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Home My WebLink About20061606.tiff Weld County Department of Social Services Notification of Financial Assistance Award for Families,Youth and Children Commission(Core) Funds Type of Action Contract Award No. X Initial Award 06-CORE-56 Revision (RFP-FYC-006-00; 06MH06) Contract Award Period Name and Address of Contractor Beginning 06/01/2006 and Jack J. Gardner,Psychologist Ending 05/31/2007 Mental Health Services 1228 8th Street Greeley, CO 80631 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Program provides screening, evaluations, and Assistance Award is based upon your Request for other assessment services intended to provide Proposal(RFP). The RFP specifies the scope of information needed by Social Services staff services and conditions of award. Except where it is Capacity is 6-12 evaluations per month,average in conflict with this NOFAA in which case the capacity is 8. Cultural/Ethnically specific NOFAA governs,the RFP upon which this award is services are not available at this time. based is an integral part of the action. Cost Per Unit of Service Special conditions Episode Rate Per 1) Reimbursement for the Unit of Services will be based Psychological Evaluations on an hourly rate per child or per family. Psychological Exam $1,300.00 2) The hourly rate will be paid for only direct face to Other Services $900.00 face contact with the child and/or family,as Diagnostic Services $1,600.00 evidenced by client-signed verification form, and as Hourly Rate Per specified in the unit of cost computation. Interactional Evaluations 3) Unit of service costs cannot exceed the hourly and Treatment Package $100.00 yearly cost per child and/or family. Parent-Child Interactions $110.00 4) Payment will only be remitted on cases open with,and Court Testimony $150.00 referrals made by the Weld County Department of Court Preparation $100.00 Social Services. Professional Consultation $100.00 5) Requests for payment must be an original submitted to Individual Counseling $120.00 the Weld County Department of Social Services by the Family Counseling $120.00 end of the 25th calendar day following the end of the Court Faciliation, Mediation, or Staffing$100.00 month of service. The provider must submit requests Daily Rate Per for payment on forms approved by Weld County Other Services* $1,800.00 Depaitiuent of Social Services. * Child Welfare Administration Funds 6) The Contractor will notify the Department of any Enclosures: changes in staff at the time of the change. X Signed RFP: Exhibit A X Supplemental Narrative to RFP: Exhibit B X Recommendation(s) X Condi ' ns of Approval Appr Program ffici 1: O1/4_, By �' By kt M. J. eile, Chair Judy A. 'ego, irector Board of Weld Couij( ommissioners Weld C ty Department of Social ' Date: JUN 14 al Date: 6/ al JO lo2006-1606 GREELEY -tsOUNSELING :VENTER P.C. ,Y Oats O• ') �j, l 1228 8th Street, Eiiaanredgiya6a(oyiJ ,Greeley, Colorado 80631 ;..9 . 62_ — 7O- 6.9646 Bid Proposal: Weld DSS March 2006 I. For several years I have provided a variety of psychological services to the department in the following modalities: • Psychological Evaluations (Standard, 1 party) • Psychological Evaluations (Standard, additional parties) • Psychological Evaluations (Sexual Specific, 1 party) • Interactional Evaluations (at DSS) • Interactional Evaluations (Home Visits) • Court Testimony • Court Preparation • Consultation • Training • Individual Therapy • Family Therapy • Court Facilitation, Mediation, or Staffing • No Shows (Client Terminated after 3 no shows). II. TARGET/ELIGIBILITY POPULATIONS a. I complete between 55 and 100 evaluations per year. I see from 1 to 10 clients in therapy per year. I usually complete 2 trainings per year. I attend approximately 25 mediation sessions per year. I consult with the department on cases approximately 25 times per year. I testify in court approximately 20 times per year. b. The total number of clients is the number of evaluations completed plus a few added family members. The children's ages are between newborn and eighteen years old. c. The total number of family units is somewhat less than the total number of total evaluations as I sometimes see both mother and father. d. I do not provide bilingual services. I am bicultural (Hispanic culture). I don't have any idea the number of persons who come to me who are of a specific ethnicity. e. I have been asked to serve some clients from south county. I estimate I see 5%of the total number of evaluations from south county. f. I do not provide 24 hour access to any clients. g. I can complete between 6 and 12 evaluations per month depending on the complexity of the cases and the timely attendance of the clients. h. The monthly average capacity is 8 evaluations per month. i. Average time from start to finish of an evaluation is between 4 to 12 weeks. j. This is Not Applicable k. There are no Cultural/Ethnically Specific Services I. See "e" above. III. TYPES OF SERVICES TO BE PROVIDED This bid is for the production of psychological and/or interactional evaluations, relevant conversations with Department of Social Services Personnel, provision of court testimony regarding evaluations, case consultation, training, and individual or family therapy. Fvaluatinn£ I request caseworkers discuss cases with me PRIOR to making a referral to insure I am the best provider for the specific needs of the case. After a referral has been made, please have the client contact my Appointment Secretary, April, at 381- 1474. My experience has been that the rate of "No Shows" is dramatically reduced when the client takes responsibility to initiate the first appointment. The client may place the call from the caseworker's office or their attorney's office. They must leave a valid phone number or message phone. If a client "No Shows" three times during the course of an evaluation, the procedure will be discontinued and either a letter or a partial report will be sent to the caseworker. Evaluations are conducted following generally accepted standards and are designed to produce useful responses to specific referral questions which should be designed by the evaluator and caseworker. The report is provided to the department worker who will disseminate it to relevant parties and review it with the client. The client can contact this psychologist to discuss the report or add relevant information. If new information will alter the responses to the referral questions, an addendum will be issued. consultation I am available to meet with caseworkers or other's involved with a client to discuss clinical issues, appropriate therapy steps, expected outcomes and other relevant Bid Proposal Greeley Counseling Center 3/30/06 Page 2 of 6 issues. I am available to the Department to consult regarding development of programs or treatment strategies. The fee will be $120.00 per hour. Training I can provide training on a wide variety of issues. The fee is $1500.00 per day of training. Fees will be prorated for partial days of training. Therapy I provide individual or family therapy but do not use books or manuals to guide my therapy. I abandoned the managed care model of therapy more than a decade ago as I am absolutely clear that it detracts significantly from the client's care and degrades the client/therapist relationship. I do not obtain formal baseline data nor accumulate exit data. I do not use pre and post therapy assessment devices. Most of my clients demonstrate significant progress, and when progress is not being made therapy is stopped, postponed, or a referral to another provider is offered. I generally follow a humanistic/behavioral model in which I work with the client to determine treatment needs and desired outcomes to improve and stabilize functioning. Therapy may focus on understanding and improving the bond/attachment between caregivers and children, or aiding in reunification of children and parents, grandparents or other caregivers. Occasionally therapy is primarily structured to maintain children in a certain living situation by furnishing education, support and behavioral strategies to both the children and the caregivers. To help the client achieve his/her goals I use a variety of techniques (biblio- therapy; relaxation therapy; hypnosis; journaling; self-monitoring; homework to be done between sessions; open and honest communication; referral to medical practitioners as needed; goal setting; clarification; empathy; installation of hope; development and nurturance of a therapeutic relationship; drug testing when needed; various educational strategies regarding child development and forms of health and illness; use of various behavioral strategies to alter behavior; instruction in self-soothing, self-reinforcement; self care; and encouragement and support). The duration of therapy is determined by the success in reaching goals; the increase in desired behaviors, healthy attitudes and emotional capacities; and the decrease in negative behaviors and attitudes. Therapy may span more than a year. Often I meet with the family or client several consecutive times to began the change process. Then I begin to titrate the frequency of visits to the level that will allow forward change to continue and prevent regression to previous maladaptive states (backsliding). This avoids the "Flight into health" or "honeymoon syndrome" that is often mistaken for actual therapeutic change. As true change is a very gradual process, I have found spaced therapy visits over a prolonged period to be far superior to a few clustered visits. This level of care is very reassuring to Bid Proposal Greeley Counseling Center 3/30/06 Page 3 of 6 the client and encourages them to grow between sessions. Clients are encouraged to titrate their own therapeutic schedule and use services only as needed to advance an issue or solve a problem. I am willing to write progress letters and to have communication with the caseworker (with signed permission by the client). The fee for individual and family therapy is $120.00 per hour. Family sessions are usually two to three hours for the initial intake and 1.5 hours for subsequent sessions. Individual sessions are usually two hours for the initial intake and 1.0 hour for subsequent sessions. No additional charge is levied for brief periodic written reports, letters or phone conversations with the client or caseworker (with the exception of emergency after hours phone calls). Emergency and after hours calls are billed at $160.00 per hour. As noted above, formal consultations are billed at $120.00 an hour. IV. MEASUABLE OUTCOMES A) I do not anticipate there will be much of a change in the time it takes to complete evaluations from start to finish. I obviously do them as quickly as possible as my livelihood is directly tied to completion of each evaluation. Each piece of work must be of top notch quality and internally consistent to withstand the rigors of court review and review by second opinions. Each report must be valuable to the caseworker for treatment planning. B) There will be no change in availability of services. I try to answer all calls the day they are received and usually within 24 hours. C) The frequency of contacts depend on the complexity of the case. We call each other as much as necessary. D) N/A E) I discuss my interventions regularly in the few instances when I have been asked to do therapy. I also communicate via letters and written reports. F) As noted elsewhere, I do not provide 24 hour emergency service. I will respond to caseworker's calls as soon as possible and usually within 24 hours. My evaluations have been well received by the courts in the past several years. I continue on-going training to provide the best reports and care possible. I also know the limits of my competency and refer the case workers and/or clients to other practitioners as needed. I do not use quantitative measures. I rarely know the outcome of my evaluations as I rarely have contact with the clients or caseworkers when an evaluation is complete. I seek informal feedback from caseworkers, but have no formal method for garnering information. For psychotherapy I usually adopt a humanistic/behavioral model that facilitates changes in frequency, duration and magnitude of both positive and negative behaviors. I rely on Bid Proposal Greeley Counseling Center 3/30/06 Page 4 of 6 the subjective reports of the client and family as well as the reports of the caseworker to determine if the client is changing. V. SERVICE OBJECTIVES Evaluations attempt to provide practical information regarding the client's personality structure, risk profiles, diagnosis, strengths, and weaknesses for the caseworker to use in planning needed interventions and assessing progress. I recommend different kinds of therapy but only occasionally provide the therapy myself. I often provide the court and attorney's with information to plan for the child's placement. I do not primarily address ways parents can find or utilize community resources. Therapy procedures are outlined above. VI. WORKLOAD STANDARDS This section does not seem to apply to the solo practitioner like myself, but rather to an agency. I work 4O+ hours a week. I am the only one providing the evaluations and/or therapy. I sometimes work with specific individuals and families who have behavioral or sexual dysfunctions, as I have specialized training in these areas. I complete six to twelve evaluations per month depending on the complexity of the cases. I have a 1/3 million dollar malpractice insurance policy. A copy of the current certificate is attached. The new certificate should arrive soon and can be forwarded to the department. VII. PROOF OF COLLABORATION A). Not Applicable B). Not Applicable C). When necessary I ask clients to sign a release of information to allow me to contact other treatment professionals who have provided services. I have the client sign a ROI to allow the evaluation to go to the Department of Social Services and usually to their attorney. The Placement Review Team is not applicable. D). Not Applicable E). Not Applicable F). Not Applicable VIII. EVIDENCE BASED OUTCOMES A). See Groth - Marnat, G. (1997). Handbook of Psychological Assessment (3rd ed.). New York: Wiley. Sattler, J. M. (1998). Clinical and forensic interviewing of children and families. San Diego, Author. B). Not Applicable C). Not Applicable D). Not Applicable Bid Proposal Greeley Counseling Center 3/30/06 Page Sof6 IX. STAFF QUALIFICATIONS I have a Psy.D. I am a licensed psychologist. I do not have a supervisor, nor do I provide supervision. I have knowledge of risk assessment in the areas of homicide, suicide, violent behavior, sexual assault/abuse, self-injury, and likelihood to benefit from treatment. I don't think new caseworker training is relevant to my work. X. UNIT OF SERVICE RATE COMPUTATION See attached budget. XI. BILLING PROCESS I submit an invoice with the evaluation and send in the forms required by the Department. XII. LOWEST QUALIFIED BID XIII. PROGRAM CAPACITY BY MONTH I can complete six to twelve evaluations per month depending on the complexity of the case. Bid Proposal Greeley Counseling Center 3/30/06 Page 6 of 6 Bid 001-06(RFP-FYC-006-00,A,B, & C) Attached A Comments by SSD Supervisor: 1.2-4.- . c.t-r3 &:,.WI 'C'Ne.-ta 3-‘,-kr. c._, s, Li,., C .. 3- i 3-cam„ / _ `` , -�Rh C� t%�t U �..J, ) / V� Sz�-G1 l�Z,,rSj/�� Jr el C�}�c., 12-�-L�-C ,f°�., P.A.;o x� ) i-✓L;�nc3 r .mtiTc L- .1°-=—'' C L, I\:. ,4_54s\-,,_-9.( at., u 'tq c4-;ik , Ina_ - �_r� S�{-2r♦r, ‘�S',C it-' S ( k C& --,-, c"--- a S V\a�i'c \-Q( IN-- J . ^� • I317)( 0 Name an Signature of SSD� rvisor Da e Page 30 of 41 INVITATION TO BID OFF SYSTEM BID 001-06 (06005--06011 and 006-00, A, B, &C) DATE: March 1, 2006 BID NO: RFP-FYC-006-00,A,B, &C RETURN BID TO: Pat Persichino,Director of General Services 915 10th Street,P.O. Box 758,Greeley, CO 80632 SUMMARY Request for Proposal (RFP-FYC-006-00,A, B, &C) for: Colorado Family Preservation Act—Mental Health Services Emergency Assistance Program Deadline: March 31, 2006, Friday, 10:00 a.m. The Families, Youth and Children Commission, an advisory commission to Weld County 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, 2006, through May 31, 2007, at specific rates for different types of services. The County will authorize approved providers and rates for services only. The Mental Health Services program provides diagnostic and/or therapeutic services to assist in the development of the family services plan, to assess and/or improve family communication, functioning and relationships. This program announcement consists of five parts, as follows: PART A...Administrative Information PART D...Bidder Response Format PART B...Background, Overview and Goals PART E...Bid Evaluation Process PART C...Statement of Work Delivery Date -3 -3O-`'Z ' "Ai 6 L/ (After receipt of order) D M /` G.O-T BE SIGNED IN INK JacK G.O-KYN•P✓ TYPED OR PRINTED SIGNATURE VENDOR a at�� l p/� ouN5 k �-4Y ocold (Name) H written ignature By Authorized facer or Agent of Vender �/ ADDRESS /02 a S S-a S� TITLE A . G6i. g, s7J c -,4Qz"o ( o Si;63/ DATE 3 - 3n-0 PHONE# 9 70 - 356 fl- The above bid is subject to Terms and Conditions as attached hereto and incorporated. Page 1 of 41 Bid 001-06(RFP-FYC-006-00,A,B, & C) Attached A MENTAL HEALTH SERVICES PROGRAM BID PROPOSAL AND REQUEST FOR CONTINUATION OF AWARD UNDER CORE SERVICES FUNDING EMERGENCY ASSISTANCE PROGRAM 2006-2007 BID PROPOSAL APPLICATION PROGRAM FUNDS YEAR 2006-2007 BID 001-06 (006-00,A,B, & C) NAME OF AGENCY: Cy-“, e !-1`11 eo k 4 5 a /,..2,, e-a^,t 1<-a-` ADDRESS: i2d7 5 8rt 59 U ` rz4J..,- gt4'(v $ PHONE(%fl) 3 Se - rYt2 CONTACT PERSON: J'a c_k 1. a rdn-,✓ -', A,r2S TITLE: A,e 1 t�rc 4"'s `sf DESCRIPTION OF EMERGENCY ASSISTANCE PROGRAM CATEGORY: The Mental Health Services program provides for"diagnostic,and/or therapeutic services to assist in the development of the family services plan,to assess and/or improve family communication, functioning,and relationships.(Volume VII, 7.303.1,G)" 12-Month approximate Project Dates: _ 12-month contract with actual time lines of: Start June 1,2006 Start End May 31,2007 End o TITLE OF PROJECT: J Ay c it a�� r t s J1, W Ll��'`' 4 �`�'yy <1ae: . fiLeioli e-A--, Ay6 3 - 30-0 b Name a 1 Signal a ofAPersonnPreparing Document Date If !l/ /�T Name and Signature Chief Administrative Officer Applicant Agency Date MANDATORY PROPOSAL REQUIREMENTS For both new bids and renewal bids,please initial to indicate that the following required sections are included in this Proposal for Bid. ✓ Project Description v Target/Eligibility Populations ✓ Types of services Provided Measurable Outcomes ;i Service Objectives —7 Workload Standards Proof of Collaboration Evidenced-based Outcomes Staff Qualifications ./ Unit of Service Rate Computation Billing Process Program Capacity per Month LL Certificate of Insurance Date of Meeting(s) with Social Services Division Supervisor: . -/3 6 Page 29 of 41 EXECUTIVE RISK SPECIALTY INSURANCE COMPANY 3/28/05 - A PSYCHOLOGISTS IS CLAIMS ADE PROFESSIONAL PLIY PLEASE READ CARETY FULLY *** RENEWAL *** NOTICE:A LOWER LIMIT OF LIABILITY APPLIES TO JUDGEMENTS OR SETTLEMENTS WHEN THERE ARE ALLEGATIONS OF SEXUAL MISCONDUCT(SEE THE SPECIAL PROVISION"SEXUAL MISCONDUCT"IN THE POLICY). DECLARATIONS POLICY NO: 008-1755292 ACCOUNT NO: CO-GREE631-0 0314607E ITEM I. (a)NAME AND ADDRESS OF INSURED: ITEM 1. (b)ADDITIONAL NAMED INSUREDS: JACK J. GARDNER, PSY.D. GREELEY COUNSELING CENTER, P.C. 1228 8TH STREET GREELEY, CO 80631 TYPE OF ORG: PROFESSIONAL CORPORATION ITEM 2. ADDITIONAL INSUREDS: BOULDER COUNTY RISK MANAGEMENT DIVISION P.O. BOX 471 BOULDER, CO 80306 ITEM 3. POLICY PERIOD: FROM: 04/01/05 TO: 04/01/06 12:01A.M.STANDARD TIME AT THE ADDRESS OF THE INSURED AS STATED HEREIN: ITEM 4. LIMITS OF LIABILITY: (a)S 1, 000, 000 EACH WRONGFUL,ACT OR SERIES OF CONTINUOUS,REPEATED OR INTERRELATED WRONGFUL ACTS OR OCCURRENCE (b)$ 5, 000 DEFENSE REIMBURSEMENT (c)$ 3 , 000, 000 AGGREGATE ITEMS. PREMIUM SCHEDULE: CLASSIFICATION NUMBER RATE ANNUAL PREMIUM 1ST PSYCHOLOGIST 1 1191 . 00 1, 191 . 00 DEFENSE LIMIT .00 ADDITIONAL INSUREDS 1 50 .00 SURPLUS LINES TAX 1 37 .23 INSPECTION FEE 1 1 .24 ITEM 6. RETROACTIVE DATE: 0 4/01/9 2 TOTAL PREMIUM: 1, 279 .47 1 ITEM 7. EXTENDED REPORTING PERIOD ADDITIONAL PREMIUM(if exercised):$ 2, 172 .00 NO DISCOUNT INCLUDED ITEM 8. POLICY FORMS AND ENDORSEMENTS ATTACHED TO THIS POLICY B22138 (7/95 ED. ) B22137 THIS IS NOT A BILL.PREMIUM HAS BEEN PAID. AUT RIZED COMPANY R.EPRE ATIVE APA22(10/95) Americ Professional Agency*95 Broadway,Amityville,NY 11701 03/24/2006 23:51 3034947759 AMERICANFAMILY PAGE 01 EVIDENCE OF PROPERTY INSURANCE Amorican Family Insurance Company ❑ American Family Mutual Insuranco Company If selection box is not chocked. 6000 American Pky Madleon,Wisconsin 53783-0001 Agent's Name,Addreee and Phone Number(Agt./Diet.) Brent Frlesth (303)449-9595 THIS IS EVIDENCE THAT THE COMPANY INDICATED HAS THE 4895 Rivetbend Road,Suite F FOLLOWING INSURANCE IN FORCE, AND CONVEYS ALL THE Boulder,CO 80301 (020/311) RIGHTS AND PRIVILEGES AFFORDED UNDER THE POLICY. Insured's Name and Address Jack Gardner Policy Number Bank One Plea Suite 600 umber 89-01.00 Greeley,CO 80831 E cation Date PSM0D VY) Effective Data lNrwooml � 11/1/2005 11/1/2006 y PROPERTY LOCATION PROPERTY DESCRIPTION (For Business Insurance Only, indicate It of gtui re.Couskn.W% u.Usti u.OL. niency,Euuipn%ent DescilptloN3edal N) 1 2206th St — Greeley,CO 80631 Personal Lines-Property Fenn/Ranch Lines Business Insurance Policy Type Policy Type Policy Type Form ❑ 1-101 ❑GS 0 MH 1 0 BO ❑FR 01 ❑ FR 05 M Bu&iles$ovmers ❑ Named Peril O H02 ❑H06 0 MH 3 ❑FR 02 0 FR 09 ❑Business Key O Basic ❑ HO 3 ❑CV 1 0 DP 01 ❑FR 03 0 FR Mil 01 ( 1 Property ❑ Broad O H04 ❑CV 3 0 DP 02 ❑FR 04 O FR MH 03 [ Inland Marine ® Special Amount al Insurance Amount of Insurance Amount of Insurance Coy.A Dwelling $ Coy A Dwcling $ Guiding $ 131,010 Coy.B Part Property $ Cov.B Pert Property $ But.Pets.Property $ Cov.B Other Struct.(Fire&E.C.) $ Sec.III Pers.Prop.Blanket $ Other comity $ 1.000.000 Cov.C Pers.Prop.(Fire&E.C.) $ Sec.III Schedule S Boatownar,-Sect.I $ Sec.IV Outbldgs. $ Other $ — Other $ Deductible Sec.I $ Deductible-Bldg. $ --2z0 Deductible $ Deductible Sec.Ill $ Deductible-Bus.Pert Prop.S Decuctl4le Sec.IV $ Deductible • monks orioidtng speclehCondnlonamadorsemetls). : . `;*., "atz �.„„T- �'�=,:Ss'4t,.. Y "�5 ;',; `x�, 'tS i C �i\''ill e'is lE:-',1 +,t'4.,1'fi:b70; kNak' -4'”'";�'4\..•A„ 1 — 1,�ti` `�,,''� d�' r,4, .�l\�' '�N-O"INk, � �.1 iv� \ >ti"' \�'14.,'rr,ti�S `. �'' \1��+ .,�, isle }� _ , ,1;; -,; . `` ;;A.t`?,: `*A' 4\,.'ti\cti,s kti.��,t.. e�"t•.1b�� ::<��' ' +),`..@.`:31•$.1.&`eh x \ , a-'. ysetst;::,. `z. ss ,:. .' . EFFECTIVE,DATE/RENEWALOFCOVERAGE/CANCELLATION . .. EFFECTIVE DATE • Date additional Interest is added. crib of the required premium on or RENEWAL OF COVERAGE/CANCELLATON-This policy may be continued for sUCner-siva policy pennda by paym eQ before the effective date of each renewal period.If this policy is terminated,the company will give the additional Interest identified below written notice. The delivery of this notice Shall be subject to the laws of the stabs whore ells.policy Is Issued.We will provide the insurance described In this policy In return for your premium payment and compliance with policy provisions. 'The Expiration Date is changed to read"UNTIL CANCELLED :.:::ADDRIONAL-'1NTERf 7NAMEAND�ADDRESS :t . . .. . . . .:NATUREOflNTEfE9T ... IX1 Mortgagee O Loss Payee Loan Number DATE ISSUED OaITEo RE a 3/28/2006 TO AGENT: It Is very Important that you mail a copy to American Family on the day incised,along with the application. 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( ; hhi1fl # ! | • r 888888888888888888 a 8 8 § | E § aa■saaaasaaaaa■asa a a a § 2 | 8 ! f ) \ § , ! / 888888888888888888 8 8 8 @ § ! ;aaaaaagagaaaggaga a a a t | ! s § p p | — - --- ] k Pa | ■■■mama■■■88888888 a 8 8 ©a;a=:a;aa:a:a a a a ] | 7 ! 2 | 5a ) § E 888888888888888888 8 8 8 ; aa2a2aaaa■a22aaaa2 ■ a a § / E E ° • §re |. . ) k z < ® e ' 8888888„888888888 8 8 8 co 28 ! ■■■sa■aaaaaaaaaasa a a a • § / ( ! r ° k0 i ■ w 88 2,288S88Sgaa 8 3 a a \ \ } \ § § 7 \§|I}'.:: sass;;■ / f / § ) { . . - | ! 8888888■ § ! r.®e.»nraw 2 § " 4 22222922222222222 4 _ 88888888 )| § K!|12!|■ \ k \ & !' 2 ! ! & § § 2 0 2-2 E | | I F. j | ! ! . 2 § \ aItlr § § k 21v I _ | } / 2 ]!f\k/!\) 2 2 2 EXHIBIT B SUPPLEMENTAL NARRATIVE TO RFP FAX COVER SHEET 'ftM.9n2'YIRY�lh.b.' wTOI:e.n orY ivf-PRO071-,,X,4 .^Wr{7 4,WA,.'.1R'p.e- k: /n.K l.2< ,,#A1 Greeley Counseling Center 1228 8th St., Greeley CO 80631 Work Voice: 9703568482 Fax: 9703569646 Home Voice: Email: drjackg@earthlink.net To: Andrea Shay Company: Fax: 970-346-7698 Work Voice: 970-352-1551 x6246 Home Voice: From: Jack Gardner Date: May 22, 2006 Time: 03:37 PM Number of pages, including cover: 2 Notes: The information contained in this facsimile message is privileged and confidential information intended for the use of the addressee(s)listed above and no one else. If you are not the intended recipient(s)or the employee or agent responsible for delivering this message to the intended recipient(s), please do not use this transmission in any way, but contact the sender by telephone. I May 22, 2006, at 03:37:12 PM S Jack Gardner di 9703569646 ntii k '�{NAF{`I�11�"��d� a^Xv�i��?C'�Z;ikrlYiLutl(i,ieu4rz":;kA`fiYg;`4 i 4+8a a S e*, S23wa 5sS Yt wl e °-"•at�r >t ,f',`s«fa4 &,�zt;�d4 -n ''9 �: S' ��h t C' •is � a ' - ti"", � s o U��vl p • �, ° �; ) , 'z,o- --_,r 40:0;;;?..-24;;tc: Mi 6',�. p, uzp � ' 'st °.x . r�i a �r•S w,.f 7a ct. � ,2rc R*,'�� , _�.•A 9.�t '� e„*ip?,°.oaf„�a t., , h �d�u ; ;. 5/22/06 This letter is in response to your May 1 5, 2006 letter re : Bid 06MH09. FEES Per Episode: • Psychological Evaluations (Standard, 1 party) $1300.00 • Psychological Evaluations (Standard, additional parties) add $900.00/ea. • Psychological Evaluations (Sexual Specific, 1 party) $1600.00 • Interactional Evaluations (at DSS) $100.00/hr • Interactional Evaluations (Home Visits) $110.00/hr • Portal to Portal • Testimony $150.00/hr • Portal to Portal • Court Preparation $100.00/hr • Consultation $100.00/hr • Training $1800.00/day • Individual Therapy $120.00/hr • Family Therapy $120.00/hr • Court Facilitation, Mediation, or Staffing $ 100.00/hr • No Shows (Client Terminated after 3 no shows) $0.00.hr Faxed under separate cover is a letter from the Housing Authority. Despite several attempts I have not been able to connect with the employment/training agency. When I do reach them I will forward their letter of collaboration. I would offer patients needing care at North Range Behavioral Health the agency phone number. Sincerely, Jack J. Gardner, Psy.D. Licensed Psychologist 05/22/2006 03:52 9703569646 GREELEY COUNSELING E PAGE 03 05/22/2006 14:02 FAX 970 348 7680 GREELEY/VELD HS6 AUTH 0001/002 GREELEY / WELD HOUSING AUTHORITIES P.O.Box 130 Creaky,CO 80632 (970)353-7437 Fu(970)353.7463 From: G l�►+ Attention: Date: Office Location: Office Location: Fax Number Phone Number: Q Urgent O Reply ASAP Q Please comment Q Please review d For your information Total pages,including cover: Commute: I 05/22/2006 03:52 9703569646 GREELEY COU LING E PAGE 04 05/22/2006 14:02 FAX 970 246 7690 GREELEV/9ELO HSG AUTH '4002/003 lip, GREELEY/ WELD_ .,4 HOUSING AUTHORITIES It P.O. Box 130 ihGreeley, Colorado 80632-0130 (970) 353-7437 May 22,2006 (970) 353-7463 Fax (800) 659.2656 TTY Relay - Mr.Jack Gardner Greeley Counseling Center 1228 8th Street Greeley,CO 80631 Dear Mr. Gardner: As a Housing Authority we would be glad to accept any appropriate rebels for clients needing our services from your office. If you are awarded a contract to work with Weld County clients we will be agreeable to enter into a Memorandum of Understanding concerning the services provided by each agency. If you have any questions please contact me at(970)353-7437 ext 103 Sincerely, ,--•----..._.----- ., 2a.-4—�'-4-1-7-' - Thomas Teixeira Executive Director Coop IC0610 Housing Authority of the City of Greeley ^ Weld County Housing Authority Ci 903 6th Street • Greeley, Colorado ..ate' jot 3/4;:::.