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Home My WebLink About20061589.tiff RESOLUTION RE: APPROVE THREE NOTIFICATION OF FINANCIAL ASSISTANCE AWARDS FOR OPTION B-HOME BASED INTENSIVE SERVICES WITH VARIOUS PROVIDERS AND AUTHORIZE CHAIR TO SIGN WHEREAS,the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS,the Board has been presented with three Notification of Financial Assistance Awards for Option B - Home Based Intensive Services between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Social Services,and various providers,listed below,commencing June 1,2006,and ending May 31, 2007, with further terms and conditions being as stated in said awards: 1. Lutheran Family Services 2. Reflections for Youth, Inc. 3. Nelson, Wolf, and Associates, P.C., dba Youth Emancipation and Services, Inc. WHEREAS,after review, the Board deems it advisable to approve said awards, copies of which are attached hereto and incorporated herein by reference. NOW,THEREFORE,BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, ex-officio Board of Social Services, that the three Notification of Financial Assistance Awards for Option B- Home Based Intensive Services between the County of Weld, State of Colorado,by and through the Board of County Commissioners of Weld County,on behalf of the Department of Social Services, and various providers listed above, be, and hereby are, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said awards. 2006-1589 SS0033 0 THREE NOTIFICATION OF FINANCIAL ASSISTANCE AWARDS FOR OPTION B - HOME BASED INTENSIVE SERVICES PAGE 2 The above and foregoing Resolution was,on motion duly made and seconded,adopted by the following vote on the 14th day of June, A.D., 2006, nunc pro tunc June 1, 2006. �I lEle ♦ BOARD OF COUNTY COMMISSIONERS �� WELD COUNTY LORADO ATTEST: ' /.tld �`II . J. 'le, Chair Weld County Clerk to the' •' ccir -' BY.) � /I' ( -�I, David E. Long, Pro-Tern De ClerkYo the Board Will H. Jerke ^n� _1 O M: �,. Vu �� A�Th Robert D. Masden rney /jet Date of signature: -16 14 Glenn Vaad 2006-1589 SS0033 **CORRECTED** rs t Q ;;Iss DEPARTMENT OF SOCIAL SERVICES P.O. A BOX GREELEY, CO. OX80632A Website:www.co.weld.co.us iglige Administration and Public Assistance(970)352-1551 Child Support(970)352-6933 COLORADO MEMORANDUM TO: M.J. Geile, Chair Date: May 31, 2006 Board of County Commissioners FR: Judy A. Griego, Director, Social Services tv41(A ( 1, 0 RE: Notification of Financial Assistance Award with Various Contractors— Home Based Intensive(Option B) Services Enclosed for your approval are Notification of Financial Assistance Awards with Various Contractors for Home Based Intensive(Option B) Services. The Department and the Families, Youth, and Children (FYC)Commission are recommending approval of these Awards. These Awards were reviewed at the Board's work session of May 24, 2006. The major provisions of these Awards are as follows: 1. The Award period is June 1, 2006 through May 31, 2007. 2. The source of funding is Core Services or Child Welfare Administration. 3. The Contractors will provide home based intensive(Option B) services to families involved in the child welfare system. 4. The Contractors include: A. Lutheran Family Services $80.00 hourly rate home based services $60.00 hourly rate court testimony B. Reflections for Youth, Inc. $90.75 hourly rate home based services $80.00 hourly rate court testimony C. Nelson, Wolf&Associates $100.00 hourly rate home based services $20.00 treatment package for roundtrip over 20 miles from Greeley $65.00 hourly rate court testimony If you have any questions,please telephone me at extension 6510. 2006-1589 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-0001 Revision (RFP-FYC-06010; 06OPB03) Contract Award Period Name and Address of Contractor Beginning 06/01/2006 and Lutheran Family Services Ending 05/31/2007 Option B,Home Based Intensive 3800 Automation Way, Suite 200 Fort Collins, CO 80525 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Services build upon primary family connections, Assistance Award is based upon your Request for helping parents improve their parenting abilities, Proposal (RFP). The RFP specifies the scope of identify parental strengths, identify and link services and conditions of award. Except where it is families to community resources and sources of in conflict with this NOFAA in which case the support, and support parental efforts to provide NOFAA governs, the RFP upon which this award is care for their children.Program is directed based is an integral part of the action. toward families,time limited and solution focused. Program provides for crisis Special conditions intervention. Capacity to serve 40 families per 1) Reimbursement for the Unit of Services will be based year,monthly average capacity 8, duration of on an hourly rate per child or per family. service to 12 weeks,2 hours per week.Bilingual 2) The hourly rate will be paid for only direct face to and South County Services. face contact with the child and/or family, as evidenced by client-signed verification form, and as Cost per Unit of Service specified in the unit of cost computation. Hourly Rate Cost Per Unit of Service 3) Unit of service costs cannot exceed the hourly and Hourly Rate Per $88.04 yearly cost per child and/or family. Individual Counseling 4) Payment will only be remitted on cases open with, and Family Counseling referrals made by the Weld County Department of Treatment Package-Intensive Social Services. Treatment Package-Moderate 5) Requests for payment must be an original submitted to Treatment Package-Low the Weld County Department of Social Services by the Early Intervention Program end of the 25th calendar day following the end of the Reunification month of service. The provider must submit requests Community Based Service for payment on forms approved by Weld County -Child Protection Depaitinent of Social Services. In-home Svcs for At Risk Delinquents 6) The Contractor will notify the Department of any Therapeutic Staffing changes in staff at the time of the change. Hourly Rate Per Court Testimony $60.00 Enclosures: X Signed RFP: Exhibit A Supplemental Narrative to RFP: Exhibit B _Recommendation(s) Condit' s of Approval Approvals: Progran Officia • By . /7 By M. J. Gei e, Chair Judy�. Grie o, Dire r I Board of Weld 4ty, mmissioners Weld ounty Departmentrt of Social Services Date: JUN L DD Date: S j0 co 0?a -/6 '? lZ�c bO(3 e INVITATION TO BID OFF SYSTEM BID 001-06 (06005--06011 and 006-00, A, B, & C) DATE: March 1, 2006 BID NO: RFP-FYC-06010 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-06010) for:Colorado Family Preservation Act--Home Based Intensive Family Intervention 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 Home Based Intensive Family Intervention Program is a family strength focused home-based service to families in crisis that are time limited, phased in intensity, and produces positive change, which protects children, prevents or ends placement, and preserves families. Services are provided primarily in the home of the client and include a variety of service elements of therapeutic, concrete, collateral, and crisis intervention services. 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 TYPED SR PRINTED SIGN RE VENDOR Lutheran Family Services of CO (Name) n en Si; ature B. Authorized Officer or •ent of Ve der ADDRESS 3800 Automation Way, Ste. 20 TITLE Fort Collins, CO 80525 DATE /de, �1' PHONE# (970) 266-1788 The above bid is subject to Terms and Conditions as attached hereto and incorporated. Page 1 of 42 Bid 001-06 (RFP-FYC-06010) Attached A HOME BASED INTENSIVE FAMILY INTERVENTION 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 (06010) NAME OF AGENCY: Lutheran Family Services of Colorado ADDRESS: 3800 Automation Way, Suite 200 Fort Collins, CO 811525 PHONE(970) 266-17RR CONTACT PERSON: Sherre DeManche TITLE: Program Director DESCRIPTION OF FAMILY PRESERVATION PROGRAM CATEGORY: The Home Based Intensive Family Intervention Program is a family strength focused home-based services to families in crisis which are time limited,phased intensity, and produce positive change which protects children.prevents or ends placement, and preserves families. 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: Home Based Intensive Family Intervention Program - Option B Sherre DeManch:� ,� f 3/30/06 Name and Signature of Person Prep. :. ►cument Date James Barclay 3-30-06 Name and Signature Chief rative Offic Applic. Agency Date MANDATORY PROPOSAL REQUIREMENTS For both new and eturning bidders,please initial to indicate that the following required sections are included in this Proposal r id. oject Description arget/Eligibility Populations Types of services Provided easurable Outcomes ervice Objectives orkload Standards Proof of Collaboration Evidenced-based Outcomes Staff Qualifications Unit of Service Rate Computation Billing Process Program Capacity per Month ertifrcate of Insurance Page 29 of 42 Core Services Proposal—Option B RFP-FYC-06010 Home-Based Intensive Family Intervention Lutheran Family Services of Colorado PROJECT DESCRIPTION Lutheran Family Services of Colorado(LFS) is a community-based agency with an experienced staff that offers a wide range of services to children,families and adults. It is a nonprofit agency that has provided human services in Colorado since 1948. Although the agency was established as an affiliate of the Lutheran Church, it is an equal opportunity agency that provides services to all individuals without consideration of religious beliefs, race, ethnicity, gender or economic status. The purpose of the Home-Based Intensive Family Intervention Program is to promote the safety and well being of children and their family members by reducing the risk of child maltreatment in the home, reducing the risk of imminent placement out of the home and/or assisting with reunifying children with their families. The services provided through this program will build upon primary family connections, help parents improve their parenting abilities, identify parental strengths, identify and link families to community resources and sources of support,and support parental efforts to provide care for their children. The program is directed toward families, focused on family strengths, is protective of children, prevents placement or reunifies children and their families, is time limited, and solution-focused. Families must be receptive to the services; however, exceptions are made for families who are ordered by the court to obtain these services. The program will expedite the return of children to their families and assist in creating a stable and nurturing family environment in which children can grow and develop. If children are returning to their permanent home from out-of-home care,we intend to help them reintegrate and stabilize in the family system as soon as possible. The program goal is to improve both individual and family functioning in a time- limited, solution-focused manner. We will provide crisis intervention services and will link families to additional community resources throughout the duration of the families' involvement with our agency. The Home-Based Intensive Family Intervention Program combines all of the elements listed below. Elements included: • Short Term(an average of 10 weeks of service duration) • Intensive(a maximum.of 20 hours of direct service,an average of two hours of direct service weekly) • Home-Based (service is provided in the family's natural environment) • Individualized (treatment focuses on the family's specific strengths and needs) • Solution-Focused (brief counseling provided on areas of greatest risk in the family) • Strength-Oriented(intervention builds on behavioral strengths of family members) • Family and clinician as partners(emphasizes relationship between family and clinician;treatment based on family's expertise) We will use the Adult-Adolescent Parenting Inventory to assess parental values. II. TARGET/ELIGIBILITY POPULATIONS: Because referrals come to LFS from Weld County Department of Social Services(DSS)caseworkers, the decision that a child is at imminent risk of out-of-home placement has been made prior to the referral of the family to LFS for home-based therapy services. However, if during the process of working with a family unit an LFS staff member feels that a child is in imminent danger, we will immediately contact Weld County DSS to discuss the conditions that exist in the family to determine whether they meet the criteria as defined in 26-5.3-103(2), C.R.S. • feels that a child is in imminent danger,we will immediately contact Weld County DSS to discuss the conditions that exist in the family to determine whether they meet the criteria as defined in 26-5.3-103(2), C.R.S. Families considered as the appropriate target population for these services are those in which family members are facing problems that have affected their well-being, safety, psychosocial growth and development, and family stability. Families in the midst of a transition, such as reunification, are also appropriate for this program. Families mandated or referred by the courts will be considered for the Option B program contingent upon their willingness to participate in and ability to profit by participation in such services. Primary caregivers must demonstrate a desire to maintain family relationships and must possess the mental stability to utilize home-based services. Children must be at imminent risk of out-of-home placement or have been removed from the home with imminent return expected. Clients will not be eligible for this program if they can be successfully treated with less intensive service programs and those services have not yet been tried. Families appropriate for this program should be able to benefit from services that are primarily therapeutic in nature(vs. concrete and collateral services). The provision of services will have a reasonable possibility of diminishing or ameliorating the problematic behaviors/issues in the home. There must be a manageable level of risk of harm to the child and/or among family members. A. Total number of clients to be served: 40 families or 160 individuals B. Total individual clients and the children's ages: The maximum number of individuals to be served would be 160(with the average family consisting of four members) with the ages of children ranging from birth to 18 years old. C. Total family units: 40 families This estimate is based on an average of 20 hours of direct service per family provided over a 10 week period of time (approximately 2 hours per week of direct service). We have budgeted 1 FTE of professional staff time to this program. D. Sub-total of individuals who will receive bicultural/bilingual services: 40(10 families) We have one bilingual master's level clinician on staff, and we have not experienced a significant increase or decrease in referrals of families who are monolingual and speak Spanish. However, in anticipation of this need within Weld County,we have budgeted approximately one quarter of our clients to receive bicultural/bilingual services. The development of treatment plans takes into consideration culturally appropriate issues,family values and family strengths, and the family is actively involved as part of the team in developing treatment goals and objectives. Spanish classes and materials are also available. E. Sub-total of individuals who will receive services in South Weld County: 32(8 families) This estimate is based on one fifth of our cases being from South Weld County. F. Crisis Intervention Services The weekly hours may be increased from the average two to accommodate unexpected crisis situations. Clinicians, or a backup supervisor,are available through our Ft. Collins office or by cell phone from 8:00am until 5:00pm. G. The monthly maximum program capacity: 10 family units This estimate is based on providing two hours of direct service per week per family unit. We have budgeted 1 FTE (20 hours of direct service per week)of professional staff time to this program. We have a total of five clinicians who are available to provide services if needed for an increased number of referrals. H. The monthly average capacity: 8 family units This estimate is based on an average of 20 hours of direct service per family provided over a 10 week period of time (2 hours per week of direct service). We have budgeted 1 FTE (40 hours per week)of professional staff time to this program. I. Average stay in the program(weeks): 10—12 weeks (20 hours of direct service) J. Average hours per week in the program: 2 hours This estimate is based on 20 hours of direct service per family provided over a 10 week period of time. K. See D. L. See E. 2 • III. TYPES OF SERVICES TO BE PROVIDED LFS offers services with a family-based focus. LFS will provide family therapy, crisis intervention, information and referral services, and will focus on skill building within the family. The program goals are to improve functioning of all family members and their interactions;to alter dysfunctional patterns of behavior in families; and to increase family functioning,cohesion and adaptability through the use of corrective attachment experiences. The program includes the following therapeutic elements: home-based, solution-focused, crisis oriented and strengths-based. Therapy is designed to resolve conflicts and disagreements within the family with specific goals identified using a structured and directive brief therapy modality. Services will