HomeMy WebLinkAbout20061588.tiff RESOLUTION
RE: APPROVE TWO NOTIFICATION OF FINANCIAL ASSISTANCE AWARDS FOR DAY
TREATMENT 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 two Notification of Financial Assistance
Awards for Day Treatment 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. Reflections for Youth, Inc.
2. Turning Point Center for Youth and Family Development, 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 two Notification of Financial
Assistance Awards for Day Treatment 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.
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.
E BOARD OF COUNTY COMMISSIONERS
La ELD OUNTY %OLORADO
ATTEST: gild � t , 4O 166
Si- .? a4 r. Geile, Chair
Weld County Clerk to the ` t,-�► �/\f
4l G 1 �Q�,`�G7 f David E. Long, Pro-Tern
BY: y ---.-
De ty Clerk to the BoardC. 1--`'-1^
Willi H. Jer e AP OV ASzI E i'"11((��
—
Rob D. Masden
u ty ney
4 I Glenn Vaad
Date of signature:
2006-1588
SS0033
fift SE DO in - c6-
S DEPARTMENT OF SOCIAL SERVICES
P.O. BOX A
GREELEY, CO. 80632
IDWebalte:www.co.weld.co.us
Administration and Public Assistance (970) 352-1551
WI
O Fax Number(970) 346-7691
• MEMORANDUM
COLORADO
TO: M.J. Geile, Chair Date: May 31, 2006
Board of County Commissioners /}
FR: Judy A. Griego, Director, Social Services Jl l W C
RE: Notification of Financial Assistance Awards'with arious Contractors—
Day Treatment Services
Enclosed for your approval are Notification of Financial Assistance Awards with Various
Contractors for Day Treatment 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 day treatment services for youth involved in the child
welfare system.
4. The Contractors include:
A. Reflections for Youth $91.46 daily rate
$80.00 per hour court testimony
B. Turning Point $16.77 hourly rate
$80.00 per hour court testimony
If you have any questions, please telephone me at extension 6510.
2006-1588
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 FY06-CORE-53
Revision (RFP-FYC-06006; 06DT03)
Contract Award Period Name and Address of Contractor
Beginning 06/01/2006 and Reflections for Youth
Ending 05/31/2007 Day Treatment Program
204 W County Road 10.5
P. O. Box 1860
Berthoud, CO 80513
Computation of Awards Description
Unit of Service The issuance of the Notification of Financial
Community-based day treatment program is open to Assistance Award is based upon your Request for
youth ages 11-18 requiring a well-structured and secure Proposal (RFP). The RFP specifies the scope of
program, consistent supervision, therapeutic mental services and conditions of award. Except where it is
health services, and extra support educationally,both in conflict with this NOFAA in which case the
academic and behavioral. Total family units is six at any NOFAA governs, the RFP upon which this award is
one time. Clients will be assessed for bicultural/bilingual based is an integral part of the action.
services. Average hours per week include 30 hours
classroom/education, and three hours therapeutic Special conditions
services per week.
1) Reimbursement for the Unit of Services will be based
Cost Per Unit of Service on an hourly rate per child or per family.
Per Daily Rate 2) The hourly rate will be paid for only direct face to
Treatment Package $91.46 face contact with the child and/or family, as specified
in the unit of costs computation.
Court Testimony Per Hourly Rate $80.00 3) Unit of service costs cannot exceed the hourly and
yearly cost per child and/or family.
4) Payment will only be remitted on cases open with,
Enclosures: and referrals made by the Weld County Department
X Signed RFP:Exhibit A of Social Services.
X Supplemental Narrative to RFP: Exhibit B 5) Requests for payment must be an original submitted
Recommendation(s) to the Weld County Department of Social Services
X Conditions of Approval by the end of the 25th calendar day following the end
of the month of service. The provider must submit
requests for payment on forms approved by Weld
County Department of Social Services.
6) The Contractor will notify the Department of any
change in staff at the time of the change.
Approvals: Program Official:
By By
M. J. Gei e, Chair Judy riego, irector
Board of JUN 1 �
WeldCount�Ocmmissioners Weld unty artment of Social Services
Date: ub Date: 5 3 00
a7a-e -/S6PY
O G v-3
INVITATION TO BID
OFF-SYSTEM BID 001-06 (06005-06011 AND 006-00, A, B, & C)
DATE: March 1, 2006 BID NO: RFP-FYC-06006
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-06006) for:Colorado Family Preservation Act--Day Treatment Program
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 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. Providers in the Day Treatment Program Category must provide a
comprehensive, highly structured service that provides education to children and therapy to children and their
families. 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 hAAittl-
(After receipt of order) BID BE SIG1NEE' n'DIN INK
TYPE OR rTED SIGNATURE
PROVIDER SI.P.N-QGCI136 cti \\ou yt •
(Name) Handwritten Signature By Authorized
Officer or Agent of Provider
ADDRESS ). \V TITLE 1?t1 -1t yn t i_—
DATE t1.1 ��1mil N, r,►Y
PHONE# �� 1 53\.. Rift)
The above bid is subject to Terms and Conditions as attached hereto and incorporated.
Page 1 of 41
- ' Bid 001-06 (RFP-FYC-06006) Attached A
DAY TREATMENT 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(06006)
NAME OF AGENCY: t G1t3nonS �( \ µ.tkn .
ADDRESS: b . v) '%\ t3 eilif t l t�� Lt ASP
PHONE: 1 5�� . 'Slick; j ILT to) ..\-4,‘.\ j ,
CONTACT PERSON: �{ l TITLE: ehvos-Trw 1)1 fL
DESCRIPTION OF EMERGENCY ASSISTANCE PROGRAM CATEGORY: The Day Treatment Program Category must
provide a comprehensive,highly structured program alternative to placement that provides therapy and education for
children.
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: OM 1 {k-Tl..h\ry V`1k a jM LAa am
Name and i tore of Person Preparing Document, � tn_— Date
��
Name and A ature Chie twe Officer Ap f ant Agency Date
MANDATORY PROPOSAL REQUIREMENTS
For both new bids and renewal bids,please initial to indicate that the following required sections are included in this
Posposal for Bid.
Project Description
Target/Eligibility Populations
Types of services Provided
Measurable Outcomes
Service Objectives
Workload Standards
Proof of Collaboration
Evidenced-Based Outcomes
taff Qualifications
Unit of Service Rate Computation
Billing Process
Program Capacity per Month
Certificate of Insurance
Provider Number for State Child Care Licensing
Page 29 of 41
Bid 001-06 (RFP-FYC-06010) Attached A
Date of Meeting(s)with Social Services Division Supervisor: 3-3-c74'
Comments by SSD Supervisor:
pet' (--12 d Art eat—•Pro •
/ e Slt m e- • f4-7/.1.9A f' y 2 S /..� pr o., E Sr ,lie [`' S
dds.. 6 Arco sIL pie ,1.re tB
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Name an gnature S sor Date
Page 31 of 42
Bid 001-06 (RFP-FYC-06010) Attached A
Program Category Home Based Intensive Family Intervention Program Bid Category
Project Title
Vendor
PROJECT DESCRIPTION
•
Provide a brief one-page description of the project.