\\\ a DEPARTMENT OF SOCIAL SERVICES P.O. BOX A GREELEY, CO. 80632 Website:www.co.wdd.co.us Administration and Public Assistance(970)352-1551 Child Support(970)352-6933 C. COLORADO May 15, 2006 Jack J. Gardner,Psychologist. Greeley Counseling Program 1228 8 Street Greeley,CO 80631 Re: Bid 06MH09 (RFP 006-00)Mental Health Services Dear Dr. Gardner: The purpose of this letter is to outline the results of the Bid process for PY 2006-2007 and to request written confirmation from you by Monday, May 22, 2006. A. Results of the Bid Process for PY 2006-2007 The Families,Youth and Children(FYC) Commission recommended approval of your Bid# 06MH09(RFP 006-00), Mental Health, for inclusion on our vendor list, attaching the following condition,recommendation,and compliance item to the bid. Your bid scored 81 points. Condition: The bidder will work with the Weld County DSS Business Office to set a rate per episode for completed evaluations. Recommendation: The bidder will work toward establishing services that are culturally and ethnically specific. Compliance Item: You must provide the required letters under the Collaboration Section from Weld County/Greeley Housing Authority, employment/training partners,and other partners as identified in the bidder's assessment of needs. You must identify the process you will utilize to facilitate Medicaid eligible clients receiving mental health services at North Range Behavioral Health. Hourly Rate for Court Testimony: You did not provide a rate for court testimony. For bidders carrying over services to 2006,the Department will use last year's court testimony hourly rate. The rate that court testimony will be billed at is $160 per hour. B. Required Response by FYC Bidders Concerning FYC Commission Recommendations and Conditions: Conditions: All conditions will be incorporated as part of your Bid and Notification of Financial Assistance Award(NOFAA). If you do not accept the condition(s),you will not be authorized as a vendor unless the FYC Commission and the Weld County Department Page 2 Gardner/Results of RFP Process for 2006-2007 of Social Services accepts your mitigating circumstances. If you do not accept the condition,you must provide in writing reasons why. A meeting will be arranged to discuss your response. Your response to the above conditions will be incorporated in the Bid and Notification of Financial Assistance Award. Recommendations: You are requested to review the FYC Commission recommendations and to: 1. accept the recommendation(s)as written by the FYC Commission; or 2. request alternatives to the FYC Commission's recommendation(s); or 3. not accept the recommendation(s)of the FYC Commission. Please provide in writing how you will incorporate the recommendation(s)into your bid. If you do not accept the recommendation, please provide written reasons why. All approved recommendations under the NOFAA will be monitored and evaluated by the FYC Commission. The Weld County Department of Social Services is requesting your written response to the FYC Commission's conditions.Please respond in writing to Gloria Romansik,Weld County Department of Social Services,P.O. Box A, Greeley, CO, 80632, by Monday,May 22, 2006, close of business. You may fax your response to us at 970.346.7698. If you have questions concerning the above,please call Gloria Romansik at 352.1551, extension 6230. Sincerely, d A. '•go,Dire r cc: Juan Lopez, Chair,FYC Commission Gloria Romansik, Social Services Administrator Weld County Department of Social Services Notification of Financial Assistance Award for Families,Youth and Children Commission (Core)Funds Type of Action Contract Award No. X Initial Award 06-CORE-59 Revision (RFP-FYC-006-00; 06MH07) Contract Award Period Name and Address of Contractor Beginning 06/01/2006 and Transitions Psychology Group Ending 05/31/2007 Mental Health Services 804 11th Avenue Greeley, CO 80631 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Provides comprehensive psychological services Assistance Award is based upon your Request for for infants to adults addressing areas including Proposal (RFP). The RFP specifies the scope of cognitive,personality, attention/memory/ services and conditions of award. Except where it is concentration,achievement/educational and in conflict with this NOFAA in which case the adaptive behaviors; specialized arena NOFAA governs,the RFP upon which this award is assessments for children 0-5 years. Bicultural based is an integral part of the action. services and South County services (Del Camino Special conditions &Greeley office) are available. Capacity to 1) Reimbursement for the Unit of Services will be based serve a total of 120 clients,maximum of 20 on an hourly rate per child or per family. clients per month, and average of 10. 2) The hourly rate will be paid for only direct face to face contact with the child and/or family, as Cost Per Unit of Service evidenced by client-signed verification form, and as specified in the unit of cost computation. Hourly Rate per 3) Unit of service costs cannot exceed the hourly and Psychological Exams $282.62 yearly cost per child and/or family. Mental Health Assessment $110.89 4) Payment will only be remitted on cases open with, and referrals made by the Weld County Department of Hourly Rate per Court Testimony $150.00 Social Services. 5) Requests for payment must be an original submitted to the Weld County Department of Social Services by the Enclosures: end of the 25th calendar day following the end of the X Signed RFP: Exhibit A month of service.The provider must submit requests X Supplemental Narrative to RFP: Exhibit B for payment on forms approved by Weld County Recommendation(s) Department of Social Services. X Conditions of Approval 6) The Contractor will notify the Department of any changes in staff at the time of the change. Approvals: Program Official: By By a / . . ile, Chair Judy Grie ,Direc •r Board of Weld County Commissioners Weld ounty epaitalent of Social Services Date: JUN 1 4 1006 Date: 631 /DC INVITATION TO BID OFF SYSTEM BID 001-06 (06005--06011 and 006-00, A, B, & C) DATE: March 1, 2006 BID NO: RFP-FYC-006-00, A, B, & C RETURN BID TO: Pat Persichino, Director of General Services 915 10th Street, P.O. Box 758, Greeley, CO 80632 SUMMARY Request for Proposal (RFP-FYC-006-00, A, B, &C) for: Colorado Family Preservation Act—Mental Health Services Emergency Assistance Program Deadline: March 31, 2006, Friday, 10:00 a.m. The Families, Youth and Children Commission, an advisory commission to Weld County 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, 2006, through May 31, 2007, at specific rates for different types of services. The County will authorize approved providers and rates for services only. The Mental Health Services program provides diagnostic and/or therapeutic services to assist in the development of the family services plan, to assess and/or improve family communication, functioning and relationships. This program announcement consists of five parts, as follows: PART A...Administrative Information PART D...Bidder Response Format PART B...Background, Overview and Goals PART E...Bid Evaluation Process PART C...Statement of Work Delivery Date (After receipt of order) BID MUST BE SIGNED IN INK Ill411 We-SOME , kth- TYPED OR PRINTED� SIGNATURE VENDOR Trail citron s P6961O tog 691,1-1-c, �/P= r-t- (Name) Handwritten Signature By Authorized Officer or Agent of Vender ADDRESS aoq ll kV& • TITLE CD-dire pr GYeele yi c0 'O(0i I DATE O3 - 3O -Q(p PHONE# (9n"0) 319-112-3 The above bid is subject to Terms and Conditions as attached hereto and incorporated. Page 1 of 41 Bid 001-06 (RFP-FYC-006-00, A, B, & C) Attached A MENTAL HEALTH SERVICES PROGRAM BID PROPOSAL AND REQUEST FOR CONTINUATION OF AWARD UNDER CORE SERVICES FUNDING EMERGENCY ASSISTANCE PROGRAM 2006-2007 BID PROPOSAL APPLICATION PROGRAM FUNDS YEAR 2006-2007 BID 001-06 (006-00,A, B, & C) NAME OF AGENCY: Tra h61 Flo b y 1)6C-1AO(O13 6f0U pi Liz& ADDRESS: 34 win fh Ave • t GYCe Ie�{ I co 2'31 PHONE(61��pp' ) '33(0 l CONTACT PERSON: Ja vYI1 MaC- I'I11Vt tvytVl i TITLE: Gd-dt rent-cv DESCRIPTION OF EMERGENCY ASSISTANCE PROGRAM CATEGORY: The Mental Health Services program provides for"diagnostic, and/or therapeutic services to assist in the development of the family services plan, to assess and/or improve family communication, functioning, and relationships. (Volume VII, 7.303.1, G)" 12-Month approximate Project Dates: 12-month contract with actual time lines of: Start June 1, 2006 Start End May 31, 2007 End TITLE OF PROJECT: PS j 0I 091 Ca 1 As6e%WlewEs ;' t1eh+ I (featfrl1 Eval11Ll 'o VA 5 :TA Vvli Moe -1-fradfl1ak11 tilR a p3--30-0 to Name and Signature of Person Preparing Document n Date JIM foot-Nzirfvha.hl t1A &L- O3 -3O-O(a Name and Signature Chief Administrative Officer Applicant Agency Date MANDATORY PROPOSAL REQUIREMENTS For both new bids and renewal bids, please initial to indicate that the following required sections are included in this Proposal for Bid. Project Description Target/Eligibility Populations Types of services Provided Measurable Outcomes Service Objectives orkload Standards Proof of Collaboration idenced-based Outcomes aff Qualifications nit of Service Rate Computation filling Process rogram Capacity per Month ertificate of Insurance Page 30 of 41 Mental Health Services Bid Proposal 006-OOA Transitions 1 j $ MENTAL HEALTH SERVICES PROGRAM BID CATEGORY • •�� Psychological Assessments and Mental Health Evaluations • • • , . Transitions Psychology Group, LLC • .•: •: . 2006-2007 -: • Transitions PSYCHOLOGY GROUP,LLC I. PROJECT DESCRIPTION Transitions Psychology Group, LLC is a private counseling agency with a multidisciplinary team of human service professionals, including a Licensed Psychologist, Nationally Certified School Psychologists and other degreed professionals. Transitions provides superior counseling, assessment, and consultation services to children and families in Northern Colorado. The purpose of the Psychological Assessment Services program, under the Mental Health Services bid category, is to provide mental health screenings and comprehensive psychological evaluations to address specific referral questions and produce recommendations to aid the caseworkers and other professionals in treatment planning and service coordination. Psychological Assessment services will serve a variety of clients from infants to adults. Evaluations will be comprehensive and will be able to address a multitude of referral concerns and issues. Assessment can be done in any combination of the following areas: cognitive, personality, attention/memory/concentration, achievement/educational and adaptive behavior. Specialized Arena assessments will be offered for children ages 0-5 years. These tests assess all areas of the child's functioning, including psychological, motor, speech/ language, pre-educational skills, social/emotional, and attention/ concentration/ memory. In addition, the Psychological Assessment Services staff will provide comprehensive, professional and timely written reports. The team of professionals providing these services will regularly consult with the caseworkers before testing to ensure the clarity of referral question. Transitions will maintain contact with social services throughout the assessment process and promptly respond to inquiries. Transitions staff will also meet with the caseworker after the assessments are completed to discuss specific intervention strategies and the most effective and efficient means to address areas of concern identified by the assessments. Mental Health Evaluations will serve a variety of adult clients. These brief evaluations are intended to provide a preliminary diagnosis and preliminary recommendations. The Mental Health Evaluation Team will develop a report of our findings. Transitions staff will be available after the assessment process to Mental Health Services Bid Proposal 006-00 Transitions 2 review the diagnosis and recommendations with the referring caseworker and consult on service planning. II. TARGET ELIGIBILITY POPULATIONS Mental Health Program participants must be referred by the Weld County Department of Social Services. Transitions does not discriminate based on race, color, religion, national origin or sex, in accordance with State and Federal Laws, rules and regulations. Transitions estimates that the Assessment Program will serve 180 clients in the second program year. As far as Psychological Assessments, the total number of clients is estimated to be 60, approximately 10 would be children between the ages of 0-18; the probable number of adults would be 50. Approximately one- fourth, or 15, clients may be from the same family and therefore comprise a family unit. Transitions would provide services to approximately 30 South County clients. Concerning the Mental Health Evaluations, the total number of clients is estimated to be 120 clients. All clients served under the Mental Health Evaluations will be adults. Approximately one-fourth, or 30 clients may be from the same family and therefore comprise a family unit. Transitions estimates that one-third of mental health evaluation clients will receive bilingual services. Transitions providers can generally be reached between the hours of 8am —6pm Monday thru Friday, as well as evenings and Saturdays by appointment. Twenty- four hour services are not available for this program. This program could serve a maximum of 20 clients per month with an average of 10 clients per month. Time in the program is dependent on the referral question, but would not exceed 10 hours of face-to-face contact for psychological evaluations. Mental Health evaluations will not exceed three hours with an average of 1 'A hours. The average stay in the Psychological Evaluation program would be approximately five hours over the course of 3 weeks. Transitions offers assessments that are culturally representative of the client base and are standardized on the appropriate population. Services will be provided to South County clients at the Del Camino Department of Social Services office and also available at Transitions' Greeley office. III. TYPE OF SERVICES TO BE PROVIDED A. Psychological Evaluation and Assessment Services for Children, Adolescents and Adults. Psychological Evaluation and assessment services consist of screenings, evaluations and other assessment services intended to provide information needed by the staff of social services. Evaluations will be conducted by licensed eligible psychologists who have an earned doctorate (PhD) in the field of psychology and are under the Mental Health Services Bid Proposal 006-00 Transitions 3 constant supervision of a licensed psychologist. The following procedure will be followed: 1. Referral Consultation- The PhD will contact the caseworker after receiving the Psychological Evaluation referral in order to gather background information and to develop specific referral questions. 2. Intake- The PhD will meet with the referred client to conduct a thorough clinical interview and sign necessary paperwork including releases of information. 3. Information gathering-Transitions will gather collateral information as applicable to the assessment and allowed by the client. The PhD will keep the caseworker apprised of the information gathered and progress of the assessment through phone, e-mail and in- person contacts. 4. Testing-The PhD will determine the appropriate assessment instruments and use a variety of instruments to address the referral questions. These assessments will allow the practitioner to address issues including, but not limited to the following: abilities, mental health impairments, parent's ability to recognize and provide a safe environment for children, ability to learn new strategies, most effective way to learn information, ability to adapt and assimilate to one's community, and an individual's ability to concentrate and recall specific information. Assessments will also identify any learning disabilities, mental health diagnoses and/or other cognitive impairments. A variety of available tests will be considered to evaluate the subject in areas relevant to the referral questions, such as cognitive (Wechsler Adult Intelligence Scale- Third Edition, Wechsler Intelligence Scale for Children- Fourth Edition, Universal Nonverbal Intelligence Test); personality (Minnesota Multiphasic Personality Inventory [MMPI], Minnesota Multiphasic Personality Inventory for Adolescents [MMPI-A], TAT, CAT, Children's Personality Inventory, Trauma Symptom Scale, Draw-A-Person Screening Procedure for Emotional Disturbance, HTP, Kinetic Family Drawing); attention/ memory/ concentration (Wechsler Memory Scale, Cognitive Assessment System, Behavior Assessment System for Children, NEPSY); achievement/ educational (Woodcock-Johnson Tests of Achievement, Wechsler Individual Achievement Test); and adaptive behavior (Vineland, Gilliam Autism Rating Scale (GARS), Gilliam Asperger's Disorder Scale (GADS). 5. Report Results- The PhD will write a comprehensive Psychological Evaluation report that delineates the methods used, contacts made, tests administered, results and recommendations relevant to the referral questions. 6. Final Consultations- The PhD will meet with the client to review the results of the evaluation. The PhD will also meet with the caseworker to address initial referral questions and assist with the • Mental Health Services Bid Proposal 006-00 Transitions 4 application of the test results into practical, effective treatment planning. B. Infant/Child Arena Assessments: An Arena Assessment targets children between the ages of birth to five years old to assess their functioning in all areas of development, including psychological, motor, speech/ language, pre-educational skills, social/ emotional, and attention/ concentration/ memory. It is also possible for the assessment team to use arena assessments with older children as well. These types of assessment are particularly relevant to young children as each area is dependent on the other areas for proper development to occur. For example, if a child has difficulty with motor movements, it may be difficult for the child to grasp and reach for toys, which then hampers the child's cognitive development by not being able to explore toys. A child with a speech language delay may have difficulty communicating, which may lead to an increase in behavior problems and may impede social development. Therefore, a comprehensive assessment, which addresses all of these areas, becomes crucial in uncovering the root of a child's difficulty. The assessment results can then lead to targeted interventions which will improve a child's ability to function in a family and community. The following procedure would be used to conduct this type of assessment: 1. Referral Consultation- The PhD will meet with the caseworker after receiving the referral to gather background information and to clarify and develop specific referral questions. 2. Intake- The PhD will meet with the client's primary caregiver to conduct a thorough clinical interview and sign necessary paperwork including releases of information. 3. Testing-The PhD will use a variety of instruments to address the referral questions. Assessment may involve the following areas and may utilize these or similar instruments: cognitive (Wechsler Preschool Primary Scale, Bayley Infant Development Scale, Wechsler Intelligence Scale for Children- Fourth Edition, Universal Nonverbal Intelligence Test); personality (Children's Personality Inventory, Trauma Symptom Scale, Draw-A-Person Screening Procedure for Emotional Disturbance, HTP, Kinetic Family Drawing); attention/ memory/ concentration (Children's Memory Scale, Cognitive Assessment System, Behavior Assessment System for Children, NEPSY); achievement/ educational (Woodcock-Johnson Tests of Achievement, Wechsler Individual Achievement Test); adaptive behavior (Vineland, GADS, GARS, ADOS). In addition, the child's speech/ language abilities would be assessed using developmentally appropriate measures. The Mental Health Services Bid Proposal 006-00 Transitions 5 child's motor abilities would be assessed by an occupational therapist, and a physical therapist. 4. Report Results- The PhD will write a comprehensive report explaining the test scores and give specific recommendations relevant to the referral question. In addition, the report would record the child's present level of abilities and recommend strategies to overcome any areas of weakness. C. Mental Health Evaluations A Mental Health Evaluation (MHE) is a brief mental health evaluation for adults. The purpose would be to provide preliminary diagnoses and recommendations for treatment. 1. Referral Consultation- The diagnostician will call the caseworker after receiving the referral to clarify the referral questions. 2. Clinical Interview— The diagnostician will meet with the referred client to collect background information, including prior mental health treatment, substance abuse history, health history, employment history and legal history. The diagnostician with also conduct a mental health status exam. 3. Report Results- The diagnostician will write report that delineates the methods used, contacts made, preliminary diagnosis and recommendations relevant to the referral questions. D. Consultation with Caseworkers Transitions will collaborate with the caseworker throughout the assessment process, beginning with the referral consultation. Transitions will be available to respond to caseworker questions and requests within 24 hours by phone or e-mail. Transitions will work directly with caseworkers to integrate assessment information into the care plans. Reports will be made available to caseworkers and other professionals as dictated by state laws and APA ethical guidelines. Transitions will collect information from and provide information to collateral contacts as permitted within these guidelines. Transitions will notify the caseworker of any suicidal ideations, homicidal ideations and any other forms of gross mental impairment exhibited by the client. Transitions will work with the caseworker to seek appropriate and immediate interventions. Transitions will work with other clinicians and agencies regarding rationale of recommendations and to determine appropriate level of care. Mental Health Services Bid Proposal 006-00 Transitions 6 E. Court Testimony The PhD will be available to provide court testimony on current and former clients when given proper notification. IV. MEASURABLE OUTCOMES A. Transitions will complete Psychological Evaluations and Arena Assessments not more than 45 days from receiving the referral, providing that the client is cooperative with keeping scheduled appointments. Transitions will track the number of days from the receipt of the referral until the report is submitted. Transitions will provide a Mental Health Evaluation report 14 days after the clinical interview has been completed. B. Transitions will meet with the caseworker to discuss specific results, recommendations and interventions. Transitions will be available to answer questions within 24 hours of receiving a question. Transitions will document that the pre and post assessment meetings have occurred and track dates of caseworker contacts and Transitions response date. C. Transitions will meet with the caseworker by phone or face to face at the beginning of the referral and at the end of the referral and document that these meetings have occurred. They will also initiate and document contact at least weekly with the referring caseworker. In addition, Transitions will be available to respond to caseworker questions within 24 hours of receipt. Transitions will keep track of the number of contacts between caseworker, clients, and other professionals and the timeliness of those contacts. D. Transitions will be available to respond to outpatient program questions within 24 hours by phone or e-mail. Transitions will track these contacts to ensure the timeliness of their response. E. Transitions will recommend therapeutic interventions based on the results of the assessment. Transitions will be available to consult with the caseworker on where to locate such services. F. Transitions will be available for emergency consultations within 24- hour of the request. Transitions will document that emergency contacts are conducted within 24 hours. Psychological Evaluations will be comprehensive and thorough, leading to specific recommendations and interventions that will meet court standards. Mental Health Evaluations will provide preliminary diagnosis and recommendations. • Mental Health Services Bid Proposal 006-00 Transitions 7 A full Psychological Evaluation that is the result of a recommendation from a Mental Health Evaluation will incorporate the results of the MHE as to not duplicate services. Each assessment will be supervised by a licensed psychologist and internally reviewed before it is submitted. When possible, Transitions staff will utilize existing referral and collateral data to avoid duplicating services. Transitions will review referrals to assure that FYC resources will not supplant existing and available services in the community. V. SERVICE OBJECTIVES A. Improve family conflict management- Transitions assessment services will provide vital diagnostic information to assist in effective service planning. This will be measured by the inclusion of diagnostic information in the results and recommendations section of the reports and documented consultations with caseworkers. B. Improve household management competencies-Transitions will assist caseworkers in evaluating the capacity of parents to provide a safe and stable home environment for their children, including the determination of any gross impairments, suicidal ideation or homicidal ideation. Transitions will discuss parent competencies with the caseworker and document them in the reports. C. Improve ability to access resources-Transitions will provide comprehensive assessment services that will determine a client's functioning in a variety of areas. The recommendations in the report will identify applicable resources that are available for the client. In some cases, the resulting diagnoses may qualify clients for new services that the client has not previously been able to access (e.g. social security). D. Address Specific Referral Issues- Transitions will be in contact with the caseworker at the beginning of the referral to clarify all referral questions. Transitions will provide specific recommendations to address each referral questions; these recommendations will be documented in the report. E. Improve Outcomes in the Performance Improvement Plan (PIP) — Transitions will recommend interventions geared to prevent out-of- home placements and the re-entry of children into the foster care system. In addition, the results will be useful in creating realistic and timely permanency and treatment plans. VI. WORKLOAD STANDARDS • Mental Health Services Bid Proposal 006-00 Transitions 8 Assessment Services will be provided Monday through Saturday from 8am — 8pm by appointment and will be scheduled to meet the client's scheduling needs and provider's availability. Assessment times will vary based on the referral questions, but will generally be completed over the course of three weeks. There will be a total of three PhDs providing Psychological Evaluation services. Each PhD will have up to five individuals to assess at any given time. Assessments will be comprised of interviews, information gathering, testing, report writing, feedback and consultation. A Licensed Psychologist (LP) will supervise all PhDs. The LP will supervise two PhD's and a maximum of 15 concurrent cases. Transitions will complete up to 12 assessments per month. All providers will maintain professional liability insurance coverage of at least $1,000,000 for each occurrence and $3,000,000 aggregate. VII. PROOF OF COLLABORATION A. See Attached A B. See Attached B C. Transitions collaborates regularly with caseworkers and other professionals in the community. At the beginning of the referral process, Transitions contacts other treatment providers involved with the client to gather collaborative information; the information from theses sources is integrated into the report. D. Transitions attends staffings that are held concerning a client to clarify the results and recommendations. Transitons is available for consultation with the caseworker regularly. Staffings are held on a monthly basis to discuss each referral and brainstorm various intervention options. E. Interventions will be comprehensive in nature to address the specific referral questions. F. North Range Behavioral Health provides psychological assessments to Medicaid eligible persons only if the assessments are medically necessary and recommended by a North Range Behavioral Health psychiatrist. Often, these evaluations will not address the referral issues relevant to Social Services involvement, such as parenting capacities. If an evaluation is conducted through North Range Behavioral Health, the test results and other data collected will be integrated into the psychological evaluation completed by Transitions Mental Health Services Bid Proposal 006-00 Transitions 9 VIII. EVIDENCED BASED OUTCOMES A. See Attached C B. See Attached C C. See Attached C D. See Attatched C IX. STAFF QUALIFICATIONS A. Transitions staff providing direct services meet or exceed the qualifications in Staff Manual VII. All psychological assessment staff have a PhD in the field of psychology. In addition, each staff member has at least three years of professional experience. For the Arena Assessments, a certified Speech Language Pathologist, Certified Occupational Therapist, Certified Physical Therapist, and Educational Psychologist will also be used to address each area: the Occupational and Physical Therapist will address the motor and adaptive functions. The Speech/ Language Pathologist will assess a child's ability to effectively use expressive and receptive language, and the Educational Psychologist will assess a students academic or pre-academic skills. All Mental Health Evaluation providers have a minimum of a Master's Degree in a Human Service field, five years' experience and a license (e.g. Licensed Professional Counselor or Licensed Clinical Social Worker). 1. Nicole R. Warnygora, PhD, LPC was a school psychologist in the Ft. Collins schools for four years, providing assessment and intervention strategies for children in preschool through high school. She also has provided emergency risk assessments and mental status evaluations through the Poudre Valley Health System. Nicole has worked as a licensed professional counselor for several years and has testified as an expert witness in numerous court proceedings. 2. Molly Geil, PhD, Licensed School Psychologist, is an adjunct faculty member at the University of Northern Colorado where she has taught courses in assessment and intervention and supervised doctoral level students. Molly consults internationally as a school psychologist and also worked as a school psychologist in Weld District 6. Molly has testified in court. 3. Charles Howard, PhD, Licensed Psychologist, has more than 12 years of experience providing psychological assessments, supervision, consultation and court testimony. 