be provided in a family's environment whenever possible and appropriate. We believe that this treatment approach reduces the stress on the family by reducing the need for the family to adjust to our environment. We further believe that we can provide more appropriate treatment in the family's natural environment. Lastly,we believe that in order to provide brief, solution-focused therapy to families that likely have more chronic needs, a concrete transition plan upon case closure is imperative. A. Brief, Solution-Focused Therapeutic Intervention: The duration of services for each referral is limited to 20 hours of face-to-face contact per referral for a period of approximately 10 weeks. Weekly family therapy sessions will be designed to provide comprehensive,diagnostic and treatment planning with the family and other service providers. Therapeutic interventions will be flexible enough to bring in other service providers, if needed. The clinician will provide home-based, short-term, solution-focused therapy which will include the development of problem solving and coping skills, strengthening of the family's communication skills, addressing the current parenting practices and developing healthier parenting habits,working with the family on parent-child conflict management skills, aiding in the transition of reunification, etc. Therapy is designed to resolve conflicts and disagreements within the family with specific goals identified using a structured and directive brief therapy modality. B. Concrete Transition Planning and C. Collateral -Community Resource Linkage The clinician will assist the family in accessing and utilizing community resources to deal with particular risk areas identified (ex: access to health care, housing,employment, extracurricular activities, support groups,continuing therapy,etc). The family's effective use of community resources is an imperative goal within this program, as accessing resources is generally a core issue for families who have achieved a level of stress that would indicate a need for family preservation services. Furthermore, access to community resources reduces isolation and increases support for the family. D. Crisis Intervention Services The Referral Coordinator or Supervisor will be available to process referrals at any time during the normal forty hour work week, and will respond to matching the family with a Clinician and scheduling services as quickly as possible. Clinicians, or a backup supervisor, will be available for contact from 8:00am to 5:00pm either through the Ft. Collins office or through individual cell phones carried by each Clinician. The regularly scheduled weekly time may be increased, if necessary,to meet crisis needs. IV. MEASURABLE OUTCOMES See the attached assessment outline(Attachment A)which will be used by the Clinicians and the family to provide a baseline of the family functioning and an outline of target areas for goals. This outline will also be used for monthly progress reports and as a final report to measure improvement during the service period. This outline will assist in assessing the family system and identifying/addressing areas of intervention to interrupt, break and reconstruct maladaptive family patterns; identifying family strengths and maximizing these strengths; and offering concrete alternatives to problematic behaviors. A. Child remains in the home at the time the case is closed: measured by the status of the child's residence at closing 3 B. Improvements in parental competency and improvements in parent/child conflict management, will be measured through constructs on the AAPI and through the clinician's case documentation, We estimate that 80% of families will improve in this area, i.e., will evidence changed or improved scores and documentation of improved family management skills. . C. Children who are currently in their own home will remain in their own home 12 months after the completion of Home Based Intensive Family Intervention family preservation services: measured by observation by the Weld County Department of Social Services. D. Children currently in long-term placement who are provided reunification Home-Based Intensive Family Intervention services will return to their own home and not reenter out-of-home placement 12 months after completion of services: measured by observation by the Weld County Department of Social Services. E. Families who receive either family preservation or reunification services will not have a substantiated abuse or neglect 12 months after completion of Home-Based Intensive Family Intervention services: measured by observation by the Weld County Department of Social Services. The child's living arrangements will be documented at the time the case is closed. (Is the child still in the home?). An aftercare plan for each family will be developed which includes referral to a less intensive family counseling program and/or the use of informal and community resources,such as family self-help groups or support network. V. SERVICE OBJECTIVES Education about child development, parenting skills and understanding the unique nature of each parent/child relationship helps parents find their own solutions to the problems they face in family relationships. Parents are also helped to find community resources to maintain stability and problem solve in case of crisis. Objective 1. When determined as a need, no less than 80%of individual/foster family households will show improved family conflict management as demonstrated by increased ability to resolve conflicts in a healthy manner, lessened child maltreatment issues, lessened incidents of domestic violence and decreased incidents of delinquent behavior in the children. Objective 2. When determined as a need, no less than 85%of individual/foster family households will show improved household management competencies as demonstrated by an improved financial situation, increased habitability of residence, equitable division of household responsibilities, etc. Objective 3. When determined as a need, no less than 80%of individual/foster family households will show improved ability to access resources as demonstrated by the number of encounters with community agencies, healthcare providers, schools, etc. Objective 4. Issues specified in the referral from the Department of Social Services will be addressed with the family and included, as necessary, in the assessment and goal planning process. VI. WORKLOAD STANDARDS A. Number of hours per day,week or month: average of 2 hours per week per family. • B. Number of individuals providing the services: 1 FTE Five master's level Clinicians are available to provide up to 1 FTE of professional staff time to this program. C. Maximum caseload per worker: 1 FTE with a maximum of 8 cases per week. D. Modality of treatment: Intervention with children and families is theoretically based in Attachment, Child Development and Family Systems theories. The program includes home-based, solution-focused, crisis oriented and strengths-based elements. See Attachment B for a partial bibliography of the research foundation for these theories. E. Total number of hours per day/week/month: average of 2 hours per week per family F. Total number of individuals providing these services: 1 FTE We have budgeted 1 FTE of professional staff time to this program. We have a total of five masters clinicians who could provide services. G. The maximum caseload per supervisor: 1:8 H. Insurance: See Attachment C. VII. PROOF OF COLLABORATION Upon assessing the needs of each family,the service provider will offer referral assistance to various community resources. In order to maximize success and change,the provider will be available to proactively work with families in order to insure connections are made. These community resources will then serve to help parents maintain stability and problem solve in case of crisis. The LFS staff member will be available to arrange and conduct multi- agency staffings as needed and a staff member will be available to attend Core Review Team meetings at the Department of Social Services. VIII. EVIDENCE BASED OUTCOMES Attachment B is a bibliography of research that is used as a foundation for the service provided by Lutheran Family Services. In addition, a theoretical framework based in Attachment, Child Development and Family Systems theory is applied. In order to ensure that the process will be solution-focused and time-limited, a standard outline(see Attachment A)will be used for assessment, monthly reporting and discharge report. IX. STAFF QUALIFICATIONS A. Minimum qualifications in education and experience Clinicians assigned to this program are qualified by a master's degree in social work or another human service field. (See Attachment D) B. Total number of staff Direct services for this program would be provided by one or more of five masters level clinicians. Referral intake, initial staffing assessment, and ongoing supervision of services and reporting documentation will be provided by a Program Director with over twenty-five years of experience and a Referral Coordinator with ten years of experience in child welfare/child protection. In addition, a contract LCSW clinical consultant with over fifteen years of child welfare experience will be available for supervision as needed. The Referral Coordinator, Program Director, Clinical Consultant and one of the available master's level clinicians have experience in county departments of social services, participating in new worker training and risk assessment training. 5 X. UNIT OF SERVICE RATE COMPUTATION The required budget spreadsheet is attached. (See Attachment E) XI. BILLING PROCESS Billing will occur on the County's prescribed billing forms and will be accompanied by the client verification form signed by all family members present when services are provided. Time will be calculated in quarter hour increments and only face-to-face time will be billed. The monthly report(see Attachment A)will accompany the filling forms and the entire packet will be submitted to the County by the 25th of the month following the service month. 6 Bid 002-05 (RFP-FYC-06005) Attached A Date of Meeting(s)with Social Services Division Supervisor: - I:3 C (- Comments by SSD Supervisor ,, • - /lir1vhtifl , Chi ,, Art ? 6 tilk ! : Rt '[ f 'v-/�itcl— (t�.l ii! r,(,. 4 . it: \- (4 G vi A (( ,t l e b �'ti , , i r .4 ' r.( k L (1jc ,Ail .L- q -i i .; ,, ', li, Lit : , ft I d ii t3— k 'TCCII —-7pr7 j r, L :1) -r 4 Name and Signature of SSD Supervisor Date Page 31 of 41 ►4TTA-C-A-kitkENT 4 I. REASON FOR REFERRAL Who referred Questions or reasons for referral Date referred Etc. (Sections II through V are OBSERVATIONS/DATA which support ASSESSMENT) II. NURTURING A. Attachment behaviors 1. Reunions 2. Feeding/ snacks 3. Proximity a. eye contact b. physical contact with parent ii. Who initiates iii. When initiated? Comfort seeking? Taking care of parent? Sharing? iv. who disconnects from interaction, child or parent? What precipites disconnect? See pattern? B. Reciprocity 1. Reading Cues 2. Empathy 3. Mutual Pleasure/satisfaction 4. How long is dialogue sustained? III. SIMULATION A. What is `content" of interaction? (game, activity, conversations, etc.) B. What is quality of dialogue? 1. Enthused, animated? 2. Parent teaches, supports—or criticizes? 3. How long is dialogue sustained? a. who disconnects/initiates b. abrupt disconnect? why, who c. mutual satisfaction, completion of task? d. emotional tone of dialogue C. How does parent facilitate/inhibit development a. cognitive b. speech c. social d. emotional e. physical IV. PROTECTION A. Physical protection of infants and toddlers B. Limit setting, all ages 1. tone, demeanor 2. flexibility v. rigidity 3. age appropriate 4. consistency 5. efficacy C. Parent sets appropriate boundaries? 1. not intrusive 2. emotionally available, responsive 3. emotional boundaries 4. physical boundaries D. Parent takes interest in child's life outside visit 1. exhibits guidance and support to child 2. helps child adjust/accept placement? 3. helps child problem solve 4. seeks to be aware/involved in child's: a. education b. healthcare c. mental health treatment d. other 5. parent communicates with infant or toddler's caregivers a. about feeding b. about routines c. development d. other V. PARENT'S ATTITUDE TOWARD VISIT A. How cooperative with structure, suggestions B. Acknowledges problems? C. Attitude toward clinician VI. ASSESSMENT A. Attachment category(secure, avoidant, ambivalent, disorganized) B. Healthy aspects of relationship C. Unhealthy aspects of relationship D. Effect on child VII. PLAN, GOALS 11774- FMCTIT L) Attachment B: Bibliography of Foundational Research Diagnostic Classification: 0-3, Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood, Washington, D.C.: Zero to Three National Center for Infants, Toddlers, and Families Chazan, Saralea E., The Simultaneous Treatment of Parent and Child, New York: Basic Books, 1995. Fahlberg, Vera, A Child's Journey through Placement, Indianapolis: Perspectives Press, 1991. Greenspan, Stanley I., Developmentally Based Psychotherapy, Madison: International Universities Press, 1997. Karen, Robert, Becoming Attached: Unfolding the Mystery of the Infant Mother Bond and Its Impact on Later Life,New York: Warner Books, 1994. Meisels, Samule J., and Emily Fenichel, eds., New Visions for the Developmental Assessment of Infants and Young Children, Washington, D.C.: Zero to Three: National Center for Infants, Toddlers, and Families, 1996. Schore, Allan N., Affect Dysregulation and Disorders of the Self,New York: W. W. Norton & Company, 2003. Seigel, Daniel, The Developing Mind, New York: The Guilford Press, 1999. Wasik, Barbara, et. al., Home Visiting: Procedures for Helping Families, London: SAGE Publications, 1990. ATTJ4&Iat N7 C ACORC?e CERTIFICATE OF LIABILITY INSURANCE 03/30/26 PRODUCER (800)200-7257 FAX (636)724-3443 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Lutheran Trust ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 70 Corporate Hills Drive ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Suite 101 St. Charles, MO 63301 INSURERS AFFORDING COVERAGE NAIC# INSURED Lutheran Social Services of Colorado INSURERA: GuideOne Specialty Mutual Ins 14559 DBA: Lutheran Family Services of Colorado INSURER B. GuideOne Mutual Insurance Co. 15032 363 South Harlan St, Suite 200 INSURER Denver, CO 80226 INSURER D INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADM. TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITSITR INSRII DATEI W MMIDD/WI DATE IMMATDII GENERAL LIABILITY 1213-263 07/01/2005 07/01/2006 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DRAMA `OIFn RE`NfEren N $ 1,000,000 CLAIMS MADE n OCCUR MED EXP(Any one person) $ 5,000 A X Includes Social PERSONAL B ADV INJURY $ 1,000,000 Workers/Counselors GENERAL AGGREGATE $ 3,000,000 �GEN'L AGGREGATE LIMIT I APPLIES PER'. PRODUCTS-COMP/OP AGG $ 3,000,000 POLICY n jECT n LOC AUTOMOBILE LIABILITY 1757-711 07/01/2005 07/01/2006 COMBINED SINGLE LIMIT (Ea accident) $ X ANY AUTO 1,000,000 ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) B HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ per accident) GARAGE LIABILITY AUTO ONLY EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLALIABIUTY 9618-912 07/01/2005 07/01/2006 EACH OCCURRENCE $ 4,000,000 X I OCCUR n CLAIMS MADE AGGREGATE $ 4,000,000 B $ DEDUCTIBLE $ X RETENTION $ 10,000 $ WORKERS COMPENSATION AND I TORY LIMITS I I3 R EMPLOYERS'LIABILITY E L EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE . . OFFICER/MEMBER EXCLUDED? E .DISEASE-EA EMPLOYEE $ If yes desuibe under SPECIAL PROVISIONS belrnv E .DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS :ertificate holder shown is listed as an additional insured for general liability regarding work with Lutheran Social Services of Colorado. CERTIFICATE HO DER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Weld County Social Services Attn: Judy A Greigo, Director BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY P 0 Box A OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Greeley, CO 80632 AUTHORIZED REPRESENTATIVE (`.- Kermit StarnesII/JUNE K }j� }'.v- ACORD 25(2001/08) ©ACORD CORPORATION 1988 4 1'l Vt-tb{lkt ENTLu Northern Colorado Program—3800 Automation Way, Suite 200, Ft. Collins, CO 80525 heran Family Services Disclosure Statement Colorado Law requires that the following information be provided to all clients. The Department of Human Services licenses the Lutheran Family Services'Foster Care program. Visitation and several program components of the Fostering Family Strengths are provided through contracts with individual Colorado counties. We are required to provide you with the following information from the Division of Child Care, Colorado Department of Human Services 1575 Sherman St, 1st Floor Denver, CO 80203-1714. Phone(303)866-5958. 1. To review the licensing file of an adoption/child placement agency call: 303 866-5088 or 1-800-799-5876. 2. To file a complaint about a licensed adoption/child placement agency call:303 866-3755 or 1-800-799-5876. 3. To obtain a copy of all licensed adoption/child placement agencies in the state of Colorado call Division of Child Welfare:303 866-3228 or Division of Child Care at 303 866-5958 or 1-800-799-5876. 