particularly regarding changes in the permanency plan away from returning home to biological parents, or to address issues between alternative family placements (e.g.. adoption by grandparents or foster parents, or sibling placement questions) are by necessity more thorough and lengthy, and therefore more time consuming. 2. Dr. Lindstrom is available for face to face, telephone or e-mail consultation with caseworkers or providers during or after the evaluation(s) to assist in and address questions regarding the implementation of evaluation findings and recommendations. He is also available to attend court facilitator staffings as requested. 3. Caseworkers will be contacted at each stage of the evaluation for case management and to share initial impressions. findings and any urgent recommendations. Consultation will occur at the time of initial referral, after the first client contact, prior to the completion of the final report and as needed during the course of evaluation, and at least twice a month. 4. Telephone calls and e-mails will be returned by the end of the next business day. Requests for letters or case updates can be completed within a week. Emergency calls will be returned the same day if identified as such. In an emergency. Dr. Lindstrom can be reached after hours via his answering service. Emergency consultations can be completed within 24 hours. March 300, 2007 Program Area: Mental Health Services Page 12 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D., LLC 5. Treatment recommendations and services will be integrated and coordinated with the Caseworker through treatment planning, reports and attendance at staffings as requested. 6. Evaluations will be conducted in accordance with professional and legal standards to be acceptable in court in support of any required expert testimony. Dr. Lindstrom is able to be qualified as an Expert witness in accordance with legal statutes. Written reports will clearly outlined, avoid professional jargon, and contain clearly stated and enumerated recommendations. March 30, 2007 Program Area: Mental Health Services Page 13 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D., LLC C. SERVICE OBJECTIVES Family and individual evaluations and treatment will provide information to assist the Department and the Court in the development of family services plans. and assess and intervene in family communication. functioning and relationships. This will include family strengths that can be used in treatment planning and delivery to address and improve identified weakness and risks to be contained or minimized in order to reduce the need for or length of placement and to meet permanency plan goals for reunification in a developmentally meaningful time frame. Treatment services will focus on family strengths by directing intensive services that support and strengthen the family and protect the child in order to address Core Services goals: Prevent out-of-home placement of the child; Return children in placement to their own home; or Unite children with permanent families. Provide services that protect the child. Evaluation and treatment services will focus on the following objectives: 1. Improve Family Conflict Management. Each client will be offered the opportunity for diagnostic feedback and discussion as part of the final interview. This feedback will address individual (for each parent and child) and family functioning. strengths and treatment needs to reduce and resolve conflicts contributing to child maltreatment or behavior problems. 2. Improve Household Management Competency. In particular. issues of parent-child attachment and parenting skills that promote safety and attachment will be addressed. These include, but are not limited to: affection and nurturance, stimulation and containment, and safety and protection. Individual assessments and evaluations will address any mental health issues or obstacles to the individual's successful completion of treatment and permanency or reunification plans. 3. Improve Ability to Access Resources. Ideally, the evaluation process will provide clients an experience, in spite of its stressful nature, that will assist them in developing a trusting relationship (therapeutic working alliance) with current or new professionals whose assistance they require. Other involved professionals will he consulted as part of the evaluation and findings shared with them to assist in the development of a therapeutic working alliance and successful treatment outcome(s). Signed releases of information will be obtained for all collateral contacts or sources. 4. Address Specific referral issues. Evaluation reports will address all questions outlined in the caseworker's referral (e.g., treatment planning and recommendations, placement and permanency questions) and be responsive to the context of the referral (see project narrative). When the caseworker's referral includes specific written questions. these will be individually responded to in the Summary and Recommendations section of the evaluation. Evaluation reports will address both strengths or protective factors, and risk factors or problems. March 30, 2007 Program Area: Mental Health Services Page 14 BID 001-07 Vendor: Barry R. Lindstrom. Ph.D., LLC 5. Improve Outcomes in the Performance Improvement Plan. Evaluations conducted as part of the present proposal will contribute to the identified need for more consistent and thorough evaluations and will provide treatment planning recommendations to address all specific referral questions and the general issues of safety. permanency and well-being as appropriate to the case and referral questions. Placement changes - Recommendations and treatment interventions will focus on how to maintain the child in his current placement, or how a change in placement would help to move the child closer to his permanency goal. If the child is legally free for adoption. recommendations will include whether the goal of adoption is appropriate at that time and/or how to move toward getting the child into an adoptive home. All mental health services will be oriented to and focused upon these objectives. particularly toward the retention of children in their placements. These service objectives will be reviewed quarterly as needed with Department supervisors. D. WORKLOAD STANDARDS Dr. Lindstrom maintains an independent private practice in the offices of Pathways: Family Wellness Associates. He is incorporated as a Limited Liability Corporation and is its sole employee/member. 1. His office hours are Monday to Friday 8am to 5pm. He has an answering service after hours. He can be available on a limited basis in the evenings for appointments or evenings or Saturdays to attend previously scheduled visitation for the purposes of family evaluation. 2. He is the only psychologist in his practice conducting these evaluations. 3. He can maintain multiple open evaluations at any given time (10 maximum) and 1 to 2 treatment cases. 4. The modality is psychological testing and clinical interviews, individual and family therapy and clinical consultation. 5. He is available 40 hours/week. 6. He is the only psychologist in his practice conducting these evaluations. 7. Dr. Lindstrom is licensed in Colorado as a Clinical and School Psychologist. He does not have a supervisor or provide clinical supervision to anyone at this time. 8. He typically completes three or more of the open evaluations each month. 9. Dr. Lindstrom maintains professional liability (malpractice) insurance, automobile insurance and has unemployment and worker's compensation insurance through Barry R. Lindstrom, PhD, LLC. Liability insurance is maintained through Pathways Management, LLC. (See attached copies, section IV K, pp. 22-24) March 30, 2007 Program Area: Mental Health Services Page 15 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D., LLC E. STAFF QUALIFICATIONS 1. All work will be completed by Barry R. Lindstrom. PhD. He is a Licensed Clinical Psychologist and School Psychologist in the state of Colorado. Ile meets all continuing education requirements to maintain these licenses. (See Appendix I : Resume pp 30—33). 2. Dr. Lindstrom is the only employee of Barry R. Lindstrom, PhD: LLC. He contracts with Pathways Management, LLC for office space and secretarial and billing services. He contracts with MKF Billing Services for transcription services. These contracts are HIPAA compliant. 3. Dr. Lindstrom has appropriate knowledge and training regarding casework. He attends regular continuing education and will be attending the quarterly Weld County Court trainings for caseworkers, therapist and attorney 4. Dr. Lindstrom has knowledge of risk assessment. F. PROGRAM CAPACITY BY MONTH This program can produce up to five (5) evaluation reports completed per month on average, with up to ten (10) open. ongoing evaluations per month on average. One or two open / active treatment cases can be maintained. There is no minimum client capacity per month necessary to support this program. March 3.0, 2007 Program Area: Mental Health Services Page 16 BID 001-07 Vendor: Barry R. Lindstrom. Ph.D., LLC G. INTERNAL TRACKING AND BILLING INORMATION Bills will be submitted to Tobi Vegter (or core services personnel) at the completion of the evaluation including Departmental paperwork (Authorization for Contractual Services, Core services Request for Reimbursement forms and Supporting Documentation including first and last pages of evaluation reports and client signature sheets) and an invoice. Clients will sign in at each appointment and these will be matched with the computer billing system and invoice to assure that only direct client contacts are billed. Requests for extensions will be submitted to Tobi Vegter (or core services personnel) if the requested evaluation is not completed within the original authorization dates, to continue with a psychological evaluation following a mental health assessment or to extend treatment. Core review team meetings will be attended as necessary. The original evaluation will be submitted directly to the referring caseworker. Billing for treatment services will be done monthly in the same manner, by the 25'11 of the following month. A monthly client progress report will include: 1) Presenting problem(s) of the client/family, 2) Specific services provided, 3) Extent of client(s) participation and commitment to program, 4) Client(s) progress to date, anticipated discharge date, 5) Efforts used to engage resistive clients. I will not be providing evaluations or treatment for Medicaid funded clients. I do not have a contract with North Range Behavioral Health for Medicaid funding. I will provide a copy of an independent annual financial audit report to the Weld Board of County Commissioners no later than September 30 following the program service year. The audit shall identify, examine, and report the income and expenditures specific to operation of the State- funded program or services. I will be available to meet with Social Services staff to explain their program, and answer questions to enhance their program. I will be available for the Families, Youth and Children Commission review and attendance at FYC Commission meetings. Note: All evaluations are being provided at the Department's request to meet court ordered treatment plans. As such, they are considered forensic evaluations and not treatment and do not meet the criteria of"medical necessity" to be eligible for reimbursement by an insurance company (public or private). I am willing to provide treatment for clients with other third party insurance, billing the insurance company for direct services that meet the "medical necessity" requirement (presence of a mental health diagnosis). Court staffings and testimony will still be billed to the department at the contracted rate March 30, 2007 Program Area: Mental Health Services Page 17 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D., LLC H. Literature Citations / Bibliography Child Abuse and Neglect Cicchetti, D. (1987). Developmental psychopathology in infancy: Illustration from the study of maltreated youngsters. Journal of Consulting and Clinical Psychology, 55, 6, 837-845. Helfer, M.E., Kempe, R.S., & Krugman, R.D. The Battered Child. (Fifth Edition.) Chicago: University of Chicago Press. Korfmacher, J. (2000). The Kempe Family Stress Inventory: A review. Child Abuse and Neglect, 24, 1, 129-140. Lindstrom, B. R. (1999). Attachment. separation and abuse outcomes: Influence of Early Life Experience and the Family of Origin. In G. Ryan and Associates. Web of meaning: A developmental-contextual approach in sexual abuse treatment (pp 32-48). Brandon, VT: Safer Society Press. Attachment American Academy of Child and Adolescent Psychiatry (2005). Practice Parameter for the Assessment and Treatment of Children and Adolescents with Reactive Attachment Disorder of Infancy and Early Childhood. Journal of the American Academy of Child and Adolescent Psychiatry, 44, 1206-1219. Cassidy, J. & Shaver, P.R., (Eds.) (1999). Handbook of Attachment: Theory Research and Clinical Applications. London: The Guilford Press. Greenberg, M.T., Cicchetti. D., & Cummings, E.M.. (Eds) (1990). Attachment in the preschool years: Theory, research and intervention. Chicago: University of Chicago Press. Pilowsky, D.J. & Kates, W.G., (1996). Foster Children in Acute Crisis: Assessing Critical Aspects of Attachment. Journal of the American Academy of Child and Adolescent Psychiatry, 35 8. 1095- 1097 Family and Culture Aranson-Fontes, L. (2005). Child Abuse and Culture: Working with Diverse Families. New York: Guilford. McGoldrick, M., Pearce, J.K., & Giordano, J. (Eds.) (1982). Ethnicity and Family Therapy New York: Guilford Press. Psychological Testing Anastasi, A. Psychological Testing. (Current Edition.) New York: McMillan. Graham, J.R. (2000). MMPI-2: Assessing Personality and Psychopathology (Third Edition). New York: Oxford University Press. March 30, 2007 Program Area: Mental Health Services Page 18 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D.. LLC Family Evaluations Budd K.S., Felix E.D., Sweet, S.C., Saul, A., & Carleton. R.A. (2006). Evaluating parents in Child Protection Decisions: An innovative Court-Based Clinic Model. Professional Psychology: Research and Practice, 37, 666-675. Budd, K.S., & Holdsworth. M.J. (1996). Issues in the clinical assessment of minimal parenting competence. Journal of Clinical Child Psychology, 25. 2-14.. Haynes-Seman, C., & Baumgarten, D. (1994). Children Speak for themselves: Using the Kempe Interactional Assessment to Evaluate Allegations of Parent-Child Sexual Abuse. New York: Brunner/Mazel Humber, N., & Moss, E. (2005). The relationship of Preschool and Early School Age Attachment to Mother-Child Interaction. American Journal of Orthopsychiatry, 75, 128-141. Ethics, testing and forensic standards Ethical Principles of Psychologists and Code of Conduct. American Psychological Association. Washington DC Specialty Guidelines for the Delivery of Services: Clinical, Counseling. Industrial/Organizational and School Psychologists. American Psychological Association. Washington DC American Psychological Association Committee on Professional Practice and Standards. Guidelines for Psychological Evaluations in Child Protection Matters. American Psychologist. 1999, 54, 586- 593. American Academy of Child and Adolescent Psychiatry. (1997). Practice parameters for the forensic evaluation of children and adolescents who may have been physically or sexually abused. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 423-442 Treatment Green. A.H. (1998). Factors contributing to the Gernaerational Transmission of Child Maltreatment. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 1334-1336 Heineman, T.V.. & Ehrensaft, D. (2006). Building a Home Within: Meeting the Emotional Needs of Children and Youth in Foster Care. Baltimore: Brookes Publishing. Kagan, R. & Schlosberg, S., (1989) Families in Perpetual Crisis. New York: W.W. Norton & Co. Pollock. C.. & Steele, B. (1972). A Therapeutic Approach to the Parents. In C.H. Kempe & R.E. Helfer (Eds.) Helping the Battered Child and His Family. (pp 3 -21). Philadelphia: Lippincott March 30, 2007 Program Area: Mental Health Services Page 19 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D., LLC Confidentiality and Participant Participation Protection This program will follow all local, state, federal (HIPAA) and professional standards regarding confidentiality and participant protection. 1. Protect Clients and Staff from Potential Risks: Evaluation and treatment procedures can be psychologically stressful for clients. They are offered diagnostic feedback at the end of the evaluation, prior to the submission of the report or court testimony as a potential benefit and to minimize any adverse effects from the stress of disclosing potentially difficult or stressful information to the court. Any adverse effects can be addressed at that time or in subsequent consultation or referral as needed. All clinical and tracking records are kept secure and confidential in keeping with HIPAA and professional standards. They are not released without specific consent or court order. 2. Fair Selection of Participants: Participants are selected by referral from the court as discussed above in the project narrative and target populations. Participants could be excluded due to the nature of the referral (i.e., Sexual Offender evaluations) or if there is a conflict of interest in completing an evaluation or treatment referral. 3. Absence of Coercion: All clients are court ordered into evaluations or treatment. They are given informed consent about the nature of the procedures and reporting of findings and outcomes, including court testimony. Release of Information forms are still obtained with the clients (or guardians) signature for all collateral sources to further inform clients. Evaluation/treatment reports are not released without specific permission on Release forms. 4. Data Collection: Psychological evaluation data will be collected directly from the clients (individuals and family members) in the form of interviews, psychological testing and observation. Collateral information in the form of records, consultation. developmental and behavioral questionnaires and assessments will be obtained from clients, foster parents. teachers, medical and mental health providers as needed with client's written permission. Interview and observational data will be obtained in a confidential clinical setting (professional psychologist's office) or visitation setting (e.g., Transitions, CARE, WCDSS) in a manner to insure confidentiality. March 30, 2007 Program Area: Mental Health Services Page 20 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D., LLC See Appendix 2: Data Collection Instruments/Interview Protocols, (pp 34—40) for examples of data collection instruments and interview protocols. 5. Privacy and Confidentiality All clinical work(interviews, observations testing) is completed by Barry R. Lindstrom, PhD a licensed clinical psychologist in keeping with legal and professional standards. Dr. Lindstrom contracts with Pathways Management, LLC for office space and secretarial, record keeping and billing services. Reports are transcribed through MKF Billing Services for transcription services. These contracts are HIPAA compliant and follow HIPAA standards for insuring confidentiality of records and information. 6. Adequate Consent Procedures Clients will be informed of the nature, scope and procedures of evaluation at the outset and their informed consent obtained in writing. This will be discussed with them and the consent form reviewed, and if necessary read, with them before obtaining their signature. For minors, consent will be obtained through their guardian (parent, foster parent, therapist, caseworker) as appropriate. Adolescents 15 years and older will be asked to also sign the Consent(and Releases of Information) on their own behalf. The client is informed that they may request copies of the Consent, our HIPAA policy and office policy and procedures, and Dr. Lindstrom's professional disclosure. See Appendix 3: Sample Consent Forms, for Consent. Release and Disclosure forms (pp 44—46). 7. Risk/Benefit Discussion Clients are offered the opportunity for diagnostic feedback as a potential benefit and to minimize any adverse effects from the stress of disclosing potentially difficult or stressful information to the court. This is also intended to facilitate the referral process and increase the clients' willingness and ability to engage in recommended treatment to resolve mental health problems and facilitate reunification of their family. March 310, 2007 Program Area: Mental Health Services Page 21 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D., LLC J. Supervisor / Provider Meeting Program Area Supervisor/Provider Meeting Verification/Comment Form Date of Meeting: (3\ 10-1 Program Area: \\KSIX\ cQ Comments (to be completed by Program Area Supervisor): -V-Ac-4 1 -t._a 1->, c-r. '�� Q.u ;�. >_.Ks2 A.G� `:;u � �^J C/(ti. \N sA y ck49-CA A. c) vl )\-\ aA c> Xk Atn s _ -: p CStI> 49-1,), larTh c5V'-i'% \"\cCs V\Q 0 6- "\CO \C;)--C)--, C , \ & >Jma,\- \C A t�� Gv Q c-t-Sir)-. .-cep a -c mss-- \"`no--7\ q : :, itr v-c\ca \a-- Ci` Q,I-N \{\a 3\ c — fl cs&vc�:cVC\ - QA .L(AAA arY, \).\.i\ W Signature of Program Area SuperVis March 3D, 2007 Program Area: Mental Health Services Page 22 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D., LLC K. Insurance Documentation Malpractice Insurance EVEREST NATIONAL INSURANCE COMPANY Fl- R VS\,. MENTAL HEALTH PRACTITIONER'S PROFESSIONAL LIABILITY DECLARATIONS OCCURRENCE POLICY Policy Number : 2200006488-061 Renewal of Number: 2200006488-051 Item 1.Named Insured and Mailing Address Broker Name and Address Barry R. Lindstrom and/or Barry R. Lindstrom PhD LLC ROCKPORT INSURANCE ASSOC 3211 20111 St. Suite D P.O. BOX 1809 Greeley, CO 80634 ROCKPORT,TEXAS 78381-1809 1-800423-5344 Item 2.Additional Insureds None Item 3. Policy Period From- 8/1/2006 To: 8/1/2007 at 12:01 A.M., Standard Time at the insured's mailing address shown above. Item 4. Description of Business: Form of Business: [X] Individual [ ] Partnership [ ]Joint Venture [ 1 Limited Liability Company [ ]Trust [ ] Organization,including a Corporation(but not including a Partnership,Joint Venture or Limited Liability Company) Business Description: Mental Health Practitioner(s) Item 5. Limits of Insurance and Regulatory Defense Amount $ 3.000,000 AGGREGATE LIMIT $ 1.000.000 EACH WRONGFUL ACT LIMIT $ 1,000.000 EACH OCCURRENCE LIMIT-PREMISES LIABILITY $ 25.000 SEXUAL MISCONDUCT AGGREGATE LIMIT $ 5.000 REGULATORY DEFENSE AMOUNT Item 6. In return for the payment of the premium,and subject to all the terms of this policy,we agree with you to provide the insurance as stated in this policy. Premium Schedule CLASSIFICATION NUMBER RATE ANNUAL PREMIUM D3 1 $900.00 $900.00 Total Premium $900.00 Item 6. Forms and Endorsements Form(s) and Endorsement(s) made a pan of this policy at time of issue: EDEC 134 09 01,EEO 00 507 09 01,EIL 00 515 01 06, IL 00 17 11 98,IL 02 28 07 02 THIS DECLARATIONS, TOGETHER WITH THE COMMON POLICY CONDITIONS AND COVERAGE FORM AND ANY ENDORSEMENT(S), COMPLETE THE ABOVE NUMBERED POLICY. AUTHORIZED REPRESENTATIVE (or countersignature where applicable) March 30, 2007 Program Area: Mental Health Services Page 23 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D.. LLC Automobile Insurance Insurance COUNTRY/ a Services COUNTRY Mutual Insurance Company 20990 P.O.Box 2100,Bloomington,Illinois 61702-2100 COLORADO INSURANCE CARD LINDSTROM S BARRY FUN] COLLINS CO POLICY NUMBER A05116374425 1999 VOLVO V70 XC EFFECTIVE DATE NOV 12, 2006 EXPIRATION DATE MAY 12, 2007 VIN YV1 LZ560XX2624682 COVERAGE BODILY INJURY LIABILITY PROPERTY DAMAGE LIABILITY COUNTRY HELPLINER 1-800-846-0100 THIS CARO MUST BE CARRIED IN THE INSURED MOTOR VEHICLE FOR PRODUCTION UPON DEMAND. TIE COVERAGE PROVIDED BY THIS POLICY MEETS THE MINIMUM LIABILITY INSURANCE LIMITS PRESCRIBED BY LAW. March 3b, 2007 Program Area: Mental Health Services Page 24 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D., LLC Liability Insurance f / W TRAVELERS One Tower Square, Hartford, Connecticut 06183 1 COMMON POLICY DECLARATIONS POLICY NO.: I-680-390N4113-COF-06 OFFICE PAC ISSUE DATE: 09-22-06 BUSINESS:PHYSICIAN INSURING COMPANY: THE CHARTER OAK FIRE INSURANCE COMPANY 1. NAMED INSURED AND MAILING ADDRESS: PATHWAYS MANAGEMENT 3211 20TH STREET SUITE D GREELEY CO 80634 2. POLICY PERIOD: From 11 -01 -06 to 11 -01 -07 12:01 A.M. Standard Time at your mailing address. 