4. Greg Creed, MA, LPC is a bilingual therapist who has provided assessment and treatment to individuals, couples and families for more than five years. He has also provided court testimony. Mental Health Services Bid Proposal 006-00 Transitions 10 5. Jami Moe-Hartman, MA, LPC has more than 10 years of experience providing assessment and counseling services to children and adults. She has testified in court as an expert witness on several cases. 6. Rosann Ross, MA, LPC has been a psychology instructor at the University of Northern Colorado for more than eight years. She has 10 years of experience in counseling and assessment. 7. C. Jean Noblitt, MSW, LCSW has been providing counseling and assessment services for 10 years and holds a license as a clinical social worker. She has experience providing court testimony. B. Transitions has two license-eligible psychologists contracted to perform assessment services and one supervisor who is a Licensed Psychologist. Transitions also has a Nationally Certified School Psychologist to perform educational assessments and will contract with physical, occupational and speech therapy professionals to perform the other facets of the arena assessments. C. Staff will participate in new caseworker training as applicable. D. All PhDs have training and experience in the area of risk assessment and intervention. X. UNIT OF SERVICE RATE COMPUTATION (See Attached) XI. BILLING PROCESS A. Transitions Billing Process: Transitions follows a structured billing process in order to maintain prompt billing for services. Transtions staff are required to submit all signed and dated verification forms for coaching and for therapeutic visitation by the 1st workday of the month. All documentation including original, signed written monthly reports for coaching and for therapeutic visitation are due by the 5th workday of the month. The administrative assistant completes all invoices, Authorization Forms, and Core Service Forms by the 5th workday of the month. The forms are audited by a co-director for accuracy and signed. The billing, which includes all signed documentation (i.e., Transitions' invoices, Authorization Forms, Core Services Forms, and monthly reports), is then hand delivered to the Department of Social Services B. Sample Monthly Bill • Mental Health Services Bid Proposal 006-00 Transitions 11 (See Attached I) XII. LOWEST QUALIFIED BID Transitions strives to provide the highest quality of professional services to Weld County families while maintaining reasonable rates. XIII. PROGRAM CAPACITY BY MONTH The maximum program capacity per month is 20 referrals. The minimum number of referrals necessary to sustain the program is four. Bid 002-05 (RFP-FYC-06005) Attached A Date of Meeting(s)with Social Services Division Supervisor: 2j- -CC o Comments by SSD Supervisor: sagoj.° O.rNek. tc) caSn� b.n r- fro. �..t 0 0. Qt ts L_AnA 40. A , Cl_p6L.a3v`Q _ o_ \oi Ct 6-Name and Signature o Supervisor Date ORIGINAL Page 31 of 41 WELD COUNTY AUTHORIZATION FOR CONTRACTUAL SERVICES Date: 02/28/06 Provider: Transitions Psychology Group, LLC Billing Contact: Karel Longan Phone #: _970-336-1123 Address: 804 11th Avenue Greeley, CO 80631 Description of Services: Mental Health Evaluations Service Month / Year 02/06 Charges: $ 3260.00 I CERTIFY THE SERVICE AUTHORIZED WAS PROVIDED ON THE DATE INDICATED AND THE CHARGES ARE MADE PURSUANT TO A BONA FIDE CONTRACT BETWEEN ME AND THE WELD COUNTY DEPARTMENT OF SOCIAL SERVICES. �+ 0/� J �v¢ ov S•Cr ,UPC Imo"(_ 2 -/ �Sl� Printed Mine of Signer rovide-signature Date AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FOR COUNTY USE ONLY: Approvals: / / Core Caseworker Date Director Date AMOUNT PAYABLE: $ ANY CHANGES LISTED BELOW: Client/ID/HH# Billed Amt Denied Paid Reason MEMVAL • Transitions Psychology Group, LLC Invoice 804 11th Avenue Date Invoice# Greeley, CO 80631 2/28/2006 442 Bill To WCDSS-MHE PO Box A Greeley,CO 80632 Due Date 3/31/2006 Client Name HH# Qty Item Rate Amount Keaton,Mallory 55252 4 Psych Eval 282.00 1,128.00 Keaton,Alex 55252 6 Psych Eval 282.00 1,692.00 Loxley,Robin 54566 1 Mental Health E... 220.00 220.00 Ball.Todd 54876 1 Mental Health E... 220.00 220.00 �..�- Total $3,260.00 O f / 0 N CA \ t &/ � a. / J § ] ) {§ ch / k E § \ 3 ) \ » % I / ; tea — » s ( ! a ( \ \ } aE < _ > � cn C . z \ {{ j ; ) /! \ 0 § q ! - 6A , _ ; cn $\{ { { 0 5 « ( C1D - . - : ), � m ] & } }/ ) \ § ( [ : \ j $\ cin V % } _ § s O • - ) q cg) ) / ) / § § ) - \ / c 2 3f 2 {\ N N NN N N \/ ! 2 ) ) ce ) ) \ ) , 'C — — Oct\ Li- § ! co o co co \/ B () \ \ \ \ : y >. 7 f3 0 0 CI N_ 4 . 7 } \ ) \ ` ^ $ \ o CA kr; [{ � � _ ' / ) 2 f3 2 ? ? 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J _- O u 0_1 'n L R 4-4 U a T O, ai 5 v > V. t > '6 T ^ �, i t s an, __ 0 y > a 11�� • $ '0 3 .U_ J "o R O W O te u c o a W '_'I = 0 ❑ U s. y I Q- .fl cfpQ O •. B -0 0 n <113 -a 6a Q. O O , v a) G '� 0 — 9 E .Hi cn v Sh '� a- > 0 Z _ '5 7 > T •O u f^i y Z "' Cl 0 O.. - .G 6. -.5.. .. U 'O Z ^-� is .` o > • .0 - = U a) o G • ` Attachment C Mental Health Services Bid Proposal 006-00A- Transitions 1 ; • • 4 • Mental Health Services Renewal Request •••� •• • � ' • • • • • •• 1 ' - *ea 4 • . Transitions PSYCHOLOGY GROUP,LLC Trails ID: 987654 HH#456789 Family Name: Larson Provider Name: Transitions Psychology Group, LLC Program: Mental Health Evaluation: Psychological Evaluations Contact Person: Ashley Ross, WCDSS Renewal Requested by: Maya Jackson, PhD, LPC End Date Requested: 8/31/06 Reason: Evaluation was not able to be completed within the time frame due to the parent being out of the country. Client has returned to the country. Provider Comments: Provider has scheduled an appointment with client. The assessment needs to be completed during the next six weeks. Le& ®b(o/ /0(� Provider Signature Date ORIGINAL • Attachment C Mental Health Services Bid Proposal 006-00 Transitions 2 • CONFIDENTIAL PSYCHOLOGICAL REPORT • • • • NAME: Jennifer R. Johnson • •• e ;• : AGE: 35 Years, 5 Months P • • DATE OF BIRTH: October 10, 1970 •Mae ' ' DATE OF EVALUATION: September 2005 Transitions EVALUATOR: Amy Jackson, PhD PSYCHOLOGY GROUP,LLC REASON FOR REFERRAL Ms. Johnson was referred for a psychological evaluation after her children were referred to the Weld County Department of Social Services. Her children were living with her mother who had contacted the Weld County Department of Social Services after Ms. Johnson had threatened to take the children away. Social Services requested that this evaluation be conducted to address Ms. Johnson mental health needs. ASSESSMENTS Review of Background Clinical Interview Wechsler Adult Intelligence Scale— Ill (WAIS-III) Minnesota Multiphasic Personality Inventory—2 (MMPI-2) Millon Clinical Multiaxial Inventory III (MCMI-III) Woodcock-Johnson Tests of Achievement—III (WJ-III) REVIEW OF RECORDS Island Grove Treatment Center Police Records Weld County Department of Social Services Colorado Mental Health Institute, Pueblo, Colorado Dr. Koons, Colorado Springs, Colorado Northern Colorado Medical Center, Greeley, Colorado LOG OF CONTACTS 08/03/05 Referral received at Transitions 08/04/05 Phone call to caseworker 08/12/05 Clinical Interview, 1 hour 08/24/05 Wechsler Adult Intelligence Scale- Ill (WAIS-III), 2 hours 09/02/05 Woodcock-Johnson Tests of Achievement—III (WJ-III) 09/05/05 Minnesota Multiphasic Personality Inventory-2 (MMPI-2), 2 hours • Attachment C Mental Health Services Bid Proposal 006-00 • Transitions 3 09/09/05 Milton Clinical Multiaxial Inventory —II (MCMI-II), 1 hour 09/09/05 Phone call to caseworker 09/14/05 Feedback, Results, and Recommendations, 1 hour SPECIFIC REFERRAL QUESTIONS ADDRESSED 1.) Specific Mental Health Diagnosis 2.) How do Ms. Johnson's mental health needs affect her parenting ability? 3.) What are her strengths/needs in regards to her ability to care for her children? BACKGROUND INFORMATION Ms. Johnson is the only biological child of Amy Anderson and Sam Barnes. Amy and Sam were involved in a short-term relationship. Ms. Johnson did not know her biological father. Jennifer's half brother, Jesse, was from a short-term relationship with a man named Jose Rodriguez. Amy then met Jack Anderson and has been married to him for the past 21 years. They have one biological child, Ben. Ms. Johnson described a very chaotic childhood in which she moved several times. Ms. Johnson lived between her mother and grandparents houses. She lived with her grandparents from the time her mother met Jose until the relationship ended when she was 6 or 7 years old, at which time, she returned to live with her mother. She moved back to her grandparents' house when she was 9. Then, she returned to live with her mother. She returned to her grandparents' house when she was 14, then returned to her mother's house. In 1990, Ms. Johnson became very suicidal and was admitted to the State Hospital for 8 % months. When Ms. Johnson was released from the State hospital, she went to live with her grandparents who had gained custody of her. Ms. Johnson described a lot of discord in mother's house when she was growing up. Ms. Johnson reported that she was physically abused by her stepfather. Ms. Johnson has two children, Mason and Jane Robinson. Ms. Johnson reported that she very much wants to have custody of her children returned to her. She stated that her purpose in life was to be a mother. Ms. Johnson readily admitted to difficulties raising her two children. She stated that they have lived on-and-off with her mother, Ms. Anderson for most of their lives. When asked about discipline, Ms. Johnson reported that she "did not do discipline". She stated that she tended to argue and yell at the children. She stated that the children would hit her and tell her that they "hated her". RECORD REVIEW SOCIAL SERVICES HISTORY • Attachment C Mental Health Services Bid Proposal 006-00 Transitions 4 The Department of Social Services received a referral on 04/22/05 that Mason and Jane Robinson, the children of Jennifer Johnson, had been living with their maternal grandmother, Ms. Anderson, for approximately 6 months because of their mother's inability to provide for them. It was also reported that Ms. Johnson was using and selling Methamphetamines in her home and that the children were at risk for exposure to drugs as well as violence. Weld County Department of Social Services caseworker met with the children who reported a violent incident at Ms. Johnson house involving three men on Easter weekend. In addition, they reported that there was often no food in the house and that they did not want to return to the house for fear of another violent incident occurring. Ms. Anderson reported that she and her husband had taken the children for extended periods of time on three separate occasions. There were no papers signed regarding medical care for the children and reportedly, Ms. Johnson refused to sign the paper allowing Ms. Anderson to seek medical care for the children. In the 6 months prior to Social Services involvement, Ms. Johnson had seen the children less and less. In addition, it was reported that she would often threaten to take the children and leave when she became angry. Records further indicate that the social worker listened to a message in which Ms. Johnson threatened to either take the kids and leave or"drive (herself) off of a bridge and the kids would go to Bob." CRIMINAL HISTORY Police records indicate that Ms. Johnson has been arrested on two occasions, once in 2003 for assault. Records indicate that the case was dismissed. Ms. Johnson reported that the incident was a domestic violence incident between her and Mr. Robinson. Reportedly, Mr. Robinson was charged with domestic violence while the charges against stemmed from self defense and were dropped. In May 2005, Ms. Johnson was arrested for possession of a controlled substance. She plead guilty and spent 38 days in jail. Records indicate that as a juvenile, Ms. Johnson was charged with driving without a license. Ms. Johnson admitted to stealing her mother's car on one occasion. She was never charged for this incident. MENTAL HEALTH HISTORY Ms. Johnson has a lengthy mental health history. Reportedly, in March of 1988 and March of 1990, the same male "friend" raped Jennifer. After the second rape, Jennifer began to feel increasingly depressed. In addition, she felt that her stepfather blamed her for the rape. Ms. Johnson also has numerous conduct problems. She was truant to the point of being expelled from school in March 1990. In addition, she had gotten in trouble for fighting, running away overnight, and lying. Ms. Johnson was first admitted to a psychiatric hospital in April of 1990. She was admitted to the hospital for 10 days due to suicidal ideation and wrist slashing. Ms. Johnson's behavior continued to escalate. Records indicate Attachment C Mental Health Services Bid Proposal 006-00 • Transitions 5 that the Pueblo County of Social Services had assumed custody of Ms. Johnson by September of 1990. Ms. Johnson was admitted to the Colorado Mental Health Institute at Pueblo in September of 1990. She remained hospitalized until May of 1991. Upon discharge, her diagnosis was: Major Depression, recurrent. Ms. Johnson was hospitalized three times at the Northern Colorado Medical Center Psych Care. Ms. Johnson was reportedly hospitalized twice for suicidal ideations in 1992 and 1998. Ms. Johnson was hospitalized in 2001 for an attempted suicide by drug overdose. Ms. Johnson reported that she has struggled on and off for years with substance abuse. Jennifer first experimented with substances as a teenager. In 2001, Ms. Johnson started using cocaine. Reportedly, Ms. Johnson left her children with her mother and went back to Pueblo in October of 2001. In December of 2001, she called her mother and told her that she had a drug problem. She moved back to the Greeley area and lived in a house in Ault, Colorado with Bob. Ms. Johnson left Bob in 2004 and met George. In August 2004, Ms. Johnson's grandmother, who helped to raise Ms. Johnson, had a heart attack. She died February 2005. Ms. Johnson reported that she started to use more and more Methamphetamines at that time. Ms. Johnson reported that she tried to OD "a couple" of times. Once, Ms. Johnson reported that her son found her on the bathroom floor. Ms. Johnson reported that her son called Ms. Anderson who came to the house. Ms. Johnson was arrested in May 2005 for possession. Since that time, she has engaged in drug treatment and has been compliant, clean, and sober. RELATIONSHIP HISTORY Ms. Johnson initially married Bob Robinson in 1994. Ms. Johnson reported that he was abusive and drank alcohol. The couple has two biological children, Mason (12) and Jane Robinson (10). The couple divorced in 1997. Mr. Robinson has had little contact with the children since that time, and currently has an active warrant for his arrest. Ms. Johnson married Doug Hall in 2002. This marriage ended in 2003. In 2004, Ms. Johnson met Mr. Vigil through a mutual acquaintance. She reported that he is a "big" support in her life. However, there was at least one violent incident in which Mr. Vigil was arrested for domestic violence. HEALTH HISTORY Ms. Johnson has struggled with health related illnesses for her entire life. As a child, she had frequent urinary tract infections. In addition, she had chronic sinus infections, difficulty sleeping, and anhedonia. As a teenager, Ms. Johnson had difficult menstrual cycles with recurrent breakthrough bleeding. As an adult, Ms. Johnson continues to have health problems. She had numerous ovarian cysts. In 1996, she had one ovary removed. In 1997, she had a complete hysterectomy. Ms. Johnson continued to struggle with pelvic pain and back pain. • Attachment C Mental Health Services Bid Proposal 006-00 Transitions 6 In 2000, doctors implanted a device similar to a TENS unit to assist Ms. Johnson in managing her pain. TENS stands for transcutaneous electric nerve stimulator and is used to stimulate nerves to control pain. The stimulator implantation is considered to be a simple procedure, done using a local anesthetic and a sedative. Typically, a stimulator is first temporarily implanted under the skin (percutaneously) to give the treatment a trial run. (A percutaneous stimulator tends to move from its original location, so it is considered temporary.) After a successful trial, a more permanent stimulator can be implanted in the epidural area between the spine and the spinal cord (surgical laminotomy), which is a more stable, effective location. The stimulator must be replaced every 2 to 3 years. Ms. Johnson surgery did not go as planned, and the TENS was never implanted temporarily. The device was permanently implanted. She was on Morphine for pain for 4 years after the surgery. She continued to be depressed about her physical condition. She has been receiving Social Security Disability since 2003 due to her physical and depression. EMPLOYMENT HISTORY/SCHOOL HISTORY Ms. Johnson graduated from Day High School in 1992. Records indicate that she struggled in the area of reading. After high school, she received her Certified Nursing Assistant certification. Ms. Johnson worked on-and off as a CNA until 2000 when she was complete pulled out of work due to health reasons. ASSESSMENT BEHAVIOR Ms. Johnson was cooperative throughout the assessment process. She was frank and forthcoming with most of her responses. The following appears to present a true clinical picture of Ms. Johnson and her functioning. On one of the standardized measures, it appears that Ms. Johnson was trying to present herself in a positive light. The impact of that response style on that measure will be discussed later. RESULTS Wechsler Adult Intelligence Scale-Third Edition (WAIS-Ill) The WAIS is an individual measure of cognitive ability. Subscales are reported in terms of scaled scores with a mean of 10 and a standard deviation of 3. Composite scores have a mean of 100 and a standard deviation of 15. Verbal Scale Scaled Score Vocabulary 06 Similarities 07 Arithmetic 10 Digit Span 08 Attachment C Mental Health Services Bid Proposal 006-00 Transitions 7 Information 06 Comprehension 06 Letter-Number Sequencing 08 Performance Scale Scaled Score Picture Completion 09 Digit Symbol — Coding 12 Block Design 13 Matrix Reasoning 13 Picture Arrangement 11 Symbol Search 11 Scale Composite Score Percentile 95%Confidence Interval Verbal 83 13 79-88 Performance 110 75 103-116 Working Memory 92 30 86-99 Index Processing Speed 108 70 98-116 Index Full Scale" 94 34 90-98 *"The difference between Ms. Johnson Verbal Score and Performance score was statistically significantly significant. This difference was found in less than 8% of the standardization population. Therefore, the full-scale score needs to be interpreted with caution. Ms. Johnson performed in the Below Average to Average range of cognitive ability with a standard score ranging from 90-98 at the 95% confidence interval. This means that if she were to re-take this same assessment, her true score would fall within this range 95 out of 100 times. Because of the difference between Ms. Johnson's Verbal ability and Performance Ability it is more meaningful to discuss each of her ability levels separately. Ms. Johnson demonstrated Average Performance ability indicates that she is able to physically and mentally manipulate objects to solve problems. This suggests that she is a "hands-on" learner and she will assimilate new information more quickly when it is presented in a "hands-on" or concrete format. Ms. Johnson demonstrated one area of relative weakness in the area of Verbal Ability. A relative weakness means that in comparison to her other abilities, and in comparison to others her age, this area was less developed. Ms. Johnson demonstrated Below Average verbal ability means that she has more difficulty, than the average person, in comprehending verbal language. She has a limited vocabulary and struggles to combine words to solve problems and answer questions. Attachment C Mental Health Services Bid Proposal 006-00 • Transitions 8 Woodcock-Johnson Tests of Achievement-►ll(WJ-Ill) The WJ-III is an individual test of reading, writing and mathematics ability. The reading portion of the test was administered due to the fact that Ms. Johnson records indicated that she struggled in the area of reading in the past. Scale Standard Score Percentile Grade Equivalent Letter-Word 88 22 6.7 Identification Reading Fluency 93 33 9.4 Passage 91 28 6.7 Comprehension Broad Reading 91 26 8.2 Ms. Johnson performed in the Low Average Range of reading. Letter-Word Identification reflects Ms. Johnson ability to sound out and recognize words. Reading fluency refers to how fast Ms. Johnson is able to read. Passage comprehension is a measure of Ms. Johnson ability to understand written language. While Ms. Johnson overall reading ability falls in the Low Average Range (8th grade, 2M month), her reading comprehension falls in the Borderline Range of ability (6th grade, 7th month). Most writing is geared towards a 7th grade reading level. This means that Ms. Johnson may struggle with reading a lot of written material at one time. Written material should be minimized. PERSONALITY ASSESSMENTS Ms. Johnson was given two standardized assessments of personality. These test provide hypotheses (which have a substantial likelihood of accuracy) to describe the clients' thoughts, feelings, and behaviors. Personality tests are not indicators of absolute fact, as many interpretive principles are highly inferential and/or actuarially based. Predictions about personality style and potential behavioral manifestations should only be made by looking at the test results and consistent historical information. MINNESOTA MULTIPHSIC PERSONALITY INVENTORY-2(MMPI-2) The MMPI-2 is a five hundred and sixty-seven true and false item test that is helpful in understanding a client's feelings about themselves, relationships, and how they view the world. Ms. Johnson's profile was valid with two scales in the pathological area (Depression=70) and (Addiction Admission=73). This suggests that Ms. Johnson continues to struggle with depression she complains about loss of appetite, low energy and sleep disturbances. She is quite tense and irritable. She becomes preoccupied with her problems and has difficulty concentrating or making decisions. While presently sober, Ms. Johnson has the tendency to resort to substances to cope with her feelings of depression. Attachment C Mental Health Services Bid Proposal 008-00 Transitions 9 The Content Scales reveal that Ms. Johnson views her physical health as failing. She has numerous somatic complaints (HEA=64). This is consistent with her difficulties in regulating her level of pain and her numerous medical issues. Ms. Johnson endorsed some antisocial beliefs, attitudes, admits to rule violations, and acknowledges antisocial behavior in the past (ASP=66). This is consistent with her substance abuse and criminal history. Finally Ms. Johnson appears to struggle with anger management and control (ANG=72). She may physically or verbally attack others when she is angry. This is consistent with collateral information about her hitting, biting, and throwing things when she becomes upset. Ms. Johnson also reported struggling to control her mood swings. People with similar profiles tend to be somewhat shy. Ms. Johnson she is a bit hypersensitive about what other people think of her and may have concerns about relationships with others. Marital difficulties are prevalent with people of this profile and are often the result of moodiness and whining. People with this profile may hold grudges. If they perceive they have been wronged, become intensely angry, hostile, and resentful of others. Milton Multiaxial Clinical Inventory-Ill(MCMhlll) Ms. Johnson also completed the MCMI-III. This one hundred and seventy-seven- item test helps to understand personality dynamics with special emphasis on the possibility of personality disorders. This test was valid, although Ms. Johnson showed a tendency to deny personal problems, symptoms, or negative feelings. She was very defensive. Test software raised some of the scales to adjust for this response style. One of the scales was clearly in the pathological range (Narcissistic=90) and four other scales fell near the clinical range (Drug Dependence=66), (Bipolar- Mania=66), (Paranoid=67), and (Compulsive=69). This suggests that Ms. Johnson likes to present herself as socially charming which hides her inner insecurities and fear of autonomy. She has an intense need to people to like her. Failure to evoke the approval of others leads to intense anxiety, depression, or withdrawal. Her habitual preoccupation with external approval may be the result of hidden dependency. This is consistent with her early history of being raised in different households. This often causes children to continually seek out the approval of others. Ms. Johnson has a tendency to repress the feelings of dependency because there is such a disparity between the person that she presents and her true feelings of inadequacy. When Ms. Johnson is faced with inadequacies, she is likely to become depressed, resentful and may resort to substance abuse. People with similar profiles are prone to substance abuse, depression, and mood swings. This is consistent with Ms. Johnson's report of mood swings, depression, and suicidal actions. In addition, people with similar profile have difficulty demonstrating empathy towards others and realizing how their actions impact other people. This Attachment C Mental Health Services Bid Proposal 008-00 Transitions 10 is with Ms. Johnson self-report that she her son found her on the bathroom floor after an attempted OD. UMMARY In conclusion, Ms. Johnson is a 31 year-old Hispanic female. She completed high school and was trained as a Certified Nursing Assistant. Ms. Johnson has difficulty with language processing and has some reading deficits. Ms. Johnson is disabled due to chronic pain and Major Depression. Ms. Johnson has not worked since 2000 due to being disabled. Ms. Johnson has a lengthy mental health history. She has suffered from Major Depression for years and has had suicide attempts in the past. Ms. Johnson also experiences mood swings, suffers from chronic pain, and has a history of substance abuse. Her early childhood experiences depict chaos and fragmented attachments leading to feelings of insecurity and inadequacy. Ms. Johnson attempts to cover these feelings of dependency by acting socially charming, aloof, and self-assured. However when her inadequacies are exposed, her pain is unmanaged, or her relationships falter, she has a tendency to have mood swings. In her mood swings, she cries, yells, hit, throws things, and/or resorts to substance abuse. The following information is offered to address the specific referral questions: 1). What is Ms. Johnson specific Mental Health Diagnosis? Axis I: Major Depression Stimulant Abuse Substance Abuse Axis II: Reading Difficulties Axis III: Chronic Pain Axis IV: Problems with Department of Social Services Problems with the legal system Discord with family Separation from children Discord in relationship Axis V: 60 2). How do Ms. Johnson's mental health needs affect her parenting ability? As long as Ms. Johnson's level of pain is managed, her depression is managed, and she is substance free, and she actively engages in treatment, prognosis of her ability to be a positive role in the lives of her children is deemed good. • Attachment C Mental Health Services Bid Proposal 006-00 Transitions 11 However, if these areas are not managed, she presents a dear and present danger to her children. The potential for a violent episode to occur is likely based on history-either due to Ms. Johnson instability or to her associations with other people who are involved with substances. In addition, there is a likelihood that if the present pattern of the children being shuffled from her home to her parent's home that the children are at risk for fragmented attachments, leading to poor bonding and thus repeating the same cycle that Ms. Johnson lived through as a child. 3). What are Ms. Johnson's strengths/needs in regards to her ability to care for her children? Ms. Johnson appears to be motivated to be a good mother. She readily admits her parenting downfalls and appears eager to receive help and assistance. In addition, Ms. Johnson has been involved in substance abuse treatment. She has been cooperative, clean, and sober. Ms. Johnson appears to be committed to living a sober lifestyle. The following recommendations are offered: 1. Ms. Johnson needs to remain in substance abuse treatment until her counselor deems that there is a strong probability of her remaining substance free. 2. Ms Johnson would benefit from hands-on parenting education. A parent educator that came to the house to work with the family would be the most beneficial. 3. Ms. Johnson needs to participate in couples counseling to develop alternative ways to deal with conflict that do not include violence. 4. Ms. Johnson needs to participate in family counseling, preferably in-home, to increase the bonding, attachment, and trust of the children with her. (Ideally, the same individual would perform family counseling and parent education. An individual who conducts Family Preservation Services may offer such services. An added benefit to this type of service is that these counselors are often on-call and could be available if conflict arose). 