II. TARGET/ELIGIBILITY POPULATIONS
Provide a one page brief description of the proposed target/eligibility populations. At a minimum
your description must address:
A. Total number of clients to be served.
B. Total individual clients and the children's ages.
C. Total family units.
D. Sub-total of individuals who will receive bicultural/bilingual services.
E. Sub-total of individuals who will receive services in South Weld County.
F. Sub-total of Individuals who will have access to 24-hour service.
G. The monthly maximum program capacity. •
H. The monthly average capacity.
I. Average stay in the program(weeks).
J. Average hours per week in the program.
K. Cultural/ethnically specific services
L. Service to South Weld clients
la. TYPE OF SERVICES TO BE PROVIDED
Provide a two-page description of the types of services to be provided. Please address if your project
will provide the service minimums as follows:
A. Therapeutic Services - includes re-parenting, limited family therapy, problem solving,
communication skills,parent-child conflict management, etc. Duration of service is limited to
20 hours face-to-face contact per referral.
B. Concrete Services - means concentrated assistance in the development and enhancement of
parenting skills, problem solving,hands-on parenting.
C. Collateral Services - teaching families to work with other community agencies such as drug
and alcohol, health care,job training, information and referral, advocacy, etc., use of
community support groups.
D. Crisis Intervention Services -including in-home counseling and other interventions available
on a 24-hour basis.
Provide your quantitative measures as they directly relate to each service. At a minimum, include a
number to be served in each service component. Describe your internal process to assure that FYC
resources will not supplant existing and available services in the community; e.g. mental health
capitation services, ADAD and professional services otherwise funded.
Page 32 of 42
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EXEC•UTIVE DIRECTOk .3, e
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THIS LICENSE'MUST • POSTED IN A'PROMINENT$OcATION ON TWR�41G NSED PREMISES �°
. �r
� STATE OF COLORADO
tDEPARTMENT OF HUMAN SERVICES
;J g DIVISION OF CHILD CARE
\. ~.f 1575 SHERMAN STREET
*1876* DFflVEl, COVn nn{, ^^?^3.17!.!
PERMANENT CHILD CARE LICENSE .
Provider ID: 1530130 Service Type: DAY TREATMENT
LOCATION:
RFY, INC -GRISMORE 204 WEST COUNTY ROAD 10-E
BERTHOUD, COLORADO 80513
P.O. BOX 1860
BERTHOUD, COLORADO 80513 COUNTY: LARIMER
License Effective Date: 11-05-2004 '
•
The licensee must comply at all times with the Child Care Act and the rules and standards of the Department of Human
Services.The licensed premises and its records must be available for inspection at all times by the Department of
Human Services or its authorized representatives.This license is valid only for the location address listed above and is
not transferable to any other person,organization or location.The licensee must surrender this license to the . • . . . . .. .. -
De.pertment of Human Services upon denial,revocation or suspension.
F.."
,--S.Numbers and ages of children cared for at the licensed premises must not at any time exceed:
x`.40 children of the age 11 years 0 months to 18 years 0 months
4" Other conditions and restrictions:
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Place Stickers Below
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0 slisterc. ANNIVERSARY DATE
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EXECUTIVE DIRECTOR
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THIS LICENSE MUST BE POSTED IN A PROMINENT LOCATION ON THE LICENSED PREMISES
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STATE OF COLORADO
. DEPARTMENT OF HUMAN SERVICES
t•V 4 DIVISION OF CHILD CARE
1575 SHERMAN STREET
DENVER,COLORADO 80203.1714
PERMANENT CHILD CARE LICENSE
Provider ID: 1530131 Service Type: DAY TREATMENT
LOCATION:
RFY, INC -WILDERNESS 1435 SOUTH COUNTY ROAD 17
BERTHOUD, COLORADO 80513
P.O. BOX 1860
BERTHOUD, COLORADO 80513 COUNTY: LARIMER
License Effective Date: 11-04.20O4
The licensee must comply at all times with the Child Care Act and the rules and standards of the Department of Human
Services.The licensed premises and Its records must be available for inspection at all times by the Department of
Human Services or its authonzed representatives.This license Is valid only for the location address listed above and is
not transferable to any other person,organization or location.The licensee must surrender this license to the
Department of Human Services upon denial,revocation or suspension.
Numbers and ages of children cared for at the licensed premises must not at any time exceed:
8 children of the age 12 years 0 months to 18 years 0 months
Other conditions and restrictions:
Unique conditions:
Place Stickers Below
476
ANNIVERSARY DATE
EXECUTIVE DIRECTOR
THIS LICENSE MUST BE POSTED IN A PROMINENT LOCATION ON THE LICENSED PREMISES
Reflections for Youth, Inc.
"Discovering the Power of Positive Choice"
Weld County Day Treatment Program
RFP-FYC-06006
03-28-06
(Currently begin offered and to continue services through 05-31-07)
I. Program Description
Reflections for Youth, Inc. is a non-profit, community based residential treatment
program and day treatment program for females and males ages 11-18 (can admit youth
18-21 provided they are admitted before there 18th birthday)regardless of race, color or
religious preference. All residential and day treatment programs are licensed by
Colorado Department of Human Services State Child Care Licensing. The license
numbers are as follows: Prairie View RTC and Day Treatment license#1530128,
Grismore RTC and Day Treatment license#1530130, and Wilderness RTC and Day
Treatment license#1530131. Services provided for the purposes of this bid proposal
include a full-day day treatment program incorporating three full academic semesters
throughout a calendar year. RFY's day treatment program has been utilized as a"step-
down"program for youth being served residentially and needing a transition period and
extra support before returning to a public school environment,and as an option for
counties and school districts needing an appropriate learning and therapeutic setting for
at-risk youth living in the home of the family or in a foster home situation.
The day treatment program will operate out of a centralized location in Loveland, CO.
The address is 1000 S. Lincoln Avenue, Loveland,CO 80537. Each of the four
classrooms employs a full-time special education teacher licensed in the area of Special
Education: Affective Needs and a certification to meet the requirements of No Child Left
Behind. Each classroom also employs a full-time paraprofessional educated at the
Bachelor's level with a state substitute teaching license. The school program will be
licensed to serve a total of 40 youth(28 residential and up to 12 day treatment). It is
important to note that the projected date for the"centralized school" site will be Julyl,
2006 pending approval of special review through the city of Loveland and final approval
form the Larimer County Health Department and the Colorado Department of Human
Services, Licensing. Until that time the day treatment program will continue to operate
out of three separate sites, with a total of no more than eight day treatment students at all
three sites combined.
