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Home My WebLink About20071746.tiff Weld County Department of Social Services Notification of Financial Assistance Award for-Child Welfare Regular AdministrationFunding Type of Action Contract Award No. X Initial Award PY07-08-HS-0033 Revision (RFP-006-00B;008-HS-07) Contract Award Period Name and Address of Contractor Beginning 06/01/2007 and Patricia Chase,Private Practice. Ending 05/31/2008 Home Studies,Updates,Relinquishment Counseling 215 Custer Street Brush,CO 80723 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Assistance Award is Services provide consistent,measurable home studies in a based upon your Request for Proposal(RFP). The RFP specifies the validated and tested format for the purpose of assuring safe, scope of services and conditions of award. Except where it is in stable,and permanent placements for children in need of conflict with this NOFAA in which case the NOFAA governs,the adoptive homes;and safe and stable placements for children RFP upon which this award is based is an integral part of the action. who are in need of placement in kinship homes,and foster Special conditions homes.Estimated home study yearly capacity is 17 home 1) Reimbursement for the Unit of Service will be based on an studies,and 17 relinquishment counseling sessions.Program episode rate per home study;home study update,and capacity is in six week increments;i.e.,two family units for relinquishment counseling.Home studies in excess of 30 home studies and two family units for relinquishment hours,relinquishment counseling court testimony,and counseling during the same six weeks increment. Bilingual travel time will be billed at an hourly rate. Mileage for interpreter available. court testimony and extended travel outside of Weld Cost per Unit of Service County will be billed at 34 cents per mile. Hourly Rate per 2) Reimbursement requests must be an original with an Home Study(in excess of 30 hours) $31.66 original signature from the provider and/or designee. Relinquishment Counseling $103.89 3) Reimbursement requests must include the date the Travel Time $75.00 home study,update,or relinquishment counseling was Court Testimony $75.00 completed.The request must reflect the amount billed Per Diem for each home study,and the month the service was Per Mile provided.Requests for services submitted 90 days Mileage for Court Testimony $.34 from the date of service,and thereafter,will not be Extended Travel Outside of Weld County 34 paid. Other 4) Payment will only be remitted on referrals made by Updated background checks/fingerprints billed at cost the Weld County Department of Social Services. Episode Rate per 5) Requests for payment must be an original submitted to the Full Home Study with Background Check $950.00 Weld County Department of Social Services by the end of Full Home Study with 3 or more additional adults the 25th calendar day following the end of the month of (includes Background Check) $1,050.00 - service.The provider must submit requests for payment on Updated Home Study(includes mileage) $450.00 forms approved by Weld County Department of Social Relinquishment Counseling $250.00 Services. Requests for payments submitted 90 days Enclosures: from the date of service,and thereafter,will not be X Signed RFP:Exhibit A paid. Supplemental Narrative to RFP: Exhibit B 6) The Contractor will notify the Department of any changes in X Recommendation(s) staff at the time of the change. o itions of Approval Approvals: Program 0 mist: By t By David E. Long,C it Judy A riego,D ector Board of Weld County Commissio ers Weld C my ep ment Social Services Date: JUN 1 8 2007 Date: 2007-1746 4 ' EXHIBIT A SIGNED RFP J - at- INVITATION TO BID BID 001-07 TE. February 28,2007 BID NO: 001-07 RETURN BID TO: Monica Mika, Director of Administrative Services 915 10th Street, P.O.Box 758,Greeley. CO 80632 Third floor, Centennial Building, Purchasing Department — SUMMARY Request for Proposal for: Colorado Family Preservation Act—Core Services Program Deadline: Friday,March 30, 2007, 10:00 a.m.(MST) The Families, Youth and Children Commission, an advisory commission to Social Services,announces that competing applications will be accepted for approved providers pursuant to the Board of Weld County Commissioners' authority under the Colorado Family Preservation Act(C.R.S. 26-5.5-101) and Emergency Assistance for Families with Children at Imminent Risk of Out-of-Home Placement Act (C.R.S.26-5.3-101). The Families, Youth and Children Commission wishes to approve services targeted to run from June 1, 2007,through May 31, 2008, at specific rates for different types of service, the County will authorize approved providers and rates for services only. This program announcement consists of the following documents,as follows: • Invitation to Bid • Main Request for Proposal (All program areas) • Addendum A—Program Improvement Plan Requirements(by program area) • Addendum B—Scope of Services(by program area) • Core Budget Form Delivery Date (After receipt of order) BID MUST BE SIGNED IN INK Program Area: f/Cl IC(iIuef to S L+pCl u U-) pp �� Kc I i ri 4 �-?-d -v, -1 TYPED OR PRINTED SIGNATURE VENDOR / CL-I R I L1 l-I L 1\(1 7 C, (Name) Handwritten Signature By Authorized c / Officer or Agent of Vendor ADDRESS J 1 ti4 S r TITLE J — nkt13N1 ( G r5-( 7_2 DATE . 3 ZS r -3 PHONE# (I 70 _ 3 ICS ' (TLi The above bid is subject to Terms and Conditions as attached hereto-and incorporated. _ ABSTRACT I am an Individual Vendor. I am on the approved VENDOR list for the State of Colorado Department of Human Services and have been approved to do SAFE home study assessments for public and private agencies. I have completed both the two day caseworker training and the 1 day supervisory training for the SAFE instrument. I carry private liability insurance through HPSO, My organization is comprised of myself as an individual vendor. My mission is to conduct SAFE home study assessments on a part time basis for private adoption agencies and for public agencies that provide foster care placements, adoption services and relinquishment services. My mission includes providing consistent, measurable home studies in a validated and tested format for the purpose of assuring safe, stable and permanent placements for children in need of adoptive homes. Providing home studies for kinship and foster homes will ensure safe and stable placements for children who need to be placed in least restrictive settings that ensure fewer placement changes before reuniting with their families. My home studies will focus on safety, permanency and well being by identifying the permanency needs of children. Home studies will facilitate preservation of placements through recommendations to facilitate communication between caseworker and foster/ adoptive parent, recommendations for placements that are in line with case plans including plans for independent living skills, and by recommendations for placements that preserve racial and cultural connections. My mission in providing relinquishment counseling and reports is to assure that parents wishing to relinquish their parental rights understand the impact of their decision for themselves and their children;that they understand the full legal impact of their decision;to ensure that their decision to relinquish their parental rights is made with full understanding of alternative options available to them such as complying with their treatment plans, continuing to work towards reunification with their child, utilizing child support and other public programs to assist with financial needs and to assure that they understand the finality of their decision. Relinquishment frees children for adoption, expedites permanency for children and is in line with case plans and permanency goals. My mission includes providing relinquishment reports to the court that include a description of the counseling provided as per statue. 2 • TABLE OF CONTENTS Invitation to Bid 1 Abstract 2 Table of Contents 3 Target/Eligibility Populations 4 Project Narrative/Supporting Documentation 5 Types of Services 5 Measurable Outcomes 6 Service Objectives 6 Workload Standards 7 Staff Qualifications 7 Program Capacity per Month 7 Internal Tracking and Billing Process 8 Budget attachment Appendices 1-3 Appendix 1 Resume attachment Appendix 2 Data Collection instruments/Protocols attachment Appendix 3 Sample Consent Form attachment Other Attachments Sample Home Study Verification of Meeting Insurance Certificate 3 • TARGET/ELIGABILITY POPULATION Target groups served by use of the SAFE instrument include those individuals who will be serving Weld County Human Services Department's clients in roles such as volunteers, foster or kinship parents, personal caregivers, adoptive parents. My organization will target individuals/families who wish to be foster parents, foster/adopt parents, kinship parents or adoptive parents and children who are identified as expedited permanency planning. Out of this target population, eligible population will be those person/persons who meet all the criteria and requirements outlined in Volume VII and in the Children's Code, 19-5-202, 19-5- 205.5 and 19-5-207. Total number of family units I will serve in a year will be 34. This includes 17 family units for home studies and 17 family units for relinquishments. A family unit means a one or two adult home, with or without children and including any other adults/children residing in or staying in that home. Total number of clients to be served is dependent on the number of persons included in a family unit. I could feasibly serve 68 adult clients for both home assessments and relinquishments. Total number of children identified as expedited permanency planning to be served will be from 15 to 25. No bi-lingual clients will be served. Clients to be served will live in Weld County, any or all of them could be from South Weld County. 2.83 clients will be served on a monthly basis. Program capacity will be in six week increments. I can serve two family units for home studies every six weeks and two family units for relinquishment counseling during the same six weeks increment. Average time per family unit is six weeks. 4 PROJECT NARRATIVE/SUPPORTING DOCUMENTATION TYPES OF SERVICE PROVIDED I will be providing adoption, foster care, and expedited permanency planning home study assessments and home study assessment updates by using a uniform and validated assessment, SAFE, which meets the requirements of the law and Volume VII rules for permanency planning that is in the best interest of children. Permanency and well being of children is provided through the use of approved SAFE home study assessments and meets the requirements of the PIP. All of the required areas and components of the assessment will be adequately addressed and will ensure that consistent accurate information is gathered and evaluated on all people who are applying for foster, kin and child adoption. The required components of the SAFE instrument are identified in Volume VII, beginning 7.500.2. These include that all adults and children in a home,both related and non related be interviewed, motivation for a child be discussed, discussion around special needs/disabled children,background checks be fmgerprint based both CBI and FBI, requires individual assessments, requires discussion and outlines factors to be considered in preserving the child's cultural background, family is assessed on ability to accept a legal risk placement, requirements for kinship assessment including kinship family ability to set boundaries with birth parents to maintain safety, kinship family ability to provide permanent home through guardianship, adoption or permanent custody and that opportunity to foster or adopt cannot be based on race, color or nation origin. Specifically,the content of the SAFE assessment will determine the character and suitability of the applicant(s), appropriateness of the home and child care practices. I will be providing relinquishment counseling and reports per requirements in Volume VII and the Children's Code. All required areas will be addressed. All relinquishment counseling will be audio taped and the tape will be provided with the report. All relinquishment services will meet the PIP goals of permanency and well being. I will be available to provide court testimony either in person or by telephone concerning all SAFE home study assessments and relinquishment counseling and reports that I provide. All services will be provided with confidentiality and the understanding I am a mandated reporter. Documentation of the Evidence Base for SAFE Home Study Services to be provided: The Federal government has a national recruitment effort to find homes for children who have waited the longest for adoption. There has been increased interest in families from both in state and out of state in Colorado's children. Standardized home assessments enable children to move quickly into permanent homes. The Structured Analysis Family Evaluation(SAFE)has been validated and is a tested instrument. In Colorado's Volume VII, 7.500.2,rules have been established for the implementation and use of the SAFE instrument. Before Colorado mandated use of the SAFE instrument, its use was piloted in several Colorado Counties. Training on the use of SAFE for these pilot counties was offered by the Consortium for Children in California. Several states,the Cherokee Nation,three Canadian Providences and British Columbia are currently using the SAFE instrument. SAFE is a psychosocial model of conducting a family assessment and covers the major components required by the Interstate Compact on the Placement of Children law and SAFE promotes uniform assessments among states. The SAFE instrument meets the requirements in statute for a standardized home study assessment(19-5-207.5). 5 MEASUREABLE OUTCOMES Effectiveness of using the SAFE instrument is evidenced in the qualitative and quantitative impact of a standardized tool which ensures consistent and accurate information is gathered and evaluated on all persons who apply for foster, kin and child adoption. Children benefit because all applicants participate in the same approval process. Positive outcomes for permanency in placements that adequately address permanency needs which are accurately identified in the assessment, are increased with the use of the SAFE instrument. This meets the PIP goals of permanency and well being for children. Outcomes that are measurable through the use of the SAFE assessment instrument include a decrease in placement changes, a decrease in disrupted adoptions due to more accurate matching of children with families, increased stability in placements and increased expedited permanency placements. SERVICE OBJECTIVES My objective as a service provider is promote permanency and well being for children by providing quality adoption, foster care and expedited permanency planning home study assessments and updated assessments in a validated and tested format following the guidelines in Volume VII and the Children's Code and to do this within a six week rime frame that is subject to timely submissions by applicants of fingerprints, central registry checks, applications and reference information. I will meet my objectives by using the SAFE format and guidelines that include meeting jointly with applicants at least three times,having an individual interview with each adult in the household and conducting an interview that is age appropriate for each child in the household. Interviews are conducted at 7 day intervals. At a minimum I will meet in the applicants home at least once but I usually meet in the applicants home two to three times during the course of the assessment. I will meet with each adult member to go over the assessment when it is finished and obtain their signature(s). I will be providing an intensive and time limited service to unite children with their permanent families. My method will be the use of the SAFE home study format. My objectives will be monitored and measured through outcomes that include children having fewer out of home placements, i.e. placement changes, children being accurately matched with permanent families therefore having fewer disrupted adoptions and an increased number of children having expedited permanency including with appropriate kin. All counties and some states will be asking the same questions that will be addressed in the same format. Use of the SAFE instrument will allow for placements across county and state lines to be expedited. Use of the SAFE instrument will allow for accuracy in assessment therefore resulting in expedited permanency in placements that are focused on the permanency needs of children. Use of the SAFE instrument in a home study will assist with identification of a child's permanency needs. 6 • Workload Standards I will provide two SAFE home study assessments and two relinquishment counseling units and reports per six week time frame. I will spend approximately 12.6 hours per week to provide these services, inclusively. This includes travel time, interview time, assessment and writing time. Any meetings, staffings and/or court hearings would be additional hours. I carry professional liability insurance through Healthcare Provider Services (HPSO). My insurance renews on May 5, 2007. My insurance is on file with the State Department of Human Services. Staff Qualifications As an individual vendor, I am on the Colorado Department of Human Services Vendor list as required through rule in Volume VII 7.000.6Q) and by statute. I have met all the requirements to be on the Vendor list as an individual vendor which includes the two day SAFE training and the one day SAFE training for supervisors. In my current full time employment as a paired team supervisor for an Intake/Ongoing Child Welfare team, I supervisor workers who provide SAFE home study assessments for Morgan County Department of Human Services. As an Individual Vendor, I have provided home studies for Logan County, Yuma County,and for several private adoptions through private adoptions agencies and attorneys. In addition I have provided home studies and custody studies for the State of Wyoming,and the State of Nebraska. I have provided relinquishment counseling for Moffat County Human Services, Routt County Human Services, Morgan County Human Services and Logan County Human Services. During my employment at Routt County Human Services, I provided home studies for foster and foster/adopt homes, kinship studies and did all of the foster parent licensing and recruitment. I previously was employed by Weld County Human Services from July 1988 to February 1997. Program Capacity As an individual vendor I can serve two family units per six weeks for two SAFE home study assessments and I can additionally serve two family units per six weeks for two relinquishment counseling and reports. I will work with families who reside in Weld County. 7 • Internal Tracking and Billing Process Home study assessments will be billed per assessment and will include all associated costs such as fees for fingerprints, background checks, mileage and travel time. Relinquishment counseling and reports will be billed per episode and will include associated costs such as mileage and travel time. Provider will keep accurate records tracking time spent on each assessment and relinquishment provided. These records will be available upon request. Home studies will be billed at the rate of$950.00 per home study that can be completed within the approximated time of 30 hours or less. Home studies that require additional hours over 30 will be billed at the rate of$31.66 per hour. Home studies with three or more adults residing in the home will be billed at rate of$1050 to cover additional background checks, fingerprints and additional interviewing time. Travel time and court testimony time will be billed at a rate of$75 per hour. Mileage for court testimony will be billed at$ .34 per mile. Extended travel outside of Weld County will be billed at a rate of$ .34 per mile. Updates for SAFE home study assessments will be billed at a rate of$450 per update and includes mileage. Any fees associated with an update such as update background checks and updated fingerprints will be billed at actual cost of the service. 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O w 888 • 8� 4a N^ 0 0 0 0 0 0 0 0 0 0 0 0 0 0 8 y 584888888888888888 2 g w a o� agggg«�«w$w2322 N $o S 6- U 2 0 0 0 - w < p�7 �n o 0 4 w en w O w K - co a J S a C a a r yu O = Q p e p w 8 8 8 ..... .... ..• . • <8 aD m o 0 0 In(11 CO zzzZZzz9z2gi iZ z R$g`• — � r oy 0 w Y f cL. a x cc .. . •U a w r Ln a a w m z ....':...:....: :'': a 0 < 0 a O > r C W • LL .. a O in N LI m 0 O O o .6 . .. w O_ f- .. .1 ... .........;;� pp use w S z z . & re U K w w 7 ... :.:.:. r w KK r • a 0 0 0 D�C7L ... 0 0 0 < 0 0 0 — Patricia Nesheim Chase 215 Custer St. Brush,Co. 80723 RESUME EDUCATION Marion High School,Marion, IN - 1965 Valparaiso University, Valparaiso,IN - 1969 Bachelor of Social Work Minor in Psychology Internship, Gary,IN, Inter-City Y.W.C.A. Internship, Gary,IN, Inter-City High School Internship,Marion,IN,V.A. Hospital NACBSW, 1991 (National Academy of Certified Bachelor's of Social Work) CURRENT POSITION 10/1/04 to present. Supervisor of a Child Protection paired team for an Intake/Ongoing Unit, Morgan County, Co. Responsibilities include oversight of the referral acceptance/screening process, assignment of referrals and oversight of the investigation process; approval of court reports and treatment plans, including staff management of cases, case planning and compliance with state requirements for Title XX and IV E recovery, as well as, staff coordination with the Child Support Recovery and the Assistance Payments units concerning eligibility for and duplication of benefits. In addition, I am involved in training community agencies such as law enforcement, schools,medical personnel, mental health and victim advocates on recognizing child abuse, collaborative investigations and updating protocol agreements. I am part of the local Domestic Violence Task Force as well as the Domestic Violence Grant Writing Committee. I participate on the State Intake Forum Committee concerning new laws and state rules that govern child protection procedures. I do staff evaluations,performance improvement plans and when required, corrective action plans. In 2005 I became an independent contractor on the state approved vendor list for adoption home studies. I contract independently to do adoption home studies. In 2001 I began contracting with AAC Adoptions in Berthoud to do adoption home studies for their agency. EXPERIENCE 11/1998 to 10/1/04. Caseworker III and Foster Care Coordinator in Routt County. Provide crisis intervention, investigative, and on going services to children, adolescents, families and other adults who are or may be at risk for abuse and/or neglect. Provide services to delinquent and/or out of control youth and families. Responsibilities include: on call, investigations,crisis intervention, family counseling,youth in conflict counseling, couple counseling, conflict resolution and mediation, home base services,referrals to other service agencies, interagency collaboration and managed care. Author and facilitator of parenting group G.A.P.P. (Growing Adolescents, Preadolescents and Parents), a CORE service adolescent/parent psycho-educational group(currently taught in both Routt and Moffat counties through contract with Mental Health). Foster Care Coordinator including home studies, adoptive home studies(I am on the state approved list for adoptive studies)and licensure. Additional responsibilities include court reports and treatment recommendations for clients. Supervised Social Worker Internship for University of Wyoming. 1 CASEWORKER III, Moffat County, Colorado 2/1997 to 11/1998. Provide services to children, adolescents, families and other adults who are or may be at risk for abuse and/or neglect. Provide services to delinquent and/or out of control youth and families. Responsibilities include intake, on call, investigations, crisis intervention, family counseling,youth in conflict counseling, couple counseling, parenting help including G.A.P.P., an adolescent/parent group, and conflict resolution counseling (I authored this CORE service and submitted to the State for approval). Additional responsibilities include court reports with recommendations for treatment. Cooperative interaction with other agencies. Independent First Aid and CPR instructor. CASEWORKER III, CPS, Intake and Ongoing, Weld County, CO 7/88 to 2/97. Established satellite office in south half of Weld County and became lead worker for four caseworkers, one assistance payments caseworker and clerical staff. Geographic area included 7 rural communities and 3 school districts. Established rapport, as well as formulated and coordinated a plan for reporting,team intervention, interagency collaboration and services including use of video and audio tapes with seven law enforcement agencies,three school systems and mental health services, all prior to protocol requirement by law. Helped to bring other services to these communities through establishment of satellite offices, and served on community boards. Have worked with American Embassy and Office of Refugee Repatriation in Mexico and Washington D.C. concerning child abuse of citizens temporarily out of the U.S., with the Attorney General's Office concerning child abuse of Native Americans and with the FBI. In addition to performance of job as intake caseworker which has included on call emergency duty, seven days per week for the south county area,have consistently trained law enforcement agencies in areas which include the Children's Code,protocol, and interviewing techniques as they relate to child abuse/neglect. Teach and certify foster parents, caseworkers, other social service personnel and teachers in First Aid and CPR. CASEWORKER V,CPS ONGOING,Allen County,IN—9/1983 to 12/1986. Provided ongoing casework services in urban area to families with children age 12 and under. Duties included court ordered custody evaluations and home studies. I also contracted privately to do custody evaluations and home studies. I was responsible for emergency duty for after hours crisis intervention in the areas of abuse/neglect. Trained foster parents and CASA volunteers in areas concerning abuse, neglect, the Children's Code, and the judicial system as it related to abuse and neglect. JUVENILE PROBATION OFFICER, Madison County, IN. Superior Court II. 1977 to 1981. Assessment of juvenile offenders, recommendations for prosecution, disposition, including treatment plan, coordination of services and monitoring offenders. Established satellite office and supervised probation volunteers. Additionally, served on Child Protection Team, Board of Directors of Madison County Mental Health and responded to emergencies for Madison County Social Services. SUBSTITUTE TEACHER, ELWOOD PUBLIC SCHOOLS, Elwood, IN. 1975 to 1977. 2 • SCHOOL SOCIAL WORKER, Hobart Township Schools, Lake County, IN. 9/1969 to 2/1975. Responsibilities included three elementary schools, a junior high school and a high school. Job encompassed classroom behavior problems, school adjustment problems, learning disabilities students, special education students, absenteeism, truancies, child abuse/neglect, individual and group counseling. Worked with Head Start program including writing of Title XX grant applications. Implemented in home services to families, including neighborhood groups designed to encourage and support better family functioning and independence. 3 • Safety Checklist K The following safety checklist is designed to ensure your house is safe enough for your toddler to play in with only minimal risk of injury. Take some time now to go over this checklist, room by room, to make your house safe for your child. Make it a habit to recheck your house at least once a month. All Rooms To Do Action Done ( ) 1. Put electric outlet covers on all unused outlets. ( ) ( ) 2. Put a gate across all stairways,top and bottom,until child can handle stairs. ( ) ( ) 3. Remove or pad sharp corners on furniture and appliances. ( ) ( ) 4. Remove throw rugs on tiled floors. ( ) ( ) 5. Use non-skid floor wax on wood,tile,or linoleum floors. ( ) ( ) 6. Keep all plants out of baby's reach. ( ) Kitchen To Do Action Done ( ) 1. Put all cleaning supplies on a top shelf out of children's reach. ( ) ( ) 2. Install safety locks on all kitchen cabinets below waist revel. You may wan: ( to keep one cabinet with pots, pans, and unbreakable bowls unlocked for child's exploration. ( ) 3. Turn pot handles toward back of stove when cooking. ( ) ( ) 4. Take knobs off of gas ranges when not in use. ( ) ( ) 5. Have a secure cover for the garbage can. ( ) ( ) 6. Install safety locks on kitchen drawers with knives and other sharp utensils. ( ) ( ) 7. Keep all breakable bowls out of the cabinets with the pots and pans. ( ) ( ) 8. Remove throw rugs from kitchen floors. ( ) • ( ) 9. Make sure highchairs are stable and have safety straps. ( ) ( ) 10. Remove tablecloth to prevent toddlers from pulling it off. ( ) ( ) 11. Keep items in use such as glasses,jars,bowls,utensils, etc.well back on the ( ) kitchen counter. ( ) 12. Remove pet food bowls to an area inaccessible to your baby. ( ) J 32 ©199_ Family Development Resources,Inc-,3160 Pinebrook Road.Park city,UT 84098. Permission is granted to Morgan County DSS to copy and distribute the Safety Checklist at no charge to the families they serve. lie f i 1 Bathroom - To I) Bathroom Done ( I. Store all electrical appliances such as hair dryers, curling irons, electric ( ) 7 toothbrushes in the bathroom cabinet or closet. ( 2. Put safety locks on all bathroom cabinets. ( ) ( 3. Remove all electrical appliances near water. ( 4. Place a non-skid bath mat on the bottom of tub. ( ) ( ) ( 5. Buy a rubber safety cover for the bathtub water faucets and spout to prevent ( ) accidental head injuries and scalding, ( 6. Keep all medicine in a locked medicine cabinet. ( ) i Living Room t To DoAction Done ( L. Secure lamps and other freestanding objects. ( ) t, \ ' I4•nce off fireplaces, wood stoves, space heaters, radiators, and heating ( ) grates. ( 3. Remove all breakable knickknacks and ashtrays. ( ) I I I)ek all gun cabinets. .•\«.i. ;; e!cc:i al lamp cords and extension cords to tables or baseboards. ( ( ) y ( n Remove coffee table and other sharp-edged fur s access furniture from child' and play areas. ( ) Bedrooms To DoAction Done. ( ) [. Install a night light for nighttime trips to the bathroom. ( ) ( ) Move furniture and cribs away from windows. ( ) ( ) 3. ['lace safety locks on all windows and screens. ( ) ( ) 4. Make sure bars on cribs arc no-more than 2 1/2 inches apart. ( ) 5. Make sure mattress fits bed frame snugly. ( ) 6. Install bumper pads on inside of crib for young infants, the soft kind that bends or folds when stood on. ( ) • ( ) 7. Remove mobiles over bed once child is capable of sitting or pulling to sit. ( ) r S s. / 2P. .o in Family Development Resources,tnc.,3160 Pinebrook Road Park City,UP 84098. Permission is {t{ f anted to Morgan County DSS to copy Safety 33 t P, and distribute the Checklist at no charge to the families thy i .m'e. Basement, Garage, Attic To Do Action ^ ( Done ) 1. Throw away all old paints you're not using. Store paint thinners, paint, stains;etc. on a high shelf if you need to keep them. ( ) ( ) 2. Store all tools in a locked tool chest or shelved out of reach. ( ) ) 3. Lock all doors securely. ( ) ( ) 4. Keep garden tools, lawn mowers, snow blowers out of reach of young ( ) children. ( ) 5. Keep keys to electric machines safely out of reach. ( ) ) 6. Take doors off of old refrigerators and freezers. ( ( ) ) 7. Store pesticides and fertilizers on high shelves out of reach of children. ( ( ) General Safety Rules 1. Never leave a young child unattended in the bathroom. 2. Install smoke alarms and fire extinguishers. 3. Keep all matches and candles out of reach. 14. Post emergency numbers beside the telephone. 5. Never refer to medication as candy. 6. Avoid letting children play with small objects he/she can swallow. 7. Never leave a young child unattended in the basement,garage, or attic. 8. Keep ashtrays and cigarette butts out of children's reach. Nicotine is a deadly poison when eaten. k a.•.v 34 ©199_ Family Development Resources.Inc.,3160 Pinebrook Road, Part; B4 098.granted to Morgan County DSS to copy and distribute the Safety Checklist at no charge to the families'they serve. • Sample Consent Form The purpose of your participation with the foster and or adoptive home study process is to determine your qualifications for providing children with a safe, stable and nurturing environment while meeting the permanency goal set for each child. Goals include reunification, long term foster care, independent living skills and adoption. The information that will be collected during the home study process is based on interviews, questionnaires and observations. The data collected from the home study process will determine if you meet the criteria for approval. All information will be kept confidential and will only be shared with Weld County Human Services staff as appropriate. If there are other agencies or individuals I need to speak with during the home study process I will request that you sign a release of information. Because I will complete the home study on behalf of the Weld County Department of Social Services, the completed copy will be kept in their records. You have the right to leave the home study process at any time and this is done on a voluntary basis. Because I am a mandated reporter, if I have concerns or observe abuse or neglect in your home I will have to report this to the Department of Social Services and/or notify local law enforcement. Signature of Home Study Provider Applicant 1 Applicant 2 Additional Household Member • SAFE Multi Purpose Home Study Report This home study was completed by Patricia Chase, Independent Vendor solely for use in foster care placement and/or adoption by and for United States licensed/authorized agencies unless otherwise i specified. I Name of Family: Barbie and Ken Doll Address Playland Court Ci Ha ille State: Co Postal Code: 80723 0000! .. tY_ ppyv. Home Phone: 123-456-7890 Cell Phone: APPLICATION DISPOSITION Select One on: Home Study Application received on: 2/21/2007 The Applicants have applied to accept placement of a child between the ages of 0 to 3 The Applicants are open to placement of a sibling group. The Applicants are primarily interested in becoming an Adoptive Family. APPLICANT INFORMATION Barbie B. nee Fun Doll Ken Doll Date of Birth: 09/04/1968 _Date of Birth 1 05/10/1973 Birthplace:Gender F ! Gender: ' M Religion. Protestant 1 Religion: Protestant I Occupation Play Girl- 1 Occupation: Model Language(s) English Language(s): 1 English 1 Education: _ ' GED, 1 year college Education High School Height: 5'4" Height: 6' I Weight: 1 108 Weight: 1 160 i Hair: I blonde Hair: I brown Eyes: I blue 1 Eyes: green Date of health questionnaire/report: 1 3/27/2007 1 Date of health questionnaire/report: 13/27/07 MARITAL INFORMATION Date of Marriage: 08/22/1998 I Marriage Verification: On File Place of Marriage Happyville, Colorado DATES OF CONTACT Date Individual/Couple Location 2/21/2007 Individual, Barbie Happyville, Co.,residence 2/25/2007 Couple Happyville,Co.,residence 2/25/2007 Children Happyville,Co.,residence 3/9/2007 Individual, Ken Happyville,Co.,office 3/9/2007 Individual,Lisa Happyville, Co., office Structured Analysis Family Evaluation(SAFE)©Colorado Couple Multipurpose Home Study Report -Version 01-18-2008 Page 1 of 10 Copyright,2005,Consortium for Children,All Rights Reserved MOTIVATION Barbie and Ken want to add to their family. Barbie has had three c-sections and Ken has had a vasectomy so they are not able to have more children of their own. Both love children and feel they are able to parent additional children. Because Barbie faced challenges of multiple step fathers and a lack of stability while growing up, she believes she has a profound understanding of how children feel who have problems and lack of stability in their lives. Barbie and Ken are willing to assume all of the legal and parenting responsibilities of adoptive parents. Barbie and Ken would like to adopt a child or sibling group of two children. They would consider adopting a child or children with some special needs and/or mild developmental disabilities. Their son, Ken Jr. has mild developmental delays and they feel they have experience in parenting a child with special needs. Because of Barbie and Ken's persistence in researching Ken Jr.'s delays and their perseverance in correcting his diet, Ken Jr. has progressed and achieved far beyond what his medical professionals predicted. HOME ENVIRONMENT Type of residence: House, single family Square Footage: 1700 Bedrooms: 4 Bathrooms 2.5 Length of Time in current residence: 17 months The Doll's live in a single family home they are purchasing. The home is a split level style in a middle class neighborhood. The home is well kept,has 4 bedrooms and two and one half bathrooms. The family room,one bedroom, laundry room and half bath are on the lower level. Babette's bedroom is in the lower level. The main level has a living room and kitchen dining area. The main level exits through patio doors to a cover deck area that goes into the fenced back yard. The house has an attached garage and a separate storage shed in the back yard. The back yard has a dry pond. The upper level has two bedrooms, one each for Ken Jr. and Karl, a bathroom, and the master bedroom with bathroom. Kenhas two shot guns with trigger locks that are stored in a locked closet. The ammunition is stored separately in the garage, out of the reach of the children. The family has two poodles and a cat.All pet vaccinations are current. The interior and exterior of the home was inspected for health and safety hazards. The inspection was completed on 02/25/2007. FAMILY Applicant#1: Barbie B. nee Fun Doll Barbie presented as straight forward,energetic and focused on a goal of adoption. She was friendly,outgoing and soft spoken. It was easy for her to settle right in and talk about herself and her family. Barbie is very proud of what she has accomplished in her life and she has a good sense of self worth. Barbie was born to Barbie nee Baby and Buster Crab,the youngest of two children born of this union. Barbie was two years old when her parents divorced and four when her mother remarried Dufus Dufus. Barbie has a half sister and a half brother from this marriage. Barbie described Dufus as being physically abusive to her mother and this being a tumultuous relationship. Dufus was not physically abusive to the children but discipline was not appropriate. For example, Barbie described being sent outside on one occasion,without her shirt.This marriage ended when Barbie's mother shot Dufus in self defense and he died. Her mother was not prosecuted. Barbie stated her mother had tried to leave Dufus on several occasions but he always found them and would threaten to kill them. Barbie's mother was married to Lincoln Logs for about a year before marrying Right Man. Barbie described Right as a good step father who provided stability during the rest of Lisa's growing up years. Right died of a heart attack after Barbie was emancipated. Barbie's mother has since remarried several more times. Barbie is very close with her mother,who resides in Nirvana,they talk almost daily. Barbie remembers her father as an absent father until she was in her teens. At that time she started spending more time with him and now they have a closer relationship. Barbie's father