5. Ms. Johnson needs to comply with all medication that is prescribed by her doctors. Ms. Johnson needs to comply with all medical treatments and recommendations. Amy Ja s , P,D Attachment C Mental Health Services Bid Proposal 008-00 Transitions 12 • ea- CONFIDENTIAL• �� ♦ $ MENTAL HEALTH EVALUATION • ••�•• + $ * • � • NAME: Denise Myers • .0 11�= 1 ; AGE: 35 Years, 3 Months DATE OF BIRTH: November 10, 1970 Transitions DATE OF EVALUATION: February 27, 2006 PSYCHOLOGY GROUP,LLC EVALUATOR: James Hamilton, PhD REASON FOR REFERRAL Ms. Myers was referred for a mental health evaluation by the Weld County Department of Social Services. Denise has been involved with the Department of Social Services for the past three years. Denise completed her initial treatment plan in 2004. A second Dependency and Neglect Petition was filed in 2005. Ms. Myers has been very inconsistent with complying with treatment requests. ASSESSMENTS Review of Background Information Clinical Interview LOG OF CONTACTS 12/31/05 Referral received at Transitions 01/03/06 Phone call to caseworker 01/05/06 Phone call to client to set up appointment 01/10/06 Clinical interview with client 01/12/06 Case consultation 01/13/06 Final Report Completed BACKGROUND INFORMATION Ms. Myers is the second of three biological children born to Alex Myers and Sally Torres. Alex and Sally divorced when Denise was eleven years old. Shortly after their divorce, Sally met Manuel Torres and the two have been married for the past 19 years. Ms. Myers described a very chaotic and abusive childhood. Denise described a lot of violence, drinking, and drugs. From the time Denise was seven years old until she was nine years old, Denise was sexually abused by an uncle. Denise, Attachment C Mental Health Services Bid Proposal 006-00 Transitions 13 who was born in Greeley, briefly moved to Washington State but returned to Greeley when she was eight years old. Her father, Alex, was incarcerated while the family was in Washington State for drug use. Denise also reported her father drank alcohol excessively and huffed paint. She stated that she had little contact with her biological father who was in and out of prison throughout most of her childhood. Ms. Myers reported that school was very difficult for her and she finally dropped out of school when she was in the 8th grade. She met her first husband Paul Anderson when she was 14 years old. She had her first child at the age of 15 years old and got married shortly thereafter. Denise remained married to Paul for 9 years. The couple has four children from this relationship. Paul Jr. (19), Cindy (18), Abigail (17), and Katie (16). Denise reported that she divorced Paul because they were constantly partying and drinking. Denise then met Tobias Robinson. The couple was never married and had three children together: Ben (6), Hannah (5), and Charles (21 months). Denise described this relationship as very conflictual. She stated that Tobias was arrested for domestic violence which she estimated to be at least 10 times. In addition, Denise admits to drinking excessive amounts of alcohol. Denise reported that when she drank, she drank a case of beer at time until she passed out. In addition, she admitted that just before the children were removed from her home, this most recent time, she was using marijuana daily. Denise described one incident of sexual abuse. Denise reported that she and Tobias went to pick up Cindy (15) and Abigail (14) from a party. She explained that both of the girls were very drunk. They were unable to get Cindy out of the party. Denise stated that Mike had hit Cindy because she was so drunk and "getting violent with him". Abigail was passed out drunk. They took Abigail home and left Cindy at the party. Mike apparently thought that Ms. Myers had left the house to go back to the party to get Abigail. However, Ms. Myers was still in the house. Ms. Myers reported that all of a sudden the room got very quiet. She walked into the room and found Mike having sex with Lane. She elaborated that Tobias's pants were down — including his underwear. In addition, Abigail's pants were down including her underwear. Mike ran out of the house and stated that he was going to kill himself. Ms. Myers reported the incident to the police and then Abigail was examined in Denver. However, Mike continued to threaten to kill him or Ms. Myers if she did not change her story. Ms. Myers reported that she told Abigail that Mike was panning to kill him or her (Ms. Myers) if Abigail did not change her story. Abigail then recanted her story. This case originated in June of 2004 after the police found Hannah, age 3 at the time, and Ben, age 5, at the time, riding tricycles down Main Street in Sterling, Colorado. The children reported that they were going to Wal-Mart. The children had no shoes or money with them. A Dependency and Neglect Petition was authorized by the courts in July of 2004. The children were left in the custody of their father, Tobias Robinson with supervised contact granted to Ms. Myers. In • Attachment C Mental Health Services Bid Proposal 00&00 Transitions 14 June of 2005, Weld County Department of Social Services received a referral from Sally Torres that Ben, Hannah, and Charles had been left at her house by their parents. The referral further reported that she could not care for all 3 children. At that time, Sally Torres had not seen her daughter, Ms. Myers in 4 months. A second Dependency and Neglect Petition was authorized by the courts in July of 2005. Ms. Myers was reportedly not cooperative with the Weld County Department of Social Services in working towards completion of her goals on her treatment plan. In addition, there were concerns regarding Ms. Myers's ability to comprehend the various components of her treatment plan. CRIMINAL HISTORY Police records indicate that Ms. Myers has been arrested on several occasions: 2002 Habitual Traffic Logan County 2003 Habitual Traffic Logan County 1992 Assault Weld 1993 DUI Weld 1994 Burglary Weld 1995 Theft Weld 1996 Drugs Weld 1992 Theft Jefferson Presently, she has three open criminal cases in which she is waiting disposition: 2000 Theft Jefferson 2006 Forgery Weld 2005 Habitual Traffic Weld MENTAL HEALTH HISTORY Ms. Myers reported that she had taken anti-depressants on and off for years. She reported she is presently taking an anti-depressant that was prescribed by the doctor from the jail. She could not recall the name of the medication. Ms. Myers reported that she had seen counselors in the past but sporadically without any consistency in treatment. Ms. Myers reported that she had felt sad and depressed for years. Ms. Myers denied ever trying to hurt or kill herself. RELATIONSHIP HISTORY Ms. Myers initially married Paul Anderson when she was 15 years old after she became pregnant with her first child. This relationship lasted for 9 years and the couple had 4 children. Ms. Myers reported that she left him due to the couple partying and drinking too much. Ms. Myers then met Tobias Robinson. The couple was never married but remained together for 7 years and had three children. Ms. Myers described the relationship with Tobias Robinson as very conflictual. Ms. Myers is presently seeing Donnie. Donnie is presently incarcerated. Attachment C Mental Health Services Bid Proposal 006-00 Transitions 15 HEALTH HISTORY Ms. Myers reported that she has been in relatively good health. She denied chronic health problems. EMPLOYMENT HISTORY/SCHOOL HISTORY Ms. Myers dropped out of school in the 8th grade. She reported that she had always struggled in school. She dropped out of school when she became pregnant. Ms. Myers's last job was with Silver Stakes Plastic two years ago. She had been employed for approximately 2 months before she started missing work and was fired. SUBSTANCE MUSE HISTORY Ms. Myers admitted to drinking alcohol until she passed out. In addition, she admitted to smoking marijuana, using cocaine, and using methamphetamines. In the past, Ms. Myers has huffed paint. PRELIMINARY DIAGNOSIS Axis I Polysubstance Abuse Axis II Anti-Social Personality Disorder Axis III None Known Axis IV Discord with legal system Discord with family Separation from children Axis V 50 RECOMMENDATIONS 1.) Ms. Myers would benefit from a substance abuse evaluation. She needs to follow all treatment recommendations. 2.) Ms. Myers would benefit from individual counseling to address past issues of trauma and abuse. 3.) A full psychological evaluation is not recommended until Ms. Myers has been substance free for at least six months. In addition, due to the fact that she is facing incarceration, the terms of her incarceration needs to be determined in order for meaningful recommendations to be implemented. --k4 421i b obloloto ‘c, J s Hamilton, PhD Date Attachment C Mental Hearth Services Bid Proposal 006-00 Transitions 16 •• •�1 1 • Bibliographic Information a• * . . x •00 • •."��-•,• Transitions PSYCHOLOGY GROUP,LLC 1) Wechsler Adult Intelligence Scale-Third Edition 2) Wechsler Intelligence Scale for Children- Fourth Edition 3) Universal Nonverbal Intelligence Test 4) Minnesota Multiphasic Personality Inventory-2, 5) Minnesota Multiphasic Personality Inventory for Adolescents [MMPI-A], 6) TAT (Thematic Aptitude Test) 7) CAT (Children's Apperception Test) 8) Children's Personality Inventory 9) Trauma Symptom Scale 10) Draw-A-Person Screening Procedure for Emotional Disturbance, 11) HTP (House Tree Person) 12) Kinetic Family Drawing (KFD) 13) Wechsler Memory Scale 14) Cognitive Assessment System 15) Behavior Assessment System for Children 16) Woodcock-Johnson Tests of Achievement - Ill, 17) Vineland, 18) Gilliam Autism Rating Scale (GARS) 19) Gilliam Asperger's Disorder Scale (GADS). 03/2862008 12:47 FAX 970 346 7890 GREELEY/WELD HSG AUTH Z002/002 PGREELEY/WELD HOUSING AUTHORITIES .315 N. I 1 th Avenue, Bldg. B P.D. Box 130 phiGreeley, Colorado 80632-0130 (970) 346-7660 (970) 346-7690 tax March 28, 2006 (800) 659-2656 TTY Relay Gregory S. Creed, MA,LPC Transitions Psychology Group, LLC 804 11th Avenue Greeley, CO 80631 Dear Mr. Creed: As a Housing Authority we would be glad to accept any appropriate referrals for clients needing our services from Transitions. If you are awarded a contract to work with Weld County clients we will be agreeable to enter into a Memorandum of Understanding concerning the services provided by each agency. If you have any questions please contact me at (970) 353-7437 ext 103 Sincerely, X..- .7 - ...:—.:‘-----7-6.--e7' 1-6r-c--- Thomas Teixeira Executive Director ORIGINAL . I LH DEPARTMENT OF HUMAN SERVICES Kai t(iEMPLOYMENT SERVICES OF WELD COUNTY 1551 NORTH 17TH AVENUE PO BOX 1805 AVENUE GREELEY, CO 80632 (970) 353-3800 FAX(970)356-3975 111k COLORADO March 21, 2006 Transitions Psychology Group, LLC Employment Services of Weld County is providing you this letter outlining the areas of collaboration when a client you serve under CORE service funds is identified as having an employment need. The collaborative areas were developed from your responses concerning the parameters you felt were practical, based upon the services you intend to provide. Transitions Psychology Group, LLC currently collaborates extensively with Employment Services of Weld County (ESWC) in serving Temporary Assistance for Needy Families (TANF) participants. The Transitions Psychology Group, LLC is proposing a variety of services which include Mental Health services to provide both Psychological and Mental Health evaluations, and Life Skills services which include Therapeutic Visitation and Life Skills Coaching to work with parents to increase the parents' ability to provide appropriate care to their children. It is unknown if these services will have a direct relationship to employment, however, the following outlines the plan for referrals when, or if, they arise: Case management: The Transitions Psychology Group, LLC agrees to provide case management for families that may require the parent to seek employment. For these individuals, the Transitions Psychology Group, LLC agrees to make a referral to Employment Services of Weld County. Referral process: For individuals identified as having employment needs, the Transitions Psychology Group, LLC will refer the client to Employment Services of Weld County and will send an email to Employment Services, under the attention of Linda Perez, stating that the client was referred. The Transitions Psychology Group, LLC agrees to forward the email within five business days of making the referral. Follow up: The Transitions Psychology Group, LLC will email a follow-up concerning the referral made to Employment Services of Weld County 10 business days after sending the initial email. Employment Services of Weld County will email the Transitions Psychology Group, LLC if the client does not contact us, and the Transitions Psychology Group, LLC agrees to discuss the matter with the fitV4 p f4 client at their next visit. The Transitions Psychology Group, LLC. will provide a written email of that discussion to the attention of Linda Perez within five business days. Cross training: As new staff come to the Transitions Psychology Group, LLC they will be made aware of this collaborative arrangement and will be provided training concerning the employment and training services offered by Employment Services of Weld County. Other collaborative areas: At this time there are no additional collaborative efforts with Employment Services. As additional areas of collaboration arise, the ...r,; lies-Transitions Psychology Group, LLC agrees to include them in the Memorandum of Understanding discussions to be completed by February 1, 2007. Employment Services will meet with representatives of the Transitions Psychology Group, LLC in July 2006 to initiate the collaborative Memorandum of Understanding process once bids for CORE services are completed and accepted. Sincerely, Linda L. Perez Director Employment Services of Weld County ORIGINAL North Range Behavioral Health March 29, 2006 Jami Moe-Hartman Transitions Psychology Group 804 11`h Avenue Greeley, CO 80631 Re: Letter to Accompany Proposal to Weld County Department of Social Services To Whom it May Concern: This letter is written to support the application of Transitions Psychology Group to provide CORE Services through the Weld County Department of Social Services. North Range Behavioral Health is pleased to commit to a collaborative relationship with Transitions Psychology Group to develop a system of care for children and families served to ensure that duplications in services are minimized, that gaps in needed services are eliminated and that services are billed to the appropriate payer source. For services involving Medicaid eligible clients North Range Behavioral Health will work with Transitions Psychology Group to determine which services are benefits of the Medicaid Mental Health program and to facilitate a process through which Transitions Psychology Group can be compensated with Medicaid funds when services provided are a benefit of Medicaid. Sincerely, Wayne A. Maxwell,Ph.D. Executive Director Mission: North Range Behavioral Health provides professional, ORIGINAL culturally competent mental health services for Weld County. 1306 11th Avenue/Greeley C()80631 /(970)347.2120/ Fax(970)353-390(3 Healthcare Providers Service CNA Organization Purchasing Group IIIHPSO CNA Plaza, (r sera fi rat,e .o :Insurance f Chicago,IL 60685 �_ OCCURRENCE POLICY FORM Producer r Branch Prefix Policy Number Policy Period from: 12:01 AM Standard Time on: 07/04/05 018098 970 HPG 270170686-8 to: 12:01 AM Standard Time on: 07/04/06 Named Insured and Address Program Administrator Healthcare Providers Service Organization GREGORY S CREED 159 East County Line Road 804 11TH AVE Hatboro, PA 19040-1218 GREELEY CO 80631-3246 Medical Specialty: Code: Insurance Provided by Clinical Counselor/LPCC 72990 American Casualty Co. of Reading, PA CNA Plaza 26S Chicago, IL 60685 COVERAGE PARTS LIMITS OF LIABILITY t A. PROFESSIONAL LIABILI`I Y Professional Liability $1,000,000.00 each claim . $6,000,000.00 aggregate Good Samaritan Liability Included above Personal Injury Liability Included above Malplacement Liability Included above B. Coverage Extensions License Protection $10,000.00 per proceeding $25,000.00 aggregate Defendant Expense Benefit $10,000.00 aggregate Deposition Representation $2,500.00 per deposition $5,000.00 aggregate Assault $10,000.00 per incident $25,000.00 aggregate Medical Payments $2,000.00 per person $100,000.00 aggregate First Aid $2,500.00 aggregate Damage to Property of Others _ $500.00 per incident $10,000.00 aggregate C. WORKPLACE LIABILITY Coverage part C. does not apply if Coverage part D. is made part of this policy. Workplace Liability Included in A. Professional Liability Limit shown above Fire and Water Legal Liability Included above subject to $150,000 sub-limit Personal Liability I $1,000,000.00 aggregate D. GENERAL LIABILITY Coverage part D. does not apply if Coverage part C. is made part of this policy. 1 Workplace Liability , None None Hired Auto & Non Owned Auto None Fire & Water Legal Liability None None Personal Liability None Total Premium $330.00 Policy forms and endorsements attached at inception QUESTIONS? CALL: 1-800-982-9491 G-121500C G-121501C G-121503C G-145184-A G-147292-A G-144872-A G-123846C-05 Healthcare Providers Service Organization is a division of_Affinity Insurance Services,Inc.:in NY and NH,AIS Affinity Insurance Agency:in MN and OK.AIS Affinity Insurance Agency,Inc.,and in CA,AIS Affinity Insurance Agency,Inc.dba Ann Direct Insurance Administrators License s0795465. Master Policy: 188711433 ^ , 4....„„ Keep this documentin a safe place. This and C)c)e'‘.l. ............/ �_, your cancetled check act as proof of coverage. Chairman of the Boar Secretary 604 XX 0000098-R 050321 RENHCP 1/05 R1C3HN 05080 Healthcare Providers Service cNAOrganization Purchasing Group CNA Plaza, (Certificate of g n uranc.e � PSO H 11 VV Chicago, IL 60685 OCCURRENCE POLICY FORM Producer Branch Prefix Policy Number Policy Period ` 018098 970 HPG 270170798-8 from: 12:01 AM standard Time on: 07/04/05 to: 12:01 AM Standard Time on: 07/04/06 Named Insured and Address _ Program Administrator Healthcare Providers Service Organization JAMI MOE HARTMAN 159 East County Line Road 804 11TH AVE Hatboro, PA 19040-1218 GREELEY CO 80631-3246 Medical Specialty: Code: Insurance Provided by Clinical Counselor/LPCC 72990 American Casualty Co. of Reading, PA CNA Plaza 26S Chicago, IL 60685 COVERAGE PARTS LIMITS OF LIABILITY A. PROFESSIONAL LIABILI fY Professional Liability $1,000,000.00 each claim $6,000,000.00 aggregate Good Samaritan Liability Included above Personal Injury Liability Included above Malplacement Liability Included above B. Coverage Extensions License Protection $10,000.00 per •roceedin• $25,000.00 aggregate Defendant Expense Benefit $10,000.00 aggregate Deposition Representation $2,500.00 per deposition $5,000.00 aggregate Assault $10,000.00 per incident $25,000.00 aggregate Medical Payments $2,000.00 per person $100,000.00 aggregate First Aid $2,500.00 aggregate Damage to Property of Others $500.00 •er incident $10,000.00 aggregate C. WORKPLACE LIABILITY Coverage part C. does not apply if Coverage part D. is made part of this policy. Workplace Liability Included in A. Professional Liability Limit shown above Fire and Water Legal Liability Included above subject to $150,000 sub-limit Personal Liability 1 I $1,000,000.00 agqreqate D. GENERAL LIABILITY Coverage part D. does not apply if Coverage pan C. is made part of this policy. Workplace Liability 1 None None Hired Auto & Non Owned Auto None Fire & Water Legal Liability None None Personal Liability i None Total Premium $330.00 Policy forms and endorsements attached at inception QUESTIONS? CALL: 1-800-982-9491 G-1215000 G-1215010 G-121503C G-145184-A G-147292-A G-144872-A G-123846C-05 Healthcare Providers Service Organization is a division of Affinity Insurance Services.Inc.;to NY and Nil,AIS Affinity Insurance Agency;in MN and OK,AIS Affinity Insurance Agency.Inc.,and in CA,AIS Affinity Insurance Agency.Inc.dba Arm Direct Insurance Administrators License#0795;65. Master Policy: 188711433 i N , Keep this document in a safe place. This and 1Cf).Y.4 ‘47-4ill your cancelled check act as proof of coverage. t� Chairman of the Boar Secretary 604 XX 0000099-R 050321 RENHCP 1/05 R1C3NN 05080 ) \ U } © ) § \ 8 co 2 ° }69 \ ; \ CO W ) ° ,a) o ! / i 2o to \ a }S \ / } 7 2 to { ~ co § k k } } § - co M w ) CO = w - - 03 r IC - o ! 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E « N m N N a w� i 0 6F -O W W W W W y�W W W W W W W W 44""""""0000 Z 0 Q»>Y YQ Q»Bp>}Yp»»Z222 Z hp G 0 S }y S�i5 4Y Ars Y y $ * 8 8 0 2. ,A ft:v r, 3 Win- 2 F '.::,aria -C O O 8 - ..✓7 / n/.7 K • K a 6 6 d 6 OW u 6 vo 4'9g It a tti �� 1 0 0 j W °' sF"fY,��9tSit 41X✓` ";, r H K 0. `fi 4,.4.$`u`" ' y e N 2cc Lu m i5/ g n, s u O C a R4 w C z z K w r w > z > Ft u u z W fb' •- ��4 N +'n5 a„ O O o -P - w q 3 ,,,,, r zt r • u of g of O0' Y0./ wa N ,,< 0 0 0 a 0 0 EXHIBIT B SUPPLEMENTAL NARRATIVE TO RFP 1 s •NIle ' • 80411mAvcnuc FAX i*al • Greeley, CO 80881 s v • + . Phone(970)330-1123 see= Y^�_ w. • • FAX(970851-0182 s"• .: Transitions Pacacta cY at u..tic TO: Gloria Romansik FAX# 346-7698 FROM: Jami Moe-Hartman, MA, LPC DATE: 05/19/06 RE: Bids PAGES: 3 COMMENTS: CONFIDENTIAL The information contained in this facsimile message is privileged and confidential information intended for the use of the individual or entity named above. If the reader of this message is not the Intended recipient or the employee or agent responsible to delver it to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If you have received this fay in error, please immediately notify us by telephone and return the original message to us at the above address via the U.S. Postal Service. Thank you. TO 39Vd Z8TBTSE TT:ST 900Z/ET/S0 • • e a-2 804 11th Avenue •. 'e• S.. • Greeley,CO 80631 • e• $ s Tel.(970)336-1123 •• •i *+ FAX(970)351-0182 re• i Transitions NYCIAMoc.cn.LW May 18, 2006 Gloria Romansik, Social Services Administrator Weld County Department of Social Services PO Box A Greeley, CO 80632 RE: Bid # 06LS15 (RFP 05005) Lifeskills Bid #06FPC09 (RFP 006-00A) Foster Parent Consultation Bid # 06HS07 (006-00B) Home Study, Relinquishment Counseling Bid #06MH07 (RFP 006-00) Mental Health Services Dear Ms. Romansik, I am writing in response to Judy Griego's letter concerning the Bid process for PY 2006-2007. Thank you for sending the results of the process; it was helpful to see our bid scores this year. A. Bid # 06MH07 (RFP 000-00) Mental Health Services Transitions agrees to work with the Weld County DSS Business Office to set the rate per episode for completed evaluations. Psychological Evaluation and Assessment Services for Children, Adolescents and Adults: These services will be provided by a licensed eligible psychologist with a PhD who is supervised by a licensed psychologist, or by a licensed psychologist. The billing rate is $282.38/face-to-face client hour. A typical psychological evaluation ranges form 4-6 hours of direct service time. Clients sign a verification form for this time and Transitions bills it at the hourly rate; test materials, scoring, analysis, collateral contacts, case management and report writing time are not pilled. The average rate for a completed evaluation will be $1270.71 Mental Health Evaluations: These services require a minimum of masters degree in the human services field, a minimum of five years' Z0 39Cd Z8T0TSE TI:GT 900Z/61/90 4 , experience, and a mental health license (e.g. Licensed Professional Counselor, Licensed Clinical Social Worker, etc). The Mental Health evaluations are billed at a Mat rate of$212.50 per evaluation. This is based on an hourly rate of$10625 for face-to-face client contact B. Transitions Psychology Group, LLC accept the recommendations as written by the FYC Commission. The Terms and Conditions on the Bid and NOFAA act as a cover sheet to Transitions' written bids. Transitions adheres to all he Terms and Conditions. Transitions accepts all of the conditi ns and recommendations set forth in the Department of Social Services letter dated May 15, 2006. Transitions will include this letter and the letter received from the Department as addendnms to our bids. Transitions confirms that it will provi a the services delineated in Bid#06LS15, Bid #UUF1'C 09, Bid #06HS07, and id #06MH07. If you have any questions about our esponses to the condition and recommendations on the bid, please let us know. We would be more than happy to discuss them with you. Thank you for your consideration. Sincerely, —60VCO-----ivi p>, Jami Moe-Hartman, MA, LPC Co-Director Transitions Psychology Group, LLC I I i 60 39Vd Z8TOTSE ii:9i 900Z/6I/90 a j DEPARTMENT OF SOCIAL SERVICES P.O.BOX A GREELEY, CO. 80632 Website:www.co.weld.co.us WI 'Kit Administration and Public Assistance(970)352-1551 C. Child Support(970)352-6933 COLORADO May 15,2006 Jami Moe-Hartman, Co-owner Transitions Psychology Group, LLC 804 11 Avenue Greeley, CO 80631 Re: Bid#06LS15 (RFP 05005) Lifeskills Bid#06FPC09(RFP 006-00A)Foster Parent Consultation Bid#06HS07 (006-00B) Home Study, Relinquishment Counseling Bid#06MH07 (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 2006-2007 and to request written confirmation from you by Monday, May 22,2006. A. Results of the Bid Process for PY 2006-2007 • The Families, Youth and Children(FYC) Commission recommended approval of your Bid#06LS 14 (RFP#06005), Lifeskills, for inclusion on our vendor list. Your bid scored a total of 98 points out of 100. • The Families, Youth and Children(FYC) Commission recommended approval of your Bid#06FPC09 (RPF 006-00A), Foster Parent Consultation, for inclusion on our vendor list. Your bid scored a total of 100 points. • The Families, Youth and Children(FYC) Commission recommended approval of Bid #06HS07, (RFP 006-00B),Home Studies and Relinquishment Counseling, for inclusion on our vendor list. Your bid scored 87 points. • The Families, Youth and Children(FYC) Commission recommended approval Bid #06MH07 (RFP 006-00)Mental Health Services for inclusion on our vendor list. Your bid scored 98 points. The FYC Commission attached the following conditions and recommendations to your bid. Condition: The bidder will work with the Weld County DSS Business Office to set a rate per episode for completed evaluations. Recommendation: You must clarify the level of expertise or credentials of the staff person who is providing each service. a Page 2 Transitions Psychology Group/Results of RFP Process for 2006-2007 B. Required Response by FYC Bidders Concerning FYC Commission Conditions and Recommendations: 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. Recommendations: You are requested to review the FYC Commission recommendations and to: 1. accept the recommendation(s) as written by the FYC Commission; or 2. request alternatives to the FYC Commission's recommendation(s); or 3. not accept the recommendation(s)of the FYC Commission. Please provide in writing how you will incorporate the recommendation(s)into your bid. If you do not accept the recommendation,please provide written reasons why. All approved recommendations under the NOFAA will be monitored and evaluated by the FYC Commission. The Weld County Department of Social Services is requesting your written response to the FYC Commission's conditions and recommendations. Please respond in writing to Gloria Romansik, Weld County Department of Social Services, P.O. Box A, Greeley, CO, 80632,by Monday,May 22, 2006, close of business. If you have questions concerning the above,please call Gloria Romansik at 352.1551, extension 6230. Sincerely, tkYi n-ego, tocc: Juan Lopez, Chair, FYC Commission Gloria Romansik, Social Services Administrator Weld County Department of Social Services Notification of Financial Assistance Award for Families,Youth and Children Commission(Core)Funds Type of Action Contract Award No. X Initial Award 06-CORE-58 Revision (RFP-FYC-006-00; 06MH09) Contract Award Period Name and Address of Contractor Beginning 06/01/2006 and Individual &Group Therapy Services Ending 05/31/2007 Mental Health Services 1020 8th Street Greeley, CO 80631 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Program provides mental health evaluations, Assistance Award is based upon your Request for couples and family therapy, domestic violence Proposal(RFP). The RFP specifies the scope of evaluation&treatment, evaluation&treatment services and conditions of award. Except where it is of youth in conflict, and therapy for those in conflict with this NOFAA in which case the involved in dependency&neglect cases. Ability NOFAA governs, the RFP upon which this award is to evaluate and treat individuals with high levels based is an integral part of the action. of anti-social traits, as well as anger Special conditions management problems. Services for Domestic 1) Reimbursement for the Unit of Services will be based Violence Offender Management Board approved on an hourly rate per child or per family. clientele, victims of sexual abuse,victims of 2) The hourly rate will be paid for only direct face to domestic violence, children and extended family face contact with the child and/or family, as members who are secondary victims of crimes, evidenced by client-signed verification form, and as including mental health sex offense specific specified in the unit of cost computation. evaluations,psychometric testing, and 3) Unit of service costs cannot exceed the hourly and plethysmograph if necessary. Monthly capacity yearly cost per child and/or family. is 12, total number of clients to be served is 30. 4) Payment will only be remitted on cases open with,and Services in Ft. Lupton, Greeley, Del Camino,the referrals made by the Weld County Department of Department of Corrections and County Social Services. Correctional facilities. 