Day treatment students are expected to participate in a level system similar to
residentially placed students, follow classroom and program rules, adhere to an academic
curriculum designed for them to meet their home school district's graduation
requirements,contribute to the writing and follow-through of their I.E.P. (if applicable)
or program-generated goals,and be willing to participate in individual,group and family
therapy. Each day treatment only student receives daily communication/behavior sheets
1
completed by their teachers to be brought home and signed by parents or guardians for
regular contact regarding their student's progress.
It is the goal of Reflections for Youth to educate students in both a traditional and non-
traditional manner by making certain each student receives core and elective classes
needed to graduate or by aiding in the attainment of a GED, and by offering community-
based activities to enhance their learning experience. The school uses the local library
and recreation center one time per week as a class,participates in frequent filed trips
designed by the teachers to supplement current classroom lessons,are involved in
service-learning opportunities such as Meals-on-Wheels, Open Space and other service-
learning as available. In the event a student and his guardian and professional team
choose to allow the youth to prepare for the GED, Reflections for Youth, Inc. educational
staff arranges for he/she to take a GED locator test where their strengths and needs will
be identified, and then designs a daily educational plan incorporating core classes in their
deficit areas and regular study time geared towards passing the GED. In addition,RFY is
committed to assisting older students nearing discharge in locating appropriate
community-based programs, such as the county workforce centers and Americorp, where
career exploration and job training and placement are addressed,
Day treatment students are required to participate in individual, group and family therapy
unless contraindicated by the placement worker and/or school district referring the youth.
The clinical services of the day treatment program are the overall responsibility of the
Clinical Director in coordination with the Executive Director and therapist(s)providing
the services. This includes the development, implementation and coordination of the
treatment program. Testing and psychiatric medication evaluations and appointments are
conducted as needed. These evaluations aid in case planning and assure that the
appropriate treatment is utilized for the youth's maximum growth and benefit.
Reflections for Youth, Inc. therapists are all masters' level and have specific training in at
least one of the following: EMDR, Dialectic Behavioral Therapy, Cognitive Behavioral
Therapy and/or Reactive Attachment Disorder. Reflections' treatment team evaluates
each day treatment youth's plan twice monthly. Monthly treatment progress reports are
submitted to the appropriate agencies representing the youth and monthly (or as needed)
staffings are scheduled to discuss the youth's progress in detail. A discharge plan and
aftercare services are designed by the Clinical Director, assigned therapist, guardian and
placement worker.
II. Target/Eligibility Populations
Reflections for Youth's day treatment program is open to any youth requiring a well-
structured and secure program, consistent supervision,therapeutic/mental health services,
and extra support educationally, both academic and behavioral. An I.E.P. is preferred but
not required. Typically such youth will demonstrate behavioral and emotional difficulties
and have a history that may involve one or more of the following: family conflict and
discord,physical abuse, sexual abuse, running away and/or truancy issues, oppositional
defiant behavior, self-defeating behaviors, delinquent acts and certain adjudications and
2
learning/emotional disorders/disabilities. RFY, Inc. employs a contracted child
psychiatrist and accepts youth currently taking or in need of psychotropic medications.
RFY's centralized school will be able to accept up to twelve day treatment youth once the
centralized school is in place. Currently RFY can accept up to eight day treatment
students; six males and two females. Ages range from 11-18 and RFY is licensed to take
18-21 year olds if necessary. Arrangements will be made to provide therapy sessions to
all appropriate family members of split families if in the best interest in of the youth in
day treatment and recommended by the placement worker or school district referring the
youth. The needs for bicultural/bilingual services will be assessed by individual/family
need and RFY will make every effort to employ a paraprofessional and a therapist that
can speak a second language. At this time we do not currently employ any bilingual staff
members in the day treatment setting. As stated,we do have two interpreters available
for family communication with treatment planning,progress and therapeutic
involvement, including attendance at family therapy sessions on an as needed basis. We
are working to employ a bilingual staff member that can assist in each of our three
settings Currently RFY employs two staff that are used for the purposes of interpreting
during sessions in which all family members can not speak English. All Reflections for
Youth, Inc. on-grounds schools are currently located in southern Larimer County but
within a few miles of Weld County. One school is located east of I-25 on Hwy 402 and
the other two programs are located near Berthoud on or near Hwy 287. All schools are
approximately 30 minutes from Greeley, and one program is 20 minutes from Greeley.
Approximately 25%of our referral base for our residential program is currently from
Weld County. RFY's monthl maximum capacity for Weld County youth not in our
residential program will be youth. As stated,an extensive amount of work has
already been completed to mb into our centralized school site in Loveland, CO. Based
on the location at 1000 S. Lincoln,this will be approximately 20—25 minutes from most
families in the Weld County/Greeley area.
The average stay of a client depends upon daily/weekly progress, individual/family needs
and availability of funding. All areas are important topics of discussion at the monthly
staffing meetings. Currently,the youth attending Reflections for Youth,Inc. day
treatment program are in the program for approximately one school semester,or close to
four months. Average hours per week that a client participates in the day treatment
program can be broken down into the following: 30 hours a week classroom/education
hours, and approximately three hours a week for therapeutic services. This does not
include the time for transportation. Transportation is provided by Reflections for Youth,
Inc.
Reflections for Youth, Inc. will not reject any referral solely on the basis of the youth's
psychiatric/emotional history, committed delinquent acts or other problematic behavior.
Youth with an extensive history of aggression to self and/or others (requiring restraint for
the protection of others) as well as adjudicated sexual offenders will be assessed on a
case-by-case basis and may not be admitted depending upon a pre-placement interview
and evaluation. Youth with a full-scale IQ below 70 and youth requiring routine medical
assistance (diabetes, seizure disorders, etc.)will also be assessed on a case-by-case basis.
3
HI. Types of Services to Be Provided
A. Site based services.
Reflections for Youth, Inc. will provide a minimum of 6hrs/day and 30 hours/week of
educational services to the youth it serves. In addition RFY will provide approximately
three hours of therapeutic service per week. These services will be provided by a state
licensed special education teacher in the area of affective needs,a paraprofessional and a
therapist/therapist intern. A Day Treatment Coordinator will also be hired as part of the
expansion and move to a centralized school site. RFY employs a Title I reading
specialist who works one full school day at each facility per week and will continue to
work within the classroom at the centralized school.
B. Community collaboration efforts.
Reflections for Youth,Inc. maintains a professional working relationship with the
Colorado Department of Education's Special Services Unit. Each of RFY's facility
schools must comply with CDE's teacher and administrator licensing requirements, state
and national curriculum standards,the administration of CSAP testing each calendar
year, October 1 and December counting reports,Title I compliance,No Child Left
Behind, Special Education Law and FAPE. Reflections for Youth, Inc,is committed to
providing excellent educational experiences for the youth it serves and welcomes
frequent communication with members of CDE's Special Services Unit for the constant
improvement of its educational program.