4. Copies of the regulations(Minimum Rules and Regulations for Child Placement Agencies—Commodity#615-82-14- 4442)governing adoption/child placement agencies are available for a charge at: Colorado State Forms and Publication Center,4200 Garfield St, Denver, CO 80216-6517. Phone 303 321-4164. Call to verify cost. In addition,the Department of Regulatory Agencies regulates the practice of licensed and unlicensed persons in the field of psychotherapy. Lutheran Family Services registers with the Department of Regulatory Agencies staff members who provide therapy services. Concerns or complaints regarding the practice of psychotherapy may be directed to the State Grievance Board at 1560 Broadway, Suite 1370, Denver, CO 80202. Phone: (303)894-7766. Program's Methods of Treatment: The program is based on systems theory,where we treat the child and their environment; therefore you will see a focus on family therapy. We also have a strengths based philosophy so we will help the child/family to identify strengths and increase those strengths in order to mitigate any difficulties. We will do behavioral therapy,generally,through consultation with the adult caregiver in order to help the family manage the child's problematic behaviors. Lutheran Family Services does not use any treatment methods that are considered 'aversive'therapies. In a professional relationship, sexual intimacy is never appropriate and should be reported to the Grievance Board. Generally speaking,information provided by you during treatment is legally confidential. Exceptions occur when a consumer is in imminent danger to self or others,when gravely disabled,when there is suspected child abuse or neglect,when your case is reviewed in supervision, consultation, and training,or when ordered by a court of law. SHERRE DEMANCHE CARRIE LANDERS BACHELOR OF ARTS IN RELIGION MASTER OF SOCIAL WORK Program Director—Foster Care and Family Services JANELL PIRTLE Community Outreach Coordinator BETSY BAIER MASTER OF SOCIAL WORK LICENSED CLINICAL SOCIAL WORKER—CSW#90 MASTProgram ER OF SOCIAL WORK Foster Care Licensing Specialist stes Director FLO HOLT Fostering Family Strengths IRD MASTER OF ARTS IN GUIDANCE/COUNSELING MR OF SOCIAL WORK LICENSED PROFESSIONAL COUNSELOR-#3181 MASTER Clinician LICENSED R CLINICAL SOCIAL WORKER—Lic.#989653 JULIE MALLORY Clinical Consultant JOE MADRID BACHELOR OF COMMUNITY HEALTH Treatment Manager MASTER OF SOCIAL WORK LICENSED CLINICAL SOCIAL WORKER-Lic.#991556 Clinician KRISTEN CHAMBERLAIN TOILYNMASTER OF SOCIAL WORK BACHELOR N EDWARDS LICENSED CLINICAL SOCIAL WORKER-CSW#479 e OF ARTS IN SOCIAL WORK Clinician Referral Coordinator and Treatment Manager TAHNEE CARLSON SHELBY DURKEE MASTER OF HUMAN DEVELOPMENT&FAMILY STUDIES MASTER OF SOCIAL WORK Clinician Clinician CHRISTINA GOMEZ CHERYL WILKINSON MASTER OF HUMAN DEVELOPMENT&FAMILY STUDIES BACHELOR OF ARTS IN SOCIOLOGY Clinician Family Educator KARA CONNELL JANELLE SPEARS MASTER OF SOCIAL WORK BACHELOR OF SCIENCE IN HUMAN DEVELOPMENT&FAMILY LICENSED CLINICAL SOCIAL WORKER-LIc.#992948 STUDIES Clinician Treatment Manager CARLA FELTS BACHELOR OF ARTS IN SOCIAL WORK Treatment Manager Z:\Foster Care Forms\Foster Child\Placement process\4. Disclosure Statement-North CO.doc 3/29/06 I have been informed of the proper procedure to file a complaint to the State Department of Human Services, Division of Child Care. I have read and understand the treatment modalities used by Lutheran Family Services' Programs. I have been informed of the degrees, credentials and licenses of the staff members of Lutheran Family Services. I have read the preceding information and understand my rights as a consumer. Signature of Consumer Date Signature of Consumer Date Signature of Guardian (if a minor) Date Z:\Foster Care Forms\Foster Child\Placement process\4. Disclosure Statement-North CO.doc 3/29/06 � E. 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F t f 0 o a O Y 1p„-=E,!t`T O O O co — a DEPARTMENT OF SOCIAL SERVICES P.O.BOX A GREELEY,CO.80632 Website:www,co.weid.co.us Writ!IlDChild Administration and Public Assistance(970)352-1551 Support(970)352-6933 O May 15,2006 JamesBarc ay RA F T •JOO Lutheran Family Services 3800 Automation Way, Suite 200 Fort Collins,CO 80525 Re: Bid ft 06OPB03 (RFP 06010)Option B, Home Based Intensive Services Bid#06LS 11 (RFP 06005),Lifeskills Dear Mr. Barclay: The purpose of this letter is to outline the results of the Core Bid process for PY 2006-2007 and to request written information or 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 ft 06OPB05, (RFP 06010)Option B-Home Based Therapy)for inclusion on our vendor list. Your bid scored 98 points out of 100. • The Families, Youth and Children(FYC)Commission recommended approval of your Bid #06LS 11, Lifeskills, (RFP 06005)for inclusion on our vendor list. Your bid scored 94 points out of 100. Compliance Item: For both bids listed above,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. The Weld County Department of Social Services is requesting your written response to the FYC Commission's compliance item listed above. Please respond in writing to Gloria Romansik, Weld County Department of Social Services, P.O.Box A,Greeley, CO, 80632, by Wednesday, 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, 970.352.1551 extension 6230. Sincerely, a y A. 'ego, D. ctor cc: Juan Lopez, Chair,FYC Commission 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 FY 06-CORE-60 Revision (RFP-FYC-(06010; 06OPB07) Contract Award Period Name and Address of Contractor Beginning 06/01/2006 and Reflections for Youth, Inc. Ending 05/31/2007 Option B—Home Based Intensive 204 West County Road 10.5,P. O.Box 1860 Berthoud CO 80573 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Assistance Solution-focused therapy to decrease conflict in the Award is based upon your Request for Proposal(RFP). home and increase communication and positive The RFP specifies the scope of services and conditions of outcomes through skills training, education and award. Except where it is in conflict with this NOFAA in access to other community agencies including mental which case the NOFAA governs,the RFP upon which this health,drug and alcohol services, educational award is based is an integral part of the action. systems and recreational systems. Capacity for 10 Special conditions families concurrently, for a total of 20-30 hours of 1) Reimbursement for the Unit of Services will be based on an services per week, for a total capacity of 40 families hourly rate per child or per family. per year. South County services available. 2) The hourly rate will be paid for only direct face-to-face contact with the child and/or family,as evidenced by client- Cost Per Unit of Service signed verification form, and as specified in the unit of cost Cost Per Unit of Service computation. Hourly Rate Per $90.75 3) Unit of service costs cannot exceed the hourly,and yearly Individual Counseling cost per child and/or family. Family Counseling 4) Rates will only be remitted on cases open with,and Treatment Package-Intensive referrals made by the Weld County Department of Social Treatment Package-Moderate Services. Treatment Package-Low 5) Requests for payment must be an original and submitted to Early Intervention Program the Weld County Department of Social Services by the end Reunification of the 25th calendar day following the end of the month of Community Based Service service.The provider must submit requests for payment on -Child Protection forms approved by Weld County Department of Social In-home Svcs for At Risk Delinquents Services. Therapeutic Staffing 6) The Contractor will notify the Department of any change in Hourly Rate Per Court Testimony $80.00 staff at the time of the change. Enclosures: X Signed RFP: Exhibit A Supplemental Narrative to RFP: Exhibit B X Recommendation(s) _Conditions of Approval Approvals: Program fficial: By By M. .Gei e,Chair Judy riego, irector Board of Weld County o Commissioners Weld unty D partment o Social Services 1 Date: JUN 4 2016 Date: S/3 1/Ole & 6 /S39 — Bid 001-06 (RFP-FYC-06010) Attached A HOME BASED INTENSIVE FAMILY INTERVENTION 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 (06010) NAME OF AGENCY: Y lj .ggecinv 1 L . ADDRESS: R.t •"T, I, to sm co <t5T1 PHONE(�+Q�u d . 5.19 R-O a\-A„.0 $ S-Ibt StRefic_semaikit. r11' mlid CONTACT PERSON: C0Ji-o\ IV}pfl L M 1 T TITLE: C .V i\ ?Nut1 151 DESCRIPTION OF FAMILY PRESERVATION PROGRAM CATEGORY: The Home Based Intensive Family Intervention Program is a family strength focused home-based services to families in crisis which are time limited,phased intensity,and produce positive change which protects children,prevents or ends placement,and preserves families. 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: %gal%-%W ) ,\\1 tla5w CAI-\l 11 ,t‘i rt. 9:fc6,, Name and a e of Person Preparing Document Date S Name and ' alure of Adminislraa ve Officer Applica&Zt Agency Date • MANDATORY PROPOSAL REQUIREMENTS For both new and returning bidders,please initial to indicate that the following required sections are included in this Proposal for id. Project Description Target/Eligibility Populations dcTypes of services Provided Measurable Outcomes Service Objectives Workload Standards Proof of Collaboration Evidenced-based Outcomes Staff Qualifications Unit of Service Rate Computation Billing Process Program Capacity per Month Certificate of Insurance Page 30 of 42 The proposal must obtain minimum points of 75%of total possible points to be considered for funding. Attachments A. Colorado Family Preservation Act Bid Proposal Page 29 of 42 Bid 002-05 (RFP-FYC-06005) Attached A Date of Meeting(s)with Social Services Division Supervisor: "4-f' (. cois by SSD Su. .sor. L - - , . Nom. ' / � •l i , 4 ' s_ . L._ 7 Q , .L�, L it K > i b, ' .1 ‘,1_, ' U i 11:Pv er &T /kNP trW ! . un Name and Signature of SSD Supervisor Date Page 31 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-06010 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-06010) for:Colorado Family Preservation Act--Home Based Intensive Family Intervention 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 Home Based Intensive Family Intervention Program is a family strength focused home-based service to families in crisis that are time limited,phased in intensity, and produces positive change,which protects children,prevents or ends placement,and preserves families. Services are provided primarily in the home of the client and include a variety of service elements of therapeutic, concrete, collateral, and crisis intervention services. 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 4 �L (After receipt of order) B E SIGNED 1N INK !� T D PRINTED SIGNATURE VENDOR ?L@'\,\QUn 0(- • (Name) and gnature By Authorized (y Officer&Agent of Vender ADDRESS r . %Q� \IN° TITLE C %ura' ' 11(0:1Ad at %ek\A `N q 2 c)51 DATE 3.1 CAp PHONE# (a`l0) S fl • 5`l°th The above bid is subject to Terms and Conditions as attached hereto and incorporated. Page 1 of 42 Bid 001-06/RFP-FYC 06005 through 06011 and 006-00,A,B,& C • TERMS AND CONDITIONS RFP-FYC-06005 through 06011 and 006-00,A,B,& C 1. The provider agrees it is an independent provider and that its officers and employees do not become employees of Weld County,nor are they entitled to any employee benefits as Weld County Employees if this RFP/Bid is accepted bythe Board of County Commissioners. 2. Weld County,the Board of County Commissioners of Weld County,its officers and employees, shall not be held liable for injuries or damages caused by any negligent acts or omissions of the provider or its employees,volunteers, or agents while performing duties as described pursuant to this RFP/Bid. The provider shall indemnify,defend, and hold harmless Weld County,the Board of County Commissioners of Weld County, its employees;volunteers;and agents. The provider shall furnish adequate liability and workers' compensation insurance for all its employees,volunteers, and agents engaged in the performance as prescribed under the RFP/Bid. 3. No portion of this RFP/Bid shall be deemed to constitute a waiver of any immunities the parties or their officers or employees may possess,nor shall any portion of the RFP/Bid be deemed to have created a duty of care with respect to any persons not a party to this RFP/Bid. 4. No portion of this RFP/Bid shall be deemed to create an obligation on the part of the County of Weld, State of Colorado,to expend funds not otherwise appropriated in each succeeding year. 5. If any section, subsection,paragraph, sentence, clause,or phrase of this RFP/Bid is for any reason held or decided to be unconstitutional, such decision shall not affect the validity of the remaining portions. The parties hereto declare that they would have entered into this RFP/Bid and each and every section,subsection,paragraph, sentence,clause, and phrase thereof irrespective of the fact that any one or more sections, subsections,paragraphs, sentences,clauses, or phrases might be declared to be unconstitutional or invalid. 6. No public official or employee of Weld County,Colorado, and no member of their governing bodies shall have any pecuniary interest, direct or indirect,in the approved RFP/Bid or the proceeds thereof. 7. The provider assures that they will comply with Title VI of the Civil Rights Act of 1986 and that no person shall,on the grounds of race,creed, color,sex,or national origin,be excluded from participation in,be denied the benefits of,or be otherwise subjected to discrimination under an approved RFP/Bid. 8. The provider assures that sufficient, auditable, and otherwise adequate records that will provide accurate,current,separate,and complete disclosure of the status of the funds received under the RFP/Bid are maintained for three(3)years or the completion and resolution of an audit. Such records shall be sufficient to allow authorized local, federal, and state auditors and representatives to audit and monitor the provider. 9. The provider assures that authorized local, federal, and state auditors and representatives shall, during business hours,have access to inspect and copy records, and shall be allowed to monitor Page 2 of 42 Reflections for Youth, Inc. "Discovering the Power of Positive Choice" Weld County Home-Based Intensive Family Intervention Program RFY-FYC-06010 03-28-06 (Currently being offered and to continue services through 05-31-07) I. Project Description Title of project: Home-Based Intensive Family Intervention Mission and Purpose Reflections for Youth will provide intensive home-based family interventions to children and adolescents in an effort to prevent out-of-home placement or to transition such youth back into the family system from placement. Youth transitioning back into the home after completion an out-of-home placement will transition with an Aftercare Plan/Agreement. The Aftercare Plan/Agreement includes an aftercare treatment plan to include family, social,emotional, spiritual, physical, legal (if applicable), educational (if not completed with high school diploma or GED), work/employment, financial, transportation,relapse prevention planning, substance abuse (if applicable), a home contract to be completed with family and an overall support contract. Design Families with children who are at risk for out-of-home placement and returning from placement to home will receive home-based services. All services will be home-based unless it is determined that a safety issue requires that services be provided outside the home. Families will be assessed through a thorough Psycho-Social and Risk Assessment to determine strengths and needs. Reflections will provide services for up to 10 client families at a time, including the youth transitioning from the residential program and in need of aftercare support. There may be the potential to serve more families as resources become available. Reflections will provide at least 20 hours of service over the course of three months. • Start-up: Reflections will gather information from the caseworker through a face-to- face meeting or phone contact to determine what are seen as important treatment issues within the family and for the youth(s). Reflections clinical staff or the Weld County caseworker will complete the psychosocial assessment and determine strengths and needs, as well as the development and use of base-line measures on areas related to the out-of-home placement criteria, i.e., abuse/neglect/domestic violence, substance abuse,mental illness, and danger to self and others in the community (Risk Assessment Measure). Interventions will be determined based on results of assessment and will include re-parenting/parenting skills/parent role modeling,problem solving, communication skills, and parent-child conflict management. Families will be assisted in attaining access to other community agencies including mental health, drug and alcohol services, educational systems and recreational programs. At start-up, service will be from 2 to 3 hours per week. • Mid-Service: Assessment of progress, assessment of skill development,ability of family to implement and utilize skills and additional interventions as needed. At mid-service Reflections will be providing 2 to 3 hours of service per week. • End-Service: Determine family's ability to utilize skills in all areas addressed and attainment of appropriate community service support, i.e.,mental health,drug and alcohol services, educational systems and recreational programs. Discuss treatment transitions as needed at this time. At end-service hours will be 1 to 2 hours per week. Reflections will use licensed therapists, masters level therapists with two years of experience and bachelor's level