5) Requests for payment must be an original submitted to the Weld County Department of Social Services by the Cost Per Unit of Service end of the 25th calendar day following the end of the Hourly Rate month of service. The provider must submit requests Treatment Package $39.44 for payment on forms approved by Weld County Court Testimony $100.00 Department of Social Services. Enclosures: 6) The Contractor will notify the Department of any X Signed RFP: Exhibit A changes in staff at the time of the change. X Supplemental Narrative to RFP: Exhibit B Recommendation(s) X Co tions of Approval App • Progra Offcial• By By . . J. G ile, Chair Jud . Grier, Direct Board of Weld Co mmissioners Wel County'epartment of Social Services Date: JUN 1` Or0� Date: 6/-31/0 Ip of /o -/6CV, INVITATION TO BID OFF SYSTEM BID 001-06(06005-06011 and 006-00, A, B, & C) DATE: March 1, 2006 BID NO: RFP-FYC-006-00, A, B, & C RETURN BID TO: Pat Persichino, Director of General Services 915 10th Street, P.O. Box 758,Greeley, CO 80632 SUMMARY Request for Proposal (RFP-FYC-006-00, A, B, & C)for: Colorado Family Preservation Act—Mental Health Services Emergency Assistance Program Deadline: March 31, 2006, Friday, 10:00 a.m. The Families,Youth and Children Commission, an advisory commission to Weld County 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, 2006, through May 31, 2007, at specific rates for different types of services. The County will authorize approved providers and rates for services only. The Mental Health Services program provides diagnostic and/or therapeutic services to assist in the development of the family services plan, to assess and/or improve family communication, functioning and relationships. This program announcement consists of five parts, as follows: PART A...Administrative Information PART D...Bidder Response Format PART B...Background, Overview and Goals PART E...Bid Evaluation Process PART C...Statement of Work Delivery Date L1 /02 C C 47 (After re ipt of order) BID MUST BE SIGNED IN INK e, c‘i hal TYPED OR PRINTED SIGNATURE 'i uAi £ CkcJ?Tlieerlry §eevIcE �J� J.J,, " VENDOR 7. Ct r. t j (Name) Handwritten Si naturety A I gn y Authorized Officer or Agent of Vender ADDRESS 'CRC b7.14 TITLE feted Of Ocitz..3 N., DATE iiilygiGlp PHONE# `i 7 6 1 363--$l 1 I The above bid is subject to Terms and Conditions as attached hereto and incorporated. Page 1 of 41 'Bid 001-06 (RFP-FYC-006-00,A,B,& C) Attached A MENTAL HEALTH SERVICES PROGRAM BID PROPOSAL AND REQUEST FOR CONTINUATION OF AWARD UNDER CORE SERVICES FUNDING EMERGENCY ASSISTANCE PROGRAM 2006-2007 BID PROPOSAL APPLICATION PROGRAM FUNDS YEAR 2006-2007 BID 001-06 (006-00,A,B,& C) ii , C '11 �, NAME OF AGENCY: �J INCA tC.A ti,e-1 E r Du.i-E lei/ at) sC;J-v., C< , ADDRESS: ICac STN 9-0„2......± r PHONE(1O 's3 -5111 CONTACT PERSON: Kerr','" e, �• c(r? het I in/1-, t,PC,LJL TITLE: .1) ,e.t-cf;`2 +'CC DESCRIPTION OF EMERGENCY ASSISTANCE PROGRAM CATEGORY: The Mental Health Services program provides for"diagnostic,and/or therapeutic services to assist in the development of the family services plan,to assess and/or improve family communication,functioning. and relationships. (Volume WI,7.303.1,G)" 12-Month approximate Project Dates: _ 12-month contract with actual time lines of: Start June 1,2006 Start•June,' , ,::2c2 4` End May 31, 2007 End x,{ y ;1,L-(s1 TITLE OF PROJECT: .) r 1Cl t v r Gt-I.:C L Cr.,!t ,C' a-> �i 1F� C ?V (,-, c .cc i l t - 3c lc'; 1, ,J L-LtE. ki ivi le, r�"c.t I-1 C4.L'('1-r Pe 60,At n-0 . X, r. `"yL( e'--n/ /t le-6 �3C/C`! Nanf and Signature of Person Preparing Document Date '^)- ' 31 °c c Name and Signature Dire Administrative Officer Applicant Agency Date MANDATORY PROPOSAL REQUIREMENTS For both new bids and renewal bids,please initial to indicate that the following required sections are included in this Proposal for Bid. Li/ Project Description Target/Eligibility Populations Types of services Provided Measurable Outcomes Service Objectives Workload Standards Proof of Collaboration W. Evidenced-based Outcomes Staff Qualifications Unit of Service Rate Computation ✓ , Billing Process i Program Capacity per Month IV Certificate of Insurance Date of Meeting(s)with Social Services Division Supervisor: -3 114 I L'(G Page 29 of 41 03/14/2006 15:43 FAX 9703535215 SOCIAL SERVICES [7j 002 03/14/2006 15:50 9703530371 IGTS PAGE 02'/ ' Bid 001-06(Rl'P-EYC-06010) Attached A Date ot'Meeting(s)with Social Services Division Supervisor. 5 141O(0 -- - - Comments by SSD Sup ,ova err- G ;aped £ to Cf'i�-QrQt�a�p ,dd _ in�ciic4ccat D✓�,t2 �„�� 0` 6 ' aV "� a✓ c� i,.cafnscw I UU w D ✓_tva.Qccca1 >- is 1aceI-c4. _DV 6.ma.tct ( ' I ' . i f)K b a: 9. I a , / E ♦ i /O ., , /. -414./e at-, aJ `bcC 0a fin//U 0- ' t 1 - -• i'GLa2 Ci-tadS c,�p _ 4 n "'At m-0, , if, E'c'.ii.c.Qd0•6k, 7�V a/a Iv ,cS ,.-e- .1W..�cQ-AEted..dwGwa..k 11 n-7 413L "5rv4.�d, OAJ 1: ame and Signature • s • Supervisor 1-)..34i k cc I ocp �er czeoc, d; sL `� `e C� � A„� Yom/! Th 3- I P-vca a 3 - I --_ 062 . \\:::, ��'I ` ��, c�:y)., ' Page 31 of 42 RFP-FYC-006-00 MENTAL HEALTH SERVICES BID PROPOSAL INDIVIDUAL & GROUP THERAPY SERVICES OUTPATIENT TREATMENT PROGRAM I. PROJECT DESCRIPTION Individual & Group Therapy Services (IGTS will utilize a non-medical, cognitive behavioral model, focusing primarily on the treatmen individuals with mental health concerns. This program will include mentalhealth evaluations,c_jples and family ther py,domestic violence evaluation and treatment, evaluation and treatment of youth in conflict, and therapy for those involved in dependency and neglect cases. This program will provide services in Ft. Lupton, Greeley, Del Camino, the Department of Corrections, and County Correctional Facilities when needed. Individual&Groun�Therapy Services has the ability to evaluate and treAt individuals with high levels oil-ant-Ls-ocial traitg, as well as anger management problems. In addition, this program would provide services for Domestic Violence Offender Management Board approved clientele, victims of sexual abuse, victims of domestic violence, as well as children and extended family members who are secondary victims of crime. This program includes performing mental health sex offense specific evaluations, including a battery of psychometric testing, and the penile plethysmograph (if deemed necessary). The mission of Individual &Group Therapy Services is to continue to offer services which reflect our care and interest in our clients, and to provide useful services to the community. By doing so we will: • Provide a structured program and environment for the safety of the client, family, and community. • Increase awareness and empathy for family members, victims, and the community on the impact of the offense. • Foster a family environment to effect positive change. • Develop the use of appropriate cognitive, social, communication, and sexual skills to reduce reactive and concerning behaviors. The Individual & Group Therapy Services outpatient treatment program will treat: • Male and female clients, ages twelve (12) and older. • Individuals with power and control, domestic violence and mental health concerns. • Individuals with developmentally delayed features and those with above average functioning. Program Services for targeted population include: • Mental health sex offense specific testing and evaluation,domestic violence offender management board offense specific evaluation, mental health evaluation • Group and/or individual anger management, and cognitive restructuring • Individual and or family therapy for general mental health concerns • Family education / support groups, general mental health concerns • Victims education of support groups (Pro Bono) • Victim empathy and awareness, general mental health concerns • Anger Management/Impulse control skills • Cognitive behavioral modification • Self esteem building • Values clarification and examination. • Relapse prevention plan for domestic violence clients • After care services for domestic violence and general mental health clients • Relationship and interpersonal social skills for general mental health clients II. TARGET/ELIGIBILITY POPULATIONS Guidelines for conducting general mental health and offense specific groups, as mandated by the Colorado Domestic Violence Offender Management Board, indicates the ideal number of clients should be approximately eight (8) individuals with one facilitator, and up to twelve (12) individuals with co-facilitation. Clients for Individual & Group Therapy Services outpatient treatment program include male and female clients twelve(12) years of age and up. Non-offending partner group therapy is offered weekly for victims of domestic violence free of charge. The children's program,offered in conjunction with the victims' services,education and support programs, range from infancy to the age of twelve (12). This program is co-facilitated by staff members of the Child Advocacy Resource and Education center (CARE), and is offered pro bono. Bilingual services are provided for Spanish speaking clients and their families. This therapist will be available for intakes and will provide individual,family and group therapy for monolingual male and female clients. All intake and group paperwork has been translated into Spanish. Written assessments in the client's primary language will be provided as needed. Bilingual /bicultural services will be limited to twelve (12 ) clients per group. Specific services for bilingual clients includes domestic violence, family therapy, sex offense specific evaluation, and general mental health services. All of the services provided by Individual&Group Therapy Services will include individual, group,and family therapy. With the exception of any services conducted in south Weld County,the services provided will take place at 1020 8th Street, Greeley, Colorado. All eligible Weld County families will need to arrange transportation to the facility. The total number of clients to be served is estimated to be thirty. Total family units are estimate to be a maximum of thirty during the fiscal year. If a facility is made available in the South Weld county area, the number of individuals who will receive services in that area include a minimum of five (5) individuals. Services will include individual, group or family services. The monthly and average maximum program capacity is 12. Average stay in the program varies, depending on the specific entity involved in the individual treatment plan. For individuals referred for domestic violence treatment, the minimum number of weeks in the program would be thirty six (36), as mandated by the Colorado Domestic Violence Offense Management Board. Regarding general mental health services, an individual may attend anywhere from one therapy session to an unlimited amount of therapy services, with an average length in the program of 12 weeks. Clients will need to attend an average of one to two hours per week. The program for youth in conflict would be similar, and would include a treatment plan to involve anywhere from one to an unlimited number of treatment sessions, with the average length in the program of 12 weeks. Emergency services will be available to all clients nights and weekends for clients in crisis. An on-call counselor is available after hours or on weekends to assist clients in dealing with a crisis. III. TYPE OF SERVICES TO BE PROVIDED PSYCHOLOGICAL EVALUATIONS This service is not applicable to this request for funding,as the psychological evaluation and report is to be conducted by a licensed psychologist. Because there is no one meeting these credentials associated with Individual & Group Therapy Services, this section is not being applied for at this time. A. FAMILY/CHILD/ADOLESCENT ASSESSMENT SERVICES To begin a mental health evaluation, an initial appointment is scheduled between the client and the evaluator. In most cases at least one comprehensive clinical/diagnostic interview will occur; however, occasionally two or three sessions will be necessary to accomplish all requirements for a mental health evaluation. The next step of the evaluation process includes a question and answer format designed to gather basic identifying information, mental status examination, the client's mental health issues, mental health history, family and medical history, substance abuse history,inpatient and outpatient history and current social situation. At times, a DSM-IV-T R diagnosis would be applicable and utilized. In addition,treatment recommendations may occur and if so,this recommendation will be in written format at the conclusion of the mental health evaluation. The next stage includes gathering collateral information from agencies noted by the client and/or supervising agency. At times, requests of the supervising agency will be made to assist in gathering collateral data. The last phase of the mental health evaluation includes psychometric testing, which may include any number of the following psychometric instruments: • HARE PCL-R(utilized in cases where psychopathy is to be assessed) • Minnesota Multiphasic Personality Inventory-II (measures personality traits) • Jesness Inventory (measures criminal thinking) • Multiphasic Sex Inventory (measures sexual knowledge, behaviors, attitudes, and beliefs) • Wilson Sex Fantasy Questionnaire (measures frequency of fantasies to various stimuli) • SASSI-III drug and alcohol inventory • Millon Clinical Multiaxial Inventory-III (measures personality traits) • Shipley Institute of Living Scales (measures intelligence) • State Trait Angry Inventory-II (measures level/control over anger) • Violence risk assessment guide (measures level of risk) After all phases of the mental health evaluation have been completed, the evaluator then combines all of the information from the clinical interview, collateral data, and testing summaries in order to ascertain the client's amenability for treatment. A written report is submitted to the appropriate caseworker outlining recommendations for treatment. Individual counseling includes one client and one therapist. Group counseling would include one therapist and two or more clients. It is a policy of Individual&Group Therapy Services to limit the ratio to one therapist per eight clients in must group scenarios,with the exception of educational settings. Family counseling will include at least one therapist, and at times may include a second therapist. In addition, at least one client and one or more family members will attend a family counseling session. All therapists establish a treatment plan, either at the conclusion of the evaluation process, or at the conclusion at the intake session. A standard treatment plan with Individual & Group Therapy Services will include: • Short or long term goals. • Measurable objectives relating to the achievement of the established goals. • Type and frequency of services the client will be receiving. • Specific criteria for treatment completion. • Anticipated time frame. • Follow up services. The therapist will document treatment plan reviews which will occur oximate every 30 days that will include the continued date for treatment. Monthly progress reports will be provided to the referring agency to inform caseworkers on clients' progress. At the conclusion of services received by a client of Individual &Group Therapy Services, a discharge summary will be submitted within fifteen (15) days of treatment termination. A standard discharge summary will include the reason the client is being discharged,treatment history with Individual & Group Therapy Services, progress or lack of progress following the care of Individual&Group Therapy Services, and any recommendations made for future care. In the case of clients of domestic violence, risk to the community will also be included. The discharge summary will clearly delineate the client's status at discharge, which may include a successful, administrative, or negative discharge. Results of the evaluation will be provided to the client, if requested, by scheduling an appointment with the evaluator. This appointment is free of charge, and will consist of reviewing their children. Children that appear to be in abusive homes will be reported to Weld Social Services as soon as possible. Outcome S2: Children are safely maintained in their homes whenever possible and appropriate. IGTS employs a victim's advocate who periodically contacts victims and offers assistance as needed. Every effort is made to contact victims when the offender is not at home in an effort to allow those persons to speak freely about safety in the home for themselves and their children. Victims who are feeling unsafe in the home will be given resources in the community where they and the children can be safe until a permanent solution can be arranged. Outcome P1: Children have permanency and stability in their living situation. IGTS provides care for offenders to assist them in developing healthier and non-abusive relationships with their partners and children. Clients have 24 hour availability to contact an on-call therapist for assistance should they feel they are placing their children in an unsafe environment. Outcome P2: The continuity of family relationships and connections is preserved for children. Abusive clients of IGTS are encouraged to complete family therapy upon completion of domestic violence treatment. Outcome WBl: Families have enhanced capacity to provide for their children's needs. A portion of client care is devoted to becoming healthier parents for their children. Some clients are referred to complete parenting classes if further education is warranted. VI. WORKLOAD STANDARDS A. Number of hours per day/week/month: Day maximum of two hours Week maximum four hours Month maximum 16 hours B. Number of individuals providing treatment: Seven group/individual /family therapists, all qualified to facilitate in these areas. C. Maximum case load per worker: twenty (20). D. Modality of treatment will be ognitive behavioral and will include group, individual, and family therapy. E. See A above F. Total number of individuals providing services: seven (7) G. Maximum case load per supervisor: twenty five (25) Total of two supervisors. H. Total completed assessments per month: 10 I. See enclosed insurance agreement VII. PROOF OF COLLABORATION Individual and Group Therapy Services is committed to locating assistance in the community for clients in need of additional services outside the treatment scope. Victims of domestic violence are referred to victim advocates in the community. In addition,IGTS provides pro bono treatment to victims of domestic violence. Victims in need of funding for individual therapy are assisted in completing Victim Compensation forms, which will provide funding for victims in certain situations. Offenders needing financial assistance and are currently underemployed or unemployed are often provided the results of the evaluation with the client. B. CONSULTATION WITH CASEWORKERS Clinical consultation will include an individual or group session with the Department of Social Services to discuss mental health supervision issues for the purpose of aiding and identification of offender problems and treatment issues. This may include a review of pre-sentence reports,prior psychological reports,and other existing information to identify the need for continued mental health services. When applicable, a written report will be submitted,which will include the mental status of the client, diagnostic impression, current psycho-social stressors, and obvious indicators of decompensation, recommended treatment activities, and report or records analysis. Evaluations and recommendations will take the overall plan for Social Services into consideration. Clients who are identified as suicidal or homicidal will be released to Northern Colorado Medical Center in Greeley, Colorado for further assessment of their safety in the community. Appropriate social services personnel will be notified of any concerns regarding client safety. C. COURT TESTIMONY The staff of Individual & Group Therapy Services are qualified and experienced in court testimony. When given proper notification, Individual & Group Therapy Services is available for court testimony regarding clients with open and/or closed cases. IV. MEASURABLE OUTCOMES Clients referred from Social Services will be scheduled for the appropriate assessment as soon as collateral information is sent. The collateral information is essential to help clinicians determine the appropriate service objective. As soon as the evaluation is completed,the appropriate caseworker will be notified about recommendations regarding treatment. Recommendations will clearly delineate the type and length of treatment needed for court purposes. At a minimum,contacts will be made at least monthly in regard to client progress. However, caseworkers will be notified immediately if any situation exists that affects the progress of the client, such as absences or failure to progress. For emergency consultations, a therapist is available by pager if a client needs after hours services. The client can be scheduled for an emergency appointment with their therapist,or if their therapist is unavailable, with the on-call therapist. Upon completion of a mental health program, clients should be able to demonstrate the following behaviors: • Consistently defined all the abuse all the time to themself, to others, and property. • Acknowledges risk in the future, andAemonstrates the ability for safety planning. • Consistently recognizes and interrupts their domestic violence cycle, anger management cycle, and general recidivism cycle. • The interruptions will take place no later than the first thought of an abusive solution. • Demonstrates new coping skills. • Demonstrates empathy and views the cues of others and responds. • Displays accurate attribution of responsibility and does not try to control the behaviors of others. • Able to manage frustration and unfavorable events in reference to anger management and self protection. • Rejects abusive thoughts as dissident and incongruent with self image. • Demonstrates pro-social relationship skills, such as closeness, trust, and trustworthiness. • Projects positive self image. • Demonstrates the ability to resolve conflict and make decisions through assertive communication, tolerance, forgiveness, cooperation, and is able to negotiate and compromise. • Celebrates good, experiences pleasure, and is able to relax and socialize. • Works toward achieving delayed gratification and is persistent in the pursuit of goals and submissive to reasonable authority. • Able to think and communicate effectively through rational cognitive processing, demonstrate adequate verbal skills, and is able to concentrate. • Has developed a family and or community support system. • Adapts a sense of purpose and future. Tracking progress through the program will take place in the following manner: • Clients attending group therapy will receive feedback weekly from their therapist in the form of a"group note." The purpose of the group note is to monitor progress on treatment goals.Group notes will be compiled by the therapist after each group. The therapist will evaluate whether the client is learning during group sessions. Feedback will be provided to help the individual obtain maximum benefit from their treatment modality. • Staff will also discuss the progress of the individual and indicate whether or not he or she is on track. • A compilation of these reports will be available to the Department of Social Services on a monthly basis, or as requested. • Progress in a computerized system will be made upon each contact with this agency by any one on the multi-disciplinary team, Department of Social Services caseworker,the client, or those who have been granted permission to associate with Individual & Group Therapy Services from the client. • For family therapy sessions,those of authority will be asked to report on the child's progress in the home. • Parents and therapists will evaluate the youth's progress on a monthly basis by verbally testing to see if they understand the concepts being taught, and can demonstrate the use of concepts learned in their home environment. • When appropriate, schools, employment sites, and additional family members can be contacted on a regular basis to monitor behavior in those environments. • With regard to general mental health issues, the caseworker will be contacted any time a team meeting involving the client is needed. These meetings should take place in the therapeutic environment most comfortable for the client. • Clients will be required to complete therapy assignments in group or individual treatment. These assignments will be part of the requirements to complete therapy successfully. • In many of the programs, clients are required to complete a relapse prevention plan designed to illustrate how they plan to avoid this situation in the future. V. SERVICE OBJECTIVES The primary objective of Individual & Group Therapy Services is to offer services that reflect our care and interest in our clients, and to provide useful services to the community. By doing so we will: A. Improve family conflict management: Family members will learn to talk about their underlying feelings resulting in anger, conflict, and their personal environments, impulse control, and general feelings of dysphoria. Family culture will be explored, and family members and the individual will learn to develop a relapse plan, implement constructive discipline, improve communication, and develop problem solving skills. Progress will be measured by successful completion of homework assignments, as well as the ability to demonstrate the concepts learned in therapy in the home. B. Improve Household Management Competency: With regard to youth specifically, parents will initially be assessed to determine their level of parenting skills. Parents will be offered parent education to increase their skilllevel. In addition,parents will be monitored weekly in family therapy to check on behaviors occurring at home, and help parents to understand"red flags,"which will indicate potential problem areas regarding safety in the home. Where appropriate, a referral will be made for parenting classes if the parenting issues cannot be resolved in this format. Progress will be measured by verbal demonstration of understanding of the concepts, successful completion of homework assignments, and participation in family discussion. C. Improve ability to access resources: Part of treatment will include what resources an individual will need to have successful transition from the therapeutic environment into a self managed environment.Therapists,family members,the Department of Social Services caseworker, and other involved parties will assess what resources are needed and will assist family members and individuals in locating the resources as they are identified. Progress will be measured by successful follow through by the individual. D. Specific Referral Issues: IGTS uses solution-focused therapy as its primary treatment modality. Clients will focus on issues as directed by the Department of Social Services. E. Improve Outcomes in the Performance Improvement Plan (PIP): IGTS supports the Colorado Department of Human Services in developing and implementing the Program Improvement Plan. IGTS can assist with supporting the following goals of the PIP: Outcome SI: Children arefirsi andforemostprotectedfrom abuse and neglect. IGTS assists with this goal by contacting victims of domestic violence and offering pro bono services to them and r ' assistance by Weld County Probation or the Department of Corrections. Clients will be requested to fill out a release of information allowing contact with involved parties, including social services, other treatment providers, copies of previously completed evaluations and any other pertinent information. Therapists will be available to attend or provide reports for the Placement Review Team meeting as requested. Staffings will be setup on an as needed basis. Therapists will be available to attend staffings for clients as requested, or the therapist will request a staffing if the client's current situation warrants it. Staffings will be conducted at a minimum of every quarter. Every attempt will be made to include all involved parties. Aftercare services are available for all clients. If a client has successfully completed treatment, they are encouraged to return to or continue with groups if they feel the need for continued support. Fees for these clients are significantly reduced. In addition, clients are often stepped down from treatment by gradually decreasing the frequency of visits to allow continued support at a lower level. Clients will also be referred to community support programs as needed. Mental health clients with Medicaid coverage will be referred to Nelson, Wolf and Associates,as they are Medicaid providers. Medicaid will not pay for domestic violence and/or sex offender treatment. For further information, please refer to the Appendix. VIII. EVIDENCE-BASED OUTCOMES Therapy provided by Individual and Group Therapy Services follows the recommendations of the Colorado Sex Offender Management Board (SOMB) and the Colorado Domestic Violence Management Board(DVOMB). Research conducted by these organizations indicates that treatment is best delivered in a cognitive behavioral format, combining education and therapy components. In most situations, therapy is delivered in a group format. For domestic violence offenders, research by the DVOMB indicates group attendance is expected to last at least 36 weeks. For high risk offenders, additional group and/or individual therapy may be recommended. Treatment for sex offenders can be expected to last a minimum of 24 months. The DVOMB and SOMB also regulate how evaluations shall be conducted. At a minimum, the DVOMB requires a post-sentence intake evaluation be conducted. Concerns regarding the offender's level of risk may result in a full domestic violence evaluation. The SOMB requires that a full evaluation be completed on each offender prior to sentencing. In both cases,the level of risk to reoffend shall be addressed. Sex offenders denying their offense will be treated on an individual basis for a maximum of six