3. DESCRIPTION OF PREMISES: ADDRESS PREM. LOC. NO. BLDG. NO. OCCUPANCY (same as Mailing Address unless specified otherwise) 01 01 OFFICE 3211 20TH STREET SUITE D GREELEY CO 80634 4. COVERAGE PARTS AND SUPPLEMENTS FORMING PART OF THIS POLICY AND INSURING COMPANIES COVERAGE PARTS and SUPPLEMENTS INSURING COMPANY Businessowners Coverage Part COF S 5. The COMPLETE POLICY consists of this declarations and all other declarations, and the forms and endorse- = ments for which symbol numbers are attached on a separate listing. • 6. SUPPLEMENTAL POLICIES: Each of the following is a separate policy containing its complete provisions. POLICY POLICY NUMBER INSURING COMPANY o= o= o= DIRECT BILL - 7. PREMIUM SUMMARY: - Provisional Premium $ 702 .00 Due at Inception $ Due at Each $ • NAME AND ADDRESS OF AGENT OR BROKER COUNTERSIGNED BY: FLOOD & PETERSON INS INC XY235 PO BOX 578 Authorized Representative March i 0, 2007 Program Area: Mental Health Services Page 25 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D., LLC V BUDGET UNIT OF SERVICE RATE COMPUTATION The budget must be submitted in an hourly unit rate cost of direct delivery of services to an individual or family unit. The bidder must address the Unit of Service Rate Computation Calculation as follows on the attached budget. See attached budget for per hour rate for direct client contact hours and court testimony. Evaluation: $ 300.00 per hour of direct client service (interviews and psychological testing). Family Therapy (office): $ 150.00 per hour (for time limited interventions such as termination visits or brief clinical intervention, with treatment planning and documentation). Individual Therapy (office): $ 125.00 per hour (for brief clinical intervention, with treatment planning and documentation). Court testimony: $ 175.00 per hour (preparation, travel and testimony: "portal to portal"). 2 hours minimum. Court Facilitation Staffings: $ 150.00 per hour (during or after evaluations or treatment). March 30, 2007 Program Area: Mental Health Services Page 26 BID 001-07 Vendor: Barry R. Lindstrom. Ph.D.. LLC V BUDGET Program Budgets PROGRAM BUDGETS PROGRAM Mental Health A TOTAL HOURS OR DAYS OF DIRECT SERVICE PER CLIENT 7 B TOTAL CLIENTS TO BE SERVED 60 C TOTAL HOURS OR DAYS OF DIRECT SERVICE FOR YEAR(A X B) 420 D COST PER HOURS OR DAYS OF DIRECT SERVICES(E/C) $173.81 E TOTAL DIRECT SERVICE COSTS FACE-TO-FACE $73,000 F ADMINISTRATION COSTS NON-FACE-TO-FACE ALLOCABLE TO PROGRAM $38,000 G OVERHEAD COSTS ALLOCABLE TO PROGRAM $14,340 H TOTAL DIRECT,ADMINISTRATION&OVERHEAD COSTS(E+F+G) $125,340 I ANTICIPATED PROFITS CONTRIBUTED BY THIS PROGRAM $1,000 J TOTAL COSTS AND PROFITS FROM THIS PROGRAM(H +I) $126,340 K TOTAL HOURS OR DAYS OF DIRECT SERVICE FOR THE YEAR(C) 420 I RATE PER HOURS OR DAYS OF DIRECT,FACE-TO-FACE SERVICE TO BE CHARGED TO WELD COUNTY SOCIAL SERVICES(.1/K) $300.81 COURT TESTIMONY $175/HR COURT STAFFINGS $150/HR March 300, 2007 Program Area: Mental Health Services Page 27 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D., LLC V BUDGET Direct Service Costs DIRECT SERVICE COSTS Minimum Budget Avenge Total %OF TIME SALARY %OF TIME SALARY Oegme FOR Salary.Bsn Salaries/ 100% SPENT ON AND SPENT ON AND DESCRIPTOR or Ceti FTEa 01.0 FIE Benellts/Other ALLOCATED PROGRAM OTHER COSTS PROGRAM OTHER COSTS PROGRAM Mental Heats A TOTAL CLIENT HOURS OR DAYS PER PROGRAM 7 B TOTAL CLIENTS TO BE SERVED PER PROGRAM 80 C TOTAL.HOURS OR DAYS PER PROGRAM FOR YEAR 42000 0.00 DIRECT LABOR FACE-TO-ACE POSITION.TITLE OR JOB FUNCTION Psychologist Salary and Benefits(Weal.ret.menl) PhD 1.00 089.000 569,000.00 yes 100.00% $69,000.00 $0.00 $0.00 NO $0.00 $0.00 50.00 NO $0.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 NO MOD $0.00 $0.00 NO MOO $0.00 $0.00 NO WOO $0.03 $0.00 NO 50.00 50.00 WOO NO $0.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 NO $0.00 $0.00 TOTAL DIRECT LABOR PER PROGRAM $69,000.00 $154.29 $69000.00 $0.00 OTHER DIRECT COSTS PER PROGRAM FACE-TO FACg Testing mawlSs(computer tense.lams,scoring fees,new tests) $3.500.00 yes 100% $3,500.00 $0.00 stp es $500.00 Yee 100% $500.00 $0.00 NO 50.00 $0.00 NO $0.00 $0.00 NO $0.00 $0.00 NO $0.00 $0.00 TOTAL OTHER DIRECT COSTS PER PROGRAM $4,000.00 $9.52 $4.000.00 $0.03 E GRAND TOTAL DIRECT SERVICE COSTS $73.000.00 $173.81 $73,00000 $0.00 March 30, 2007 Program Area: Mental Health Services Page 28 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D., LLC V BUDGET Administrative Costs Non Face to Face ADMIN COST NON-FACE-TO-FACE Minimum Budget Aroma Total %OF TIME SALARY %OF TIME SALARY Degree tl#O Salary/Bens Salarlea/ 100% SPENT ON AND SPENT ON AND DESCRIPTION ®1.0 FTEBenelblOmer ALLOCATED PROGRAM OTHER COSTS PROGRAM OTHER COSTS PROGRAM Mental Health A TOTAL CLIENT HOURS OR DAYS PER PROGRAM 7 B TOTAL CLIENTS TO BE SERVED PER PROGRAM 60 C TOTAL HOURS OR DAYS PER PROGRAM FOR YEAR 420.00 0.00 DIRECT LABOR NOT FAR:Ftens aae mxtegwnert,casters=facts,records review,report wriGq PhD 1.00 309000 $69,000.00 NO 50.00% $34,500.00 $0.00 Transcription HS 1.00 $3,000 $3,000.00 YES 100.00% $3.000.00 $0.00 $0.00 NO $000 $0.00 $0.00 NO $0.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 NO $0.00 WOO $0.00 NO $0.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 NO $0.00 $0.00 TOTAL DIRECT LABOR PER PROGRAM NOT FACE-TO-FACE $72,00000 $89.29 $37,500.00 $0.00 OTHER DIRECT COSTS PER PROGRAM NOT FACE-TOFACE Sryp$se $50000 yes 100.00% $500.00 50.00 NO $0.00 $0.00 NO $0.00 $0.00 NO $0.00 $0.00 NO $0.00 $0.00 NO TOTAL OTHER DIRECT COSTS NOT FACE-TO-FACE PER PROGRAM $500.03 $1.19 $500.000.00 $0.00 $0.00 F GRAND TOTAL DIRECT SERVICE COSTS NOT FACE-TO-FACE $72.500.00 $90.48 $38,000.00 $0.00 March 3.0, 2007 Program Area: Mental Health Services Page 29 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D., LLC V BUDGET Overhead Costs and Profits OVERHEAD COSTS AND PROFITS TOTAL ALLOCATED I .., Ir• OVERHEAD 100% %ALLOCATED OVERHEAD COSTS %ALLOCAT • OVERHEAD • - %ALLOCAT • OVERNEI DESCRIPTION COSTS 0 TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM TO PRI PROGRAM Mental Health A TOTAL CLIENT HOURS OR DAYS PER PROGRAM $7.00 B TOTAL CLIENTS TO BE SERVED PER PROGRAM $60.00 C TOTAL HOURS OR DAYS PER PROGRAM FOR YEAR 420.00 0.00 0. OVERHEAR Rant/OMca Shea-Pathways $25.000.00 NO 40.00% $10.000.00 $0.00 U81Mss(calf and Interne!) $1.350.00 NO 40.00% $540.00 $0.00 Malpactice Insurance $1,000.00 NO 40.00% $400.00 $0.00 Vehlce and gas $2000.00 NO 40.00% $800.00 $0.00 Accounting $3,000.00 NO 40.00% $1200.00 $0.00 Professional Dues and Licenses $1,500.00 NO 40.00% $600.00 $0.00 CoMkruk1P Education(books,journals.COMelances) $2.000.00 NO 40.00% $800.00 $0.00 $0.00 NO NO $0.00 $0.00 NO $0.00 $0.00 NO $0.00 $0.00 NO $0.00 $0.00 NO $0.00 00.00 NO $0.00 $0.00 NO $0.00 $0.00 NO $0.00 $0.00 NO $0.00 $0.00 NO $0.00 $0.00 G TOTAL OVERHEAD COSTS $35,85000 $14,34000 $0.00 I TOTAL ANTICIPATED PROFITS $1.000.00 !Yes 100% $1.000.00 $0.00 TOTAL OVERHEAD AND ANTICIPATED PROFITS $38,850.00 $15,340.00 $0.00 March 3'0. 2007 Program Area: Mental Health Services Page 30 BID 001-07 Vendor: Barry R. Lindstrom. Ph.D., LLC VI APPENDIX 1: Resume BARRY RICHARD LINDSTROM, Ph.D., LLC Licensed Clinical Psychologist 3211 20th Street. Suite D Greeley, Colorado 80634 (970) 356-3100, Fax (970) 356-4827 CREDENTIALS Licensed Clinical Psychologist - Colorado# 1303 (05/12/1989) Licensed School Psychologist - Colorado # 0308917 (11/01/1989) National Register of Health Service Providers in Psychology #41119 (12/1991) EDUCATION 1982 - 1987 Loyola University of Chicago. Chicago, IL Ph.D. in Clinical Psychology, August, 1987. Subspecialty in Clinical Child Psychology. M.A. in Clinical Psychology, May, 1985. 1977 - 1981 Carthage College, Kenosha, WI B.A. in Psychology. magna cum laude, Gamma Kappa Alpha Honor Society. CLINICAL EXPERIENCE 1989 - Present Psychologist in Private Practice. General practice including individual, marital and family therapy and assessment; focus on child abuse and neglect, adoption. attachment, attention deficit disorders, trauma, and sexual abuse; forensic evaluations and expert testimony; training and consultation to treatment programs, schools and social services agencies. 1991 - 2004 Clinical Director. Namaqua Center. Responsible for program direction and development of residential, day- and outpatient treatment and therapeutic foster care programs; hiring, training and supervision of clinical staff; assessment and treatment of seriously emotionally disturbed children and their families. Agency became COA accredited. Implemented HIPAA policies and procedures as Privacy Officer. 1987 - 1991 Psychologist, Center for Therapeutic Learning-Annex. Treatment Coordinator for severely emotionally disturbed children and adolescents in a long-term residential treatment center. Provided diagnostic and psychometric assessments, individual and family therapy, parent assessment and education, expert testimony. and consultation and supervision for childcare professionals and special education teachers. March 30, 2007 Program Category: Mental Health Services Page 31 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D., LLC 1986 - 1987 Denver General Hospital, A.P.A. approved internship in Clinical Psychology. Completed six-month rotations on Adolescent Inpatient Unit and Outpatient/ Consultation- Liaison Service. 1985 - 1986 Center for Family Studies / The Family Institute of Chicago, Department of Psychiatry, Northwestern University Medical School. Externship in Family Therapy. 1982 - 1984 Doyle Center and Day School of Loyola University. Clinical Practicum in child and family psychology. HOSPITAL AFFILIATIONS 1992-present North Colorado Medical Center/ Psychcare, Greeley, CO. 1994-1998 Mountain Crest Hospital, Fort Collins, CO. PUBLICATIONS Lindstrom, B. R. (1999). Attachment, separation and abuse outcomes: Influence of Early Life Experience and the Family of Origin. In Ryan. G. and Associates, Web of meaning: A developmental- contextual approach in sexual abuse treatment (pp 32-48). Brandon. VT: Safer Society Press. TEACHING 1995 -1996 Regis University. Denver Colorado. Independent Study in psychology. Individual course consultant for graduate students in MLS extension program. 1985 Loyola University of Chicago, Lecturer in Psychology. Undergraduate Developmental Psychology. RESEARCH Lindstrom, B. R. (1986). Factors related to discontinuation at several phases of clinic contact. Unpublished Doctoral Dissertation, Loyola University of Chicago. Lindstrom. B. R. & Durlak, J. A. (1985). Factors affecting parental agreement regarding their child's behavior. Presentation at Annual Midwestern Psychological Association convention. Lindstrom, B. R. (1985). The use of parent data in measuring the outcome of child psychotherapy. Unpublished Master's thesis, Loyola University of Chicago. AWARDS & HONORS Fellow, American Orthopsychiatric Association, 1990. Clinical Training Award: Alcohol, Drug and Mental Health Administration. 1984 - 1985. Match 30, 2007 Program Category: Mental Health Services Page 32 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D., LLC: PROFESSIONAL AFFILIATIONS Fellow. American Orthopsychiatric Association since 1990: member since 1987. Member. Colorado Psychological Association since 1988. Member, American Psychological Association since 1988. Member, Division 53, Society of Clinical Child and Adolescent Psychology, American Psychological Association since 1985. Member, International Society for Prevention of Child Abuse and Neglect since 1991. Member, Perpetration Prevention Study Group, Kempe National Center for Prevention of Child Abuse and Neglect since 1990. PUBLIC SERVICE Pro Bono Project, Weld County, 1992- 1998 Board Member. Children's Law Center of Larimer County, 1993-95. Member, Behavior Program Review Committee, Foothills Gateway Rehabilitation Center, 1992-1993. Vice Chairman. Larimer County Mental Health Center, Advisory Board; Chairman. Child / Adolescent Mental Health Task Force. 1989-91 . Board Member, Loveland City Council, Human Relations Commission, 1989-91. RECENT PRESENTATIONS November 13, 2006. Mental Health Issues Associated with Autism Spectrum Disorders. Thompson Autism/Asperger's Parent/Community Group Meeting, Loveland, CO. August 19, 2004. Effective Motivation, Behavior Management, and Discipline. Staff inservice at Knowledge Quest Academy (Charter School), Milliken, CO. January 26, 2004 & December 5, 2003. A Developmental-Contextual Approach to Supervised Visitation. Weld County Department of Social Services. Greeley, CO, with Toni Pasquale. MA, LPC. December 12, 2003. If You Succeed, Then You-11 Try Harder: Managing Test Anxiety for Students, Parents and Teachers. Poudre School District, Fort Collins. CO. November 12, 2003. Developing Mentoring Relationships with Abused and Neglected Children. For Partners of Larimer County. Loveland, CO with C. Gray, MA. LPC and M. Lawler, MA. July 10, 2002. A developmental-Contextual Understanding of the Experience and Effects of Child Sexual Abuse. 14th International Congress on Child Abuse &Neglect, Denver CO, with G. Ryan, et. al. May 17, 2002. I Resist, Therefore I am! Working with Oppositional/Defiant Children. Workshop presented at 2002 Spring Educational CAFCA Conference, Denver, CO. April 15, 2002. Anxiety 101: Understanding and Responding to Child and Adolescent Anxiety. Poudre School District Major Mental Health Issues of Childhood, through Colorado State University, Fort Collins, CO, with T. Pasquale, MA, LPC. Match 30, 2007 Program Category: Mental Health Services Page 33 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D., LLC CONTINUING EDUCATION (selected) 1990 to present I am a member of a multidisciplinary study group on child sexual abuse and the prevention of juvenile perpetration, which meets monthly at the Kempe National Center for the Prevention and Treatment of Child Abuse in Denver. January26, 2007 Types of Domestic Violence: Research Updates and Divorce Implications, & Living Arrangements Following Separation and Divorce. Joan B. Kelly, PhD. Denver. CO. October 13. 2006 Ethical Decision-Making for Mental Health Professionals and the New APA Ethics Code. Stephen H. Beneke, JD. PhD. Director, Ethics Office APA. Denver, CO. August 10, 2005 Methamphetamine: Biopsychosocial Effects and Treatment. Nicholas. Taylor, PhD, and Kathryn Wells, MD. Greeley, CO. May 6, 2005 The MMPI-2 and Clients with Neurological / Neuropsychological Conditions. Alex Caldwell, PhD. Denver, CO. February 11, 2005 Involved Fatherhood: What Difference Does it Really Make? & Young Children: Developmentally Appropriate Parenting Plans. Marsha Kline Preuett. PhD, MSL. Denver. CO. May 6 — 8, 2004 Therapeutic Jurisprudence: The Tension Between Law and Psychology. Vail, CO. April 15, 2004 New Developments in Bipolar Disorder Treatment. Tammas Kelly, MD & Larry Denmark. EdD. Fort Collins, CO. February 10, 2004 Is It Just a Stage? Mental Health and Substance Use Disorders in Children and Adolescents. Paula Riggs, MD. Fort Collins, CO. August 7, 2003 Focusing on Integration: The Relationship Between Child Maltreatment and Juvenile Delinquency Symposium. Fort Collins. CO. March 28, 29, 30, 2003 Raising the Bar: Using Science to Inform and Improve Treatment of Traumatized Youth in Residential Treatment. The National Center for Child Traumatic Stress, UCLA. Los Angeles, CA. October 20, 1999 Weld County Child Abuse Coalition: Child Abuse Reporting Protocol. Greeley. CO. Mach 30. 2007 Program Category: Mental Health Services Page 34 BID 001-07 Vendor: Barry R. Lindstrom. Ph.D., 1.LC VII APPENDIX 2: Data Collection Instruments/Protocols 670 BUDD,FELIX, SWEET, SAUL,AND CARLETON Table 1 Behavioral Definitions Related to the Current Research Category Behavior description Evaluation context Evaluation types Psychological—clinical interviews and measures of cognitive,personality, social,behavioral,and/or parenting functioning Psychiatric—clinical interviews and mental status examinations Multidisciplinary—assessment of parents(and possibly children)by professionals from more than one discipline Other—substance use,mental health intake, neuropsychological,or other evaluation No.of sessions Single in-person sessions Location of sessions Office or clinic Home Naturalistic environment—for example,visitation room at an agency,foster home,or park Other—for example, inpatient facility Referral context Content area(s)identified in Cognitive or emotional functioning referral questions Parenting ability Parent-child relationship Substance use Service needs Specificity of referral General—global statement of content area to be assessed(e.g.,evaluate parent's emotional functioning) questions Specific—lists one or more parent behaviors,areas of functioning,childcare circumstances,or service issues to be assessed(e.g.,questions about parent's psychiatric diagnosis or need for medication management,ability to provide for children's special needs or to discipline children appropriately,degree of attachment with child,or therapeutic needs to manage depression) Additional referral Presenting problems for current evaluation—for example,child upset upon returning from visits with biological parent, information new child abuse allegations Permanency options or legal decisions being considered at the time of the referral—for example,family reunification, change in visitation arrangements,termination of parental rights Methods used Instruments administered Cognitive Achievement Objective personality Projective personality Symptom questionnaire Parenting questionnaire Parent-child observation Background sources used Client Children) Worker/therapist Collateral informant Written records and source—for example,child welfare or mental health agency,police,or hospital Explained purpose of Statement that examiner explained the reason(s)why the evaluation was conducted and/or who can have access to the evaluation and/or limits results of the evaluation of confidentiality Reliability/validity of data Statement about the believability of the information obtained in the assessment or the effectiveness of methods used to produce an accurate account of the parent's functioning (e.g., confidence ranges of IQ scores, lie scales,or social desirability indexes) Report of findings Parent's personal attributes Strengths—for example,ability to handle stress,coping style, cooperation with treatment and behavior(must be Weaknesses—for example, impulsive,impaired capacity to direct and control own behavior offered as examiner's How attribute impacts on parenting—for example,parent's impulsive behavior limits ability to be patient with the opinion or as information children received from sources other than the parent) Parent's caregiving skills Strengths—for example,developmentally appropriate expectations,responsive to child's physical and emotional needs and beliefs(offered by Weaknesses—for example,inconsistent discipline,unaware of danger in allowing child to throw scissors someone other than Individualized to children—for example,relates characteristics to number or age of children,child's developmental parent) level,or special needs Child's relationship with Strengths—for example,expresses affection toward parent,responsive to parent's initiations parent(offered by Weaknesses—for example,child says he does not want to live with parent,appears fearful of parent someone other than parent) Match 30. 2007 Program Category: Mental Health Services Page 35 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D., LLC Barry R. Lindstrom, Ph.D. LLC Psychological Evaluation: Individual: ❑ Child ❑ Adolescent ❑ Adult; Interactional: o Parents ❑ Grandparent o Sibling Confidential for Professional Use Only Client: with: Dates/Times: DOB/Age: Race: ;Marital Status: S M1 2 3 4 D Cohabit Referred by: Eval to include: MMPI-2 MCMI-III IQ Other: Child(ren): Age(DOB): at: Home; FC / GH/ RTC: since: Age(DOB): at: Home; FC / GH/ RTC: since: Age(DOB): at: Home: FC / GH/ RTC: since: Age(DOB): at: Home; FC / GH/ RTC: since: Age(DOB): at: Home; FC / GH/ RTC: since: Visitation: x/wk; for ; w/fin Supervised? Therapeutic? Reason for DSS involvement: March 30. 2007 Program Category: Mental Health Services Page 36 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D., LLC SOCIAL / FAMILY HISTORY: (GENOGRAM) (full page) Relationship /Family: Medical: PCP: OK to contact? 