lives in Long,Ways, and they talk often. As a child Barbie moved frequently. She was born in Long, Ways, and lived there until age 6, Structured Analysis Family Evaluation(SAFE)®Colorado Couple Multipurpose Home Study Report -Version 01-18-2006 Page 2 of 10 Copyright,2005,Consortium for Children,All Rights Reserved next moving to California for a year,then Florida for 4 years and finally Brooklyn,New York until she married. Barbie finished her GED in Fun City,Co.,after she married her first husband,Rolo Polo. Barbie's older sister, BB is divorced and has 5 children. BB works as cashier and lives in Long, Ways. Barbie and BB do not see each other often due to geographic distance and until recently had little contact because of problems BB had with drugs. BB has now resolved her drug issues and the relationship is building and getting stronger. Barbie's half brother, DD, 36, lives close to Marineland, is married with 4 children,and has a naval career. Barbie and DD have a close relationship,they talk frequently and visit less often. Barbie's half sister,CC is married to navy career man. They live in Marineville, and have 3 children. Barbie and CC have a good relationship but don't often have the opportunity to visit in person. Barbie and her siblings recently surprised her mother with a visit. Barbie said it had been several years since all of them had been together. Barbie said in spite of moving around and having several step father's when growing up, she always felt loved and had a close relationship with her mother and siblings. Barbie said her mother was very protective of her and her siblings. Most of what Barbie knows about her step father's is from what she was told by her mother and she only remembers two occasions of physical fighting between her mother and Dufus. On the occasions that Dufus was inappropriate in his discipline,Barbie remembers her mother telling him to stop. Barbie credits Right Man with providing stability for the family. Barbie married Rolo Polo when she was 17. Barbie met Rolo when she was on vacation with her father in Nirvana. Barbie and Rolo have two children,Rola Jr,age 19 and Babette, 15. Rolo Jr. is emancipated,works as a carpenter's apprentice and lives in Fortville,Co. Barbie and Rolo share joint custody of Babette.Rolor and Barbie divorced after 10 years. Babette continued to live with her mother as did Rolo Jr.When Babette was 11 and Rolor Jr.was 14 they wanted to live with their father so Barbie and Role agreed they could try being with him during the school year and with Barbie during the summer,weekends and holidays. Barbie and Rolo have a good relationship and they do not argue over the children. Three years after her divorce from Rolo,Barbie met and married Ken Doll in Nirvana. Barbie worked as a secretary and in sales for manufactured homes. Since her marriage to Ken, she has taught aerobics. Barbie's work schedule is flexible and she is able to provide care for the children. When Barbie and Ken were married they had a blended family,with Barbie's two children and Ken's son, Karl. Being a blended family created some parenting issues but they worked hard co parent and believe they do not have parenting any more. Barbie and Ken do not have any major areas of conflict and believe the things they argue about are minor things most couples would disagree about. Barbie describes her self as a loving person with more love in her heart than she can give away. Barbie is a motivated and encouraging person who likes people and family; she doesn't take things at face value and researches things to get answers and in this way also educates herself. Barbie seeks to learn and grow,making positive changes in herself. Barbie described her weaknesses as impatience with circumstances not with people, in that she doesn't like to wait for things to happen. Barbie sets high standards for herself that can be difficult at times because she is somewhat of a perfectionist. Barbie tends to be results oriented and she becomes focused on an issue she is driven to have a resolve. Barbie said she prefers to resolve issues immediately and that she pushes to have that resolve while Ken needs time to work things through before communicating. Barbie strives to have patience and feels Ken is a good balance for her. Barbie believes she and Ken have good communication and are able to talk about anything.Barbie feels she grown immensely in patience since her marriage to Ken. Applicant#2: Ken Doll Ken presented as easy going,friendly, socially oriented and willing to talk about his life and family. Ken was born to Ken Sr. and Cupie nee Baby Doll,he was the oldest of two children.Ken's father worked in the gold and silver mines while Ken was growing up but his father now has own welding business.Ken has one younger brother,Ken II,who is married and has 1 daughter.Ken II lives in Nirvana. Ken II was recently laid off from his job at the gas company and is seeking other employment. Ken grew up on a ranch in Nirvana. He has a good relationship with his parents and brother. Ken said his family is very close and they have a lot of communication. Ken visits with his family at least once a year. Ken talks with his brother weekly. Growing up,Ken described being surrounded by lots of extended family and having frequent contact with them. Ken described feeling lots of love and always being supported and encouraged to do his best. Ken said his parents expected him to graduate from high school,to always do his best,to be respectful,to follow the rules like curfew and to let his parents know where he was going Strudured Analysis Family Evaluation(SAFE)©Colorado Couple Multipurpose Home Study Report -Version 01-18-2006 Page 3 of 10 Copyright,2005,Consortium for Children,All Rights Reserved .to be. Ken said growing up he was spanked rarely, grounded or had privileges taken away. Ken felt like discipline was determined by age. Ken said growing up he and his brother raised cows in the summer and sold them in the fall for school clothes,teaching them responsibility.Until his freshman year in high school,Ken played basketball, baseball and wrestled. After graduating from Nirvana High School in Nirvana,Ken worked as a carpenter's apprentice for six months followed by a job in the gold and silver mines in Nirvana. Ken said before he was 21 he got in trouble for underage drinking,ticketed as a minor in possession,resisting arrest,and having a false I.D. Ken also got a DWAI(driving while ability impaired)and an assault charge after he got into a fight with a neighbor when he was 22. Ken said he was on probation for a year. During this time period Ken married his first wife and this union produced Karl. Ken divorced after 3-4 years. After his divorce from Karletta,Ken began drinking a lot and got involved with drugs,he lost his job,lost his house and 'hit rock bottom'. Ken moved back home and was able to get back on his feet. He was able to get his job back in the mines and worked there for another 8 'h years. Ken met Barbie while he was working in the mines and they married after a short courtship. They have been married 8 'h years. Because Ken had turned his life around,he was able to get custody of Karl.Ken has had custody of Karl for 10 years.Ken said Karletta also was into alcohol and drugs but it took her longer to make changes in her life. Ken said he now has a positive relationship with Karletta and her husband.Ken described being Christian and said he doesn't drink any more especially because Barbie doesn't like drinking and he respects her and doesn't want to make her uncomfortable.Ken said he and Barbie have good communication and that they talk about everything. Ken stays active and in shape by working out at the gym,Ken and Barbie spend a lot of time with the kids. Ken described Barbie as good parent because she is always trying to learn, understand and excel as a parent. Ken said Barbie sacrifices for kids and wants what is best for them. She has great appreciation for family and the security of their marriage. Barbie said they nurture their marriage,they communicate and stay on same page,they don't let things go,and they try to understand each others wants,needs and desires. Sometimes Ken and Barbie have date night and after the kids go to bed they have time together. They teach respect for personal privacy. Ken and Barbie decide on major purchases by deciding if it is a need or a want and they consider where their finances stand. Ken and Barbie resolve differences through communication.When Ken is angry he takes time to think about things and to pray for guidance. Lying and not being trustworthy are qualities that are most upsetting to Ken. Ken feels fortunate these are not problems in his marriage. Applicants' Sons and Daughters Both Ken and Barbie have one child from a previous marriage and together they have one son Ken Jr.,who has mild developmental disabilities. When Ken Jr.was not developmentally on target especially with language as well as having sleep problems Ken and Barbie had him tested. Barbie did extensive research about Ken Jr.'s issues and has been able to control much of his behavior through diet. Ken Jr.has extensive food allergies and when these were controlled through diet he began to progress developmentally. Ken Jr.has progressed dramatically and currently is only about one and a half years behind for his age. Barbie and Ken have been very dedicated to Ken Jr.'s progress and his diet. Barbie prepares all of his food ahead of time and takes it with them where ever they go, including school. Babette Polo is Lisa's daughter through her marriage to Rolo Polo. Babette was born 3/30/92 and is in the 9th grade at Happyville HighSchool. Babette lives with her father,who is her residential custodian. Babette explained she lived with her mother until she was 11 and visited with her father during holidays and summers. Babette stated she wanted to live with her dad so her parents,who share joint custody,allowed her(and her brother Justin)to move.Babette visits her mother on weekends, holidays,during the summer and any other time if she wants. Babette presented as polite,well spoken and sincere.Babette likes to cook and she helps her mom and step mom in the kitchen. Babette especially enjoys pizza night and a movie with her dad. She likes spending time with her friends both from church and school. Babette spoke openly about her relationships with both of her parents,step parents and siblings. Babette believes it would be great to have more siblings and feels her mother is a good mom who has lots of love to share. Babette said she usually isn't in trouble about anything but if she ever is in trouble she would be grounded. Babette said her mom, step dad,her dad and step mom all get along real well and she thinks this is great because she can have a good relationship with both of her parents. Karl was born 3/20/92,and is Ken's son from his marriage to Karletta. Karl is in the 7th grade and achieves all A's. Karl presented as polite,well spoken and sincere. Karl likes to hang out with his friends,mostly he goes to his friends but sometimes they come to his house. Karl likes sports and plans to play football next school year. He structured Analysis Family Evaluation(SAFE)C Colorado Couple Multipurpose Home Study Report -Version 01-18-2006 Page 4 of 10 Copyright,2005,Consortium for Children,All Rights Reserved spends the summers with his mother in Nirvana,and plays baseball on a summer league when there. Last summer Karl was voted 'most valuable player' in the league. Karlk also has an interest in karate. Karl has two half siblings that live with his mother and step father. Karl believes it would be great for Barbie and his father to adopt more children. Karl doesn't think more children would take time away from him and he is excited about helping with any new siblings. Karl said he really likes kids and he helps with Ken Jr. because he chooses. Karl likes learning to cook and he especially enjoys baking treats.Karl said that treats are limited because of Ken Jr.'s diet but that's ok. Both Karl and Babette demonstrated patience and caring during their interaction with Ken Jr. Karl and Babette said they have lots of fun on weekends. They go to church,visit cousins, and play with friends. Ken Jr. said usually his step mom is home by the time he is home from school,that she picks up Karl after school and then comes home. Karl said if his step mom stops at the store, she will take Ken Jr.with her and then he is home by himself for a short while. Karl said he is usually never in trouble for anything but he has been grounded.Karl said his dad,mom and step dad all get along good. what Ken Jr. likes best about school is recess and the playground equipment but he also likes math. Ken Jr. said he has friends at school and in neighborhood and likes playing with them. Ken Jr. said sometimes he is happy and sometimes he gets upset at mom when she says clean up your room. Ken Jr. said when he gets in trouble he has time outs. He explained that when mom and dad get mad they go to their room and talk about stuff. Ken Jr. said his mom picks him up after school and they go home with Karl. Other children living or frequently in the home None Other adults residing or frequently in the home None Family Lifestyle Barbie works when Karl and Ken Jr. are in school. On a typical day,Barbie takes the kids to school,she goes to work and then picks up Ken Jr. up from school and is home when the kids are home.The family goes to church on Sundays,they go to gym as a family where Ken works with Karl on weight training. The family goes on hikes, drives to mountains,bike as a family,play roller hockey at the park,plays cards,do lots of outdoors activities and spend lots of time together. Ken and Barbie take care of their marriage by `dating',they like going to the mountains and riding their bikes together. Ken Jr.takes lots of time with his special diet requirements. Ken and Barbie have a few friends they know who understand Ken Jr.'s dietary needs so it is easier to do things with them. These friends watch Karl and Ken Jr. if Barbie and Ken go out.The children have to knock to come in parents room. The children share chores according to their age and ability.The family deals with privacy and nudity through rules that the boys can't go in Babette's room or her in their room without permission.Ken Jr. is becoming more aware of self and is learning the rules around respect and privacy.The family celebrates holidays and birthdays. On Christian holidays they go to church and often share holidays with families who don't have extended family close geographically. Ken helps with the housework and the other household chores are distributed among family members as are age appropriate. Everyone shares yard work,however Barbie enjoys working in the yard so she does a lot.Ken helps with cooking when Barbie is busy but Barbie is the primary person who cooks. Barbie and Ken enjoy hiking with kids,going to the mountains, and doing lots of outdoor activities. Barbie manages the family finances but they make joint decisions about purchases that are over$50. They have budget and if something is not in the budget they discuss it. Barbie and Ken have friends from church that they get together with for fun.They attend the Happyville Community Church weekly including weekly bible study. Barbie works when the children are in school. Ken and Barbie's expectations for the children are for them to respect and love each other and their parents,to abide by moral standards;they want the children to achieve grades as good as each is capable and they don't compare the children to each other. They expect the children to let know the parents know where they are. Karl rides his bike to school sometimes but he has to be home by certain time. He is allowed enough time to get home from the time school is out.Barbie and Ken are structured around what is best and safe for each child. If Karl does Structured Analysis Family Evaluation(SAFE)®Colorado Couple Multipurpose Home Study Report -Version 01-18-2006 Page 5 of 10 Copyright,2005,Consortium for Children,All Rights Reserved ,homework he can play outside until dark. Ken stated he remembers being secure and carefree during childhood and he wants the same for his children. Previous adoptions or foster care experience None FINANCES Combined monthly gross earned income: $4,340. Total monthly debts: $1,560. Total liabilities are $168,470 and total assets are$177,275. CRIMINAL/CHILD ABUSE RECORD The required criminal record and Child Abuse Index checks were completed for Barbie nee Fun Doll and Ken Doll. State automated system,CBI,ICON/Co Courts,and FBI(if applicable)Clearance Findings: Barbie had no history on the CBI and the FBI. Ken had a history of DWAI and minor in possession more than 10 years ago. Other findings: None EMERGENCY CARE PLAN Barbie and Ken have designated Barbie's brother DD as the person who would care for their children should something happen to them or they become incapacitated. This is in writing and DD and his wife both agree to the plan. CONTACT WITH FAMILY OF ORIGIN AND SIGNIFICANT OTHERS Depending on security and situation Barbie and Ken would encourage maintaining family contact with family of origin. REFERENCES References were received and all were supportive of Barbie and Ken as parents who are committed to each other and their children. The references stated Barbie and Ken were continual learners in order to be the best parents they can be. The references recommended Barbie and Ken as good candidates for adoption. FAMILY TRAINING Barbie and Ken have completed all CORE training requirement. They are both certified in CPR and First Aide. They have participated in and completed additional parenting classes and seminars. LEGAL/FINANCIAL RIGHTS AND RESPONSIBILITIES Barbie B. nee Fun Doll and Ken Doll have been provided with information concerning the different roles, responsibilities, legal and financial rights and benefits of relative/child specific kin caregivers, foster parents, legal guardians and adoptive parents. Also, should they file a petition to adopt,Barbie B. nee Fun Doll and Ken Doll understand that they will be accepting full legal and financial parental responsibility once an adoption is finalized. The agency's grievance procedures were explained to the Applicants. Structured Analysis Family Evaluation(SAFE)®Colorado Couple Multipurpose Home Study Report -Version 01-18-2006 Page 6 of 10 Copyright,2005,Consortium for Children,All Rights Reserved PSYCHOSOCIAL INVENTORY RESULTS NOTE: Below is a list of the psychosocial factors found on the SAFE Psychosocial Inventory. Using the Psychosocial Inventory, each factor was considered and rated several times by the social worker during the course of this home study. The ratings below represent the final ratings. The ratings are defined as follows: I =an exceptional strength,2=a strength, 3 = an issue of concern, 4 = a major issue of concern and 5 = very serious problem. The OVERALL EVALUATION OF SECTION ratings reflect the degree to which all issues of concern identified in the section were either resolved,mitigated or the prognosis for change. #1 #2 HISTORY #1 #2 EXTENDED FAMILY RELATIONSHIPS 2 2 Childhood Family Adaptability 2 2 Extended Family Cohesion 2 2 Childhood Family Cohesion 2 2 Extended Family Adaptability 3 2 Childhood History of Deprivation/Trauma 2 2 Relationship with own Extended Family 2 2 Childhood History of Victimization 2 2 Relationship with Spouse's/Partner's Family 2 2 Adult History of Victimization/Trauma 2 2 OVERALL EVALUATION OF SECTION 2 2 History of Child Abuse/Neglect 3 3 History of Alcohol/Drug Use PHYSICAL/SOCIAL ENVIRONMENT 2 3 History of Crime/Arrest/AllegationsNiolence 2 Cleanliness/Orderliness/Maintenance 2 2 Psychiatric History 2 Safety 2 2 Occupational History 2 Furnishings 2 2 Marriage/Domestic Partner History 2 Play Area/Equipment/Clothing 2 2 OVERALL EVALUATION OF SECTION 2 Finances 2 Support System #1 #2 PERSONAL CHARACTERISTICS 2 Household Pets 2 2 Communication 2 OVERALL EVALUATION OF SECTION 2 2 Commitment and Responsibility 2 2 Problem Solving #1 #2 GENERAL PARENTING 2 2 Interpersonal Relations 2 2 Child Development 2 2 Health and Physical Stamina 2 2 Parenting Style 2 2 Self-esteem 2 2 Disciplinary Methods 2 2 Acceptance of Differences 2 2 Child Supervision 2 2 Coping Skills 2 2 Learning Experiences 2 2 Impulse Control 2 2 Parental Role 2 2 Mood 2 2 Child Interactions 2 2 Anger Management and Resolution 2 2 Communication with Child 2 2 Judgment 2 2 Basic Care 2 2 Adaptability 2 2 Child's Play 2 2 OVERALL EVALUATION OF SECTION 2 2 OVERALL EVALUATION OF SECTION MARITAL/DOMESTIC PARTNER #1 #2 SPECIALIZED PARENTING RELATIONSHIP 2 2 Expectations 2 Conflict Resolution 2 2 Effects of Abuse/Neglect 2 Emotional Support 2 2 Effects of Sexual Abuse 2 Attitude toward Spouse/Partner 2 2 Effects of Separation and Loss 2 Communication between Couple 2 2 Structure 2 Balance of Power 2 2 Therapeutic/Educational Resources 2 Stability of the Marriage or Partnership 2 2 Birth Sibling Relationships 2 Sexual Compatibility 2 2 Child Background Information 2 OVERALL EVALUATION OF SECTION 2 2 Birth Parent Issues 2 2 OVERALL EVALUATION OF SECTION SONS/DAUGHTERS/OTHERS RESIDING OR FREQUENTLY IN HOME #1 #2 ADOPTION ISSUES 2 Minor Sons and Daughters 2 2 Infertility 2 Minors Residing or Frequently in the Home 2 2 Telling Child about Adoption 2 Adult Sons and Daughters 2 2 Openness in Adoption 2 Adults Residing or Frequently in the Home 2 2 Adoptive Parent Status 2 OVERALL EVALUATION OF SECTION 2 2 OVERALL EVALUATION OF SECTION Structured Analysis Family Evaluation(SAFE)©Colorado Couple Multipurpose Home Study Report -Version 01-18-2006 Page 7 of 10 Copyright,2005,Consortium for Children,All Rights Reserved PSYCHOSOCIAL EVALUATION REPORT HISTORY In spite of the numerous moves and marriages,Barbie's mother was able to create a sense of family,connectedness and adaptability that has carried over to Barbie's adult life. Barbie remains close with her mother and siblings and has formed close attachments with Ken's extended family.Barbie emerged into adulthood with a good sense of self worth and a determination to be the best she could. Barbie has admitted to trying marijuana on a couple of occasions but never has had a problem with drugs and/or alcohol, she does not use alcohol. Barbie's mother was her primary parent as her father was absent from her life until she was a teen. Barbie's mother set clear boundaries for her children as well as appropriate rules and expectations. There was minimal contact with extended family while Barbie was growing up due to frequent geographic moves. Barbie does not have any criminal history as a juvenile or adult. Ken's parents are still married. In his family,roles,rules and expectations were appropriate and adjustable. Family boundaries were clear and created both a sense of family belonging and a connectedness to the outside world.Ken had some problems with underage drinking and drug experimentation that lead to arrests and misdemeanor convictions after he was 18 and emancipated,particularly during his first marriage and following his divorce. Ken was able to turn his life around and was granted custody of his son Karl.Ken's parents supported him through all of his problematic situations. Ken remains close with his family and his extended family. Ken grew up with a large extended family and frequent family gatherings.Both Barbie and Ken have one previous marriage both were mutually dissolved and relationships with ex spouses and their new partners are good. All of the parents have been able to maintain positive relationships,creating security for the children. PERSONAL CHARACTERISTICS Barbie and Ken are dependable and responsible people with good moral standards and ethics.Neither have any significant health problems. They are culturally sensitive,respectful and support cultural diversity. Barbie and Ken are self confident,warm and engaging. They deal well with stress and seldom find reason to become angry. They are adept at problem solving through a process of communication and compromise. Both have good judgment skills and demonstrate responsible decision making. Responsibility and accountability are reflected in their daily lives. MARITAL/DOMESTIC PARTNER RELATIONSHIP Barbie and Ken have been married 8 '/s years. They are sensitive to each others needs and desires and both strive to make the other happy. They are committed to their relationship and actively nurture their marriage. Barbie and Ken believe in communication and work hard to keep communication open in their relationship and with their children.They are accepting of differences and allow the other to be an individual. Responsibilities within their home and family are shared appropriately including parenting responsibilities.Their marriage is stable and mutually satisfying. SONS/DAUGHTERS/OTHERS RESIDING OR FREQUENTLY IN THE HOME Barbie has two children from a previous marriage, her oldest is emancipated. Custody of Barbie's daughter is shared with the father. Ken has one son from a previous marriage,he is primary residential custodian. Residence and visits are arranged amenably between the parents according to what is in the best interest of the each child. All of the children presented as polite,happy,open and demonstrated a good sense of self. The children were excited about Ken and Barbie adopting. EXTENDED FAMILY RELATIONSHIPS Barbie and Ken maintain healthy emotional connections with extended family. Extended family is supportive of Barbie and Ken's plan to adopt. Extended family members have close relationships with all the children. PHYSICAL/SOCIAL ENVIRONMENT Structured Analysis Family Evaluation(SAFE)C Colorado Couple Multipurpose Home Study Report -Version 01-18-2006 Page 8 of 10 Copyright,2005,Consortium for Children,All Rights Reserved The Doll home is well maintained and free from any safety hazards/defects. It provides a comfortable living environment and affords adequate play space inside and out.The back yard is fenced and there are no safety concerns in the yard or with the exterior of the house.Family pets are current on vaccinations,gentle and good with children. They would not be overwhelming to a small child. Barbie and Ken are fully aware of their financial matters and make decisions responsibly. GENERAL PARENTING Barbie and Ken have demonstrated good parenting skills and abilities.They are knowledgeable about child development and behavior. They are able to set and enforce appropriate boundaries as well as maintain a warm and loving relationship with their children. They have age appropriate expectations and understand about age appropriate discipline. They have individual time with each child as well as lots of family time to interact with their children. They recognize each child is different and has their own needs and are able to meet the needs of each of their children. They support each child's interests and encourage each child to achieve according to their ability. Healthy diet is especially important due to Ken Jr.'s allergies and special needs. Barbie and Ken do not believe physical discipline is effective and use alternate methods of discipline.They continually seek to improve their parenting knowledge by reading and taking classes. SPECIALIZED PARENTING Barbie and Ken understand about providing unconditional love that may not be reciprocated and that there are pleasant and unpleasant parenting experiences. Children are important and they are willing to make necessary adjustments in routines and activities to accommodate the needs of a child they would adopt. Barbie and Ken are especially aware of the difficulties of parenting a child with special needs because of their own challenges with their son Ken Jr. Both have demonstrated exceptional willingness and ability to accommodate Ken's needs.They use discipline as a teaching tool and discipline is always age appropriate. ADOPTION ISSUES Neither Barbie nor Ken have fertility issues. They have biological children. They are open to discussing adoption with a child. When they discuss with a child that he/she is adopted will depend on the child and what is best for that child. They are open to contact with birth parents and extended family depending on the circumstances around security and what would be in the best interest of the child.They understand a child's right to know about their past. They believe cultural connectedness and heritage are important for a child and plan on supporting cultural awareness with any child they adopt. PSYCHOSOCIAL EVALUATION CONCLUSIONS Barbie and Ken will provide a safe,stable and loving home environment for any child they adopt. They are ready, willing and able to meet the challenges of adoption. They are prepared to meet a child's needs independent of agency involvement. They understand all of their legal and financial responsibilities.Their biological and step children are a reflection of their ability to provide appropriate parenting with stability,security and nurturing. CHILDREN THE FAMILY CAN BEST SERVE Barbie and Ken would like to adopt a child or small sibling group of two between the ages of birth to three years. Gender is not important and they are interested in a child or children with mild developmental disabilities as they have experience with mild developmental disabilities in their child,Ken Jr. structured Analysis Family Evaluation(SAFE)©Colorado Couple Multipurpose Home Study Report -Version 01-18-2006 Page 9 of 10 Copyright,2005,Consortium for Children,All Rights Reserved • RECO s NDATION It is recommended that Barbie B. nee Fun Doll and Ken Doll be approved for Foster Care Placement and Adoption. Patricia, ACBSW Supervisor Independent Vendor Title Date: 3/28/2007 Date Additional Attachments Questionnaires,Criminal Histories,Fingerprint Cards REVIEW OF COPY OF HOME STUDY REPORT By signing below I acknowledge that I have read a copy of this report. Barbie B. nee Fun Doll Ken Doll Date: Date To check for form u ates mess the cM kev�d click this link Structured Analysis Family Evaluation(SAFE)*Colorado Couple Multipurpose Home Study Report -Version 01-18-2006 Page 10 of 10 Copyright,2005,Consortium for Children,All Rights Reserved /04-7— C61se— Program Area Supervisor/Provider Meeting Verification/Comment Form Date of Meeting: 7/6 (07 Program Area: /]dfrne fit/el,es /fie-Ziyoli h n-t Comments (to be completed by Program Area Supervisor): acdSsi,or-ti >yC/udeI SAC, _CA vccos /,e. // fyvotieef Vpl#4.f/ ahoy in S 4 maid lou4J .c/4 C#, wo ' ice 2 , 0ltfataAL f2facess, 71/ise_y-hninit Cjcpacfif4s,5� rO , ' * Se ersA y g neat Se cs '( tor eta' /P SAtc.f 71-R4v e L/ ht-sty fr 21/ /#*/ 04.4 s Asti ,A..J7 tsu ( �u �` M , C" n f7�9AJ�io.y C4/ro /his c vcs,cp O,aa x !µb G/ /lt-v °t Comp/e>eQ new-1-e_ S rs £& nø- "inns in, h.'..4 Axe_ L.s leit-o( vegdee /, s / arliale#541 Signature of Program Area Supe • Print Date: 05/05/06 HCNA SERVICE RG PROVIDERS SERVICE ORGANIZATION PURCHASING GROUP CERTIFICATE OF INSURANCE OCCURRENCE POLICY FORM 018098 970 HPG 0281961014 from:12:01 AM Standard Time on:05/05/06 to: 12:01 AM Standard Time on 05/05/07 ISfi nlei inSift It i Pat M Chase Healthcare Providers Service Organization 215 Kuster St. 159 East County Line Road Brush, CO 80723 Hatboro, PA 19040-1218 Medical Special Code: riff " Social Worker,Clinical 72990 e _ ,: ,._ _-:� American Casualty Co. of Readi P ng, PA CNA Plaza 26S Chicago, IL 60685 GVE P 111 W a.;', awe;: ,x lustre ' iffiBi W k . .r .3 ,., -, „ ::.. A. PROFESSIONAL LIABILITY Professional Liability (PL) $ 1,000,000 each claim $ 3,000,000 aggregate Good Samaritan Liability included above r Injury Liability - Personal included above Mal LiabilityIacement _.. P included above B. COVERAGE EXTENSIONS: License Protection $ 5,000 per proceeding $ 12,500 aggregate Defendant Expense Benefit :;, , ;.,. , , _ $ 5,000 aggregate Deposition Representation $ 1,250 per deposition $ 2,500 aggregate Assault $ 5,000 per incident $ 12,500 aggregate Medical Payments _,.. $ 1,000 per person $ 50,000 aggregate -- First Aid $ 1,250 aggregate Damage to Property of Others $ 250 per incident $ 5,000 aggregate .............................. . C. WORKPLACE LIABILITY Coverage part C.Workplace Liability does not apply if Coverage part D.General Liability is made part of this policy. Workplace Liability included in A. PL limit shown above Fire & Water Legal Liability included in A. PL limit shown above subject to$150,000 sub-limit Personal Liabilityril $500,000 aggregate D. GENERAL LIABILITY Coverage pan D.General Liability does not apply if Coverage part C.Workplace Liability is made part of this policy. General Liability (GL) none none Hired Auto& Non Owned Auto none l Fire &Water Legal Liability none none Personal Liability — _.. :J 0 ., w..� . _ 0 .: -,., iii0 0 none.. Total Premium: $ 144 . 00 QUESTIONS!CALL: 1-800-982-9491 111 )r€strnit lt1Sien as ro t inception: G-121500-C G-121503 -C G-121501-C G-145184 -A G-147292 -A G-144872 -A G-123846-005 Master Policy#188711433 Keep this document in a safe place. II and pied of payment are evidence of your insurance coverage. 67-4-Y-4. e--sr- /177 IC6AAjA Zk --- Chairman of the Board - Secretary G-141241-A (07/2001) Coverage Change Date: Endorsement Change Date: Eel c v c4 C") Is u ell O C7:4 t to 4.4 \y� Q . W CO V � w E ,2 " cg l. Lt pt x O O E it 8 trzt v 7c 4 • EXHIBIT B SUPPLEMENTAL NARRATIVE TO RFP May 17,2007 Tobi Vegter,Core Services Coordinator Weld County Department of Human Services P.O. Box A Greeley, Co. 80632 Dear Tobi, I have read the recommendation concerning my bid approval, Home Studies,Updates and Adoption Home Studies for inclusion on your vendor list. I am writing to accept the recommendation of the FYC Commission. I estimate that approximately 20% of the clients I will serve through my bid will need bilingual services. I have adjusted my overhead costs to include interpreter services for these clients. This means approximately 3.5 home studies per year will need interpreter services at a rate of$15 per hour, average,times 6 hours per study,for a total overhead cost increase of$315 per year. Sincerely, atricia Chase J� Bid#007-HS-07(RFP 006-00B)Home Studies reta 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 Patricia Chase 215 Custer Street. Brush,CO 80723 Re: Bid#007-HS-07 (RFP 006-00B)Home Studies Dear Ms. Chase: The purpose of this letter is to outline the results of the Bid process for PY 2007-2008 and to request written confirmation from you by Monday,May 21, 2007. The Families,Youth, and Children Commission appreciate your interest in providing services for families in Weld county. This year,strides were made in structuring an RFP that is clear and concise,and more user friendly, for both prospective bidders and evaluators. It is important to stress the value of following formatting guidelines and addressing the required sections concisely and appropriately. A. Results of the Bid Process for PY 2007-2008 • The Families,Youth and Children(FYC)Commission recommended approval of your Bid# 007-HS-07, (RFP 006-00B)Home Studies,Updates, and Adoption Home Studies for inclusion on our vendor list. The FYC Commission attached the following recommendation to your bid. Recommendation:The approved bidder will pursue bilingual interpreters/translators/staff in order to better serve bilingual and monolingual clients.This may include offering incentives, accommodations,and encouragement to Spanish bilingual interpreters,translators, and staff. B. Required Response by FYC Bidders Concerning FYC Commission Recommendations: You are requested to review the FYC Commission recommendations and to: 1. accept the recommendation(s) as written by the FYC Commission; or 2. request alternatives to the FYC Commission's recommendation(s); or 3. not accept the recommendation(s)of the FYC Commission. Please provide in writing how you will incorporate the recommendation(s)into your bid. If you do not accept the recommendation,please provide written reasons why. All approved 'Page 2 Patricia Chase RFP 001-07/2007-2008 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, Core Services Coordinator, Weld County Department of Social Services,P.O.Box A,Greeley, CO, 80632,by Monday,May 21, 2007,close of business. If you have questions concerning the above,please call Tobi Vegter, 352.1551, extension 6392. Sincerely, A. ' go,Dir tor cc: Juan Lopez,Chair,FYC Commission Tobi Vegter, Core Services Coordinator Gloria Romansik, Social Services Administrator Weld County Department of Social Services Notification of Financial Assistance Award for Child Welfare Regular Administration Type of Action Contract Award No. X Initial Award 07-HS-0029 Revision (RFP-006-00B;008-HS-07) Contract Award Period Name and Address of Contractor Beginning 06/01/2007 and Transitions Psychology Group,LLC Ending 05/31/2008 Home Study,Updates,and Relinquishment Counseling 804 11th Avenue Greeley,CO 80631 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Assistance Provides timely,in-depth assessments of potential Award is based upon your Request for Proposal(RFP). foster homes, foster/adoptive homes,relative The RFP specifies the scope of services and conditions of placements and existing foster homes utilizing the award. Except where it is in conflict with this NOFAA in SAFE model,as required in the State of Colorado. which case the NOFAA governs,the RFP upon which this Total maximum monthly capacity is 18 families,with award is based is an integral part of the action. a monthly average of 10 families.The average stay in Special conditions the program is six weeks for home studies,four 1) Reimbursement for the Unit of Service will be based on weeks for updates and relinquishment counseling, either an episode or hourly rate per home study and home with an average of two hours per week. study update;and an hourly rate for relinquishment Approximately 100 individuals will receive bilingual- counseling and court testimony. bicultural services,and an estimated 105 individuals 2) Reimbursement requests must be an original with an will receive services in South Weld County. original signature from the provider and/or designee. 