Reflections for Youth, Inc. currently works in collaboration with the Weld County
Department of Social Services to provide residential treatment services, day treatment
and In-home Intervention Services for adolescents and their families receiving services
through the social service system. RFY receives referrals from caseworkers for the
placement of adolescents 11-18 years of age. After placement, RFY and the caseworkers
meet on a monthly basis to discuss progress, struggles, home passes, current and future
planning and aftercare plans for the youth being served. The Facility Manager, Therapist,
counseling and administration staff communicate with the caseworker regularly to
discuss any educational,therapeutic or residential issues that arise while the youth is
placed. The same type of collaboration takes place for the current day treatment youth
that RFY serves from Weld, Larimer and Boulder Counties, Larimer Center for Mental
Health,North Range Behavioral Health), and St. Vrain, Boulder Valley and Thompson
Unified school districts.
If a student receives services from a local mental health center, Reflections for Youth,
Inc. makes every effort to communicate with the center and determine the student's
current therapeutic and medication needs. We have developed a good relationship with
North Range Behavioral Health, Larimer Center for Mental Health, Jefferson Center for
Mental Health and the Mental Health Center of Boulder County. Prior to discharge we
4
do and will continue to make every effort to assist in the arrangement of continued
therapeutic and/or psychiatric services as needed by individual youth and families.
C. Program Components
1. Reflections for Youth, Inc's. educational program consists of a minimum of a six and
a half hour day and is offered year-round. Teacher's work year-round with a short period
off during the summer semester and traditional holidays off during the school year. 240
days of education are offered per year. Upon entering the program,requests are
immediately made for past school records, including the current I.E.P. (if applicable).
Students are administered the P.I.A.T. (Peabody Individual Achievement Test)if valid
and current grades and achievement levels can not be established and if deemed
necessary by the educational team. In the even the referred youth is a special education
student,the I.E.P. is reviewed for compliance and used as-is if appropriate. When a
special education student is admitted with an out-of-date I.E.P.,RFY's educational team
will hold either an annual or triennial meeting as necessary and with proper
notification/communication being given to the student's home district. If a triennial
review is appropriate,the home district will be asked to collaborate with RFY for needed
testing requirements. RFY's educational team can and does administer the Woodcock-
Johnson III,P.I.A.T., BASC and host or attend I.E.P.meetings as agreed up[on by the
home district and RFY. RFY will ask that a school psychologist and speech/language
pathologist from the home district be available for the remaining portions of triennial
I.E.P. testing.
2. The therapeutic components of the day treatment program at Reflections for
Youth,Inc. include individual, family and group therapy. Drug and Alcohol Therapy can
also be provided and is offered one evening per week(after school hours). Therapy
techniques used by therapist include Structural Family Therapy, Cognitive Behavioral
Therapy, Solution-Focused Therapy, Play Therapy,EMDR and Dialectic Behavioral
Therapy(DBT). Therapists provide flexibility in scheduling family sessions in order to
facilitate full involvement in the treatment process. The Clinical Director and licensed
clinicians develop treatment plans to target behavioral, social, emotional and family goals
in both therapy and program. The clinician participates in treatment planning meetings to
review goal progress and facilitate new interventions or target goals as needed, and also
participates in monthly staffings. RFY also provides psychiatric/medication evaluations
and monitoring to the youth being served. RFY contracts with Dr. Scott Shannon, child
psychiatrist to provide these services on an as needed basis and within 30 days of intake
for each youth in the residential and day treatment program.
3. The day treatment program of Reflections for Youth, Inc. utilizes a behavior
management phase system that is peer driven,but with extensive staff support and
involvement. When students meet the expectations of the day treatment program they
move up the phase system,gain more responsibility and earn"better"privileges unique to
the level. Each student is given goals developed by educational,therapeutic, counseling
staff and him or herself. The goals may be current I.E.P. goals,if appropriate, or
"schoollprogram goals" depending upon individual academic,therapeutic or behavioral
5
needs. Students must meet a certain percentage on each goal before they can reach a
higher phase. At the end of each school day,teachers fill out daily communication logs
that include information regarding points for the day,positive accomplishments,and/or
areas needing improvement. It is our hope that parents see this information each day and
the expectation is for the students to have it signed at the end of each week and given to
the classroom teacher. Responsibilities and earned privileges are outlined for incoming
students in the Day Treatment Handbook.
4. Day treatment students are able to participate in any recreational activity or event
scheduled during the school day, as long as rules and expectations are being met to
ensure safety. All students have access to the Chilson Recreational Center and Longmont
Recreational Center(YMCA), and the female youth have access to Curves. A minimum
of one time per week they can swim,workout with weights,run on an indoor track or
play basketball for physical education. Outdoor classroom activities are also planned
frequently.
D. Parent/Caretaker involvement in all program components as indicated in the
case plan and as required.
Parents/Caretakers are expected to be involved in monthly staffing meetings, family
therapy, I.E.P. meetings and other educational meetings, and through weekly
communication with the educational staff through written materials. Individual therapy
meetings are set for assessment and goal development. During intake, parents/caretakers
and students are given an orientation packet that described the program components and
give access phone numbers for the educational,clinical and administration staff.
Parents/Caretakers receive copies of all treatment plans and progress reports. The
educational or administration staff contacts parents/caretakers of severe behavioral
difficulties and other significant concerns that may arise during the day treatment day.
Homework and treatment goals progress are shared daily with the parent/caretaker
through daily reports and a signed copy must be turned into the teacher at the end of each
week to ensure communication and continuity between home and placement.
E. Assessment and plan to meet the needs of child and family.
1. All teachers employed by Reflections for Youth,Inc are licensed through
Colorado Department of Education's educator licensing unit. All RFY teachers are
required to possess or be working towards a Master's Degree in Special Education:
Affective Needs. Special Education teachers' at RFY have historically moved into a
teaching position after working as a counselor or paraprofessional within the agency,
giving them more experience with the behavior management system and overall program
philosophy. To meet the qualifications of No Child Left Behind each teacher will also
have a specialization to include Reading,Math, Science and/or Social Studies.
2. Any youth being served through Reflections for Youth, Inc. will have a
school/therapeutic services aftercare plan upon discharge. Most students either return to
a public or alternative school within their home district or continue the preparation to take
the GED. For students needing work skills or job training,RFY is committed to helping
6
the student find the appropriate resources within their community to receive assistance in
these areas. RFY currently works with county workforce agencies, local community
colleges,probation departments, mental health centers and other community-based
services offering assistance to youth.
3. Reflections for Youth, Inc. offers flexibility in scheduling family therapy
sessions to encourage and provide opportunity for all family members to be involved.
All individual and family therapy sessions are run by therapists with experience in
adolescent, family, group and individual therapy(LCSW, LMFT or LPC or Intern in any
one of the three licensure areas). Group education sessions are run by bachelor's level
counseling or education staff with training in running the groups being offered.