0 YES 0 NO DX: Meds: Sleep: Appetite: Caffeine: Nicotine: Exercise: Mental Health TX: Outpatient: Inpatient: Developmental: Trauma / Loss: March 30, 2007 Program Category: Mental Health Services Page 37 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D., LLC Education: HS GRAD? Drop Out? Year: School: College?: Learning Problems? SPED? ADHD: Work Hx: Substance Abuse Hx: Tx: None Inpatient Outpatient Legal Hx: ' March 30, 2007 Program Category: Mental Health Services Page 38 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D., LLC INTERVIEW: MENTAL STATUS: Alert and Oriented X: Appearance: Eye Contact: Speech: Thought: Impulse Control: Mood: Affect: Behavior: Frustration Tol: Aggression: _ __Boundaries: IQ estimate: MR; Borderline; Low Average; Average:Above; Gifted Object Relations: Danger to Self: None Ideation Intent Plan: HX: Attempts: Self Harm: Cutting Burning Other: Danger to others None Ideation Intent Plan: HX:Aggression Domestic violence FORMULATION: Stressor: Strengths/Supports: Dynamics: Stage/Motivation for change: Prognosis: March 30, 2007 Program Category: Mental Health Services Page 39 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D., LLC ASSESSMENT(7CD-9/DSM-I17: Axis I Rule Out: Axis II Axis III Axis IV: family school work financial health legal Axis V: GAF (current): (highest in past year): RISK FACTORS: PROTECTIVE FACTORS: PLAN: Case management: Barry R. Lindstrom, Ph.D. LLC, Licensed Clinical Psychologist#1303 3211 20th Street. SteD 970.356-3100 Greeley, CO 80634 fax 970.356.4827 March 30, 2007 Program Category: Mental Health Services Page 40 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D., LLC KEMPE Family Stress Inventory Parent/ Family: Date: 1. Parent Beaten or Deprived as a Child 2. Parent has history of Criminal Record, Mental Illness, or Substance Abuse 3. Parent Suspected of Abuse in the Past 4. Parent with Isolation, Low Self-Esteem or Depression 5. Multiple Stresses or Crises 6. Violent Temper Outbursts 7. Rigid, Unrealistic Expectations of Child's Behavior 8. Harsh Punishment of Child 9. Child Difficult or Provocative or Perceived to be by Parent 10. Child unwanted or at Risk for Poor Bonding/ Attachment Difficulties Barry R. Lindstrom, PhD, LLC, Licensed Clinical Psychologist#1303 March 30, 2007 Program Category: Mental Health Services Page 41 BID 001-07 Vendor: Barry R. Lindstrom. Ph.D.. LLC Family Assessment Outline Interaction Poor quality Moderate quality High quality Coordination Little or unproductive interaction Sometimes unclear or imbalanced Excellent interaction Little flexibility Little flexibility Most differences resolved Lacks smoothness Lacks smoothness Synchrony,harmony Separate and unrelated activities Separate and unrelated activities Balance of who initiates/ responds Intense friction Intense friction Communication Inconsistent, incongruent Sometimes indirect or routinized Clear.direct,meaningful Ignoring of messages Some missed messages Words and gestures clearly congruent Withdrawal Some awkward silences Silences are comfortable Awkward silences Messages not always Reflects back acknowledged as received Conversation minimal Sometimes clear but lacking in Message clear,direct quality Irrelevant talking Some reciprocity Balance of who does the talking Verbal/nonverbal incongmencies Appropriate role Role reversal Functional control Appropriate assumption Child uses fear and humiliation Adult assumes his or her role as Parent offers choices as control agent a parent some of the time Oppositional shifts Child able to return to child Adult assumes parent role role most of the time Gaze aversion Some evidence of control from Parent rewards desired child child behaviors Rigid pattern or laissez-faire Child permitted to share certain aspects of the situation Emotional Disruptive emotional expression Moderate balance of emotional Affective expression expression expression enhances flow Difficulty with both expressing Positive and negative Emotional expression and responding expressions encouraged Very constricted Physical posture implies some Full range of emotions accessibility accepted Intense,overcharged Emotions blended Physical posture implies openness emotionally Responsivity/ Missed cues Basic levels of response Balanced response pattern sensitivity Poor interpretation of cue Regards the other but Evidence of ability to see sometimes does not gauge other's perspective cue appiuptiately Underinvolved or intrusive Sometimes aloof Good attention to other Distracted,inhibited Pays moderate attention Accepting,empathy Rejecting,preoccupied Some imbalance Balance Indifferent Tension/relaxation Tense,anxious Moderate anxiety Open,relaxed Nervous mannerisms(e.g.,foot Nervous mannerisms but not No anxiety evident on shaking) prevailing either part Elevated activity level(e.g., At ease generally but shows At ease for whole taped unable to sit still) differences between free and event structured activities Run-on speech Questions genuine, related Mood Negative Mixed quality Positive Exceptions to negative mood Negative mood less than 10% Exceptions to positive are infrequent and brief and positive mood less than mood are related to 25%of the time something obvious and real Anger,annoyance,irritation, Encouragement criticism Worry,depression Modulated affect Enjoyment Little pleasure Moderate Acceptance Low approval of child Approval of child at some point High approval of child Rebuffs contact attempts Warmth evident at some point Long or frequent engagement in activity Frequent or long duration of Enjoyment evident more by one Sustained warmth disinterest partner Cold,bored Detached some of the time Empathic involvement Engagement clear Overall rating Poor quality Moderate quality High quality Basically not interested in the Balance of interaction Authentic interest other,indifference Inaccessible Appears accessible,moderately Continually responsive Match 30, 2007 Program Category: Mental Health Services Page 42 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D., LLC EVALUATION TRACKING Clients: DSS: Individual Interviews: Names & Date(s): Time: Direct Indirect Parent 1. Testing: ❑ MMPI-2 ❑ MCMI-III ❑ WASI ❑ Checklists ❑ TAT ❑ Parent2. Testing: ❑ MMPI-2 ❑ MCMI-III ❑ WASI ❑ Checklists ❑ TAT ❑ Child 1. ❑ FP ?naire ❑ Dev Hx ❑ Checklists ❑ BASC(s) P FP T S O Drawings ❑ WASI ❑ T/CAT ❑ BGVMT ❑ MMPI-A ❑ M(-P)ACI ❑ Child 2. o FP ?naire ❑ Dev Hx ❑ Checklists ❑ BASC(s) P FP T S ❑ Drawings o WASI ❑ T/CAT ❑ Family Interviews: P/C *al 1. 2. 3. Marital 1. Sibling *al 1. 2. • Match 30, 2007 Program Category: Mental Health Services Page 43 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D., LLC. Clients: Indirect Collateral Contacts: With: Records? Date(s): Time: DSS ext. School Psych Dx Tx Medication Dx/Tx Medical Dx/Tx Subst Abuse Dx/Tx Domestic Viol Anger Mgt Visitation Parenting Class Attorney/GAL Probation Date(s): Time: RECORDS: NO SHOWS TRAVEL DICTATE PROOF Phone Numbers: NRBH Child 346-1166 f/346-9800 Adult 353-3686 0353-3906; records 0392-1354; KPLC 352-2201 f/ PsychCare 352-1056 0356-0110 Probation 356-4000; 392-4589 0351-8695 LFS 266-1788; 356-6080 f/226-1799 Transitions 336-1123 f/351-0182 Care 356-6751 f/506-2726 IGTS 353-8171 f/353-0371 IsGrove 356-6664; TRT(Dan)313-1182; !OP(Dave)313-1178; OP 351-6678; fax 356-1349; Loveland 669-1700 Subtotals: p2 p.l a p.I b Totals: • Match 30, 2007 Program Category: Mental Health Services Page 44 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D., LLC Summary Statistics Barry R. Lindstrom, Ph.D. LLC Psychological Evaluation: Individual: ❑ Child ri Adolescent ❑ Adult; Interactional: ❑ Parents ❑ Grandparent ❑ Sibling Confidential for Professional Use Only Clients: with: ## of Adults: ❑ Ongoing case n Termination case Children: Referral date: First Client Call: First Appt date: Report date: Completion: days Subtotals: p2 p.l a p.l b Totals: Direct + Indirect= /Total hours Report pp: ❑ Court Staffing: Time: $: ❑ Court Testimony: Time: $: Match 30, 2007 Program Category: Mental Health Services Page 45 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D.. LLC VIII APPENDIX 3: Sample Consent Forms Barry R. Lindstrom, Ph.D., LLC Licensed Clinical Psychologist INFORMED CONSENT: COURT ORDERED EVALUATION /TREATMENT Date : Client Name: DOB: Individual: Evaluation: treatment: Family: Evaluation: Treatment: Including: DOB: DOB: DOB: DOB: DOB: DOB: DOB: I have been informed that this evaluation / treatment has been ordered by the Court and the information I provide is not confidential. I understand the results of this evaluation, or my progress in treatment, will be reported verbally and/or in written reports and letters to the court directly or through my Caseworker with the Department of Social Services or my Probation Officer. I understand this will include information about my attendance and participation, interviews and clinical findings, and the results of psychological testing. I understand this may also include Dr. Lindstrom's participation in court facilitation staffings and/or testimony at future court hearings. Signed, Client or legal representative Relationship to Client Date: Witness: 01/07 • - Match 30, 2007 Program Category: Mental Health Services Page 46 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D., LLC .ta.,. ways 321120" Stxeet,Suite D,Qxeetey,CC 80634 (970)356-3100 (970) 356-4827 Sax Authorization for Release of Protected Health Information For: PATIENT NAME: Date of Birth: Social Security #: From the Records of: Jeff Huff, Psy.D., M.D. Russ Johnson, M.D. - Sandy Sup, MA, LPC Barry R. Lindstrom, Ph.D. Robert W. Stewart, Ed.D. 7 Toni Pasquale, MA, LPC Cathy Frantz, RN, CS, MS, CAC Ill INFORMATION TO BE RELEASED: ❑ Initial Eval / H &P C Treatment/ Progress Notes Psychiatric /Mental Health _ Lab/Path Reports ❑ Psychological Testing H Drug and Alcohol Treatment H Special Education ❑ Medical Records • Family / Marital Therapy Other I hereby authorize Pathways to: release the information/records indicated above to: obtain the information/records indicated above from: Name: Address: City/State/Zip Code: Phone: For the purposes of C Case Management/Coordination Shared Record Keeping I Continuity of Carel l Verbal Communication ET Legal 7 Insurance I Employer i Other EXPIRATION OR REVOCATION OF AUTHORIZATION: I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken to comply with it. Without my expressed revocation, this authorization will automatically expire on December 31, 2007 or one year from the date of my signature whichever is later. I understand that the records to be released may contain information related to substance/alcohol abuse, psychiatric or psychological conditions, which may be protected by Federal Confidentiality Regulations, 42 CFR Part 2. A copy of this authorization (including facsimile copy) may be used with the same effectiveness as the original. I have read the above and understand the terms and conditions of this Authorization. I release Pathways and the above named practitioners /agencies from any liability in complying with this Authorization. Patient or authorized representative / Relationship to Patient Date (Continued) Witness Date NOTICE TO RECIPIENTS: This information has been disclosed to you from records which are protected by federal law. Regulations prohibit your further disclosure without the specific written consent of the person to whom it pertains. !;latch 30. 2007 Program Category: Mental Health Services Page 47 BID 001-07 Vendor: Barry R. Lindstrom, Ph.D.. LLC Barry R. Lindstrom, Ph.D., LLC Licensed Clinical Psychologist PROFESSIONAL DISCLOSURE Thank you for entrusting me with your psychological health care. Colorado state law (CRS 12-413-214) mandates that Psychologists provide specific information to clients during their initial office visit. Please read and sign this disclosure about our professional working relationship. The information you provide to me during treatment is confidential except as provided by law. I am required by law to breach confidentiality to report cases of known or suspected child abuse or neglect, or if a patient presents a serious threat to themselves or others (suicide, homicide, or grave disability). I will discuss any such situation with you if the need arises. I have been a Licensed in Colorado as a Clinical Psychologist (#1303), and a School Psychologist (#0308917) since 1989. I am on the National Register of Health Providers in Psychology (#41119, since 1991). I hold Ph.D. (1987) and M.A. (1985) degrees from Loyola University of Chicago in Clinical Psychology with a subspecialty in Clinical Child Psychology. I interned at Denver General Hospital. I am a fellow of the American Orthopsychiatric Association, and a Member of the Colorado and American Psychological Associations, and the International Society for the Prevention of Child Abuse and Neglect. I contract with Pathways Management, LLC, for professional business services. Sexual intimacy between patient and therapist is not part of any recognized therapy, is illegal in Colorado, and should be reported to the Grievance Board. If you have any concerns about licensed or unlicensed mental health practitioners you can contact the Mental Health Grievance Board at: 1560 Broadway, Suite 1370. Denver, CO 80202 (Phone: 303.894-7766). You have the right to know about the type and expected length of treatment related to your diagnosis; my approach and available alternatives; the right to a second opinion; and the right to end treatment at any time. Please talk with me about any questions, concerns or complaints that you may have now or at any time in our work together. This is a usual part of therapy and addressing your concerns is integral to our successful work together. Please see additional information about office practices, policies, and fees. My signature below indicates that I have been informed of Dr. Lindstrom's degrees, credentials and licenses and have read and understand my rights as a patient: Patient or authorized representative / relationship to patient: Date: Thank you, Barry R. Lindstrom, Ph.D., LLC Licensed Clinical Psychologist, #1303 Licensed School Psychologist#0308917 EXHIBIT B SUPPLEMENTAL NARRATIVE TO RFP Barry R. Lindstrom, Ph.D., LLC Licensed Clinical Psychologist 3211-20th Street, Suite D Greeley, CO 80634 (970) 356-3100 May 17, 2007 Tobi Vegter Weld County Department of Social Services PO Box A Greeley, CO 80632 RE: Core Service Bid 2007-2008 Dear Ms. Vegter: I am writing to respond to the May 11, 2007 letter I received via email on May 16, 2006 from Judy A. Griego, Director, confirming that my RFP was accepted for placement on the vendor list. This letter serves as my acceptance of continuing as a vendor and my response to the FYC Commission recommendation regarding an interpreter/translator. While I appreciate the need for bilingual services, I am not in a position to provide such services and cannot accept this recommendation. As a sole practitioner I have no staff, and made no provision for retaining one in my budget or proposal. I do have the MMPI2 in Spanish language for clients who speak, but have trouble reading, English. If clients are monolingual, it would be infeasible to conduct an entire Psychological Evaluation through an interpreter and a Spanish speaking psychologist should be utilized from the vendor list. I am looking forward to another year of working with the Department providing psychological and interactional evaluations. Respectfully, Barry R. Lindstrom, PhD Licensed Clinical Psychologist • DEPARTMENT OF SOCIAL SERVICES P.O. BOX A GREELEY, CO. 80632 Website:www.co.weld.co.us Administration and Public Assistance(970)352-1551 OFax Number(970)353-5215 • COLORADO May 11,2007 Barry Lindstrom,Ph.D.,L.L.C. Licensed Clinical Psychologist 3211 20 Street#D Greeley,CO 80634 Re: Bid#002-MH-07(RFP 006-00)Mental Health Services Dear Dr.Lindstrom: The purpose of this letter is to outline the results of the Bid process for PY 2007-2008 and to request written confirmation from you by Monday,May 21,2007. The Families,Youth,and Children Commission appreciates your interest in providing services for families in Weld county.This year,strides were made in structuring an RFP that is clear and concise,and more user friendly,for both prospective bidders and evaluators. It is important to stress the value of following formatting guidelines and addressing the required sections concisely and appropriately. A. Results of the Bid Process for PY 2007-2008 The Families,Youth and Children(FYC)Commission recommended approval of Bid 002-MH-07(006-00),Mental Health,for inclusion on our vendor list,attaching the following recommendation. 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. 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,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, � I 'I• J y A. iego,Di e tor cc: Juan Lopez,Chair,FYC Commission Gloria Romansik,Administrator Tobi Vegter,Social Services Administrator Weld County Department of Social Services Notification of Financial Assistance Award for Core Funds Type of Action Contract Award No. X Initial Award 07-CORE-57 Revision (RFP-FYC-006-00;007-MH-07) Contract Award Period Name and Address of Contractor Beginning 06/01/2007 and Victor H. Cordero Ending 05/31/2008 Mental Health Services 2828 Speer,Unit 118 Denver,CO 80211 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Assistance Program provides mental health, family/parent Award is based upon your Request for Proposal (RFP). interactional, and psychological evaluation services to The RFP specifies the scope of services and conditions children,adults, and families. Specific services include of award. Except where it is in conflict with this psychological evaluations and parent-child interactional NOFAA in which case the NOFAA governs,the RFP evaluations, family assessments,and adjunct therapeutic upon which this award is based is an integral part of the services to include family and individual therapy, and action. consultation with caseworkers. Services are linguistically Special conditions (Latino,Hispanic, Bilingual/Spanish)and culturally 1) Reimbursement for the Unit of Services will be based on sensitive. South County services available in Firestone, an episode or hourly rate per child or per family. Frederick, Ft. Lupton, including South Weld Annex or 2) The episode or hourly rate will be paid for only direct WCDSS Ft. Lupton offices. Maximum monthly capacity face-to-face contact with the child and/or family,as for psychological evaluations per month is four;maximum evidenced by client-signed verification form,and as number of mental health evaluations per month is six, specified in the unit of cost computation. maximum number of parent-child interactional evaluations 3) Unit of service costs cannot exceed the hourly and per month is three,maximum number of therapy cases per yearly cost per child and/or family. month is five. 4) Payment will only be remitted on cases open with, and Cost Per Unit of Service referrals made by the Weld County Department of Social Rate per Episode Services. Mental Health Assessment(Evaluation) $600.00 5) Requests for payment must be an original submitted to Psychological Exam(Evaluation) $1,200.00 the Weld County Department of Social Services by the Other Services (out-of-office added fee) $75.00 end of the 25h calendar day following the end of the Parent-Child Interactions(Interactional) $1,200.00 month of service. The provider must submit requests for Rate per Hour payment on forms approved by Weld County Department Individual Counseling(Treatment) $100.00 of Social Services. Requests for payments submitted 90 Family Counseling $100.00 days from the date of service, and thereafter,will not be Court Testimony $ 120.00 paid. Enclosures: 6) The Contractor will notify the Department of any X Signed RFP: Exhibit A changes in staff at the time of the change. X Supplemental Narrative to RFP: Exhibit B X Recommendation(s) C ditions of Approval Approvals: Program £fic al: C� By By • David E. Long,Chair Judy Grieg�Director i Board of Weld County Commissio rs Weld ou ty Department of Social Services Date: JUN 1 8 2007 Date: (/ (1(1 (1 EXHIBIT A SIGNED RFP • ■ ■ . Q7-MH-07 _ INVITATION TO BID BID 001-07 DATE: February 28, 2007 BID NO: 001-07 RETURN BID TO: Monica Mika, Director of Administrative Services 915 10th Street, P.O. Box 758, Greeley, CO 80632 Third floor, Centennial Building, Purchasing Department SUMMARY Request for Proposal for: Colorado Family Preservation Act—Core Services Program Deadline: Friday, March 30, 2007, 10:00 a.m. (MST) The Families, Youth and Children Commission, an advisory commission to Social Services, announces that competing applications will be accepted for approved providers pursuant to the Board of Weld County Commissioners' authority under the Colorado Family Preservation Act(C.R.S. 26-5.5-101) and Emergency Assistance for Families with Children at Imminent Risk of Out-of-Home Placement Act (C.R.S. 26-5.3-101). The Families, Youth and Children Commission wishes to approve services targeted to run from June I, 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 313o/aOO.3 (After receipt of order) BID MUST BE SIGNED IN INK Program Area: MEIQTRL. HEALTH VItTh \A , 0.0 DEN O t�sy,D, TY ED OR PRINTED SIGNATU \ \, J V. VENDOR V IC'CoR C,ORDERQ) (Name) Handwritten Signature By Authorized Officer or Agent of Vendor ADDRESS aa(8 C JEER , -61Va. TITLE I � N2ECP.Z �YCt \\8 DATE 3 ac,)a©o9- �aiv , Qc 'aoatt PHONE # 3 O-3—H 5 6—q'-18a The above bid is subject to Terms and Conditions as attached hereto and incorporated. Victor H. Cordero, Psy.D. Mental Health Services, Bid NO: 001-07 TABLE OF CONTENTS Brief project Description 2 Target/eligibility populations 4 Types of services to be provided 5 Measurable outcomes 8 Service objectives 10 Workload standards 12 Staff Qualifications 13 Program capacity per month 14 Internal Tracking/Billing 15 Confidentiality & Participant Protection 17 Budget 19 APPENDIXES 2O Appendix 1 Program supervisor signature sheet, Resumes.....21 License Appendix 2 Data Collection Instruments/Interview Protocols.22 Appendix 3 Sample Consent Forms 23 3 Victor H. Cordero, Psy.D. Mental Health Services, Bid NO: 001-07 ABSTRACT BRIEF PROJECT DESCRIPTION This project is designed to provide mental health related therapeutic and psychological evaluation services to adults, adolescents, adults,families, and children involved with Weld County Department of Social Services. The project will strive to provide the highest levels of competence in the execution of all evaluation, therapeutic, and skills building services. These services will be provided in a context that is congruent with ethical standards and practices in the field of psychology. Services will also be linguistically (bilingual/Spanish) and culturally sensitive as a means of providing the most effective psychological evaluations, mental health evaluations, parent-child evaluations, and therapeutic interventions. Recommendations, approach, and clinical conceptualization will account for the culturally,linguistically,and socioeconomically diverse population to be served. Specific services available will include: psychological evaluations, parent-child interactional evaluations, mental health evaluations, and family/individual therapy. 2 • Victor H. Cordero, Psy.D. Mental Health Services, Bid NO: 001-07 TARGET/ELIGIBILITY POPULATIONS A. Total Number of Clients to be served: 55 B. Total individual clients and the children's ages: 55 clients, age range from elementary school age children, through geriatric C. Total Family Units: 55 D. Sub-total of individuals who will receive biculturaUbilingual services: 60% E. Sub-total of individual who will receive services in South Weld County: 40% F. Subtotal of individuals who will have access to 24-hour service: 100% G. Monthly maximum program capacity: 8 ongoing evaluations, 5 ongoing therapy cases. H. Monthly average capacity: 4 evaluations I. Average stay in the program: 3 months J. Average hours per week in the program: 7 hours for evaluations, 1.25 for therapeutic services. K. Cultural/ethnically specific services: Latino, Hispanic,Bilingual/Spanish L. Service to South Weld Count Clients: Services available and encouraged in Firestone, Frederick, Ft. Lupton area, including South Weld County Annex or WCDSS Ft. Lupton offices if requested by The Department. 