counselors with at least three years of experience as required by Staff manual volume VII Section 7.303.17 and section 7.3006,q. Each family will receive a case management plan within 30 days of initial contact with the family. The case management plan will be based on the results of the psycho-social and risk assessments and will take into consideration the family strengths. The plan will include at a minimum: goals, goal timelines and a measurement of success. Copies of this case management plan will be sent to the caseworker and the supervisor of the program area(C.O.R.E. or other area) Thereafter, a monthly report will be provided that describes presenting problems of the client family, specific services provided, extent of client's participation and commitment to the program,clients progress to date,any new areas of concern,and the anticipated date of discharge. Reflections will contact the case worker a minimum of two times a month to provide updates on any concerns and progress. Fifteen days after the fmal service to client,a discharge summary will be provided to social services that describes service outcomes and, if needed, recommendations for further support services. II. Target/Eligibility Populations: Reflections for Youth, Inc.agrees to work with a total of 10 families at a time. Family constellations may include one child up to an undetermined number of children per family with at least one child at risk for out-of-home placement or returning to home from out-of-home placement. Based on our program description,it is our plan is to provide all services within 20 hours not to exceed a three-month period of time per family. Reflections will provide for a total of 40 families per calendar year. All families will be able to receive bicultural services but bilingual services will only be provide if Reflections can employ a Family Intervention Specialist that is able to speak a second 2 language. Reflections currently employs two interpreters to assist with family communication on an as needed basis. Generally this has included attending staffings, family therapy and other communication between the program and the parent(s). Services will be offered as often as possible on a 24-hour basis to client families living in all parts of Weld County, provided they are within one hour of the city of Loveland. RFY will provide services to south Weld County clients. III. Types of Services to be provided: Solution focused therapy to decrease conflict in the home and increase communication and positive outcomes though skills training, education and access to other community agencies including mental health,drug and alcohol services, educational systems and recreational programs. Concrete services will be provided through specific programs that educate parents, and improve listening and communication skills between children and parents. Techniques utilized will involve Structural Family Therapy,Cognitive Behavioral Therapy,role plays and/or family exercises to enhance the understanding of these skills and dynamics. Collateral services will be provided though communication with caseworker and other community services to provide access or encouragement to utilize community services, i.e.,mental health, drug and alcohol, educational, medicaldental/psychiatric, domestic violence/crisis intervention, etc. Crisis Intervention: An on-call 24-hour service to all clients will be provided. Measurement of goals as described in the case management plan will be reported in monthly progress reports. Reports will highlight goal attainment and skill development along with decreases in concerned areas as originally identified. Based on needs as determined in assessments,all families may have access to any of the four outlined services: therapeutic, concrete, collateral and crisis intervention at any time during the duration of service. Through the initial assessments Reflections will work to determine services already being made available to the family. With two contacts(minimum)per month with caseworkers,we will address newly identified concerns or problems that may require additional resources that are not within our purview of service or that may require a request for a program extension. In addition we agree to provide court testimony services on an as needed basis. The cost of court testimony is$80.00/hr. • IV. Measurable Outcomes 3 • Program will be considered successful as youth remain in the family home, hopefully permanently,but for a minimum of 12 months after the home-based family service has been provided. • Improvements in parental competency and skills, i.e., problem solving skills, communication, decrease in parental/child conflicts and other problematic behaviors as identified will be measured through a pre test during initial start-up and post test at the end-stage of services, as well as observation and self-report throughout the period of service. • For youth at risk for out-of-home placement and for those youth returning home from out of home placement, it will be the goal of our program at discharge to assure that all families have access to community services within Weld County in an effort to keep the child in the home permanently and for a minimum of 12 months after the completion of our services. • Parental skill levels will be evaluated in a pre and post test and though clinical observation of hands-on parenting with the goal of preventing further instances of abuse or neglect. The risk assessment measure will indicate improvement in all areas of needs as indicated in the initial assessment. Reflections will evaluate measure and monitor our quantitative measures through observation, self-report of clients, monthly case management progress reports, collateral meetings, completion of any homework assignments given to family, crisis counseling interventions,and goal progress and attainment. V. Service Objectives • Solution focused interventions that increase parental skills and parental knowledge of child developmental areas,communication, logical and reasonable rules and expectations will improve and/or eliminate escalated conflicts with emotional discord between parents and children. • Household management that effects the safety and protection of the children in the home will be measured though the increased competency of the parent in parenting skills,communication, ability to provide adequate, consistent and logical discipline, regular schedules for meals,bedtime, school attendance, homework, free time, decrease in parental conflicts with child, and self report of overall satisfaction in parent/child relationship. • Through our communication with assigned case worker,parents will be informed of all services provided in Weld County(county, state and federal)and counseling/support will be provided on how to access these services. Progress will be measured though parents ability to follow-through and access these services. 4 • Specific referral issues will be addressed prior to and through-out the treatment process. It is Reflections intent to provide all the services(within our purview) needed as identified by the Weld County Department of Social Services in the categories of collateral, concrete,therapeutic and crisis intervention services. • We will evaluate, measure and monitor our service objectives throughout the treatment process with on-going observation, self-report of clients,monthly case management progress reports, contact with assigned case worker, collateral meetings, completion of any homework assignments given to family, crisis counseling interventions, and goals progress and attainment. The Home-Based Intensive Family Intervention program at Reflections will work to improve outcomes in the Performance Improvement Plan in a few key ways. First, the program will work to reduce the need for any kind of out-of-home placement for all clients served. Second,the home-based program will work to provide additional skills and new cognitions of old problems and new family systems for the caregivers and families,with the overall goal of increasing the parent's ability to cope better with the child; less chance of asking the youth to be removed to be placed in an out- of-home care placement and away from his/her family of origin. Third, assessments and aftercare support are part of the overall services offered by the home-based program. RFY has developed an aftercare plan to be used as part of the discharge process and to be used during and after the successful; completion of Option B services. Case planning will continuously occur and crisis intervention and support will be part of the plan. Finally, RFY will complete needs assessments for the families that are comprehensive enough to identify as many underlying problems as possible and address them as thoroughly as possible over the course of the 20 hours of face-to-face intervention and support. The assessment will also include the needs of the parents and not just of the youth in the family. Home-based services will have a goal of addressing the needs of the caretakers/parents experiencing the problem and to increase the likelihood that the youth will stay in the home. VI.Workload Standards • Based on a workload of 10 families at a time, Reflections will provide a minimum of twenty to thirty hours per week of home-based intensive family intervention. • Reflections will provide a minimum of 7 licensed therapists, master's level counselors with two years experiences or bachelor's level counselors with three years of experience all working under the umbrella of Reflections for Youth, Inc. • Reflections for Youth, Inc. will provide services for up to 10 families at any one time. • Reflections for Youth, Inc. will utilize solution focused interventions that targets family strengths and educational material that increases parental knowledge in crisis 5 management, de-escalation, communication, child development,parenting skills and discipline. Success will be measured throughout the treatment process with on-going observation, self-report of clients,monthly case management progress reports and contact with assigned case worker, clinical meetings,completion of any homework assignments given to family, crisis counseling interventions, and the goal progress and attainment. • Reflections for Youth, Inc. employs four licensed therapists to provide direct service and oversee the home-based intensive family intervention program, i.e.,the maximum caseload per supervisor will be from two to three service providers. The coordinator and direct supervisor for the program is a licensed LMFT. • All insurance coverage for RFY is shown on the Certificate of Liability Insurance and exceeds the amount requested in the bid proposal. Insurance coverage includes general liability, automobile liability, comp and collision,worker's compensation and employer's liability and professional liability. Weld County has been named as a certificate holder. VII. Proof of Collaboration Reflections for Youth, Inc. currently works in collaboration with the Weld County Department of Social Services to provide residential treatment services, day treatment services and home based family intervention services. Our routine collaboration occurs with the caseworker asking for the services, Weld County core service caseworker, PRT team as needed and any other individuals involved in the child's family's life. If a client is receiving or will receive services from North Range Behavioral Health, we will make every effort to communicate with them regarding therapeutic needs and work to involve them in aftercare planning,including obtaining a release(example attached) and forwarding on a discharge summary including continuing recommendations for the client served. If needed,referral information for Greeley/Weld Housing Authorities and Employment Services of Weld County is provided and is attached. VIII. Evidenced-Based Outcomes Reflections for Youth, Inc. as an agency and the Family Intervention Specialists working under the umbrella of Reflections for Youth, Inc. uses evidenced-based therapies and interventions as part of providing quality services to the clients served. What follows is a bibliography highlighting some of the research as it relates to the interventions used in the course of providing services. 1. Juvenile Justice Bulletin—April 2000—Brief Strategic Family Therapy. Comparing Structural Family Therapy with other types of therapy. www.nyrs.gov./html/oiidpnibul 2000. 6 2. E. George, C. Iveson, H. Rather; Problem to solution; brief therapy with individuals and families. BT Press, 1990. 3. Berg, I.K. (1994)Family-Based Services: A Solution-Focused Approach.New York: Norton. 4. Parenting Teenagers: Systematic Training for Effective Parenting of Teens. Don Dinkmeyer, Sr., Gary D. McKay. Circle Press, MN: American Guidance Service, 1980. 5. Don Dinlaneyer and Lewis E. Losoncy, The Encouragement Book: Becoming a Positive Person. Englewood Cliffs,N.J..: Prentice Hall, 1980. 6. Evidenced-Based Therapy: Cognitive Behavioral Therapy. www.nacbt.org/evidenced-based-therapy.htm 7. Gingerich, W.J., & Eisengart, S. (2000) Solution-focused brief therapy: A review of the outcomes research. Family Process. , 39, 477-498. 8. Chambless, D.L., Baker, M., Baucom, D., et al. (1998). Update on empirically validated therapies, II. Clinical Psychologist 51:3-16. 9. Elizabeth C. Hair, Ph.D., Justin Jager, and Sarah B. Garrett(July, 2002). Helping Teens Develop healthy Social Skills and Relationships: What the Research Shows about Navigating Adolescence. www.childtrends Examples of assessments used and transition/aftercare plan after services are completed/in the process of being completed are attached. A request for renewing services is attached. An example of a monthly report is attached. IX. Staff Qualifications • All service providers and supervisors under the umbrella of Reflections for Youth, Inc. meet the requirements as listed in Staff manual volume VII Section 7.303.17 and section 7.3006, q. The supervisors for the program will also carry a caseload. All supervisors are licensed therapist, either with licensure as a LPC, LMFT and in two cases, LCSW. All other home-based intervention specialist will have either a master's degree with two years experience or a bachelor's degree with three years experience in the field. All staff involved directly in the Option B program have knowledge of risk assessment and in some cases very thorough and complete knowledge of risk assessment. All Reflection's staff are required to have an annual full-day class on assessing risk and suicide prevention/intervention. At the time of this contract I am unaware of the State Home Based Intensive Family Services training component. I would very much like to have the opportunity to send all of our intervention specialists to the training. Please advise. Program Capacity is 10 families at any one time. With services being offered within a three month period of time,it is the plan of Reflections for Youth,Inc. to meet the needs of 40 families per calendar year. X. Unit of Service Rate Computation 7 The hourly unit rate computation is $90.75 per hour for 20 hours of in-home face-to-face intervention contact. XI. Billing Process Reflections for Youth, Inc's current billing process for Option B is attached. A current monthly billing is attached. XII. Lowest Qualified Bid XIII.Program Capacity By Month The minimum number of clients per quarter(3 months)to support the program is two. RFY has provided additional training and support for the interventionists available for the program and it is our hope that we will be serving approximately two to four families at a given time throughout the year. The maximum number of families that RFY can serve per year is 40(no more than 10 at any given time throughout the year). 8 ATTACHMENTS RFP-FYC-06010 1. AFTERCARE AGREEMENT/PLAN 2. REFERRAL INFORMATION: GREELEY/WELD HOUSING EMPLOYMENT SRVCS. OF WELD CO 3.CONSENT TO RELEASE INFORMATION EXAMPLES 4. EVALUATIONS/ASSESSMENTS EXAMPLES 5. REQUEST TO RENEW SERVICES EXAMPLE 6. MONTHLY REPORT EXAMPLE 7. COMPUTERIZED BUDGET INFORMATION 8. DESCRIPTION OF BILLING PROCESS ci ciatt-i(41t u- Igp&hX Al-TER-CASE A,GREEMESr., NAME: . GUARDIAN: ADDRESS: CITY: STATE: ZIP: TELEPHONE: HOME ( ) WORK ( ) ADMISSION DATE: DISCHARGE DATE: TOTAL DAYS: AFTER-CARE TREATMENT PLAN: In the following area of your life,please identify problems or needs that you want to change. What have you learned at acy sjc,C. ,r,,how are you planning to continue work in these areas? • • FAMILY: • Please discuss each of the following regarding your future plans: Communication: Time spent with family and what you will do: How will you involve family in your transition home/after you transition home: SOCIAL: Please outline your plan for: 1. Dealing with friends that drink'use drugs: 2. Leisure Time (what will you do to fill your time productively): 3. How will you begin to make new friends/increase your support network? 4. What will you do when bored or lonely? 