months. Continuation of denial will result in being referred back to the original referral source as not treatable. Domestic violence deniers will attend individual therapy to help break down denial or will be referred to anger management groups to assist in reducing their frequency and intensity of anger outbursts. For samples of an assessment,treatment plan,transition plan,request to renew and a monthly report, please refer to the Appendix. IX. STAFF QUALIFICATIONS A. The Individual & Group Therapy Services mental health outpatient treatment program will meet or exceed the minimal qualifications in education and experience. Services will be provided by seven (7) Masters level counselors who have met the standards of practice to perform mental health intake assessments and reports, as established by the State of Colorado Department of Regulatory Agencies. Three therapists are Licensed Professional Counselors for the State of Colorado and one therapist is a Licensed Clinical Social Worker. In addition, two therapists have completed the requirements to provide domestic violence treatment by the Colorado Domestic Violence Offender Management Board and four therapists have completed credentials to provide treatment through by Colorado Sex Offender Management Board. The remaining therapists have completed all course work requirements and are under the direct supervision of a licensed Masters level psychotherapist,Kim R. Ruybal,MA,LPC,NCAC II. All practitioners who are not licensed with the state of Colorado are listed with the Department of Regulatory Agencies in the non-licensed data base. B. Total staff available for the project= seven, including two supervisors. C. Individual and Group Therapy Service employees are not required to attend mandated new caseworker training. D. All therapists at Individual and Group Therapy Services have received extensive risk assessment training through various workshops provided by the Colorado Domestic Violence and Sex Offender Boards. X. UNIT OF SERVICE RATE COMPUTATION= $39.44 per hour XI. BILLING PROCESS Billing occurs once a month. Bills are generated at the beginning of each month, with the bills being sent out to each individual agency by the 5th day of each month. The billing program generates the payments and session for each month, with past balances included. Each bill is counter checked with the funding form to ensure the appropriate sessions are being billed for and the total funds approved matches the sessions being billed. A copy is made for the agency. The enclosed sample billing illustrates the process. XIII. PROGRAM CAPACITY BY MONTH Minimum capacity: 1 Maximum capacity: 30 January 1, 2006 Weld County Department of Social Services Attn: Caseworker P. O. Box A Greeley, Colorado 80632 RE: Joe No Name DOB: 01/01/1970 SSN: 555-55-55555 Education Level: 1 Grade Referral Date: January 1, 2006 Assessed by: Alyx McGuire, MA DVOMB Evaluator and Treatment Provider SOMB Evaluator and Treatment Provider Kim R. Ruybal, MA, LPC,NCAC II DVOMB Supervisor, Evaluator and Treatment Provider SOMB Evaluator and Treatment Provider Assessment Date(s): Initial Intake Assessment: Formal Clinical Interview: Psychometric Testing: MENTAL HEALTH DOMESTIC VIOLENCE EVALUATION Dear Caseworker: Mr. Joe No Name was initially referred to Individual&Group Therapy Services(IGTS)for the purpose of completing an intake assessment to determine his appropriateness for group treatment in a Domestic Violence Treatment Program. After two (2) canceled appointments, he completed the intake assessment on November 15,2004. He was found to be marginally appropriate for group treatment and was placed on a ninety(90) day Program Probation Contract, which required him to attend each session and remain financially responsible for the duration of the probationary period. During the course of his treatment, Mr. No Name missed a total of four(4) non medical absences. He completed nine (9) group sessions. Mr. No Name was negatively discharged from his domestic violence treatment program on February 22,2005,due to violations of his treatment contract and terms and conditions of probation. He did so by accumulating excessive absences and being arrested for allegedly committing another domestic violence offense against the same victim. In the discharge summary, Mr. No Name was recommended to complete a Full Domestic Violence Evaluation. The purpose of this evaluation is to explore possible psychological issues related to relapse, to assess risk to the community and to determine personality traits, which may be contributing to his tendencies toward power and control and violence. This is not a full psychological evaluation. PROCEDURES: Intake Assessment Clinical Interview Shipley Institute of Living Scale Minnesota Multiaxial Personality Inventory-II (MMPI-II) SASSI-3 - Drug and Alcohol Inventory Jesness Inventory State-Trait Anger Inventory-2 (STAXI-2) The Hare Psychopathy Checklist-Revised (Hare PCL-R) Violence Risk Assessment Guide (VRAG) Review of Collateral Information Domestic Violence Screening Instrument (DVSI), Weld County, Conditions of Probation Greeley Police Department, Incident Report Greeley Police Department Incident Report Criminal History Report, Dated 07/11/05 Spousal Assault Risk Assessment Guide (SARA) MENTAL STATUS: Mr. No Name was interviewed at IGTS. He was dressed appropriately for the perspective weather conditions and was moderately cooperative throughout the evaluation process. Mr. No Name was oriented to person, place, and time of day. He was explained the process of the evaluation he would be participating in. He expressed an understanding of the procedures by his signature on various documents. The documents included the Consent for Release of Confidential Information and the Disclosure Statement. INSTANT OFFENSE: In a review of collateral information, it is noted Mr. No Name was first arrested for Harassment-Strike/Shove/Kick(M-3)against his wife of fourteen(14)years. He pled guilty and was sentenced to eighteen (18) month's Probation. He was to pay court costs and participate in a Domestic Violence Intake Evaluation. 3 • According to the police report, the victim stated prior to the instant offense, she and Mr. No Name were having marital problems. On the day in question, she informed Mr. No Name came home and she believed he was intoxicated. She stated she did not want him driving while intoxicated, so she took his car keys away from him. She reported Mr. No Name began struggling with her to get the keys back. The police report indicated their seven(7)year old son was present at the time of the offense. When questioned,the son reported witnessing the assault. He stated he heard his mom tell his dad, "stop pinching me." He remembered his dad told him he was "just playing." When officers contacted Mr. No Name at his place of business, they noted a distinct odor of alcohol,his eyes were bloodshot and watery,and his speech was slurred. When informed of why he was under arrest, Mr.No Name responded, "Does she have any marks?Can you prove it?" The report noted Mr. No Name then proceeded to spit on the officer's patrol vehicle and called the officers profane names. The officers wrote he remained uncooperative during the transport to jail. In the second offense,Mr.No Name again assaulted his wife. According to the police report, the victim stated after arguing over personal property,Mr. No Name allegedly shoved her, causing her to fall and hit her back on the coffee table in the living room. She reported a witness observed Mr. No Name shove her. The witness stated Mr. No Name stood over the victim"cussing her out." He then placed the victim on the couch;when she attempted to contact the police,he took the phone from her. CLINICAL INTERVIEW: During the initial intake assessment,Mr.No Name was asked to describe his behavior in the instant offense. He was guarded and vague when answering. He eventually stated him and his wife had been married fifteen (15) years (a noted discrepancy from the police reports) and two (2) children were born to this union.He informed on the night of the instant offense he went home after work and began talking with his wife. They were"joking around,"and he"poked her on her chest." He recalled he left and went to eat and returned to work. He admitted he drank a beer after the incident and was arrested later that day. When asked to describe the second offense, Mr. Prince was again guarded and vague. He informed his wife and he had been in verbal arguments involving his jealousy. He said "only one time did it get physical, toward the end," and "I didn't punch her or anything." On the day of the offense,he stated he and his wife were again arguing.He said they were in the garage and the victim tried to leave,he then tripped over a toy and"fell down."In order to catch his balance he"grabbed hold of her and ripped her pant leg." He also informed his oldest son was present at the time. Mr. No Name appeared to be a poor historian, as his accounts of the domestic violence incidents were inconsistent with both police reports. In addition, his prior accounting during the initial intake assessment deviated from his statements in this evaluation. When asked what kind of effect his current charges would have on his life,he reported"no effect." When asked who was to blame for his offenses, Mr. No Name reported they "both are to 4 blame." In regard to what he could have done to avoid committing the offense, he stated "I could have just let her leave."He did regret his behavior and again stated he wished he had walked away or let her leave. Mr. No Name was unable to articulate how his crimes had affected his wife and son. BRIEF SOCIAL HISTORY: Mr. No Name is the youngest child born in his family. He reported he has one (1) older brother. Mr. No Name'parents were divorced when he was seven(7)year's old. He initially lived with his father after the divorce, until the age of fourteen (14) when he moved in with his mother. He reported he did not know why his parents divorced because he saw them "getting along"most of the time. Mr. No Name indicated he got along "good" with his brother and parents. He reported the rules in his home were strict with weekly chores and curfews.He remembered his consequences for rule infractions included being grounded,having additional household chores,loss of privileges,and doing homework. He noted these dynamics remained the same after the divorce no matter which home he lived in. Mr. No Name did not witness physical, emotional, or sexual violence between his parents and denied ever being abused as a child. He indicated no members of his family have serious mental or physical problems nor do they suffer from alcohol or drug addiction. Mr.No Name attended one(1)elementary school and two(2)secondary schools.His grades were average and he reported his attendance was"good,"as he only ditched school once, on the last day of school. He liked school and reported having"close friends." Mr. No Name denied cheating or stealing in school, and reported he was suspended one (1) time in high school, for bringing chewing tobacco to school. Mr.No Name informed he completed the eleventh(11th) grade and quit school to get married. He wanted to begin working to support his family. He stated, "I didn't think I needed it (an education) for my job as a truck driver." After leaving high school,Mr.No Name began working in his chosen field as a truck driver. He reported having a full-time job consistently since he was sixteen (16) years old. He indicated he has driven trucks his whole life and was a mechanic on the side. He explained"I was born with a wrench and steering wheel in my hand." Regarding his work ethic, Mr. No Name described himself as "easy going, a hard-working employee who is an asset to a company" and denied ever getting in trouble at work, or being fired. He denied leaving a job without another job lined up, and stated he does not"burn bridges." He denied ever being unemployed or collecting unemployment insurance. He stated he collected workman's compensation one (1) time when he was injured on the job. Mr. No Name reported his career goals and aspirations are to continue in his chosen field, driving a truck.He stated,"I am happy with where I am." He could not think of anything that would interfere in achieving his goals. 5 Regarding financial responsibility, Mr. No Name indicated he has had approximately two (2)bank loans or personal loans, and has paid them in full. He indicated he is currently required to pay court ordered child support.He fell behind in the beginning,but reported he is currently caught up. There were no indicators of financial irresponsibility noted throughout collateral data. Mr. No Name did not report any serious medical problems. He denied ever seeing a counselor, psychologist or psychiatrist, other than when he attempted domestic violence treatment with IGTS. He also denied suicidal ideation or ever attempting to commit suicide. He denied ever being prescribed medication for emotional disturbances. Mr. No Name indicated he has engaged in two (2) significant relationships, one live-in and one marriage.He has been involved in his current relationship for six(6)months.No children were born to this union. He reported his current relationship is "good," and he has no plans to marry. When asked if he has ever been deeply in love, Mr.No Name replied, "Yes, with my ex-wife. You can't help who you love." Mr. No Name has two (2) children with his ex-wife, the victim in both offenses. He indicated his ex-wife has custody and he sees them every other weekend. He noted he has a"great" relationship with his sons. Mr. No Name informed his marriage to first wife ended due to jealousy issues and increased arguments.He noted the relationship became physically violent toward the end. Before this,their relationship was"stable,"for the most part,and he"liked her personality." He did not feel he was "100% over the relationship." Mr. No Name indicated he was seventeen(17)years old when he engaged in his first sexual relationship. He believed he has been sexually intimate with a total of two (2) partners. He denied ever being unfaithful or having multiple relationships at the same time. Regarding Mr.No Name's substance abuse history,he reported beginning the use of alcohol at the age of twenty-one(21) and continued use on a frequent basis. He noted alcohol use weekly and denied experiencing any life disruptions due to his use. He stated he"never abuses"substances and reported alcohol "never interfered" in his life, in spite of evidence to the contrary. Mr. No Name indicated his drug use consisted of trying cocaine one time after his divorce over a year ago. He denied any other drug use or abuse. As a juvenile,Mr.No Name denied being involved in physical altercations or doing anything rowdy outside of school. He stated when he was l for twelve 12, he was spray painting and left a dusting on a car which was an accident. He informed he received probation for his efforts. Mr. No Name reported one (1)prior Domestic Violence conviction(the initial offense) and one(1) Assault charge against the same victim, which was set for a jury trial. It should be noted he pleaded guilty to the Assault charge and was sentenced to probation. His formal criminal history is consistent with his self-report and did not indicate any further prior arrests or convictions. Mr. No Name reported having approximately twelve (12) close friends who he keeps in contact with. He reported feeling"good"about himself and had an average self-image. He said he was satisfied with his life so far and could always work on his relationship with his ex-wife. Mr. 6 No Name stated the most depressed he has ever been was when he divorced this past year. When asked about the happiest he has ever been, he stated when his kids were born. PSYCHOLOGICAL FINDINGS: Mr.No Name was referred for psychometric screening to aid in treatment planning and this assessment. To that end, Mr. No Name completed a battery of psychological tests including the Shipley Institute of Living Scales,SASSI-III,State-Trait Anger Inventory-2(STAXI-2),the Jesness Inventory, and the Minnesota Multiaxial Personality Inventory-II (MMPI-II). The following test findings are based on Mr. No Name's responses to widely used standardized psychological tests. These tests were designed primarily for diagnosis and treatment planning purposes. The findings below focus on problems, deficits and pathology and may de-emphasize Mr. No Name's strengths. As with all such tests,the validity of test results is limited by Mr.No Name's honesty and self-awareness. The following report should be taken as generalized probability statements. The test results are suggestive of the following: Shipley Institute of Living Scales: Mr. No Name's performance on the Shipley suggests he is functioning in the low average range of estimated intelligence. He appears to have low general intelligence as measured by vocabulary skills and abstract reasoning skills. He may also suffer from some type of intellectual impairment. If he is experiencing learning difficulties, a more through intelligence test could help to determine the nature and possible cause of the difficulties, as well as aid in developing a plan to address the issue. SASSI-III: Mr.No Name's performance on the SASSI suggests that he has a low probability of having a substance dependence disorder. STAXI-2: Mr. No Name's performance on the STAXI suggests that his expression of anger is not interfering with his optimal level of functioning. Jesness Inventory: Mr.No Name's performance on the Jesness suggests that he holds attitudes and beliefs that are more common among people of a younger age group. He may tend to deny feelings and psychological issues to himself and to others. Minnesota Multiaxial Personality Inventory-2: Mr. No Name's performance on the MMPI-2 suggests that he likely has significant denial about psychological issues. He may also have attempted to create an extremely favorable impression of himself Due to his response style, it is likely an under representation of his true psychological make up. He is probably not experiencing any type of emotional distress despite his physical symptoms. He is likely to be calm, happy,and interested in his daily life. His feelings are 7 probably not easily hurt. He is not likely to spend much energy trying to understand his or anyone else's psychological reactions. It is reported he is generally fearful and afraid. Integrated Summary: Mr. No Name's performance on the testing battery suggests low average intelligence with possible intellectual impairment. He attempted to manipulate testing by presenting himself in the best light possible. He is probably immature. He is reporting fearfulness and several physical symptoms. OFFENSE SPECIFIC TESTING The Hare Psychopathy Checklist-Revised (PCL-R) The Hare Psychopathy Checklist-Revised (PCL-R) was used as an adjunct to the other assessment instruments utilized in this assessment. The PCL-R provides a scoring system for the evaluator to rate items based upon information gained through the Clinical Interview and the case file of the respondent. For further information, please refer to the Appendix. Total Score 41.0 % Factor 1 51.0 % Factor 2 38.0 % Mr. No Name's Total Score does not indicate psychopathic personality traits. However, it does support a moderate trend toward antisocial features. RISK ASSESSMENT: Domestic Violence Screening Instrument (DVSI): Collateral data indicated Mr. No Name scored at moderate to high risk due to two (2) or fewer prior non domestic violence convictions,two(2)or more prior arrests for assault,harassment, or menacing, history of domestic violence related restraining orders, children being present during the domestic violence incident,being unemployed,the victim having a restraining order at the time of the offense, and the defendant being under community supervision at the time of the offense. Spousal Assault Risk Assessment Guide (SARA) Collateral data indicated Mr. No Name scored at moderate too high for imminent risk of violence toward his partner, and moderate imminent risk of violence toward others. Violence Risk Assessment Guide (VRAG): The VRAG is an actuarial instrument designed to estimate the probability for reoffense in a violent fashion. Mr. No Name scored in the low range for the propensity for violent recidivism. DISCUSSION: Mr. No Name is currently on probation for his second domestic violence conviction. He takes minimal responsibility for both offenses and has little insight into the effects of his violent 8 behaviors on his wife and son. He continues to minimize and justify his violent behaviors by victim blaming and justifying. Mr. No Name was moderately cooperative throughout the intake and evaluation process. While in domestic violence treatment,he continued victim blaming and justification of his offense, his participation was minimal and he failed to progress during the time he was in treatment. Despite some prior treatment, he continued to act in a violent and aggressive manor. Testing indicates he attempted to portray himself in the best possible light. It appears he is of low to average intelligence, and may suffer from some form of intellectual impairment, which should be explored further. It appears Mr. No Name does not have any overt psychological issues. His risk for recidivism in a power and controlling fashion is moderate. His personality traits are such that he would likely benefit from treatment if monitored closely and held to strict rules and guidelines. Mr. No Name minimizes his offenses, justifies his behaviors, and blames the victim which may contribute to his increased tendencies toward power and control and violence. Mr. No Name failed to progress in prior treatment;however,his testing indicted a low to average intelligence level which may be a contributing factor in his lack of participation and growth. This should be taken into consideration in a future therapy setting. Given the above noted information the following recommendations are made: RECOMMENDATIONS: 1. Mr. No Name is found to be marginally appropriate for a domestic violence treatment program. He is recommended to participate in open-ended treatment. He should be placed on a ninety (90) day Program Probation Contract which requires continual attendance and payment. Failure to pay or attend group sessions for any reason,other than a medical emergency should result in termination with swift and immediate consequences to follow. 2.Mr. No Name is recommended to participate in a medical examination to further explore his physical complaints reported in the testing battery. 3. Mr. No Name is recommended to participate in parenting classes to further address the effects of his violence on his children. 4. Mr.No Name is recommended to participate in weekly random urine analysis and breath analyses to maintain sobriety while under supervision. 9 If there are further questions or concerns, please feel free to contact this agency. Respectfully submitted, Alyx McGuire, MA DVOMB Evaluator and Treatment Provider Supervised by, Kim R. Ruybal, MA, LPC,NCAC II DVOMB Evaluator and Treatment Provider 10 APPENDIX PSYCH SCREEN This is an assessment battery that utilizes valid, reliable, standardized objective psychological tests which together evaluate a broad range of vital factors that include cognitive processing, mental health symptoms, underlying personality patterns/dynamics, emotional functioning (including anger and impulse control), criminal characteristics and motivations,thinking errors,substance use patterns/characteristics, and normal and deviant sexual functioning. Shipley Institute of Living Scale This instrument measures both vocabulary (an index of prior learning that is not easily affected by organisity) and verbal abstract reasoning(a measure of present information processing that is sensitive to organic damage). The Shipley can help determine if organic brain damage exists, as well as detect possible learning disorders. Reasoning ability and learning disorders are vital for determining program needs,as well as a client's potential for benefitting from verbal interventions. The Substance Abuse Subtle Screening Inventory-3 (SASSI-3) This instrument is designed to detect addiction even in resistant clients. Based on empirical data, the SASSI-3 not only measures reported substance use, but more importantly, detects personality and social system characteristics that research has shown to be disproportionally present in addicted individuals. This includes subtle characteristics that are not easily predicted and so are harder to fake. Levels of present exposure to systems that use alcohol are identified by the SASSI-3 and may prove important to rehabilitative efforts. Additionally, the SASSI-3 sub-scales provide clinically useful information regarding the client's attitude toward the assessment, defensiveness, emotional pain, ability to acknowledge problems, and risk of legal problems. Jesness Inventory Normed for both adolescents and adults, the Jesness Inventory assesses characteristics and thought patterns common to offenders such as social immaturity,knowledge of social rules, asocial values, and levels of authority conflicts. Most important, the Jesness Inventory suggests the most likely motivations behind criminal behavior. The Minnesota Multiaxial Personality Inventory-II (MMPI-II) The MMPI-II is a useful psychological test for assessing the degree and nature of emotional upset. It is designed to assess some major personality characteristics that affect personal and social adjustments. It is a very reliable and valid instrument for assessing psychological and/or emotional disturbance. It can also be a valuable assessment tool for investigating emotional components of physical disease. 11 • The State-Trait Anger Expression Inventory-2 (STAXI-2) The State-Trait Anger Expression Inventory (STAXI; Spielberge, 1988) provides concise measures of the experience,expression,and control of anger. The STAXI-2 was developed for two (2)primary reasons: (a) to assess components of anger for detailed evaluations of normal and abnormal personality,and(b)to provide a means of measuring the contributions of various components of anger to developments of medical conditions, particularly hypertension, coronary heart conditions, and cancer. The STAXI-2 consists of fifty-seven(57)items,with six(6) scales, five(5)sub-scales, and an Anger Expression Index,which provides an overall measure of the expression and control of anger. OFFENSE SPECIFIC TESTING The HARE Psychopathy Checklist - Revised (HARE PCL-R) The Hare Psychopathy Checklist-Revised (PCL-R) is used as an adjunct to the other assessment instruments utilized in this assessment. The PCL-R provides a scoring system for the evaluator to rate items based upon information gained through the clinical interview and the case file of the respondent. The PCL-R is used for and purported to be a relevant instrument for use with male prison and forensic populations. The construct of Psychopathy refers to a pattern of interpersonal,affective,and behavioral symptoms. The rating for Total Score is an overall representation of the combination of Factors 1 and 2 for the construct of Psychopathy. Factor 1 descriptors include: Glibness and superficial charm, grandiosity, pathological lying, conning and manipulating, lack of remorse and guilt, shallow affect, callousness and a lack of empathy, and a failure to accept responsibility for one's own actions. Alternatively,Factor-2 descriptors include:Need for stimulation,parasitic lifestyle, poor behavioral controls, early behavior problems, lack of realistic goals, impulsivity, irresponsibility,juvenile delinquency and revocations of supervised release. Research has indicated that sexual offenders with high scores on this instrument are at greater risk for recividism than offenders with lower scores. A score of 89% out of a possible 100% is usually used as the cut off score to indicate the presence of significant and serious psychopathic personality traits. This indicates only 11%of the male forensic clients display the highest degrees of antisocial traits. ASSESSMENT OF RISK Risk assessment is a very important part of evaluating, treating, and supervising offenders. To that end, risk assessment instruments have been constructed to better assess the likelihood of general recidivism. While it is not possible to predict the behavior of any one person, a large body of research has determined there are a number of risk factors which have been empirically validated (both static and dynamic) which can yield a useful prediction of the likelihood of recidivism. Below is a brief description of one (1) risk assessment instrument used in this assessment which has been shown to be valuable a tool for the purpose of evaluating and managing offenders. 12 Violence Risk Appraisal Guide (VRAG) The VRAG is among the most accurate risk measures for general violence. However,it does not assess the risk for sexual recidivism. (Hanson, 2000). 