4. Reflections for Youth, Inc. provides a structured recreational activities schedule
for all residential and day treatment residents in placement. Recreational activities for
day treatment students most often take place at a local recreation center and include
swimming, weight training,walking or jogging on an indoor track,basketball and any
aerobic activities offered. There are also specific times at each facility for sport activities
such as football, soccer, volleyball,and basketball. The recreational activities that take
place are documented daily on an Activity Log Sheet and the document details each
activity that takes place in the designated time slot(s).
Reflections for Youth, Inc works with USDA and in collaboration with a
registered dietician who designs each facilities menu(lunch menu for day treatment
students). Reflections provides a snack and lunch for each youth in the day treatment
program. The menu is posted in the school, is seasonal and rotates every other week. It
details each food item and amount to be served at each meal and snack time. The meal
and the number of youth receiving a meal are documented on a Daily Food Production
Record Form(USDA).
The facility manager in each of RFY's three programs is responsible for ensuring
that each youth's medical and dental appointments are completed and properly
documented. In the case of day treatment youth, RFY has typically not been involved
with medical and dental appointments unless a medical emergency occurs in the course
of a day that the youth is present in program. Day treatment youth taking psychotropic
medications or in need of a psychiatric/medication evaluation will have an appointment
scheduled with RFY's psychiatrist within 30 days of intake. Ongoing appointments will
occur on an as needed basis. Typically appointments occur every 30 days unless the
psychiatrist has specifically stated he wants to see the youth more or less frequently or in
the event of an emergency.
Within the day treatment setting, RFY, Inc. offers sex education as an elective
course. Presentations by the Larimer County Department of Health and Planned
Parenthood take place regularly and include topics of safe sex, sexually transmitted
diseases, contraception and HIV. Educational groups are also offered and are
documented on a Daily Schedule Form.
7
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
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 I.E.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 place 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
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
been made for some students attending day treatment that earning their GED is a better
option. When deemed appropriate by the professionals involved with the youth(age,
credit situation, etc.)RFY staff will schedule the student for a GED locator test. Based
on the results of the test, the student will continue to take classes in his/her areas of need
(reading,math, etc.) and be given daily preparation time for the GED as well. In addition
to preparation time the student will be evaluated by suitable community-based programs
to assist in the areas of career exploration and job training/placement. If the GED is not
completed while at RFY, the student,guardian and placement worker will be notified of
formal GED preparation class offerings within his/her community to further prepare for
taking and passing the GED. It is also our goal that unless another approved plan is put
into place prior to discharge from day treatment, all youth served will enter public school
upon completion of the day treatment program.
Quantitative measurements of success include satisfactory progress on individual
academic,behavioral and/or I.E.P. goals,progress and attainment of individual and
family therapeutic goals and satisfactory compliance with rules and expectations of the
program, including expectations for the home environment while in the program. We
will measure and evaluate improvement in attendance,classroom participation, grades,
behavioral interactions with teachers,clinical staff and peers, and consistency of positive
family interactions and outcomes(communication, conflict resolution,limit setting and
follow through). This is accomplished through monthly treatment plan and update
reports including assessment and measurement of progress in the areas of social,
emotional, family,recreational and educational(drug and alcohol if applicable); daily
goals and percentages;reports from therapist regarding therapy progress in terms of
positive decision making,conflict resolution and communication; and parental feedback
and compliance and completion of treatment plan and goals related to the home
environment. Students are evaluated and monitored weekly in improving their grades and
consistently have access to teachers and can expect that appropriate accommodations will
be made to aide in their overall success. RFY uses a wide range of assessment materials
in evaluating student progress and performance. Teachers are trained in administering
individual achievement tests and behavior rating scales and they are consistently used to
measure and evaluate where a student is,what is needed and how to provide what is
needed. When a student enters RFY he/she will be given formal assessments in the areas
of reading and written language by the Title I reading specialist and informal assessments
by the classroom teacher. Each student's needs will be assessed using past school
records, I.E.P. goals and objectives, discharge summaries and educational history. Goals
will be set to measure and evaluate that the student's true needs are being met.
Reflections for Youth holds annual and triennial reviews for special education students as
indicated by the I.E.P. and teachers report on annual goals at each grading period. In
addition a monthly education summary, including the measurement and evaluation of
behavioral, emotional and/or academic goals(depending upon assessed need) is
completed by the Special Education Teacher.
V. Service Objectives
10
Reflections for Youth, Inc. will work diligently to assure that all youth attending its day
treatment program will have a successful transition upon completion of the program. It is
currently our experience that nearly all of our day treatment youth are living with their
families at the time of placement. The exception has been for youth in which the parental
rights are tenninated or a family or even appropriate family member is not available to
reunify with. In those cases the youth is with a foster family at the time of placement and
remains with that family after completion of the day treatment program. As previously
stated, our average length of placement in day treatment has been for one semester or
approximately 16 weeks (4 months). Our longest stay in day treatment has been nine(9)
months and was based on some extenuating circumstances that neither RFY nor the
placement worker had control of.
The vast majority of students that have discharged from RFY's day treatment program
have returned to public school or a non-day treatment school that the home school district
manages. To date, over 90%of the day treatment youth have returned to public school.
Decisions have also been made for some students attending day treatment that after
completion of the program,the GED is a better and more realistic option when compared
to public school settings.
All youth in the day treatment program at RFY participate in staffmgs, family therapy
and case plan meetings in which resources and available services are discussed.
Comprehensive educational and therapeutic discharge plans are written and an aftercare
plan is put together prior to the referred youth completing treatment. The aftercare plan
is very community resource based and discusses in detail services that are available and
may be helpful. Access to those services is discussed during regular staffmgs and case
planning meetings with the family, youth, caseworker and program present.
The day treatment program at RFY will help improve the outcomes for the Performance
Improvement Plan(P.I.P.)in a couple of key ways. First, the program will work to
reduce the need for any kind of out-of-home placement for any youth that has not yet
been placed out of home,and it will work to increase the likelihood that a youth will not
need to be removed from the home a second(or more)time if the youth had been
previously placed out of the home. Secondly,the day treatment program will work to
lessen some of the behavioral problems the youth faces through individual and group
therapy, psychiatric support as needed, specialized education support and more positive
attention and supervision overall. The program will also work to provide additional skills
and new ways of looking at old problems for the caregivers and families, with the overall
goal of increasing the caregiver or 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 placement or
higher level of care. Thirdly, assessments and an aftercare plan are part of the overall
services offered by the day treatment program. RFY has developed and Aftercare plan to
be used as part of the discharge process and to be used once the child has successfully
completed the day treatment program and is at home with fewer services. Case planning
will occur,and crisis intervention and support will be part of the plan. Since Reflections
for Youth, Inc. also offers in-home family intervention services,this may be used as a
step down when needed,to again,reduce the need for out-of-home placement. Lastly,
11
RFY holds regularly scheduled staffing with all parties involved and in particular with
the caseworker, family member(s), and the youth receiving the services. In this way, it is
assured that the youth and guardian participate in all case planning.