3) Reimbursement requests must include the date the home Cost Per Unit of Service study,update,or relinquishment counseling was completed. Episode Rateper The request must reflect the amount billed for each home Home Study with Background Check $1,200.00 study,the month the service was provided,and the Update to Home Study $780.00 completion date. Hourly Rate per 4) Payment will only be remitted on referrals made by Home Study or Update $120.70 Weld County Department of Social Services. Relinquishment Counseling $120.70 5) Requests for payment must be an original submitted to the Court Testimony $150.00 Weld County Department of Social Services by the end of 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 X Supplemental Narrative to RFP:Exhibit B from the date of service,and thereafter, will not be Recommendation(s) paid. X Conditions of Approval 10) The Contractor will notify the Department of any changes in staff at the time of the change. ApprovsEfst• Program Official: By CJ By l David E. Long,Chair Ju y riego, irector Board iry oµgtfiommi ioners Weld unty D a ent o Social Services Date: ��JrJ j LO Date: (0 1 1 07 O2D67-7296 • EXHIBIT A SIGNED RFP INVITATION TO BID BID 001-07 DATE: February 28,2007 BID NO: 001-07 RETURN BID TO: Monica Mika,Director of Administrative Services 915 10th Street-P.O.Box 758,Greeley,CO 80632 Third floor,Centennial Building,Purchasing Department SUMMARY Request for Proposal for: Colorado Family Preservation Act—Core Services Program Deadline: Friday,March 30, 2007, 10:00 a.m. (MST) The Families,Youth and Children Commission, an advisory commission to Social Services,announces that competing applications will be accepted for approved providers pursuant to the Board of Weld County Commissioners' authority under the Colorado Family Preservation Act(C.R.S. 26-5.5-101)and Emergency Assistance for Families with Children at Imminent Risk of Out-of-Home Placement Act (C.R.S. 26-5.3-101).The Families,Youth and Children Commission wishes to approve services targeted to run from June 1, 2007,through May 31,2008, at specific rates for different types of service,the County will authorize approved providers and rates for services only.This program announcement consists of the following documents,as follows: • Invitation to Bid • Main Request for Proposal (All program areas) • Addendum A—Program Improvement Plan Requirements(by program area) • Addendum B—Scope of Services(by program area) • Core Budget Form Delivery Date (After receipt ofJorder) BID "ST BE SIGNED IN INK Program Area: µolme 91441 f u ma k,/ �(i Sk jA s(/1 wept f- C0141/15, TYPED OR PRINTED SIGNATURE VENDOR Tra htittovls Ii4o IC L J . I�G %P IM, "°e-(+a V vvw v► , MA I LPL (Name) ✓ Handwritten Signature By Authorized Officer or Agent of Vendor ADDRESS 004 I ( 1 Ve. TITLE CO—P l Migf OI"eeIet, l CO x0(v3] DATE ',Val a PHONE# (1 -o) 33(0- I I ..3 1 The above bid is subject to Terms and Conditions as attached hereto and incorporated. • Program Area Supervisor/Provider Meeting Verification/Comment Form Date of Meeting: 7/r /07 Program Area: Am a �/vd,ef //Re-, K pv� � 4 yy� �F-- Comments(to be completed by Program Area Supervisor): / Oscan/on- . /NC/odes./ _cart_ I �e,4vlet, /f. // Srve-mpf , Ups/it/af / �t�/e+,.e Lit s h ss€a' 1pC.lvr /isk t'# WO nA-e Reif-e/1 paint., 5 71/sse 1.51 lot. 74/tt at~ ./ / gnegAt Ole iP.5 it Gca2f et, /Ps-745 ^f RpueL/ 7tn t7erra brit as" p4al. eale 1u.7` i% +e 4- (Pen ./A//a•., /4 o /7/s c a °Ida/ 4/1 GI Afi-a t Cokrp/a7`e.P SY�a t en 'qtr.__ S #)'e Ve nid /( .% s ,t . Signature of Program Area Supe Home Study, Update and Relinquishment Counseling Bid Proposal 2007-2008 ransitions ABSTRACT Transitions Psychology Group, LLC (Transitions) is a team of counseling, consulting and assessment professionals working together to provide innovative, effective behavioral health services to children, adults and families. The agency attracts creative, experienced professionals who are inspired to help others fulfill their potential, improve their relationships and strengthen their connection to their community and their world. The mission of the Home Study, Update and Relinquishment program offered by Transitions is to develop community resources of stable and nurturing foster homes and relative placements in order to help abused and neglected children find permanency in family settings that can adequately meet their needs for safety, development and affection. The purpose of the Home Study, Update and Relinquishment Counseling program is to provide high quality home assessment and consultation services to expedite permanency placements of children in Weld County. Transitions' Home Study, Update and Relinquishment Counseling program provides timely, in-depth assessments of potential foster homes, foster/adoptive homes, relative placements and existing foster homes utilizing the SAFE model as required in the State of Colorado. Family strengths and concerns are identified throughout the home study process and discussed openly with the prospective family. This process empowers the family to develop their strengths further and to address any specific concerns. Recommendations are made in order to remediate concerns, ensure appropriate support for the family and the children, and to promote stability of the placement. Efforts are made by Transitions counselors to train the family to proactively access community resources and improve their communication with agencies, providers, caseworkers. Transitions helps families to focus on meeting the needs of the children in their care by fostering independence, development, accessing medical and dental care, and maintaining cultural and racial connections. TABLE OF CONTENTS I. Target/Eligibility Populations 3 II. Project Narrative/Supportive Documentation 3 A. Types of Services Provided 3 B. Measurable Objectives 7 C. Service Objectives 8 D. Workload Standards 8 E. Staff Qualifications 9 F. Program Capacity by Month 10 G. Internal Tracking and Billing Process 10 H. Literature Citations 11 I. Confidentiality and Participant Protection/Human Subjects 12 III. Budget 14 IV. Appendices 14 A. Appendix I: Resumes B. Appendix 2: Data Collection Instruments/Protocols C. Appendix 3: Sample Consent Forms TARGET/ELIGIBILITY POPULATIONS ➢ Total number of clients to be served: 320 ➢ Total family units: 80 ➢ Sub-total of individuals who will receive bicultural/bilingual services: 100 Sub-total of individuals who will receive services in South Weld County: 105 ➢ The monthly maximum program capacity per group: 18 families ➢ The monthly average capacity: 10 families ➢ Average stay in the program (weeks): 6 weeks for home studies and 4 weeks for updates and relinquishment counseling ➢ Average groups per week in the program: families participate an average of two hours per week PROJECT NARRATIVE/SUPPORTING DOCUMENTATION A. Types of Services Provided 1. Home Study a. Background Checks and References When an authorized referral is received from the CORE services coordinator, Transitions e-mails the coordinator and the referring caseworker to confirm that the referral has been received. Transitions then delivers a packet of information to the prospective family. The family will be asked to complete an application, release of information, and the SAFE Questionnaire I. All adults in the household will be supplied with fingerprint cards to complete the CBI and FBI checks. Transitions will coiled and submit the fingerprint cards, incurring the costs for fingerprint processing for individuals referred by Weld County child protection caseworkers. Prospective foster/adoptive parents will be responsible for their own fingerprint processing cost. Additionally, Transitions will pay for and complete background checks with CoCourts to identify criminal, civil, traffic and money offenses cited in the Colorado court system. Transitions communicates with the caseworker to verify Central Registry information and to check for open cases with DSS. Transitions will distribute reference forms for up to four references provided by applicants. The references will be provided with a postage paid return envelope in which to return the reference form. Transitions staff will continue to contact the referred family by phone to address any questions posed by the family and expedite the completion of the paperwork. b. Family Screening A counselor from Transitions meets with all the members of the prospective foster family in the family home. The counselor explains the Home Study process and collects all materials from the family including the application, SAFE Questionnaire I, finger print cards, and reference lists. The counselor reviews the application with the family, discusses their responses on Questionnaire I, and assesses family interactions and functioning. Attention is placed on the potential of the family to provide stable placements, foster independent living, and the likelihood of accessing outside support and maintaining productive communication with providers and caseworkers. Family members over the age of 12 complete the FACES (Family Adaptability and Cohesion Evaluation Scales) IV instrument. The FACES IV scores, along with counselor observations, help to assess the family ability to meet the needs of children in their care. The SAFE Psychosocial Inventory is completed by the counselor after the interview. c. Parental Unit Interview A second counselor from Transitions meets with the prospective parent(s) to administer the SAFE Questionnaire II in person and review the answers with the parent(s). Some answers related to more sensitive topics will be reviewed in further detail in the Individual Interviews. During this interview the counselor evaluates the parent(s) ability to function as effective caretakers of children. The counselor further evaluates the parents' ability to maintain stability of placements, foster independent living, and access support services for the children in their care. The counselor will discuss the importance of maintaining open communication and monthly contact with caseworkers. Parents will also be educated on promptly accessing medical and dental care for children within two weeks of placement. Foster parents have the unique role of mentoring children and youth in their care; Transitions make efforts to make foster parents aware of this important role and assesses the parents' ability to effectively teach life skills. This interview will occur at least one week after the Family Screening. When appropriate, corroborative information from agencies and individuals that have been involved with family members will be included in the Home Study to supplement the family's self-reports. After the interview, the second counselor rates the family on the SAFE Psychosocial Inventory. d. Individual Interviews Following the Parental Unit Interview, in households with more than one parent, each parent will be interviewed individually. These interviews focus on evaluating each parent's general functioning, personal history, views on childrearing and motivation to become a foster parent. Questionnaire II is reviewed with each parent separately • during this assessment. An age appropriate, developmentally sensitive interview will also be held with each child residing in the home. The purpose of these interviews will be to assess the probable impact of fostering on the child and explore any child issues that could adversely impact foster children. The location of the individual interviews will be either in the family home or in the Transitions office, at the counselor's discretion. The SAFE Psychosocial Inventory will be completed again following this interview to ensure that the strengths and concerns in all areas are being sufficiently addressed. e. Team Consultation After the interviews have been completed and the background and reference and collateral data has been compiled, both Transitions counselors involved in the Home Study meet with a Transitions supervisor to review the case. The supervisor will have at least three years experience performing home assessments and have completed the SAFE training and the SAFE supervisor's training. The team reviews all of the information collected in order to formulate conclusions about the home study and delineate specific recommendations for the family. Recommendations are focused on the permanency needs to the children and geared towards strengthening the family. The report also includes recommendations to caseworkers to help them make successful matches between foster families and the children. f. Follow-up Contact The parental unit is contacted to review the issues identified in the Team Consultation. The counselor will share some of their perceptions with the family and any recommendations made by the team. g. Written Report Within six weeks of the receipt of the Home Study request from Weld County, the Transitions counselor will submit a written report to the referring caseworker. The report, signed by the counselor, supervisor and parent(s), will follow the State of Colorado format. The original fingerprint cards, CBI or FBI reports, application, original written reference forms and copies of the Questionnaires will be included with the report. After submitting the report, the Transitions counselor will contact the referring caseworker to ensure that the report was received and compiled satisfactorily. 2. Update a. Review of the Initial Home Study A Transitions counselor will review the previous Home Study and/or updates. The counselor will then contact the referring Weld County caseworker in order to determine the focus of the Update. b. Family Interview and Home Inspection The Transitions counselor will meet with all members of the household in the family home. The counselor will view the home and observe the interactions among family members. The SAFE Psychosocial Inventory will be review to ensure that all areas of assessment have been included in the update. c. Parental Unit Interview Parent(s) will meet with a Transitions counselor to discuss any changes that have occurred since the last Home Study or Update. Family strengths will be re-evaluated and progress towards improving areas of need identified in the previous study will be determined. The SAFE Psychosocial Inventory will be completed by the counselor. d. Supervisory Consultation The Transitions counselor will meet with the Transitions supervisor to review the case and develop recommendations. e. Written Report The Transitions counselor will submit a written report to the referring caseworker within four weeks of the date on which the Update request was received. The report will include specific conclusions and recommendations regarding the family's ability to provide a safe, nurturing environment for children. 3. Relinquishment Counseling a. Individual Parent Consultation After receiving a referral from the CORE services coordinator, a Transitions counselor will meet with the referred parent(s) to address questions from the Weld County Relinquishment Counseling Outline. The Transitions counselor will complete a risk assessment as deemed necessary. b. Follow-up Consultation and Review At least seven days after the first parent consultation session, the Transitions counselor will again meet with the referred parent(s) to review the previous session, check for understanding and address any further questions the parent may have. The counselor will also provide the parent with referrals and recommendations for other services as deemed appropriate. c. Written Report The Transitions counselor will provide a written description of the services provided that addresses all of the questions in the Weld County Relinquishment Counseling Outline. It will be submitted to the referring Weld County caseworker within four weeks of the date on which the referral was received. Transitions will provide Home Studies, Updates and Relinquishment Counseling as referred by the Weld County Department of Social Services. These services will not supplant existing services in the community, as these services are not funded by mental health capitation services, ADAD or other funding. Furthermore, Transitions encourages a continuum of care and service in collaboration with other providers so as to compliment services in order to enable families to meet treatment goals and to effect positive changes. B. Measurable Outcomes 1. More Expedient Placement of Children Transitions will track the date on which the referrals from the Weld County caseworker are received as well as the date the Transitions reports are submitted to the referring Weld County Caseworker. There will be no more than six weeks that transpire between the date of the receipt of the referral and the date the report is submitted to the County for Home Studies. Reports for Home Study Updates and Relinquishment Counseling will be submitted within four weeks of the receipt of the referral. If Transitions experiences delays, (e.g. applicants not completing the required paperwork, applicants not keeping appointments or applicant vacations), the referring caseworker will be notified and an adjusted time line will be determined. Submitting the majority of the reports within the four to six week time parameters will enable Weld County caseworkers to place children more quickly. To further facilitate caseworkers' decisions regarding placement, Transitions will perform an internal review of each Home Study and Update to ensure that it includes definitive conclusions and specific recommendations regarding the viability of referred families to become foster or adoptive homes. 2. Quality Adoptive Home Studies Done in a Timely Manner Transitions' Home Studies, Updates and Relinquishment Counseling, including bilingual services, will be performed only by degreed human service professionals. All Transitions counselors possess at least a Master's Degree in a human service field; most providers are licensed by the State of Colorado as Licensed Professional Counselors (LPC) or Licensed Clinical Social Workers (LCSW). Transitions has two bilingual LPCs contracted to perform home studies. Proof of each counselor's education will be provided to Weld County. The Transitions counselors and supervisors have also applied for inclusion on the State Vendor List. All Transitions counselors and supervisors will have completed the required SAFE training. Supervisors will have completed an additional training session for SAFE supervisors. Transitions uses a multidisciplinary team approach to staff each Home Study before the final report is completed and recommendations are made. This will be measured by at least three members of the Team Consultation, including the initial counselor, the primary counselor and the supervisor, signing off on the final report. Transitions will further ensure quality by perforrning an internal review of ail Home Study, Update and Relinquishment Counseling reports. The reviewer will document that the review has been completed. Transitions will track received dates for Home Study, Update and Relinquishment Counseling requests as well as the submission dates of the corresponding reports. Home Studies will be submitted within six weeks from the received date; Updates and Relinquishment Counseling reports will be submitted within four weeks from the referral date. 3. Number of Acceptable Home Studies Submitted The Transitions counselor submitting the written report will contact the referring Weld County caseworker within one week of the report's submission to ensure that the Home Study, Update or Relinquishment Counseling report was acceptable. Transitions staff will then document the contact in order to track the number of acceptable studies submitted. C. Service Objectives 1. Provide Quality Home Studies, Updates and Relinquishment Counseling for Adoptive Parents, Foster Parents and Department of Social Services' Clients. a. Transitions Home Studies, Updates and Relinquishment Counseling will be performed only by degreed human service professionals. Proof of each counselor's education will be submitted to Weld County. All of the services provided, including bilingual services, will be performed by Master's level counselors, with the exception of the tasks listed in the Background Check and Reference portion of the home study; these tasks may be performed by paraprofessional staff. b. Transitions Home Studies and Updates follow the SAFE model of analysis and evaluation. All counselors and supervisors are trained in and possess a thorough understanding of the SAFE model. c. A multidisciplinary team approach will be utilized to staff each Home Study referral before the final report is completed and recommendations are made. This will be measured by at least three Team Consultation participants signing the final report: the initial counselor, primary counselor and the supervisor. Updates will be staffed between the primary counselor and the supervisor as documented by both signing the final report. d. Transitions will perform an internal review of all reports to check for overall quality, writing skills, definitive conclusions and specific recommendations. The reviewer will document in the chart that the review has been completed. e. The Transitions counselor submitting the Home Study will contact the referring Weld County caseworker to ensure that the Home Study, Update or Relinquishment Counseling report is acceptable. Transitions staff will then document the follow-up contact and track the number of acceptable studies submitted. D. Workload Standards 1. Number of hours per day/week/month: Families in the Home Study program will participate for a minimum of one hour per week for a maximum of eight weeks. Update families will participate for a minimum of three hours during the four weeks of service. Weld County clients referred for Relinquishment Counseling will participate for a minimum of two hours during the four weeks of service. 2. Number of individuals providing the services: Each Home Study will be performed by two individuals: one counselor who conducts the initial Family Screening and another counselor who completes the remaining interviews of the family members and produces the report. A licensed psychologist will also be involved in the Home Study in a supervisory capacity, to assist with the evaluation of the family and recommendations. However, the supervisor will typically not have direct contact with the referred family. Updates will be performed by one counselor, but will also have the Team Consultation component with a supervisor for evaluation and recommendation purposes. Relinquishment counseling will be performed by one Master's or doctoral level, licensed counselor or social worker. Transitions currently contracts with one PhD, Licensed Psychologist for supervisory services; both co-directors have also completed the SAFE supervisor training. Three doctoral level staff and four master's level staff provide direct services. 3. Maximum caseload per worker: Each counselor will not carry more than four open Home Studies or Updates at any time. Counselors will not carry more than two Relinquishment Counseling cases at a time. 4. Modality of Service: Home Studies and Updates will consist of individual, couple and family service modalities with the referred family. Most of the services will be delivered in the family home, with the possible exception of the individual interviews, which may be held in the Transitions office. Case management services, case reviews, data collection and consultation without the family members present are also included. 5. Total number of hours per day/week/month: Transitions will provide approximately 2 hours of direct services per day, 10 hours per week and 43 hours per month. 6. Maximum caseload per supervisor: The Transitions supervisor will not exceed 24 open cases for Home Studies and Updates. 7. Insurance: Transitions co-directors and employees are insured through Healthcare Providers Service Organization Purchasing Group (HPSO). The limits of liability are $1,000,000 per occurrence and $6,000,000 aggregate. Contract staff members maintain their own policies, each with a minimum of $1 M/$3M liability. Current contracted staff members are insured through HPSO and the Philadelphia Indemnity Insurance Company. E. Staff Qualifications 1. Transitions co-directors and employees are insured through Healthcare Providers Service Organization Purchasing Group (HPSO). The limits of liability are $1,000,000 per occurrence and $6,000,000 aggregate. Contract staff members maintain their own policies, each with a minimum of $1M/$3M liability. Current contracted staff members are insured through HPSO and the Philadelphia Indemnity Insurance Company. 2. Transitions has 9 staff members, including a supervisor, available for the project F. Program Capacity per Month The Transitions program can serve a total of 85 family units, including 60 families for Home Studies, 15 families for Home Study Updates and 20 families for relinquishment counseling. As a minimum requirement to support the program, we would need to have 30 referrals for Home Studies, and 8 referrals for Updates for the program year. There is not minimum requirement for relinquishment counseling because the program can operate on Home Study and Update referrals alone. Referrals for relinquishment counseling are, of course, always welcome. G. Internal Tracking and Billing Process 1. Transitions receives new referrals via email, FAX and the post from the CORE services coordinator and the foster parent coordinators. Once a new referral is received, Transitions emails the CORE coordinator or foster parent coordinator and the primary caseworker to confirm that the referral has been received. Transitions' administrative assistant records the referral, including the due dates for our timeline. The referral is then assigned to an intake counselor and primary counselor by a co-director. The administrative assistant processes all necessary documents and tracks progress on the timeline for each referral and records this information for billing. 2. For this project, Transitions follows a continuous billing process in order to maintain prompt billing for services. Billing is initiated as soon as the home study, update or relinquishing counseling is completed. Transitions staff members are required to submit all signed and dated home study reports, updates, and relinquishment counseling reports upon completion with the accompanying documentation. Billing is submitted with original signed reports, Questionnaire I and II, all references, copies of the background check information, the invoices and authorization forms. The forms are audited by a co-director for accuracy and signed. The billing packet is then hand delivered to the Department of Social Services. H. Literature Citations Consortium for Children. (2005). SAFE: Structured Analysis Family Evaluation: Desk guide to the psychosocial inventory. Consortium for Children. (2005). SAFE: Structured Analysis Family Evaluation: Supervisor training curriculum. Consortium for Children. (2005). SAFE: Structured Analysis Family Evaluation: Workbook. Olson, D.H. (2004). Family Satisfaction Scale (FSS). Minneapolis, MN: Life Innovations. Olson, D.H. & Barnes, H. (1985). Family communication. Minneapolis, MN: Life Innovations. Olson, D.H. & Goral, D.M. (2003). Circumplex model of marital and family systems. In F. Walsh (Ed.). Normal Family Processes (3rd ed.). New York: Guilford (pp. 514-47). Olson, D.H. & Gorall, D.M. (2004). FACES IV; Innovation and Applications. Minneapolis, MN: Life Innovations. Olson, D.H., Gorall, D.M. & Tiesel, J.W. (2006). FACES IV package: Administration manual. Minneapolis, MN: Life Innovations. • • I. Confidentiality and Participant Protection 1. Protect Clients and Staff from Potential Risks Transitions counselors explain privacy rights in the State of Colorado and give informed consent with a HIPPA consent/release form to all client participants in our programs (see Appendix 3). The forms are signed by the clients. In order to protect confidentiality, a release of information is always requested and signed by clients (see Appendix 2). There are no foreseeable physical, medical, psychological, social or legal risks that would be caused by the program. It is possible the results of a home study or update would not be in favor of the family applying, which could have legal and psychological implications. In the best interests and protection of foster children and relative children, there are times when a home would be denied despite program goals to promote development of community resources. To mitigate the effects of this, families are informed in the family screening that they are being evaluated. Families are also routinely advised to seek legal advice when they have question of a legal matter. Furthermore,the results of the home study are discussed with the family during the follow-up contact, and when necessary, risk assessment and appropriate referrals for counseling are made by the counselor. 2. Fair Selection of Participants Participants for the project are not selected by Transitions. We accept referrals from DSS and do not discriminate for age, gender, racial/ethnic background or other reasons. 3. Absence of Coercion Often referrals are made for Transitions' social service programs as a result of a court order. In these cases, clients are essentially being required to participate in order to see their children, be considered as a placement for a child, or achieve other family goals. Transitions counselors recognize this dynamic and try to encourage positive interaction with the clients and help them to feel motivated to make positive changes in their lives. Clients are informed that they may seek a second opinion from another counselor or may terminate services at any time. Transitions is always willing to refer to other counselors and agencies as needed. Furthermore, Transitions discusses treatment alternatives with the referring caseworker. Nevertheless, Transitions recognizes our duty to help protect the well-being of children and to consider child safety when making recommendations for treatment. 4. Data Collection Data is collected directly from families, from the referring agency, and from other corroborative sources as necessary to complete the home study/update process. Data for relinquishment counseling is received directly from DSS and collected from the clients as needed in the process. A release of information from the client is always requested and signed prior to obtaining data. Transitions collect data from the families directly during interviews and through the use of forms designed for the program. The forms include the application, reference list, reference questionnaire, Questionnaires I and II, and the FACES IV instrument (see Appendix 2; SAFE materials are not included; home study application is not included because it is a DSS document). Each chart has a checklist that contains the protocol for the entire home study process (see Appendix 2). 5. Privacy and Confidentiality Transitions adheres to privacy and confidentiality laws and statutes in Colorado and the ACA (American Counseling Association) code of ethics. All data collected is used for the compilation of the home study report, update or relinquishment counseling report. The data is stored in a password protected database with a backup system and/or physical charts which are secured and maintained for seven years. 6. Adequate Consent Procedures Informed consent (see Appendix 3) is used according to the ACA code of ethics utilizing a HIPPA consent/release form. The program is not a research project and does not require assent forms for youth. It is sufficient and ethical to have parents agree to consent and to sign release forms (see Appendix 2) for their children. Youth age 15 and over are required to sign release forms. 7. Risk/benefit Discussion Completing a home study or update is necessary for a family to become a foster family, adopt children or to be considered for a relative placement. Thus, it is a choice of the family/individual to complete the process. Considering the well-being and safety of children, it is well worth the risk to make thorough assessments of families for placement of children. Relinquishment counseling is an important step in making sure the biological parents understand the implications of their choice. It also helps them to process the loss and separation. • BUDGET See attached form. Cost for Services: Home study with background check $1,200.00 Update to home study $ 780.00 Hourly $ 120.70 Hourly for relinquishment counseling $ 120.70 APPENDICES Appendix 1: Resumes for key staff members Appendix 2: Data collection instruments/protocols Items Included: 1. FACES IV, questionnaire and answer sheet 2. Reference list 3. Home study checklist 4. Release forms Appendix 3: Sample consent forms E H = E ) 2 8 I, \ 2 " ©O 2 \ 2 \ a co ® ® - / 63 Til IAD \ CV C. R _ 2 LO CV k / k R ~ co C° § ) k \ 2 2 a ® a I § .criw ) § k ? S § 0 k 2 § a. E 2 2 CNi 2 ) iii k n o , CO k k $ _7. ° S . 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S oo o'wwoNNonnoN$woo °z a a sp U H r 88$8888$$$888.$$$88 $ 8 8. $ w gag g » R p» tii 3 x x a n z age o el ggAgagAA446ggAg4g 88886 R'�8gR8�J S088 Co .= 8$8,8888888.8288$888 8 8 8 Ell 1 8 8 $ IIPAI ligInT11»$ R 1 glawRFIRRHg8R9RRRo9RR R0! glgg444gAAAA64IAA %3 Q O tg N N�NyyN�yN�yN��Ny N�Ny yN�yN��Ny "72 2 )YY CY))>Y))))YYY>)2 2 88$88888$888888$$ $ $ 8§§§1§§111n§1§§11§. § & R .0 »a8»iXS»»S�i» .$°J&»2 w r r - g t W a o e i ililliiii Iiii I illlifilligifillililli 4 4 4 H 0 0 • Jami Moe-Hartman, MA, LPC Transitions Psychology Group, LLC 804 1e Avenue Greeley, CO 80631 (970) 336-1123 Licensed Professional Counselor August 1999 to present State of Colorado, License #2296 National Board Certified Counselor April 1999 to present American Counseling Association Member 2002 to present EDUCATION Master of Arts in Community Agency Counseling August 1995 University of North Dakota, Grand Forks, ND • ND Board of Higher Education Tuition Waiver Scholarship • G.P.A. 4.0/4.0 Bachelor of Arts in Psychology May 1991 University of North Dakota, Grand Forks, ND • Minors in Chemical Use/Abuse Awareness and Visual Arts • Phi Beta Kappa PROFESSIONAL EXPERIENCE CounselorlCo-Director October 2001 to present Transitions Psychology Group, LLC, Greeley, CO • Develop and implement agency programs • Conduct assessments of foster and adoptive homes • Provide expert testimony in court • Provide individual and family therapy • Specialize in treatment of children, including play therapy • Provide therapeutic parent training, parenting education and life skills training • Coordinate services with multidisciplinary team and other agencies • Serve on community boards Therapist March 1999 to September 2001 North Range Behavioral Health/Child& Family Services Team, Greeley, CO • Provide individual, group and family therapy, including intensive in-home family therapy and outpatient services • Develop and implement treatment plans • Coordinate services with other agencies • Provide court testimony • Substance Abuse Counselor July 1998 to October 1999 ARC Counseling Center, Greeley, CO • Facilitate substance abuse education, anger management and relapse prevention therapy groups for court ordered adults (July 1998 - March 1999) • Substitute as facilitator of relapse prevention groups (March 1999—October 1999) • Provide progress reports to law enforcement and courts. Mental Health Therapist August 1996 - March 1999 North Range Behavioral Health I Children's Acute Treatment Unit, Greeley, CO • Provide intensive individual, group and family therapy to children and adolescents in a residential setting. • Coordinate services with other agencies • Develop and implement treatment plans • Assist in the development and management of the therapeutic milieu • Supervise clinical care assistants Family Advocate February 1995 -July 1996 Domestic Violence and Rape Crisis Center, Dickinson, ND • Assist in the development of policies, procedures and program services • Facilitate education/therapy groups for children and adolescents • Recruit, train and supervise children's group volunteers • Conduct public education seminars • Assist with grant writing and the compilation of statistics and reports • Develop, plan and execute fundraising events • Serve as the local coordinator for statewide criminal justice system monitoring project • Represent agency on community boards • Provide case management services to families utilizing the shelter facility • Provide crisis intervention services, information, referrals and advocacy to victims of physical/emotional/sexual abuse Victim Advocate July 1994 -February 1995 Community Violence Intervention Center, Grand Forks, ND • Provided individual therapy to victims of physical/sexual/emotional abuse • Facilitated an education/therapy group for victims of domestic violence • Screened and assisted persons applying for protection orders and disorderly conduct restraining orders; provided court advocacy; drafted permanent orders • Conducted public education seminars and assisted in training volunteers Gregory S Creed Transitions Psychology Group, LLC 804 11th Avenue, Greeley, CO 80631 Tel (970) 336-1123 FAX (970) 351-0182 Cell (970) 590-1424 e-creed(c)comcast.net Highlights of Qualifications • Doctoral level marriage and family therapist with over 8 years experience • Licensed Professional Counselor &National Certified Counselor • Professional training in family systems therapy • Proficient in Spanish and Japanese with highly develop cultural competencies. Relevant Experience Sept 1999-Pres Agency Co-Director & Marriage and Family Therapist, Transitions Psychology Group, LLC • Provide high quality marital and family therapy • Supervise counselors on several programs • Perform administrative functions for the agency Jan 99-Aug 99 Counselor/Case Manager,North Range Behavioral Health, 1306 11th Avenue, Greeley, CO 80631 • Provided in-home therapy services for family preservation referrals from DSS and for an interagency collaborative program • Maintained productive working relationships with caseworkers from DSS • Conducted therapy with Spanish speaking families • Produced positive outcomes with families and individuals Jan 98-Dec 98 Internship,North Range Behavioral Health, 1306 11th Avenue, Greeley, CO 80631 • Family, group and individual therapy with children, adolescents, and adults • Experience with family preservation, HeadStart and outreach programs • Case consultation with parents,teachers and program directors. 1996-1998 Program Coordinator, Center for International Education, UNC, 1945 10th Avenue, Greeley, CO 80639 • Coordinate cross-cultural programming campus-wide • Facilitate retention programs for international students • Direct home stay program for Japanese students 1994-1996 Assistant Language Teacher, Kyoto City Board of Education, Oike-Teramachi,Nakagyo-ku, Kyoto 616, Japan • Taught English to high school students in team-teaching format wit Japanese teachers • Encouraged Japanese teachers to be model learners of English and to explore new methods of teaching • Designed teaching materials and teaching plans • Helped team to develop new pilot English course 1990-1996 Owner& Instructor, Gregory's English School,Kyoto, Japan. • Taught 35 sutdents weekly in small groups, parent/child classes and in individual sessions • Helped demystify the learning process for students and helped them to develop a taste for self-guided learning 1989-1990 Spanish Instructor, Aims Community College, Greeley, CO 198-1988 Assistant English Teacher,Japan Exchange and Teaching Program, Kyoto Prefectural Research and Training Center,Nishi- machi,Morinagato, Momoyama, Fushimi-ku, Kyoto, Japan • Presented seminars and training workshops to Japanese educators • Taught English to high school students • Regional representative for Assistant English Teacher Association Education Ph.D., Counselor Education& Supervision,2006 M.A., Community Counseling,Marriage & Family Emphasis, University of Northern Colorado, 1999 B.A., McPherson College,McPherson, Kansas, Business Management& Spanish, 1986 Junior Year Study Abroad, University of Granada, Granadad, Spain, 1983-84 Certification & Licensure Licensed Professional Counselor,#2869 National Certified Counselor Presentations A Balancing Act: Strengths& Stressors for Families in Cross-Cultural Transitions,FIGT (Families in Global Transitions)Annual Confence, March 29-30, 2007, Houston, Texas The Mystery of Parenting Teens, Parent Training Seminar, St Mary Catholic Church Fall 2004 and St Peter Catholic Church Fall 2005 International Relocation:Implications for Families,Poster Session, Rocky Mountain ACES annual meeting, Oct 5-7, 1989, Jackson, Wyoming FACES IV Questionnaire Directions to Family Members: 1. All family members over the age 12 can complete FACES IV. 2. Family members should complete the instrument independently, not consulting or discussing their responses until they have been completed. 3. Fill in the corresponding number in the space on the provided answer sheet. 1 2 3 4 5 DOES NOT SLIGHTLY SOMEWHAT GENERALLY VERY WELL describes our describes our describes our describes our describes our family at all family family family family 1. Family members are involved in each others lives. 2. Our family tries new ways of dealing with problems. 3. We get along better with people outside our family than inside. 4. We spend too much time together. 