4 Victor H. Cordero, Psy.D. Mental Health Services, Bid NO: 001-07 TYPES OF SERVICES TO BE PROVIDED A. Family/adult/child/adolescent Psychological Evaluation & Mental Health Evaluation services 1. Psychological evaluation services are intended to provide clinical information requested by Social Services and will include/incorporate the following: a. Evaluation procedures, reports and recommendations will be designed to produce useful responses to specific referral questions. A licensed psychologist or qualified candidate for licensure under supervision by a licensed clinical psychologist will complete all evaluations. b. Evaluators will make all reasonable efforts to collaborate with case related contacts prior to the completion of the evaluation either by personal contact,telephone contact, or via written communication including electronic communication. c. Evaluation reports will clearly state methods utilized, contacts made, tests administered, and results and recommendations relevant to the referral question. d. Evaluation and assessment content will be made available to the family or other relevant parties and will comply with the ethical standards and practice of the American Psychological Association and/or other legal considerations. B. Parent-Child Interactional Evaluations a. Evaluation procedures, reports and recommendations will be designed to produce useful responses to specific referral questions and from arising clinical issues as observed by the 5 Victor H. Cordero,Psy.D. Mental Health Services, Bid NO: 001-07 evaluator. A licensed psychologist or qualified candidate for licensure under supervision by a licensed clinical psychologist will complete all evaluations. b. Evaluators will make all reasonable efforts to collaborate with case related contacts prior to the completion of the evaluation either by personal contact,telephone contact, or via written reports. c. Evaluation reports will clearly state methods utilized, contacts made,tests administered, and results and recommendations relevant to the referral question. d. Evaluation and assessment content will be made available to the family or other relevant parties and will comply with the ethical standards and practice of the American Psychological Association and/or other legal considerations. C. Individual & Family Therapy Services a. Therapeutic services will be designed to address the needs of The Department, or referral request, in line with the best interests of the children or family involved. b. Therapeutic services will be congruent with recommendations stemming from referral sources, or other evaluation procedures previously performed. c. Therapeutic approach is defined as cognitive-behavioral, outcomes based. 6 Victor H. Cordero, Psy.D. Mental Health Services, Bid NO: 001-07 D. Consultation with Caseworkers 1. Service providers will consult with Social Service caseworkers regarding the integration of assessment results into the overall care plans for the child, adolescent, adult, or family involved. These consultations will include impressions and evaluations of suicidal clients, need for in-patient placement or other levels of intervention. 2. Service providers will assist in obtaining feedback from agency clinicians regarding the rationale for decisions on these issues when required. 7 Victor H. Cordero, Psy.D. Mental Health Services, Bid NO: 001-07 MEASURABLE OUTCOMES A. This program will shorten the time required to obtain evaluation results after a referral is made by means of commencing the referral by internet and/or phone; and coordination of allotted appointment times with the caseworker. Evaluator/clinician will make efforts to inform caseworker of initial appointment or request that caseworker inform client of appointment date and time. Efforts to communicate anticipated impressions with verbal feedback will occur when possible in anticipation of the written report. B. Social Service staff will have ease of access to the practitioner/clinician by means of a direct phone line, mobile telephone, internet, or other device which will result in a response as soon as is reasonably possible. C. Frequency of contact between the practitioner/clinician and Social Service staff will be defined by the needs of the case and the needs of the referring staff member. D. Timeliness of responses will be pursued as a high priority as will client scheduling. E. Coordination of assessment and therapeutic services between the practitioner/clinician and Social services will be ongoing. Urgent requests for information will be returned as soon as is possible, non-urgent requests will be returned within one business day when possible. F. This program will provide emergency consultations within 24 hours of such request or will make all efforts to assure this outcome, pending coordination with social services and the client, and client cooperation. Evaluation results 8 Victor H. Cordero,Psy.D. Mental Health Services, Bid NO: 001-07 will demonstrate clear recommendations and utilize methods that will be accepted by the court, and which are reasonable. Quantitative measures of usefulness to be utilized will be based on direct caseworker feedback regarding timeliness,usefulness, and professionalism of reports for evaluations. Psychological evaluations, mental health evaluations, and parent-child evaluations will incorporate psychometrically sound instruments in addition to non- standardized and observational procedures. Instruments utilized will be congruent with normal and common practice in the field. Therapeutic services will employ pre and post screening assessments regarding the specific issue of concern as identified in the initial referral when applicable and possible to assure outcome based monitoring is taking place. This clinician utilizes a cognitive-behavioral therapeutic model and approach in treatment cases. 9 Victor H. Cordero, Psy.D. Mental Health Services, Bid NO: 001-07 SERVICE OBJECTIVES Services of the project will improve family conflict management by providing clear diagnostic guidance and effective therapeutic recommendations/services to assist in the development of the family services plan, to assess and improve family communication, improve parenting skills, and to improve functioning of familial relationships. Services will improve household management competency in families by providing parents and caregivers improved insight,direct education,and therapeutic as well as skills based guidance, in regards to safety of the household and the protection of children. Services shall assist parents in identifying and accessing assistance from other community based resources within local, state,and federal governments when applicable. When required, clinicians will identify such resources or provide assistance or direction as to the process of obtaining such services with clients. Services shall remain within the scope of the initial referral question(s) or service request. Consideration of variation from these initial requests will be made in collaboration with caseworker and/or other professions involved in the case when possible. A solution focused approach will be paramount in consideration of both evaluation recommendations, and therapeutic approach. 10 Victor H. Cordero, Psy.D. Mental Health Services, Bid NO: 001-07 Each of the latter service objectives will be measured via direct observation, caseworker feedback, client feedback, recidivism, and when applicable, pre and post intervention screening measures. Evaluator/clinician will be readily available and open to feedback and potential modification if appropriate from social service workers. 11 • Victor H. Cordero, Psy.D. Mental Health Services, Bid NO: 001-07 WORKLOAD STANDARDS The program will provide a minimum of 25 hours per week of clinical services. Up to three practitioners/clinicians will provide these services. The maximum caseload per worker on evaluations will be 4 clients per week. Modality of treatment interventions will be individual or family. Maximum caseload per supervisor will be 4 cases of evaluation per week, and 10 cases of individuaUfamily therapeutic services. The number of total ongoing assessments per month will be a maximum of eight. Insurance: Attached 12 Victor H. Cordero,Psy.D. Mental Health Services, Bid NO: 001-07 STAFF QUALIFICATIONS A. All staff providing direct services will have at least the minimum qualifications in education and experience. Psychologists and clinicians will be licensed in the state of Colorado, be eligible for licensure,or evidence competence in the area of service. All non- licensed clinicians will be directly supervised by a licensed clinical psychologist and the psychologist will supervise and sign off on all documents provided to Social Services. 13. Total staff number: 1 to 3 C. Staff will receive and comply with any training required by Social Services. D. All staff have knowledge in risk assessment. E. Staff providing bilingual (Spanish) services will demonstrate adequate levels of fluency in both linguistic competencies, and in cultural competencies. 13 Victor H. Cordero,Psy.D. Mental Health Services, Bid NO: 001-07 PROGRAM CAPACITY PER MONTH A. Minimum number of psychological evaluations per month: 2 B. Maximum number of psychological evaluations per month: 4 C. Minimum number of mental health evaluations per month: 3 D. Maximum number of mental health evaluations per month: 6 E. Minimum number of Parent-Child Interactionals per month: 2 F. Maximum number of Parent-Child Interactionals per month: 3 G. Minimum number of therapy cases per month: 1 H. Maximum number of therapy cases per month: 5 14 Victor H. Cordero, Psy.D. Mental Health Services, Bid NO: 001-07 INTERNAL TRACKING/BILLING STANDARDS OF RESPONSIBILITY Services will reflect time limits, anticipated number of sessions and evidence a direct link to the evidence-based criterion which will be used for treatment and as outlined in the initial family/individual therapy assessment. Clinical efforts to reduce renewals or minimize reinstated service cost will be initiated by means of comprehensive initial assessment pre-treatment, and specific, behaviorally based objective and goal setting. Clinical approach will consider appropriate step-down procedures to include periodic reassessment of the appropriateness of the current frequency of contact such that options for fewer client contacts and/or transitioning to community based support services can take place. Evaluators/clinicians will make reasonable efforts to participate in Core Review Team as requested, be available to meet with Social Services staff for the purposes of clarification, and available for the Families,Youth and Children Commission review if requested. Evaluators/clinicians agree to be available for court testimony, including preparation,testimony when given proper notification. Service provider will work with families to prepare them for further services beyond established time frame and/or services out of the scope of those contracted with Social Services. BILLING Billing will be conducted according to the guidelines providing by the Department of Social Services Billing Department. The latter includes delivery of required authorization for services (provider information, amount, original signature, month of service), request for reimbursement (Trails/case ID, rate, units billed, dates of service), and supporting documentation (i.e. copies of evaluations,client verifications,original client signature, dates-hours of client contact, etc.). Billing will be submitted monthly to the appropriate department staff person on or about the 10th day of the month following the service month and must be date-stamped by Social Services by the 25`h of the month following services. 15 Victor H. Cordero, Psy.D. Mental Health Services, Bid NO: 001-07 LITERATURE CITATIONS N/A 16 Victor H. Cordero, Psy.D. Mental Health Services, Bid NO: 001-07 CONFIDENTIALITY & PARTICIPANT PROTECTION 1. Protecting Clients from Risk The particular services of this program possess few foreseeable physical, medical, psychological, social, and legal risks or potential adverse effects as a result of the project isteslf or ay data collection acitivity. Primary risk to clients is the event of mandatory reporting disclosures made to clinicians (i.e. disclosure of child abuse, intent of harm to self or others, etc.). Clients are primarily protected by means of adequate disclosure at the onset of the professional relationship and before any critical data or information is obtained. Clients are informed as to the rules of confidentiality, risks to confidentiality,and the professionals mandatory reporter status. In addition, full disclosure regarding potential use of the information gathered is executed. Clients will have the option to resolve issues via direct contact with the professional and this contact will also provide an environment in which to repair the professional relationship,or locate additional sources of assistance if the case will be transferred. Primary alternative treatments applicable to this project will involved connecting the client to community based resources. 2. Fair Selection Target population is addressed in "Target/Eligibility Populations" section. 3. Absence of Coercion All participation is voluntary 4. Data Collection Data collection needs are highly dependent on referral question but can include social workers,school, clients, family members, prior professionals involved. Procedure for data collection first begins by obtaining appropriate releases of information. Sources include records, interviews , prior evaluations, observation, and questionnaires and can occur in an office,community, or home setting. Dissemination of psychological instruments to the public domain is not considered a professional maneuver in the field as this jeopardizes the integrity of these psychometric tools. The included psychological evaluation report does provide a list under the "techniques utilized" section and reflects commonly used 17 Victor H. Cordero, Psy.D. Mental Health Services, Bid NO: 001-07 instruments in the field. As such,this evaluator respectfully requests that he be allowed to omit Appendix 2 5. Privacy and Confidentiality Privacy and confidentiality is assured by means of appropriate storage, communication, and delivery of client information. Data collection instruments will be utilized by means of their published standardization procedures and will be stored in locked storage when not in immediate use. Only the director of the program or other authorized clinicians will have access to this information. Identities of clients will be kept private by means of the above safeguards. 6. Adequate Consent Procedures Obtaining informed consent will begin by clarifying the nature of the service being offered, risks to confidentiality, risk to involvement, risk of future use of the information,that their participation is voluntary, and that they can leave at any time or ask any questions they wish clarified at any time. Consent for youth will be obtained from the legal guardian and assent from the minor. Consent for the elderly will be obtained from the client, unless competency is not intact Consent from limited reading ability clients will be obtained by verbal means Consent from non-English speaking clients will be obtained in their language with efforts in place to assure understanding, such as inquiry about the nature of their consent. Consent will be documented by the individual's signature after the form is reviewed with them and they have the opportunity to review the form and ask questions. They will receive copies after they sign the form. 7. Risk/Benefit Discussion In light of all efforts put in place to minimize risk for clients, the benefits of engaging in this project are multiple. Outcomes, data, impressions, and recommendations obtained can provide guidance to caseworkers, and other professionals involved and increase the probability of appropriate service delivery. 18 Victor H. Cordero, Psy.D. Mental Health Services, Bid NO: 001-07 BUDGET 19 Fee Schedule/Cordero From the office of: 2828 Speer Blvd., Unit 118 Victor H. Cordero, Psy.D.,P.C. Denver, CO 80211 Licensed Clinical Psychologist Office (303)455-9480 Fax (303) 651-3773 Fee Schedule English & Bilingual/Spanish Language Services Weld County Department of Social Services Mental Health Services Bid No.: 001-07 Service Fee Evaluation Services Mental Health Evaluation $600 (Clinical interview, mental status examination, brief psychological testing/symptom screening measures, record review, recommendations)- can be tailored to specific referral question. Intended to rule out mental health issues/problems or specific concerns. Psychological Evaluation $1,200 (Comprehensive evaluation, includes assessment of intellectual functioning, emotional/personality/interpersonal functioning, relevant psychosocial history, mental status examination, clinical interview, and treatment/management recommendations) In some instances an out of office evaluation fee will be charged (psychological and mental health evaluations in detention centers or other facilities outside immediate metro area) may add $75 Parent-Child Interactional Evaluation $1,200 (Comprehensive evaluation of the parent-child dynamic, includes multi-hour behavioral observation of parent(s) and child, interview with parent(s), chart/report review, collateral contacts, report generation with treatment, management recommendations). Observations can take place at almost any metro area location for the same fee (WCDSS, family visitation center, community visitation center, clinician's office). Therapeutic Services Individual Treatment $100/clinical hour Family or Couples $100/clinical hour }§ , in 6 § a a 7 a \ ® ( [; _C. _ , 49 [ f 8 2 m m \01 \ a CI \ \ a \ m \ 8 s 02 a } - e e a ) \ R. \ el \ ` ( w 0> r- & % ® OA a $ a } g ■ ( ` _ 03 el® / k a _ � } w O. 0 a Ci § < _ K L, k I i Co o G > ( » a / ) Co < e ) § § - w } + § ) 5 § \ 0 r 0 7 o ° a ` b H 0 -- w cc k ct ` W - 0 § k 0 0 2 2 \ § _ 0 2 T- o B b 0 L.L. ° � $ } [ a b § \ \ o -J co o 2 0 ® § § > a H a °- ) 0 2 6 � o © \ 2 CO W0 o ± = 5 E m — w o § b ) ® §e , e � _ I § ) § § ) \ P \ % ) 3 \ < 3 ° 3 < ) Co -J 2 § ) CC cd< ( § w g w c a o < 3 - eL f 0 ° >- < R o / Co ° Co < ) \ a /$ 3 D o _ , # z E o o H o \ 0 r # 0 P D u = 1W & c ° Co = = o E 2 0 Li 0 ) § I. ) § 2 S ? ) B [ $ -J < < e < - CC < g < < � $ ) o e e e = e s e e e e e a R H H 0 H < o H < H C ± H 0 < = 0 = u u_ 0 = _ -1 Y . 88888888888888 8 $88888 8 8 o|) 444§44k2t22444 # 7;#&## # # , 2 - - - - - \ „| , ° 8 8 $ g $ $ as ! '§ ||m§|§;Z|§;||§ E 888888 8 ) || | ; a a _ „4 ° 8 8 } N kk S{| 2 ` e 8 8888 88888888 8 888888 8 8 woo ■§■ga■#2#222■■ ; ggggg t f ,-■ ! . a -a o \. \ 9 8 \ ( g \ \ = 88888888888888 . 888888 8 8 \ »■;a##■#aek■2 # )4222! # 2 ,<§ ; ; ;; a a O 20g § ® 8 8 | 88 r tES*@ [ t § cos ) §) §m§§2;2,:==2== 2»,2:2 5 82288888888888 ■ 88 . g °w !| r* ##2■&2&&&gk B f# / a '•t J&#= a 22 " A re 5 QE ®«$§ <|i ;l., t.1 8888 aat . . . tk _ ! 0 L k 0 2 la B 0 W k - a 2 4 ® - § d | 0 § ` k ( § - \ \ \ `§\2§ § - j \ ) ) of § |®# ) / R § -!\\\ ) ow- / \ 88888.888888888 8 8888888 8 . > § agggaa2■;&&■;2 ■ k■;&&■; a ||§ ) 0 ,■| > § ) §k§ a \ 88x88888888888 8888888 ;&wa&2k;;a■;,= § ggggage § „cos1, ! 0 4' 0 2 0 }2 : a [ -8 \ � § - 86888888888888 , 8888888 : &-o§ Sg28828R82822k p ;;&&a:e ! : : - j ■ ?. | 8 - : k \ ` / - - " ` - *0E z , ;8888888888888 ; 8888888 2 §|\ k■&2k■#k2■;k / \k;#&a} § § 0 8 8 � \ o r \ " R - S ) ec§g8 ww. % 0000 », zzzzzzzzzz > zzzz 2 o 2 ` OF 88888888888 6 8 ; I- (6 � !i ,mo, a#2■;k#a , \ \ o ' !| -- k a 4 I t #§! I !, ,. ; m S88 a wt | ) 2 . § 22 | 7 & 0 G § `0 _ z | 2 � 2 } j It` | ■ : I , a \ ! | ( 8 § ) tri � g •C _ a 5 § cc o of 58 a0 | ] \ ) §/k§ k §w I- 000 , ! 7 k § ) k§§§ F §■ \ k § | 888888888888888888 8 8 8 § B| e.»■a2aaaaagasa■as a a ■ § ) .. \ 4 §j ]| ■in- 888888888888888888 8 8 8 § a| gaflo"dda&22kk#2a / ■ ; 822 & 8 ` - ' , §a kg 888 g 000 re :| g 0 $88888888888888888 8 8 8 B || m (llagaaa#;u;2##»;2 ; ■ ( § 1| m ! \ / . |2 - k §| \\f k , z 0 888888888888888888 8 8 8 8 / \ 7f / 8 \ 8 494. a#ka#kkk2#22 \ g \ ■ 2 !° w P� ||§ L| §) :G: 1222=2222=;2=2 _ 888 ) 0 \§ 72\ 8 \ \ g » | cc , cc o. | 15 ! | QI | w w • a ot O 0 of § | to. r o , 2E2 2 / i § a 1w Ill 328 ) / \ ) k§§§ 1 Victor H. Cordero,Psy.D. Mental Health Services, Bid NO: 001-07 APPENDIXES Appendix 1 Program supervisor signature sheet, Resumes Appendix 2 Data Collection Instruments/Interview Protocols Appendix 3 Sample Consent Forms 20 _ Victor H. Cordero, Psy.D. Mental Health Services, Bid NO: 001-07 Appendix 1 Program supervisor signature sheet, Resumes 21 Program Area Supervisor/Provider Meeting Verification/Comment Form Date of Meeting: 3/22/07 Program Area: Mental Health Comments (to be completed by Program Area Supervisor): This supervisor spoke with Dr. Cordero about the Mental Health Program area. Dr. Cordero is going to bid for psychological evaluations, parent child interactionals, mental health evaluations and individual therapy. Dr. Cordero mentioned again that it takes him more time with is Spanish speaking clients. This supervisor authorized Dr. Cordero to bid a higher rate for his Spanish speaking clients. This supervisor spoke to Dr. Cordero about the changes in evaluations. The Department is now be referring most clients for mental health evaluations and if the psychologists feels that a full psych eval is needed pal they will need to request that from the Department 1 Signature of Program Area SfupenvSor rg u h g¢ p I a ./ •,g ig;,--.• ,•:---Ii----, ..i, ...: -:,,-, .,�O- ..:I .. Q m,. cn 0 c 2. 11 0 °,0) Luz 1I1 4 Victor H. Cordero, Psy.D. Licensed Clinical Psychologist 2828 Speer Blvd., Unit 118 Denver,CO 80211 Office(303)455-9480 Offices in Denver,Greeley,Longmont EDUCATION and PROFESSIONAL CREDENTIALS Colorado Psychologist License Number 2722 September 95-96 Post-doctoral Fellowship-Rehabilitation Psychology Supervised one-year appointment. University of Colorado Health Sciences Center, University Hospital, Department of Rehabilitation Medicine. August 1995 Doctor of Clinical Psychology-Psy.D. University of Denver, Graduate School of Professional Psychology APA Accredited Program. August 94-95 Clinical Psychology Internship. Audie L Murphy Memorial Veterans Hospital, San Antonio Texas APA Accredited Internship. Emphasis on Division 40 criteria. May 1990 Bachelor or Arts-Psychology Bachelor of Arts-Communication Disorders and Speech Science Minor-Chicano Studies University of Colorado,Boulder Bilingual -Spanish Fluency CLINICAL EXPERIENCE 10/96-Current Clinical& Forensic Psychology Independent Practice Provide contract psychological services to various private, government,and public agencies. Services include psychological evaluations,cognitive assessment,parent-child interactionals, competency,and other referral questions. Client base includes individuals involved with the department of human services, corrections, community corrections, probation, and public/private attorneys. All of the above services are also offered in Spanish. Victor H.Cordero,Psy.D. Licensed Clinical Psychologist Mental health services include therapeutic interventions offered in individual, couples,family or group format. Psychological services are provided to address a variety of referral questions in both English and Spanish speaking populations. Sex offense specific evaluations, offense specific treatment, and related services are performed under the supervision of a Colorado Sex Offender Management Board certified and state licensed psychologist. Treatment and evaluation protocols adhere to the guidelines and standards of the CSOMB. 4/97-10/97 Outpatient Bilingual Therapist- Boulder County Mental Health Center Responsibilities included outpatient mental health services to adults,children, families,and geriatric clients of a community mental health center. Employed a brief therapy, solution focused approach. Therapeutic format included individual, group, family, and couples. Case management, client advocacy, and collaboration within a multi-agency system including schools, social service agencies, and medical institutions were regularly performed. 