13 Individual and Group Therapy Services Intake Assessment Outline 1. Name: Date: DOB/AGE: / Gender: Male Female Race/Ethnicity: Current Legal Status: Probation Intervention Parole Unsupervised Current Case Number Restraining Order(s) County where charges filed: 2. Current Offense: Current charge: Plea bargains taken: Sentence: Time in jail: Detailed Description of Offense: Severity of Offense: Use of weapons/homicidal or suicidal threats: Children present: Who called police: Residential status of victim/offense: Previous Offense Specific Treatment(DV?): Criminal History(Misdemeanor or Felony): 3. Psycho-Social History: Family/childhood history: Family dynamics (genogram of family of origin): Multiple primary caretakers (divorce or single parent upbringing): Frequency of residence change: Sibling violence: Parental loss: History of victimization, abuse, neglect or abandonment as child/adult: Witnessing of DV in family: Childhood Problems: Health problems: School problems/discipline: Peer violence: Arrests as a juvenile: Suicide attempts as a child: Childhood/Adolescent Drug/Alcohol abuse: Educational/Employment history: Employment, Residential, and Financial Stability/Instability: History of violent, abusive, or neglectful behavior toward partners, children, animals (including sexual): Intimate Relationship History: Relationships: Accusations of infidelity, drug abuse, etc. Restraining orders: Relationship patterns: 4. Medical History: Current conditions and medications: Head injuries: 5. Substance Abuse and Addiction Assessment: Alcohol/drug use history: Substance use in family of origin: Use patterns and attitudes: Criminal History related to use: Use of Substance at time of offense: Other addictions: 6. Mental Health Evaluation: History of mental health treatment/diagnosis/current medications: Family mental health history: Adult history of suicide: Current suicidal and homicidal ideation/risk: Current obsessive/compulsive thoughts regarding victim: Assessment of Axis I disorders: Personality functioning: Mental health status exam/clinical impressions: 7. Assessment for treatment amenability: Attitude toward treatment: Learning styles: Previous response to treatment: Disabilities and special needs: 8. Assessment of risk of re-offending: Risk factors: 9. Other factors for consideration: Sexual orientation/gender identity: Language/cultural issues: High level offender resistance: Transportation barriers: 10. Strengths: Other Pertinent Information: INDIVIDUAL, & GROUP THERAPY SERVICES DOMESTIC VIOLENCE TREATMENT PLAN Problem Statement: I have been referred for and completed my assessments for the Individual and Group Therapy Services (IOTS) Domestic Violence Program. As a result of my violent behavior, I will lean to improve my skills in the following areas: 1. to learn to better control my violent behavior by understanding the following: Time-out skills Rational emotive therapy concepts Anger is a choice I am 100% responsible for my own thoughts, feelings, and behaviors Cycle of violence and key intervention points Types of violence [physical, psychological, sexual, stalking, property,-child abuse] Assertiveness/communication skills Stress management techniques Victim empathy Healthy coping mechanisms The impact of alcohol and drug on my cycle, my family, parenting skills, and my self-esteem Create a relapse prevention plan Family dynamics, intergenerational effects of domestic violence, and related topics other 2. to learn how drugs and alcohol can reduce my inhibitions and thereby affect the effectiveness of my thinking. I have agreed to submit to: Alcohol/Drug Assessment and follow any recommendations Antabuse Abstinence Attend AA and/or NA meetings Other 3. to learn how to be responsible for my own thoughts, feelings, and behavior and thereby improving my behavior with children. I have agreed to attend: parenting classes individual counseling other 4. to learn about the types of violence and how my sexual behavior effect others. I have agreed to attend: sexual violence group individual counseling other 5. to learn more about my thinking skills as they relate to my behavior. I understand that at times additional help is important to help with my thinking skills. I have agreed to: psychiatric evaluation individual counseling other I understand and agree with the above treatment plan. My inability to follow the treatment plan and client contract could result in a negative termination from the Individual and Group Therapy Services Domestic Violence Program. Client Signature Dat--- Therapist Signature Date LETHALITY CHECKLIST Identification of Client Check all that apply. 1. objectifies partner (calls her names, body parts, animals) 2. blames victim for perceived injuries to self 3. is unwilling to turn victim loose 4. is obsessed with victim 5. is hostile/angry/furious 6. appears to be distraught 7. relationship is extremely tense, volatile 8. is extremely jealous, blaming victim for all types of promiscuous behavior 9. has perpetrated previous incidents of significant violence 10. has killed pets 11. has made threats 12. has made previous suicide attempts 13. is threatening suicide 14. has access to victim 15. has access to guns 16. alcohol involved 17. amphetamines, (speed, cocaine, crack) or other drugs involved 18. has thoughts/desires of hurting partner 19. has no desire to stop violence/control behavior If batterer perceives the relationship as at risk of ending, the potential of danger increases drastically. I believe the victim is at risk: strongly agree 1 2 3 4 5 strongly disagree Evaluation Summary: — — — — -- — etc. CAUTION: THE ABSENCE OF MOST OF THE ABOVE IN ANY CASE DOES NOT MEAN THE PERPETRATOR IS HARMLESS . . . BUT AN INCREASE IN ITEMS CHECKED DOES INCREASE THE DANGER. INDIVIDUAL & GROUP THERAPY SERVICES 824-B 9th Street Greeley, Colorado 80631 970-353-8171 970-353-0371-FAX DOMESTIC VIOLENCE INTAKE SUMMARY Date: Client: Case Number: To: The following report has been prepared to reflect the outcome of the client's Domestic Violence Intake Assessment. Date Referral Received: The Referral Packet was Complete Incomplete(It was missing the following items): Date client made initial contact with IGTS: Date client is/was scheduled for an intake assessment: Date client completed an intake assessment: Date(s)client canceled or did not appear for intake assessment: Date client is/was scheduled to attend his/her first group: Recommendations for treatment: Pending(Reason explained below) Minimum of 36 week DV treatment Individual Sessions Drug and Alcohol Treatment Marginal Acceptance- 90 Day Probation Period Mental Health Offense Specific Domestic Violence Evaluation Antabuse Parenting Classes Drug and Alcohol Counseling Other: If you should have any questions or concerns regarding this assessment, please contact Individual and Group Therapy Services. Signature Date pc: Client pc: Other Individual & Group Therapy Services (IGTS) —Monthly Progress Report Date: Client's Name: DOB: Supervising Officer: Case #: DV NOP MH AM COG SO DDSO Counselor: Group #: Number of Medical Absences: Number of Non Medical Absences: Balance Due: Date of last polygraph: Maintenance Specific Issue Sex History Instant Offense Date of last PPG: Level of Participation: Client does not participate openly in group sessions. Client participates to some degree. Client's participation is average. Client participates more than expected. Client is interactive in groups and individual sessions and contributes more than expected. Homework Assignments: Client rarely turns in homework and minimally completes assignments. Client frequently turns in homework and does an average job. Client completes all homework assignments thoroughly and turns them in on time. Group Notes: Client minimally completes group notes without applying what was learned in group. Client puts an average amount of thought into the group notes. Client puts significant thought in the group notes with personal. reflection. Comments to include changes and level of risk: • op Individual & Group Therapy Services 824-B 9tk Street, Greeley, Colorado, 80651 • Pk: 970353.8171 • Fax:970.353.0371 Date: Weld County Department of Social Services ATTN: Caseworker P.O. Box A Greeley, CO 80632 Dear Caseworker: We are requesting an extension of services for Joe No Name for the following reasons: Client has not completed the required number of sessions. Client has not completed treatment goals. Client is in need of additional sessions, as he/she has not internalized material covered in treatment. Client is unable to complete treatment in the time frame allowed. Please forward the appropriate paperwork to be filled out in order to expedite this process. If you have any questions regarding this issue, please feel free to contact us. Respectfully submitted, Kim R. Ruybal, MA, LPC, NCAC II DVOMB/SOMB Approved Provider Psychotherapist Family • Couples Adolescents Victim Services Mental Health Assessments Domestic Violence Evaluation and Treatment • 5OM5 Evaluation,Treatment and Pletkysmograp y h 0 } = AI- § k ® !@ ft i— te In B \k B � Ui § \B )§ / J & ) kk / ca 4...J \ » \ U \ e k0 % u 9 n 2 § w \ } u 9 D � ) § � — S � � Ill ) 1.1 I 0 Sc ) u m �� U. 5 - aa a |f( \ ! 2 ; / li 4.4 Ca 6� � / } ma } z O o z 0 u. ea O La O L1/4- IT a. cc ce w \ | B | j 2 CO IT CC 0 cn i— §IT Ili _ | \ a ce — 111 1— re O a ) k Ill o - k \ ) � \ } O � 2 ]] k § § OLu b ( I §7 ke co ) § ) 0 � \ 2 4 ; 0 0 5 Q Q § § \ \ \ \ a 0 \ ; 11• � § 2 S }. § - .3 z ) . 0 / ) ,-e 4 $ k ° c « et al 75 eo ci |!§ ! � , i !s ! O ! - � a . .-t BO @ ! 0 b. o ± to 0 \ } p o o.0 La k 0 ) ) § 9 ) 0 co I- § O ` 0 0 \ \ _• i• x_ cc 3 . I-- 0 0 1- a co i- O O w a I- (— QOo _Ira m ell wee 0• O • CD O e O . 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CD 2 __ -, Y J U _ o cc0 INDIVIDUAL & GROUP THERAPY SERVICES MENTAL HEALTH DOMESTIC VIOLENCE EVALUATION January 1 , 2006 NOTICE Information disclosed in this document is confidential and protected by federal law. Federal regulation prohibits unauthorized use of this information or further disclosure of this report without the specific written consent of the persons to whom it pertains. NELSON, WOLF & ASSOCIATES, PC (Fervor c lounseling March 30, 2006 To Whom it May Concern, This is to verify that Nelson, Wolf& Associates, P.C. will be providing services for the Medicaid clients who are seen by Individual and Group Therapy Services (IGTS). Our Medicaid number is 82929378. Please don't hesitate to contact me with any questions you may have. es P. Nelson MA, LPC icense Number 1626 3400 16th Street* Suite 3-R* Greeley, CO 80634* (970) 353-5577 \ 4 \ _ b m I \ • \ \j \/ 41 ) ( ' 2 < t-- AC tti /cc c,.‘ / ± LL, . % ® 4F\ B :4. Z.- *x \ ci \ ti ± ` } ) ( \40 \ f 2 © < 2 » ) } { \ \� \ \ a. 2j { k \ \ © ) c ! \ } j ..--, ) { ) ! » / ) , \ ) \ / � > \ \ \ \ \ \ Zr24 � \ \ ) � k \ \ {\E � ) 0 - 01 k $ $ / CI 2\ \ � � ■ / , / - Hcoil Z 040 - ) 0 = f . . . . C.0 o - § G I/I �' I��I I Ell VIllerel LO-t0 9l00111-ELOZt091f III ) H | ADDITIONAL INSURED ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. In consideration of the premium charged, the "Designated Entity" or "Designated Entities" shown below shall be included as additional insured(s), but only as respects claims arising out of the sole negligence of the individual or entity specified in the Persons Insured section of the policy. Additional Definition: "Designated Entity" or"Designated Entities" as used in this endorsement shall mean: DEPARTMENT OF CORRECTIONS DIVISION OF COMMUNITY CO LAKEWOOD,W OD COCO DRIVE 80022 88 NAME ADDRESS DEPT OF SOCIAL SERVICES OF WELD COUNTY 915 10TH STREET POB 758 YOUTH AND CONFLICT NAME GREELEY, CO 8O63O63 2 ADDRESS DEPT OF SOCIAL SVS OF WELD COUNTY CHILDREN AND FAMILY SVS 915 10TH STREET POB NAME GREELEY, CO 8O6363 2 ADDRESS JEFFERSON COUNTY DEPT OF HUMAN SVS 900 JEFFERSON COUNTY PARKWAY NAME GOLDEN, CO 8O4O1-6O1O ADDRESS ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. The premium for this endorsement is included in the premium shown on Additional Premium $ 23.11 the declarations unless a specific amount is shown here. Return Premium $ 0.00 ENDORSEMENT NO.: 01 Effective: 06/14/2005 Is attached to and forms part of your evidence of insurance no.: 80M-2001461 Issued by: the Company named in the Declarations Executive Offices: 55 E.Monroe Street Chicago, Illinois 60603 Insured: PERKELEN ENTERPRISES INC Date Issued: Authorized Representative: 7/12/05 0 e 4C-,,. PLE-8003(2/88)(Ed. 09/93)(Dec)a { Branch B/A Producer Number Issue Date Renewal/Replacement No. 32 A 0003107 06/03/2005 RENEWAL PROFESSIONAL LIABILITY OCCURRENCE INSURANCE POLICY FOR PROFESSIONAL COUNSELORS AND HUMAN DEVELOPMENT PRACTITIONERS PURCHASING GROUP POLICY NUMBER: 44-2010129 Item DECLARATIONS CERTIFICATE NUMBER 80M- 2001461 1. Named Insured PERKLEN ENTERPRISES INC 2. MAILING ADDRESS 824-B 9TH STREET GREELEY CO 80631 3. Policy Period 12:01 AM Standard Time At Location of Designated Premises From: 04/01/2005 To: 04/01/2006 4. The insurance afforded is only with respect to such of the following types of insurance as indicated by specific premium charge or charges: COVERAGE PREMIUM A. Professional Liability X $ 2,295.00 B. General Liability $ 2,295.00 5. LIMITS OF LIABILITY each Incident $ 1,000,000 or each Occurrence $ 3,000,000 in the Aggregate 6. The Named Insured is: Sole Proprietor (including Individual)) Partnership X Corporation 7. Business or Occupation of the Named Insured: COUNSELING 8. This policy is made and accepted subject to the printed conditions of this policy together with the provisions, stipulations and agreements contained in the following forms(s) or endorsement(s): PLJ-2016 (10/94) PLE-2040 PLE-8003 PLE-2081 PON-2003 PLE 2189 (9/97) CHICAGO INSURANCE COMPANY 55 E. MONROE STREET, CHICAGO, ILLINOIS 60603 REPRESENTATIVE: Agent or Broker: Kirke Van Orsdel Office Address: 1776 West Lakes Parkway Town and State: West Des Moines, IA 50398 Toll-free Number: 1-800-557-5092 PLP-2016 (10/94) (Elec.) Branch B/A Producer Number Issue Date Renewal/Replacement No. 32 A 0003107 06/03/2005 RENEWAL PROFESSIONAL LIABILITY OCCURRENCE INSURANCE POLICY FOR PROFESSIONAL COUNSELORS AND HUMAN DEVELOPMENT PRACTITIONERS PURCHASING GROUP POLICY NUMBER: 44-2010129 Item DECLARATIONS CERTIFICATE NUMBER 80M- 2001461 1. Named Insured PERKLEN ENTERPRISES INC 2. MAILING ADDRESS 824-B 9TH STREET GREELEY CO 80631 3. Policy Period 12:01 AM Standard Time At Location of Designated Premises From: 04/01/2005 To: 04/01/2006 4. The insurance afforded is only with respect to such of the following types of insurance as indicated by specific premium charge or charges: COVERAGE PREMIUM A. Professional Liability X $ 2,295.00 B. General Liability $ 2,295.00 5. LIMITS OF LIABILITY each Incident $ 1,000,000 or each Occurrence $ 3,000,000 in the Aggregate 6. The Named Insured is: Sole Proprietor (including Individual) Partnership X Corporation Other: 7. Business or Occupation of the Named Insured: COUNSELING 8. This policy is made and accepted subject to the printed conditions of this policy together with the provisions, stipulations and agreements contained in the following forms(s) or endorsement(s): PLJ-2016 (10/94) PLE-2040 PLE-8003 PLE-2189 (9/97) PLE-2081 PON-2003 CHICAGO INSURANCE COMPANY 55 E. MONROE STREET, CHICAGO, ILLINOIS 60603 REPRESENTATIVE: Agent or Broker: Kirke Van Orsdel Office Address: 1776 West Lakes Parkway Town and State: West Des Moines, IA 50398 Toll-free Number: 1-800-557-5092 PLP-2016 (10/94) (Elec.) Coverage Information ESTIMATED PREMIUM Location : I PERKLEN ENTERPRISES. INC. 824 9TH ST. STE B GREELEY, CO 80631 Period : 02/01/2006 -02/01/2007 Class RT Description Emp Payroll Rate Prem charge 883205 EM PHYSICIANS & CL 6.00 $100,328 0.779100 $782 Total Payroll : $100,328 Manual Premium : $782 Minimum Premium: $192 Premium Information Description Period Adjusnnent Amount Ratable Manual Premium 02/01/2006-02/01/2007 $782 Designated Provider Discount 02/01/2006 -02/01/2007 0.975 $20- Annual Policy Fee 02/01/2006-02/01/2007 $165 Terrorism Act Premium 02/01/2006 -02/01/2007 $28 DTEC -Catastrophic Loss Charge 02/01/2006 -02/01/2007 $10 Net Estimated Annual Premium 02/01/2006 -02/01/2007 $965 POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE COVERAGE FOR ACTS OF TERRORISM IS INCLUDED IN YOUR POLICY. YOU SHOULD KNOW THAT, EFFECTIVE NOVEMBER 26, 2002, UNDER YOUR EXISTING COVERAGE, ANY LOSSES CAUSED BY ACTS OF TERRORISM WOULD BE PARTIALLY REIMBURSED BY THE UNITED STATES UNDER A FORMULA ESTABLISHED BY FEDERAL LAW. UNDER THIS FORMULA, THE UNITED STATES PAYS 90%OF COVERED TERRORISM LOSSES EXCEEDING THE STATUTORILY ESTABLISHED DEDUCTIBLE PAID BY THE INSURANCE COMPANY PROVIDING THE COVERAGE. PREMIUM FOR THE TERRORISM ACT OF 2002 IS CALCULATED ON THE BASIS OF TOTAL PAYROLL. THE TOTAL COLORADO PAYROLL IS DIVIDED BY$100 AND MULTIPLIED BY THE APPROVED TERRORISM RATE, .0275 PER$100 OF PAYROLL. THE CALCULATION IS EXPRESSED AS(COLORADO PAYROLL/$100 X APPROVED TERRORISM RATE = PREMIUM). THIS PREMIUM IS NOT SUBJECT 7'O ANY OTHER MODIFICATION, BUT NOT LIMITED TO, PREMIUM DISCOUNT, EXPERIENCE RATING, SCHEDULE RATING,OR RETROSPECTIVE RATING. ADDITIONALLY,EFFECTIVE JANUARY 1. 2005, ALL WORKERS'COMPENSATION CARRIERS ARE REQUIRED TO CHARGE PREMIUM TO COVER LARGE LOSSES. INCLUDED IN THE DEFINITION OF LARGE LOSSES ARE DOMESTIC TERRORISM, EARTHQUAKES AND/OR CATASTROPHIC INDUSTRIAL ACCIDENTS(DTEC). PREMIUM FOR DOMESTIC TERRORISM, EARTHQUAKE, AND CATASTROPHIC INDUSTRIAL ACCIDENTS(DTEC)IS CALCULATED ON THE BASIS OF TOTAL PAYROLL. THE TOTAL COLORADOPAYROLL IS DIVIDED BY$10(1 AND MULTIPLIED BY THE APPROVED DTEC RATE, $0.01 PER$100 OF PAYROLL. THE CALCULATION IS EXPRESSED AS(COLORADO PAYROLL/$100 X APPROVED TERRORISM RATE = PREMIUM). THIS PREMIUM IS NOT SUBJECT TO ANY OTHER MODIFICATIONS, BUT NOT LIMITED TO, PREMIUM DISCOUNT,EXPERIENCE RATING, SCHEDULE RATING, OR RETROSPECTIVE RATING. This Policy Information Page reflects coverage, premium and payroll information as of the date of issuance. clung 10 rsa.200o 1442ao unnfin Updated: P<.w.. 7501E Lowry Blvd PINN/ACOL Denver, CO 80230-7006 ASSURANCE www.pinnacol.com POLICY INFORMATION PAGE POLICY #: 4077601 POLICY TYPE: ADVANCE Date: February 10, 2006 ITEM 1 . POLICYHOLDER: AGENT: PERKLEN ENTERPRISES, INC GLEN WALL INSURANCE SERVICES, INC. 1020 8TH STREET 826 28TH AVE GREELEY CO 80361 GREELEY, CO 80634 (970) 353-2020 ST / 7.00 ITEM 2. POLICY PERIOD: FROM 02/01/2006 TO 02/01/2007 12:01 A.M. MOUNTAIN STANDARD TIME ITEM 3. A. Workers' Compensation Insurance: Part One of the policy applies to the workers' compensation law of the states listed here: COLORADO B. Employers Liability Insurance: Pan Two of the policy applies to work in each state listed in Item 3 A. 'The limits of our liability under part two are: BODILY INJURY BY ACCIDENT $100,000 EACH ACCIDENT BODILY INJURY BY DISEASE $100,000 EACH EMPLOYEE BODILY INJURY BY DISEASE $500,000 POLICY LIMIT C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: NONE (Please contact Pinnacol Assurance for information on coverage outside the state of Colorado) D. This policy includes the attached endorsements and schedules: 0404 Premium Credit Addendum 426 New/Pending Policy Rate Change ITEM 4. We will determine the premium for this policy by our manuals of rules,classifications, rates and rating plans. All information required helow is subject to verification and change by audit. The statements of estimated advanced premium are also a part of this policy. U e.ne 10 FEB 200u I ui2120 45775,l upio1N_ P4ALA INDIVIDUAL AND GROUP THERAPY SERVICES 824-B 9`h Street Greeley, Colorado 80631 (970) 353-8171 Bill To: Bill For: Agency 555 5th ave Joe No Name Greeley, CO 80631 Bill as of: July 1, 2005 Date Transaction Method of Payment Total Owed 6/02/05 MH Individual 65.00 6/09/05 MH Individual 65.00 6/16/05 MH Individual 65.00 6/23/05 MH Individual 65.00 6/30/05 MH Individual 65.00 Total $325.00 Total for Month of June, 2005 $325.00 Balance due as of July 1, 2005 $520.00 (May, 2005 -June, 2005) Please make payment payable to Individual and Group Therapy Services. Payment is due within thirty (30) days of receipt. - Thank you! al ; � ) ( (\ ] C , } \ \ {CO I ± EC 43 o 0Ej a ems } CO O - ) ■ 2 = ; Q � ? 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PSONAI ARID CCNRID NTIAI This fax transmission, and any documents accompanying if, may contain confidential information belonging to the sender, and ,which may in part or whole be protected by federal regulations. This information is intended solely for the use of the individual or agency named above. ou are not the intended recipient you are hereby notified that any disclosure, copying, distribution, arthe taking of action upon the contents of this information is prohibited, f you have received this fax in error, please notify our o—ice immediately Ly telephone at 070-353.8_,171 for instructions on how to return the document(s) or arrangements for destroying the document(c). Thank you for your cooperation_ MLSSAG& # 4 Pages (including cover page): r Time eeing {--aged: a.m. / M. 05/22/2006 13:58 9703530371 IGTS PAGE 02 aIndividual & Group Therapy Services 824-$ 9th Street,Greeley, Colorado,so631 • Ph:970.353.8171 - rax:97O.353.O)71 May 22,2006 Weld County Department of Social Services ATTN: Judy Griego P.O. Box A Greeley, CO 80631 RE: REP 006-00 Mental Health Services Dear Ms. Griego: This letter serves to respond to questions regarding the bid named above: Condition#1: Individual and Group Therapy Services (IGTS)employs a full-time, Spanish speaking therapist to assist monolingual clients. Mental health services available to monolingual clients includes individual, group, family and couples therapy. All new monolingual clients requesting information on our services are provided with her number to assist in providing information about our services and to arrange intakes when their needs are determined. Intake information, including paperwork, is provided in Spanish. Upon completion of the intake, the client will be referred to the appropriate mental health service. They will continue to meet with their bilingual therapist until therapy is completed. Condition #2: All testing, with the exception of the Minnesota Multiphasic Personality Inventory(MMPI) and the Hare Psychopathy Checklist Revised,may be administered by a person who has completed a master's degree or higher, has completed a course in psychometric testing, and has administered psychometric testing under the supervision of a psychologist. The administration of the MMPI,as well as other testing instruments, is supervised by Dr. Larry Denmark, a licensed psychologist. The Hare Psychopathy Checklist Revised can only be administered by a person who has attended Dr. Hare's training. The Hare is administered by Kim R. Ruybal, who has attended this specialized training. See attached vitae. Condition #3: Northrange Behavioral Health will also be a primary consideration for Medicaid clients,particularly those clients that are in need of psychotropic medications. Family • Couples • Adolescents • Victim Services • Mental health Assessments Domestic Violence Evaluation and Treatment • SOMB Evaluation,Treatment and Plethysmography ' 05/22/2006 13:58 9703530371 IGTS PAGE 03 • Condition#4: The bid administered is for evaluations or treatment of mental health clients only. Condition#5: Goals will be established with each client at the first session. Progress on clients will be reported monthly. Upon completion of treatment, a termination report will be completed, addressing whether the client's treatment was successful, unsuccessful or partially successful. Condition#6: The Social Services business office will be contacted regarding the amount of completed evaluations. Compliance Item: IGTS was not able to get letters from Job Services,Housing Authority or Northrange Behavioral Health on such short notice. However, these letters will be sought immediately and will be forwarded to your offices. Respectfully submitted, Kim R. Ruybal, MA,LPC,NCAC Ii Director • 05/22/2006 13:58 9703530371 IGTS PAGE 04 • Kim R. Ruybal,MA,LPC,NCAC II Executive Director/Owner Individual& Group Therapy Services 1020 8i*Street Greeley, Colorado 80631 (970) 353-8171 Fax- (970)353-0371 VITAE EDUCATIONAL AND PROFESSIONAL CREDENTIALS Masters of Arts. Professional Psychology: Agency Counseling.Summa Cum Laude. University of Northern Colorado. August, 1998. Bachelors of Arts. Psychology. Cum Laude. University of Northern Colorado. December, 1994. Licensed Professional Counselor (LPC) with the State of Colorado, Department of Regulatory Agencies, Division of Registrations, #2647. October, 2000,to present. Nationally Certified Addiction Counselor, Level H. March 2003 Sex Offender Management Board(SOMB)Full Operating Level Supervisor, Treatment Provider, Evaluator and Plethysmograph Examiner Adults. January, 1998, to the present. SOMB Full Operating Level Supervisor, Evaluator, Treatment Provider, and Plethysmograph Examiner for Juveniles Who Have Committed Sexual Offenses. November,2003,to the present. SOME Full Operating Level Supervisor, Evaluator, Treatment Provider, and Plethysmograph Examiner for Developmentally Delayed Sexual Offenders. September 2004, to the present. Domestic Violence Offender Management Board (DVOMB) Supervisor, Treatment Provider and Evaluator. June, 1997,to the present. DVOMB Approved Evaluator and Treatment Provider for Gay and Lesbian Domestic Violence Offenders. Approved Treatment Provider for the Colorado Department of Corrections(DOC). August, 1996, to the present. Approved Treatment Provider for the United States District Courts. July 2003 to the present. ' 05/22/2006 13:58 9703530371 IGTS PAGE 05 • EMPLOYMENT HISTORY Clinical Supervisor: Turning Point, Ft. Collins, Colorado (May 2005 to the Present). Provide supervision to the staff and one therapist at a juvenile residential treatment facility for youth wbo have sexually offended. Executive Director/Owner-Individual&Group Therapy Services,Greeley,Colorado(February 01, 2001 -Present). In addition to the description which follows,direct the daily activities of a staff of nine. Psychotherapist-Individual&Group Therapy Services, Greeley,Colorado(April, 1996-Present). Provide individual,and group therapy services to adults, adolescents,males, females,and families. In addition, provided are psychometric testing, and psychological evaluations, in the areas of domestic violence, sexual violence, victim's issues,and general mental health. Counselor:Externship-North Colorado Medical Center,Psych Care/Family Recovery Center,and Youth Passages, Greeley,Colorado. (January, 1998-July, 1998). Facilitated family,individual,and group counseling sessions for adults and adolescents in inpatient and outpatient settings. Populations served included chronicallymentally ill,bi-polar,chemically dependent,sexual abuse survivors and offenders, and conduct disordered individuals. Groups facilitated include Psychodrama/experiential groups, anger management groups, life skills groups, process groups, stress management, grief and loss groups, and psycho-educational groups. Also facilitated were multi-family groups for adult alcohol dependency, and adolescent adjustment issues. Crisis Counselor - A Woman's Place, Greeley, Colorado. (May, 1994 - September, 1995). Facilitated individual and group counseling sessions. Maintained a twenty-four(24)hour crisis line. Collaborated with local authorities for the safety and security of women and children wbo were battered and seeking safe, temporary shelter. Legal Advocate: Intern - A Woman's Place, Greeley, Colorado. (January, 1994 - May, 1994). Assisted women who were battered in filing restraining orders, provided assistance with court procedures, and counseled throughout the legal process. PROFESSIONAL Al'1'1LIATIONS Colorado Organization for Victim's Assistance (COVA). Member# 36. 1997 to Present. Association for the Treatment of Sexual Abusers(ATSA). January,2000 to Present. American Counseling Association (ACA). Member#06084761. July 2001 to Present. COURT EXPERIENCE Weld County-People vs. Goode. July, 2005. Revocation Sexual Offense. Expert Witness 05/22/2006 13:58 9703530371 IGTS PAGE 06 Weld County-People vs.Prince. June,2005. Revocation Domestic Violence. Weld County-People in the interest of the R. children. April, 2005. Expert Witness: Domestic Violence and Psychopathy. Weld County-People vs.Krips. January 5,2005.Revocation Hearing. Sexual Assault on a Child. Weld County-People vs. Blackledge. January 3, 2005. Motions Hearing. Sexual Offender. Arapaho County-People vs.Hunter.December 17,2004.Revocation Hearing. Sexual Assault on a Child. Weld County-People in the Interest ofthe V. Children:July 28,2004. Expert Witness in the field of general mental health practices. Sexual Assault, Dependency and Neglect, Parental Rights Termination. Weld County-People vs.Dabler:June 2004.35B motion and revocation hearing.Expert Witness: Sexual Offense. Weld County -People in the Interest of the B. Children: February 2004. Child Custody and Visitation Hearing. Expert Witness: Domestic Violence. Weld County - People vs. Amundson: November 2003. Revocation Hearing. Expert Witness: Sexual Abuse and Domestic Violence. Weld County-People vs. Lucero: October 2003. Revocation Hearing. Sexual Assault. Weld County-People in the Interest ofthe V. Children:September 2003. Expert Witness.Sexual Assault and Dependency and Neglect,Parental Rights Termination. El Paso County-People in the Interest of the O. Children:May 2003. Expert Witness. Juvenile Sexual Offense. Weld County-People vs. Cardoza: January 2003. Revocation Hearing. Sexual Assault. United States District Court, District of Colorado vs VonRiesen: February, 2002 and May 2002. Revocation Hearing, Sexual Offender. Weld County-People vs. Dahlgren: March, 2002. Revocation Hearing, Sexual Offender. Weld County-In The Matter Regarding J. M. vs A. B. Permanency Hearing: February, 2001. Expert Witness. Domestic Violence. Weld County-Re The Marriage of: V. C. vs J. C: February, 2001. Expert Witness Domestic Violence and Post Traumatic Stress Disorder(PTSD). 05/22/2006 13:58 9703530371 IGTS PAGE 07 Weld County-People vs Cordova:January, 2001. Revocation Heating. Sexual Assault. 