5. List three (3) resources you have/people you can call before making a Decision that may have negative results for you: • SPIRITUAL: How do you understand your spiritual self and how has this;can this help you make better choices for yourself? What activities are you planning to further develop your spiritual life? • EMOTIONAL: How will your sense of self and self-esteem help you or hinder you to cope with the following? Given that information how will you cope with the following: • 1. Anger/Resentment 2. Guilt: 3. Worry: 4. Frustration: • 5. Sadness: - .. S. Fear: • 6. Embarrassment: PHYSICAL: Be sure to include plans regarding eating, sleeping,healthy lifestyle, and resolution of any medical problems. It you are currently taking medication to assist you with behaviors, emotions, etc., what is your plan regarding continuing to take medication and how will you ensure that the plan is followed: LEGAL: If you have any legal pending concerns (probation requirements, community service, work crew. Please outline your plan of action. • Probation Officer(if applicable) NAME: PHONE NUMBER( ) COUNTY: Caseworker: NAME: PHONE NUMBER( ) COUNTY: SCHOOL I have the following short range plans for school: (include summer school, continuation school, regular school, trade school, independent study, Jr. College or other involvement. Please give name, address, and phone number of school, as well as school counselor). NAME: ADDRESS: PHONE NUMBER: ( ) I have the following long range plans for school: (Include plans for right after high school. Start with the most realistic and likely plan, then state the most hoped for and dreamed of goals). • WORK: I have the following plans regarding work: (Include the kind of work you are interested in and the steps involved, including training, to get the job you would like) • How will.you begin looking for a job? Who can help you? (Include resources and individuals): ;/hat are your long term plans for work/career? (What would you like to be doing in one year? Five years)? If you already have a job please write down the name of the company or employer and the hours you work/will work? COMPANY/EMPLOYER: FINANCIAL: How will you earn/get money? How will you save money? What expenses will you be responsible for? What expenses will your family be responsible for? Realistically, how much money will you need each week to go about your business? How much money do you owe and to whom? How will you begin to pay back money you owe? • • • CAR and DRIVING: , Do you own a car and a license? If you do not have a license, what are your plans for obtaining one? If you do not own a care, what car will you use? Who will pay for insurance and maintenance on the car? If you use your parents car who will pay for the • gas? If you receive moving violations or parking tickets how will you take care of the matter? TRANSPORTATION: If you do not have a license and/or access to a car,how will you get to work?To school? To personal appointments? If using public transportation, how will you pay for the bus? How will you find out about the bus routes and times involved in meeting your obligations? What will you do for transportation in the event that public transportation is not available to you? RELAPSE PREVENTION PLAN: Relapse prevention is most closely associated with substance abuse and for many of you this is the case. Relapse prevention is also based on working and making an effort to not engage in old patterns of behavior that have led to unhealthy if not destructive choices in the past. What kinds of situations, feelings, thoughts, behaviors, etc.may contribute to relapse? • When these happen I will say to myself: I will do the following: I will deal with cravings by: IN TERMS OF SUBSTANCES I AGREE TO THE FOLLOWING CONTRACT: A: No drugs or alcohol to be brought into your room or your house/your parent's house at any time. B: No paraphernalia or drug related material to be in your possession or personal belongings at anytime. C: No use of any kind of mind alternating substance, any illicit drug, alcohol, or prescription drugs. Use of prescription drugs being prescribed to you by a doctor are O.K. D: Submit to random drug tests at any time parents and/or probation officer deem necessary. CONSEQUENCES FOR VIOLATIONS: (It is understood that the consequences listed are my ideas and must be agreed upon by my probation officer and/or parent before they actually become a part of my aftercare agreement). First Violation: • • • Second Violation: • Third Violation: SPONSER INFORMATION (IF APPLICABLE) ••,` Spon orName: Address: Home Phone Number( ) Work Phone Number( ) Best Time to Call: HOME CONTRACT 1. In changing my lifestyle, I will not go to the following places: 2. If I go to any of the above places: A. I will tell my Individual/Family therapist B. I will discuss my behavior in group; and/or C. I will tell my parents or guardians and accept the following consequences: • 3. I am changing my friends. These are the people I will no longer call or see: A. B. C. D: • E. F. a H. 4. If I do see and communicate with any of these people: Al I will tell my Individual/Family therapist ' . - B. I will discuss my behavior in group C. I will tell my parents or guardians and accept the following consequences: • • • 5. This is list of the friends and acquaintances with whom I spend time and plan to continue to spend time with: A. B. C. D. E. F. G. H. 6. These are the time limits which I am setting for myself: A. I will be home by On weekdays, Sunday thru Thursday. B. I will be home by On weekdays, Friday and Saturday. C. I will be awake and out of bed by On Weekdays. D. I will be awake and out of bed by On weekends. 7. If I am irresponsible and do not comply with these limits. I accept the following consequences: 8. When Igo out: A. I will inform my parents or guardian where I am going, who is providing transportation, who I am going to be with, when I plan to return, and get their permission. B. I will call if I change locations. C. If I have to do a short errand before my parents or guardian return home, I will leave a note as to my whereabouts and time of return. D. I will put a calendar of all upcoming events in a prominent place at home for consistency and structure. If I am irresponsible and do not comply with the above limits, I accept the following consequences: • 9. I understand that I have chore-based and personal responsibilities that must be completed to my parent's;guardian's satisfaction prior to earning privileges at home: A. Daily Weekly As needed B. Daily Weekly As needed C. Daily Weekly As needed D. Daily Weekly As needed E. Daily Weekly As needed F. Daily Weekly As needed G. Daily Weekly As needed 10. I will not need to be reminded of completion and I will set my schedule and follow through with the chores and responsibilities thoroughly and promptly. If I do not follow though, I accept the following consequences: AGREEMENTS WITH Recognizing that your successful re-unification will probably fail if you and your family do not actively and fully participateJ;n continuing car�i you and your family make the following contractual agreements with \Len ksak�l`(1{i 'CC+ lcytiAAO I. We, the client and family, agree to actively and fully participate in the After Care phase of treatment at• V er-WAIJY,Fo( • We recognize that this requires our attendance at aftercare meeting r month at the facility, or via phone if attendance at the facility is not possible. In,so dding• we agree to comply with the policies and procedures f Va c-d 3'1 and the . therapeutic recommendations of its professional start. We ur tand that the . •Aftet-Care'phase of treatment is for 96 days. '" • 2. We, the client and family agree to the periodic testing of the client for the use of drugs and alcohol throughout the After-Care phase of treatment.We recognize that regular testing actually assists the client t e:Am.int. We agree to provide the results of the periodic testing to 3. We agree to initiate and continue a weekly Family Home Night to be'devoted to family discussion or recreation. The night will not include any television watching and will focus on communication and connection. 4. We all agree to develop such support group affiliations as may be necessary to continue the success achieved. We recognize that such groups, if needed, may include Alcoholics Anonymous,Narcotics Anonymous, support groups and recreational activities/family involvement. 5. We all agree to closely monitor and maintain our family commitments concerning honesty, school attendance, grades, curfew, homework, and family activities. This includes regular school conferences to monitor the child's performance in school. 6. We all agree to contact the group home within forty-eight(43)hours if we have a crisis, major disturbance, or serious problem within the family relating • to the child's drug abuse or behavior at any time during the After-Care phase of treatment. DATED: Client • DATED: Parent'Guardian(s) DATED: Caseworker/P.O. DATED: House Manager DATED: Discharge Coordinator DATED: Clinical/Family Therapist DATED: Mental Health Director DATED: Director of Operations Greeley/Weld Housing Authorities Yage I of 1 1MtirkebU3 Vleikt t&u4o Crete k's erC Greeley / Weld S heal' "`t wbusingftuthonties vilmt-ktift_ • Office Information Our office is located at 315 N. 11th Avenue, Building B, Greeley, Colorado. Our hours are Monday through Friday from 8 a.m. to 5 p.m. Application are taken in person during these hours, no appointments are necessary. Applications are also accepted by mail at PO Box 130, Greeley, CO 80632. - We will send-applications to applicants who are handicapped, or live • outside the local area who call and ask for this accommodation. You may also print an application form from our FORMS page. Our phone number is (970) 346-7660. We utilize the Colorado Relay Service for TTY. The TTY number is 1-800-6597.2656. Our fax number is 970-346-7690. I Office Information I Forms I Public Housing I Section 8 I Stage Coach Gardens ILa Casa Rosa I Dacono Senior Apartments I I Housing Rehabilitation Loan Program I Resident.Satisfaction Survey I Other _Local Social Service Agencies I Staff I Other Links I I-Tomel Maintenance Work Orders We would like to hear what you think of our information, please e-mail us with your comments. The Housing Authority of the City of Greeley Weld County Housing Authority Equal Opportunity Housing Greeley/Weld Housing Authorities rage 1 of 2 Greeley /Wef f ffousing Authorities Office Application Process FORA/D. Information Public To access an Housing The Housing Authority of the City of Greeley and the Welt{ obe Acrol County Housing Authority accept applications for Public reader click 1 Maintenance Housing and Section 8 during normal business hours. No Work Orders appointment is necessary to complete an application. • Appli • Chan Section 8 Once your application has been processed and entered into • Child the computer, you will receive a letter in the mail confirming• Emph Stage Coach that your application is now on the waiting list. We cannot • Term! Gardens estimate your place on the list please do not call and ask Verif your place on the list. All information will be sent to you in • Notic' La Casa Rosa the mail. Correct and current mailing addresses are important' Stude It is important that you notify us through a change report • Verif Dacono form any time your cirmcustances change. Some changes in • Requ( Senior your.circmustances may change your place on the waiting Apartments list. Housing During the call-up phase (when you are called from the list) Rehabilitation you will be sent a color coded letter. The letter will require Loan you to follow the directions in the letter. If you do not Program respond to the letter by the deadline stated in that letter, your application will be denied and you will need to reapply. Resident Satisfaction Survey Staff Other Local Social Service Agencies GREELEY/WELD HOUSING AUTHORITIES APPLICATION 315 N. 11th Avenue, Bldg. B PO Box 130 Greeley, CO 80632-0130 INSTRUCTIONS FOR COMPLETING YOUR APPLICATION 1.Fill out entire application in ink pen. You must complete the entire application, including social security numbers for all household members who have them, dates of birth, and a mailing address.Incomplete applications or applications filled out in pencil will be returned. 2. Read the descriptions of the priorities and check those that apply to you. 3. Turn in your completed application with the following verification: • Original social security cards for all household members (Non-citizens must sign a statement that they elect not to contend eligible immigration status.These forms are available in our office.Birth certificates can be used for babies who have not been issued a social security card.) • Photo ID's for all family members 18 or older, including applicant • Original state-issued birth certificates(originals) for all household members • Verification of all income to your family 4. APPLICATIONS WILL NOT BE ACCEPTED WITHOUT THE INFORMATION LISTED ABOVE. Incomplete applications will be mailed back to the applicant for completion. 5. All applicants will be contacted by mail and notified of their eligibility. You may drop off your application at 315 N. 11th Avenue,Building B, or mail it to: • Greeley/Weld Housing Authorities P.O.Box 130 Greeley, CO 80632-0130 EQUAL OPPORTUNITY HOUSING GREELEY/WELD HOUSING AUTHORITIES APPLICATION Please mark all programs you wish to apply for: Public Housing: These are apartments owned by the Housing Authority. There are three locations: Ist Avenue, 17th Avenue, and 28th Street. These are NOT available to couples without children, or one-person households as we have no one bedroom units. Section 8 is a rental assistance program that subsidizes rent to private Greeley Section 8 landlords. We have two Section 8 lists,one for Greeley city residents and one for Weld County residents.Greeley residents get a priority on the City Section Weld County Section 8 8 list.Weld County residents get a priority on the County Section 8 list. HOUSEHOLD INFORMATION Name: Social Security# (Last) (First) Street Address: Apt.# City: • State: Zip Code: Phone # Mailing Address(If different from above): List family members, include yourself: Name Birth Relationship Sex Age Social Security Date M/F Number INCOME List all sources of income including employment,welfare,social security,SSI,disability or unemployment compensation,interest on accounts,alimony, child support,etc. Family Member Source of Income Amount Received How Often Continued on Back PRIORITY QUALIFICATION: Check as many as apply. Verification will be required when your name comes up on the list. Displaced by domestic violence: You have left your home to escape domestic violence within the past six months. You are still homeless. You and your abuser were living together at the time, and the incident that caused you to be displaced is documented by a Police Department, a woman's shelter, counseling agency or court action. Displaced by fire,flood or condemnation: You are homeless and have been displaced from your home through no fault of your own, due to a fire, flood or condemnation of your home by a government entity. Enrolled in a Homeless Case Management Program: You are homeless and actively participating in a Homeless Case Management Program with the Greeley Transitional House,A Woman's Place, Catholic Charities,North Range Behavioral Health,or Room At The Inn. Head of household is elderly,handicapped or disabled. Participating in the TANF work program: You are participating in the TANF work program without sanctions. If you are receiving TANF benefits only for your children or grandchildren, or if you are disabled,you do not qualify for this priority. Live,work or attend school inside Greeley city limits. ' Live;work or attend school in Weld County; outside Greeley city limits. Handicapped accessibility requirements: Check here if you need a unit with handicapped fitted restrooms,wider doorways,no stairs, and a ramp. Verification by a medical professional required. PROGRAM INFORMATION: Have you ever participated in a rental assistalt ce or public housing program? If yes,where and when did you participate? ALL APPLICATION INFORMATION IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements of misrepresentation to any Department of Agency of the United States as to any matter within its jurisdiction. Signature: Date: RACIAL GROUP INDENTIFICATION: The following information is required for statistical purposes so the Department of Housing and Urban Development may determine the degree to which minority families utilize its programs. RACE—Check one: White Black/African American Asian Native Hawaiian/Pacific Islander Multi-cultural ETHNICITY—Check one: Hispanic Non-Hispanic mployment services or weta County rage t of z ts 411 1.4 Employment Services of Weld County COLORAAJO • �_ ._ what'sNev/1 - l3npbyer lab Seeker t¢b�Reiated Convnumry. Map/0uecbans flame Site Mary.. .. - Services Services Res¢uces . . Links..:.. - t¢t1¢r0ffice.. yx A Colorado Workforce 2° ; Center x t Address: s< d • 1551N.17th Avenue *?7 ' r ,.av""` �� P.O.Box 1805 ..�'y"�'+u r,'C d a"�1'. Greeley,CO 80632 .. --j- a Phone: - - z g' ° �* 1.