5. There are strict consequences for breaking the rules in our family. 6. We never seem to get organized in our family. 7. Family members feel very close to each other. 8. The parents check with the children before making important decisions. 9. Family members seem to avoid contact with each other when at home. 10. Family members feel pressured to spend most free time together. 11. There are severe consequences when a family member does something wrong. 12. We need more rules in our family. 13. Family members are supportive of each other during difficult times. 14. Children have a say in their discipline. 15. Family members feel closer to people outside the family than to other family members. 16. Family members are too dependent on each other. 17. This family has a rule for almost every possible situation. 18. Things do not get done in our family. 19. Family members consult other family members on personal decisions. 20. In solving problems, the children's suggestions are followed. 21. Family members are on their own when there is a problem to be solved. 22. Family members have little need for friends outside the family. 23. It is difficult to get a rule changed in our family. 24. It is unclear who is responsible for things (chores, activities) in our family. 25. Family members like to spend some of their free time with each other. 26. We shift household responsibilities from person to person. 27. This family doesn't do things together. 28. We feel too connected to each other. 29. Once a task is assigned to a member, there is little chance of changing it. 30. There is no leadership in this family. 1 2 3 4 5 DOES NOT SLIGHTLY SOMEWHAT GENERALLY VERY WELL describe our describes our describes our describes our describes our family at all family family family family 31. Although family members have individual interests, they still participant in family activities. 32. Family members make the rules together. 33. Family members rarely depend on each other. 34. We resent family members doing things outside the family. 35. It is important to follow the rules in our family. 36. No one in this family seems to be able to keep track of what their duties are. 37. This family has a good balance of separateness and closeness. 38. When problems arise, we compromise. 39. Family members know very little about the friends of other family members. 40. Family members feel guilty if they want to spend time away from the family. 41.Family members feel they have to go along with what the family decides to do. 42.It is hard to know who the leader is in this family. 43. Family members are satisfied with how they communicate with each other. 44. Family members are very good listeners. 45. Family members express affection to each other. 46.Family members are able to ask each other for what they want. 47. Family members can calmly discuss problems with each other. 48.Family members discuss their ideas and beliefs with each other. 49. When family members ask questions of each other,they get honest answers. 50. Family members try to understand each other's feelings 51. When angry, family members seldom say negative things about each other. 52. Family members express their true feelings to each other. 1 2 3 4 5 Very Somewhat Generally Very Extremely Dissatisfied Dissatisfied Dissatisfied Satisfied Satisfied 53. The degree of closeness between family members. 54. Your family's ability to cope with stress. 55. Your family's ability to be flexible. 56. Your family's ability to share positive experiences. 57. The quality of communication between family members. 58. Your family's ability to resolve conflicts. 59. The amount of time you spend together as a family. 60. The way problems are discussed. 61. The fairness of criticism in your family. 62. Family members concern for each other. Thank you for Your Cooperation! +-tome stu.d Checldist For the svulth �pvu.t,Li� Referral source: _WCDSS Ivttalee Due Date: 4/C9/oj H-ovue stud Due Date: 5/4/07 o Covt.f,rvu. R..eferrai, sev„d out rfrttake Letter Assevu.bLe chart Map Q1,cest directiows Assigw to rte vutP Cou'tselor Ivtttalee Cou►nceLoY _FawLLly ScreewLwg IotervLew PLcl2 up Applicatiow, Refere1 .ce List, FLvt,gerprLwt cards, avt,d Q11est I covuplete Release, disclosure, I-flPAA av4 DMv coiksevtt forvu. FACES �Psychosocial Ivwevttory rativt.gs Favu.Lly screeo,Lwg report �ac2grouvtol Checl2s: CoGourts /CPA or F 1 /DMv Score FACES sevti,d out Re ferevuce questio. waLres Copy applicatiov+, avt,d QxestLouvoire ,AssLgvt,toPrivuary Counselor PrLWt cwj Couvt&eLor Parevtttal hitter/Lew (auestio1n.O,aire II) _Itndividual IvttewLews with EACH fat/v.11 vwew.ber CviecI2 Lw with referral source _Psychosocial Iwveutory ratLA.gs after each £&tervIew _reavu,Cowsult with prLwtoru couv.selor g supervisor (all sLgw sig. page) Subvuit Report to Iwtal}e Cou. selor for review _FINIAL FaMALLy IwtewLew (favuLly reviews aural sLgws covu,pleted report) TE-Mail f`Lvt.al report to o f fi.ce Returu chart to of fLce e _Subv&Lt ttovue Study to referral source (report, referevtoes, Quest I II) _Log covupletiow date Contact referral source to verify receipt of I-#owt.e study ____close Chart •i , 804 11th Avenue CONSENT/RELEASE . • •• • * Greeley, CO 80631 Home Studies • •�• • • Phone (970)336-1123 • ••�• • • S •. FAX (970)351-0182 • Transitions PSYCHOLOGY GROUP,LLC I authorize Transitions to release the information indicated to the agency or persons listed below for the purpose of completing the home study. Circle YES NO. I authorize Transitions to obtain the information indicated from the agency or persons listed below for purposes of service, completing a home study. Circle YES NO. This is the indicated information—circle every item YES or NO YES NO Treatment information to include history,attendance,diagnosis, progress in treatment,prognosis, treatment prognosis,treatment approaches/plan/goals, medication intervention and prescriptions. YES NO Motor vehicle,Criminal and financial court records. YES NO Psychological evaluation and testing summaries. YES NO Clinical evaluation/assessment summaries. YES NO Alcohol and drug treatment information. YES NO Physical exam,lab studies,and diagnostic evaluation. YES NO Personal references. YES NO Other(specify) The release pertains to: (Please Print) Name: Date of Birth: Name: Date of Birth: _ Name: Date of Birth: List complete names of no more than six(6)agencies or individuals regarding this release: Name of Agency or Person Address/Phone 1. Weld County Department of Social Services, Greeley CO (970)352-1551 2. Colorado Bureau of Investigation, Denver CO(303)239-4208 3. CoCourts, Denver CO 80203(303)861-1111 4. Federal Bureau of Investigation 5. 19th Judicial District, Weld County Co. 6. I understand that my records and/or those of any individual(s)listed above are protected under federal and slate confidentiality regulations. I understand that if I have authorized the release of drug abuse and/or alcohol abuse information that the confidentiality of this information is protected by Federal Law(42 CFR,part 2). This information cannot be disclosed without my written consent,unless otherwise specifically provided for in the regulations. I understand that I may revoke this consent at any time. Copies of this form may be used in lieu of the original. I understand and agree that this release form may be sent to the agencies and persons identified above. This consent expires and cannot be used past the following date: (Not more than one year) (Signature) (Date) (Signature) (Date) (Witness Signature) (Date) • . 20411t"Avewue ftIPPA CONSENT/RELEASE I. • •• Greele j,CO 20631 • • • " . Phone 570)336-1123 • ; FAX DA0)351-0132 1:.„.° • •• ♦ . ••Aim ' Transitions PSYCHOLOGY GROUP,LLC PRIVAC`r STATEMENT: NOTICE OF PRIVACy RIC -UTS THIS NOTICE CONTAINS INFORMATION CONCERN INCf f-tOW CONFIDENTIAL MENTAL AFALTH-TREATMENT INFORMATIoN CONCERNING you M.Ay gE RSED AND DISCLOSED AND f-tOW''OA.CAN O$TAfN ACCESS TO THIS INFORN IATION. PLEASE REVIEW IT CAREFVLLy AND LET Lis KNOW ANy QUESTIONS TI-(AT yovb MAY RAVE CONCERNING THIS NOTICE. DurLvO the process of provLdLhg services to lhou, KANSITIONS PS`(CH'OW ( c ROLIP LLC wLLL obtaLh and use vuehtaL heaLth curd tuec oaL LvrforrvotLow cowcerwLwg udou.that Ls both cc sfLdewtLaL avrd prLvLLeaed. ordLhareeLv this coo:Ld,ehtLaL Lvefovs&atLovi.wLL be used Lh the vwa vu/ter that Ls deso'rLbed Lh thL5 statev/.ev.t, awd wLLL hot be dLsclosed without vour consent except for the cLrcuvnstav,,ces dessyLbed Lv,this N ot:ce. RSES AND➢ISCLOSu.RES Of PROTECTED INFORMATION general uses awd Disclosures Not reofuiriv g the Client's Covsewt.Trawsttiows PsudchoLo?, c rcop LLC et 804_'Avew,ce, c reeletd,Co 20031`will Use awd disclose protected health iwforw.atLow LA the foLLowwrg via us. 1. Treahuent Treatw.ewt refers to the provtsiow., coordLwatLOW, or wl.a v,age'✓kewt of vvewtaL heaLth core av4 related seWtces bo owe or IM-Ore heaLth care avid related services bo owe or Luore health care providers.For exavv.pLe,Travvsltows PsYYchoLogb Group LLC Therapists awd staff Lwvolved War (Jour core o<aud use tour ivy*orntatiov.to Savo Id/our Course of treatwbert awd cowsu,lt with other heaLth care pro fessiowals or their staff cowcerwlvvg services weeded m-oravLded to um.b, 2. 7saenben.t.Padw.ewt refers to the activities v.wdertah.,ew bbu a health care providerto ob`alwor provide reivNburse*bewt for the provision of health care. For exavrL.pLe, Trawsitiows PsucI,Iologud Group LLC, awd other health core professionals will use Lwforvm.atiow that Eider/fifes Uou, Lwcludiwa Lwforvaatlow concerning uCour diagnosis,services provided to uou, dotes of services, awd services weeded bd UUou,and hold) discLose such iwforwtatiow to iwsuray.ee covw.pawies, to businesses that review bills for heaLth care services awd handle claims for pad w.ewt or heaLth care benefits iw order to obtalr pa bLvwewt for services. f Uou ore covered bu medicaid, iwforwbatiow rray be provided to the State of Colorado's medicaid prorafu, Lwe..udiwg but veot Lvuited to u,ovrtreatr.ewt, condition., dioawosis,awd services received. f+ealth Care Operation. Health Core Operatiow.s w.eaws activities uwdertarLew hd health lnsurawce covnpawies,businesses that advwiwister health plans, awd covwuawies that review bills for health care services iw order to process claiwts for health care benefits.These fuwctiows include vwavosevwewt awd adwuwistrative activities. For example,such cow.pavties vr.oee use dour health Lwforvwatiow tw vw-0witoriwg of service ofuatitu,staff train ivbs awd evaluation, medical. reviews, Legal services, auditing fuwctiows, corn.pliarce progravvs, business piano. e, and Accreditation, certification,Licevesiwg awd credewtialiwg activities. 4. eonkaetin a the Client.Trawsitiows Psddcholosud Group LLe vwaud covtaot udou to rewbiwd duou of appalwtveewts awd to teLL ud ou about treatw.ewts or other services that wbLght be of benefit to ud ou_ s. R.egedred be Law.Trawsitiows Ps udcholog Crroup LLC wile disclose protected heaLth iwforvvotLon whew required to Law. This Lwcludes, but is rot Linuted to (a) reporting child abuse or v.eoLect to the Depa rtncewt o f H AVVLSI w services or to Low ew foreew.ent;(b) whew court ordered to reLease Lwfori otiow;(c) whew there is a Legal drtc to warn of a threat that a client hoc *bade of Lrmvw4wewt phbsical violence, health core professionals ore required to wotifl/ the potential victim Of such 0 threat,and Yeport Lt to Law ewforcevte'nt;(d) When a client is L sosft entLUL dangerous to herself/htvusel f or to others,or is graveLu disabled,health core professionals w.ad hove a dutd to hospitalize the client in order to obtain 0 72-hour evaluation of the client; and(e! whew required to report a threat to the watiov.aL securLtuL of the sLwited states. E. Health oversight Activities. your confidential,protected health Ln forvuatiow v✓in.d be dscLosed to health oversight activities authorized b Low and necessaru for the the oversight of the health core ssysteru, govervuuewt health core'oenefLtprogravus, awd regvLatoruL progravus or doete✓winvwg covrpd.awce with program.standards. 7. Chi cues cps the premises or observed by rransi.tioas Psvchelog//yrouptL.C Personnel.CdLshes that ore observed bij TrowsLtLows Psdeholo9U croup LLC staff that Ls aLrected toward sto.fr,or occurs on Transitions PsbichoLogb tiroup LLC premises,will be retorted to law ewforcevuewt. g_ 8usiuess/4ssatiates. CowfLdentLaL health core Lv.formatLow cowcerwLwg von,provided tc insurers foY pin-poses orpaAw.ewt for Len/ices that ijou receive vua✓ be discLosed to business associates-For exnw.pLe,some advuLvtistrative, cLL,tLooi, e(uaLitu assurance, billing, Legal. audLti,wg avid aractice w.anageruent services vu.a l� oe provided by contracting with outside entities to peforvw those services- tw those situations,protected health information will be provided to those contractors as needed to perform,theLr contracted tosl s.BusLv.ess associates are required to enter into an. agreewest vuaiwtaLng the privac of the protected health LIMF0YVV.PtiOvt released to thew.. ? Research.Protected health Lnforw,azson cowcerkivtg 0U rv,o be used'N„tfl UOvr permS5ion for research purposes if the relevantprovLsiows of the Federal rtiPPA Privacy izegvLatiovs are followed. so. in✓oluntara Clients. 'n.forntatLon regarding clients,who are being treated Lwvoluntorad, pursuant to tow,will be shared with other treatvuestproviders, Legal entities,third part payers add, others,as necessary to provide the care amt nianaaew,ewt coordisatLon weeded Ls eow.pLLawce with Colorado Law. Is. Faneile MewbLYs. Exce_t for cercoLn stLsors, ivtcowpetent clients, or invoLvvttarbb csents, protected hen Lth Lwforvuatiow eawwot be provided to fa vuLLut vuewbers without the client's consent. iw sLtuations where fa wdt rv,-ennbers are present durinc,a d.Lse'.,ssiow with the e'.Lewt, and it caw 'he veasov.abld inferred from,the circur4.sea woes that the client does sot object, Ln.forw.atiow w,au he disclosed in the course of that discussLon. However, Lf the client objects,protected health LwforvuatLon will not be disclosed. 12. Fncergewoies. iw.LL fe th✓eaten:ono ewergewcies Transitions PsicichoLoo Group L.LC staff wLLL disclose information necessarH to avow serLous harvu.or death Client Release ofln{onration orAuthorization.Transitions PsvohoLogbi Crovp LLC.and other health care professionals nnauL nor use or dLsoLose protected health is forw.ation Ls ow2 wauL without a slowed release of LnforwatLos or authorLzatLon. when id On slot a release of Lnforw,atLow, or on avethorLzatLon, Lt vwaut Later be revolted,trovLded that the revocation Ls',n wrLtLng.The reVocatLon wLLL appu , excett to the extent T'a wsLtions PsvohoLogb Group LLC hoc aLreadd taltew octisw Lw reLLawce thereon. . . yoL&R RICH-TS AS ACLlENT A. Access to Protected wealth lwforw,atLov..you hove the right to receive a suvuwnarun of cov.fLdewtLaL health Ln forvuatiov.concerning uou, cowcerv.Lng vuental health services weedea or provided to don.There are sowte LLvtLtatLows to thLs right,which wLLL be provided to tdou at the time of Liour request, Lf and such LLwtLtatLon applies.To vwalte a request, Os2 Transitions PsltdchoLogm Croup LLC St0f.F for the appropriate reo vest form. B. Avuendvu.ent of your Record. you.have the right to request that Transitions Ps ucho'.ogu Croup LLC or dour health professionals avuend uJour protected health LwforvuatLon.Transitions Psuchologd Croup LLC es not reavLred to amend the record if it is determined that the record Ls accurate and cowpLete.There ore other exceptions,which will be-provided to both at the tLwte of uL our request, Lf relevant along vAth the appeal process avaLLable to you.To ma'2e 0 request, asl2 TransLtLows PsuLchologLi Croup LLC staff for the appropriate request forva. C. Accounting of DLsoLosures.you have the right to reeeLve on accovntLng of certain disclosures Traw5LtLOn5 PsychoLogb Croup LLC has vuade regarding Hour protected health iwforstotLon. However,that accountLng does sot_LncLude disclosures that were made for the purpose of treatw,ewt,?QUI/Kest, Or health care operosions. In adhLtLon, the accountLng does not Lndude disclosures wade to dow disclosures wtade pursuant too sLgwed Author'LZotL0n,or dLssclosures vwad.e prior to_Juluu 1,2004.There are other exceptions that wLLL be provided to tuow should uJou request an accounting.To wraree a request, ass Transitions staff for the appropriate recvicest fora+.. D. Additional.Restrictions. you have the right to request additional restrictions on,the use or disclosure of your health iciformatiow.Transitions Psduchologo Group LLC does not have to agree to that request,and there are certain Limits to ant restriction,which will be provided to sou at the tine of uyour request.To molfe a request as'R Transitiows staff for the appropriate request form. E. ALter'narEv'e Mtaws of Receiving Confidential Communications,you have the right to real test that you receive covwvu.uwieatiows of protected health ivvforw.atlow from Transitions Psvnchologg group LLC by alternative means or at alternative locations.For example,if dot.do not wort Transitions Psudehology Group LLC to mail bills or other materials to Umrr horse, Uou caw Ireque5t that this inforw.atiow be sent to another address,There are Limitations to the granting of such reouests,which will ne provided to Uou at the time of the request process.To vnals reovtest, ash Transitions star for the appropriate request form. F. Coed of this Notice. You have a right to obtain another copy of this notice upon request. al. ADDITIONAL INFORMATION A. Privaad Laws.Transitions PSHchologu Croup LLC Ls required bri state and Federae Law to w,.aiwtaiw the privacg of protected health information. In addition, Transitions Ps JchoLogud Grovp LLC is required bid law to provide clients with notice of its legal duties and privac j practices with respect to protected health information.That is the purpose of this Notice. S. rr_rws of the Notice and Changes to the Notice.Transitions PS.ychologti Group LLC is required to abide bi the terms of this Notice,or anti amended Notice that mod follow.Transitions reserves the;.fight to change the terms of its'notice and to maize the new notice provisions effective for allprotected health information that is w_a!ntains. whew the notice is revised,the revised notice will be posted and available span request_ a Gavwplai•nts Regarding Privacid Rights. I f Ijou believe Transitions Psuchologud Group LLC has violated doter privacbe rights; gout have the right to compiainto Transitions Psudehoiogm Group LLC mawagew.ent.Please submit vosr statement in,writiwg addressed to Transitions Psve'hoiogi/ Group LLC, 504 1St'Avenue, .reeLey, Co 8003?, concerning d our CoroLairt and the basis for it.yon.also have the right to complain to the united states secretard of Health and riuw.an se vices but sending Elortr complaint to the office of civiiL Rights, H.S.Depa,sent of ttealth and !-!uman services, 200 independence Avenue,s.w.RAam stsf, r+r'l-F pldg. washi.ngtow D_e.20201. It Cs the policy of Transitions Psduchologv Group LLC that there wiLL be no retaliation for odour filing of such complaints D. Additional nformation,. If bou desire additional,inforwatiow about yourprivaoJ rights at Transitions Psd,choLocT Group LLC.,please asl2 its any ovestions that dou r.to,sj have. Iv. CONFIDENTIALITY'OF ALCOHOL AND DRR4 ASR.Se PATIENT RECORDS A. The confidentialitd of alcohol and drug abuse patient records maintained bid Transitions Pswchologgd Group LLC is protected by Federal Law and regulations. GeneraLLud, the program maud not spud to a person outside the program that a patient attends the program., or disclose anti information identifuding a patient as an alcohol or drug abuser nnless 1. The patient comments in writing. 2. The Disclosure is allowed bd a court order. Or 3. The disclosure is wade to medical personnel sin o medical emergenc or to qualified personnel for research, audit,or program evaluation. violation of the Federal Law and regulations bpi a program is a crime.suspected violations mad be reported to appropriate authorities in accordance with Federal regulations. C.. Federal Law and regulations do not protect anud information about a crime committed bud a patient either at the program or against anti person who worns for the program or about and threat to commit such a crime.Disclosure matt.) be wade concerning anti threat made to commit imminent phudsicat violence against another person to the potential victim who has been threatened and to Law enforcement. D. Federal Low and regulations do not protect any information about suspected child abuse or neglect from being reported under state Law to appropriate sate or Local authorities. • V. EFFECTIVE DATE,Tf}IS NOTICE IS EFFECT1VEJKLY 1,2004 I KN➢ERSTAND THESE DISCLOSKRES; 11tAVE RECEIVED A COPY OF TI-HS➢ISCLOSKRE STATEMENT AND NOTICE OF PRIVACY RIly F{T5. CLIENT SI C,NATKRE DATE EXHIBIT B SUPPLEMENTAL NARRATIVE TO RFP 80411th Avenue �s • .{ Greeley,CO 80631 4! Tel.(970)336-1123 - FAX(970)351-0182 Transitions N<T<NOLOLI MNMVN, LL<N May 18, 2007 Tobi Vegter, Core Services Coordinator Weld County Department of Social Services P.O. Box A, Greeley, CO, 80632 Re: Bid #006-.6-07 (RFP 05005) Lifeskills Bid# 003-FPT-07 (RFP 006-00C) Foster Parent Training Bid #008-HS-07 (006-00B) Home Study, Relinquishment Counseling Bid #006-MH-07 (RFP 006-00) Dear Ms. Vegter. I am writing in response to the award letter dated May 11, 2007 for the 2007 RFP process. We greatly appreciate the awards for our programs and would like to respond to questions on our bids. • Bid #006-LS-07 (RFP#07005), Lifeskills. Responses: Recommendation: The approved bidder will pursue bilingual interpreters/translators/staff in order to better serve bilingual and monolingual clients. This may include offering incentives, accommodations, and encouragement to Spanish bilingual interpreters, translators, and staff • Transitions currently has three bilingual providers available for this program. We continually seek out experienced bilingual therapists. In addition, we supply educational materials in Spanish for clients. Conditions: The bidder must clarify and submit information that was not addressed or included with the original bid submission. 1. Provide a copy of insurance. See enclosures. 2. Provide staffing information, including resumes and education levels of staff. See enclosures. 3. Address mandated caseworker training for staff. This was addressed in Section E, 3; `Mandated New Caseworker Training: One full-time • Page 2 • Transitions Psychology Group/Results of RFP Process for 2007-2008 Transitions counselor has received mandated new caseworker training. Other counselors will not receive this training.° Additional providers would attend New Caseworker Training if required by the Department. 4. Address bilingual/bicultural services. Transitions has three Spanish/English bilingual therapists. All master level counselors have had coursework and training in multicultural competencies. 5. Provide rates for levels of service (parent education and therapeutic visitation). We do not have different levels of service on this program. Transitions Lifeskills services are all therapeutic and as such are provided by Master's level clinicians. The rate for services is $100.06 per hour. 6. Address step-down services. Transitions works with an internal consultation team to tailor and adjust the level of service according to the family's needs and progress. We attend Core Review Team meetings monthly to ensure the level of service is appropriate for each case. Transitions regularly refers families to less intensive services after therapeutic services. We transition visits from the more restrictive office environment to the less restrictive home environment when possible. Hours of service are decreased gradually to phase out treatment. • Bid #003-FPT-07 (RFP#006-00C), Foster Parent Training. Responses: 1. Bidder must address and clarify class size. The evaluating committee requests that the bidder not limit class size. Transitions will not limit class size. Transitions determined class size in order to provide optimal training. We have since understood that class size normally does not exceed 20 participants and that it is critical not to delay certification for funding purposes. 2. Bidder must address whether there is a lead"trainer. Address the consistency and continuity of hainers4raining. Dennette Janus, MA, NCC, a therapist and former child protection caseworker, is the designated lead trainer for Transitions. Other profressional staff and consultants will provide training on various topics in order offer additional expertise and maintain the interest of participants. a Provide a curriculum as requested in the RFP. 'See enclosure. 4. Provide a copy of insurance. See enclosure. • Bid#008-HS-07 (RFP#006-00B), Home Studies,Updates, and Relinquishment Counseling. Repsonses: 1. All staff must attend Core Caseworker Training. All staff attended the required SAFE training and three staff attended an additional training for SAFE supervisors to satisfy the vendor requiremenets. In a discussion with Dave Aldridge, we were told that the Core Caseworker Training requirement is waived for home study providers. 2. The bidder must address the Program Improvement Plan (PIP). The PIP Page 4 Transitions Psychology Group/Results of RFP Process for 2007-2008 out qualified, experienced, bilingual therapists and psychologists. The acquisition of psychological testing materials in another language is difficult due to limited availability and cost. It is not ethical to translate the standardized tests as they have not been normed on multicultural populations. The program has had no referrals for psychological evaluations last year and only two in the previous program year. As the program progresses, this service could be developed. Conditions: The bidder must submit information that was not addressed or submitted with the original bid submission, including: 2. Evidenced-based Practices: Transitions utilizes only norm-referenced psychological tests. All are nationally recognized and have been extensively researched in order to develop the norms required to interpret the tests. Transitions uses Parent-Child Interaction Therapy as an evidenced-based component of the interactional assessments. Transitions uses the Parent Stress Index as an evidence-based component of the mental health assessment. Please see reference section of the bid for additional research information. 3. Bilingual services: Transitions has one bilingual provider, a licensed professional counselor, available for mental health assessments and interactional assessments with Spanish-speaking clients. Psychological Assessments are not available in Spanish for this program year. 4. Program Improvement Plan (PIP), a placement changes: Transitions providers are experienced in assessing children and adolescents and will make written recommendations in the reports for psychological evaluations, mental health assessments and interactional assessment to help maintain a child in their placement Alternately, if this is not appropriate, providers will delineate how a change in placement will advance the child's permanency goals. If a child is free for adoption, providers will include specific recommendations to assist the Department in how to prepare the child for an adoptive home as well as identify when a goal of adoption is not appropriate for a child. 5. Copy of insurance. See enclosures. Sincerely, --� C (( 7 Gregory S Creed, PhD, LPC Co-Director, Transitions Psychology Group, LLC Page 3 Transitions Psychology Group/Results of RFP Process for 2007-2008 was addressed in the bid proposal in the narrative. However, the following summarizes that content: • Placement Changes: Transitions will never advise or give permission for a child to be removed from a placement. Our role is to assess the home and make recommendations that will help establish permanency and help foster parents and relative placements access the supportive services they need in order to preserve placements. • Independent Living: Transitions home study providers will assess the prospective parents capacity to develop independent living skills with children in their care. In addition, the home study makes appropriate recommendations for the education and support of foster parents to development new capacities that will encourage independent living skills in children. • Maintaining Cultural and Racial Connections: Transitions home study providers will assess the family's ability and willingness to maintain the cultural and racial identity of the children in their care. Transitions will help prospective foster care providers access community resources where applicable through recommendations and conditions. • Monthly Face-to-Face Visit with Caseworkers: Transitions home study providers will emphasize to prospective foster famlilies the importance of communication and collaboration with the Department . Home study providerrs will reinforce the requirement of monthly face-to-face contacts between caseworkers and foster children and encourage foster parents to be proactive in maintaining this contact with the Department. • Timely Initial Assessment within Two Weeks of Placement Transitions will assess the potential foster family's ability and willingness to complete medical and dental appointments for each child placed in their care within the alloted time (2 weeks for medical and 8 weeks for dental). • Health Needs Identified and Services Provided: Transitions will assess the potential foster family's awareness and willingness to • communicate with caseworkers in identifying health needs and services of children and adolescents in their care. • Bid#006-MH-07 (RFP#006-00), Mental Health, Responses: Recommendation: The approved bidder will pursue bilingual interpreters/translators/staff in order to better serve bilingual and monolingual clients. This may include offering incentives, accommodations, and encouragement to Spanish bilingual interpreters, translators, and staff 1. Transitions has one bilingual provider available for mental health assessments and interaction assessments. Transitions continues to seek a rtte DEPARTMENT OF SOCIAL SERVICES P.O. BOXA ' GREELEY, CO. 80632 Website:www.co.weld.co.us Administration and Public Assistance(970)352-1551 OMay 11,2007 Fn Number(970)353-5215 • COLORADO Jami Moe-Hartman,Co-owner Transitions Psychology Group,LLC 804 11 Avenue Greeley, CO 80631 Re: Bid#006-LS-07(RFP 05005)Lifeskills Bid#003-FPT-07(RFP 006-00C)Foster Parent Training Bid#008-HS-07(006-00B)Home Study,Relinquishment Counseling Bid#006-MH-07(RFP 006-00)Mental Health Services Dear Ms.Moe-Hartman: The purpose of this letter is to outline the results of the Bid process for PY 2007-2008 and to request written confirmation from you by Monday,May 21,2007. The Families,Youth, and Children Commission appreciates your interest in providing services for families in Weld county.This year,strides were made in structuring an RFP that is clear and concise,and more user friendly,for both prospective bidden and evaluators. It is important to stress the value of following formatting guidelines and addressing the required sections concisely and appropriately. A. Results of the Bid Process for PY 2006-2007 • The Families,Youth and Children(FYC)Commission recommended approval of your Bid#006-LS-07(RFP#07005),Lifeskills for inclusion on our vendor list.The FYC Commission attached the following recommendations and conditions to your bid. Recommendation:The approved bidder will pursue bilingual interpreters/translators/staff in order to better serve bilingual and monolingual clients.This may include offering incentives, accommodations, and encouragement to Spanish bilingual interpreters,translators, and staff. Conditions: The bidder must clarify and submit information that was not addressed or included with the original bid submission. 1. Provide a copy of insurance, 2. Provide staffing information,including resumes and education levels of staff, 3. Address mandated caseworker training for staff, 4. Address bilingual/bicultural services, 5. Provide rates for levels of service(parent education and therapeutic visitation), 6. Address step-down services. Page 2 Transitions Psychology Group/Results of RFP Process for 2007-2008 • The Families,Youth and Children(FYC)Commission recommended approval of your Bid#003-FPT-07 (RFP#006-00C),Foster Parent Training,for inclusion on our vendor list.The FYC Commission attached the following conditions to your bid. 1. Bidder must address and clarify class size.The evaluating committee requests that the bidder not limit class size. 2. Bidder must address whether there is a"lead"trainer. Address the consistency and continuity of trainers/training. 3. Provide a curriculum as requested in the RFP, 4. Provide a copy of insurance. • The Families,Youth and Children(FYC)Commission recommended approval of your Bid#008-HS-07(RFP#006-00B), Home Studies,Updates,and Relinquishment Counseling for inclusion on our vendor list.The FYC Commission attached the following conditions to your bid. 1. All staff must attend Core Caseworker Training, 2. The bidder must address the Program Improvement Plan(PIP). • The Families,Youth and Children(FYC)Commission recommended approval of your Bid#006-MH-07(RFP#006-00),Mental Health,for inclusion on our vendor list.The FYC Commission attached the following recommendation and conditions to your bid. Recommendation: The approved bidder will pursue bilingual interpreters/translators/staff in order to better serve bilingual and monolingual clients.This may include offering incentives, accommodations,and encouragement to Spanish bilingual interpreters,translators, and staff. Conditions: The bidder must submit information that was not addressed or submitted with the original bid submission,including: 1. Evidenced-based Practices, 2. Bilingual services, 3. Program Improvement Plan(PIP), 4. Copy of insurance. B. Required Response by FYC Bidders Concerning FYC Commission Conditions and Recommendations: 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. Conditions: All conditions will be incorporated as part of your Bid and Notification of Financial Assistance Award(NOFAA). If you do not accept the condition(s),you will not be authorized as a vendor unless the FYC Commission and the Weld County Department of Social Services accept Page 3 • Transitions Psychology Group/Results of RFP Process for 2007-2008 your mitigating circumstances. If you do not accept the condition,you must provide in writing reasons why. A meeting will be arranged to discuss your response.Your response to the above conditions will be incorporated in the Bid and Notification of Financial Assistance Award. The Weld County Department of Social Services is requesting your written response to the FYC Commission's conditions and recommendations.Please respond in writing to Tobi Vegter,Core Services Coordinator,Weld County Department of Social Services, P.O. Box A,Greeley,CO, 80632,by Monday, May 21,2007,close of business. If you have questions concerning the above,please call Tobi Vegter, 352.1551,extension 6392. Sincerely, V� J y A. 'ego,D. for cc: Juan Lopez,Chair,FYC Commission Gloria Romansik, Social Services Administrator Tobi Vegter, Core Services Coordinator Weld County Department of Social Services Notification of Financial Assistance Award for Child Welfare Regular Administration Funding Type of Action Contract Award No. X Initial Award PY07-08-HS-0032 Revision (RFP-006-00B; 005-HS-07) Contract Award Period Name and Address of Contractor Beginning 06/01/2007 and Keith Wawrzyniak, Private Practice. Ending 05/31/2008 Home Studies,Updates, Relinquishment Counseling 36376 Mason View Road Eaton,CO 80615 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Total number of clients to be served is the Assistance Award is based upon your Request for combination of any proposed services that Proposal(RFP). The RFP specifies the scope of equals 30 hours a week.Total number of clients services and conditions of award. Except where it is will be determined by evaluator's ability to in conflict with this NOFAA in which case the complete a thorough evaluation within the NOFAA governs, the RFP upon which this award is designated time period. The provider will utilize based is an integral part of the action. the County and State to conduct background Special conditions checks on each family. It is expected that this 1) Reimbursement for the Unit of Service will be based provider will complete the home studies in the on an episode/hourly rates for home study; home allotted time frames, conducting home studies in study update,and hourly rate for relinquishment a timely manner in an effort to expedite counseling. placement of the child. 2) Reimbursement requests must be an original with an original signature from the provider and/or designee. Cost Per Unit of Service 3) Reimbursement requests must include the date the Hourly Rate per home study, update, or relinquishment counseling was SAFE Home Study with Background Check* $46.52 completed.The request must reflect the amount billed SAFE Home Study Update** $46.52 for each home study, and the month the service was Terminated(by DSS) SAFE Home Study $46.52 provided. Requests for services submitted 90 days Relinquishment Counseling $95.29 from the date of service, and thereafter, will not be Court Testimony $75.00 paid. Episode Rate per 4) Payment will only be remitted on referrals made by SAFE Home Study with Background Check* $930.55 the Weld County Department of Social Services. SAFE Home Study Update** $465.28 5) Requests for payment must be an original submitted to Additional Adults in Household(per adult) $200.00 the Weld County Department of Social Services by the end of the 25th calendar day following the end of Enclosures: the month of service. The provider must submit X Signed RFP:Exhibit A requests for payment on forms approved by Weld X Supplemental Narrative to RFP: Exhibit B County Department of Social Services. Requests for Recommendation(s) payments submitted 90 days from the date of service, X Conditions of Approval and thereafter, will not be paid. 6) The Contractor will notify the Department of any changes in staff at the time of the change. BApproval Program ffici 1: (1 David E. Long, Chair Judy . riego, irector Board of Weld County Commi ioners Weld unty Department Social Services Date: JUN 1 8 2007 Date: (O/I I/Ui 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 Ma k, (After receipt of order) BID MUST BE IGNED IN INK H Program Area: Hale STUO i �✓ JJ I, TYPED OR PRINTED SIGNATU VENDOR Kedi P Witi.Jr2yntak(Name) f Handwritten Signature By Authorized / Officer or Agent of Vendor ADDRESS 34 371 fl4 ri9w/D TITLE 0WN se. 