VI. Workload Standards
Reflections for Youth, Inc. will have the capacity to serve ten(10) youth and their
families in day treatment at any one time. Program capacity per month is ten(10)youth
and their families. This number may increase depending upon length of stay of the youth
served. This number is based on the incorporation a centralized school into its services
and expands the number of youth it can serve in a non-residential setting. As stated, this
is projected to occur prior to the beginning of the school year 2006/2007 with a projected
date of July 1, 2006.
The length of time in the day treatment program is currently averaging four months and
there is no reason to expect that there would be a significant increase or decrease in terms
of length of time in the program.
Total number of hours per week, including transportation would be approximately 38-40
and includes 30 hours of educational instruction,three hours of therapy services and
approximately one hour a day of transportation. Given that RFY is planning on serving
ten(10)youth at any one time the total number of hours per week would be 380 hours per
week. RFY offers 240 days of instruction per year or approximately 35 weeks of
instruction in a calendar year. Over the course of the calendar year with ten(10)youth in
the day treatment program, RFY will offer 13,300 hours of service per calendar year.
The individuals offering the direct and non-direct services for the youth in the day
treatment program and their families will include Special Education Teachers,
Paraprofessionals, Therapists/Case managers,Educational Director, Executive Director,
Day Treatment Coordinator, Clinical Director, Transportation Coordinator,and Financial
Administrator. This is approximately 16 individuals that will either directly or indirectly
be involved with the day treatment program at RFY.
All insurance coverage for RFY is shown on the enclosed Certificate of Liability
Insurance and exceeds the amounts asked for in the bid proposal. Insurance coverage
includes general liability, automobile liability, comp and collision, workers 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. maintains a professional working relationship with the
Colorado Department of Education's Special Services Unit. Each of RFY's facility
schools must comply with CDE's teacher and administrator licensing requirements, state
and national curriculum standards, the administration of CSAP testing each calendar
year, October 1 and December counting reports,Title I compliance,No Child Left
12
Behind, Special Education Law and FAPE. Reflections for Youth, Inc, is committed to
providing excellent educational experiences for the youth it serves and welcomes
frequent communication with members of CDE's Special Services Unit for the constant
improvement of its educational program.
Reflections for Youth,Inc. currently works in collaboration with the Weld County
Department of Social Services to provide residential treatment services, day treatment
and In-home Intervention Services for adolescents and their families receiving services
through the social service system. RFY receives referrals from caseworkers for the
placement of adolescents 11-18 years of age. After placement, RFY and the caseworkers
meet on a monthly basis to discuss progress, struggles, home passes, current and future
planning and aftercare plans for the youth being served. The Facility Manager,Therapist,
counseling and administration staff communicate with the caseworker regularly to
discuss any educational,therapeutic or residential issues that arise while the youth is
placed. The same type of collaboration takes place for the current day treatment youth
that RFY serves from Weld, Larimer and Boulder Counties, Larimer Center for Mental
Health,North Range Behavioral Health),and St. Vrain,Boulder Valley and Thompson
Unified school districts.
If a student receives services from a local mental health center, Reflections for Youth,
Inc. makes every effort to communicate with the center and determine the student's
current therapeutic and medication needs. We have developed a good relationship with
North Range Behavioral Health, Larimer Center for Mental Health,Jefferson Center for
Mental Health and the Mental Health Center of Boulder County. Prior to discharge we
do and will continue to make every effort to assist in the arrangement of continued
therapeutic and/or psychiatric services as needed by individual youth and families.
If needed,referral information for Greeley/Weld Housing Authorities and Employment
Services of Weld County is attached.
VIII. Evidenced-based Outcomes
Reflections for Youth, Inc. makes every effort to utilize evidenced-based therapies in
working with the youth and families that are served. The following bibliography relates
to the types of therapies and services that are offered by the clinical staff at Reflections
for Youth, Inc.
1. Juvenile Justice Bulletin—April 2000—Brief Strategic Family Therapy.
Comparing Structural Family Therapy with Other Types of Therapy.
www.nyrs.gov./ojidpljjbul 2000.
2. Szapocznik,J., Williams, R.A. (2000, June). Brief Strategic Family Therapy:
Twenty-Five Years of Interplay Among Theory,Research and Practice in
Adolescent Behavior and Drug Abuse. Clinical Child and Family psychology
Review, 3 (2), 117-134.
3. Corcoran, J. (1997) Solution-oriented approach to working with juvenile
offenders. Child and Adolescent Social Work Journal, 14 (4), 277-288.
13
4. Seagram, B.C. (1997)The efficacy of solution-focused therapy with young
offenders. Doctoral Dissertation, York University,New York, Ontario.
5. Durrant,M. (1995)Creative Strategies for School Problems: Solutions for
Psychologists and Teachers.New York:Norton.
6. Gingerich, W.J., & Wabeke, T. (2001)A solution-focused approach to mental
health intervention in school settings. Children and Schools. 23, 33-47.
7. Evidenced-Based Counseling and Psychotherapy,National Association of
Cognitive-Behavioral Therapists (2005).
www.nacbt.org/evidenced-based-therapy.htm
8. Cognitive behavior therapy: the basics. John Winston Bush(1996-2003)
jwb@alumni.stanford.org
9. Donlan, J. (2000)What makes sandplay unique?How sandplay relates to verbal
techniques and the beneficial effects of using these modalities concurrently.
Dissertation Abstracts International, 60 (9-B): 4884.
10. Lowenfeld, M. (1946). Discussion on the value of play therapy in child
psychiatry. Proceedings of the Royal Society of Medicine,39. 439-42.
11. Segal, J. (1990) Sandplay: a validation study of sandplay as a projective
technique. Abstract from: Dissertation Abstracts International, 51 (06-B).
12. Chambless,D.L., Baker, M.,Baucom,D.,et al. (1998). Update on empirically
validated therapies, II. Clinical Psychologist 51:3-16.
13. Greenwald,R., and Rubin, A. (1999). Brief assessment of children's post
traumatic symptoms: development and validation of parent and child scales.
Research on Social Work Practice 9:61-75.
14.Van Etten,M., and Taylor, S. (1998). Comparative efficacy of treatments for
posttraumatic stress disorder: a meta analysis. Clinical psychology and
Psychotherapy 5:126-145.
Examples of assessments used and a transition/aftercare plan after services are
completed/in the process of being completed is attached. A request for renewing
services is not applicable in day treatment as services and the continuation of services is
determined in regular scheduled staffings and collaboration meetings with all parties on
the treatment team. Examples of educational and therapeutic monthly reports are
attached.