- ---"'333- • a t(97o -3800 iDD)Ac essible Fax: (970)356-3975 am, ' -:- ! l ._ Office Hours: r , �` f."44 8:ooam-5:oo Labor Market Information Click Here for State Labor Market IMPORTANT NOTICE: Information Our Computer Resource Room will be closed Click Here tor Every Wednesday from 2:15pm to 5:00pm, Lacimer/weld Starting October 5th,2005 Labor Market 'a Information hick Here for EmQmation • Information What's New: Apply for Owens-_Illinois • Work Shops • Employer's Guide to Language Based Needs*Adobe Reader®is needed to Adobe view this file. �a " . Reader. Register Online With the Workforce Center Here Employment Services of Weld County is a View Workforce Center Positions comprehensive workforce center which connects resources with America's for employment,education,and training services.The Job Bank Here ESWC offers these services at the local,state,and national level.The ESWC prides itself in offering self-service resources,promotion of personal and career development, furnishing access to Internet tools for employment and training opportunities, and providing information about Looking for both, local and regional employers as well as other labor Employment Services of Weld County Page 2 of 2 Workers?Post a markets.The ESWC also strives to assist those local and Job Order with regional employers with applicant referrals and other the Workforce employer specific services.Our courteous and professional Center Here staff provide a wide variety of services including labor exchange,job referrals,skills assessment,eligibility screening for career counseling and training programs. Connecting employers and job seekers is our business. Our services are available to anyone seeking work,and employers at absolutely no cost.We hope these pages provide both job seekers and employers useful information about our services as well as the Colorado Workforce Development. • COLORADO WORKFORCE CENTER WHERE COLORADO COMES TO WORK. E-mail with comment or questions about this web Upon request, any information on this website that is published by Employment Services site will he made available in alternate format Copyright O 2000 Employment Services of Weld County You are visitor 131077 free hit counter Job Seeker Services Page 1 of 2 46 t 1, Employment Services of Weld county IIIlk COIARA,o . ... ... l" `ElE„7,r EEmplayer: tab Seeker : iah-Related Hfiat ser . Community MaptDaectioas Home, 4 BftcMap Services. . -.,..Services . ,,:.Resources .._ ._. uaks toaurOtfiice: Job Seeker Job Seeker Services Services ***NOTE****This section is to inform how the registration process Regional Job Match works at Employment Services of Weld Couny. As well to inform of other services and information provided. To view links to Hot Career Sites and Employment other helpful Job Search related material look under the Job-Related Services Job Lines Resources section. Additional Services The goal of Weld County Employment Services is to assist you in finding Employment employment and to provide career development information and Programs opportunities. This page outlines the services we provide and gives you some information on how to take advantage of our services. Follow the Workforce Partners seven steps below for a successful job search! Veterans Services How do I begin my job search? • Equal Opportunity Step 1 - Make an appointment with the receptionist at our office at 1551 Information N. 17th Avenue,to meet with a Registration Technician to be registered at Know Your Rights - (970)353-3800 ext 3431.. The receptionist will give you a skills form to be completed before your appointment OR register online here. Register Online With the Workforce Step 2 -Review the current Labor Market Information in our office Center including the postings of current state, federal, and local job openings on our bulletin boards and clipboards,job search publications, and other information available in our office. • Review the current labor market information for our region here. Step 3 - Make a list of the jobs you have had and the duties you performed. • List your skills and the number of months of experience you have had for each skill. • List any machinery or office equipment you can operate. • List the types of jobs you are interested in and feel qualified for. Step 4- Complete your skills form using the information from Step 3. Step S-Bring the completed form to your appointment with the Registration Technician. Job Seeker Services Page 2 of 2 Step 6- During your interview,the Technician will ask questions about your job skills, experience, and educational background. In addition,you will be provided with information on other resources and employment and training programs to assist you in your job search. This meeting will take about 30 minutes. Step 7- Once registered,your skills, work history and other application data are recorded in our computer database where it will remain active for six months. What happens after I register? Back to Top When an employer contacts our office with a job opening, a computerized search through the database is completed. Applicants whose skills, education, and experience match the job requirements will be called. What else should I do? • Come to the office regularly to review newly posted jobs and to update your application with regard to address,telephone number, additional job interests or to extend the active period of your application. • Call our Job Line numbers for a recorded list of job openings by category. • . When you obtain employment,telephone our Registration ' • Department at(970) 353-3800 ext. 3428,to notify us to inactivate your application. This will save us from contacting you about jobs for which you are unavailable. Job Seeker Employment Programs Employment Services lob Regional Job Match Additional Services Lines Employment Programs Workforce Partners Veterans Services Your Rights lob Seeker omer Service Moty Equal Opportunity Information lob Employment Services of Weld County-Job Related Resources rage 1 or 2 A 2.' Employment Services of weld County O\ k ootol:e:,o Emplorr iob5eetet Job Related Community Map/Oireciians Name Site Map . .. Nest . .-� _ . ...,..:. . ._.. Services.:::. ..Services. -... Resources . .:- .. [inks. ;., ta0arfltficg. Job-Related Job-Related Resources Resources If you need additional help in locating regional and national job openings, Regional Job lines government jobs, information about a successful job search (cover letters,resumes, interviewing hints), employer profiles,or finding Regional Employers education or trainingproviders, explore the links on this page. Northeastern DISCLAIMER:Employment Services of Weld County does not maintain, monitor, nor Colorado Jobs take responsibility for the content or accuracy of information appearing in the websites listed. The inclusion of the links to listed sites is not intended to reflect their importance Hot Career Sites nor to endorse any views expressed or services offered, but only as a source of employment information. Federal Links Local Newspaper Classified Links WiA Eligible Training Providers • The Greeley Tribune Education • The Denver Post • . • Rocky Mountain News File On-line for • Fort Collins Coloradoan Unemployment • The Daily Camera (Boulder) Benefits • The Johnstown Breeze • Loveland FYI Newspaper Colorado Navigator • Program Getting Around Greeley Colorado's Workforce Centers The Following are Interview Tip Websites: • Monster Career Center • Career Consulting Center • Career Journal The Following are Resume Tip Websites: • The Damn Good Resume • Job Star • Majig's Cheats and Hints The Following are Cover Letter Tip Websites: Employment Services of Weld County - Job Related Resources Page 2 of 2 • Monster Career Center • Job Star • Advanced Resume Concepts Have a website to recommend?Please email any suggestions to us . Aw A, . Email AUTHORIZATION TO RELEASE INFORMATION FORM MINOR CHILD , hereby authorize (Print name) , to release (Therapist/Physician/School/Facility the information designated below for This authorization is valid only to: Individual: Agency: Reflections for Youth, Inc. Address: P.O.Box 1860, Berthoud, CO 80513 970-472-1736(fax) For the purpose of: Designate which of the following is to be released: Summary of Social/Family History Summary of Psychiatric History Summary of Medical History Educational Records Psychological Testing Other (Specify) I understand that I may revoke this consent at anytime and that upon fulfillment of the above stated purposes(s), this consent will automatically expire without my express revocation. Date: Client or Guardian Signature Relationship to Client AUTHORIZATION TO RELEASE INFORMATION FORM , hereby authorize (Print name) to release (Therapist/Physician/Facility/Probation or Parole/Employer) the information designated below for This authorization is valid only to: Individual: Agency: Reflections for Youth, Inc. Address: P.O.Box 1860, Berthoud, CO 80513 970-472-1736(fax) For the purpose of: Designate which of the following is to be released: Medical Psychiatric/Mental Health Treatment Drug and/or Alcohol Employment Educational Criminal History Financial Social Other (Specify) I understand that some of this information is protected by federal law and that my signature authorizes release of all of the above noted information. I also understand that I may revoke this consent at anytime and that upon fulfillment of the above stated purposes(s),this consent will automatically expire without my express revocation. Date: Signature Printed Name Family Evaluation Summary Structured Family Assessment Method (completed by therapist) Date: Family ID: Case Coordinator: Evaluation Team: Evaluation Dates: A.PRESENTING PROBLEM I.Per Referring Source 2.Per Family(including minority opinion,if any) 3.Relevant History of Presenting Problem AAMFT Forms Book-111.-4 7. Salient aspects of family images and themes: D. INDIVIDUAL FUNCTION AND DYSFUNCTION(personal strengths and psychological disabilities of individual members) E.FORMULATION AND TREATMENT STRATEGY I.Systemic Assessment(relationship to presenting problem,how problem works,who is involved,who is served by problem, who is most interested in real change,etc.) 2.Overview of Family Treatment Strategy AAMFT Forms Book-!/L-4 2.Family Strengths 3.External Boundaries rigidly diffusely closed I 2 3 4 5 6 7 8 9 open 4.Coupling/involvement enmeshed I 2 3 4 5 6 7 8 9 disengaged 5.Rigidity/Flexibility rigid 1 2 3 4 5 6 7 8 9 chaotic 6.Salient aspects of family's style of organization and process: AAMFT Forms Book-111-4 B.FAMILY CONFIGURATION(Complete below and/or attach diagrams) 0 family system map 0 family genogram(three generations) 1. Family Constellation(members,other household members,significant others,etc.) 2.Subsystems(salient aspects or intergenerational boundaries,couple system,sibling subsystem,other evident subsystems,etc.) 3.Interpersonal connections(alliances,coalitions,identifications,mappings,etc.) 4.Interface with larger system(attach ecomap if available) C.FAMILY SYSTEM FUNCTIONALITY I.Systemic Challenges(What challenges are facing the family as a whole?Which members are included in each challenge?) AAMFT Forms Book-111.-4 Parent Questionnaire PLEASE NOTE: There are 8 sections in this questionnaire Read instructions in each section carefully. Please do not leave any item unanswered unless asked to skip. Choose just one out of the different options given to you for each item unless asked otherwise. Please be frank while responding. There are no right or wrong answers. Each of us have our own individual way of living so please respond accordingly. Your responses will be kept strictly confidential. Please fill In the following details and then proceed further. Section I DATE NAME OF YOUTH NAME OF PARENT/ADULT BEING INTERVIEWED YOUR AGE PHONE NUMBER ADDRESS Zip Code Street City PLEASE CHECK ONLY ONE OF THE OPTIONS: EDUCATION ❑grade school or junior high 0 attending/attended college 0 technical school degree 0 graduate degree(Masters) ❑ attending/attended high school O college graduate ❑high school graduate O attending/attended graduate O graduate degree g (Doctoral) school RACE/ETHNICITY ❑White(European American) 0 Native American 0 Asian American 0 Black(African American) 0 Black(Other) 0 Mexican American(Latino) ❑Other Latin or Spanish 0 Other. 0 Multiracial heritage SEX ❑Male ❑Female AAMFT Forms Book-111.-7 RELATION TO YOUTH ❑ Father(biological,step,adoptive) O Mother(biological,step,adoptive) ❑ Grandfather O Grandmother ❑ Uncle O Aunt ❑ Foster father ❑ Foster mother ❑ Other male(specify) O Other females ci ( Pe fY) PRESENT MARITAL OR RELATIONSHIP STATUS ❑ Single O Significant Other O Engaged O Cohabitating O Married ❑ Separated O Divorced O Remarried O Widowed APPROXIMATE CURRENT ANNUAL HOUSEHOLD INCOME ❑ $1,000-4,999 O $20,000-29,999 O $75,000-99,999 O $5,000-9,999 O $30,000-39,999 O $100,000_149,999 ❑ $10,000-14,999 O $40,000-49,999 O $150,000 and above O $I5,000-19,999 O $50,000-74,999 WHERE DOES THE MAJORITY OF YOUR INCOME COME FROM? ❑ Wages for work ❑ Public assistance ❑ Unemployment/worker's compensation ❑ Other(specify) OCCUPATION: ❑ Unemployed ❑ Service-general laborer ❑ Skilled trade ❑ Professional HAS YOUR INCOME GONE DOWN SIGNIFICANTLY IN THE LAST YEAR? ❑ Yes ❑ No Section 2:This section has some questions regarding people living at your home. PLEASE CHECK ONLY ONE OF THE OPTIONS I.HOW MANY TIMES HAS YOUR FAMILY MOVED IN THE PAST YEAR? ❑ None O Once O Twice ❑ Three or more times 2.HAS AN ADULT BESIDES YOURSELF MOVED OUT OF YOUR HOME IN THE LAST YEAR? ❑ Yes ❑ No AAMFT Forms Book-111-7 3.HAS AN ADULT BESIDES YOURSELF MOVED INTO YOUR HOME IN THE LAST YEAR? ❑ yes ❑ No 4.DOES YOUR WIFE/HUSBAND/GIRLFRIEND/BOYFRIEND LIVE IN THE HOME? ❑ yes ❑ No 5.DESCRIBE HOW WELL YOU GET ALONG WITH YOUR WIFE/HUSBAND/GIRLFRIEND/BOYFRIEND. ❑ Well ❑ Fairly well ❑ Poorly 6.DOES THE YOUTH'S GRANDFATHER/GRANDMOTHER LIVE IN THE HOME? ❑ Yes ❑ No 7.DESCRIBE HOW WELL YOU GET ALONG WITH THE YOUTH'S GRANDFATHER/GRANDMOTHER. ❑ Well ❑ Fairly well ❑ Poorly 8.DOES THE YOUTH'S UNCLE/AUNT LIVE IN THE HOME? ❑ Yes ❑ No 9.DESCRIBE HOW WELL YOU GET ALONG WITH THE YOUTH'S UNCLE/AUNT. ❑ Well ❑ Fairly well ❑ Poorly 10.HOW MANY OF THE YOUTH'S BROTHERS AND SISTERS LIVE IN THE HOME? ❑ None ❑ I ❑ 2 ❑ 3 ❑ 4 or more O Has no brothers or sisters 11.DO ANY OF THESE BROTHERS AND SISTERS OUTSIDE THE HOME OFFER THE YOUTH ADVICE AND UNDERSTANDING WHEN HE/SHE NEEDS IT? ❑ Yes ❑ No 12.HAS A PSYCHOLOGICAL OR PSYCHIATRIC EVALUATION EVER BEEN DONE ON YOUR CHILD? O Yes ❑ No 13.HAS YOUR FAMILY EVER BEEN INVESTIGATED BY CHILD PROTECTIVE SERVICES? ❑ Yes O No AAMFT Forms Book-111-7 Section 3:This section is about some of your family activities. Please check the answer that best describes your family. 1.How often does your family have dinner together? O Never ❑ Ito 3 times a week O 4 or more times a week ❑ Daily 2.How many holidays(e.g.,Christmas,birthdays)does your family celebrate together? ❑ All of them O Most of them ❑ Very few of them ❑ None of them 3.How often do you do activities(i.e.church,sports,meetings)with your family? ❑ Never O Once a month ❑ Once a week. O More than once a week If you do activities with your family,what are they? Section 4:This section talks about some supervision techniques that you use as parents. Please CHECK ONLY ONE OPTION I.WHAT TIME IS YOUR CHILD'S CURFEW ON SCHOOL NIGHTS? O Before 6 pm ❑ Between 6 pm and 8 pm ❑ After 8 pm,but before 10 pm ❑ After 10 pm,but before midnight O No curfew 2.WHAT TIME IS YOUR CHILD'S CURFEW ON WEEKEND NIGHTS? ❑ Before 6 pm ❑ Between6pmand8pm ❑ After 8 pm,but before 10 pm ❑ After 10 pm,but before midnight ❑ No curfew 3.DO YOU GIVE YOUR CHILD SPECIFIC CHORES AROUND THE HOUSE?(e.g.,cleaning houseroom,yard work, taking out the trash,etc.) ❑ Yes ❑ No AAMFT Forms Book-IIL-7 4.IN GENERAL,HOW OFTEN DOES HE/SHE DO THESE CHORES? ❑ Always ❑ Most of the time ❑ Sometimes ❑ Not at all 5.IN GENERAL,DOES HE/SHE DO THESE CHORES? ❑ Without being told to do them ❑ Only after being told to do them ❑ Only after repeated warnings ❑ Not at a0,even after repeated warnings 6.DO YOU AND/OR YOUR PARTNER WORK EVENINGS OR NIGHT SHIFTS? ❑ Neither one or both primary caregivers work evenings ❑ One of the two works evenings ❑ Both primary caregivers work evenings 7.WHEN YOU AND/OR YOUR PARTNER AREN'T HOME,WHO STAYS WITH YOUR CHILD? ❑ Another adult ❑ A minor-teenager or child O No one 8.HOW OFTEN ARE YOU HAPPY WITH THE SUPERVISION HE/SHE GETS WHEN YOU AREN'T HOME? ❑ Most of the time ❑ Only some of the time O Not very often 9.DO YOU KNOW WHAT YOUR CHILD IS DOING DURING NON-SCHOOL HOURS? ❑ Have clear knowledge of his/her activities ❑ Have some knowledge of his/her activities ❑ Have little or no knowledge of his/her activities 10.WHAT TIME DOES YOUR CHILD GET HOME ON SCHOOL NIGHTS? ❑ Before 6 pm ❑ Between 6 pm and 8 pm ❑ After 8 pm,but before 10 pm ❑ After 10 pm,but before midnight ❑ After midnight 1 I.WHAT TIME DOES YOUR CHILD GET HOME ON WEEKENDS? ❑ Before 6 pm ❑ Between 6 pm and 8 pm ❑ After 8 pm,but before 10 pm ❑ After 10 pm,but before midnight ❑ After midnight AAMFT Forms Book-111-7 Section 5:This sections asks questions about your child's friends I.HOW MANY OF YOUR CHILD'S FRIENDS CAN YOU DESCRIBE? ❑ 3 or more of child's friends ❑ 2 of child's friends ❑ 1 of child's friends ❑ Cannot describe any of child's friends 2.DOES YOUR CHILD HAVE FRIENDS OLDER THAN HE/SHE? ❑ Don't know ❑ All friends are no more than 2 years or older than him/her ❑ 1 friend is more than 2 years older than him/her ❑ 2 friends are more than 2 years older than him/her O 3 or more friends are more than 2 years older than him/her 3.DO YOU KNOW YOUR SON/DAUGHTER'S FRIENDS? O None of them O Some of them ❑ Most of them ❑ All of them 4.DO YOU LIKE YOUR SON/DAUGHTER'S FRIENDS? O None of them ❑ Some of them O Most of them O All of them 5.HAVE ANY OF YOUR SON/DAUGHTER'S FRIENDS BEEN IN TROUBLE WITH THE LAW-(INCLUDES HAVING BEEN TO JUVENILE OR ADULT COURT)? ❑ Don't know ❑ None ❑ Yes,have been arrested or charged with an offense O Yes,have appeared in court 6.DO YOU THINK THAT YOUR SON/DAUGHTER'S FRIENDS HELP TO GET HIM/HER IN TROUBLE WITH THE LAW AT HOME OR AT SCHOOL? ❑ Don't know ❑ Not to my knowledge O Very little,if at all ❑ Have some influence ❑ Yes,definitely AAMFT Forms Book-IJJ.