'AWN/ ci? n/,r DATE V?? 07 PHONE# (vo) yos 77/J The above bid is subject to Terms and Conditions as attached hereto and incorporated. INVITATION TO BID BID NO.: 001-07 CORE SERVICES CONTRACT FOR SAFE HOME STUDIES, UPDATED SAFE HOME STUDIES, AND RELINQUISHMENT COUNSELING RESPONSE FORMAT PROPOSAL Submitted By: Keith Paul Wawrzyniak, Jr. 36376 Mason View Road Eaton, Colorado 80615 1 TABLE OF CONTENTS 1. Project Description 1 page 2. Sample Home Study 10 pages 3. Sample Relinquishment Counseling Outline 1 page 4. Target/Eligibility Populations 1 page 5. Type of Services to be Provided 1 page 6. Measurable Outcomes 1 page 7. Service Objectives 1 page 8. Workload Standards 1 page 9. Staff Qualifications 1 page a. Resume Attachment 1 page 10. Unit of Service Rate Computation 1 page a. Unit of Service Rate Computation- SAFE Home Study 1 page b. Unit of Service Rate Computation- Update SAFE Home Study 1 page c. Unit of Service Rate Computation- Relinquishment Counseling 1 page 11. Billing Process a. Description of Process 1 page b. Demonstration of a Monthly Billing i. Cover Letter 1 page ii. Original Billing 1 page iii. Request for Reimbursement 1 page 12. Lowest Qualified Bid 1 page 13. Program Capacity by Month 1 page PROJECT DESCRIPTION The mission of this project is to conduct and complete a comprehensive home study to determine the appropriateness of placement of a child into a foster home, adoptive home, or a relative's home. The home study will be conducted using the tools provided by SAFE and statutory and regulation requirements. The thorough evaluation process will be initiated by gathering as much information as possible with the target family through interviews and the tools provided by SAFE. That information will be evaluated and analyzed, without bias or prejudice. The issues of concern will be addressed with the family and education or training may be implemented or recommended. A thorough assessment of all the information gathered will be conducted, which will help with evaluating the family and identifying strengths and weaknesses and will facilitate a good match or assess the appropriateness of an existing placement. The home study will be conducted using interviews, structured questionnaires, assessment guides, family references, and a preformatted home study report to assist in focusing on individual and family functioning. This will contain factual and descriptive information. The goal of this evaluation process is to determine whether a particular home is safe and viable for a particular child, to determine if the parents are equipped or knowledgeable to handle the inherent needs of a foster child, to identify strengths and weaknesses in the home and provide education in those areas of weakness, and to, ultimately, determine if a home environment is a good match for a child in need of a nurturing and safe home. I have successfully completed the SAFE home study certification. The objective is to conduct good quality home studies, updates, and relinquishment counseling in a professional and timely manner. TARGET/ELIGIBILITY POPULATIONS The target populations will be determined through the request for home studies submitted by the Department of Social Services. The majority of this population will reside within the County of Weld, but not limited to this area. The total number of clients to be served will be the combination any proposed services that equals 30 hours a week. The total number of clients will be determined by this evaluator's ability to complete a thorough evaluation I within the designated time period. The monthly maximum program capacity is to be determined. It is expected that this provider will complete the requested home studies in the allotted time frames. The services provided to the families will be determined by the Department of Social Services. This provider will make recommendations based on any noted weakness of the family. This provider will utilize the county and state to conduct backar and >checks on each .famil T 's rovider II utili to Vic a —of Y y vailable and authorize y e Department of Social Services that will supplement the ome s y evaluation process. 7`' -------_. ---/_— — — t C TYPE OF SERVICES TO BE PROVIDED This provider is interested in conducting home studies, updated homes studies, and relinquishment counseling as referred by the Weld County Department of Social Services. This provider is able and willing to invest 30-40 hours of work, on a weekly basis, that may be a combination of participation in the above-mentioned services. 7 The services of this provider will not su lant existing and available services in the community. The use of services in e community is o e determined by the epartmen o ocia e ices. This provider will utilize the tools provide SAFE to conduct home studies. This provider will utilize personal transportation to make visits to the home. Questionnaires and evaluation tools will be used to complete the home study. This provider will conduct home studies in a timely manner in effort to expedite placement of the child. MEASURABLE OUTCOMES This provider has a SAFE certification from January 07'. The provider will utilize the tools of SAFE to conduct acceptable home studies. SAFE is set up to provide an objective assessment of the home environment and the personalities within the home. It provides structure and organization to the home study that should help expedite the placement of children. There will be a minimum of four hgroe visits within at 7-14 day period_ This provider will attempt to have the home study completed within two to three weeks. Updated home studies within one to two weeks, after request. This provider will meet the allocated contact hours with a client for relinquishment counseling. It is a priority of this provider to ensure the home study to be thorough and precise upon completion. Qualitative and quantitative measures will be determined by the Department utilizing this provider more and more as they appreciate the effort of this provider. SERVICE OBJECTIVES This provider will conduct quality home studies, updates, and relinquishment counseling. The use of the tools of SAFE is required by the state, when conducting home studies. This provider will gather information through interviews with the family members. Other information will be gathered from the questionnaires offered by SAFE. This provider will analyze the results of the questionnaires and the information gathered in the interviews. A psychosocial evaluation will also be completed. This provider will use this information to identify the weaknesses and strengths of the parents. This will help to determine the permanency needs of children in out-of-home placements or the ability of this home to meet the needs of a certain foster child. Background checks will also be conducted. The information received from the childhood history of the parents, their current functioning capacity, disciplinary approaches, morals and values, their surrounding family system and how they interact, and other information and observations, will all be evaluated and assessed to determine the viability and safe placement of a child. • WORKLOAD STANDARDS A. Number of hours per day, week or month per SAFE home study, updated SAFE home study, and relinquishment counseling services • SAFE Home Study-At a minimum, each individual home study requires 20 hours per month. The time allowance may include but is not limited to family contact hours, travel time, documentation, research and other time expenditures necessary to complete the home study. • Updated SAFE Home Study-At a minimum, each individual home study requires 10 hours per month. The time allowance may include but is not limited to family contact hours, travel time, documentation, research and other time expenditures necessary to complete the home study. • Relinquishment Counseling Services- Relinquishment counseling services will be assessed on an hourly basis as needed. B. Number of individuals providing the services Keith Paul Wawrzyniak, Jr. is the sole individual providing the services described in this RFP C. Maximum caseload per worker The maximum caseload per worker assuming the minimum time allotment per service provided is 30 hours per week, 120 hours per month, or any combination of the services provided equaling 30 hours per week or 120 hours per month. (Example#1: 6 home studies Example#2: 5 home studies and 2 updated home studies.) D. Modality of service Utilize the SAFE home study method and procedure as a model approach to ensure an accomplished, thorough final product. E. — G. Do not apply because source of bid is an individual H. Insurance Insurance coverage to include:• Standard Workman's Compensation and Employer's Liability „e �fri • General Liability(PL and PD) state required minimums �i}� • Professional Liability Insurance • MEASURABLE OUTCOMES This provider has a SAFE certification from January 07'. The provider will utilize the tools of SAFE to conduct acceptable home studies. SAFE is set up to provide an objective assessment of the home environment and the personalities within the bogie. It provides structure and organization to the home study that should help expedite the placement of childrerfdThere will be a mini n umof four home v sits within ar 7.14 day period. This provider will attempt to have the home study completed within two to three weeks. Updated home studies within one to two weeks, after request. This provider will meet the allocated contact hours with a client for relinquishment counseling. It is a priority of this provider to ensure the home study to be thorough and precise upon completion. Qualitative and quantitative measures will be determined by the Department utilizing this provider more and more as they appreciate the effort of this provider. ve cciff-C vi 0/2 c7.0 Aoy 7Cchi-C 7C- Cairea7 c�� rr roc 4 "73.c . U " arc S ' s STAFF QUALIFICATIONS Keith Paul Wawrzyniak, Jr. is the sole provider of services under this RFP. All qualification descriptions will be limited to the qualifications of Keith Paul Wawrzyniak, Jr. to complete SAFE home studies, updated home studies and relinquishment counseling services for Weld County. See attached Resume for a comprehensive description of education, experience, certification and training. KEITH P. WAWRZYNIAK JR. 36376 Mason View Rd. Eaton, CO 80615 Email:keithwawrzyniak@peoplepc.com FORMAL EDUCATION: James Madison University, Harrisonburg, VA Bachelor of Art in Psychology: May 1994 University of Northern Colorado Masters in Special Education coursework Bachelor of Art in Spanish coursework WORK EXPERIENCE: 6/98 —9/02, Department of Social Services 7/06 - current Child Protection/Youth-in-Conflict Caseworker III/Foster Parent Liaison • Investigated allegations of physical abuse and neglect as well as emotional and sexual abuse. • Collaborated with law enforcement and community resources to provide intervention for families. • Provided expert court testimonies and conducted telephone screening. 6/06-8/06 NRBH-Kathleen Littler Center(Residential Treatment Center for Adolescents). Unit Supervisor • Provide supervision for inpatient staff of approximately 20 members • Collaborate with staff, teachers, and therapist to provide the best care and education to the children. • Therapeutic Crisis Intervention (TCI) facility trainer(to be completed September 2006). 9/02—5/06 Banner Health Systems Behavioral Health Inpatient Unit Co-Lead • Provided supervision for discharge planners and inpatient staff of approximately 35 members • Maintained collaborative effort and ongoing communications with outpatient and adolescent programs to ensure smooth transitions, appropriate case management and proper care. Behavioral Health Case Worker • Provide individual case management including obtaining collateral information for MDs, psych-social evaluation, substance abuse assessment and discharge planning. • Collaborate with MDs, RNs, and Therapist to coordinate inpatient and aftercare treatment planning. • Provide patients with community resources, referrals to appropriate human service agencies, outpatient disposition, and facilitate transfers to other hospitals or long term care facilities. • Act as advocate providing education, counseling, and crisis intervention to patients and their families. 3/96—9/02 Banner Health Systems Psychiatric Team Assistant • Provided psychiatric and non-licensed nursing care for mentally ill and dual diagnosis patients within an acute medical psychiatric unit. • Provide Milieu management and crisis intervention/de-escalation for patients within facility. • Facilitate inpatient groups, observed and charted patient behaviors and conducted order entry. PROFESSIONAL SKILLS SAFE Certification BLS- Health Care Provider/AED CAC License coursework Practical fluency in Spanish Sexual abuse interview and investigation certification Mental health physical restraints training MedSeries computer training CPR-current REFERENCES Upon request ATTACHMENT UNIT OF SERVICE RATE COMPUTATION See Attached Budget Worksheet Note: Column G- "Overhead Costs" may include, but are not limited to, allocating funds to the following items: • Background Checks • Insurance Costs • Travel/Mileage • Phone Conversations • No-Shows • Discussions with Involved Parties • Meeting Preparation • Report Completion • Facility Usage 2 o in § / } � k CO o E , 0 § et I / = 0 / . (13 2 0 _ 0- 0 , c t ra I— 8 § ! m ) | 22 C.) 1/43 c � cp CO � / a g , _ 0 i.1152 rk ) / 2 � 0 , / � f/ k ° ■ E r 2 ` § a � / � \ = ; t .0 . § !J I2. \ 0L � k � TA aalt \ ) � � la® $ ▪ co • o 4 , e q Co / § \ CD a. 0 � 0 0 / \ktit � p 4 _ 'CM • o ( 0 O 46- Us. a) ffi to a w To VI\ {• k \ � m co 0 ▪ CO k \• m \ / | $ } 7 . § co o E o 00 _ ) § 2 � A r ( ) ) \ o CO o 22co q o a ° § « § S ) i + a co sO. r B § / rt > on ) \$ \ 2 § o ! / ! ko 0 o \� k ) ) LiJ � k " ° f ! 0 0@ o To� 5 , en co o 0or ° E ° § ; /o | ! \ § b2 o .2 in o 0 3 4—L2 BILLING PROCESS A. Description of Process Monthly billing form(s) will be submitted to Ms. Elaine Furister CPS/CAP, Core Services Specialist, on or about the 10th day of the month after the month the services were provided. The monthly billing form(s) will include: • Cover Letter o Introduction o Summary of Contents o Contact Information • Original Billing o Provider name, address, phone number o Provider billing contact, phone number o Program area or type of service o Total dollars ($) billed o Month of service o Original signature from provider and/or designee • Request for Reimbursement o Client information (provider number/household number) o Caseworker name o Rate o Units billed o Date(s) of service o Completion date B. Monthly Billinq Demonstration See Attached • Cover letter • Original Billing • Request for Reimbursement 36376 Mason View Road Eaton,Colorado 80615 March 30,2007 Ms. Elaine Furister CPS/CAP, Core Services Specialist Weld County Department of Social Services P.O. Box A, 315 B N 11 Avenue Greeley, Colorado 80632 Re: Month of Services Dear Madam: Enclosed please find the Weld County Core Services Original Billing Document and the Weld County Core Services Program Monthly Request for Reimbursement for the referenced month of services. If there are any questions or concerns, please don't hesitate to contact me. Sincerely, Keith Paul Wawrzyniak,Jr. Core Services Provider Attached: Original Billing, Request for Reimbursement ATTACHMENT WELD COUNTY CORE SERVICES PROGRAM MONTHLY ORIGINAL BILLING- PY 2007-2008 Keith Paul Wawrzyniak, Jr. Services Provider: 36376 Mason View Road Eaton, Colorado 80615 Keith Paul Wawrzyniak, Jr. Services Provider Billing Address: 36376 Mason View Road Contact/Information: Eaton, Colorado 80615 Email: Keith.wawrzyniak@peoplepc.com Phone: (970) 405-7716 Home Studies Services Provided: Update Home Studies Relinquishment Counseling Total Amount Billed: Month of Service: Provider Name- Keith Paul Wawrzyniak, Jr. Provider Signature- Keith Paul Wawrzyniak, Jr. Date ATTACHMENT WELD COUNTY CORE SERVICES PROGRAM MONTHLY REQUEST FOR REIMBURSEMENT - PY 2007-2008 SAFE Home Studies, Home Study Updates, Relinquishment Counseling Provider: Keith Paul Wawrzyniak,Jr. 36376 Mason View Road Eaton, Colorado 80615 Client/Foster Provider No. Completion Units Rate Per Monthly Services Payments Social Services Family Name HH No. Date Unit Total Payable Denied/Delayed Comments Only Monthly Totals Provider Signature- Keith Paul Wawrzyniak, Jr. Date Remit to: Elaine Furister, Core Services Specialist Weld County Department of Social Services P.O. Box A, 315 B N 11 Avenue Greeley, Colorado 80632 Telephone: 970 352-1551, Extension 6295 Fax: 970 346-7698 Email: ATTACHMENT LOWEST QUALIFIED BID The lowest qualified bid for services proposed and submitted herein by Keith Paul Wawrzyniak are as follows: Service Details Cost SAFE Home Study Home Study with Background Check $930.55/Per Case Study or $46.52/Per hour Unit(as per budget calculation) SAFE Home Study Update to Home Study $465.28/Per Case Study Update or Update $46.52/ Per hour Unit (as per budget calculation) Terminated SAFE Home Study cancelled by DSS 46.52/Per hour Unit Home Study Additional Adults in Background Check and SAFE Home Study to $200.00/ Flat fee per additional Household include additional adults in household adult for home study Relinquishment Relinquishment Counseling $95.29/per hour for relinquishment Counseling counseling PROGRAM CAPACITY BY MONTH Minimum The minimum capacity per month for services provided by Keith Wawrzyniak, Jr. is to be determined by need and availability of Weld County Social Services. Maximum The maximum capacity of clientele per month for services provided by Keith Wawrzyniak, Jr. is a total of 160 hours per month or in excess of 40 hours per week. SAFE Child Specific Home Study Report This home study was completed by KEITH WAWRZYNIAK to consider the placement of a specific child or specific children with the applicants for the purpose of either relative or foster care placement, Legal Guardianship and/or adoption. Name of Family: Mike and Jan Core Address: 1212 Ash In Home greeley ' State: co Postal Code: 80631 o.,,... City: Phone: (970)111-1111 Cell Phone: (970)222-2222 APPLICATION DISPOSITION The Applicants applied specifically to be considered for the placement of Kevin Michael Bacon. Certified for Foster Care/Approved for Adoption on: January 1, 2007 Home Study Application received on: October 3, 2006 APPLICANT INFORMATION Jan May Core Mike James Core Date of Birth: Feb. 2, 1970 Date of Birth: Nov. 10, 1968 Birthplace: Omaha,NE Birthplace: Boystown,NE Gender: Female Gender: Male Religion: Christian Religion: Christian Occupation: Secretary for their business Occupation: Contractor Language(s): English Language(s): English Education: College Education: High School Height: 5'6' Height: 5'10" Weight: 130 Weight: 190 Hair: brown Hair: brown Eyes: blue Eyes: brown Date of health questionnaire/report: Nov. 29, 2006 Date of health questionnaire/report: Nov. 29, 2006 MARITAL INFORMATION Date of Marriage: 06/15/96 Marriage Verification: On File Place of Marriage: Greeley, CO DATES OF CONTACT Date Individual/Couple Location October 10, 2007 Joint interview with Mr. and Mrs Core residence Core October 10, 2007 Indiv. interview with Adam Core Core residence October 16, 2007 Interview with Mr. Core Core residence October 16, 2007 Interview with Mrs. Core Core residence October 21, 2007 Joint Interview with Mr. and Mrs. Core October 24, 2007 Joint Interview with Mr. and Mrs. Core Structured Analysis Family Evaluation (SAFE) Colorado Couple Child Specific Home Study Report -Version 03-19-2007 Copyright,2005,Consortium for Children,All Rights Reserved • CHILD OR YOUTH BEING CONSIDERED FOR PLACEMENT Kevin Michael Bacon is a 3-year old male child, who was born on April 9th, 2003. Kevin was taken into protective custody after the Department of Social Services responded to numerous reports of a neglectful environment with concern of drug use in the home. Kevin was removed from the home and placed into foster care on January 6, 2006. The biological parents have been unsuccessful with their treatment plans after many attempts. Mr. and Mrs. Bacon have agreed to termination of parental rights. Mr. and Mrs. Core met Kevin for the first time last week at the current foster home. They stated that he was pretty shy towards them during the visit. The caseworker has provided Mr. and Mrs. Core with any pertinent information relating to Kevin and his biological family. Kevin is a very active 3-year old, appearing to be developmentally on track. Kevin has shown a little aggression toward the other children in the foster home when they take something he is playing with. Kevin has responded appropriately to behavior redirection by the foster parents. Kevin is physically active and likes to color. Kevin may have some Attachment Disorder traits. Kevin has not had any contact with his biological parents in two months. Kevin has been observed to cry out for his biological parents. Kevin portrays some attachment issues that are not being therapeutically addressed at this time. Kevin also has a temperament with children that are his age or younger. Kevin can throw quite a yelling tantrum if something is taken away from him when he is no ready to give it up. The tantrums are loud, but short. Time outs have worked well with Kevin. Kevin may need therapeutic services for attachment issues or any other behavioral/emotional concerns that may arise. MOTIVATION Mr. and Mrs. Core expressed their enjoyment with raising their child, Adam. Mrs. Core stated that she had complications while giving birth and could not have any more children. Mr. Core stated that their business is finally established and comfortable, and they are excited that they are pursing the adoption of a child. Mr. and Mrs. Core stated that they believe they can provide a safe and secure home for a child and look forward to being able to share their love with another child. Mr. Core stated that their son is looking forward to having a brother or sister. HOME ENVIRONMENT Type of residence House Square Footage 2950 Bedrooms: 4 Bathrooms 2 1/2 Length of Time in current residence: 5 years This is a 5-year old ranch style home sitting on 2 acres of land. The home has been maintained with nice landscaping. There is a 1200 sq. ft. workshop behind the home where Mr. Core keeps his work tools and equipment. There are four bedrooms in the home. Three bedrooms on the main floor and the bedroom in the basement is used as an office for their business. Mr. Core stated that their mortgage payment is only$1000.00 a month, as he built the home. The home has city water and runs off propane for heat. The backyard consists of approximately 3000 sq. ft. of grass with a play set for children. This area is surrounded by a 3 ft. tall, chain link fence. The rest of the land is gravel or dirt, with a vegetable garden to the side of the shop. There is no pool on this property. The Cores have a 4-year old black lab that is an outside dog. He has a very good temperament and does very well with children. Mrs. Core stated that Adam is always outside running and playing with the dog(Ralphy). Mr. Core stated that he likes to hunt and has a rifle and shotgun that he keeps, unloaded, on the top shelf in his closet. This home is surrounded by a small community of homes that appear to be sitting on 2-5 acre parcels of land. Mrs. Core said that their community has an annual community barbeque. The home is 10 miles from town and 5 miles from the school that Adam attends. The interior and exterior of the home were inspected for health and safety hazards. The inspection was completed on October 14,2007. Structured Analysis Family Evaluation (SAFE) Colorado Couple Child Specific Home Study Report -Version 03-19-2007 Copyright,2005, Consortium for Children,All Rights Reserved FAMILY Applicant#1 - Jan May Core Mrs. Core presents as very welcoming and warm person that is easy to talk with. She periodically voices her excitement about having another child in her home. She indicates how life is just, "fun", now that the business is established and they don't have to work as hard. She talked about the enjoyment of life. She joked about, how it is, actually, she who runs the business and Michael is just her slave labor. Mrs. Core enjoys managing the books, but jokes about working on her garden most of the day. Mrs. Core stated that she volunteers at Adam's school when more adults are needed for extracurricular activities. When asked about her childhood,Mrs. Core feels she was fortunate as a child. She stated that she grew up in a home of 4 children, she being the second oldest, and her parents are still married. She described typical sibling rivalries, but stated that she has good relationships with each one of them and their families. They were raised in Omaha,NE and her dad was a store manager. Her mother did some secretarial work over the years, but was home taking care of the children most of the time. Mrs. Core and her siblings received spankings at times,but chuckled when I asked her if she was abused. Mrs. Core speaks well of her parents and their parenting styles. Mrs. Core stated that her parents were a little more devoted to the Christian faith than her family and, as children, they went to church and bible school every Sunday. Mrs. Core described nothing significant about her school life. Mrs. Core attended the University of Omaha and majored in financing. She stated that she had a three year relationship,that ended during her Junior year as a result of him being unfaithful to her. She stated that she had a difficult time finishing that year but she did. She stated that she saw a school counselor and started going back to church for support. Mrs. Core finished her senior year and graduated. She stated that she met Michael the following summer at a James Taylor concert and has been with him since. They had a small wedding a year after they met. She stated that they moved to Colorado due to an opportunity for Mr. Core to expand his business. Adam was born 2 years later. Mrs. Core stated that their marriage has been relatively stable. She stated that it was tough for the two of them to deal with the fact that they couldn't have any more children. They didn't know that there were other options, at that time. So, they focused on the care of their only child and strengthening their business. Mrs. Core stated that her siblings remained in Nebraska. She tries to make a trip to Nebraska 1 to 2 times a year. Mrs. Core stated that her sisters try to do the same and her brother has visited on one occasion. Mrs. Core feels that she has a strong relationship with all her siblings. She maintains, at a minimum, weekly contact with her sisters and her parents. Mrs. Core stated that her parents are still in good health and try to come visit her family on the holidays, unless Core family goes to Nebraska. Applicant#2 -Mike James Core Mr. Core presents himself in a casual and outgoing manner. He takes pride talking about the home that he built for his family and appears excited when talking about his business and its' success. He indicated that he is involved in all aspects of building, including residential and commercial buildings. He joked about having to also balance the books, referring to his wife not doing adequate job. Mr. Core talked about disappearing for a couple days here and there when hunting seasons come around. He believes that his wife enjoys her quiet time when he goes hunting for the weekend. Mr. Core stated that he had a comfortable childhood. He stated that he had two siblings, an older brother and sister,that he believes paved the way to soften up his parents as he grew up. He indicated that he was disciplined, appropriately, and denied being abuse or neglected. Mr. Core stated that he has a good relationship with his siblings. He believed their household to be a normal middle class family. Mr. Core indicated that his family was of the Christian faith. He stated that they only went to church on holidays or when they weren't building. Mr. Core denies any trouble at school. Mr. Core stated that he loved going to work with his father and learning to build. Mr. Core stated that he started working for his father, full-time, after he graduate from high school and never had interest in going to college. His father helped him branch out on his own and his father used him as a subcontractor rather than an employee. Mr. Core talked about how focused he was to be successful with his own business. He stated that being so focused with his work, made it easier to deal with losing his high school sweetheart. He indicated that his girlfriend, of three years, went to college and met somebody else. He did not report any other significant relationships until he met Jan. Mr. Core chuckled a bit as he talked about Jan. He sees her as the perfect partner and indicated that they have a lot of fun together. He,jokingly, repeated that she is a poor book keeper for his business, but he"loves her to death." He believes they have done well raising their Structured Analysis Family Evaluation(SAFE) Colorado Couple Child Specific Home Study Report -Version 03-19-2007 Copyright,2005,Consortium for Children,All Rights Reserved only son and are looking forward to sharing their loving home with another child. He stated that it took a little while for it to sink in that they would never be able to have another biological child. Mr. Core said that Adam is such a wonderful and well rounded child. Mr. Core stated that his parents and siblings remained in Nebraska. He wanted a change of scenery and wanted to get closer to the mountains, so he moved to Colorado with Jan. Mr. Core believes them to be in good health and maintains phone contact with them. He stated that his parents have been out to visit on a couple of occasions and his siblings came out one time. Applicants' Sons and Daughters Adam James Core is the biological son of Jan and Mike. Adam is 12 years old and was born on June 3, 1994. Mr. and Mrs. Core report that Adam is developmentally on track with no physical or mental health concerns. Mrs. Core stated that Adam is very active and involved with some sports and extra curricular activities at school. Adam gets along well with his peers and appears to be very sensitive to his friends' needs. Other Children or Youth living or frequently in the home NONE Other adults residing or frequently in the home Mr. and Mrs. Core indicated that there are no adults that frequent their home, other than an occasional barbeque with the neighbors or a visit by a relative. Family Lifestyle Mr. and Mrs. Core bragged about their daily work schedule, indicated that it is whatever they want it to be. Mr. Cores stated that it is always better for him to be on site, but he has good crews that he trusts to be productive when he is not around. Mrs. Cores reminded the worker that she works from home managing the business and stated that she prefers Mike to be on the job site, instead, of home bugging her. They said the can alter their schedule to meet any of the needs of the child placed with them. Mrs. Core stated that respect and consideration are important values in their home. She stated that they all agree to knock on closed doors before entering or asking for things that aren't theirs, before taking or using them. Mrs. Core stated that nudity in their home is expected to be behind closed doors. Adam's chores consist of cleaning his room, helping with dishes, sweep kitchen floor, and help care for the dog. Adam knows he can not leave the property without permission. Mrs. Core stated that she prepares most meals, but can it off to Mike on occasion. Mrs. Core manages the finances, while Mike runs the business. They have two personal vehicles and two work vehicles for transportation. Mr. and Mrs. Core describe themselves as a typical comfortable family. They go to church on Sundays, but stated that there are times when they other things going on and don't make it. They feel they celebrate most holidays as most people do,by having family over or going to someone's home for a family gathering. Previous adoption and/or foster care experience NONE FINANCES Combined annual gross earned income: $95,000 Sources of additional income: NONE CRIMINAL/CHILD ABUSE RECORD The required criminal record and child abuse/neglect (including Trails and all the states the individuals have resided in the past 5 years) checks were completed for Jan May Core and Mike James Core. No other individuals were screened. CBI,FBI and ICON/state contracted internet providers Clearance Findings: Mr. and Mrs. Core were clear of any findings. Other findings: NONE Structured Analysis Family Evaluation(SAFE) Colorado Couple Child Specific Home Study Report -Version 03-19-2007 Copyright,2005,Consortium for Children,All Rights Reserved EMERGENCY CARE PLAN In case of any incapacitating illness or death, Mrs. Leslie Smith would be the designated caretaker of any child adopted in this home. Leslie is the biological sister to Mrs. Jan Core. She currently resides in Lincoln,NE. She has accepted and agreed to having this responsibility. She has two children of her own and is willing and able to assume responsibility of this child, if needed. At this time,this is on per verbal agreement. CONTACT WITH FAMILY OF ORIGIN AND SIGNIFICANT OTHERS Mr. and Mrs. Core state that they will comply with the recommendations of the Department of Social Services. They are open to establishing a relationship with birth parents of child or any other person that has significant connections to child, if the Department feels it is in the best interest of the child. Mr. and Mrs. Core understand that reunification if a priority. There is no written post-adoption contact agreement at this time. REFERENCES References received: Yes FAMILY TRAINING Mr. and Mrs. Core participated in the agency's foster/adoptive parent training program during October and Novermber of 2006. They acquired a good understanding of the agency's policies and procedures and gained a better understanding of what they may experience as a foster/adopt home. The Cores are both CPR certified. LEGAL/FINANCIAL RIGHTS AND RESPONSIBILITIES Jan May Core and Mike James Core have been provided with information concerning the different roles, responsibilities, legal and financial rights and benefits of relative/child specific kin caregivers, foster parents, legal guardians and adoptive parents. Also, should they file a petition to adopt,Jan May Core and Mike James Core understand that they will be accepting full legal and financial parental responsibility for Kevin Michael Bacononce an adoption is finalized. Structured Analysis Family Evaluation(SAFE) Colorado Couple Child Specific Home Study Report -Version 03-19-2007 Copyright,2005, Consortium for Children,All Rights Reserved PSYCHOSOCIAL INVENTORY RESULTS NOTE: Below is a list of the psychosocial factors found on the SAFE Psychosocial Inventory. Using the Psychosocial Inventory, each factor was considered and rated several times by the social worker during the course of this home study. The ratings below represent the final ratings. The ratings are defined as follows: 1 = an exceptional strength, 2 = a strength, 3 = an issue of concern, 4 = a major issue of concern and 5 = very serious problem. The OVERALL EVALUATION OF SECTION '.. ratings reflect the degree to which all issues of concern identified in the section were either resolved, mitigated or the prognosis for change. #1 #2 HISTORY #1 #2 EXTENDED FAMILY RELATIONSHIPS 2 2 Childhood Family Adaptability 2 2 Extended Family Cohesion 2 2 Childhood Family Cohesion 2 2 Extended Family Adaptability 2 2 Childhood History of Deprivation/Trauma 2 2 Relationship with own Extended Family 2 2 Childhood History of Victimization 2 2 Relationship with Spouse's/Partner's Family 2 2 Adult History of Victimization/Trauma 2 2 OVERALL EVALUATION OF SECTION 2 2 History of Child Abuse/Neglect 2 2 History of Alcohol/Drug Use >PHYSICALJSOGIAL ENVIRONMENT 2 2 History of Crime/Arrest/Allegations/Violence 2 Cleanliness/Orderliness/Maintenance 2 2 Psychiatric History 2 Safety 2 2 Occupational History 2 Furnishings 2 2 Marriage/Domestic Partner History 2 Play Area/Equipment/Clothing 2 2 OVERALL EVALUATION OF SECTION 2 Finances 2 Support System '#1 #2 PERSONAL CHARACTERISTICS 2 Household Pets 2 2 Communication 2 OVERALL EVALUATION OF SECTION 1 1 Commitment and Responsibility 2 2 Problem Solving #1 #2 GENERAL PARENTING 2 2 Interpersonal Relations 2 2 Child Development 2 2 Health and Physical Stamina 2 2 Parenting Style 2 1 Self-esteem 2 2 Disciplinary Methods 2 2 Acceptance of Differences 2 2 Child Supervision 2 2 Coping Skills 2 2 Learning Experiences 1 2 Impulse Control 1 1 Parental Role 2 2 Mood 1 1 Child Interactions 2 2 Anger Management and Resolution I 1 Communication with Child 1 2 Judgment 1 1 Basic Care 1 2 Adaptability 2 2 Child's Play 2 2 OVERALL EVALUATION OF SECTION 2 2 OVERALL EVALUATION OF SECTION MARITAL/DOMESTICPARTNER #1 #2 SPECIALIZED'PARENTING RELATIONSHIP 2 2 Expectations 2 Conflict Resolution 2 2 Effects of Abuse/Neglect 2 Emotional Support 2 2 Effects of Sexual Abuse 1 Attitude toward Spouse/Partner 2 2 Effects of Separation and Loss 2 Communication between Couple 2 2 Structure 2 Balance of Power 2 2 Therapeutic/Educational Resources 2 Stability of the Marriage or Partnership 2 2 Birth Sibling Relationships 2 Sexual Compatibility 2 2 Child Background Information. 2 OVERALL EVALUATION OF SECTION 2 2 Birth Parent Issues 2 2 OVERALL EVALUATION OF SECTION SONS/DAUGHTERS/OTHERS RESIDING OR FREQUENTLY IN HOME #1 #2 ADOPTION ISSUES .. 