IX. Staff Qualifications
All staff, including supervisors,providing direct services have the minimum
qualifications in education and experience as defined in Staff Manual Volume VII,
Section 7.303.17 and Section 7.0006,Q Colorado Department of Human Services. All
therapists involved in the project are master's level and fully licensed as a LCSW, LMFT
or LPC or working toward licensure as one of the above. All Special Education Teachers
are either fully licensed with a master's degree in special education: affective needs or are
an emergency licensed special education teacher in the area of affective needs. Based on
the requirements of No Child Left Behind,the Special Education teachers will also be
certified in one of the four core areas to include written language, science, social studies
and/or mathematics. The paraprofessionals employed within the classroom of RFY all
14
have a minimum of a bachelor's degree and are state substitute certified. The Clinical
Director is a LCSW with over ten years experience providing services in community
mental health,educational and residential settings and the current Lead Therapist is in her
third semester of study working towards licensure as a LPC. She has over eight years
experience working with pre-adolescent and adolescent youth in a day treatment and/or
residential setting. The Educational Director is a professionally licensed special
education teacher, grades K-12 and a provisionally licensed special education director
with 6 years experience in public school and residential/day treatment classrooms. She
also has 4 years experience in an educational administrative role. The Day Treatment
Coordinator will hold a minimum of a Bachelors Degree and two years experience
working in a day treatment or school-based setting. Total number of staff, including
supervisors,available for the project is 14, excluding the Transportation Coordinator
(bachelor's level) and Financial Administrator(Master's level and also a LMFT). The
minimum ratio offered in the program is 1 qualified staff member to 5 children. A few of
the youth placed are 11 and 12 years old but historically the majority have been 13 years
old or older to date.
IX. Unit of Service Rate Computation
The hourly unit rate cost is$12.03 per hour or$91.46 per day for day treatment services.
The program budgets, including direct service costs, administrative costs non face-to-
face, and overhead costs and profits is attached.
X. Billing Process
A description of the billing process is attached.
XII. Lowest Qualified Bids
Our bid has been computed at$91.46 per day for all services including psychiatric,
education, therapeutic and transportation. The$91.46 per day is based on a 38 hour week
(including transportation). This breaks down to $12.03 an hour in an hourly unit rate
cost.
XIII. Program Capacity by Month
The minimum number of clients on a monthly basis to support the program is two. Our
preference,particularly for transportation purposes, is a minimum of four at any one time.
The maximum number is the stated maximum for the entire program on a monthly basis,
which is 12.
15
ATTACHMENTS
RFP-FYC-06006
1. AFTERCARE AGREEMENT/PLAN
2. REFERRAL INFORMATION: GREELEY/WELD HOUSING
EMPLOYMENT SRVCS. OF WELD CO
3.CONSENT TO RELEASE INFORMATION EXAMPLES
4. EVALUATIONS/ASSESSMENTS EXAMPLES
5. MONTHLY EDUCATIONAL/THERAPEUTIC REPORT EXAMPLE
6. COMPUTERIZED BUDGET INFORMATION
7. DESCRIPTION OF BILLING PROCESS
8. PROVIDER #'S FOR LICENSURE
9. CERTIFICATE OF INSURANCE
AFTER-CAR$ Acite@MEN ..
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 a,cy loVt.Mnihow are you planning to continue work
in these areas?
•
•
•
FAMILY: •
Please discuss each of the following regarding your future plans:
Communication:
Ices
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:
.
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
[ 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):
What 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)
Sponsor Name:
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.
G. H.
4. If I do see and communicate with any of these people:
• A: 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 I go 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 participate *I1
n� continuing car you and your family make
the following contractual agreements with '\ Va \puLkkA,kV, r
1. We, the client and family, agree to actively and fully participate in the After
Care phase of treatment at 'NQc N. 'Ve 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. Ir}so doing we agree to
comply with the policies and procedures f f e A iL and the
therapeutic recommendations of its professional start. W e uril,.;..,tand that the
•After-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 tra tm.:rt. We agree to
provide the results of the periodic testing to
3. We agree to initiate and continue a weekly Family Home Night to bedevoted
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
conceming 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
ureetey/weta mousing Aumormes -b - �•Greeley y t)c ' - e 4-trossii-3/4- -
„rousing ,Authorities ' -
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 1-800-659-2656. Our fax
number is 970-346-7690.
Office Information I Forms I Public Housing I Section 8 I Stage Coach Gardens ILa Casa Rosa I Dacono
Senior Apartments
Housing Rehabilitation Loan Program I Resident Satisfaction Survey I Other Local Social Service
Agencies
I Staff I Other Links I Home' 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
http://www.greeley-weldha.org/office.html 3/22/2006
ureeley/w eat nousulg tluulullucJ
k4, greeley / Well
lik Wbusing Authorities .
Office Application Process FORMS
Information
Public To access an
Housing The Housing Authority of the City of Greeley and the Weilldobe Acrol
County Housing Authority accept applications for Public reader click]
Maintenance Housing and Section 8 during normal business hours. No Work Orders appointment is necessary to complete an application. ••
Appli
. Appli
Chan!
• Childs
Section 8 Once your application has been processed and entered into ,
Cm 1
the computer, you will receive a letter in the mail confirming• Empli
Stage Coach that your application is now on the waiting list. We cannot • TermVerifi
Gardens estimate your place on the list please do not call and ask Notice
your place on the list. All information will be sent to you in •
La Casa Rosa the mail. Correct and current mailing addresses are important? Stude
It is important that you notify us through a change report • Requf
Dacono form any time your cirmcustances change. Some changes in •
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
http://www.greeley-weldha.org/forms.html 3/22/2006
GREELEY/WELD HOUSING AUTHORITIES APPLICATION
315 N. 11`h 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: lst 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 assistance 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
n 1pluylllellL ocl vlccs I)l VI,Gill l.vUllty _ate v
Employment Services of Weld County
1114
. commune Ma Directions
#^— •Home Site M"'""" " Fmp{oYer. . Job Seeker Joh Related Wtlat's Nlw(t P/
Site Map Services Services Resources Links to Our Office
A Colorado
Workforce
yr
Center
Address: ".-
1551N.i7th Avenue f s„� p �,.�s
P.O.Box 1805
Greeley,CO 80632
Phone: `: i:,r•� '" � R
(970)353-3800 x cas'Jetr
TDD Accessible _ "
Fax: (970)356-3975
Office Hours:
8:00 am-5:oo pm
Labor Market
Information
Click Here for State
Labor Market IMPORTANT NOTICE:
Information
Our Computer Resource Room will be closed
click Here for Every Wednesday from 2:15pm to 5:00pm,
Larimer/Weld Starting October 5th,2005
Labor Market
Information -,-
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Employers • What's New: Apply for Owens-Illinois
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With the
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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
http://www.eswc.org/ 3/22/2006
employment Jery ices O1 vv e1LL Loma),
•
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.