-7 Section 6:This section asks about how your child gets along in school. Please CHECK ONLY ONE OPTION 1.HOW MANY CLASSES IS YOUR CHILD FAILING THIS YEAR? ❑ None ❑ 1 to 2 ❑ 3to4 ❑ More than 4 ❑ Don't know 2.HOW MANY CLASSES DID YOUR CHILD FAIL LAST YEAR? ❑ None ❑ lto2 ❑ 3to4 ❑ More than 4 ❑ Don't know 3.IS YOUR CHILD A DISCIPLINE PROBLEM AT SCHOOL THIS YEAR? ❑ Yes ❑ No ❑ Don't know 4.WAS YOUR CHILD A DISCIPLINE PROBLEM AT SCHOOL LAST YEAR? ❑ Yes ❑ No ❑ Don't know 5.DOES YOUR CHILD LIKE SCHOOL? ❑ Very much ❑ Somewhat ❑ Don't know ❑ Not at all 6.HOW REGULARLY DOES YOUR CHILD ATTEND SCHOOL? ❑ Everyday ❑ Most days ❑ Only sometimes ❑ Not at all AAMFT Forms Book-III.-7 Section 7:This section is about criminal involvement in the family. 1.ARE ANY MEMBERS OF YOUR FAMILY HOUSEHOLD INVOLVED WITH THE COURT SYSTEM? D No family members are involved • ❑ A close family member has committed minor crimes ❑ A distant relative is heavily involved in the system ❑ A close family member has been imprisoned ❑ More than one member of the family has been involved 2.DO YOU EVER WORRY BECAUSE OF YOUR FAMILY'S INVOLVEMENT IN THE CRIMINAL COURT SYSTEM? ❑ Yes ❑ No Section 8:This section is about alcohol and drug use. Please CHECK ONLY ONE OPTION 1.DOES YOUR CHILD USE ALCOHOL OR DRUGS? ❑ Never ❑ Has experimented with alcohol/drugs once or twice ❑ Uses once or twice a month ❑ Uses every weekend ❑ Uses several times a week ❑ Uses everyday 2.DO OTHER ADULTS IN YOUR HOME USE A LOT OF ALCOHOL/DRUGS? ❑ Yes ❑ No ❑ No other adults in the home 3.DO OTHER CHILDREN(UNDER 18 YEARS)IN THE HOME USE ALCOHOL/DRUGS? ❑ Yes ❑ No ❑ No other children in the home AAMFT Forms Book-III-7 Youth Questionnaire PLEASE NOTE: There are 10 sections in this questionnaire Read instructions in each section carefully. Please do not leave any item unanswered(unless asked to skip). Choose lust one out of the different options given to you for each item unless asked otherwise. Please be frank while responding. There are no right or wrong answers.Each of us have our own individual way of living so please respond accordingly. Your responses will be kept strictly confidential. Please fill in the following details and then proceed further. Section 1 DATE NAME OF YOUTH YOUR AGE PHONE NUMBER ADDRESS Street City Zip Code PLEASE CHECK ONLY ONE OF THE OPTIONS: RACE/ETHNICITY 0 White(European American) 0 Native American 0 Asian American El Black(African American) 0 Black(Other) ❑Mexican American(Latino) 0 Other Latin or Spanish heritage 0 Other: 0 Multiracial • SEX ❑ Male ❑ Female AAMFT Forms Book-111-8 Section 2:This section has some questions regarding people living at your home. PLEASE CHECK ONLY ONE OF THE OPTIONS I.DO YOU LIVE WITH YOUR MOTHER? ❑ Yes ❑ No 2. HOW WELL DO YOU GET ALONG WITH YOUR MOTHER? ❑ Well ❑ Fairly well ❑ Poorly 3.IF YOU ARE NOT LIVING WITH YOUR MOTHER,WHAT IS THE REASON? ❑ Divorced/Separated ❑ Deceased ❑ Hospitalized ❑ Incarcerated ❑ Other(Specify) 4.HOW OFTEN DO YOU SEE YOUR MOTHER,IF YOU DO NOT LIVE WITH HER? ❑ Daily ❑ Weekly ❑ Monthly ❑ Several times a year ❑ Once a year ❑ Not at all 5.ARE YOU LIVING WITH YOUR GRANDMOTHER? ❑ Yes ❑ No 6.DESCRIBE HOW WELL YOU GET ALONG WITH YOUR GRANDMOTHER. ❑ Well ❑ Fairly well ❑ Poorly ❑ N/A 7.ARE YOU LIVING WITH YOUR AUNT? ❑ Yes ❑ No 8.DESCRIBE HOW WELL YOU GET ALONG WITH YOUR AUNT. ❑ Well ❑ Fairly well ❑ Poorly ❑ N/A 9.ARE YOU LIVING WITH ANY OTHER ADULT FEMALES BESIDES SISTERS? ❑ Yes ❑ No AAMFT Forms Book-III.-8 10.DESCRIBE HOW WELL YOU GET ALONG WITH THIS ADULT FEMALE WHO IS NOT YOUR SISTER. ❑ Well ❑ Fairly well ❑ Poorly ❑ N/A 11.ARE YOU LIVING WITH YOUR FATHER? ❑ Yes ❑ No 12.DESCRIBE HOW WELL YOU GET ALONG WITH YOUR FATHER. ❑ Well ❑ Fairly well ❑ Poorly 13.IF YOU ARE NOT LIVING WITH YOUR FATHER,WHAT IS THE REASON? ❑ Divorced/Separated ❑ Deceased ❑ Hospitalized ❑ Incarcerated ❑ Other 14.HOW OFTEN DO YOU SEE YOUR FATHER,IF YOU DO NOT LIVE WITH HIM? ❑ Daily ❑ Weekly ❑ Monthly ❑ Several times a year ❑ Once a year ❑ Not at all 15.ARE YOU LIVING WITH YOUR MOTHER'S BOYFRIEND? ❑ Yes ❑ No 16.DESCRIBE HOW WELL YOU GET ALONG WITH YOUR MOTHER'S BOYFRIEND. ❑ Well ❑ Fairly well O Poorly ❑ N/A 17.ARE YOU LIVING WITH YOUR STEPFATHER? ❑ Yes O No 18.DESCRIBE HOW WELL YOU GET ALONG WITH YOUR STEPFATHER. O Well ❑ Fairly well ❑ Poorly ❑ N/A AAMFT Forms Book-111.-8 19.ARE YOU LIVING WITH ANY OTHER ADULT MALES BESIDES BROTHERS? ❑ Yes ❑ No 20.DESCRIBE HOW WELL YOU GET ALONG WITH THIS ADULT MALE WHO IS NOT YOUR BROTHER. ❑ Well ❑ Fairly well ❑ Poorly ❑ N/A 21.HOW MANY BROTHERS AND SISTERS LIVE WITH YOU? ❑ None ❑ I ❑ 2 ❑ 3 ❑ 4 or more ❑ I have no brothers or sisters Section 3:This section is about some of your family activities. Please CHECK ONLY ONE OPTION that best describes your family. 1.How often does your family have dinner together? O Never ❑ 1 to 3 times a week O 4 or more times a week O Daily 2.How many holidays(e.g.,Christmas,birthdays)does your family celebrate together? ❑ All of them ❑ Most of them ❑ Very few of them ❑ None of them 3.How often do you do activities(i.e.church,sports,meetings)with your family? ❑ Never ❑ Once a month ❑ Once a week O More than once a week If you do activities with your family,what are they? AAMFT Forms Book-IIL-8 Section 4:This section talks about some supervision techniques that your parents use. Please CHECK ONLY ONE OPTION 1.WHAT TIME IS YOUR CURFEW ON SCHOOL NIGHTS? ❑ Before 6 pm ❑ Between 6 pm and 8 pm ❑ After 8 pm,but before 10 pm ❑ After 10 pm,but before midnight ❑ No curfew 2.WHAT TIME IS YOUR CURFEW ON WEEKEND NIGHTS? ❑ Before 6 pm ❑ Between 6 pm and 8 pm ❑ After 8 pm,but before 10 pm ❑ After 10 pm,but before midnight ❑ No curfew 3.DO YOU HAVE SPECIFIC CHORES AROUND THE HOUSE?(e.g.,cleaning house/room,yard work,taking out the trash,etc.) ❑ Yes ❑ No 4.IN GENERAL,HOW OFTEN DO YOU DO THESE CHORES? O Always ❑ Most of the time ❑ Sometimes O Not at all 5.IN GENERAL,DO YOU DO THESE CHORES ❑ Without being told to do them ❑ Only after being told to do them ❑ Only after repeated warnings ❑ Not at all,even after repeated warnings 6.WHAT TIME DO YOU GET HOME ON SCHOOL NIGHTS? ❑ Before 6 pm ❑ Between 6 pm and 8 pm ❑ After 8 pm,but before 10 pm ❑ After 10 pm,but before midnight ❑ After midnight 7.WHAT TIME DO YOU GET HOME ON WEEKENDS? ❑ Before 6 pm O Between 6pm and 8pm ❑ After 8 pm,but before 10 pm _ ❑ After 10 pm,but before midnight ❑ After midnight AAMFT Forms Book-11L-8 Section 5:In the following questions more than one answer may apply. Please CHECK ONLY ONE OPTION. --'' 1.How often do you drink alcoholic beverages like beer,wine,mixed drinks,or hard liquor? ❑ never ❑ once or twice a year O once or twice a month ❑ every weekend ❑ several times a week O everyday 2.When did you have your last drink of alcohol? ❑ 1.never ❑ 2.not for over a year ❑ 3.between six months and a year ago ❑ 4.several weeks ago ❑ 5.last week ❑ 6.yesterday ❑ 7.today 3.When you drink alcoholic beverages,what do you drink? ❑ do not drink ❑ wine O beer ❑ mixed drinks ❑ hard liquor 4.When you drink alcohol,how much do you drink? ❑ do not drink ❑ 1 drink ❑ 2 drinks ❑ 3-5 drinks ❑ 6 or more drinks Section 6:This section asks questions about your friends. Please CHECK ONLY ONE OPTION 1.WHAT ARE THE AGE DIFFERENCES BETWEEN YOU AND YOUR FRIENDS? O All friends are no more than 2 years or older than you ❑ I friend is more than 2 years older than you ❑ 2 friends are more than 2 years older than you ❑ 3 or more friends are more than 2 years older than you AAMFT Forms Book-111.4 2.HOW MANY FRIENDS ARE INVOLVED IN THE JUVENILE COURT SYSTEM? ❑ No friends are involved in the system ❑ I friend is involved in the system ❑ 2 friends are involved in the system ❑ 3 or more friends are involved in the system 3.HOW MANY FRIENDS WERE INVOLVED IN THE CRIME THAT YOU COMMUTED? ❑ No friends were involved ❑ I or more friends were involved ❑ I or more friends were involved in other crimes,but not this one ❑ I or more friends were involved in this crime and in others 4.HOW MANY OF YOUR FRIENDS ARE INVOLVED IN A GANG? ❑ No friends are involved ❑ I or more friends are involved 5.DO YOU REGULARLY PARTICIPATE IN CHURCH ACTIVITIES? ❑ Yes ❑ No 6.DO YOU REGULARLY PARTICIPATE IN SCHOOL ACTIVITIES AFTER SCHOOL HOURS? ❑ Yes ❑ No 7.DO YOU REGULARLY PARTICIPATE IN COMMUNITY ACTIVITIES(e.g.,boy's/girl's club,YMCA/YWCO)? ❑ Yes ❑ No Section 7:This section has some questions regarding your school. I.WHAT SCHOOL DO YOU ATTEND? AAMFT Forms Book-111-8 2.WHAT IS YOUR CURRENT GRADE LEVEL? 3.HAVE YOU EVER BEEN HELD BACK IN SCHOOL? ❑ Yes ❑ No 3.HOW MANY TIMES HAVE YOU BEEN IN IN-SCHOOL DETENTION THIS YEAR? O None ❑ 1 ❑ 2 ❑ 3 ❑ 4 or more 5.WERE YOUR PARENTS NOTIFIED? ❑ Yes ❑ No 6.HOW MANY TIMES WERE YOU IN IN-SCHOOL DETENTION LAST YEAR? O None ❑ I ❑ 2 ❑ 3 O 4 or more 7.WERE YOUR PARENTS NOTIFIED? ❑ Yes O No 8.HOW MANY TIMES HAVE YOU BEEN SUSPENDED THIS YEAR? ❑ None ❑ 1 ❑ 2 ❑ 3 ❑ 4 or more 9.WERE YOUR PARENTS NOTIFIED? ❑ Yes ❑ No 10.HOW MANY TIMES WERE YOU SUSPENDED LAST YEAR? O None ❑ 1 ❑ 2 ❑ 3 ❑ 4 or more AAMFT Forms Book-111-8 I1.WERE YOUR PARENTS NOTIFIED? ❑ Yes ❑ No 12.DO YOU LIKE SCHOOL? ❑ Very much ❑ It is all right O Not at all 13.HOW REGULARLY DO YOU ATTEND SCHOOL? O Everyday ❑ Most days ❑ Only sometimes O Not at all 14.HOW EASY IS YOUR SCHOOLWORK? ❑ Very easy ❑ Kind of easy ❑ Sort of difficult ❑ Very difficult Section 8:This section is about other general questions. Please CHECK ONLY ONE OPTION 1.DO YOU HAVE ANY FRIENDS THAT YOU CAN TALK TO ABOUT YOUR PROBLEMS? ❑ Yes ❑ No 2.ARE THERE ANY ADULTS THAT YOU LIKE TO TALK TO ABOUT YOUR PROBLEMS? ❑ Yes ❑ No 3.HAS SOMEONE IMPORTANT TO YOU DIED OR MOVED AWAY WITHIN THE LAST 12 MONTHS? ❑ Yes ❑ No 4.HOW DID THE SITUATION AT HOME CHANGE? ❑ Home life is better ❑ Home life is worse ❑ Made no difference to me AAMFT Forms Book-111-8 5. HAS A PERSON MOVED INTO YOUR HOUSE WITHIN THE LAST YEAR? ❑ Yes ❑ No 6. HOW DID THE SITUATION AT HOME CHANGE AS A RESULT OF THIS PERSON COMING INTO YOUR HOUSE? ❑ Home life is better 0 Home life is worse ❑ Made no difference tome 7. HOW MANY HOURS A WEEK ARE YOU EMPLOYED? ❑ Less than 5 ❑ 6-10 ❑ 11-19 ❑ 20-30 ❑ More than 30 ❑ Not employed Section 9:This section is about other general questions. Please CHECK ONLY ONE OPTION 1. DO YOU THINK YOUR MOTHER(FEMALE CAREGIVER)DRINKS OR USES DRUGS TOO MUCH? ❑ Yes ❑ No ❑ Does not apply 2. DO YOU EVER WORRY BECAUSE OF YOUR MOTHER'S(FEMALE CAREGIVER'S)DRINKING OR DRUG USE? ❑ Yes ❑ No ❑ Does not apply 3.DO YOU THINK YOUR FATHER(MALE CAREGIVER)DRINKS OR USES DRUGS TOO MUCH? ❑ Yes ❑ No ❑ Does not apply 4.DO YOU EVER WORRY BECAUSE OF YOUR FATHER'S(MALE CAREGIVER'S)DRINKING OR DRUG USE? ❑ Yes ❑ No ❑ Does not apply 5.DO OTHER ADULTS IN YOUR HOME USE A LOT OF ALCOHOLJDRUGS? ❑ Yes ❑ No ❑ Does not apply AAMFT Forms Book-111-8 6.DO OTHER CHILDREN(UNDER 18 YEARS)IN THE HOME USE ALCOHOL/DRUGS? ❑ Yes ❑ No ❑ No other children in the home Section 10:This section is about criminal involvement in the family. I.ARE ANY MEMBERS OF YOUR FAMILY/HOUSEHOLD INVOLVED WITH THE COURT SYSTEM? ❑ No family members are involved ❑ A close family member has committed minor crimes ❑ A distant relative is heavily involved in the system ❑ A close family member has been imprisoned ❑ More than one member of the family has been involved 2.DO YOU EVER WORRY BECAUSE OF YOUR FAMILY'S INVOLVEMENT IN THE CRIMINAL COURT SYSTEM? ❑ Yes ❑ No ❑ Does not apply AAMFT Forms Book-111-8 Initial Family Evaluation (completed by therapist) Date: Name or Case#: 1. PRESENTING PROBLEM:What is each family member's view of what is wrong? II. HISTORY OF PRESENTING PROBLEM:Family members'view a.Onset and duration b.Attempts to deal with problem(s).What solutions succeeded?Failed? c.What changes would have to take place,in family members'views,for the situation to improve? III.LIFE CYCLE AND/OR SITUATIONAL STRESSES ON FAMILY MEMBERS: Include life cycle stages,transitional phases,specific dates of significant events,illnesses,deaths,etc. AAMFT Forms Book-111-9 IV.PREVIOUS PSYCHIATRIC TREATMENT: a.For family's identified problem member --- b.For other presenting family members c.For family-of-origin members V.DESCRIPTION OF FAMILY SYSTEM: a.Nuclear Family Relationships: i.e.alliances,triangles,pivotal members,labels,myths,themes,etc. b.Extended Family Relationships:intergenerational patterns,boundaries,alliances,ethnic influences,themes,triangles,"shoulds," conflict and cooperation,cutoffs,etc. c.Interface with Other Systems:friends,work,school,church,professionals,agencies. d.Existing Support Systems of Family:significant relatives,friends,and others who could be involved in solution of family's problems. AAMFT Forms Book-111-9 VI.THERAPISTS EVALUATION OF FAMILY AND PROBLEM(S): Therapist's view of family relationship and difficulties,major triangles,family strengths/weaknesses,flexibility/rigidity, ability to change and to participate in therapy. VII.TENTATIVE TREATMENT PLAN:goals and therapeutic strategies a.What are the major triangles,relationship difficulties?How are they to be dealt with?Statement of OBJECTIVES for first phase of treatment,focus and strategies b.Potential difficulty for therapist c.Statement of tentative long range goal Therapist Signature Date AAMFT Forms Book-/I/.-9 Reflections for Youth, Inc. P.O.Box 1860 Berthoud, CO 80513 carol@reflectionsforyouth.org Andrea Shay shayxxah@co.weld.co.us REQUEST TO RENEW OPTION B SERVICES Date: Re.: Client Name: HH#: Andrea, This is a request for either additional time to complete the already approved 20 hours or a request for an additional 20 hours to be approved. Both requests would include summaries to date of the dates and hours used and why the renewal was being requested. Sincerely, Carol S. Johnson, LMFT Financial Administrator Supervisor for Option B Family Support Workers Reflections for Youth, Inc. P.O.Box 1860 OPTION B REPORT Berthoud, CO 80513 Client Name HH# Date Clients present. Total time Session summary Date Clients present. Total time Session summary Date Clients present. Total time Session summary Date Clients present. Total time Session summary Date Clients present. Total time Session summary Date Clients present. Total time Session summary Total hours being billed: 1 | I I I cn § 2 ■ g o , ® R to a in re ° co kCL # k k \ ' \ e k < 2 I 8 e / ) z 0 w 2 = 2 w 2 0 / § i / § Lij § \ § \ . < - \ 2 A O 5 / § < f 2 ; ° q re w w) § 0 § >- E (0 (0 / < 0 § 0 w 05 w § w w § § w Z § u.,_co § & e w w CO § ; § F. § b / k \ k k ) § / k u_ 017 a k § k ! 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I\ !!,l,,,, 2 ; . ! § § O 4 2 kk ! § ° ! | | ` ' 8 g ' kick { - / }||||||l 5 § 6666!!|t - ( { / ( )I�I}§|7 / k \ . . Cona §| s. 888888888888888888 8 8 8 _ o §| ,a,a;e&aea;2a; ; a . 8 «| 8co , |e s.§| ;f 88888888888888888. 8 8 8 #;ga&■aa##■#;kga=a g =| |� ! . k §O. e I- §| T. )| § Em 888888888888888888 8 8 8 2aa&a;ega#«;■&g■&■ » a g § 628 8 w � O. /X § §| §§ r 88888888888888.888 8 8 • § §| 8 8. . -!(!#2#ag#■gaa;;aa , ; § 2EI a § - - - - < 2r 21 §||| )/ § §k , 2§§FYZZZZZZZZZZZZZ 88888 8 8 2• 50 gIng k 8 } • § § 8• 82 ' ( a . re 09 wa. | a _ ow k 10 e § ( ! ! \ § \ ! [ 0 � !■| § ( | a. } } { t l-0 - I - . Reflections for Youth, Inc. P.O.Box 1860 Berthoud, CO 80513 970-532-5990 • DESCRIPTION OF BILLING PROCESS OPTION B At the 10-hour point for each family: 1. Therapist submits an Option B report with dates met, total times of sessions and session summaries (with total hours to date totaled at bottom) to financial administrator. 2. Therapist submits a signed client verification form for the same total hours to the financial administrator. 