10/95-10/96 Rehabilitation Psychology Post-doctoral Fellowship University of Colorado Health Sciences Center University Hospital Department of Rehabilitation Medicine (1900 Hours supervised clinical experience) Primary responsibilities included overseeing and providing cognitive evaluations, brief neuropsychological assessment, and psychological/behavioral medicine services to a 14 bed, multidisciplinary acute medical rehabilitation unit. In addition,behavioral medicine,cognitive and mental status evaluation consultation services were performed on various acute medical units throughout the hospital including neurology,neurosurgery, oncology, neuro-oncology,trauma,orthopedics, burn clinic,and transplant services. Supervision of doctoral level students and psychology interns was formally conducted. 8/94-8/95 Clinical Psychology Intern Audie L.Murphy Memorial Veterans Hospital,San Antonio Texas (1900 Hours of Supervised Clinical Experience) Full APA accredited internship program. Training year meets Division 40 guidelines for pre-doctoral training in neuropsychology. General duties included long-term and short term individual therapy with outpatients from a cognitive-behavioral perspective, and short term therapy with inpatients on the psychiatry ward, spinal chord injury ward, and outpatient substance abuse programs. Neuropsychological, personality and intellectual assessment of outpatient and inpatient adults was also regularly conducted. Patient populations included psychiatric,neurological disorders,vascular disorders, chronic pain and HIV/AIDS to name a few. Cultural and linguistic Victor H.Cordero,Psy.D. Licensed Clinical Psychologist diversity was also a prominent aspect of the patient population and was regularly incorporated into the training program. Pre-Internship Clinical Experience 8/1/92 - 8/5/94 Adams Community Corrections Program 1100 Hrs. -Licensed Psychologist supervised Provided individual long and short term therapy,group therapy and psychodiagnostic assessment services to both residents and non- residents of a community corrections program. Vocational rehabilitation assessment services were also administered as necessary. Referrals ranged from post maximum security Department of Corrections clients, to county court sentenced clients. 8/91 -9/94 University of Denver,Professional Psychology Center 400 Hrs. -Supervised by multiple Licensed Psychologists. Individual, family and couples therapy to clients with a variety of clinical problems. Forensic evaluations, custody evaluations and other assessment cases were also conducted. 11/92 -3/93 Denver Police Department,Victim Assistance Unit Supervised by Licensed Psychologist On call, after hours crisis intervention services to residents of the City and County of Denver. Interventions included on scene crisis intervention and de-briefings with victims of domestic violence, sexual assault, family death,burglary, and kidnapping. 2/93 - 5/94 Contract Bilingual Psychological Evaluations-Private practice Social Services Disability Evaluations 306 Hrs. -Supervised by Licensed Psychologist. Psychological evaluations and neuropsychological screenings were performed to assist in determination of disability compensation. Services were conducted in Spanish or Bilingually. 4/1/92 - 11/1/92 Denver Victims Service Center 560 Hrs. -Supervised by Licensed Clinical Social Worker. Duties included supervision of volunteer counselors for a 24-hour hotline for victims of crime. Responsible for crisis intervention, both by telephone and in individual short-term therapy, as well as psychoeducational groups, case management, follow-up and on-call after hours pager rotations for English and Spanish speaking victims of crime hotline . 8/1/91 -4/15/92 Servicios de la Raza-Adult/Family Mental Health 288 Hrs. -Supervised by Licensed Clinical Social Worker Provided short and long term therapy to individuals and families in an agency serving primarily Hispanic and Spanish speaking clients. Intake and patient case management were also conducted. Victor H.Cordero,Psy.D. Licensed Clinical Psychologist 9/90- 5/91 Denver Public Schools- Special Education Bilingual Evaluation Services. 1260 Hours-Provided bilingual or monolingual (Spanish) speech and language evaluation services for the Denver School District. Services were part of a multicomponent team comprised of Psychologists, Speech/LanguageTherapists, Social Workers and Education Specialists. Report writing and student staffing services were also required. 8/90- 8/91 Boulder County Mental Health Center 1000 Hrs. -Supervised by Licensed Clinical Social Worker Primary responsibilities included outreach mental health services to individuals and families in rural areas of Boulder County. Individual and family therapy was conducted with the target population consisting of Hispanic and/or Spanish speaking low SES individuals and their families. 8/1/92 - 8/15/93 Clinic Assistant-University of Denver,Professional Psychology Center 240 Hrs.-Intake and information referral services to prospective patients/clients at the Graduate School of Professional Psychology Clinic. TEACHING EXPERIENCE Winter 1999 Part-Time Faculty-Metropolitan State College of Denver Responsible for curriculum development and conducting course in Cross-Cultural Psychology. Summer 1993 Graduate Teaching Assistant-University of Denver Cognitive Assessment Course Responsibilities included conducting two hourly lab sections per week. Duties included instruction in proper administration and scoring of intellectual assessment tools. Summer 1991 Boulder Valley Public Schools-Summer School ESL Teacher Responsible for a 32 student classroom of ethnically diverse beginning English speakers. Students ranged from Junior High to High School in current enrollment. Responsible for curriculum content, lesson plans and recreational activity organization for the class. REFERENCES AVAILABLE UPON REQUEST Victor H. Cordero, Psy.D. Mental Health Services, Bid NO: 001-07 Appendix 2 Data Collection Instruments/Interview Protocols 22 VICTOR H. CORDERO, PSY.D. Licensed Clinical Psychologist 2828 Speer, Blvd., Unit 118 Denver, CO 80211 303-455-9480 List of Data Collection Tools This list is not exhaustive Wechsler Adult Intelligence Scale-III Wechsler Intelligence Scale for Children -IV General Abilities Measure for Adults Woodcock-Munoz (cognitive scale) Universal Nonverbal Intelligence Scale Minnesota Multiphasic Personality Inventory-II The Personality Inventory The Millon Clinical Multiaxial Inventory-III The Hare Psychopathy Checklist/SV The Beck Depression Scale The Beck Anxiety Scale The Pain Presentation Inventory The State Trait Anger Expression Inventory The Thematic Apperception Test The Rorschach Ink Blots The Parenting Stress Index The Child Abuse Potential Inventory From the office of: 2828 Speer Blvd.. Unit 118 Victor H. Cordero, Psy.D.,P.C. Denver, CO 80211 Licensed Clinical Psychologist Office (303)455-9480 Clinical &Forensic Psychology Fax (303)651-3773 Checklist of Suicide Risk Factors Client: Date: The following ratings are based on my: -1 Review of records (specify): C Interview with staff, friends, relatives (circle and name): ❑ Observations of this individual over the last C interview C day H week L'. month Li Other(specify): Demographic risk factors • Caucasian or Native American C Male C. Lowest socioeconomic class H Age: Young adult (15—24) or very elderly(75—85 or older) C Medical, dental, or mental health professional, lawyer, etc. C Protestant H Suicidal partner • Divorced status (especially repeated divorce or divorce in last 6 months) C Never-married or widowed status Historical risk factors C A relative or close friend who died by suicide Li Criminal behaviors ▪ Self-mutilating behaviors I Substance abuse or dependence C Checking off"suicide" on intake form or other assessments C Suicidal behaviors: C Multiple threats/attempts of I I high lethality 'I high violence L high pain H Clearly intended death -1 Secretive attempts 1 Anniversary attempts ▪ Other risk factors: H Chronic psychiatric problems C Frequent accidents Recent specific risk factors In the last C 24 hours few days C week H. month ❑ few months C year, the client has: C Had passive death wishes ❑ Experienced fleeting ideation ❑ Experienced persistent ideation C Made threats C. Made gestures ❑ Engaged in actions, rehearsals C Made an attempt of ❑ high C medium C low lethality with ❑ high 7 medium C low potential for rescue i Seen recent/relevant media reports • Talked with therapist or other staff about suicide intentions/plans • Made a clear statement of intent to others Written a suicide note FORM 7. Checklist of suicide risk factors (p. 1 of 2). From The Paper Office, pp. 106-107. Copyright 1997 by Edward L. Zuckerman. Permission to photocopy this form is granted to purchasers of The Paper Office for personal use only(see copyright page for details). Checklist of Suicide Risk Factors (p. 2 of 2) ▪ Described a practical/available method or plan L Given away an important personal possession n Made a will ❑ Made funeral arrangements H. Made suicide plans that involve a highly lethal method and a time without interruption I I Established access to means/methods n Had a minimal social support system (no nearby friends, close relationships, therapeutic alliance; lives alone) E Experienced significant stressors (major losses, irrevocable losses, failure in life roles, humiliation) • Other(specify): Current psychiatric symptoms (circle a number) n Psychological pain Little 1 2 3 4 5 Intolerable n Vegetative symptoms (sleep disturbances, restlessness) Low 1 2 3 4 5 High n Perceived external stressors Low 1 2 3 4 5 High li Agitation, irritability, rages, violence Low 1 2 3 4 5 High ' I Hopelessness Absolutely 1 2 3 4 5 Absolutely hopeful hopeless n Self-regard Extremely 1 2 3 4 5 Extremely positive negative i Impulsivity (low self-control, distractibility) Low 1 2 3 4 5 High E Depression (blunted emotions, anhedonia, isolation) Low 1 2 3 4 5 High n Cognitive disorganization (organic brain syndrome, psychosis) Low 1 2 3 4 5 High H Other factors (homicidal intent, few/weak deterrents, motivated by revenge): Low 1 2 3 4 5 High Low 1 2 3 4 5 High n Low 1 2 3 4 5 High Additional information on the items checked can be found in/at: Additional factors for a child or adolescent H Gender: ❑ Female (more likely to attempt) n Male (more likely to succeed) ❑ Age above 15 E Rural resident C Strained family relationships Other stressors (legal difficulties, unwanted pregnancy, change of school, birth of a sibling, etc.) Therapist: Supervisor: This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law. From the office of: 2828 Speer Blvd., Unit 118 Victor H. Cordero, Psy.D., P.C. Denver, CO 80211 Licensed Clinical Psychologist Office (303)455-9480 Clinical & Forensic Psychology Fax (303) 651-3773 Intake Interview Questions and Guide Client's name: Date: Interviewer's initials: Z OK to thank referrer?2 Yes Z No Z Entered into phone book Z Entered into birthday book Introductory questions 1. Who suggested that you come to see me? Referral code: 2. What is the problem, in your own words? How do you see the situation? (Chief complaint/concern, presenting problem; symptoms—frequency, duration, intensity, latency, recurrence, course; distress caused, change efforts; why help is being sought now—precipitants, stressors, consequences; contexts, relevant history; needs, goals, strengths.) Essential information 3. Previous psychological episodes, treaters, and treatments. a. For what? b. Where/by whom? c. Treatment? d. When (from—to)? e. Outcome? f. Satisfaction/difficulties? (Especially follow up any hints of problems/abuse by therapists—e.g., dual relationships, sexual intimacies, litigation.) g. Release for records signed? 4. History of abuse. (Interview partners separately: Disagreements and decisions; verbal, physical, sexual abuse; marital, elder, childhood, family-of-origin abuse; kinds of violence; coping and protections; actions taken against abuser; fears, danger.) 5. Follow-up on responses to client information forms. a. Health problems. (Injuries, illnesses, allergies, eating patterns, exercise, sleep, sex; all current medications; last exam by an MD?) b. Legal history. (Involvement with the law/police, arrests; charges lodged—civil and criminal, not paying bills, fraud, violence; consequences, sentences; litigation anticipated, pending or in past, especially against therapists; lawyer's name and phone number.) (cont) FORM 31. Intake interview questions and guide (p. 1 of 2). From The Paper Office, pp. 235-236. Copyright 1997 by Edward L. Zuckerman. Permission to photocopy this form is granted to purchasers of The Paper Office for personal use only (see copyright page for details). ' Intake Interview Questions and Guide (p. 2 of 2) c. Family of origin. (Make genogram. Parents: ages, health, education, etc.; Sibs: number, ages, relationships, etc.; Important friendships; For all relatives: issues of abuse, affection, control, discipline, expectations, aspirations, personalities, mental health, religion, schooling, occupations, marriages, legal issues.) d. Substance use history. (For client, family of origin, current family: Alcohol, drugs—street and prescription, chemicals, caffeine, tobacco; current and past use.) e. Current relationship/family situation. (How client met current partner; attraction, love; family's role; duration, transitions, stressors, and effectual tone of relationship; number and ages of children; problems with or concerns about children.) Optional questions 6. What changes do you hope therapy will lead to? (Realism, readiness to change, changes of self vs. others, consistency with therapist.) 7. What do you want to change about yourself? (Locus of responsibility, control.) 8. How will therapy help you make these changes? (Understanding, sophistication, dependence.) 9. What do you think a therapist should be like? 10. How long do you think these changes will take? (Realism of time frame.) 11. What are your major strengths? (Abilities, resources, education, employment, personality, feelings, habits, relationships.) 12. What have been your major crises of the last 1— 5 years, and how have you handled them? (Precipitants, coping mechanisms/skills, defenses.) 13. What are your goals? (Ambitions, family situation and satisfaction, school/work situation and satisfaction.) 14. What persons, ideas, or forces have been most useful or influential to you in the past? 15. When are you happy? What are the positive factors in your life right now? (Hobbies? Sports? Family? Security?) 16. What spiritual or religious issues are important to you? How does your culture influence you? 17. Is there anything we haven't talked about that is relevant or important, or that you feel I should know about? 18. [Add other questions that seem called for or appropriate.] 19. Examiner's confidence in accuracy of information obtained (high, adequate, marginal, poor) 20. Quality and intensity of alliance (positive, meshing; positive, building; neutral, cautious; negative, distant/guarded; negative, hostile/suspicious) From the office of: 2828 Speer Blvd..Unit 118 Victor H. Cordero,Psy.D.,P.C. Denver, CO 80211 Licensed Clinical Psychologist Office (303)455-9480 Clinical &Forensic Psychology Fax(303)651-3773 Progress Note If a checkbox (Li) is inappropriate or insufficient, enter a letter and write additional comments on a separate page. A. Client and meeting information Client: Date: Meeting#: of authorized on this date with provider# . Meeting was: 1i i Scheduled I Emergency Others present: Meeting lasted: ❑ 15€30€45-50€60€90€ minutes Client: €Was on time€Was late by min. € Did not show€ Cancelled and was rescheduled for Meeting took place at: € Office€ By phone€ Clinic€ Hospital€ Client's home €Workplace Mode of treatment: € Individual therapy€ Family€ Group€Couple€ Consultation B. Topics/themes discussed Notes € Homework assignments € Relationship(s) € Stressors € Identity/role € Work problem € Alcohol/drug problem € Childhood/fam. of origin € Sexual problem € Parenting € Dream(s) € Other C. Treatments/interventions/techniques € Insights € Behavioral € Cognitive € Homework given € Family € Relationship € Problem solving € Support (cont.) FORM 39. Structured progress note form (p. 1 of 2). From The Paper Office, pp.281—282.Copyright 1997 by Edward L. Zuckerman. Permission to photocopy this form is granted to purchasers of The Paper Office for personal use only(see copyright page for details). Progress Note (p. 2 of 2) D. Assessments 1. Symptoms Change since last evaluation (enter a check mark) Current Symptom/concern/complaint severity No Less Much Resolved/ More Much rating* change severe improved absent severe worse *Rate from 0 to 10 as follows:0=not a problem/resolved;5=distressing/limiting;10=very severe distress,disruption,harm/risk. 2. Stressors Current severity Changes in Current level of Changes in Coping skills Stressor rating* severity? coping/functioning** coping level? employed 'Rate from 0=not a problem to 10=very severe,continuous,omnipresent,preoccupying. **Rate from 0 to 10 as follows:0=much less able to cope;5=no change from last meeting/evaluation;or 0=much improved level of coping. 3. Mood: € Normal/euthymic€Anxious€ Depressed€Angry€ Euphoric Affect: € Normal/appropriate€ Intense€Blunted€ Inappropriate€Labile 4. Mental status: € Normal€ Lessened awareness€ Memory deficiencies€ Disoriented € Disorganized€Vigilant€ Delusional€ Hallucinating€ Other: 5. Suicide/violence risk: € None€ Ideation only€Threat€Gesture€ Rehearsal€ Attempt 6. Sleep quality: € Normal€ Restless/broken€ Insomnia€ Nightmares€ Oversleeps 7. Participation level: €Active/eager€Variable€Only responsive€Minimal€None€ Resistant 8. Treatment compliance: € Full € Partial€ Low/noncompliant 9. Response to treatment: €As expected€ Better than expected€ Much better€ Poorer€Very poor 10. GAF (Global Assessment of Functioning) from 100 to 0 is currently: 11. Other observations/evaluations: E. Changes to diagnoses: € None or F. Changes to treatment plan:€ None or If treatment was changed, indicate rationale, alternatives considered/rejected/selected in notes. G. Follow-ups € Next appointment is scheduled for next€week€ month €2 months€3 months€ as needed. € Referral/consultation to: For: € Call/write to: For: I. Clinician's signature: Date: This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law. X Confidential Psychological Evaluation From the office of: 2828 Speer Blvd., Unit 118 Victor H. Cordero, Psy.D., P.C. Denver, Colorado 80211 Licensed Clinical Psychologist Office (303) 455-9480 Clinical & Forensic Psychology Fax (303) 651-3773 Confidential Psychological Evaluation Client: X DOB: November 30, 1979 Date of Evaluation: 10/24/2004 Case #: 09JV 1234567 Reason for Referral Ms. X was referred to undergo a psychological evaluation by XXDepartment of Human Services Case Worker, MM. Specifically this evaluation was requested in order to assist in determining Ms. X's emotional and psychological functioning as these are related to Ms. X's capacity to appropriately function in the parenting role. Techniques Utilized The Personality Assessment Inventory(PM) Millon Clinic Multiaxial Inventory-HI (MCMI-III) The Parenting Stress Index (PSI) The Beck Depression Inventory-II (BDI-II) The Beck Anxiety Inventory (BAI) Incomplete Sentences Blank Clinical Interview Mental Status Examination Psychosocial History Interview Review of Records/Collateral Contacts )O Department of Human Services Records MM, XXHS, Personal Communication Conclusions and recommendations are based on the above sources of data only. Information or disclosures not provided to this evaluator may, or may not impact the findings of this evaluation. Brief Relevant Background Family, Relationships and Early History Ms. X is originally from the state of Durango, Mexico. She reports she was born and raised in a rural small town atmosphere. She also spent approximately eight years of her childhood living in small city, but returned to the more rural environment at about ten years of age. Ms. X has resided in the United States for approximately four years and her husband has resided in the United States for approximately five years. She states her future plans are to return to Mexico with her children once the current XXHS case is resolved. Ms. X describes the motivation for 1 X Confidential Psychological Evaluation these plans include the presence of too much pressure due to lifestyle requirements in the United States. She specified that life in the United States requires that both parents work. Consequent to the latter, she is not able to provide enough time and care for her children due to work related demands. In terms of relationship history, Ms. X described having been involved in a cohabitating relationship for approximately two months at the age of fifteen. She alleges this relationship terminated quickly as the man was physically aggressive and violent toward her. Ms. X described, "he would hit me a lot and I was not allowed to go out with him or look at other people." At the age of 18, she married her current husband and they have been involved in a common-law marriage for approximately eight years. The couple have four children from this union, ages, seven, six, three and two. Her children are currently placed with her siblings. Ms. X reports the six-year-old child was raised by her mother as she left the boy with her when they immigrated to the United States when the child was one year of age. Ms. X emotionally recalled that when she sent for the child to be sent to her in the United States, her family did not want to return him. With regard to the quality of the relationship with her current husband, Ms. X described it as"supportive." She alleges, however, her husband is not happy with her not wanting to dress up or go out during the current Human Services case as he perceives her to be somewhat depressed. However, she reports she has great difficulty experiencing enjoyment without her children. In regards to Ms. X's childhood and adolescence, she reports having spent a large portion of childhood without her father present. She states her father spent large amounts of time in the United States providing financial support for her and her family in Mexico. She recalled one incidence of a five year span in which she did not see her father. Ms. X's perception of her family of origin as a child is that she was not treated equally to the remaining children. She describes some difficulties in that time span which reflected an older male sibling who abused alcohol and received much of the family's attention due to this condition. She described having a lot of"hand-me-down" clothing and perceiving that her family did not love her as they did the rest of her siblings. Though as an adult, she now looks back and realizes her at-risk brother required more attention than she did, as she was a low-demand child. In regards to difficult childhood experiences, Ms. X emotionally and tearfully described having experienced sexual abuse by her grandfather at the age of five. She recalled her parents did not believe her at that time, until she was admitted to a hospital due to "feeling bad, difficulty walking and bleeding in the genital area." She reports that during the sexual assault she broke a bottle on the perpetrator's head and blankly recalled, "I remember this like it happened yesterday." She states she recalls thinking she would never marry anyone again for fear