05/22/2006 13:58 9703530371 IGTS PAGE 08 Weld County-C. T. vs K. T. : June, 2000,Divorce proceedings involving domestic violence and allegations of sexual assault towards the minor daughter. Larimer County - People in the Interest of S. and C Children vs. J. C , J. C and L. B.: December, 1999, Expert Witness. Dependency and Neglect; specifically, sexual abuse of the children and sexual perpetration by the children. Weld County-People vs. Lampe:July, 1999,Expert Witness, Sexual Assault. Morgan County-People vs. Taylor: May, 1999,Expert Witness Sexual Assault. Weld County-People vs. Lujan:January, 1999, Revocation Hearing. Sexual Assault. Weld County-People vs. Harris:January, 1999,Domestic Violence. Jefferson County-People in the Interest of the D. H. Minor Children vs. M. J. H. and D. H.: July, 1998. Expert Witness. Dependency and Neglect; specifically, non-offending parents of sexually abused children. Weld County-People vs. Trissler:June, 1997, Domestic Violence. Weld County-People vs. Woods: September, 1997, Sexual Assault. CONTINUING EDUCATION 2005 November Protection Orders: Guidelines of Weld County Courts. Alyx McGuire, MA, DVOMB and SOMB Treatment Provider and Evaluator. Greeley, CO. 1.0 Hour 2005August:BiopsychosocialEfJects and Treatment ofMethamphetamineAddiction.Treatment and effects of meth use.Children effected by Methamphetamine.Nicolas Taylor,Ph.D.,CACIII,and Dr. Katheryn Wells. Greeley, Colorado, CEU 8 hours. 2005 May: The System as a Perpetrator Are we Offending or Defending the Victims of Sexual Abuse? And Beyond Our Beliefs: Healing the Wounds of Sexual Abuse Trauma. Colorado Chapter of the Association for the Treatment of Sexual Abusers. Denver, CO. 7 hours. 2005 February: Level II Clinician Training: The Monarch 21 System and Plethysmography. Peter M. Byrne, Ph D. Alliance Programs, a Division of Behavioral Technology, Inc. Salt Lake City, Utah. 12.0 hours. 2005 February:Level I Clinician/Technician Training: Using Monarch 21 PPG System. Peter M.Byrne,PbD.Alliance Programs,a Division of Behavioral Technology,Inc. Salt Lake City,Utah. 12.0 hours. ' 05/22/2006 13:58 9703530371 IGTS PAGE 09 • 2004 October:Association for the Treatment ofSexual Abusers:Family Reuni fi cation,Outcomes of Interventions with Offenders(J.McGuire),CommunityNotification,Risk Assessment(Hanson), Managing High Risk/Dangerous Offenders(L. Ellerby and A.Harris),Being Accountable: How to Measure Your Program's Integrity and Effectiveness, Sexual Assault: What Motivates and What Disinhibits(Richard Pelson), Assuring Community Readiness: An Open Dialogue with Survivors of Sexual Abuse and Recovering Sex Offenders.Developmental Issues. Albuquerque,New Mexico. 18 hours. 2004 October:A Journey Through the Link: The Link Between Cruelty to Animals and Violence Towards Humans. Domestic Violence,Sexual Abuse and Fire Starting.Colorado Bar Association, Colorado Alliance for Cruelty Prevention, and the Dumb Friends League. Aurora, CO 8 hours. 2004 October:Awesome Alliances and Creative Collaborations Conference. Advanced domestic violence training in the areas of homicide prevention, women's health risk, program evaluation issues,batter intervention research, interventions to protect victims and children, creating a family justice center as a containment module. Denver, CO 8 hours. 2004 September:Pikes Peak Regional Domestic Violence Summit Dual arrests,women offenders, victim dynamics, Deluth Model,treatment of offenders, family systems,psychopharmacology, juvenile offending dynamics.Gilbert Martinez, Chief Judge, State of Colorado 4th Judicial District Colorado Springs, CO 14 credit hours. 2004 September: Gay, Lesbian, Bisexual, Transgender Counseling Issues. Behavioral Health Services Department, Denver Health Medical Center. Peter DiLeo. Denver, CO 14 credit hours. 2004 June: Contact with Victim's and Potential Victims: Section 5.7 of the Standards and Guidelines for the Assessment,Evaluation, Treatment and Behavioral Monitoring of Adult Sex Offenders. The Colorado Sex Offender Management Board and The Colorado State Judicial Branch. Denver, CO 5.5 hours. 2004 June: Outward Bound:Survivors of Violence Wilderness Course. A three day wilderness course designed for survivors of violent crime. I facilitated a group of six clients in conjunction with two Outward Bound personnel. Leadville, CO 36 hours. 2004 April: Understanding and Responding to the Sexual Behavior of Children. Individualized Training and Consultation Services.Mary Marcantonio&Eileen Courtney,LMFT.Ft.Collins,CO, 3.5 clock hours. 2004 April: Victim Advocacy and Dynamics: Greeley Police Department: Victim Assistance Coordinator. Cecil O'Farrell. Greeley, CO, 2 clock hours. 2004 April: Understanding and Responding to the Sexual Behavior of Children. Individualized Training and consultation Services. Eileen Courtney, LMFT and Mary Marcantonio. Ft. Collins, CO, 3.5 clock hours. 05/22/2006 13:58 9703530371 IGTS PAGE 10 2004 March:Is is ADHD or Pediatric Bipolar?Deferential Diagnosis and Effective Treatment Cross Country University. Dr. Hano Kirk, LICSW. Denver, CO, 6 CEU's. 2004 January: Psychotropic Medications in the Treatment of Sexual Abusers by Dr. Brad Johnson. Colorado Chapter of the Association for the Treatment of Sexual Abusers. Denver, CO 7 clock hours 2003 November:A Day with David Hinsburger:Expert in the field of Developmentally Delayed Sexual Offenders. Colorado Chapter of the Association for the Treatment of Sexual Abusers. Denver, CO 7 clock hours. 2003 October: Sexually Violent Predator Assessment Training. Colorado Sex Offender Management Board and the Colorado Judicial Department-Division of Probation Services. Kim English and Chris Rowe. Denver, Colorado. 3 clock hours. 2003 September:Jan Hindman. Hooks,Hopes,and Healing. Leading expert in the field of adult and juvenile sexual assault. Colorado Springs, Colorado. 14 hours. 2003 June: Outward Bound:Survivors of Violence Wilderness Course. A three day wilderness course designed for survivors of violent crime. I facilitated a group of eight clients in conjunction with two Outward Bound personnel. Leadville, CO, 36 hours. 2003 March: Marilyn VanDeber Atler. An incest survivors story. University of Northern Colorado, Greeley. 2.0 hours. 2003 February: Empathy: Definition, Intervention Strategies, and Victim Impact Colorado Continuum Network Serving Sexually Abusive Youth. Golden, CO. 2.5 hours. 2002 October: Association for the Treatment of Sexual Abusers. Best Practices: Clinical and Research Collaborations.Juvenile ex offenders,developmentally delayed sexual offenders,victim's issues, statutory rape, Internet offenders,risk assessment. Montreal, Quebec Canada. 20 hours. 2002 September: Standards for Treatment with Court Ordered Domestic Violence Offenders. Greeley, Colorado. Cheryl Milliken, LPC, DVOMB Program Administrator. 4.0 hours. 2002 June: Outward Bound:Survivors of Violence Wilderness Course. A three day wilderness course designed for survivors of violent crime. I facilitated a group of nine clients in conjunction with two Outward Bound personnel. Leadville, CO, 36 hours. 2002 March:Risk Assessment:SORAG& VRAG. Greeley,Colorado. A.Mervyn Davies. 1 Hour 2002 March:Polygraph Response, Greeley, Colorado. A. Mervyn Davies. 1 Hour 2001 November:Association for the Treatment of Sexual Abusers. Building Safe and Healthy Communities. Juvenile sexual offenders, PPG, risk assessment, victims issues, Internet porn, developmentally delayed sexual offenders. San Antonio, Texas. 20 hours. 05/22/2006 13:58 9703530371 IGTS PAGE 11 2001 October: Dale Carnegie Leadership and Supervision Course. Denver, Colorado. 8 clock hours. 2001 October: Colorado Association for the Treatment of Sexual Abusers Presentation: Perpetrators, Contact With Their Children, When Does it Hurt? When Does it Help? Denver, Colorado. 8 clock hours. 2001 August: Dr. Judith Becker: Juvenile Sex Offender Standards Training Series. Jefferson County Judicial Building. 3 clock hours. 2001 July:Rob Freeman-Longo: Juvenile Sex Offender Standards Training Series. Jefferson County Judicial Building. 3 clock hours. 2001 June: Outward Bound SchooL A three day wilderness course designed for survivors of violent crime. I facilitated a group of nine clients in conjunction with two Outward Bound personnel. 2001 June: Dr. Robert Prentky: Juvenile Sex Offender Standards Training Series. Jefferson County Judicial Building. 3 clock hours. 2001 June:Standards Implementation Training: Colorado SOME. Greeley, Colorado. 12 clock hours. 2001 March:Early Life Experience and Brain Development:How We Can Help Our Children Reach Their PotentiaL Two separate workshops and one community luncheon.Bruce Perry,M.D., Ph. D. Greeley, Colorado. 6 clock hours. 2001 March: Domestic Violence Management Board Meeting. Department of Regulatory Agencies and Violence Risk Assessment. Denver, Colorado. 3.0 Clock hours. 2001 February: Polygraph and Sex Offender Management The Sex Offender Services Committee-Adult.Through the Office of Probation Services. Colorado Judicial Branch. JeffJenks, Karen Vigil, Doug Carpenter. 8.0 clock hours. 2001 February: Chemical Castration:Clients vs Criminals. Colorado ATSA Sponsored. Ethical and bio-medical considerations in the treatment and supervision of sex offenders. Fred S. Berlin, MD, Ph. D. John Hopkins University School of Medicine. Denver, Colorado. 7 clock hours. 2000 December: Sex Offender Re-Offense Risk Assessment R. Karl Hanson, Ph.D.; Thomas Grisso,Ph.D.;Douglas Epperson,Ph.D.;Robert Prentky,Ph.D.;David Thornton,Ph.D.;Dennis M. Doren, Ph. D.; Robert Hare, Ph.D.; Venon L. Quinsey, Ph.D.; Anna C. Salter, Ph.D. Sinclair Seminars: Video Series. 12 Clock hours. 2000 November:Northeastern Region Restorative Justice Conference. Greeley, CO. 16 hours of training. 05/22/2006 13:58 9703530371 IGTS PAGE 12 2000 November:Colorado Organization for Victims Assistance(COVA)1,Annual Conference. Keystone, Colorado, 20 clock hours. 2000 October: Victim Rights Act Compliance Training. This act ensures victims of crime to be informed,present, and heard, and treated with fairness, dignity and respect through critical phases of the criminal justice process. Colorado organization for Victim Assistance (COVA), Cynthia J. Geissinger,MSW. Greeley, Colorado. 1.5 clock hours. 2000 August: SART: Dr. Janine M. D'Anniballe, Ph. D. The effects of trauma on brain development with an emphasis on Post Traumatic Stress Disorder. Greeley, Colorado, 2 clock hours. 2000 August: Conflicts in Ethics: Challenges in the Team Approach in Managing Convicted Sexual Offenders in Evaluation and Treatment Colorado ATSA presentation focusing on the conflicts of the teat approach. Dr.Handelman,keynote speaker. Denver,Colorado. 5.5 clock hours. 2000 May: Breaking the Trauma Bond-Restitution Therapy. Jan Hindman Seminar. Rocky Mountain Council on Sexual Aggression,Addiction,and Compulsivity.Golden,Colorado. Contact hours: 6.5. 2000 April:Practical Approaches to Successful Healing. Sexual Abuse Helping Adult& Child Survivors. Adena Bank Lees,CISW,ICADC.Corondelet Management Institute.Boulder Colorado. Contact Hours 6.5 2000-April:Family Reunification:Implications in Sexual Offender Treatment Jill Levenson, MSW,investigated child abuse allegations,worked in communityagencies treating abused children, perpetrators,adult survivors,and non-offending parents.Colorado Association for the Treatment of Sexual Abusers(CATSA). Denver, Colorado. 7 Clock hours. 2000-April:Dr.Pollack Keynote Address:Colorado School Counselor Association Conference. Denver, Colorado. 3 Clock hours. 2000-March : Juvenile Fire-setter Prevention, Intervention, and Treatment Paul L. Cooke, Director of Colorado Division of Fire Safety; Jennifer Moyer, LCSW, Colorado Mental Health Institute at Fort Logan; Ari Zavaras, Executive Director of Colorado Department of Public Safety; Richard Gonzales, Chief of Denver Fire Department; Chris Olson, Director of Englewood Safety Services; and case review. Denver, Colorado. 6.5 Clock hours. 2000 - February : National Adolescent Perpetration Network JS`" Annual Conference. Integrating Multiple Interventions for Sexually Abusive Youth. Anna Salter, Ph. D., Keynote speaker. New England Forensic Associates. Denver, Colorado. CEU: 17 2000 - January : Vicarious Trauma. Vicarious Trauma and its effect on the interventionist, organization, and community. Provided were tools with which to mitigate the effects of vicarious trauma. Colorado Organization for Victim Assistance (COVA). Cynthia J. Geissinger, MSW, Training Coordinator. Greeley, Colorado. 2.5 Clock Hours. 05/22/2006 13:58 9703530371 IGTS PAGE 13 1999 -December : Microsoft Office. A Fred Pryor Seminar on Windows Refresher, Microsoft Word, Microsoft Excel, Microsoft Power Point, Microsoft Outlook, and Microsoft Access. Jens Norgaard. Ft. Collins, Colorado. Continuing Education Units .6. 1999-November: The Association for the Treatment of Sexual Abusers(ATSA). New England Forensic Associates. General Assembly and Pit-Conference Workshop:Using&Testifying about Sex Offender Risk Assessment. Lake Buena Vista, Florida. CEC: 18 hours. 1999 -November: The Dual Diagnosis of Developmental Disability & Mental Illness. Issues regarding the developmentally delayed sexual offender were addressed. Greg Thaler, Ph. D, and Georgia Collimore, LCSW. Greeley, Colorado. 7 Contact Hours. 1999-August: Treating Specialized Populations. Colorado Chapter of the Association for the Treatment of Sexual Abusers (ATSA). Specialized Treatment for Developmentally Delayed Clients. Treating Adult Female Sex Offenders.James Haaven,Director,Social Rehabilitation Unit, Oregon State Hospital. Debbi Crapeau, MS, LPC, and Peggy Heil, LCSW. Golden, Colorado. 6 Clock hours. 1999-June:Hare Psychopathy Checklist Training. Dr.Robert Hare and Dr.Adele Forth with the Darkstone Institute. Denver, Colorado. 20 Clock hours. 1999- February:Domestic Violence Risk Assessment Training. AMEND. Greeley, Colorado. 5.25 CEC's. 1999-February:Community Victim Empathy Group Facilitator Training. Jill Weston,California Youth Authority/OVC Trainers Bureau/MADD. Greeley, Colorado. 32 Clock hours, 1998-November:Colorado Organization for Victim's Assistance(COVA),10th Annual. Summit at the Summit." Keystone, Colorado. 20 Clock hours. 1998 - November: Albert Bandura, Ph. D., lecture on Self-efficacy. University of Northern Colorado, Greeley, Colorado. 2 Clock hours. 1998 - September: Colorado Chapter of the Association for the Treatment of Sexual Abusers (A TSA). Violence, Psychopharmacological treatments of violent offenders, case studies of serial killers, and sexual sadism. Bradley R. Johnson, MD, P.L.L.C. Case studies of victims of violent sexual assaults and victim characteristics. Dana Easter,Jefferson.County District Attorneys Office. Denver, Colorado. 6 Clock hours. 1998-July:National Coalition Against Domestic Violence. Denver, Colorado. 30 Clock hours. 1998-July:Psychodrama:A means offtndingpersonal truth through dramatic action. Georgia A. Rigg, LCSW, C.P., P.A.T. Greeley, Colorado. 2 Clock hours. 05/22/2006 13:58 9703530371 IGTS PAGE 14 1998 - July: Jurisprudence Workshop. Department of Regulatory Agencies, legal and ethical overview for the licensed professional. Denver, Colorado. 8 Clock hours. 1998-June:Colorado Chapterfor the Association for the Treatment ofSexualAbusers(ATSA). Standards and Guidelines for the Assessment,Evaluation,Treatment,and Monitoring of Adult Sex Offenders. Denver, Colorado. 6 Clock hours. 1998-May:Sexual Assault&Stalking Cases:Investigative Techniques. An overview of sexual assault crimes and investigative measures. Investigating difficult cases, forensics, interview and interrogation skills, and stalking. COVA, Denver, Colorado. 8 Clock hours. 1998-May: Connecting Colorado Prevention Coalition:A Feast of Knowledge for Prevention Providers. Conflict Resolution, Creativity in Prevention, and Styles of Leadership. Fort Collins, Colorado. 8 Clock hours. 1998-April: Colorado Chapter for the Association for the Treatment ofSexual Abusers(ATSA). Understanding the role of Penile Plethysmograph,the Abel Screening Devise,and Polygraphy in the treatment of sexual offenders. Denver, Colorado. 6 Clock hours. 1998-February: Understanding Medical Findings In Child Sexual Abuse Cases. Patti Rosquist, MD,Kempe Children's Center, Child Protection Team,Instructor/Fellow, University of Colorado School of Medicine. Cindy Tanner, CHA,PA,Kempe Children's Center, Child Protection Team, Instructor of Pediatrics University of Colorado School of Medicine. Greeley, Colorado. 4 Clock hours. 1997-October: Colorado Organization for Victim Assistance(COVA),Ninth AnnuaL "Soaring to higher justice for victims." Steamboat, Colorado. 20 Clock hours. 1997-September:The Ending Violence Against Women Project. Kelsey Barnes,LCSW;Yolanda Gotier, LCSW; Dean Curd, MA; Anne Munch, Esq., Janinie M. D'Anniballe, Ph. D. Greeley, Colorado. 16 Clock hours. 1997-August: Sex Offenders Assessment, Risk Management and Treatment A Gathering of Leading Experts. Gene Abel,MD;John Hunter,Ph.D.;Fred Berlin,MD;Reid Meloy,Ph.D.;Anna Salter, Ph.D.; William Marshall, Ph.D. San Diego, California. CEC: 18 hours. 1997-May:Legal Responsibilities Under the Victim Rights Amendment. 131 Annual Northeast Regional Colorado Conference for Law Enforcement, Prosecution, and Judicial Agencies. Greeley, Colorado. CDC: .7 1997-April: Constructivist Psychotherapy. Greeley, Colorado. Michael J. Mahoney, Ph.D. 1997-April:Religious Perpetrators ofDomestic Violence. Daryl Woodward,MS,LPCC,Director, Colorado MOVES. Denver, Colorado. CEC: 3 hours. 05/22/2006 13:58 9703530371 IGTS PAGE 15 • 1997 - April: 1997 Annual ADAD Conference. Youth: Assets for Today and Tomorrow. Nonviolence in Parenting. Pat Patfoort. Children Exposed to Domestic Violence:Recognizing and Responding to the Social and Psychological Consequences of Trauma. Anne Tapp. Denver, Colorado. ADAD CEU: 12.25 hours. 1997-March:Attachment Disorders: Greeley, Colorado. J. Lynn Rhodes, MA, LPC. 4 Clock hours. 1997 - February: Intensive Psychotherapy for Adults Abused as Children: The Self-Trauma Model John N. Briers,Ph.D.,Associate Professor of Psychiatry and Psychology at the University of Southern California Medical School in Los Angeles, California. Boulder, Colorado. CEC: 14 hours. 1997-January: Wisconsin Sex Offender Video Series. Greeley, Colorado. 12 hours. 1996-November: The Association for the Treatment of Sexual Abusers(ATSA). New England Forensic Associates, Chicago, Illinois. CEC: 20 hours. 1996- October:Evaluation of Persons with PTSD. Dan Frantz, RN, MS, CS, Director, Mental Health Clinic, Denver Veterans Affairs. Greeley, Colorado. 4 Clock hours. 1996 - October: Connections - Domestic Violence and Child Maltreatment Linda S. Spears, Director of Child Protection for the Child Welfare League of America. University of Northern Colorado, Greeley, Colorado. CEC: 20 hours. 1996-August:Psychopathy and Criminal Behavior. Robert Hare,Ph.D.,and Steven D. Hart,Ph. D. of British Columbia. Colorado Sex Offender Treatment Board. Denver, Colorado. 8 Clock hours. 1996 -August: Mueller Sex Offender Treatment Progress Continuums. Charles M. Mueller, MSW,ACSW, BCD. Greeley, Colorado . 8 Cock hours. 1996-May: Understanding and Treating the Batterer:Greg White,MA,LPC. Greeley,Colorado. ADAD CEU: 7 hours. 1995-October:Supervisory Development Workshop: Lloyd Arnsmeyer, MA,; Sally Esscnburg; and Doug McCallum. Kansas City, Kansas. 24 Clock hours. 1987-May: Parent Effectiveness Training (PET): Certificate. Judith M. Rogers, BA. Hanau, West Germany. LITERATURE REVIEW Douglas,John.and Olshaker,Mark(1975) Mind Hunter:Inside the FBI's Elite Serial Crime Unit New York: Scribner 05/22/2006 13:58 9703530371 IGTS PAGE 16 Saminow,Stanton. The Criminal Mind. Forward Susan and Buck, Craig(1978). Betrayal of Innocence. New York: Penguin. Hare,Robert D. (1993). Without Conscience. The Disturbing World of The Psychopaths Among Us. New York: Simon& Schuster Inc. Marshall, W., Fernandez, Y., Hudson, S., Ward, T., (1998). The Source Book of Treatment Program for Offender:An Eleven Year Speculative of Working with Female Sexual Offenders by Jane Kinder Matthews. New York: Plenum Press. Salter, Anna C (1995). Transforming Trauma: A Guide to Understanding and Treating Adult Survivors of Child Sexual Abuse. Thousand Oaks, California: Sage. PROFESSIONAL ACTIVITIES University of Northern Colorado:Domestic Violence Overview and Treatment Methods. A three hour lecture for a Professional Psychology course. Professor Lia Softas-Nall, Ph.D. May, 2006. University of Northern Colorado:Domestic Violence Overview and Treatment Methods. A three hour lecture for a Professional Psychology course. Professor Lia Softas-Nall, Ph.D. July 2005. University of Northern Colorado:Domestic Violence Overview and Treatment Methods. A three hour lecture for a Professional Psychology course. Professor Lia Softas-Nall, Ph.D. March 2005. Metro State College: Domestic Violence Overview and Treatment Methods. Two, 90 minute lectures for a Professional Psychology: Psychology of Gender. Professor Vanessa Ewing. 3 hours of lecture time. December, 2004. University of Northern Colorado:Domestic Violence Overview and Treatment Methods. A three hour lecture for a Professional Psychology course. Professor Lia Softas-Nall, Ph.D. November, 2004. A Woman's Place: Treatment Process for Offenders of Domestic Violence. Provided training in the area of offender treatment for victim advocates in who were in training. University of Northern Colorado:Domestic Violence Overview and Treatment Methods. A three hour lecture for a Professional Psychology course. Professor Lia Softas-Nall, Ph.D. June, 2004. Metro State College: Domestic Violence Overview and Treatment Methods. A two hour lecture for a Professional Psychology:Psychology of Gender.Professor Vanessa Ewing. 1.5 hour of lecture time. April, 2004. University of Northern Colorado:Domestic Violence Overview and Treatment Methods. A two hour lecture for a Professional Psychology,Violence Against Women and Children. Professor Lia 05/22/2006 13:58 9703530371 IGTS PAGE 17 Softas-Nall, Ph.D. June, 2003. University of Northern Colorado:Domestic Violence Overview and Treatment Methods. A two hour lecture for a Professional Psychology,Violence Against Women and Children, Professor Lia Softas-Nall,Ph.D. February,2003. University of Northern Colorado:Domestic Violence Overview and Treatment Methods. A two hour lecture for a Professional Psychology, Violence Against Women and Children. Professor Lia Softas-Nall, Ph.D. March, 2002. University of Northern Colorado: Domestic Violence and Treatment Methods. Presented a lecture for the Psychology of Women class. Professor Lia Softas-Nall, Ph.D. February, 2001. Colorado Organization for Victims Assistance(COVA)121°Annual Conference:Awareness and Action in the Community: The Clothesline Project. A two hour presentation for an audience primarily consisting of victim's advocates in communities state wide. Co-presented with Anpeytu L. Raben, Director of Sexual Assault Survivors, Inc. Keystone Colorado,November 14,2000. Northeastern Region Restorative Justice Conference: The Impact of Crime on Victims. A two hour presentation for an audience primarily consisting of criminal justice employees. AIMS Community College, Greeley, Colorado, November 8, 2000. University of Northern Colorado:Domestic Violence Overview and Treatment Methods. A two hour lecture for a Professional Psychology,Violence Against Women and Children. Professor Lia Softas-Nall,Ph.D. June, 2000. Colorado School Counselor Association Conference: Family Dynamics of Domestic Violence. Conference presentation on basic components of domestic violence and its effects on all parts of the family. Two general sessions 4 hours. Denver Colorado. April 10, 2000 University of Northern Colorado: Assault Survivors Advocacy Program. Sex Offender Treatment. Presented a lecture on the differences between general mental health and scx offender treatment dynamics. April 3,2000. Denver Police Academy. Special Investigations: Sexual Abuse of Children. Presented lectures on the unique dynamics of sex offenders, with an emphasis on child molesters and pedophiles. June, 1999. Denver Police Academy. Special Investigations:Sexual Abuse of Children. Presented lectures on the unique dynamics of sex offenders, with an emphasis on child molesters and pedophiles. December, 1999. Weld County Pro Bono Program:Family Dynamics ofDomestic Violence. Presented with Deana Davies, MA, LPC. November, 1999. 05/22/2006 13:58 9703530371 IGTS PAGE 18 Emergency Medical Services Potpourri on Domestic Violence:Presented the Clothesline Project and lectured on treatment modalities for offenders and victims of domestic violence. Nov., 1999. University of Northern Colorado: How Children Are Affected By Domestic Violence. Presented a lecture for Masters Level educators. July, 1998. University of Northern Colorado: Domestic Violence and Treatment Methods. Presented a lecture for the Psychology of Women class. Professor Lia Softas-Nall, Ph.D. March, 1997. University of Northern Colorado: Motivation, Team Building and Effective Communication Training for supervisors and student employees of the University Center. 1994- 1996. A Woman's Place: Treatment Process for Offenders of Domestic Violence. Provided training in the area of offender treatment for victim advocates in who were in training. November, 1997; August, 1998; February, 1999; June, 1999; November 1999, and February 2000, October, 2000, February 2001. A Woman's Place: Community Outreach Lectures. 1994 to 1995. Individual & Group Therapy Services: Victims Perspective Training. 1996 to Present. STATE AND LOCAL COMMUNITY ACTIVITIES Executive Board Member for the Colorado Chapter of the Association of Sexual Abusers(CO- ATSA). (March 2003, to present.) Domestic Violence Offender Management Board Committee Member. (June 2003 to January 2004.) Co-Chair of the Weld County Coalition Against Domestic Violence. (January, 2000, to January 2002.) Executive Board Member for A Woman's Place. A shelter for women and children who are being battered (January, 1999, to December 2002). Co-Chair of the Potpourri/General Interest Workshop Track for the 2000 COVA Conference Committee. Co-Chair with Anpeytu Raben. June through November 2000. Victim Empact Panel: Committee Member and Trained Facilitator. May, 1998,to present. First PAGE for Primary prevention(Professional Assistance and Greeley Educators). Committee member. First PAGE advocates awareness and provides primary prevention and education for victims issues throughout the community. May, 1997, to December 1998. 05/22/2006 13:56 9703530371 IGTS PAGE 19 AWARDS AND RECOGNITIONS V-Day Warrior:A Community Service Award:Acknowledgment for outstanding achievement in the area of community safety, victim safety, and offender containment. Vagina Monologues: February 13,2004. Faye Honey-Knopp Memorial Award first annual). A full scholarship for attending the Association for the Treatment of Sexual Abusers (ATSA) conference was granted. Spoke at a reception in honor of Faye Honey-Knopp at ATSA on the merits of working with both offenders of violent crimes and victims of violent crimes. November, 1995. Sunshine Peace Award Nominee. National Coalition Against Domestic Violence (1998). State Personnel Employees Executive Counsel(SPEEC)Employee of the Month: University of Northern Colorado. September, 1995. DEPARTMENT OF SOCIAL SERVICES P.O. BOX A GREELEY, CO.80632 .tilet Website:www.co.weld.co.us ' Administration and Public Assistance(970)352-1551 Child Support(970)352-6933 C. COLORADO May 15, 2006 Kim R. Ruybal M.A., LPC,NCAC II Individual&Group Therapy Services 824 B 9 Street Greeley, CO 80631 Re: RFP 006-00: Mental Health Services Dear Ms. Ruybal: The purpose of this letter is to outline the results of the Bid process for PY 2006-2007 and to request written confirmation from you by Monday,May 22, 2006. A. Results of the Bid Process for PY 2006-2007 • The Families,Youth and Children(FYC)Commission recommended approval of your bid, 06MH09 (RFP 006-00), Mental Health Services, for inclusion on our vendor list. Your bid scored 93 points out of 100. The FYC Commission attached the following conditions to your bid. Condition#1: You must clarify how you will address the Spanish speaking population. Condition#2: You must provide proof that your staff is qualified to use the assessments listed in your bid. Condition#3: When referring Medicaid clients, providers other than Nelson,Wolf, and Associates should be considered. Condition#4: This bid(06MH09)is for mental health services only. Other services must be addressed in a separate contract or bid. Condition#5: Your bid did not provide clear and measurable outcomes. You must provide a more clear way of measuring outcomes in order to determine if your services are working, if they are being effective, and to what degree. Condition#6: The bidder will work with the Weld County DSS Business Office to set a rate per episode for completed evaluations. Hourly Rate for Court Testimony: You did not provide a rate for court testimony. For bidders carrying over services to 2006,the Department will use last year's court testimony hourly rate. The rate for court testimony will be billed at$100 per hour. Page 2 Individual&Group Therapy Services/Results of Bid Process 2006-2007 Compliance Item: You must provide the required letters under the Collaboration Section from Weld County/Greeley Housing Authority, employment/training partners,and other partners as identified in the bidder's assessment of needs. You must identify the process you will utilize to facilitate Medicaid eligible clients receiving mental health services at North Range Behavioral Health. B. Required Response by FYC Bidders 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 conditions.Please respond in writing to Gloria Romansik Weld County Department of Social Services,P. O. Box A, Greeley, CO, 80632,by May 22, 2006,close of business. You may fax your response to us at 970.346.7698. If you have questions concerning the above,please call Gloria Romansik at 352.1551, extension 6230. Sin erely, J A. Gji o,Dire r cc: Juan Lopez, Chair,FYC Commission Gloria Romansik, Social Hello