2 Minor Sons and Daughters 2 2 Infertility 2 Minors Residing or Frequently in the Home 2 2 Telling Child about Adoption 2 Adult Sons and Daughters 2 2 Openness in Adoption 2 Adults Residing or Frequently in the Home 2 2 Adoptive Parent Status 2 OVERALL EVALUATION OF SECTION 2 2 OVERALL EVALUATION OF SECTION Structured Analysis Family Evaluation(SAFE) Colorado Couple Child Specific Home Study Report -Version 03-19-2007 Copyright,2005,Consortium for Children,All Rights Reserved • • PSYCHOSOCIAL EVALUATION REPORT HISTORY JAN CORE Jan describe her childhood as normal, portraying that her relationships with her parents and siblings were very close. She stated that she did well with academics in school and participated in some extracurricular activities. She feels that her family contained all the elements of healthy and balanced family cohesion and adaptability. Jan experienced a difficult ending to a college relationship caused by actions of infidelity by her boyfriend. Jan believed they were going to be together forever. Jan indicated that she experienced some depression and utilized a school counselor to process through her loss. She feels the she successfully processed through that experience of loss. Jan also felt she experienced some depression after the birth of her son when she was informed that she could not have any more children. She stated that was a difficult time for her and her husband, but they were good support to each other and worked through it. Jan indicated that they were referred to counseling upon discharge from the hospital. She feels that they did not discount the referral and knew that it was an option. Jan stated that she and Mike eventually determined that they were in a good place and did not need it. Jan indicated that she has not experienced any losses in her life that had significant impact on her. She stated that her grandparents died in a car accident when she was little, but only remembers what her parents told her about it. She believes that she would witness her mother crying, at times, but her mother would always wipe her eyes and tell her that nothing was wrong. Jan has experienced losing a cousin with whom she maintained contact. She described sadness for the loss, was not severely impacted by the loss. When asked about her history with drugs or alcohol, Jan stated she and Mike, sometimes, have a glass of wine or a beer with dinner. They may have one or two drinks at a barbecue or when they go out to eat. The only alcohol in their home is a bottle of wine and a couple of beers in the refrigerator. Jan stated that she tried marijuana her freshman year in college, with her boyfriend and his friends. She did not like it and never did it again. She denied use of any other substance. Jan stated that there were occasional nights in college that she may have over done it with drinking. She knew this by stating that she would wake up with a headache. She denied every passing out or blacking out. Jan stated it was just letting loose with some of her college friends. MIKE CORE Mike described his childhood as normal and stable and disclosed no information of abuse or neglect. Jim indicated that he was grounded quite a bit when he was a teenage. He stated that this usually was the result of him and his friends doing stupid things or things that put their safety at risk. Mike described these behaviors as typical of teenagers pushing limits and boundaries. Mike felt that his family had all the elements necessary for healthy and balanced family cohesion and adaptability. Mike described his parents as being very supportive and understanding. He stated that his father has been such an influence in his life and is the reason why Mike had a good start to his own business. Mike also stated that he and Jan might have a beer or glass of wine with dinner. He stated that he might have two or three drinks at an outing or social gathering, as long as Jan is driving. Mike stated that his father always had a couple of beers with dinner, but he never saw his father intoxicated. Mike thinks his father may have drank more after the children went to bed. He only knew this because there were sometimes more than 2-3 beers in the trash when he took it out. Mike denied ever using any illegal substances. He did stated that he and some friends would usually go out to the bars on Friday nights, after a long week of work. He stated that some nights he over did it with the drinking, as it would take him a day to recover. He stated that those were some fun nights. When asked about the last time that he drank over his limit, Mike responded that he couldn't remember the last time he had more that two or three beers. Mike denied any significant losses in his life. Mike indicated that the most difficult loss he had was when his dog, 4 years of age, was hit by a car. He felt he was responsible for not having his dog on a leash. Mike also talked about dealing with some depression, after finding out that Jan couldn't have any more children. Mikes, then stated, that he isn't too sure if it was depression of confusion. Mike does believe that Jan was experiencing some depression because she became a little emotionally distant and seemed to have less energy. Mike stated that he tried to be home more during that period to be supportive. Mike also stated that they recognized that counseling Structured Analysis Family Evaluation(SAFE) Colorado Couple Child Specific Home Study Report -Version 03-19-2007 Copyright,2005,Consortium for Children,All Rights Reserved was an option. Mike believed that Jan would have made the decision to go if she couldn't pull through this. Mike stated that he was also willing to go. Mike stated that Jan was been a strong,wonderful and supportive wife. PERSONAL CHARACTERISTICS JAN CORE After evaluation, Jan Core has the personality characteristics of a mature, healthy, and responsible adult. She appears to be a very compassionate, caring and open-minded person. She does not appear to have any biases or prejudices. The only minor concern is that she has not experienced any significant losses throughout her life. However, she stated that she is open to counseling or other support services if ever in need. Jan describes herself as being a very calm and understanding person. She avoids making impulsive decisions and states that sometimes she may over analyze a situation in order to make the right decision, especially with important decisions that involve others. She indicated it is important to look at a situation or problem from the "outside in"to have a different perspective and make sure all variables are taken into consideration. Jan expresses confidence in her judgment, because of her thoroughness. When she commits to something, she states that she is devoted to seeing it through to the end. She believes her persistence and focus keeps her on track with achieving her goals, whether big or small. Jan stated that it is important to her to have strong adaptability. She is very open to new ideas and experiences and tends to get excited when she learns new skills and ways of doing things. MIKE CORE Mike presents a very confident and sincere person. Mike stated that he recognizes there is always something to learn and is open minded to change, but he has already learned a lot in life and is very comfortable with whom he is as a person. From talking with his wife and son, Mike is a very respectable father and husband and puts his family before himself. He communicates very well and has receptive nonverbal communication. He appears to be emotionally sound and very responsible. He speaks highly of his family and other people that are in his support system. His humor and enthusiasm are very noticeable during conversation. Mike doesn't believe in broken promises, and is reliable to any commitment he makes. Mike appears to do anything he is involved with to the best of his ability. Mike appears to be a remarkable person with a good support system. He presents as a"family man" and puts his family first. Mike reported to have an average childhood experience with good family relationships. He has not suffered any significant losses other than losing his dog to a car accident. He is not afraid to share his emotions when talking about personal issues. Mike runs a successful business and portrays himself as a successful hunter. Mike presents to be in good physical health and occasionally goes for a jog. MARITAL/DOMESTIC PARTNER RELATIONSHIP Jan and Mike have been married for approximately 14 years. There has never been any talk about separation or divorce during this time. Mike talked about the rare arguments that lead to him needing to take some space for a couple hours to assess the situation and to take in the other side of the argument. Jan agreed that Mike is very good at stopping an argument when it isn't going anywhere. He may take a short period of time to himself and reengage in conversation in a more supportive way. It appears that Jan and Mike seemed to drift apart,emotionally, after the birth of their son. Although the did not seek counseling through this sensitive period in their lives,they believed that it took about three to four months before they were able to move forward. Mike and Jan, both speak of each other as best friends and soul mates. There is an observable strong bond between the two of them. SONS/DAUGHTERS/OTHERS RESIDING OR FREQUENTLY IN THE HOME Adam is their only son. Adam appears to be a well-rounded, active and talkative 12-year old. He is very polite and seems to have adopted the sense of humor and warmth of his parents. Adam enjoys school, playing with his dog in the back yard, and football. Adam is favorable to the adoption and stated that he would take a little brother or sister. Adam didn't think that he would ever have a sibling, but was excited when his parents told him that they were thinking about it. Structured Analysis Family Evaluation(SAFE) Colorado Couple Child Specific Home Study Report -Version 03-19-2007 Copyright,2005,Consortium for Children,All Rights Reserved EXTENDED FAMILY RELATIONSHIPS All the family members were all supportive to Jan and Mike's decision to adopt a child. Although they all live in Nebraska, they express their support to this family. Jan's sister gladly accepted the role of providing care of the child in case of an emergency or if anything ever happens to Jan and Mike. Both sides of the family have displayed a healthy balance of cohesion and adaptability. PHYSICAL/SOCIAL ENVIRONMENT This home is very well maintained on the interior and exterior. There are adequate bedrooms with a big play area downstairs. There is a nice sized fenced in grass area to play in with more land and space to play around the house. The neighbors in this small community maintain contact with each other, are supportive and understanding, and occasionally have social gatherings. GENERAL PARENTING Mike and Jan seem to always collaborate in their parenting efforts. Based on Adams behaviors and attitude, they have done a great job with their parenting roles. They are not quick to make any decisions without consulting the other. It is apparent that Adam has respect for his parents. They are both playful with Adam. Adam has not been in trouble at school, receives good grades, and is attentive to his parents. Mike and Jan stated that"time outs"or a firm voice have always worked with redirecting Adam. SPECIALIZED PARENTING Although Jan and Mike appear to be very good parents,the concern in this section is the lack of experiencing some of the special issues in this section. Jan and Mike feel that they learned a lot in their training group and gained an understanding of some of the special or different needs of children in the system. Jan and Mike display no hesitancy in accepting whatever child that Social Services may introduce to their family. They are very open- minded and will utilize any support offered to them to provide for the best interest of the child. ADOPTION ISSUES Jan and Mike were very open about going into this adoption/foster parent role and not knowing what to expect. They have been good parents to Adam, but they are nervous about being the same good parents to a child that is not theirs. They have become more knowledgeable as they demonstrated their ability and receptiveness to learning in the trainings that they participated in. Jan and Mike are more comfortable with any issues or concerns they had that were specific to adoption. They now have an excellent understanding of birth parent issues and the importance of openness in adoption and are committed to play a role in a child's life based on what is best for the child. PSYCHOSOCIAL EVALUATION CONCLUSIONS Based on the results of this psychosocial evaluation, Jan and Mike Core are ready to take on the challenges that are inherent with foster care and adoption. The have strong attachments to their parents, siblings, and their son,that is evidence for them having the capability of have a strong attachment to an additional child in their home. There are no unresolved issues from their pasts that may reappear. They show no religious or cultural biases. They have created a warm and welcoming environment in the home. They are both open and enthusiastic about learning new skills and taking on another responsibility. They are optimistic about utilizing the skills and tools that they acquired in trainings. They have been open and honest with all their concerns with the expectations of foster parents. They clearly understand the guidelines and accept them. The Cores live a moderate lifestyle and are financially comfortable to be able to provide for a new addition to their home. Jan and Mike clearly possess the characteristics to be successful foster/adoptive parents. There daily schedules are very flexible,which enables them to meet any of the needs of another child. PLACEMENT COMPATABILITY Jan and Mike have a 12-year old son, Adam. Their knowledge of parenting revolves around their experiences with Adam. They have clearly been successful with their parenting of Adam. Gender was not issue to the Cores. The have decided to follow the wishes of Adam to have a younger brother or sister, so they are requesting a child under the age of 11, but preferably in the 3-5 year old range. They are open to consider children of special needs. They have no cultural or gender biases. I believe Jan and Mike would do very well with a younger child that needs a lot Structured Analysis Family Evaluation(SAFE) Colorado Couple Child Specific Home Study Report -Version 03-19-2007 Copyright,2005,Consortium for Children,All Rights Reserved • of nurturing and attention. They may also do well with a child with some behavior issues. Jan works from home and Mike is able to adjust his schedule to assist with the needs of a child. RECOMMENDATION It is recommended that Mrs.Jan May Core and Mrs. Mike James Core be approved as adoptive parents for the placement of Keying Michael Bacon. Keith Wawrzyniak Contract worker for Social Services Date: 01/01/2007 Additional Attachments none REVIEW OF HOME STUDY REPORT By signing below I acknowledge that I have read a copy of this report. Jan May Core Mike James Core Date: Date: To check for form updates click this link. Structured Analysis Family Evaluation(SAFE) Colorado Couple Child Specific Home Study Report -Version 03-19-2007 Copyright, 2005,Consortium for Children,All Rights Reserved • WELD COUNTY SOCIAL SERVICES RELINQUISHMENT COUNSELING OUTLINE Background of Case: This child was taken into custody of the Department of Social Services in 5/05. The child was 9 years old at the time and was victim of abuse and neglect. The mother involved with significant use of methamphetamines, with a history of Psychiatric admissions. The child was often left home alone and witnessed the intense alcohol and drug use in the home. The child was placed in foster home for a period of seven months. The mother attempted to follow the treatment plan with several failed attempts. The child was moved to a foster adopt home where he has been for the past 8 months. Mother has made occasional visitations, and continues to have some UA indicate positive for Methamphetamines. The mother has maintained phone contact with her child and attempts to make weekly visits. A meeting was conducted by all parties involved, including: the mother, her attorney, DSS attorney, GAL, child's counselor, foster parents and mother's therapist. Mother agreed to relinquish her rights, with the agreement of occasional contact with her child. A. Where is the child, why is he in custody of Weld County Social Services. See above. He was a victim of abuse in neglect in his home. B. Reason for relinquishment. See above. Failed attempt to completed treatment plan. Mother has not been in contact in over two weeks. C. Other options considered. Mother has no family connections or support. D. How long have the parent(s) been considering relinquishment? A couple months E. Relinquishment does not automatically absolve the parent of financial responsibility for the child. The courts will make a determination. Severs all rights-is permanent. E. Does the parent feel pressured by anyone? Mother was counseled through this decision. F. Is relinquishment in the child's best interest? Yes. Child has been victim to many broken promises by his mother. Mother is Homeless at this time G. What will relinquishment change for the child? It will provide a safe, stable, and consistent environment for him. It will give him a sense of security. H. Is a final good-bye visit necessary? The mother did not show for the final good-bye but she maintains occasional contact with child by phone. I. Who is the attorney? Lou downs J. Who is the G.A.L. Lisa burns K. Who is the caseworker? Bob Smith L. Native American Status: Not affiliated with any tribal nation SUB_TOC Header Page 1 of 5 7.500.2 ASSESSMENT OF FOSTER HOME AND ADOPTIVE HOME [Rev. eff. 1/1/07] A. Content of the Assessment A family assessment, using the Structured Analysis Family Evaluation (SAFE) instrument to determine the character and suitability of the applicant(s), appropriateness of the home, and child care paractices, must be completed. The assessment shall include, but not be limited to, the following: 1. Social History/Background (Adults and Children) Separate and joint interviews with the applicant(s), all adults residing in the home (both related and non-related to the applicant), and all children residing in the home regarding at least significant events in family background, evaluation of applicants' knowledge and capacity to care for children and ability to maintain long term relationships and life changes including issues of grief and loss. 2. Current Status of the Family (Family System/Lifestyle) Marital relationship, interrelationships with significant persons outside the nuclear family, lifestyle chnages, methods of decision making, parenting/child rearing, methods of discipline, religion, finances, extended family, child care plan in the event of emergency and/or when parents work away from the home; assessment of any children in the home; an assessment of the family's interest and ability to meet the special needs of a child, including financial responsibility; assessment of ability to accept legal risk placement; and, assessment of family's strengths, including individual/family strengths and self-esteem. For kinship care, ability to meet the individualized needs of the specified child(ren), and assessment of the relationship with birth parents and extended family members as they impact capacity of the applicants to care for the child(ren). When completing the assessment, Section 7.708, "Rules Regulating Family Foster Care Homes" should be consulted. 3. Motivation for a Child Include a discussion of the child to be placed, attitudes toward foster care/adoption by applicants, other adults residing in the home, children, and others such as extended family, and discussion of fertility, if relevant. Assess the physical, mental and emotional capability of the applicant(s) to parent a child(ren) through adoption and their ability to reevaluate and readjust expectations. 4. Transracial Assessment Applicants fostering/adopting a child of a different ethnic and cultural background shall preserve continuity of the child's ethnic and cultural identity in a positive manner. Factors should include, but are not limited to, consideration of the child's family, community, neighborhood, faith or religious beliefs, school activities, friends, and child's and family's primary language. Documentation of this requirement shall be in the case file. 5. Child Safety and Well-Being http://stateboard.cdhs.state.co.us:8008/CDHS/rule_display$.Calling_DisplaySection?P_V... 4/19/2007 SUB_TOC Header Page 3 of 5 B. State Department's Automated System, Colorado Bureau of Investigation(CBI), and Federal Bureau of Investigation(FBI) 1. Prior to full certification of a family foster home, there shall be a review and documentation in the provider record of: a. Findings from the State Department's automated system, regarding applicants and persons who reside in the home of the applicant; b. Written statements from references; c. Health information; d. The review of existing agency case records, including the automated system, for prior foster home certifications or denials; and, e. Investigations of any concerns raised from the application and/or aforementioned sources of information. f. The results of the face-to-face interview on all members of the household. g. A fingerprint-based criminal history record check with the CBI. h. A comparison search on the ICON State's contracted system, using the name and date of birth, with available criminal history information. The purpose is to determine any crime(s) for which an applicant was arrested or convicted and the disposition. This search must be completed regardless of whether the CBI fingerprint history confirms or does not confirm a criminal history. Section 7.708 outlines specific additional requirements for family foster homes. 2. Prior to the placement of any child or prior to provisional certification of a "child specific" or kinship care home, the county department shall obtain fingerprints and complete a criminal record check on the applicant(s) and any other person 18 years of age or older living in the household from the Colorado Bureau of Investigation (CBI). 3. Fingerprint-Based Criminal History Background Checks a. FBI Checks for Foster Parents: Federal Bureau of Investigation(FBI) checks shall be initiated for any applicant(s) if the applicant(s)has resided in Colorado for less than 24 months, except for emergency placement as described in Section 7.304.21, D, 2, f. The Federal Bureau of Investigation reports shall be sent directly to the county department submitting the request for information. b. FBI Checks for Prospective Adoptive Parents: Federal Bureau of Investigation(FBI) checks shall be intiated for all prospective adoptive parents. The Federal Bureau of Investigation reports shall http://stateboard.cdhs.state.co.us:8008/CDHS/rule_display$.Calling_DisplaySection?P_V... 4/19/2007 SUB_TOC Header Page 5 of 5 4. As part of the assessment, the agency must: a. Conduct a minimum of one joint face-to-face interview with a couple, one individual face-to-face interview with each adult member of the household and an age/developmental appropriate face-to-face interview with all children residing in the home. For single applicants, a minimum of two interviews will be required. b. Conduct at least one face-to-face interview in the applicant's home. c. Perform an on-site inspection for foster homes to determine compliance with the Minimum Rules and Regulations for Family Foster Homes, Section 7.708. Approval of local zoning, health, or fire departments must be documented in the foster home file when the situation warrants. d. Spread out interviews over a period of not less than seven(7)consecutive days. e. Update the assessment annually in the form of an addendum. An addendum shall include at least one home visit and a review of the current medical status. During each subsequent addendum, applicants shall be questioned regarding any child abuse investigations during the previous year. 5. The application and medical records will be reviewed; any issues that are identified will be discussed with the applicants. No physical examination shall be required of any person who in good faith relies upon spiritual means or prayer in the free exercise of religion to prevent or cure a disease unless there is a reason to believe such persons physical condition is such that he/she would be unable to care for a child, or such person has a communicable illness. 6. The county department shall not perform a foster home or adoptive home assessment on a member of its own staff. The worker should check with the supervisor for county policies and procedures regarding completing assessments on county staff. 7. Water, if from any source other than a regular municipal water supply, shall be tested for compliance with water quality requirements. 8. A current photograph of the family shall be requested and maintained in the file. 9. For the purposes of conducting an adoptive home study, the home study is to be completed ninety (90) working days from receiving the completed background checks. http://stateboard.cdhs.state.co.us:8008/CDHS/rule_display$.Calling_DisplaySection?P V... 4/19/2007 EXHIBIT B SUPPLEMENTAL NARRATIVE TO RFP Keith Wawrzyniak 36376 Mason View Rd Eaton, CO 80615 May 21,2007 Tobi Vegter Core Services Coordinator Re: Bid #005-HS-07, (RFP-00B) Home Studies This letter is to notify you of my acceptance to be a provider of services to the Weld County Department of Social Services. There were some requested clarifications that of my services,which are as follows: 1. I contract will be terminated with the Department of Social Services as of May 31, 2007. 2. I can not provide monolingual Spanish services at this time. 3. I am willing to accept up to 5 full home study requests a month. This may depend on the amount of updated home studies or relinquishment counseling referrals that I may receive. I will ensure you that I will meet deadlines,within my control and I will inform you before I become overloaded. 4. I only submitted a bid for what falls under the category of Home Studies and Relinquishment Counseling. If needed, I could also provide Life Skills Education. Thank you for this opportunity, Keith Wawrzyniak // 4,f/I7 t714;N:: DEPARTMENT OF SOCIAL SERVICES P.O. BOX A 111111e GREELEY, CO. 80632 Website:www.co.weid.co.us Administration and Public Assistance(970)352-1551 Fax Number(970)353-5215 COLORADO May 11, 2007 Keith Wawrzyniak Jr. 36376 Mason View Road. Eaton,CO 80615 Re: Bid#005-HS-07 (RFP 006-00B)Home Studies Dear Mr. Wawrzyniak: 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 your Bid# 005-HS-07, (RFP 006-00B)Home Studies,Updates, and Adoption Home Studies for inclusion on our vendor list. The FYC Commission attached the following conditions to your bid. Condition: The bidder must clarify information that was not addressed or submitted with the original bid submission, including: 1. Report in your letter of response that you will terminate your status with the Department of Social Services as a contracted employee if this bid is accepted and approved, 2. Clarify whether you can provide monolingual Spanish services, 3. Clarify and define program capacity, 4. Define other services you might provide beyond home studies. B. Required Response by FYC Bidders Concerning FYC Commission Conditions: Conditions: All conditions will be incorporated as part of your Bid and Notification of Financial Page'2 Keith Wawrzyniak RFP 001-07/2007-2008 Assistance Award(NOFAA). If you do not accept the condition(s),you will not be authorized as a vendor unless the FYC Commission and the Weld County Department of Social Services accept your mitigating circumstances. If you do not accept the condition,you must provide in writing reasons why. A meeting will be arranged to discuss your response. Your response to the above conditions will be incorporated in the Bid and Notification of Financial Assistance Award. The Weld County Department of Social Services is requesting your written response to the FYC Commission's recommendation.Please respond in writing to Tobi Vegter, Core Services Coordinator, Weld County Department of Social Services, P.O. Box A, Greeley, CO, 80632, by Monday,May 21, 2007,close of business. If you have questions concerning the above,please call Tobi Vegter, 352.1551, extension 6392. Sincerely, et J y A. 'ego, D for cc: Juan Lopez, Chair,FYC Commission Tobi Vegter, Core Services Coordinator Gloria Romansik, Social Services Administrator Weld County Department of Social Services Notification of Financial Assistance Award for Child Welfare Regular Administration Funding Type of Action Contract Award No. X Initial Award PY07-08-HS-0035 Revision (RFP-006-00B; 003-HS-07) Contract Award Period Name and Address of Contractor Beginning 06/01/2007 and Helene Wurth,Private Practice. Ending 05/31/2008 Home Studies,Updates,Relinquishment Counseling 4306 Beaver Creek Drive Fort Collins,CO 80526 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Assistance Award Services provide home studies and home study updates for is based upon your Request for Proposal(RFP). The RFP adoption,foster care,permanency planning,and ICPC,and specifies the scope of services and conditions of award. Except relinquishment counseling to Weld County parents where it is in conflict with this NOFAA in which case the considering relinquishment. Program capacity is a NOFAA governs,the RFP upon which this award is based is an maximum of 10 home studies or updates per month,or 60 integral part of the action. home studies and 60 home study updates per contract year. Special conditions Average stay in program is four to six weeks.Bilingual 1) Reimbursement for the Unit of Service will be based on services through an interpreter. an episode rate per home study and home study update.. Relinquishment counseling,court testimony,and Cost per Unit of Service interpreter services will be billed at an hourly rate. 2) Reimbursement requests must be an original with an Hourly Rate per original signature from the provider and/or designee. Court Testimony $75.00 3) Reimbursement requests must include the date the Relinquishment Counseling $75.00 home study,update,or relinquishment counseling was Interpreter Services $25.00 completed.The request must reflect the amount billed Episode Rate per for each home study,and the month the service was Full Home Study with Background Check $950.00 provided. Requests for services submitted 90 days Updated Home Study $450.00 from the date of service,and thereafter,will not be paid. Enclosures: 4) Payment will only be remitted on referrals made by X Signed RFP:Exhibit A the Weld County Department of Social Services. X Supplemental Narrative to RFP: Exhibit B 5) Requests for payment must be an original submitted to X Recommendation(s) the Weld County Department of Social Services by the _ Conditions of Approval end of the 25th calendar day following the end of the month of service.The provider must submit requests for payment on forms approved by Weld County Department of Social Services. Requests for payments submitted 90 days from the date of service,and thereafter,will not be paid. 6) The Contractor will notify the Department of any changes in staff at the time of the change. Approvals: Program OM 'al: BY 0,A. By David E.Long,Chair Ju y . riego Director Board o ld County Commi ioners Weld oun epa ent f Social Services Date: 1 8 2007 Date: I Li 71277-/999 EXHIBIT A SIGNED RFP ' /JS _ C I L C - Core Services Program Bid Proposal Home Study/Relinquishment Counseling March 20, 2007 Helene Wurth 4306 Beaver Creek Dr. Fort Collins, Co 80526 970-226-2692 970-631-6235 (cell) hwurth@msn.com 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 Deg/nine: Friday, March 30,2007, 10:00 am. (MST) The Families,Youth and Children Commission, an advisory commission to Social Services, announces that competing applications will be accepted for approved providers pursuant to the Board of Weld County Commissioners' authority under the Colorado Family Preservation Act(C.RS. 26-5.5-101)and Emergency Assistance for Families with Children at Imminent Risk of Out-of-Home Placement Act (C.R.S. 26-5.3-101). The Families,Youth and Children Commission wishes to approve services targeted to run from June 1,2007,through May 31, 2008, at specific rates for different types of service,the County will authorize approved providers and rates for services only. This program announcement consists of the following documents, as follows: • Invitation to Bid • Main Request for Proposal(All program areas) • Addendum A—Program Improvement Plan Requirements(by program area) • Addendum B—Scope of Services(by program area) • Core Budget Form Delivery Date (After receipt of order) BID MUST rBE SIGNED IN INK Program Area: kknMQ ktIAlSi .1�(�C�Udsh + tK� v sV-k Wa , r � qq U �q TYPED OR PRINTED SIGNATURE VENDOR l4eie,ne UJ Bari(v�- (Name) Handwritten Signature By Authorized Officer or Agent of Vendor ADDRESS 4r 3 r(p fjeatnn r C qrP�-P�.kf,pr-• TITLE 5frfE 1'1c1�a-e.Sdud p✓ofsslnn4Q Rr rt CA l l t M , CO RZE7X1 DATE 3. 1(0•07 PHONE# 9 la • au° - 2109 Z The above bid is subject to Terms and Conditions as attached hereto and incorporated. . Helene Wurth 4306 Beaver Creek Dr. Fort Collins, CO 80526 970-226-2692 cell: 970-631-6235 hwurth@msn.com Abstract: My name is Helene Wurth, and my organization would be a private for profit business that completes SAFE home studies, home study updates, expedited permanency plan home studies, ICPC home studies and relinquishment counseling. My mission statement is as follows: To complete home studies for prospective foster and adoptive families. These home studies will be completed in a way that will help minimize placement changes for children, encourage prospective parents to cooperate with the case plan and case worker, maintain cultural and racial connections, encourage monthly face to face contact with caseworkers, identifying the health needs of the placed children, and completing home studies in a timely fashion to expedite permanency for these children. My overall proposed project is to complete SAFE home studies and home study updates and be present for court hearings as necessary for Weld County Social Services. I will provide home studies for adoption, foster care, and expedited permanency planning and ICPC. In a 4-6 week time frame I would be able to complete 1-10 home studies and/or home study updates. I will be the sole worker in this business. I am willing to contract with a Spanish language interpreter to help in the interview process for Spanish speaking families. I enjoy helping children find permanent families and helping families through the foster/adoption process. I am also willing to provide relinquishment counseling to Weld County parents who are considering relinquishing children. Helene Wurth - 2 - Table of Contents: Target/Eligibility Populations: page 4 Project Narrative/ Supporting Documentation: Types of services provided pages 5-6 Measurable outcomes/Service objectives page 7 Workload Standards page 8 Staff Qualifications page 9 Program Capacities page 9 Internal Tracking/Billing Process page 9 Supporting Documentation pages 10-12 Budget: pages 13-15 Appendices 1-5: Appendix 1: Resume and Staff Qualifications page 16 Appendix 2: Proof of Individual Professional Liability Insurance page 17-18 Appendix 3: Sample Consent/Release Forms page 19-20 Appendix 4: Original SAFE home study completed by Helene Wurth pages 21-3-3 Appendix 5: Program Area Supervisor/Provider Meeting Verification/Comment Form page 34 Helene Wurth - 3 - Target/Eligibility Populations: The population to be served by this contract includes: - Families who wish to adopt children from the Weld County Department of Social Services - Applicants for foster care certification - Children identified as expedited permanency planning - ICPC cases - Foster care, adoptive families, or ICPC families who need updated SAFE home studies - Relinquishment counseling for Weld county parents who are considering relinquishing children Total family units: - during the course of this contract I estimate serving between 12 and 120 family units Sub-total of individuals who will receive bicultural/bilingual services: - All of these families will receive bicultural services as needed - I estimate the population needing bilingual services to be approximately ¶4th to 1/3rd of the total population, approximately between 3 and 36 family units. Sub-total of individuals who will receive services in South Weld County: - Home studies will be completed on an as needed basis for families residing in South Weld County Monthly program capacity per group: - The monthly program capacity for this contract will be 10 home studies or updated home studies per month. Monthly average capacity per group: - The monthly average capacity will be between 2-5 home studies or updated home studies per month. Average stay inprogram: - The average home study will take between 4-6 weeks to complete, depending on timely submissions of background checks, application and reference information by the families being studied. Average groups per week in the program: - The average number of family units per week participating in a home study is 2-5. Helene Wurth -4 - Project Narrative/Supporting Documentation: Types of Services Provided: - Adoption, foster care, expedited permanency planning and ICPC home studies - Home studies will be conducted in compliance with the uniform format utilized by the State Department of Human Services - Home studies will be completed following the SAFE format and guidelines - Relinquishment counseling will be provided to Weld County parents who are considering relinquishing children - Home study workers will meet the Program Improvement Plan requirements by: Focusing on the permanency needs of children, and focus on preserving the placement of children through supportive services, at no time will a Home Study provider advise for a child to be removed from placement. - Home Study providers will aid in facilitating out of home providers to cooperate with a child's case plan for independent living and daily life skills instructions. - Home Study providers will provide assistance to caretakers in maintaining the cultural and racial identity of children in their care, they will provide cultural resources, community connections and help maintain spiritual needs of the children, these connections will be considered during the conducting of the home study. - Home Study workers will help facilitate cominunicatiion between the out of home provider and the caseworker and help train these parents to be proactive if the children in their care are not being regularly contacted by the caseworker and what steps to take if necessary. - Home Study workers will address the importance of out of home providers setting up medical and dental appointments at the time of placement and will provide lists of Medicaid providers if necessary. - Home Study workers will address the role of foster/adopt parents in working with caseworkers in identifying health needs and services and will explain caseworker and foster/adopt parent responsibilities. - Home Study workers will aid in matching children to potential foster/adoptive homes, this will aid in permanency for these child(ren).. - The content of home studies will include: - Social Histories and Background of all adults in the home. - Adult General Functioning with focusing on how adults function with daily management and how they adapt to change as well as their ability to communicate, judgment and decision making, impulse control, culture, religion, substance abuse and mental health issues as well as strengths and weaknesses of the parent. Helene Wurth - 5 - - It will also include parenting practices, discipline approach, providing a structured environment and openness to new discipline techniques, experiences with children and trying new and different ways to parent. - It will include sections on each child currently in the household, focusing on their temperament, emotions, behaviors, mental health and substance abuse issues, the child's ability to accept another child in the household. - It will include information on the family system and how the family functions, communicates, family roles, decisions, how communication is used, affection, racial, religions and cultural needs as well as roles and responsibilities. - The home study will talk about the effects of fostering and adopting has on the family, including marital issues communication, strengths and weaknesses of the marriage relationship and conflict and stress on the family. - It will also include information on the families support network. As well as information on the demographics of the household including racial, cultural and religions integration in the community, financial issues, references, drivers license, home owners and life insurance and car insurance. - The home study will talk about birth family issues, and how to understand and support positive relationships with the birth family. It will also include the family's openness towards adoption and ability of families to accept children with different values and helping children cope with separation and loss. - The home study will also include family's viewpoints towards foster and adopted children and family preparation. The home study will talk about the family's level of motivation and commitments as well as the family's ability to comply with agency involvement and the willingness of the family to seek cross cultural models and experiences. - It will discuss the resources needed for the families to support the placement of the child. It will talk about the families training and experiences in fostering and adopting children. The home study will include my recommendations and conclusions. - Relinquishment counseling will include: - Background of the case, reason for relinquishment, other options considered, how long the parent(s)have been considering relinquishment, explain that relinquishment does not automatically absolve the parent(s) of financial responsibility for the child(ren), the court will make a final determination, severs all rights is permanent,as the parent(s) if they feel pressured by anyone, or ask them if anything was promised to them,is relinquishment in the child's best interest,what will relinquishment change for the child, find out if a final goodbye visit is necessary, obtain who the attorney, G.A.L. and caseworker are on the case, and inquire about the parent(s) or child(ren)Native American Status. - Home Study workers will comply with 19-1-120 C.R.S. which requires all information to be kept confidential Helene Wurth - 6 - The number of family units served through this contract will be between 12 and 120. Each family will receive quality home studies, updates and/or