that "this would happen again." Ms. X went on to say, she recalled that on her grandfather's deathbed, he asked to see her in order to ask forgiveness. However, Ms. X reports she could not bring herself to see him or forgive him. She states this experience is one reason why her girls are not allowed out of the home. In addition, she also stated she was regularly physically abused by her older brother and that her mother was not able to control this sibling. Prior to the sexual abuse, Ms. X recalled being "a happy and singing girl." After the sexual assault, Ms. X states she changed drastically. Specifically, she reports she no longer trusted anyone, felt guilty for anything that went wrong 2 X Confidential Psychological Evaluation and perceived the whole incident was her fault. She states that while her mother was a good person, her mother was unable to protect her. She reports that consequent to the latter, she moved in with a godmother for some time. She recalled that a significant reason why she moved in with a man at 15 years of age as noted above, was to leave the house, "so that my brother would not hit me any more." Ms. Xis one of eight siblings and currently she reports she gets along well with all of her siblings except for one. All of her siblings reside in the United States, with the exception of one and her parents who continue to reside in Mexico. Ms. X described current relationships with these extended family members by stating that they engage in frequent family gatherings and that their is supportive relatedness between them. According to her, her family greatly supports her in the current case. She alleges that they inform her was careless in her supervision of the children, but that she has to demonstrate to the Department that she is responsible and can get ahead in life. Educational History Ms. X reports she completed eight years of formal schooling in Mexico. According to her, she discontinued her schooling secondary to getting married at the age of 15. Ms. X alleges that while she did not require special education instruction and denied a formal learning disability, she would experience difficulty in learning based on"memory problems." At the times of this evaluation Ms. X was engaged in English instruction classes on a one-time per week basis. Vocational History At the time of this evaluation, Ms. X was not employed. She recalled that her last period of employment was in March, where she was employed for approximately five months in a restaurant/bar. She reports she left this position secondary to a difficult work schedule, which required her to be there from 8:00 p.m. until 2:00 a.m. Ms. X alleges that this schedule left her "sleepy" and therefore perceived she could not care for her children adequately. Prior to that position, she was also employed for approximately one year in three other restaurants as a waitress. In Mexico, Ms. X was not employed on a regular basis. Ms. X reports her husband is currently employed as a roofer. Medical History According to Ms. X, she has experienced what she termed "two small strokes". One allegedly occurred approximately one month prior to this evaluation and the other approximately two years ago. She alleges that these incidents were minor and she has no ongoing weakness, paralysis or other cognitive problems consequent to these events. However, she does complain of increased headaches since these occurred. Ms. X alleges she has ongoing medical checkups for this condition and is ingesting only over the counter pain medication. She reports she was told by medical professionals that she needed to"take care of herself and not stress out." Formal records to verify Ms. X's report of her medical condition were not made available to this evaluator and are worth pursuing to assure no significant or relevant conditions are present. At the time of this evaluation, she was no ingesting any prescribed medications. 3 • Confidential Psychological Evaluation Mental Health and Psychiatric History At the time of this evaluation, Ms. X reports having had no prior contact with a mental health related provider. She reports having no knowledge of ever being diagnosed with a mental health related condition and denies a family history of mental illness. In terms of current functioning, Ms. X does report having experienced what she termed a"serious depression" after the removal of her children. She described this incident as being"locked in" her room and not ingesting significant amounts of nutrition for a period of approximately one month. Additional symptomatology not related to the current XXHS case also stems from Ms. X's reports of ongoing emotional difficulties stemming from childhood sexual abuse at the hands of her grandfather. She also claims ongoing resentment and upset due to perceptions of a lack of support and caring behaviors from her family of origin as a minor. Criminal History According to Ms. X, beyond police contact and charges stemming from the current child abuse/neglect case she has no other prior criminal record. No records to contradict Ms. X's report were provided to this evaluator. Drug and Alcohol History According to Ms. X, she does not ingest alcohol or illegal drugs. No records to the contrary were provided to this evaluator. XXHS Concerns According to XXHS, primary concerns stem from Ms. X's questionable supervision of the children, and her capacity to recognize the potential for harm during episodes of unsupervised time. In addition, as of the writing of this report, caseworker reports indicate that while Ms. X has completed a parenting course, she has not followed through with prior referrals for therapy/counseling. In addition to Department concerns regarding questionable supervision and minimizing of the potential harm to the children, caseworker noted the presence of childhood sexual abuse and whether or not this impacted Ms. X's current mental health state. Client Perspective of XXHS According to Ms. X, her perspective of The Department's concerns them from their allegations of poor supervision of her children. In addition, she reported she has been accused of medical neglect of one of her children who was suffering from some form of vaginal infection, stating she was accused of not attending to this medical condition promptly. In regards to these reports from the Department, Ms. X stated that in fact the girls had been left unattended on the first occasion. She admitted that at the time, she perceived that the six-year-old child was able to adequately supervise the other children for a brief period of time. She reports that her assumption about her children's safety stemmed from her ordering the child not to open the door, touch the stove or other instructions which she perceived the child would be able to comply with during mother's absence. She states she only left them for brief amounts of time, and specified she would leave the home to a location one to two blocks away. The second removal concerns, again stemmed from the Department finding the children alone and unsupervised. Ms. X, 4 X Confidential Psychological Evaluation however, recalls that on this particular incident she left the girls in the upstairs portion of the home where they rent a basement. She alleges her understanding of what occurred is that the children went downstairs to the basement and were there alone when the Department made a visit. Ms. X states she trusted in her neighbor(the upstairs resident)to have kept an eye on the girls and not allow them to be unsupervised. However, she admitted that it was her mistake as she should have just taken the girls with her. In regard to the allegation of possible medical neglect, Ms. X reported her understanding was that the appointment to treat the child's condition was not a two-day away medical appointment as claimed by XXHS, but rather was a six-week appointment. She alleges she had paper proof of this more extended appointment. When discussing the Department's concerns regarding inadequate supervision of the girls, Ms. X stated she now realized she was completely in the wrong and that her perceptions of the girls' ability to supervise themselves was mistaken. She stated, "I realized anything could have happened, the stove, hot water, a stranger..." She went on to say that she feels badly as in the event of an emergency, "it could have been bad." She perceived that this mistaken mentality stems in part from"how it was in Mexico". When asked to clarify, she related that she perceived outright dangers were not as readily present in Mexico and that customs and beliefs regarding such child rearing behaviors were more tolerated. Mental Status Examination and Behavioral Observations Ms. X arrived for her appointment session on time. She presented as a neatly dressed young woman and hygiene is unremarkable. Ms. X appears her stated age and responds to all questions that were asked of her in a cooperative manner. Psychomotor activities are mildly decreased and Ms. X is noted to sit in a fairly rigid posture. No other specific mannerism or gestures are noted during the evaluation session. No gross evidence of distractibility or exaggerated self-absorption is noted. Speech is unremarkable in terms of volume and rate. Mood is mild to moderately dysthymic and affect is largely decreased in range. Ms. X presents with episodes of weeping when discussing her children's removal and some aspects of her history as well. No episodes of uncontrolled lability are noted at any point of the evaluation session. She does not demonstrate episodes of irritability or hostility regardless of topic of discussion. Per Ms. X's report, sleep patterns are improved toward more normal levels. She describes frequent crying spells when discussing her children with others. Ms. X perceives herself to be more motivated and looking forward to the future in contrast to the beginning weeks of this case. Ms. X is fully oriented at the time of this evaluation. Simple tasks of memory and concentration are performed adequately. Thought processes are logical, coherent and goal-directed. No delusional thought content was noted. Ms. X does not evidence signs or symptoms suggesting hallucinations and there is no evidence of a thought disorder. Ms. X denies suicidal and homicidal ideation. 5 • Confidential Psychological Evaluation Results and Impressions Intellectual and Cognitive Assessment Ms. X does not present with gross evidence of significant organic dysfunction based on clinical interview, mental status examination, and psychosocial interview. Informal estimation of intellectual functioning was felt to fall within the average range based on vocabulary, comprehension, abstract reasoning, fund of information and educational attainment. No concerns or reports of intellectual cognitive difficulties were reported by any available source. In light of these results, there appear to be no cognitive or intellectual deficits present which should significantly and specifically interfere with Ms. X's capacity to modulate behavior, modulate emotional expressiveness, appreciate right from wrong, or benefit from therapeutic interventions designed to improve parenting skills. Consequently, limits to or inefficiencies in general parenting skills, if identified, are felt to stem from dynamics in the realms of parenting skills deficits and/or other areas of emotional/psychological functioning. Emotional and Personality Assessment On the PM, an instrument utilized to generate hypotheses about an individual's characterological and emotional functioning, Ms. X's response profile was determined to be valid. Ms. X's profile on this particular instrument reflected a fairly elevated profile, with notable clinically elevated • scores on multiple scales. Generally speaking, the most notable clinical scale elevations suggest that Ms. Xis currently experiencing multiple symptoms of anxiety related problems. The pervasiveness of her symptom endorsement would suggest she is experiencing high levels of anxiety, worry and tension to a point where it may interfere with her ability to carry out day-to- day roles and which suggests she may experience episodes of overwhelming emotional discomfort. In addition, less intense, but nonetheless present, symptom endorsement suggesting mild to moderate levels of dysphoria and despondency were also present. A notable result, particularly given Ms. X's biographical information, is an elevated profile on the anxiety related subscales which would suggest that she continues to experience difficulties with a traumatic event of the past. While the specific etiology of this event is not noted, the traumatic event continues to cause her distress and recurrent anxiety. This result would be congruent with Ms. X's self report of ongoing emotional difficulties stemming from childhood sexual abuse. From an interpersonal perspective, Ms. X's profile would suggest that at this point in time, she perceives her environment in fairly distrustful and suspicious manners. She likely perceives herself to be largely misunderstood and may be perceived by others as unattached, impulsive or irritable at times. On the treatment scales profile, Ms. X's item endorsement would suggest she is currently experiencing high levels of stress consequent to some major life area. This level of stress causes her high levels of worry, rumination and anxiety. Ms. X's profile also identifies that she currently acknowledges major difficulties in functioning and perceives herself to be in high need of help to resolve these current difficulties. On the MCMI-III, a measure utilized in conjunction with additional data to generate hypotheses about an individual's emotional functioning and potential negative characterological conditions, Ms. X's response was valid. Generally speaking, Ms. X's profile identifies clinically significant elevations on scales, which as noted above, suggest the presence of high levels of anxiety, tension and worry. In addition, elevated levels of suspicion, distress, and vigilance toward others 6 • Confidential Psychological Evaluation and the environment were also present. Ms. X's profile on this instrument also suggests a propensity toward negativity and perceptions of herself as a victim of circumstance. Interpersonally, these results identify Ms. X as not highly prone toward increased levels of interpersonal contact and connectedness, preferring smaller circles of support and a reserved lifestyle. The PSI is a measure which assesses potential stressors in the parent-child relationship. Ms. X's profile on this particular instrument was valid. This instrument distinguishes between those characteristics or dynamics in the child which the parent perceives contributes to stressful dynamics from those characteristics or dynamics the parent perceives are inherent to the parent themselves. On the child domain, Ms. X's profile identified clinical elevations on two of the six scales. Clinical elevations on the Adaptability Scale are associated with characteristics that challenge the parent by virtue of the child's alleged inability to adjust changes in his or her physical or social environment. Examples of such difficulties include the inability to change from one task to another without upset, over reaction to changes, avoidance of strangers, and difficulty calming after upset. Demandingess Scale elevations are produced when the parent experiences the child as placing many demands upon her. These demands may come from various sources, including crying, clingy behavior, frequent requests for help or a high frequency of minor problem behaviors. Young parents tend earn somewhat elevated scores on this subscale, as do parents of children who are very dependent or who have failed to successfully negotiate the task of individualization. On the Parental Domain of the PSI, Ms. X's profile identified clinical elevations on two of seven scales. High scores on one scale, the Depression Scale, are suggestive of the presence of significant depressive symptoms in the parent. Some items relate to guilt or unhappy feelings, which may correspond to dissatisfaction with the self and life circumstance and not necessarily to a clinical depression. Generally speaking, high scores on this subscale suggest the parent may find it difficult to mobilize the psychic and physical energy needed to fulfill parenting responsibilities. Withdrawal and an inability to act with assertiveness and authority toward parenting may manifest when such scale elevations are observed. The second scale was sub-clinical but elevated relative to the remaining scales nonetheless. This scale, the Competence Scale, suggests there are a number of factors which the parent perceives are lacking such as practical child development knowledge or a limited range of child management skills. Parents who find the role of parent not as reinforcing as they had expected, also evidence elevations on this scale due to feelings of being overwhelmed. The hypotheses generated by the PSI should be verified by means of direct observation of parent- child dynamics and relatedness. Two screening instruments utilized for depression and anxiety symptoms resulted in various endorsements in both of these areas of functioning. A depression inventory results corresponded to moderate levels of symptom endorsement with particular emphasis on those aspects of depression considered more cognitive in nature. The later include a higher endorsement of symptoms such as self-criticism, self-loathing and feelings of guilt. Similarly, the anxiety screening inventory resulted in milder levels of anxiety with particular emphasis on those aspects of anxiety considered more cognitive, such as worry about the future, fears that the worst will happen, followed by more physiological aspects of anxiety such as feelings of tension, 7 X Confidential Psychological Evaluation nervousness, difficulty breathing and weakness. A simple projective instrument did not identify bizarre or distorted themes or thought processes. Diagnostic Impressions AXIS I Anxiety Disorder, Not Otherwise Specified Traits of Posttraumatic Stress Syndrome (PTSD) Depressive Disorder, Not Otherwise Specified, mild Neglect of Child AXIS II Deferred AXIS III Chronic headaches per client report Unclear report per client of what is described as"mini strokes", mild, no alleged ongoing significant problems per client report (no documentation to verify) AXIS IV XXHS Involvement, removal of children AXIS V Current GAF: 60 Summary and Clinical Impressions Ms. X presents as a 55 year old Spanish speaking young woman, currently referred for psychological evaluation consequent to distinct episodes of inappropriate supervision of her children. This evaluation identifies that Ms. X is not limited by intellectual or cognitive abilities, and therefore, possesses and adequate cognitive capacity to appreciate the potentially harmful nature of her actions and to benefit from interventions which might be implemented in order to improve her functioning in the general area of parenting skills. In regards to personality and emotional-behavioral functioning, Ms. X currently endorses various signs and symptoms suggestive of an anxiety related disorder foremost and secondarily, demonstrates lesser, yet impacting, symptoms of a depressive disorder. With regard to the anxiety related difficulties, these appear to be largely chronic in nature and most likely stem from Ms. X's ongoing difficulties with early childhood sexual abuse. As the sexual abuse was allegedly committed by a now deceased grandfather, the familial connections to not only the perpetrator, but more importantly to re-exposure of linked traumatic stimuli are likely present. The most specific and detailed symptoms as described in testing and corroborated by Ms. X's self report, include intrusive recollections of the abuse, episodes of emotional numbing or lability, as well as nightmares and ongoing subtle resentment toward parental figures. It would appear the current trauma of having her children removed also potentially triggered this prior 8 X Confidential Psychological Evaluation experience of trauma-based symptoms, though these appear to have diminished in recent months, per her own report. With regard to depressive symptoms, Ms. X's presentation and item endorsement would suggest milder levels of difficulty, though these do appear to impact her interpersonal and familial functioning to some degree. Her experience and symptom complaints will fluctuate depending on circumstance. Consequently, at this point in time, Ms. X would benefit from both therapeutic and pharmacological consideration as a means of improving overall mood and familial functioning. With regard to Ms. X's instances of lacking parental supervision and errors of judgment with regard to the care taking of her children, it would appear these actions on her behalf were not malicious or of ill intent. Rather, these do appear to reflect not only life circumstance (i.e. the unavailability of proper childcare), but also distinct errors of insight,judgment, and distorted attitudes toward expected norms for parenting. In addition, an initially decreased level of appreciation for the potential risks involved was present. Her emotional status as reflected in anxiety/depressive symptoms is also a potential contributor with regard to the possible influence of lacking motivation, diminished capacity to prioritize, diminished concentration, and perhaps a diminished capacity to plan ahead and invest appropriately in her children's emotional well being. As such, episodes of parenting skills deficits appear to be amenable to a skills enhancement approach and prognosis is considered positive with respect to this specific area of functioning if she can demonstrate full accountability and recognition of the risky nature of her actions and seek assistance for her emotional well being. With regard to emotional/psychological constraints, Ms. X's motivation for treatment will be important to gauge. This assessment clearly identifies that she is emotionally impacted by difficult, historical events in her life. High investment in exploring these issues may prove fruitful to her personally, but may also provide insight as to other emotional contributions to maladjustment in the family, will improve self insight, and may identify other catalysts for the observed neglectful parenting behaviors. Recommendations Ms. X should be referred to undergo a medication evaluation to assess the appropriateness of pharmacological agents with respect to her anxiety and depressive symptoms. Ms. X would benefit from a referral to individual therapy. The specific areas or goals to address in this setting include, but are not limited to the following: - Assist Ms. X in positive coping and adaptation to the current Human Service case. - Assist Ms. X in exploring and appropriately processing childhood sexual abuse issues, particularly as these affect current levels of emotional and interpersonal well being, availability to her children, and personal decisions. -Assess and assist Ms. X in identifying those areas of functioning that interfered with optimal parenting and supervision/caretaking of her children as identified by Human Services. 