3. Financial administrator then transfers information to Weld County billing sheets and submits all paperwork to Elaine Furister. ..nc.er .sisv/avvv LLout al9y en TO: Jett (e 1-970-472.1736 Page: 002 • • Client :24876 REFLFOR ACORD,. CERTIFICATE OF LIABILITY INSURANCE o ( DITYYTI PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION HRH of Colorado ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 720 S.Colorado Blvd Ste 600-N HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O.Box 489025 Denver,CO 80246-9025 INSURERS AFFORDING COVERAGE NAIC I INSURED INSURER A: Tudor Insurance Co. 37982 Reflections for Youth,Inc. INSURER B: Great American Insurance Co. 16691 P.O.Box 1880 INSURER O Pinnacol Assurance 10780 Berthoud,CO 80513 INSURER D. INSURER E I COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDmON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN6R AlsO'C POLICY EFFECTIVE POLICY EXPIRATION LTR NBR TYPE OF INSURANCE POLICY NUMBER T� DATE INWDA[CYL DATE IMMIOCITY1 LIMITS A GENERALUABILITY PGL739507 09/20/05 09/20/06 EACH OCCURRENCE 11,000,000 DAMAGE TO RENTED X COMMERCIAL LIMNER GENERAL LILRY P 150.000PREMISES fFw�sure+tml ^X ,CLAIMS MADE n OCCUR MED EXP(Any one peamn) $1,000 PERSONAL&ADV INJURY s1,000,000 GENERAL AGGREGATE ;3,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG 11,000,000 7 POLICY F1 JjECaT n LOC 'B AUTOMOBILE LIABILITY CAP5154804 09120/05 09120/03 COMBINED SINGLE LIMIT X ANY AUTO (Eseccden0 , $1,000,00D ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY X NON-o NEO AUTOS (Per ecfbait) $ PROPERTY DAMAGE s (Per ecodent) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ I 1 ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG I EXCESSAIMBRBLA LIABILITY EACH OCCURRENCE I OCCUR n CLAIMS MADE AGGREGATE $ $ OEDUCTIBLE _ -I RETENTION $ $ C WORKERS COMPENSATION AND 4085090 10/01/05 10/01/06 X r We r uMRs STATU-I 10TH- EMPLOYERS'LIABILITY E.L.EACH ACCIDENT s100,000 R)ANY PROPRETOR/PARTNEEXECUTIVE . OFFICER/LIEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $100,000 Hyes,eesaN.cider SPEGIAL PROVISIONS below E-L.DISEASE-POLICY LIMIT ;500,000 A DINER professional PGL739507 09/20/05 09/20/06 $1,000,000 per incident Claims Made Policy $3,000,000 Aggregate DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS REVISED CERTIFICATE*THIS CERTIFICATE SUPERSEDES ANY ISSUED THIS POUCY YEAR CLAIMS MADE POUCY The following are Additional Insureds as respects General Liability only to the extent coverage might apply according to the policy terms, (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Weld County,Dept of Social DATE THEREOF,THE ISSUING NSURER WILL ENDEAVOR TO MAIL 1 A DAYS WRITTEN Services NOTICE 10 THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FALURE TO DO SO SHALL P.O.Box A 315 North 11th AVE. IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Greeley CO 80632 REPRESENTATIVES, Greeley,CO 80632 AUTHORIZED REPRESENTATIVE ACORD 25{2001/08)1 of 3 #S285755/M285753 UR 0 ACORD CORPORATION 1988 ..e.e. ,i.nr.eeo uuw. axes re to, dolt e 1-970-472-1736 Paget 003 • IMPORTANT If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemem(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the Issuing insurer(s), authorized representative or producer,and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25-S(2001108) 2 of 3 #S285155/M285753 naLas 4iviavvo 'rimet 4,99 45 TO: Jett a 1-970-472-1736 Pager 004 pest R IS (Continued rarri Page`s} . conditions and exclusions. Additional Insureds: Certificate Holder 8:State of Colorado The following cancellation conditions always apply: -10 days for non-payment of premium -If policy shown, 10 days for workers'Compensation for fraud; material misrepresentation; non-payment of premium;other reasons approved by the Commissioner of Insurance • Awls 25.3(2001108) 3 of 3 #S2857551M285753 EXHIBIT B SUPPLEMENTAL NARRATIVE TO RFP iviay to uo uJ:33p Jen and Uarol Johnson 9(0-4/2-1/f6 p.1 FAX TRANSMISSION REFLECTIONS FOR YOUTH, Inc. 'Discovering the Power of Positive Choice' P.O. Box 1860 Berthoud, CO 80513 (970) 532-5990 (p) (970) 472-1736 (f) DATE:SinSioki TO: �Srp � FROM:)-4--1224 qtt o If t RE: 42 ,it, U fl CNL — E9- Sktusc , COMMENTS: Ut „Lot& Total Pages CONFIDENTIAL This facsimile is intended only for the use of the individual or entity to which it is addressed and may contain information that is privleged,confidential,and exempt from disclosure under applicable law. If the reader of this facsimile is not the intended recipient nor the employee a agent responsible for delivering the facsimile to the intended recipient,you ae hereby notified that any dissemination,disMbution,or copying of this communication is strictly prohibited. If you have received this communication In error,please notify us immediately by telephone and return fhe original message to us at the above address via the U.S. Postal Service. Thank you. Ivlay LS vu u`J:a4p Jett and Carol Johnson 970-472-1736 p.2 • Reflections for Youth, Inc. "Discovering the Power of Positive Choice" Elaine Furister Weld County DSS 315 N. 11th Avenue Greeley, CO 80631 Elaine: Here is my response to the letter I received on 05-23-06 regarding the results of the Core Bid process for PY 2006-2007. As it relates to Option B- Intensive Home Based Therapy (RFP#06010) we will be able to provide some bilingual services. Reflections for Youth, Inc. has a bilingual person that has accepted a position as a contracted in-home worker for our agency. She has stated that she will be available for work beginning in mid-June. The rate of $80.00 per hour for court testimony is acceptable. As it relates to Life Skills (RFP#06005) we will provide transportation at a rate of$30.00 per hour. Secondly, staff qualifications will be either a bachelor's degree person with three years in the mental health/psychology field working with youth and families or a master's degree person with a minimum of two years of the same (some are fully licensed therapists). The addition is a person that currently works with us that does not have a bachelor's degree (she does have an associate's and is less than one year from a bachelor's degree) but has nearly three years of experience working with life skills as a Case Aide in Larimer County. She has attended all of the trainings and is very knowledgeable in the subject. Thirdly, the level of service provided will be dependent upon the referral. Lastly, we are able to travel to South Weld County. Our hope would be to stay within a 30 mile (one way) radius of the city of Berthoud. In terms of court testimony I would request the same amount for all court testimony by representatives of our agency. This amount is $80.00 per hour. As it relates to Day Treatment (RFP# 06006), as discussed in section III. E. "Assessment and plan to meet the needs of child and family", all youth served through Reflections for Youth, Inc. Day Treatment will have a school/therapeutic services aftercare plan upon discharge. The therapist, teacher and family will begin to work on the plan at least 60 days prior to the youth's projected discharge date. The plan will include but is not limited to educational needs, resources and recommendations, therapeutic needs, resources and recommendations and any follow-up or referrals needed prior to discharge. Home-based services can be Iviay LJ vo uy:34p Jen and uaroi Johnson 970-472-1736 p.3 provided by Reflections for Youth, Inc. if necessary at the time of discharge and if so desired by the treatment team. The youth's transition back to the school system is clearly defined in section III. F. (Proactive planning for transition to public school setting). Clarification of the process includes a school transition meeting with the receiving school and a discharge planning meeting with the caseworker, family and other involved professionals. Visits to the new school can be arranged and a full written therapeutic and educational discharge summary is submitted within five days of the youth's discharge that include student progress, IEP progress (if applicable), credit information, grades, strengths and positive strategies and techniques that were successful, overall progress and recommendations. The rate of$80.00 per hour for court testimony is acceptable. Letters have been requested and messages have been left for Greeley/Weld Housing Authorities, Salvation Army (emergency housing) and Employment Services of Weld County. Follow-up has continued and we will again follow-up to obtain the letters required for the bid proposals. In the event that Reflections for Youth, Inc. receives a Core referral for a Medicaid eligible client, our process will be to contact North Range Behavioral Health directly in terms of the referral and work to arrange how the mental health services part to the referral can occur through North Range Behavioral Health. If problems occur or the process becomes too complicated or unclear, Reflections for Youth, Inc. will involve the caseworker making the referral and/or the Core Services Supervisor in Weld County to help facilitate the process. Reflections for Youth, Inc. has reviewed the FYC Commission recommendations and agrees to accept the recommendations as written. Please call (970) 217-4435 or email ieff@reflectionsfaryouth.ora if you have any questions or need further clarification. Thank you. Sincer I trim Nk Jeff J. Jo nson, L CL Executive Director rviay La vo ua:.wp Jen and uaroi Johnson 970-472-1736 p.4 5. Reflections for Youth, Inc. provides psychiatric services to all of our day treatment youth. The students are seen by our contracted psychiatrist,Dr. Scott Shannon,MD, a Board Certified Child and Adolescent Psychiatrist. He will complete an initial evaluation within the first 30 days of placement. Emergency appointments generally can occur within two weeks of intake. The student(s)then see the psychiatrist on a regular basis to monitor mental health status,progress and medications. The psychiatrist is also available in emergencies for consultation and medication management. Prior to discharge and in conjunction with social services and the family,all efforts will be made to have psychiatric services in place prior to a youth's discharge on an as needed basis. At discharge Dr. Shannon will provide prescriptions that will assure a 30-day supply of medications. F. Proactive planning for transition to public school setting or independent living r_ 1. Prior to a student leaving RFY's day treatment program, educational staff will schedule a transition meeting with the receiving school's or program's counseling or special education department. This meeting will serve as a "change of placement" meeting for special education students. Topics of discussion will be the LE.P. (if applicable), current progress and grades and recommendations. The student leaving RFY can also tour the new school or setting at that time. 2. Prior to a student leaving RFY's day treatment program,a discharge planning meeting will take plate with the clinical and administrative staff representing RFY,the caseworker, youth and family,and any other wanted/needed professionals to discuss aftercare and what services are needed_ Needed services can include individual therapy, family therapy, drug and alcohol therapy, community-based NA/AA, mental health/psychiatric through North Range Behavioral Health or similar provider. Individual therapy, family therapy and home-based services can be provided by RFY is necessary at discharge and if so desired. 3. A date for discharge will be set by the team of people involved with the student's case plan. If the student is a non-GED student, Reflections for Youth, Inc. will advocate for a date that least upsets the transition back to public school_ Students can lose valuable clock hours/credits if expected to return to public school in the middle of a semester or academic quarter. 4. A key area that will be addressed throughout the course of placement but certainly during a transition meeting is student progress. For special education students this will be a discussion of the I.E.P. goals and objectives and outcomes. Teachers will be able to give the receiving school information regarding the progress students made towards achieving their I.E.P. goals and their present level of functioning. Teachers and clinicians will also report on effective behavioral and academic interventions and modifications used within the classroom and throughout the day treatment day. 8 may to 1.1O1.1 .O14p yen ana carol Jonnson 9/U-4/2-1/36 p.5 5. Students who have consistently attended school,retained acceptable or above- average grades,actively participated in the therapeutic program offered, and have followed the rules and expectations of the program are considered"being successful". IV. Measurable Outcomes Students attending Reflections for Youth's day treatment program will receive clinical and educational services by licensed staff. Educational services include small structured classrooms (1:5 or 1:6 ratios)with a certified special education teacher,a full-time paraprofessional and no more than 12 students in a classroom. RFY schools provide a safe environment for youth to grow and experience functional and healthy relationships with adults and other students. Basic expectations, tracked daily and evaluated weekly, include the relationship virtues of trust,responsibility, acceptance and accountability'. RFY staff members teach social skills as well as academic skills and are role models of positive and appropriate behavior for the youth served. Students are asked to begin to take personal responsibility for passing core and elective classes with support from RFY's educational and therapeutic staff. This is measured and evaluated by each student's level of organization, responsibility for assignments and homework completion. RFY, Inc. teachers work with students to achieve I.E.P. goals if applicable or individualized learning goals if a student does not have an I.E.P. Each semester teachers switch elective class offerings to give students different options to gain elective credit. RFY students earn clock hours for each class while in the day treatment program. Upon leaving the program, a comprehensive educational and therapeutic discharge summary is written including total clock hours earned. The receiving school/district will convert the earned clock hours into credits depending upon their credit system. RFY assures a continuity care for each of the youth served in its day treatment program by providing educational experiences which remediate,maintain and improve academic,intellectual and social functioning. Students receive highly individualized instruction and attention, supportive mental health/therapeutic intervention and complete, comprehensive transition and aftercare plans. All transition and aftercare plans include input from all current and future professionals involved with the youth. These students are more successful upon transition back to their homes and public school systems and it is the goal of Reflections for Youth, Inc to serve each of its youth in this manner. The success of RFY, Inc. will be monitored, measured and evaluated through compliance with the written Day Treatment Policy and Procedures and through classroom observations and educational and therapeutic staff supervision. To date,it has been our experience that all but one of our previous and current day treatment students has returned to his or her family or to a foster home if family was not available. With the one exception all were residing in their own home immediately after discharge. It is our goal that this trend continue with the goal of all youth served returning to their home as soon as possible after discharge, hopefully immediately, and in no longer than six months barring any safety(D & N) issues. The majority of students who discharge from RFY day treatment program have entered public school or an alternative,non-day treatment school managed by their home district. Decisions have 9 { DEPARTMENT OF SOCIAL SERVICES rs A sP.O.BOX GREELEY,CO. OX Website:www-co.weld.co.us ' Administration and Public Assistance(970)352-1551 Child Support(970)352-6933 111 C. COLORADO May 15, 2006 Jeffery Johnson, Executive Director Reflections for Youth 204 W County Road 10.5, P O Box 1860 Berthoud, CO 80513 Re: Bid 06OPB05 Option B Bid 06DT03 Day Treatment Bid 06LS13 Lifeskills Dear Mr. Johnson: The purpose of this letter is to outline the results of the Core Bid process for PY 2006-2007 and to request written information or confirmation from you by Monday, May 22, 2006. Results of the Bid Process for PY 2006-2007 A. The Families, Youth and Children (FYC) Commission recommended approval of your RFP# 06010, (Bid # 06OPB05) Option B-Intensive Home Based Therapy for inclusion on our vendor list. The score given to your bid was 95. The FYC Commission attached the following recommendation to this bid. Recommendation: You must clarify that you provide Bilingual services. 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 is $80 per hour. B. The Families, Youth and Children (FYC) Commission recommended approval of your RFP# 06005, (Bid # 06LS13) Lifeskills, for inclusion on our vendor list. The score given to your bid was 90. The FYC Commission attached the following recommendation to this bid. • Page 2 Reflections for Youth/Results of RFP Process for PY 2006-2007 Recommendation: • You must clarify in writing that you will be providing transportation at$30 an hour. • You must provide details of staff qualifications. • You must clarify that the level of service provided is dependent on the referral. • There is no information included on your bid about travel to South County. Hourly Rate for Court Testimony: You did not provide a rate for court testimony. For new bidders, the Department will use your requested hourly rate. The rate for court testimony will be billed at is $53.80 per hour. C. The Families, Youth and Children (FYC) Commission recommended approval of your RFP# 06006, (Bid# 06DT03) Day Treatment for inclusion on our vendor list. The score given to your bid was 90. The FYC Commission attached the following recommendation to this bid. Recommendation: You must clarify and define the youth's after care and transition back to the school system. 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 is $80 per hour. Compliance Item: For all of the above bids, 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. Required Response by FYC Bidders Concerning FYC Commission Recommendations: You are requested to review the FYC Commission recommendations and to: 1. accept the recommendation(s) as written by the FYC Commission; or 2. request alternatives to the FYC Commission's recommendation(s); or 3. not accept the recommendation(s) of the FYC Commission. Page 3 Reflections for Youth/Results of RFP Process for PY 2006-2007 Please provide in writing how you will incorporate the recommendation(s) into your bid. If you do not accept the recommendation,please provide written reasons why. All approved recommendations under the NOFAA will be monitored and evaluated by the FYC Commission. The Weld County Department of Social Services is requesting your written response to the FYC Commission's recommendations. Please respond in writing to 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, 970.352.1551 extension 6230. Sincerely, y A. G "ego, Di for cc: Juan Lopez, Chair, FYC Commission Gloria Romansik, Social Services Administrator Hello