relinquishment counseling for adoptive, foster parent and social services clients. The home study families will have a minimum of three joint couple interviews and one individual interview with each member of the household (adult and child). For single applicants a minimum of 3 interviews will take place with the individual. The home study worker will walk through the family's residence, noting any safety concerns and conduct at least one of these interviews in the family's residence. Home Study worker will complete background checks and submit them to Weld County Department of Human Services. Measurable Outcomes: - Outcomes will include more expedited placement of children - Quality home studies will be completed in a timely manner, 4-6 weeks subject to a family's timely submission of background check information, references and making and keeping appointments that are scheduled. - The number of acceptable home studies submitted will range from between 1 and 10 per month, based on the Departments needs. This program will be successful if it meets these guidelines. Service Objectives: - This contract will provide quality home studies and home study updates in a timely manner - These home studies will follow the SAFE format and use SAFE guidelines - The average home study will take between 4-6 weeks to complete from initial date of service - For initial home studies they will include at minimum three joint interviews with a couple, one individual interview with each adult member in the household and a developmentally appropriate interview with all children residing in the home. For single applicants a minimum of three individual interviews will take place. - At least one interview will be completed in the family's home - These interviews will be spread out over a period of no less than seven consecutive days - Background checks will be completed unless otherwise indicated on the referral form. The background check will be completed for all individuals living in Colorado. Background checks will include: o Fingerprint results sent by CBI to Weld County will be returned directly to CBI to Weld County Social Services. The provider will distribute, collect and submit the fingerprint cards. The provider will pay CBI the processing fee. If the individual has lived in the state less than two years, an FBI search will be requested; o Department of Motor Vehicles; Helene Wurth - 7 - o Local County DSS search for open cases; o Reference questionnaires will be sent out and returned to the provider with SASE; o Local police/social services; o Central Registry - All original background check information will be forwarded to the Weld County Social Services with the written home study. A copy will be retained in Social Services files for the mandated length of the record retention - Service time frames for this contract are 4-6 weeks from initiation. This time frame is subject to timely submissions by the family being studied, including fingerprints, Central Registry check, application,and reference information. - This contract will improve outcomes in the Performance Improvement Plan by: o Minimizing placement change for children o Aid in connecting children with appropriate families o Encouraging prospective parents to comply with the case plan and the case worker o Encourage and help facilitate maintaining the child's cultural, racial and spiritual connections o Encourage monthly face to face contact with the caseworker o Explain the health needs of a child placed with the potential foster/adoptive family, including medical and dental appointments made at the time of placement o Completing home studies in a timely fashion encourage expedited permanency planning o Complete ICPC home studies in the six week time frame that is mandated o Focusing on the retention of children in their placement Workload Standards: - Each couple will receive at a minimum 8 hours of direct interviewing time by the home study worker - Each individual will receive at a minimum 4.5 hours of direct interviewing time by the home study worker - For each additional member of the household they will receive at minimum one hour of interviewing time by the home study worker, not included in previous totals - I will provide my services for at minimum 5 hours per week for each family who is completing the home study process - I will be the sole worker for this business - Maximum caseload per worker is 10 - I am covered by Individual Professional Liability Insurance for Social Workers, in Appendix 2 following this is bid proof of this insurance Helene Wurth - 8 - - The home studies, home study updates, ICPC home studies, home studies for expedited permanency planning, and relinquishment counseling will be provided with a family centered approach. Staff Qualifications: - Helene Wurth, received a high school diploma from Bear Creek High School in Lakewood Colorado. I also received a Bachelor of Arts in Social Work from Colorado State University located in Fort Collins, Colorado in 1998. - I received SAFE home study training in 2005 through the State of Colorado - I am currently on the SAFE home study vendor list from the Colorado Department of Human Services - I have worked for two years completing home studies for Larimer County Department of Human Services (2005-2007) - Total staff available for this contract is one. - I received new caseworker training at Larimer County Department of Human Services, as well as SAFE home study training - I have worked on risk assessments for two years through the Larimer County Department of Human Services Program Capacity Per Month: - The total capacity for this program is between 1 and 10 home study and home study updates per month - At minimum this program will need one home study per month to support the program - The capacity for relinquishment counseling per month is between 0 and 2 per month - Relinquishment counseling is not required to support this program Internal Tracking and Billing Process: - Home studies will be complete in a 4-6 week time frame from initiation - Invoices will be completed for each individual home study finished and submitted within one week of the completion of the home study - I am the only worker for this contract and will be tracking and billing for these home studies myself - The billing invoice will include the providers name, address, and phone number, billing contact person and phone number, program area billed for, amount billed, original signature and month of service. I will also include the Family Name or Foster Parent name and provider number, case worker name, rate, units billed, dates of service, and completion date Helene Wurth - 9 - - Submitted will be the original copy of the home study as well as any related supporting documentation including the background check information and reference check information - All home studies will be submitted within 30 days of the last date of service Supporting Documentation: Protecting Clients and Staff from Potential Risks: - A goal of this project will be to protect it's participants from potential risks. These risks will include confidentiality. - This program will maintain confidentiality by using password protected programs on the computer - All home study and relinquishment counseling paperwork and files will be kept in a locked file cabinet - At no time will anyone other than the home study worker and/or employees of Weld County Department of Human Services have access to the home study, paperwork or files as a result of this project - If a translator is used with bilingual families,they will be required to sign a confidentiality agreement,protecting families from potential risks, before translating any interviews Fair Selection of Participants: - Participants will be selected by Weld County Department of Human Services - This worker will accept a home study referral from the caseworker and complete the home study regardless of racial/ethnic background, substance abusers, women, age, gender or sexual preference - The target population for this contract is families who have applied to become adoptive or foster parents through Weld County Department of Human Services, foster or adoptive parents who need a home study update, ICPC cases, expedited permanency planning children, parent(s)who are choosing to relinquish their parental rights - There are no participants who will be excluded from this population,the participants will solely be referred by Weld County Department of Human Services Absence of Coercion: The home study project is voluntary, only families who are interested in becoming foster or adoptive parents or families who are already foster or adoptive parents will participate in this program. Participation in this is solely by their choice. - The relinquishment counseling program is also solely voluntary. Parent(s)who are interested in relinquishing their rights will be participants in this program. Participation in this program is solely by their choice. - Participants will not be allowed to become foster or adoptive families if they choose not to participate, there will be no other alternative services Helene Wurth - 10 - Data Collection: - Data will be collected by questionnaire to see if the participants are satisfied with their home study process - Data will be collected by caseworkers in the form of questionnaires to gauge the level of satisfaction with the home study and the home study process Privacy and Confidentiality: - Helene Wurth, and Weld County Department of Human Services caseworkers and employees are the only people who will have access to the data collected. - The questionnaires will be distributed by Helene Wurth and returned to Helene Wurth anonymously through the mail service - Helene Wurth will store the data in a locked file cabinet in her office Adequate Consent Procedure: - SAFE questionnaires will be given to the participants. - Participants will fill out the SAFE questionnaires and return them to the home study worker - The home study worker will then keep the information while completing the home study - After the home study is completed the home study worker will give the SAFE home study and corresponding paperwork to the Weld County Department of Human Services and the caseworker who is working with the family - Participants will have an opportunity to review the home study and sign it before the final home study is submitted to Weld County Department of Human Services - Participation in this project is voluntary - Participants have the right to leave the project at any time without problems - The risks from participating in this program are risks to confidentiality - Participants will be protected from risks through password protected computer systems, locked file cabinets and signed confidentiality agreements - The home study worker will gain consent from youth, elderly, people with limited reading skills by explaining the process of confidentiality and explaining that their participation in the program is optional. Those participants who do not have English as their primary language this procedure will be explained through an interpreter and will have SAFE questionnaires and confidentiality releases provided to them in their primary language. - Participants will be giving copies of signed consent forms - Home study workers will ask prospective participants questions to obtain if they understand the forms - Samples of consent forms and release of information forms can be found in Appendix 3. - All participants will be required to sign consent forms and release of information forms to participate in the program - When sign releases of information are signed by participants, the information obtained from these releases will only be used to complete the home study or relinquishment counseling Helene Wurth - 11 - Budget: Program Budgets: Program: Helene Wurth, Home Study/Relinquishment Counseling A. Total Hours or Days of Direct Service Per Client 4-7 days B. Total Clients to be Served 12-120 C. Total Hours or Days of Direct Service for the Year 48-840 days of service D. Cost Per hours or Days of Direct Service 112.00-237.00 E. Total Direct Costs of Face-to-Face 2770.00 F. Administration costs, non face-to-face allocable to program 0 G. Overhead Costs allocable to program 2300.00 H. Total Direct,Administration and overhead costs 5070.00 I . Anticipated Profits contributed by this program 17930.00 J. Total Costs and profits from this program 23000.00 K. Total Hours or Days of Direct Service for the year 48-840 L. Rate Per hours of Days of Direct, face to face service to be Charged to Weld County Social Services $950.00 per original SAFE home study submitted $450.00 per SAFE home study update submitted $75.00 per hour for court testimony and/or relinquishment counseling Helene Wurth - 13 - Minimum Budget Average Total Degree #Of Salary/Bene Salaries/ 100% DESCRIPTION or Cert FTEs @ 1.0 FTE Benefits/Other ALLOCATED PROGRAM 1.00 contract payment 950.00 original Home Study/Relinquishment per homestudy SAFE homestudy A TOTAL CLIENT HOURS OR DAYS PER PROGRAM submitted 450.00 updated 4-7 days per client I 950.00 original SAFE homestudy B TOTAL CLIENTS TO BE SERVED PER PROGRAM SAFE homestudy 12-120 total number of clients ( 450.00 SAFE update C TOTAL HOURS OR DAYS PER PROGRAM FOR YEAR homestudy 48-480 days DIRECT LABOR NOT FACE-TO-FACE U TOTAL DIRECT LABOR PER PROGRAM NOT FACE-TO-FACE $0.00 OTHER DIRECT COSTS PER PROGRAM NOT FACE-TO-FACE TOTAL OTHER DIRECT COSTS NOT FACE-TO-FACE PER PROGRAM $0.00 F GRAND TOTAL DIRECT SERVICE COSTS NOT FACE-TO-FACE $0.00 TOTAL ALLOCATED ALLOCATE OVERHEAD 100% D OVERHEAD COSTS TO DESCRIPTION COSTS ALLOCATED PROGRAM TO PROGRAM Program 100% 100% $5,070.00 Home Study/Relinquishment A TOTAL CLIENT HOURS OR DAYS PER PROGRAM 4-7 days B TOTAL CLIENTS TO BE SERVED PER PROGRAM 12-120 C TOTAL HOURS OR DAYS PER PROGRAM FOR YEAR 48-480 OVERHEAD rent ::$1,583.00':yes $1,700.00 utilities :. $25000 Yes $250.00 office.Supplies $350.00:'.yes $350.00 car payment $495.00::yes $495.00 Car insurance $125.00:yes $125.00 gasoline $550.00 res $550.00 Spanish Languageintrepreter :$1.$00.00:yes $1,600.00 PmlessionalLiaaaityInsuurance $117.00;yes $117.00 G TOTAL OVERHEAD COSTS $5,070.00 $5,070.00 TOTAL ANTICIPATED PROFITS $17,930:00 $17,930.00 TOTAL OVERHEAD AND ANTICIPATE!$23,000.00 $23,000.00 - 1S- Helene Wurth 4306 Beaver Creek Dr. Fort Collins, CO 80526 970-226-2692 Objective: Complete home studies using SAFE guidelines, and following the SAFE format. Complete home studies in a professional and timely manner. To help explain and to help families feel comfortable with the home study process. Job History: Larimer County Child Protection: July 2005-March 2007 Intake/Home Study worker Job Duties: SAFE home studies, documentation, Colorado Trails system, case management, child protection intake, crisis management, family meetings, facilitation, mediation, work collaboratively with adoption, ongoing and intake case workers. Mountain Crest: May 2003-July 2005 Mental Health Counselor Job Duties: Worked with adolescents age 12-18 in a psychiatric inpatient hospital. Crisis management, case management, counseling, group facilitation, monitoring adolescents,work collaboratively with-DHS,probation officers, and the children's families. The Remington House April 2000-March 2003 Counselor/team leader Work with adolescents age 12-18 in a residential treatment center. Supervise 6-8 floor staff members at a time. Crisis management, counseling, group facilitation,working collaboratively as a team, monitoring adolescents,providing supervision and training to floor staff members. References: Molly Hardy 970-416-5849 Janeah Weaver 970-310-9752 Sasha Whitcomb 303-947-9274 Lisa Hester 303-682-5645 Helene Wurth - 16 - ALLIED HEALTHCARE PROFESSIONAL AND SUPPLEMENTAL LIABILITY INSURANCE POLICY DECLARATION Policy Number: PHCPE23777 Philadelphia Indemnity Insurance Company Name: Helene Wurth Administered By: CPH&Associates Address: 4306 Beaver Creek Dr 711 S.Dearborn,Suite 205 Address 2: Chicago,IL 60605 City,State Zip: Fort Collins,Colorado 80526 Affiliation: NSP Professional Occupation: SOCIAL WORK Policy Terms From: 5/30/2007 Policy Terms To: 5/30/2008 Ending at 12:01 a.m.Standard Time. :COVERAGE A-PROFESSIONAL LIABILITY COVERAGE :LIMITS OF LIABILITY ::PREMIUM ---��— Individual-Each Incident $1,000,000.00 -Th117.00 Aggregate: $5,000,000.00 Association,Partnership or Corporate Each Incidental N/A Aggregate N/A (COVERAGE B SUPPLEMENTAL LIABILITY COVERAGE Individual-Each Incident :$1,000,000.00. _.. _.. ............_____..._.---____._.....-_...______.........._...._.._.... - Aggregate: $5,000,000.00 COVERAGE C-NON-OWNED AUTOMOBILE(optional) Individual-Each Incident:( Aggregate:.:: .____ Premium(including taxes): $117.00 Policy Forms&Endorsements: PHCP-0I(03/01) Jamie Maguire,Authorized Representative State Endorsement(s)made a part of this policy at the time of issue: refer to www.cphins.com Certificate of Insurance(Proof of Coverage) Date Issued:(3/17/2007) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND,OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Insured Name and Mailing Address* Program Administrator Name Helene Wurth .....,. Administered By:CPH and Associates..«.........._.«...__...,a Street 4306 Beaver Creek Dr ! 711 S.Dearborn,Suite 205 Chicago,IL 60605 City Fort Collins , }yip 80526 State Colorado Underwritten By: Philadelphia Indemnity Insurance Company *Additional insured locations are often requested by ind viduat business owners who have more than one office. 3 Your coverage is portable,meaning that you are covered at any location for practice under the occupation(%)listed on your policy. Coverage 'P..o .�licy#:PHCPE23777 Effective Date:(5/30/2007) iExplration Date:(5/30/2008) f HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. r Limits of Liability — — Each Occurrence -�« Aggregate (Per individual claim) 5 (Total amount per policy year) 7 } Sl,00g000:ao "� Coverage Part $5,000,000.00 Professional Liability .W_......_.._..""" $1,000,000.00 i $5,000,000.00 l 1 Supplemental Liability I Includes: ` i A)Bodily Injury and Property Damage Unlimited B) Personal Injury Unlimited Defense Expense Coverage l S25,000 State Licensing Board Inver _... S5,000 ? •...",.. .....,.+ .,......, ,.,.,,• ., ..,.... Investigation Expense Coverage i .......... «.............a.......«..................u..p. R....__.......,«... .......„,_..,,,,...... «...,..«.,,....;.. $5,000 Assault Coverage $5,000 ...w......_._w.......,_.......,_. «..,..,«._....«....„«...._..................«...,,._..._...Wµ.,...... _,.....,..W._.W.«....«_.......q SI5,000 $2,500/person . `�«v $25,000___.__ ^- _,__, Deposition Expense Benefit ...� i 52,500 -'-"._...,_.,... - Medical Expense Coverage __i $2,500 '_.. i -------' First AAid Coverage Certificate Bolder ,i . " , 'r -- - -- - -. Cancellation Proof of Coverage thould any of the above described policy be cancelled before the expiration date ';-thereof,the issuing insurer will endeavor to mail 30 days written notice to the "-lcertifcate holder named to the left,but failure to do so shall impose no obligation or liability of any kind upon the insurer,its agents or representatives. i Holder has also been added to the policy as an Authorized Representative M additional insured:** _Yes I XN0 C.Philip Hodson **If the certificate holder is an ADDITIONAL INSURED,the : policy(ies)must be endorsed.A statement on this certificate does not confer rights to the certificate holder in lieu of such I endorsement(s). DISCLAIMER:The Certificate of Insurance does not constitute a contract between the issuing insurer(s),authorized representative or producer, and the certificate holder,nor does it affirmatively or negatively amend,extend,or alter the coverage afforded by the policies listed thereon. — I Consent Form: I am giving my consent to participate in a SAFE home study. This home study is for the purposes of becoming a foster or adoptive parent or updating a previous home study. I understand that I am not under any obligation to complete this home study. By participating in the home study I am doing so by my own will. I understand that during this home study process I will be required to let the home study worker walk through my home and make a visual safety inspection of my home, belongings, and property. I must participate in a minimum of three interviews as a couple and one individual interview. If I am a single applicant I must participate in a minimum of three individual interviews. I understand that one of these interviews will need to be at my residence. During this process any other people living in the home will be required to complete an individual interview as well, including children, family members or room mates. I understand that I will be required to complete a background check, and that I will have to pay for this on my own. I understand that submitting my background check, safe questionnaires and any other required documentation in a timely manner is important. I will be required to give the home study worker copies of the background checks, copies of my drivers' license, car registration, and car insurance, as well as copies of my health insurance cards and/or life insurance policy. I understand that completing this home study in a timely fashion is subject to my timely admission of required paperwork and flexibility in scheduling interviews. By signing below I am in agreement with everything in the above paragraph. Signed Printed Name Date Home Study Worker Printed Name Date Signature Helene Wnyth - 1 Q - • Authorization to Release Information I authorize the release and disclosure of information and records pertaining to me or my children to Helene Wurth, SAFE home study professional, from the agencies and individuals listed below. I also authorize Helene Wurth to release and disclose information and records pertaining to me or my children to the individuals or agencies listed below. I release the below indicated individuals,agencies and Helene Wurth from any and all liability from the release and disclosure such information and records. This release shall continue in effect for three years if not rescinded in writing earlier. The termination of this release shall not affect previously release information. This release shall also authorize the re-release of information and documents to individuals and agencies marked below: Initial: Attorneys: List names or agency: Department of Social/Human Services (local, state and national) Counselors of Therapists: List names or agency: Schools: List Schools: Employer(s) List Employers: Probation(including probation officers) Law Enforcement(sheriff, police, district attorney, state and federal agencies) Guardian ad litem(s) Family members(immediate family-sibling, parent, spouse and children) Doctors or other medical professionals: list names or agency: Placement Providers: List names/agency: Others: I authorize the release and re-release of psychological/mental health information or records pertaining to me or my children. This information is releasable only to the above indicated people or agencies. I authorize the release and re-release of substance abuse testing, treatment and evaluation information or records,pertaining to me or my children. This information is releasable only to the above indicated people or agencies. I authorize the Weld County Department of Human Services to release any information about me or my children to Helene Wurth in order to complete my SAFE home study. Name Signature Date Heine Stud 'Professional Signature Date Helene Wurth —20 - SAFE Child Specific Home Study Report ' This home study was completed by County Social Services to consider the placement of a specific child or specific children with the applicants for the purpose of either relative or foster care placement, Legal Guardianship and/or ! adoption. ' Name of Family: J.and R. Address: City_ State: I_Postal Code: 00000-0000 Home Phone: jI-_Cell Phone: APPLICATION DISPOSITION The Applicants applied specifically to be considered for the placement of A and C.. Certified for Foster Care/Approved for Adoption on: July 24,2006 Home Study Application received on: June 1,2006 APPLICANT INFORMATION LT- __.- I R. ' Date of Birth: Date of Birth: Birth lace:----+--- — — ——--- — Birthplace: Gender: • RI. Gender: Religion: l Religion_ I Occupation:_ Occu ation: I- Lan= age(s): Languageis_ES__ _.__ Education: Education: I __I - Hei_ht: _ Height: I Wei_ t: i TWeight: Hair: . ' - = — I Hair: E es: I I Eyes: Date of health •uestionnaire/report: I Jun. 1,2006 I Date of health questionnaire/report: I Jun. 1,2006 MARITAL INFORMATION Date of Marriage: Marriage Verification: On File Place of Marriage: -- DATES OF CONTACT Date Individual/Couple Location Couple Couples residence Individual J. Couples residence Couple Couples residence Individual R. Couples residence Couple Couples residence Individual T. Couples residence Individual S. _Couples residence Couple Couples residence Individual R. Couples residence Structured Analysis Family Evaluation(SAFE) Colorado Couple Child Specific Home Study Report -Version 11-16-2006 Copyright,2005,Consortium for Children,All Rights Reserved -21- CHILD OR YOUTH BEING CONSIDERED FOR PLACEMENT CI. "nd A_ , female, are currently placed with ' and R J and R took in C and A parents from the homeless shelter and allowed them to stay in their home in 2005. A few weeks later they became concerned about possible drug use by the biological parents and called the police. The police arrested the biological parents and C. and A went to a receiving home on a 72 hour police hold. R and J went to court and were granted temporary custody of C' and A and they returned to the Lee home. A and C have lived with the L 's for one year now. The biological parents did not follow through with the court ordered treatment plan and did not make an effort to attend parenting time visits. The biological parent's rights have been terminated and C and A are free for adoption. A due to her age, had an easy adjustment to the L family. To P this is the only family she has ever known and R and J are her mom and dad. According to R and J A adjusted quickly and easily. C' is old enough that she remembers her relationship with her mom and stepfather. C 's biological father is deceased. Her biological mother had remarried and this man lived with C' most of her life before placement. C: was physically and sexually abused by her step father and neglected by her mother and step father. According to the L 's, C attached to R instantly. She feels comfortable and safe with R and spends a lot of time with her. C has had a difficult time attaching to.' She seems to be working through her prior abuse issues. J says that C. is fine around him as long as it's on her terms. If J approaches C she does not talk to him. If J allows C to be in control she does interact with him. Jc _ states that it is difficult, but that he understands the reasons behind it and will allow C. to move at her own pace. Joe stated that Chastity has shown big improvements in the year that she has been living with them. C seems to feel like part of the family. She interacts with the other siblings and seems to feel comfortable in the home. She is enrolled in the neighborhood school and has several friends in the neighborhood as well. C seems to be adjusting well. She will need to continue to work on her relationship with J' through counseling. A has a bubbly bright personality. She enjoys people and talking with them. She seems to enjoy her siblings and playing with other children. A.' is outgoing, bright,loving and curious and developmentally on track. This home is the only home she remembers and she seems well adjusted because of it. A. is predisposed to mental _ health issues. This does not seem to be affecting her at this.point. Due to her age A . -does not understand that she is being adopted. R . and J are Mom and Dad to her. A does have contact with her biological family, at her age she does not understand the difference between the L 's and her biological family. C. is a more sullen, shy little girl. She can be sensitive, caring, clumsy, clingy and loving however,Joe describes her as distant. C: for the most part seems developmentally on track. She tends to fall behind in school work. C interacts well with R - and her siblings, but struggles with J . She will make very little eye contact and does not speak to J very often. J allows C.. to interact with her as to her comfort level. C. does understand that she is being adopted but does not talk about it with R and J They both state that C. _ seems to like being in their home and that she is very close with R C. .5ontinues to suffer from the affects of the abuse and neglect that she went through and pain with being removed from her biological mother. C understands that her mom did not follow through with visitation and her treatment. C. •also continues to have contact with her biological family. C enjoys contact with her grandparents and aunt,and this will be important for her in the future. C is genetically pre-disposed to mental illness and substance abuse issues. C is currently attending counseling to work through her abuse and neglect issues C and A have been placed together since their removal from the family. It is very important that this connection be maintained. It is important for C to have the stability of a two parent family and to maintain connections with her biological family. C currently suffers from night terrors stemming from her sexual abuse victimization and extreme neglect. C will need to have continued/ongoing therapy to deal with these issues. C is currently in counseling with Dr. Rodden. She is phasing out of her appointments at this time and R states that she is ready to move on and let go. There are going to be some ongoing issues stemming from the sexual abuse. CI is also in counseling through her elementary school. The L 's plan on continuing this counseling for C For A it is also important that she be placed with her sibling. It will also be important for her to maintain connections with her biological family. A may benefit from a home that has a stay at home parent. A and C are pre-disposed to mental health and substance abuse issues. Structured Analysis Family Evaluation(SAFE) Colorado Couple Child Specific Home Study Report -Version 05-08-2006 Copyright,2005,Consortium for Children,All Rights Reserved _ZZ - Neither C nor A , suffer from difficulty with temperament. C is having a difficult time attaching to J due to her abuse issues by her stepfather. The L family may benefit from family counseling in the future to address these attachment issues. C currently has issues with being sexually abused, and extremely neglected. C, suffers from night terrors as a result of this. C. is currently attending counseling and may require ongoing counseling in the future. MOTIVATION and R state that they immediately knew that they wanted to care for C.. and A, They stated that when the parents were arrested that they knew they wanted the girls to live with them. They wanted to provide a stable environment for the girls and help their mother get her life together. When C and A mother did not follow through with the treatment plan they stated that they knew they wanted to adopt the girls. They feel like this is C and A 's home. R and J would like to become adoptive parents to C and A They are anxious for the adoption to become complete. HOME ENVIRONMENT Type of residence House Square Footage 1820 Bedrooms: 4 Bathrooms 2 Length of Time in current residence: 2 years The L 's home is located in north Fort Collins on the beginning of a cul-de-sac street. The street they live on has several other homes in adequate to good condition. The L 's state that they moved into their home not realizing that some of the houses on the street are rented by college students. They also state that their street is quiet, but that because they live on the corner of two streets, they worry about how fast people drive on the main road. As a result the children are not allowed to play out front unsupervised, and do not play by the side of the front yard that faces the main road. The house is a ranch style home without a basement. It has an addition in the back of the house that is used as a living room. R-. . and J( have renovated the garage into their master bedroom, and have an added additional garage that is not attached to the home. J. and R. . . 's bedroom is on one side of the home,and the other three bedrooms for the children are on the opposite,side of the home. T and S each have their own bedroom. Ci and A share a bedroom. In C and A. 's bedroom they have a bunk bed;and several age appropriate toys. The family shares one bathroom that is equipped with a shower and tub. They have another bathroom that they use as an extra toilet and sink. Their backyard is fenced in and there are age appropriate toys in the back yard for A and C:_ -_. . R -ran a licensed home daycare in the family's home until August 2006. As a result,the backyard is set up as a daycare playground. They do not have any pools or ponds in their yard. The Lr e s have several animals in their home. They have two dogs. One is a Golden Retriever and the other is a Chow/Rottweiler mix. Both dogs seem acclimated to the children in the home. The dogs are in the house most of the time. They also have four cats. The cats also seem comfortable with the children. J and WI seek regular veterinarian care at Cache la Poudre Veterinary. There are no guns or weapons in the home. The interior and exterior of the home was inspected for health and safety hazards. The inspection was completed on 6/19/06. FAMILY Applicant#1 -J L J was born in 1968 in San Jose California. J -'s parents were divorced when he was three years old and he did not have much of a relationship with his father afterwards.Joe describes his father as a workaholic, money grubber, and stated he is a womanizer and a businessman. He currently lives in California and J states that they don't have much to talk about. Jr 's father has been married and divorced three separate times. J- has one half- sister Jaime from his father's third marriage. J has an older brother Tom from his mother and father's relationship. Jr 's mother has been married four times and Jr has had three different stepfathers. J- describes his second stepfather as a strict Marine. Jr stated that he would be spanked for no reason. J ;aid that his mom took good care of him and his brother and that he believes his mom ended this marriage because of the physical Structured Analysis Family Evaluation(SAFE) Colorado Couple Child Specific Home Study Report -Version 05-08-2006 Copyright,2005,Consortium for Children,All Rights Reserved , punishment by the step father. J 's mom remarried and had another son as a result of this marriage named, Don. J describes his childhood as relatively normal, happy, fun, stable and secure. He said that his mom was a very good mom and that she kept him shielded from anything bad going on in the family. He describes his mother as caring supportive, warm, affectionate and loving.Joe stated that he has two uncles who were alcoholics but his mom did not let them around J. . Jr 's morn would try to shelter him from negative influences in the family. J• describes his teenage years as pretty uneventful. He stated that he was happy, friendly, responsible, active and shy. He said that he followed the rules and was rarely rebellious. J describes himself as hyperactive. He stated that he has never been diagnosed but that it affected his schoolwork because he couldn't sit still. J - stated that it continues to affect him today because he becomes easily distracted. J went into the army at the age of eighteen. He stated that he was in the 82"a Airborne Division. He used to jump out of airplanes. J served in Desert Storm,but stated that he stayed out of combat. He said that he never had to shoot anyone and didn't see anyone die. He stated that he does not feel like he suffered any trauma as a result of being in the war. J stated he knew the Army wasn't what he wanted to do for the rest of his life and he knew he was smarter than that. J moved back to Oregon at the age of 22 and left the Army. J stated that he initially had difficulty readjusting to normal life, as opposed to army life. He stated that he became short tempered and impatient. He felt like he needed something to do constantly and that was difficult for him to readjust. J , and Rt met and began dating when I ;was 22. They moved in together a few months later. R had a son T, from a previous relationship and k - adopted him when T was 4 years old. J and R had their own daughter SI and married one year later. They have been married for 13 years. Joe states that when he and R first were together that they would fight and lose their tempers more frequently. He states that he is now more relaxed and has different priorities in his life. He states that they do not argue very often anymore, and that they have learned better communication skills and that he is more tactful and careful about how he says things. Jc states that he works hard but that his priorities are now more on being a father. He states that he would rather come home and spend time with his children. J states that he believes he is a better father the second time around with C__. ... and A_ The current issues that are affecting J and R. relationship are time together, discipline of the children, emotional closeness and sexual relations. Joe states that RL can be distant from him and that intimacy can be difficult. J thinks that this is a result of R being raped at 18, and the abuse she suffered as a child. He states that R is not as affectionate with him as he'd like her to be. J 's mom Jackie _ is currently in her fourth marriage. The couple married when J was 14 and currently live in Oregon. Jackie is married to a man named Gene. J describes his relationship with them as caring, but reports that he only sees them about once a year. J states that he is closer to Gene than his own father. J said that about two years ago his stepfather Gene was caught groping his brother's stepdaughter(16 years old). Gene now has to register as a sex offender and is not allowed to see any children. J. states that although it's not an excuse Gene has Erectile Dysfunction and he was taking new hormonal medication at the time for it.. Joe states that his mom took it very hard and that she almost ended the relationship. He states that Gene had not had any prior incidents of sexual assault. J. states that he doesn't remember Gene ever being inappropriate with children at any time before this. f also states that he does not trust Gene with his children. He said that he is now not allowed to see children but even in the future he does not think he will ever trust Gene with the children. Gene has never met C' and A_ . J_ states that he goes up to his mom's once a year to visit by himself. Jr has worked forRoto-Rooter for the past 7 years. He is a supervisor there. J hopes to have his own plumbing business that he can pass on to T " some day. He states that he wants to teach Tyler a skill for the future. J and R hope to relocate to Oregon after the adoption is finalized. Jr mom, step-dad, and his brothers live in there. He hopes to move his family out there so that he can be close to them. I describes his Structured Analysis Family Evaluation(SAFE) Colorado Couple Child Specific Home Study Report -Version 05-08-2006 Copyright,2005,Consortium for Children,All Rights Reserved family as willing and able to accept CI and A as part of the family. He states that they are all supportive of the adoption process. k , presents as outgoing, fun, loving and as having a good sense of humor. J .tends to be straight forward and to the point in his discussions. J ,can become easily distracted and reading can be difficult for him unless it is quiet. Jr likes to work on cars and ride his bike. He enjoys spending time with his children. He is a patient and caring father to his children. Applicant#2 - R_ . L R was born in Beeville,Texas. R. is number four of five children. She had all sisters. R 's parents divorced when she was three years old. She had little contact with her father after the divorce. R stated that she saw her father a few times from when she was 6 until the age of 10. He lived in New York and she lived in Arizona at the time. R .describes her early childhood as not very good, unhappy, lonely, chaotic, confusing, and sad. She said that she did not have.a relationship with her mother because she worked all the time. 12,._ a describes her morn as moody and unpredictable. R described being physically abused and slapped by her mother her sister Denise, and her sister Terry. Ri said that her sister Denise would hit her all the time, slap her across the face, pull her by the hair and that her mother would spank her with objects. She also describes emotional abuse, being called stupid, skinny and ugly. R described her childhood as independent, and stated she had to take care of herself a lot of the time. She stated that she was close to her sister Cindy. When R was ten years old she began smoking pot and stated that she"used lots of other drugs and pills". She said that her older sisters would give her drugs and she would use them. She stated that her motivation was that she hated being home and she and Cindy would use drugs together. R stated that her mom found out about the drug use and moved the family to Oregon at the age of 12. The family's motivation was to get away from the drugs. R. stated that she began drinking alcohol in 8`h grade. She said that she drank alcohol every once in awhile until she was a senior in high school. She stated that during her senior year she drank all the time all weekend, every weekend. R stated that this continued until she was 20 years old. At the age of 18, R -'s mom sent her to live with her sister and her husband. R x had a tuba) pregnancy, and was recovering at her sister Terry's home. Rr .describes her brother in law as an alcoholic. She stated that Terry and her husband were fighting and that Terry left the home. After Terry left R ' was raped by her brother in law. R stated that"he was drunk",and "I don't think he remembered it". R stated that she did not tell her sister, or her mother because she didn't think they would have believed her. R stated that she returned to her mother's house a short time later. R stated that she was not close to her sister before and is not close with her today. R , also stated that to this day, she has not told her mom or sister and has never attended counseling for this. When Rr was about 16 years old she stated that she had a blow up with her mom. They began talking about why her mom allowed her sisters to abuse her, said awful things about her father and lied about her dad being physically abusive to her. R stated that as a result of this conversation they have a good relationship now. R - talked with her father when she was 18. He stated that he never physically abused his wife, that she abused him. He also claims that R 's mom was having an affair and that's why the relationship ended. R currently has little contact with her father. When RC was 20 years old, she moved to California and got ajob. She stated that she was"growing up" and getting away from the drinking. R. _xi._became involved in a relationship and was engaged to be married when she became pregnant with Y r. Her fiancée left her immediately after he found out she was pregnant. R describes herself as devastated. She called her mom and moved back with her to give birth to her son. R, stated that her ex-fiancee never had any contact with T, . R eec and J met when T- - was 18 months old and began dating. They moved in together a few months later in 1992. The couple had their daughter Scv- and were married when S, was one year old in 1994. J adopted T when he was 4 years old. Re continued to have a close relationship with her sister Cindy. In 1995 Cindy had kidney disease. R ` donated a kidney to Cindy. Cindy ended up getting lymphoma from all of the anti rejection medication -- Structured Analysis Family Evaluation(SAFE) Colorado Couple Child Specific Home Study Report -Version 05-08-2006 Copyright,2005,Consortium for Children,All Rights Reserved —25— , and passed away quickly after the transplant. R stated that she was very depressed when Cindy died. She said that she doesn't remember anything for a few months after that. She stated that sometimes she wasn't even sure if she had fed her children. A few months later, a friend and Jr ;encouraged Rc to seek help. She went to a doctor and was put on Prozac, and was later switched to another medication. Rebecca stated that she weaned herself off of the medication after 4-5 months of it. She stated that she could again feel herself becoming depressed. She went back to the doctor and was again put on medication. She stated that she stayed on this medication for 6 months and was weaned off of the medication by her doctor this time. R_ stated that she has not had any recurrences of depression since then. R___ a stated that in 1998 she was on vacation and began having anxiety and panic attacks. She said that she became very paranoid of her family being in an accident and began throwing up. She stated that with the encouragement of J she again sought medical attention and was put on an anti-anxiety medication. R{ stated that she took these medications for about I year and was weaned off of them. R, stated that she does not have issues with anxiety now and that when she feels stressed she knows to take a break and get a night out. R and J have been married for 13 years. They stated that initially in their relationship they would argue and both overreact and lose their tempers. They stated that over time they have been able to figure each other out and do not argue very much anymore.They also state that they have settled with age. Current issues in their marriage are time together, money, emotional closeness and discipline of the children. They stated that when they have a disagreement now, they discuss the issue, take time outs, yell or become silent. Their current issues of emotional closeness seem to stem from the abuse R suffered as a child and as a teenager. R stated she loves! , but that she would not curl up and die if he weren't there anymore. She stated she does not need anybody and that she can survive on her own. R never received counseling for the abuse she suffered as a child and teen and these issues seem to affect her current functioning. RI states that she is not as emotionally close and affectionate as she should be and that this is probably a result of her childhood. R presents herself as quiet, serious, friendly,and somewhat guarded. She has worked as a licensed in home daycare mom for the past 13 years. R< stated that she recently needed a change and that she did not want to do daycare anymore. In August 2006, R " ended her daycare business and found employment out of the home. R ;s currently working at Overland foods at the deli counter and as a cashier. It states that she likes getting out of the home. R is patient and loving towards her children. She takes the time with them and does not seem to become easily irritated with them. She seis clear limits and expectations with her children. R seems to really enjoy being a mom and spending time with her children R currently has a relationship with her mother. She lives in Fort Collins and is involved in R •'s life and her children's lives. R states that her children love their grandma and going to her house. She states that today her and her mom are best friends and are really close. R - _.has three siblings that are still living, Denise, Stephanie, and Terry. Rc describes her relationship with Denise and Stephanie as close, but she does not have much of a relationship with Terry. R states that her family is willing to accept C' and • into the family. She stated that her family and friends are currently able to be supportive to their family throughout the adoption process. Applicants' Sons and Daughters T is Rc sar 's biological son and J 's adopted son. He is 15 years old and his DOB is . T " likes to hang out with friends, skateboard, play soccer, and play other sports. T, has ADD and has difficulties in school. He is currently in 9th grade at Cache La Poudre Middle School. T - can be moody and Joe describes their relationship as difficult sometimes. .' . states that recently T, :has had better behavior. T - seems to have a good relationship with his siblings. He takes an active care taking role for A. and is kind and loving with both C _._"_ and A TY, It likes being the"big brother"and he likes to help in being responsible for his sisters. Tyler states that he is a very caring person. According to T. ' 's health questionnaire he is in good health, S' 3 12 years old and her DOB is _ 1. She is currently in the 7th grade at Cache La Poudre Middle School. S: vat is a happy, outgoing and funny girl. She states that she likes music, going to the park, playing football, basketball and softball. She also stated that she likes running track and hopes to do it this year in school. Shyann enjoys spending time with C and AL;:_ She seems close to C and spends a lot of time Structured Analysis Family Evaluation(SAFE) Colorado Couple Child Specific Home Study Report -Version 05-08-2006 Copyright,2005,Consortium for Children,All Rights Reserved �Zb- with her. J -.states that although the girls have separate rooms,they like to sleep in the same bedroom together and that they often take turns sleeping in each other's bunk beds. S. states that she is very glad to have another member in the family. According to her health questionnaire S' - t is in good health. Other Children or Youth living or frequently in the home CI and A. are the only other children residing in the Lee home. Other adults residing or frequently in the home R 's mom lives in Fort Collins and cares for C and A. sometimes. R .had a daycare helper who worked in her hcn:e business until recently, who now cares for Ashley while she works. R goes to work at 11p.m.. and J.r returns from work at approximately 5-6p.m.. During this time frame is when she watches the children. This happens three days a week. Family Lifestyle J ., works for Roto-Rooter and is a supervisor. He works five days a week and is on call one evening a week. Occasionally J has to work additional on call shifts. J ,describes himself as somewhat of a workaholic. Up until a few months ago R _ . 4 was employed doing home daycare. She recently found other employment at Overland Foods. She works in the deli and at the cash register. She works four days a week and has Monday, Wednesday and Thursday off. Her current work hours are 11 am-7 p.m. R. is home in the morning and gets T. SI and CI off to school. Ashley remains at home with R - and has a daycare helper watch her when she goes to work. The daycare helper watches her and the other children until Joe returns home at about 5:30 or 6. Household rules include no drinking, doing drugs,or swearing. J ;and R. say that it is very important that their children are honest and truthful with them. They want to know where they are at all times, and would prefer for their children's friends to play at their house. They say that they encourage their children to talk respectfully to each other and not talk down to each other. R. .and Jr encourage the children to get dressed in their own rooms and except for T. taking his shirt off that they be covered up when in the joint family areas. Joe states that privacy is important to them and that they give each other privacy when changing or in the shower. Each of the children have chores such as cleaning dishes, picking up their rooms, helping cook dinner, and taking out the trash. The entire family helps with household chores: Consequences in their home are loss of privileges, grounding or time outs in their rooms. R .and l share in parenting responsibilities. They each watch the children and provide transportation when the other is working. Previous adoption and/or foster care experience The L family does not have any previous foster care or adoption experience. R • a has had a licensed home daycare for 13 years until recently when she decided to change careers last month. FINANCES Combined annual gross earned income: $53,209 Sources of additional income: R continues to watch 2 or 3 other children when she is not working at her other job. CRIMINAL/CHILD ABUSE RECORD The required criminal record and Child Abuse Index checks were completed for J L and R r= L, State automated system,CBI,ICON/Co Courts,and FBI(if applicable) Clearance Findings: CBI findings were clear. Other findings: Local Law Enforcement checks were clear as well as Crimilink. DMV checks revealed only a few minor traffic violations. Structured Analysis Family Evaluation(SAFE) Colorado Couple Child Specific Home Study Report -Version 05-08-2006 Copyright,2005, Consortium for Children,All Rights Reserved , _27_ EMERGENCY CARE PLAN The L 's have decided that if anything happens to them that the children will go to R 's sister Stephanie and her husband Paul who live in Washington. This has been discussed with Stephanie and Paul. CONTACT WITH FAMILY OF ORIGIN AND SIGNIFICANT OTHERS J. and Rr ..were initially working with C: and A "'s biological mother in an attempt to reunite their family. They were supportive of the girl's relationship with their biological family. The children's biological mother did not follow through with her treatment plan and her rights were terminated. R- and J both stated that they would be willing to let their biological mother have contact with the girls now if she was able to get her life together, stop using drugs, be responsible and reliable for C and A. . The Lee family is not willing for the girls to maintain contact with A `c;'s biological father due to sexual abuse issues and his being violent in the past. C: 's biological father is deceased. R and J. currently allow C and A. to have contact with their biological mother's family. They have contact with their Aunt and Grandparents. R stated that the girl's family is supportive of the L ..'s adopting Cl. and A. and think it is the best place for them. There are no known siblings to the girls at this time, and they did not have any prior significant relationship with a foster family. They were placed in a receiving home for 72 hours, but were immediately returned to the L The's home. This is the only other placement they have had. There is no written post-adoption contact agreement. REFERENCES References received: No FAMILY TRAINING The L 's attended Larimer County DHS's PRIDE training. R i and J are current in first aid and CPR. LEGAL/FINANCIAL RIGHTS AND RESPONSIBILITIES J L and R L.:have been provided with information concerning the different roles, responsibilities, legal and financial rights and benefits of relative/child specific kin caregivers,foster parents, legal guardians and adoptive parents. Also, should they file a petition to adopt, L .L and R L understand that they will be accepting full legal and financial parental responsibility for C: and A. ;once an adoption is finalized. The agency's grievance procedures were explained to the Applicants. Structured Analysis Family Evaluation(SAFE) Colorado Couple Child Specific Home Study Report -Version 05-08-2006 Copyright,2005,Consortium for Children,All Rights Reserved . PSYCHOSOCIAL INVENTORY RESULTS NOTE: Below is a list of the.psychosocial factors found on the SAFE Psychosocial Inventory. Using the Psychosocial '.. Inventory, each factor was considered and rated several times by the social worker during the course of this home study. The ratings below represent the final ratings. The ratings are defined as follows: I = an exceptional strength, 2 = a strength, 3 = an '.. issue of concern, 4 = a major issue of concern and 5 = very serious problem. The OVERALL EVALUATION OF SECTION ratings reflect the degree to which all issues of concern identified in the section were either resolved, mitigated or the prognosis for change. #1 #2 #1 #2 #i: gttr`fr 2 3 Childhood Family Adaptability 2 3 Extended Family Cohesion 2 3 Childhood Family Cohesion 2 2 Extended Family Adaptability 3 4 Childhood History of Deprivation/Trauma 2 3 Relationship with own Extended Family 2 4 Childhood History of Victimization 2 2 Relationship with Spouse's/Partner's Family 2 3 Adult History of Victimization/Trauma 2 : 2 OVERALL EVALUATION OF SECTION 2 2 History of Child Abuse/Neglect 2 4 History of Alcohol/Drug Use " s .• ys"_�¢ xPii ., 2 2 History of Crime/Arrest/Allegations/Violence 2 Cleanliness/Orderliness/Maintenance 2 3 Psychiatric History 2 Safety 2 2 Occupational History 2 Furnishings 2 2 Marriage/Domestic Partner History 2 Play Area/Equipment/Clothing 2 4 OVERALL EVALUATION OF SECTION 2 Finances 2 Support System #1 #2 xt14't1# 11, °3' agi ,r1.ki.45H . 0 s , 2 Household Pets 2 3 Communication 2 OVERALL EVALUATION OF SECTION 2 2 Commitment and Responsibility 2 3 Problem Solving #1 #2 � € c €3 t"yg µu �yy+F.g ._ t. Y{m�� i �'�tA+v",r 2 2 Interpersonal Relations 2 2 Child Development 2 2 Health and Physical Stamina 2 2 Parenting Style 2 2 Self-esteem - 2 2 Disciplinary Methods 2 2 Acceptance of Differences 2 2 Child Supervision 2 3 Coping Skills 2 2 Learning Experiences 2 2 Impulse Control 2 2 Parental Role 2 3 Mood 2 2 Child Interactions 2 3 Anger Management and Resolution 2 2 Communication with Child 2 2 Judgment 2 2 Basic Care 2 2 Adaptability 2 i 2 Child's Play 2 3 OVERALL EVALUATION OF SECTION 2 2 OVERALL EVALUATION OF SECTION tt \4r, tAE0,4,;c ' tip iF'T . #1 #2 -•-":411(t.•;'1- L kF }A€IFtkR1 6 A. sips( sr,�, 2 2 Expectations 3 Conflict Resolution 2 2 Effects of Abuse/Neglect 3 Emotional Support 2 2 Effects of Sexual Abuse 2 Attitude toward Spouse/Partner 2 2 Effects of Separation and Loss 3 Communication between Couple 2 2 Structure 2 Balance of Power 2 2 Therapeutic/Educational Resources 2 Stability of the Marriage or Partnership 2 2 Birth Sibling Relationships 2 Sexual Compatibility 2 2 Child Background Information 3 OVERALL EVALUATION OF SECTION 2 2 Birth Parent Issues 2 2 OVERALL EVALUATION OF SECTION y0.� °5.4115.4.4'd t 1'S4)Ts l tb4 " &6iL$G VS S,r,W ,cjv. rii RS-1.11A4.11—'. b ..,:s I #1 #2 �P C `. t741- 2 Minor Sons and Daughters 2 2 Infertility 2 Minors Residing or Frequently in the Home 2 2 Telling Child about Adoption 2 Adult Sons and Daughters I 1 Openness in Adoption 2 Adults Residing or Frequently in the Home I I Adoptive Parent Status 2 OVERALL EVALUATION OF SECTION 2 2 OVERALL EVALUATION OF SECTION Structured Analysis Family Evaluation(SAFE) Colorado Couple Child Specific Home Study Report.-Version 05-08-2006 Copyright,2005,Consortium for Children,All Rights Reserved • `zG_ PSYCHOSOCIAL EVALUATION REPORT HISTORY J„ U : L had moderate family instability while growing up. His mother was married four separate times and his biological father was not involved much in J 's life after his parents divorced. J received a two for all other categories in this area. He did not have a history of being abused as a child or an adult. He has a good occupational history and history of his marriage. He had very little alcohol use and no drug use during his life. J did not describe any history of trauma or deprivation. L received a two for the section overall because his past family instability does not seem to affect his current functioning. R. L Rc received several rating of threes and fours. During her childhood P had difficult adapting to change. After her parents divorced her mother had a difficult time raising her daughters on her own. The family seemed to become more unstable after that and never regained stability. R 's father was not involved in her life after the divorce. She has only seen him a few times since then. During P 's childhood there was substantial family instability. R 's emotional and developmental needs were not met because of the family's issues. R ,and her sisters were left to care for themselves most of the time. She experienced traumatic separation when her father left the family. R s mother may have suffered from mental health issues that affected the way she was able to parent. During her childhood she was physically abused by her mother and her older sister. She was slapped hit and emotionally abused. F ,.:,. was shamed and ridiculed by her family and rarely received recognition for her accomplishments. When R was an adolescent/adult she was sexually assaulted by a family member. She does not seem to have dealt with this issue. Rebecca has a lengthy history of alcohol and drug abuse. She describes herself at the ages of 10-12 years old experimenting with drugs. This issue was so concerning for her mother that she moved the family to another state. R ,stated that while she was in high school and during her early adulthood she drank alcohol excessively. She stated that this ended when she was 20 years old. R stated that when she was 20 she moved to California to start her life over. She wanted to get away from the partying and become an adult. Drug and alcohol abuse does not seem to affect R e: i today. She describes herself as an occasional drinker and she never uses illegal drugs. R ;a has had mental health issues in her life where she has sought out care from a medical professional. R• 1 states that after the death of her sister she became extremely depressed. After several months she went to a doctor and went on medication. She remained on the medication for about 1 years until she was taken off of it by her doctor. Rebecca also describes that several years ago she suffered from anxiety and panic attacks. She stated that she would have irrational fears and it was affecting her everyday functioning. R• again sought out medical care and was given prescription medication. R. - was again weaned off the medication by her health professional.Rebecca did suffer from mental health issues but each time sought out help from a medical professional. These issues don't seem to affect her daily functioning at this time. R _ has had a stable occupational history. R and 1 's relationship is a long term and stable relationship. They have made it through several adversities during their time together. They do not describe at any time having difficulties that put their relationship in danger. R received an overall evaluation of 4 for this section. She seems to have not dealt with some of the issues of physical abuse and sexual . assault during her life. These issues seem to affect the way she functions with her husband and her family. She has difficulty letting her guard down and fully trusting her husband. She does not want to feel like she needs anyone and that she can survive on her own. She denies that these things cause her issues now and states that the things that she went through just made her who she is and she can't change it, but she won't let it ruin her life. PERSONAL CHARACTERISTICS J He received a two for each of the categories. Jr has good, open, and honest communication with others. He has a good ability to problem solve. J has been through some difficult times but has allowed those times to change him for the better. He states that he is a better parent the second time around because he has learned from his mistakes and is a calmer person. J. seems to adapt well to change and has good coping skills. He describes his family as the most important thing to him. R : She received a three for her interpersonal relationships. She seems to have difficulty getting to close to others. She does not want to feel like she needs anyone else, and that she can survive on her own. She seems to not seek support from others when it is needed, but relies on herself. She also received a three for the area of coping skills. She seems to have had difficulty coping with the difficulties in her childhood and adolescents. She used Structured Analysis Family Evaluation(SAFE) Colorado Couple Child Specific Home Study Report -Version 05-08-2006 Copyright,2005,Consortium for Children,All Rights Reserved - 30- drugs and alcohol to cope with those issues. She also seems to now internalize most of her problems and not seek • support from others. She has a history of becoming depressed or suffering from anxiety when faced with difficult situations. Rt also received threes for her mood and anger management. Her husband describes R as moody. She is subject to depression and can be distant and come across as cold. Her affect can be occasionally flat and her mood overly serious. She can become easily irritated and has difficulty expressing her needs and wants to her husband. In all other categories R • received a two. She seems to have good problem solving skills, and is committed to her family. She has good self esteem and is accepting of others differences. She has good judgment and is adaptable to change. Rt- received an overall rating of a three for this area, because the areas that received threes seem to affect her current functioning. MARITAL/DOMESTIC PARTNER RELATIONSHIP Jr and R. received a rating of one in the stability of their marriage. They seem to have made it through several difficult situations. They have been together for over ten years and have not had any issues that have almost ended their relationship. J ;and R i received ratings of three for conflict resolution. They seem to have a marginal ability to talk through conflicts. They tend to avoid the issues or not talk about them. When they disagree they can give each other the cold shoulder or refuse to see the other's point of view. They also received a three in the area of emotional support. R _ seems to have difficult responding to J 's emotional needs. There seems to be an unbalance of emotional support in their relationship. They can sometimes have difficulty expressing their feelings to one another. They also received a rating of three in the area of communication between couple. Their communication can sometimes not be mutually satisfying. The couple received ratings of two's for all other areas. They have a good attitude towards each other. They have a good balance of power taking each other's ideas in mind. The couple describes a sexually compatible relationship. SONS/DAUGHTERS/OTHERS RESIDING OR FREQUENTLY IN THE HOME T. U : The parenting of T. incorporates warmth and control. The family expectations are clear and realistic. T. does not have any history of behavior that would harm himself or others. Tyler is excited about adding two new sisters to his home. He is accepting of C' and k and already accepts them as his sisters. S The parenting of S' incorporates warmth and control. The family expectations are clear and realistic. S' does not have any history of behavior that would harm herself or others. 5i is also prepared and excited to add CI • and A - to their home. She has already accepted them as her sisters EXTENDED FAMILY RELATIONSHIPS J : He seems to have an adequate relationship with his extended family.J 2 is close to his mother and talks about her with warmth and affection. J does not have much contact with his biological father but this does not seem to affect his current functioning. Jr describes his stepfather as his father and has a close relationship with him. Joe's stepfather recently sexually molested a female family member, he has to register as a sex offender and cannot have any contact with children. Jr •states that he loves him, but will never trust him around the children. J( visits his family once a year by himself,the children have not seem their step grandfather since the incident. Jr; seems to have an adequate relationship with R, 's family. Re. :: Rt received a rating of three in the areas of extended family cohesion and relationship with her extended family. Rr' • states that she has forgiven her mother and has a good relationship with her now. She describes herself as close to some of her sisters and not to others. RL'-z 's relationship with Terry suffered even more when her husband sexually assaulted her. R has never told Terry or her mother about the incident and it seems to have affected their relationship. This seems to continue to affect R 's functioning with her family. R s relationship with her mother seems to have improved over the years. They live in the same town and seem to have a close relationship now. R .'s extended family seems to have adapted adequately through the years and is now functioning on a more healthy level. She seems to have an adequate relationship with J family. Structured Analysis Family Evaluation(SAFE) Colorado Couple Child Specific Home Study Report -Version 05-08-2006 Copyright,2005,Consortium for Children,All Rights Reserved - fl - PHYSICAL/SOCIAL ENVIRONMENT ' The U 's received two for all areas in this section. Their home is clean and orderly. R did home daycare up until recently and the home is safe and adequate for the children. They have several pets in the household but they seem to function well around the children in the home. They have a past history of having difficulty with finances but seem to be functioning within their means now. GENERAL PARENTING J' and R " : seem to be wonderful parents. They both received twos for all areas in this section. They have adequate knowledge of child development. They use adequate disciplinary methods and supervise the children well. They understand the need for the children to have learning experiences and communicate well with the children. Their children are well cared for and their basic needs are always met. SPECIALIZED PARENTING .1 and RL i received twos in all areas of this section as well. They understand the effects of abuse, neglect and sexual abuse. They are helping C' with her issues of abuse and loss of her parents. They provide adequate structure, and therapeutic resources. They understand the need for the children to have a relationship with their birth family and encourage that. They seem to seek out knowledge and do wh 's in the best interest of C • and A ADOPTION ISSUES J_ , and R do not have any issues with infertility. R recently had a hysterectomy, but the couple stated that they did not want to have any more biological children. The family received a one for their openness to adoption, adoptive parent status and telling the children about adoption. They seem very open and honest about the adoption. They were initially willing to work with the children so that they could return to their biological family and are still willing to allow the children to maintain contact with their birth family. They seem to understand the importance of being open to adoption and are secure in their parenting role. They are willing to talk with the children about their past and do what's in the best interest of the children. PSYCHOSOCIAL EVALUATION CONCLUSIONS b and.Rc seem ready to parent two more children. They have a strong commitment to C -- and already see them as their children. They stated that C. and Ashley moved into their home and fit in right away. They always seem willing to do what's in the best interest of Chastity and Ashley. The issues in the family seem to be issues between J •.'and R They both seem to put their parenting role first and as most important. They have difficulty with communication and getting their needs met by each other. C? • 's sexual abuse may bring up issues for R ' ; in the future. Re seems willing to seek help if this does become an issue. R " seems to parent with a balance of warmth and control. She has never physically abused her children as frequently happened to her during her childhood. R. • seems to want to parent differently than she parented and has made a conscious effort to do so. R i and J seem to need to work on the issues of emotional closeness and talking through their issues. This seems to be because R_ has difficulty being totally open and trusting of J The couple is aware of this issue. They seem to genuinely love and care for each other and are committed to each other. They seem like they will have the ability to stick with each other and continually work on issues as they arise. PLACEMENT COMPATABILITY C; and A _ seem to be a good match for the Lee's home. They already seem like they are part of the family and fit in well. Because of R is past she seems to have the ability to relate to and understand where Chastity comes from. They seem to have a special bond because of it. A only knows the L 's as her home. She calls them Mom and Dad and does not remember her birth family. C and A_' • • seem to fit well with the 's family C! has issues related to sexual abuse. She has been caught kissing boys at school and telling her friends how to french kiss. Chastity will have ongoing, lifelong issues regarding this. C;", " and A - both genetically are predisposed towards substance abuse and mental health issues. These may be ongoing lifelong issues for the children. Re' and J seem like they will be able to manage these issues. R is history includes mental health issues, substance abuse and sexual abuse issues. She seems like she will be understanding and able to know Structured Analysis Family Evaluation(SAFE) Colorado Couple Child Specific Home Study Report -Version 05-08-2006 Copyright,2005,Consortium for Children,All Rights Reserved - 3z— ,what the children nee: J. and Rt already have problem solved with chastity's issues and come up with ideas that have been helpful. They show the ability to be flexible and understanding to C! • and A. T, has a history of ADHD and difficulties with learning'at school. They have been successful with helping T_ overcome these issues and continue to work with him RECOMMENDATION It is recommended that Jc Lc and RA- L. be approved as adoptive parents for the placement of C. W and A.- C. Caseworker Helene Wurth Supervis9/ • Title Social Caseworker Title Social Casework Manager Date: October 2, 2006 Date: October 2, 2006 Additional Attachments None REVIEW OF HOME STUDY REPORT By signing below I acknowledge that I have read a copy of this report. • Jr- L R Lr Date: Date: To rheck for Form updates press the ctrl key and click this link. Structured Analysis Family Evaluation(SAFE) Colorado Couple Child Specific Home Study Report -Version 05-08-2006 Copyright,2005,Consortium for Children,All Rights Reserved - 33- Me ter ithin fk Program Area Supervisor/Provider Meeting Verification/Comment Form Date of Meeting: *4 ,,��i Program Area: /7A'me rite/chess /Re-I, yvl $ �t Atett724— Comments (to be completed by Program Area Supervisor): / OCco cp.oa-L, 1 N P/U ck _cart_ 'J 524 Vic 4, /..e. c�// J valip V 060'1'af l�t"-�.+,.t y� s h need leG+vy •�/,s.... f C'�s'�wa n�.e2 c ceitd .Q Lp n o c e s 5, T/Mse ,n ,st s++e_ Ems/ x e« fr01/aa s, roc, (of- 7 ,a4 c...t / gnielmideerS ''Ga✓t f e...,1 R_es fRpueG 7tAtt wrfrll s Awl 4 J it tenn lan1.0911/01.9 /At fro Ms `( d)ele g-n-c !µ/,u AND e° env,/e-iteg 53 G .7g vn p— Ywo-islr,H; 4-‘441 Axe_ A/5i'e( �'i ,titto c*'vle- ve n1e 4 /, / .atiei#cal Signature of Program An Supe -3L1- EXHIBIT B SUPPLEMENTAL NARRATIVE TO RFP May 17, 2007 Tobi Vegter Core Services Coordinator Weld County Department of Social Services, P.O. Box A Greeley, CO 80632 Re: Bid#003-HS-07 (RFP 006-00B)Home Studies To Whom It May Concern: The following is my response to the FYC Commission's recommendation and condition for my home study bid. I will follow the recommendation of the FYC Commission. Approximately 20%of all Home Studies, Home Study Updates and Adoptive Home Studies will involve a bi-lingual interpreter. During this contract it is estimated that I will complete 20 original Home Studies or Adoptive Home Studies and approximately 9 Home Study Updates. The approximate number of hours that an interpreter will be needed for each original Home Study or Adoptive Home Study is 10 hours, for each Home Study update approximately 5 hours . The estimated number of hours that an interpreter will be needed during this contract is 85 hours at a rate of 25.00/hr. This would approximately equal $2125.00 for the duration of the contract. This is a response for the-Condition attached tothe-Home ch,ly Rid: The maximum capacity is 60 original Home Studies and Adoptive Home Studies for the duration of the contract. Additionally,the maximum capacity for Home Study Updates is 60 for the duration of the contract. This would equal a maximum capacity of 120 for the duration of this contract. "^' Please contact me if you need any additional information regarding the Recommenda in or the Condition described in this letter, (970)226-2692, cell (970)631-6235. N • n Thank you, -C dkW Q , �- Helene Wurth Kika DEPARTMENT OF SOCIAL SERVICES P.O. BOX A liD 1111De 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 Helene Wurth 4306 Beaver Creek Drive. Fort Collins, CO 80526 Re: Bid#003-HS-07 (RFP 006-00B)Home Studies Dear Ms. Wurth: The purpose of this letter is to outline the results of the Bid process for PY 2007-2008 and to request written confirmation from you by Monday, May 21, 2007. The Families, Youth, and Children Commission appreciate your interest in providing services for families in Weld county. This year, strides were made in structuring an RFP that is clear and concise, and more user friendly,for both prospective bidders and evaluators. It is important to stress the value of following formatting guidelines and addressing the required sections concisely and appropriately. A. Results of the Bid Process for PY 2007-2008 • The Families, Youth and Children(FYC) Commission recommended approval of your Bid# 002-HS-07, (RFP 006-00B)Home Studies, Updates, and Adoption Home Studies for inclusion on our vendor list. The FYC Commission attached the following recommendation and condition to your bid. Recommendation: The approved bidder will pursue bilingual interpreters/translators/staff in order to better serve bilingual and monolingual clients.This may include offering incentives, accommodations,and encouragement to Spanish bilingual interpreters,translators, and staff. Condition: The bidder must clarify the capacity of 12-120 home studies per year as reported in the bid. 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. Paae 2 Helene Wurth RFP 001-07/2007-2008 Please provide in writing how you will incorporate the recommendation(s)into your bid. If you do not accept the recommendation,please provide written reasons why. All approved recommendations under the NOFAA will be monitored and evaluated by the FYC Commission. Concerning FYC Commission Conditions: All conditions will be incorporated as part of your Bid and Notification of Financial Assistance Award (NOFAA). If you do not accept the condition(s), you will not be authorized as a vendor unless the FYC Commission and the Weld County Department of Social Services accept your mitigating circumstances. If you do not accept the condition, you must provide in writing reasons why. A meeting will be arranged to discuss your response. Your response to the above conditions will be incorporated in the Bid and Notification of Financial Assistance Award. The Weld County Department of Social Services is requesting your written response to the FYC Commission's recommendation and condition Please respond in writing to Tobi Vegter, Core Services Coordinator,Weld County Department of Social Services, P.O. Box A, Greeley, CO, 80632,by Monday, May 21, 2007,close of business. If you have questions concerning the above,please call Tobi Vegter, 352.1551, extension 6392. Sincerely, y A. ri go, Dir r cc: Juan Lopez, Chair, FYC Commission Tobi Vegter,Core Services Coordinator Gloria Romansik, Social Services Administrator Hello