9 X Confidential Psychological Evaluation -Monitor Ms. X's mood and coping to include self harm monitoring. Efforts to assure Ms. X has complied and has obtained adequate levels of progress in all Department interventions requested to date, should be pursued. Given the findings of this evaluation, this evaluator would recommend that informal assessment of Ms. X's interactions with her children take place. If concerns are identified, a formal parent child interactional or other visitation time assessment should take place to specify areas of need. If interactions and relatedness between mother and children are adequate, primary focus on skills building and individual therapy/medication evaluation should suffice. Ms. X's motivation and compliance with the family service plan will be an important indicator of her ability to prioritize and place her children's needs in the forefront. As such, inability to demonstrate appropriate compliance and progress in all the above would raise concern as to her internal resources and motivation at this point in time. Ms. X should demonstrate the ability to provide for the physical, educational, health, and nutritional needs of her children. This mother will require linguistically and culturally competent service providers as a means of increasing probability of success. Efforts to assure mother is pursuing medical care for herself with regard to her complaints of a "mini stroke" should be pursued. Verification of her alleged MRI and other laboratory exams should be pursued despite lack of overt symptomatology. Please contact this evaluator with any further questions or clarifications regarding the evaluation of Ms. X. • Victor H. Cordero, Psy.D. Licensed Clinical Psychologist Bilingual Evaluator 10 X Family From the office of: 2828 Speer Blvd., Ste. 118 Victor H. Cordero, Psy.D., P.C. Denver, CO 80211 Licensed Clinical Psychologist Office (303) 455-9480 Fax(303) 651-3773 Treatment Summary Brief Family Therapy Client(s) MOTHER OF CHIILDREN Ms. X DOB: 01/01/1971 Age: 30 Children: A Age 12 B Age 11 C Age 8 D Age 3 Span of Treatment: 10/12/2005 -01/31/2006 Format: Biweekly, In-Home Total Number of Sessions Completed: 6 Reason for Referral & Brief Background Information: This family was originally referred by X Department of Human Services Caseworker, MM to undergo 6-8 sessions of brief individual family therapy. The goal of the therapy was to assure that the family members were adequately coping with recent instabilities including housing, financial, separation of parents, and chronic exposure to significant domestic violence in the home by their father in years past. Mental health evaluations were previously performed on all family members and a brief number of sessions were recommended to follow-up and assure adequate family functioning prior to closing this case. Impressions of Family Member Dynamics & Coping The family was seen in different constellations of family members to increase observation of differing family dynamics and intensity of services per single visit. All family members will be discussed in relation to the larger family system. Most notable in A, the oldest child, was his emerging adolescence and mother's reaction to this developmental stage. Therapy sessions were utilized to assist mother in recognizing A's experience of the previous domestic violence and how his role as her "protector" at that time, has now changed to more expected and developmentally appropriate levels since father is no longer involved. Mother was counseled regarding appropriate expectations of his behavior and how A should not be allowed to re-engage in a parentified role. A himself was allowed to discuss his feelings in terms of the previous 1 X Family domestic violence he witnessed. Recommendations to mother included enrolling him in a"big-brother" or mentorship type program, or school based extracurricular activities as A needs a place to grow both in terms of self-esteem, and socially. B is the"brain" in this family system and her role in this family manifests as a passive, obedient, and quiet girl. In contrast C, is spunky and playful. These girls seem to balance each other out and formed a close dyad during family sessions. They were generally smiley, happy, and despite their different communication styles, did not have difficulties in expressing relief of their"new life" without violence in the home. The girls were able to communicate their needs to mother and both displayed age appropriate behaviors during all sessions. No regression or anxiety related behaviors were observed in these two young girls. D is the youngest child and presents as mother's greatest challenge. This is a very active little boy who requires frequent structuring, direction, and limit setting. He was too young developmentally to be greatly impacted by father's violence and thus, his"hyper" state is likely to reflect other etiology. It was recommended to mother that she look into enrolling D in a school based program or preschool program next year. This would hopefully assist in providing a more structured learning environment for D as well as give mother respite. Despite high activity and rambunctious behavior, D did not present with concerning aggression or other indices of poor adaptation or emotional difficulties. Mother continues to present with resilience, although, she does lack some direction in terms of"life ambition". It may be that stepping out of the domestic violence "cycle" appears to have left her with uncertainties in regards to what her role is beyond that of "mother" to four children. In part, recommending that D be enrolled in school would also provide mother the opportunity to increase her social support system, which is somewhat lacking. Additionally, seeking employment of some type was highly recommended as there was a sense that mother's activities outside the home were very limited. Generally speaking, mother's coping was adequate and it is felt that with some direction and prompting, she is capable of directing more energy toward self-care in terms of activities which will build her esteem and personal identity such as employment and a social life. Conclusions As previous mental health evaluations of these family members suggested, this family's coping and adaptation to past instability is surprisingly positive. Brief family therapy sessions revealed high amounts of resiliency in this family and problems in functioning, if identified, are not felt to reflect ongoing difficulties in adjustment to previous circumstance or reason for XXHS involvement. It appears that now that many of the previous pressures have been minimized (housing, financial, father's violence), the children's personal identities are emerging and all are regaining developmentally appropriate attitudes and behaviors. Mother has also begun to experience some cognitive discomfort in terms of her role beyond "mother" and while this provides for some frustration on her part, it is felt to be a healthy response. Most notable in all family members, the older children in particular, is a common sense of relief and a maturity in 2 • X Family terms of their thoughts and feelings about their father. While all displayed an appropriate emotional connection to him, they also expressed no desire for his presence as their perspective on the unchanging nature of his aggression toward their mother is fairly realistic. Overall, this family's manner of coping and dealing with difficult circumstance in the past appears positive. All family members have utilized their resources in terms of moving on and appear to be settling into their"new" family roles appropriately. It is hoped that mother will accept the recommendation that she begin to emerge, as her children have emerged, into new roles and activities. She is in the initial stages of this change and hopefully, exploring occupational and social activities will impact her in a positive way and reflect on her children. If this family can maintain the cohesion that has been displayed throughout this ordeal, indicators for a positive outcome, with time, remain. Thank you for the opportunity to work with this family. Please contact me with any further questions or follow-up concerns. Victor H. Cordero,Psy.D. Licensed Clinical Psychologist 3 Victor H. Cordero, Psy.D. Mental Health Services, Bid NO: 001-07 Appendix 3 Sample Consent Forms 23 From the office of 2828 Speer Blvd..Unit 118 Victor H. Cordero, Psy.D.,P.C. Denver, CO 80211 Licensed Clinical Psychologist Office (303)455-9480 Clinical&Forensic Psychology Fax(303)651-3773 What You Should Know about Confidentiality in Therapy I will treat what you tell me with great care. My professional ethics (that is, my profession's rules about moral matters) and the laws of this state prevent me from telling anyone else what you tell me unless you give me written permission. These rules and laws are the ways our society recognizes and supports the privacy of what we talk about—in other words, the "confidentiality" of therapy. But I cannot promise that everything you tell me will never be revealed to someone else. There are some times when the law requires me to tell things to others. There are also some other limits on our confidentiality. We need to discuss these, because I want you to understand clearly what I can and cannot keep confidential. You need to know about these rules now, so that you don't tell me something as a "secret" that I cannot keep secret. These are very important issues, so please read these pages carefully and keep this copy. At our next meeting, we can discuss any questions you might have. 1. When you or other persons are in physical danger, the law requires me to tell others about it. Specifically: a. If I come to believe that you are threatening serious harm to another person, I am required to try to protect that person. I may have to tell the person and the police, or perhaps try to have you put in a hospital. b. If you seriously threaten or act in a way that is very likely to harm yourself, I may have to seek a hospital for you, or to call on your family members or others who can help protect you. If such a situation does come up, I will fully discuss the situation with you before I do anything, unless there is a very strong reason not to. c. In an emergency where your life or health is in danger, and I cannot get your consent, I may give another professional some information to protect your life. I will try to get your permission first, and I will discuss this with you as soon as possible afterwards. d. If I believe or suspect that you are abusing a child, an elderly person, or a disabled person I must file a report with a state agency. To "abuse" means to neglect, hurt, or sexually molest another person. I do not have any legal power to investigate the situation to find out all the facts. The state agency will investigate. If this might be your situation, we should discuss the legal aspects in detail before you tell me anything about these topics. You may also want to talk to your lawyer. In any of these situations, I would reveal only the information that is needed to protect you or the other person. I would not tell everything you have told me. 2. In general, if you become involved in a court case or proceeding, you can prevent me from testifying in court about what you have told me. This is called "privilege," and it is your choice to prevent me from testifying or to allow me to do so. However, there are some situations where a judge or court may require me to testify: a. In child custody or adoption proceedings, where your fitness as a parent is questioned or in doubt. (cont.) HANDOUT 8. Patient handout on the limits of confidentiality (p. 1 of 3). From The Paper Office, pp. 301-303. Copyright 1997 by Edward L.Zuckerman. Permission to photocopy this form is granted to purchasers of The Paper Office for personal use only (see copyright page for details). What You Should Know about Confidentiality in Therapy (p. 2 of 3) b. In cases where your emotional or mental condition is important information for a court's decision. c. During a malpractice case or an investigation of me or another therapist by a professional group. d. In a civil commitment hearing to decide if you will be admitted to a psychiatric hospital. e. When you are seeing me for court-ordered evaluations or treatment. In this case we need to discuss confidentiality fully, because you don't have to tell me what you don't want the court to find out through my report. 3. There are a few other things you must know about confidentiality and your treatment: a. I may sometimes consult (talk) with another professional about your treatment. This other person is also required by professional ethics to keep your information confidential. Likewise, when I am out of town or unavailable, another therapist will be available to help my clients. I must give him or her some information about my clients, like you. b. I am required to keep records of your treatment, such as the notes I take when we meet. You have a right to review these records with me. If something in the record might seriously upset you, I may leave it out, but I will fully explain my reasons to you. 4. Here is what you need to know about confidentiality in regard to insurance and money matters: a. If you use your health insurance to pay a part of my fees, insurance companies require some information about our therapy. Insurers such as Blue Cross/Blue Shield or other companies usually want only your diagnosis, my fee, the dates we met, and sometimes a treatment plan. Managed care organizations, however, ask for much more information about you and your symptoms, as well as a detailed treatment plan. b. I usually give you my bill with any other forms needed, and ask you to send these to your insurance company to file a claim for your benefits. That way, you can see what the company will know about our therapy. It is against the law for insurers to release information about our office visits to anyone without your written permission. Although I believe the insurance company will act morally and legally, I cannot control who sees this information at the insurers office. You cannot be required to release more information just to get payments. c. If you have been sent to me by your employer or your employer's Employee Assistance Program, either one may require some information. Again, I believe that employers and companies will act morally and legally, but I cannot control who sees this information at their offices. If this is your situation, let us fully discuss my agreement with your employer or the program before we talk further. d. If your account with me is unpaid and we have not arranged a payment plan, I can use legal means to get paid. The only information I will give to the court, a collection agency, or a lawyer will be your name and address, the dates we met for professional services, and the amount due to me. 5. Children and families create some special confidentiality questions. a. When I treat children under the age of about 12, I must tell their parents or guardians whatever they ask me. As children grow more able to understand and choose, they assume legal rights. For those between the ages of 12 and 18, most of the details in things they tell me will be treated as confidential. However, parents or guardians do have the right to general information, including how therapy is (cont.) What You Should Know about Confidentiality in Therapy (p. 3 of 3) going. They need to be able to make well-informed decisions about therapy. I may also have to tell parents or guardians some information about other family members that I am told. This is especially true if these others' actions put them or others in any danger. b. In cases where I treat several members of a family (parents and children or other relatives), the confidentiality situation can become very complicated. I may have different duties toward different family members. At the start of our treatment, we must all have a clear understanding of our purposes and my role. Then we can be clear about any limits on confidentiality that may exist. c. If you tell me something your spouse does not know, and not knowing this could harm him or her, I cannot promise to keep it confidential. I will work with you to decide on the best long-term way to handle situations like this. d. If you and your spouse have a custody dispute, or a court custody hearing is coming up, I will need to know about it. My professional ethics prevent me from doing both therapy and custody evaluations. e. If you are seeing me for marriage counseling, you must agree at the start of treatment that if you eventually decide to divorce, you will not request my testimony for either side. The court, however, may order me to testify. f. At the start of family treatment, we must also specify which members of the family must sign a release form for the common record I create in the therapy or therapies. (See point 7b, below.) 6. Confidentiality in group therapy is also a special situation. In group therapy, the other members of the group are not therapists. They do not have the same ethics and laws that I have to work under. You cannot be certain that they will always keep what you say in the group confidential. 7. Finally, here are a few other points: a. I will not record our therapy sessions on audiotape or videotape without your written permission. b. If you want me to send information about our therapy to someone else, you must sign a "release-of- records" form. I have copies which you can see so you will know what is involved. c. Any information that you also share outside of therapy, willingly and publicly, will not be considered protected or confidential by a court. The laws and rules on confidentiality are complicated. Situations that are not mentioned here come up only rarely in my practice. Please bear in mind that I am not able to give you legal advice. If you have special or unusual concerns, and so need special advice, I strongly suggest that you talk to a lawyer to protect your interests legally. The signatures here show that we each have read, discussed, understand, and agree to abide by the points presented above. Signature of client (or person acting for client) Date Printed name Signature of therapist Date • • From the office of 2828 Speer Blvd., Unit 118 Victor H. Cordero, Psy.D., P.C. Denver, CO 80211 Licensed Clinical Psychologist Office (303) 455-9480 Clinical & Forensic Psychology Fax (303) 651-3773 The Rights of Clients 1. You have the right to decide not to enter therapy with me. If you wish, I will provide you with the names of other good therapists. 2. You have the right to end therapy at any time.The only thing you will have to do is to pay for any treatments you have already had. You may, of course, have problems with other people or agencies if you end therapy—for example, if you have been sent for therapy by a court. 3. You have the right to ask any questions, at any time, about what we do during therapy, and to receive answers that satisfy you. If you wish, I will explain my usual methods to you. 4. You have the right not to allow the use of any therapy technique. If I plan to use any unusual technique, I will tell you and discuss its benefits and risks. 5. You have the right to keep what you tell me private. Generally, no one will learn of our work without your written permission. There are some situations in which I am required by law to reveal some of the things you tell me, even without your permission, and if I do reveal these things I am not required by the law to tell you that I have done so. Here are some of these situations: a. If you seriously threaten to harm another person, I must warn that person and the authorities. b. If a court orders me to testify about you, I must do so. c. If I am testing or treating you under a court order, I must report my findings to the court. 6. If I wish to record a session, I will get your informed consent in writing. You have the right to prevent any such recording. 7. You have the right to review your records in my files at any time, to add to or correct them, and to get copies for other professionals to use. HANDOUT 5. First clients' rights form. Adapted from Everstine et al. (1980). Copyright 1980 by the American Psychological Association (APA). Adapted by permission. The APA grants purchasers of The Paper Office the right to make photocopies for personal use only.Further use of this material without the express written permission of the APA is strictly prohibited.—From The Paper Office, p. 155. From the office of 2828 Speer Blvd., Unit 118 Victor H. Cordero, Psy.D., P.C. Denver, CO 80211 Licensed Clinical Psychologist Office (303)455-9480 Clinical & Forensic Psychology Fax (303) 651-3773 Client Bill of Rights You have the right to: • Get respectful treatment that will be helpful to you. • Have a safe treatment setting, free from sexual, physical, and emotional abuse. • Report immoral and illegal behavior by a therapist. • Ask for and get information about the therapist's qualifications, including his or her license, education, training, experience, membership in professional groups, special areas of practice, and limits on practice. • Have written information, before entering therapy, about fees, method of payment, insurance coverage, number of sessions the therapist thinks will be needed, substitute therapists (in cases of vacation and emergencies), and cancellation policies. • Refuse audio or video recording of sessions (but you may ask for it if you wish). • Refuse to answer any question or give any information you choose not to answer or give. • Know if your therapist will discuss your case with others (for instance, supervisors, consultants, or students). • Ask that the therapist inform you of your progress. HANDOUT 7. Third clients' rights form. Adapted from Quinn(n.d.).This document is in the public domain.—From The Paper Office, p. 157. From the office of: 2828 Speer Blvd., Unit 118 Victor H. Cordero, Psy.D., P.C. Denver, CO 80211 Licensed Clinical Psychologist Office (303)455-9480 Clinical & Forensic Psychology Fax (303) 651-3773 Agreement for Psychotherapy with a Minor I, , the parent/legal guardian of the minor, , give my permission for this minor to receive the following services/procedures/treatments/assessments: 1. 2. 3. These are for the purpose(s) of: 1. 2. 3. services are to be provided by the therapist named above, or by another professional as the therapist sees fit. The fees for these services will be $ per hour of service, or$ for the full services. This therapist's office policies concerning missed appointments have been explained to me. I have been told about the risks and benefits of receiving these services and the risks and benefits of not receiving these services, for both this minor and his or her family. I agree that this professional may also interview, assess, or treat these other persons: 1. 2. 3. Because of the laws of this state and the guidelines of the therapist's profession, these rules concerning privacy will be used: 1. 2. 3. A report or reports concerning the therapist's findings will be available after this date: . Progress in this minors treatment will be reviewed on or about this date: and on a regular basis after that. My signature below means that I understand and agree with all of the points above. Signature of parent/guardian Date I, the therapist, have discussed the issues above with the minor client's parent or guardian. My observations of this person's behavior and responses give me no reason, in my professional judgment, to believe that this person is not fully competent to give informed and willing consent to the minor client's treatment. Signature of therapist Date 2 Copy accepted by parent/guardian ₹ Copy kept by therapist This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law. FORM 9. Contract with parent/guardian for psychotherapy with a minor. From The Paper Office, p. 166.Copyright 1997 by Edward L. Zuckerman. Permission to photocopy this form is granted to purchasers of The Paper Office for personal use only (see copyright page for details). From the office of: 2828 Speer Blvd.. Unit 118 Victor H. Cordero,Psy.D.,P.C. Denver. CO 80211 Licensed Clinical Psychologist Office (303)455-9480 Clinical&Forensic Psychology Fax (303)651-3773 Agreement for Individual Therapy , the client, agree to meet with the therapist named below at the appointment times and places we agree on, starting on for about sessions of minutes each. I have read the following materials on the therapy, which have been provided to me by this therapist: 1. 3. 2. 4. I believe I understand the basic ideas, goals, and methods of this therapy. I have no important questions or concerns that the therapist has not discussed. In my own words, I understand the following: 1. According to this therapy, the causes of my problems lie in: 2. The main methods to be used in this therapy are: 3. During these sessions, we will focus on working toward these goals: a. b. I understand that reaching these goals is not guaranteed. 4. I understand that I will have to do the following things/take the following actions: a. b. With enough knowledge, and without being forced, I enter into treatment with this therapist. I will keep my therapist fully up to date about any changes in my feelings, thoughts, and behaviors. I expect us to work together on any difficulties that occur, and to work them out in my long-term best interest. At the end of _ meetings, we will evaluate progress and may change parts of this agreement as needed. Our goals may have changed in nature, order of importance, or definition. If I am not satisfied by our progress toward goals, I will attempt to make change in this agreement, and I may stop treatment after giving this therapist at least 7 days' notice of my intentions and meeting with the therapist for one last time. This agreement shows my commitment to pay for this therapist's services. It also shows this therapist's willingness to use and share his or her knowledge and skills in good faith. I agree to pay $ per session, and to pay at the end of each session. I agree to pay for uncancelled appointments or those where I fail to give enough notice that I will not attend. The only exceptions are unforeseen or unavoidable situations arising suddenly. I understand and accept that I am fully responsible for this fee, but that my therapist will help me in getting payments from any insurance coverage I have. I understand that this agreement will become part of my record of treatment. I also give my permission for the therapist to audiotape/videotape our sessions for personal review and use with a consultant, who is also bound by the legal framework of privacy and confidentiality. I understand that any information in this recording that could identify me in any way will not be published or given out without my written consent. My signature below means that I understand and agree with all of the points above. Signature of client Date I, the therapist, have discussed the issues above with the client. My observations of this client's behavior and responses give me no reason, in my professional judgment, to believe that this person is not fully competent to give informed and willing consent. Signature of client Date Copy accepted by client Li Copy kept by therapist This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law. FORM 8. Contract for individual adult therapy. From The Paper Office. p. 163. Copyright 1997 by Edward L. Zuckerman. Permission to photocopy this form is granted to purchasers of The Paper Office for personal use only(see copyright page for details). • From the office of: 2828 Speer Blvd., Unit 118 Victor H. Cordero, Psy.D., P.C. Denver, CO 80211 Licensed Clinical Psychologist Office (303) 455-9480 Clinical & Forensic Psychology Fax (303) 651-3773 Consent to Treatment I acknowledge that I have received, have read (or have had read to me), and understand the "Information for Clients" brochure and/or other information about the therapy I am considering. I have had all my questions answered fully. I do hereby seek and consent to take part in the treatment by the therapist named below. I understand that developing a treatment plan with this therapist and regularly reviewing our work toward meeting the treatment goals are in my best interest. I agree to play an active role in this process. I understand that no promises have been made to me as to the results of treatment or of any procedures provided by this therapist. I am aware that I may stop my treatment with this therapist at any time. The only thing I will still be responsible for is paying for the services I have already received. I understand that I may lose other services or may have to deal with other problems if I stop treatment. (For example, if my treatment has been court- ordered, I will have to answer to the court.) I know that I must call to cancel an appointment at least 24 hours before the time of the appointment. If I do not cancel or do not show up, I will be charged for that appointment. I am aware that an agent of my insurance company or other third-party payer may be given information about the type(s), cost(s), date(s), and providers of any services or treatments I receive. I understand that if payment for the services I receive here is not made, the therapist may stop my treatment. My signature below shows that I understand and agree with all of these statements. Signature of client (or person acting for client) Date Printed name Relationship to client (if necessary) I, the therapist, have discussed the issues above with the client (and/or his or her parent, guardian, or other representative). My observations of this person's behavior and responses give me no reason to believe that this person is not fully competent to give informed and willing consent. Signature of therapist Date u Copy accepted by client Li Copy kept by therapist This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law. FORM 12. Form for generic consent to treatment of an adult. From The Paper Office, p. 174. Copyright 1997 by Edward L. Zuckerman. Permission to photocopy this form is granted to purchasers of The Paper Office for personal use only(see copyright page for details). From the office of 2828 Speer Blvd.,unit 118 Victor H. Cordero,Psy.D.,P.C. Denver, CO 80211 Licensed Clinical Psychologist Office (303)45.5-9480 Clinical&Forensic Psychology Fax(303)651-3773 Consent and Agreement for Psychological Testing and Evaluation , agree to allow the psychologist named below to perform the following services: Psychological testing, assessment, or evaluation L Report writing ❑ Consultation with lawyers C Deposition (that is, written testimony given to a court, but not made in open court) Testimony in court C Other (describe): This agreement concerns L myself or ❑ I understand that these services may include direct, face-to-face contact, interviewing, or testing. They may also include the psychologist's time required for the reading of records, consultations with other psychologists and professionals, scoring, interpreting the results, and any other activities to support these services. I understand that the fee for this (these) service(s) will be about $ , and that this is payable in two parts: a deposit of $ payable before the start of this (these) services, and a second payment of the balance due on the completion and delivery of any report (or, for depositions, testimony, or other services, at the time these services take place). Though my health insurance may repay me for some of these fees, I understand that I am fully responsible for payment for these services. I understand that this evaluation is to be done for the purpose(s) of: 1. 2. I also understand the psychologist agrees to the following: 1. The procedures for selecting, giving, and scoring the tests, interpreting and storing the results, and maintaining my privacy will be carried out in accord with the rules and guidelines of the American Psychological Association and other professional organizations. 2. Tests will be chosen that are suitable for the purposes described above. (In psychological terms, their reliability and validity for these purposes and population have been established.) These tests will be given and scored according to the instructions in the tests' manuals, so that valid scores will be obtained. These scores will be interpreted according to scientific findings and guidelines from the scientific and professional literature. 3. Tests and test results will be kept in a safe place. I agree to help as much as I can, by supplying full answers, making an honest effort, and working as best I can to make sure that the findings are accurate. Signature of client (or parent/guardian) Date I, the psychologist, have discussed the issues above with the client (and/or his or her parent or guardian). My observations of this person's behavior and responses give me no reason, in my professional judgment, to believe that this person is not fully competent to give informed and willing consent. Signature of psychologist Date L Copy accepted by client P Copy kept by psychologist From the office of: 2828 Speer Blvd., Unit 118 Victor H. Cordero, Psy.D., P.C. Denver, CO 80211 Licensed Clinical Psychologist Office (303) 455-9480 Clinical & Forensic Psychology Fax (303) 651-3773 Request/Authorization to Release Confidential Records and Information Source of information: Person or facility: Address: Phone: A. Identifying information about me/the patient Name: Address: Phone: Birthdate: Social Security#: Parent/guardian (if applicable): Address and phone of parent/guardian: B. I hereby authorize the source named above to send, as promptly as possible, the records listed below marked by an X in the boxes below. (The items not to be released have a line drawn through them. Page numbers are indicated where appropriate.) Inpatient or outpatient treatment records for physical and/or psychological, psychiatric, or emotional illness or drug or alcohol abuse: H Date(s) of inpatient admission: Date(s) of discharge: u Start of outpatient treatment: End of treatment: CliniGpatient number: •1 Other identifying information about the service(s) rendered: ii Psychological evaluation(s) or testing records, and behavioral observations or checklists completed by any staff member or by the patient. Psychiatric evaluations, reports, or treatment notes and summaries. H Treatment plans, recovery plans, aftercare plans. E, Admission and discharge summaries. H Social histories, assessments with diagnoses, prognoses, recommendations, and all similar documents. C Information about how the patient's condition affects or has affected his or her ability to complete tasks, activities of daily living, or ability to work. Workshop reports and other vocational evaluations and reports. n Billing records. ❑ Academic or educational records. LI Report of teachers' observations. H Achievement and other tests' results. ❑ A letter containing dates of treatment(s) and a summary of progress. HIV-related information and drug and alcohol information contained in these records will be released under this consent unless indicated here: Li Do not release. H Other: (cont.) FORM 43. Requesting or releasing confidential records and information (p. 1 of 2). From The Paper Office. pp. 321—322. Copyright 1997 by Edward L. Zuckerman. Permission to photocopy this form is granted to purchasers of The Paper Office for personal use only(see copyright page for details). Request to Release Confidential Information (p. 2 of 2) C. I authorize the source named above to speak by telephone with the therapist identified in part K about the reasons for my/the patient's referral, any relevant history or diagnoses, and other similar information that can assist with my/the patient's receiving treatment or being evaluated or referred elsewhere. D. I understand that no services will be denied me/the patient solely because I refuse to consent to this release of information, and that I am not in any way obligated to release these records. I do release them because I believe that they are necessary to assist in the development of the best possible treatment plan for me/the patient. The information disclosed may be used in connection with my/the patient's treatment. E. This request/authorization to release confidential information is being made in compliance with the terms of the Privacy Act of 1974 (Public Law 93-579) and the Freedom of Information Act of 1974 (Public Law 93-502); and pursuant to Federal Rule of Evidence 1158 (Inspection and Copying of Records upon Patient's Written Authorization). This form is to serve as both a general authorization, and a special authorization to release information under the Drug Abuse Office and Treatment Act of 1972 (Public Law 92-255), the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act Amendments of 1974 (Public Law 93-282), the Veterans Omnibus Health Care Act of 1976 (Public Law 94-581), and the Veterans Benefit and Services Act of 1988 (Public Law 100-322). It is also in compliance with 42 C.F.R. Part 2 (Public Law 93- 282), which prohibits further disclosure without the express written consent of the person to whom it pertains, or as otherwise permitted by such regulations. F. In consideration of this consent, I hereby release the source of the records from any and all liability arising therefrom. G. This request/authorization is valid during the pendency of any claim or demand made by or in behalf of me/the patient, and arising out of an accident, injury, or occurrence to me/the patient. I understand that I may void this request/authorization, except for action already taken, at any time by means of a written letter revoking the authorization and transfer of information, but that this revocation is not retroactive. If I do not void this request/authorization, it will automatically expire in 90 days from the date I signed it. H. I agree that a photocopy of this form is acceptable, but it must be individually signed by me, the releaser, and a witness if necessary. I. I affirm that everything in this form that was not clear to me has been explained. I also understand that I have the right to receive a copy of this form upon my request. J. Signatures Signature of client Printed name Date Signature of parent/ Printed name Relationship Date guardian/representative I witnessed that the person understood the nature of this request/authorization and freely gave his or her consent, but was physically unable to provide a signature. Signature of witness Printed name Date K. I, a mental health professional, have discussed the issues above with the patient and/or his or her parent or guardian. My observations of behavior and responses give me no reason to believe that this person is not fully competent to give informed and willing consent. Signature of professional Printed name Date 1 Copy for patient or parent/guardian r Copy for source of records H Copy for recipient of records From the office of: 2828 Speer Blvd., Unit 118 Victor H. Cordero,Psy.D., P.C. Denver, CO 80211 Licensed Clinical Psychologist Office (303)455-9480 Fax (303)433-0111 CONSENT TO BE PHOTOGRAPHED/VIDEO/AUDIO TAPED By signing this document, I am agreeing to have my interactions video/audio taped for the purposes of clinical,therapeutic, or evaluation utility. I understand that these recording will be erased or destroyed and not provided to others without my express, written consent. I understand and agree that I can void this consent at any time and that this consent is provided voluntarily. Client Date Witness Date VICTOR H. CORDERO,PSY.D.,P.C. Licensed Clinical Psychologist 2828 Speer Blvd.,Unit 118 Denver,CO 80211 303-455-9480 CLIENT DATA SHEET Name: DOB Age If Child,Parent Name: Address: Street City, State, Zip Home Phone Work/Cell Phone Emergency Contact: Name/Number/Relation Date Referred Referral Source Date(s) of Initial/Ongoing Contact (pre face to face) Date(s)of Evaluation/First Face to Face Contact Other Agency/Individuals Involved: Name & Phone# Notes: VICTOR H. CORDERO,PSY.D., P.C. 2828 Speer Blvd.,Unit 118 Licensed Clinical Psychologist Denver,CO 80211 303-455-9480 Office 303-651-3773 Fax Authorization to Release Confidential Information Information to be released for: Name DOB Agency/Individual Releasing Information To the Office of Dr.Victor Cordero: Agency/Individual Address (J Phone INFORMATION TO BE RELEASED: Psychiatric History _Psychological Evaluation _Medical History _Discharge Summary _Drug/Alcohol History/Evaluation Treatment Records IEP/Educational Records _Medical Examination Reports Other(Specify): PURPOSE INFORMATION IS TO BE USED: CONTINUITY OF CARE(Evaluation and/or Treatment) OTHER(Specify): _I understand that this information will be used as part of a court ordered evaluation. As such it is subject to further disclosures under Colorado Rules of Evidence and I give permission of further disclosure to the Court and all attorneys of record only as required by law. I UNDERSTAND THAT DOCUMENTS RELEASED MAY CONTAIN INFORMATION REGARDING: Medical History,Psychiatric History,Psychological Evaluations,Criminal/Court Records, Drug&Alcohol use and history,or other personal information. A copy of this request may be used with the same effectiveness as the original. I acknowledge that this request/release is made voluntarily and can be rescinded at any time. Client Signature or Parent Signature Date Write Name This document expires after written retraction Witness Date or after one year from above date. VICTOR H. CORDERO,PSY.D. Licensed Clinical Psychologist 2828 Speer,Blvd.,Unit 118 Denver,CO 80211 303-455-9480 DISCLOSURE STATEMENT Dr. Victor H. Cordero received his Doctorate in Clinical Psychology from the University of Denver, Graduate School of Professional Psychology in 1995. He is licensed as a Clinical Psychologist in the state of Colorado(#2272). The Colorado State Grievance Board is the agency that is responsible for regulating the practice of licensed psychotherapists and psychologists. You can reach the Grievance Board by contacting: Colorado Grievance Board 1560 Broadway, Suite 1340 Denver, CO 80202 303-894-7766 CLIENT RIGHTS I cannot legally discuss your case or that of your child with others without your permission, except for specific conditions which are outlined below. You can seek other professional opinions and treatment at any time. Both treatment and evaluations are voluntary and you have the right to terminate at any time. You will be given the names of other mental health professionals if you terminate. Sexual intimacy or relations between a therapist and a paticnt/clicnt is never appropriate. Please ask questions about your treatment or evaluation including methods. techniques,estimated duration and fee structure. Conditions which will be reported as stated by law: Danger to self or others or gravely disabled Physical or Sexual abuse of others(child. elder, or dependent adult abuse) I hereby acknowledge that I have read.understand, and received a copy of the above disclosure statement. Client/Guardian Signature Date Psychologist/Witness Date EXHIBIT B SUPPLEMENTAL NARRATIVE TO RFP From the office of: 2828 Speer Blvd., Unit 118 Victor It Cordero, Psy.D., P.C. Denver, CO 80211 Licensed Clinical Psychologist Office (303)455-9480 Fax (303) 651-3773 May 19, 2007 Weld County Department of Social Services ATTN: Tobi Vegter Core Services Coordinator RE: Response to Commission Bid Process PY 2007-2008 I accept the recommendations and Conditions as written by the FYC commission in the document dated May 11, 2007. The following conditions will be addressed: Clarifying and submitting information on Evidence-based practices Clarifying and submitting elements regarding a Program Improvement Plan Providing a copy of Insurance This vendor requests additional time to contact the program coordinator and assure the appropriate information is delivered. Please detail a timeline in which you require these materials be provided. Thank you. Please contact me with any questions or clarifications. Sincerely, *01, 4 Col, 130.12 Victor H. Cordero, Psy.D. Licensed Clinical Psychologist DEPARTMENT OF SOCIAL SERVICES P.O. BOX A ik GREELEY, CO. 80632 Website:www.co.weld.co.us Administration and Public Assistance(970)352-1551 Fax Number(970)353-5215 COLORADO May 11, 2007 Victor H. Cordero Psy. D. 2828 Speer, Unit 118 Denver, CO 80211 Re: Bid 007-MH-07 (RFP 006-00)Mental Health Services Dear Dr. Cordero: The purpose of this letter is to outline the results of the Bid process for PY 2007-2008 and to request written confirmation from you by Monday, May 21, 2007. The Families, Youth, and Children Commission appreciates your interest in providing services for families in Weld county.This year, strides were made in structuring an RFP that is clear and concise,and more user friendly, for both prospective bidders and evaluators. It is important to stress the value of following formatting guidelines and addressing the required sections concisely and appropriately. A. Results of the Bid Process for PY 2007-2008 • The Families, Youth and Children(FYC)Commission recommended approval of Bid 007- MH-07 (RFP 006-00), Mental Health, for inclusion on our vendor list,attaching the following recommendations and conditions. Recommendation: You must clarify the calculation methods used for billed service hours. Conditions: The bidder must clarify and submit information that was not addressed,or included with the original bid submission,by providing or addressing: 1. Evidenced-based practices, 2. Program Improvement Plan, 3. Copy of Insurance. 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. r • y • Page 2 Victor H. Cordero/Results of Bid Process 2007-2008 Please provide in writing how you will incorporate the recommendation(s) into your bid. If you do not accept the recommendation,please provide written reasons why. All approved recommendations under the NOFAA will be monitored and evaluated by the FYC Commission. Concerning FYC Commission Conditions: MI conditions will be incorporated as part of your Bid and Notification of Financial Assistance Award(NOFAA). If you do not accept the condition(s),you will not be authorized as a vendor unless the FYC Commission and the Weld County Department of Social Services accept your mitigating circumstances. If you do not accept the condition,you must provide in writing reasons why. A meeting will be arranged to discuss your response.Your response to the above conditions will be incorporated in the Bid and Notification of Financial Assistance Award. The Weld County Department of Social Services is requesting your written response to the FYC Commission's 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, at 970.352.1551, ext. 6392. Sincerely, y A. riego, 'rector cc: Juan Lopez, Chair,FYC Commission Tobi Vegter, Core Services Coordinator Gloria Romansik, Social Services Administrator Hello