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***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 skill's 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.
http://www.eswc.org/JobSeekerServices/jsservices.htm 3/22/2006
Job seeKer services rage t 01 t
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
Regional lob Match Employ Services lob Additional Sera ices
Lines
Employment Programs Workforce Partners Veterans Services
Equal Opportunity Information Job Seeker Customer Service know your Rights
Survey
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Employment Services of welt uounty - .iuo &erarcu ncsuurecJ
VIP f vos- Employment Services of Weld County
mnpla e..'-• " Communi Ma Directions
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Home Site Map Services Services Resources Links toDurDtfice
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 wehsltes
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
• The Denver Post
Education
• 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:
http://www.eswc.org/JobRelatedResources/jobrelatedresources.htm 3/22/2006
Employment Services of Weld County - JOD tceiateu tcesuurces
• Monster Career Center
• Job Star
• Advanced Resume Concepts
Have a website to recommend?Please email any suggestions to us .
Ema l
http://www.eswc.org/JobRelatedResources/jobrelatedresources.htm 3/22/2006
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
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
Family Evaluation Summary
Structured Family Assessment Method
(completed by therapist)
Date:
Family ID:
Case Coordinator.
Evaluation Team:
Evaluation Dates:
A.PRESENTING PROBLEM
1.Per Referring Source
2.Per Family(including minority opinion,if any)
3.Relevant History of Presenting Problem
AAMFT Forms Book-III.-4
B.FAMILY CONFIGURATION(Complete below and/or attach diagrams)
0 family system map 0 family genogram(three generations) -
I. 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-/lL-4
2 Family Strengths
3.External Boundaries rigidly diffusely
closed 1 2 3 4 5 6 7 8 9 open
4.Coupling/involvement enmeshed 1 2 3 4 5 6 7 8 9 disengaged
5.Rigidity/Flexibility rigid I 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
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-III.-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 ask_ eA oth erwise.
Please be frank while responding. respond
There are no right or wrong answers. Each of us have our own individual way of living so please accordingly.
Your responses will be kept strictly_ co�fidendal.
Please fill in the following details and then proceed further.
Section 1
DATE
NAME OF YOUTH
NAME OF PARENT/ADULT BEING INTERVIEWED
YOUR AGE
PHONE NUMBER
ADDRESS City Zip Code
Street
PLEASE CHECK ONLY ONE OF THE OPTIONS:
EDUCATION
0 attending/attended attended college 0 technical school degree
❑grade school orattending/attended junior high ❑graduate degree(Masters)
❑ highsooladu high school 0 attending/attended ctlde graduate 0 graduate degree(Doctoral)
❑high school graduate 0 graduate
school
RACE/ETHNICITY
0 Native American 0 Asian American
0 White African American) O Mexican American(Latino)
❑Black(African American) ❑Black(Other) 0 Multiracial
❑Other Latin or Spanish O Other.
heritage
SEX
❑Male
❑Female
AAMFT Forms Book-111-7
RELATION TO YOUTH
❑ Father(biological,step,adoptive) 0 Mother(biological,step,adoptive)
❑ Grandfather O Grandmother
❑ Uncle 0 Aunt
❑ Foster father 0 Foster mother •
❑ Other male(specify) ❑ Other females(specify)
PRESENT MARITAL OR RELATIONSHIP STATUS
❑ Single 0 Significant Other 0 Engaged 0 Cohabitating 0 Married
❑ Separated 0 Divorced 0 Remarried 0 Widowed
APPROXIMATE CURRENT ANNUAL HOUSEHOLD INCOME
❑ 51,000-4,999 0 520,000-29,999 0 $75,000-99,999
❑ 55,000-9,999 ❑ 530,000-39,999 0 $100,000-149,999
❑ $10,000-14,999 0 $40,000-49,999 0 $150,000 and above
❑ 515,000-19,999 0 550,000-74,999
WHERE DOES THE MAJORITY OF YOUR INCOME COME FROM?
❑ Wages for work
O Public assistance
O Unemployment/worker's compensation
❑ Other(specify)
OCCUPATION:
❑ Unemployed
❑ Service-general laborer
O Skilled trade
O 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
❑ Once
❑ Twice
O 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
O 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.
O Well
❑ Fairly well
❑ Poorly
10.HOW MANY OF THE YOUTH'S BROTHERS AND SISTERS LIVE IN THE HOME?
❑ None
❑ l
❑ 2
❑ 3
❑ 4 or more
❑ 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?
❑ Yes
❑ No
13.HAS YOUR FAMILY EVER BEEN INVESTIGATED BY CHILD PROTECTIVE SERVICES?
❑ Yes
❑ 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
0 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
❑ Most of them
❑ Very few of them
O 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
❑ 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
1.WHAT TIME IS YOUR CHILD'S 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 CHILD'S 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 GIVE YOUR CHILD SPECIFIC CHORES AROUND THE HOUSE?(e.g.,cleaning house/room,yard work,
taking out the trash,etc.)
❑ Yes
❑ No
AAMFT Forms Book-//L-7
4.IN GENERAL,HOW OFTEN DOES HE/SHE DO THESE CHORES?
❑ Always
❑ Most of the time
O 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
O Only after repeated warnings
❑ Not at all,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 ARENT HOME,WHO STAYS WITH YOUR CHILD?
❑ Another adult
❑ A minor-teenager or child
❑ No one
8.HOW OFTEN ARE YOU HAPPY WITH THE SUPERVISION HE/SHE GETS WHEN YOU ARENT HOME?
❑ Most of the time
❑ Only some of the time
0 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
11.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-III.-7
Section S:This sections asks questions about your child's friends
1.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
❑ I friend is more than 2 years older than him/her
❑ 2 friends are more than 2 years older than him/her
❑ 3 or more friends are more than 2 years older than him/her
3.DO YOU KNOW YOUR SON/DAUGHTER'S FRIENDS?
❑ None of them
❑ Some of them
❑ Most of them
❑ All of them
4.DO YOU LIKE YOUR SON/DAUGHTER'S FRIENDS?
❑ None of them
❑ Some of them
❑ Most of them
❑ 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
❑ 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
❑ Very little,if at all
❑ Have some influence
❑ Yes,definitely
AAMFT Forms Book-III.-?
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
❑ Ito2
❑ 3to4
❑ More than 4
❑ Don't know
2.HOW MANY CLASSES DID YOUR CHILD FAIL LAST YEAR?
❑ None
❑ Ito2
❑ 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-111-7
Section 7: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
O A close family member has been imprisoned
O 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
I.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-111.-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 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 1
DATE
NAME OF YOUTH
YOUR AGE
PHONE NUMBER
ADDRESS Zip Code
Street City
PLEASE CHECK ONLY ONE OF THE OPTIONS:
RACE/ETHNICITY
❑White(European American) 0 Native American
0 Asian American
❑Black(African American) 0 Black(Other)
0 Mexican American(Latino)
❑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
1.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-/I/.-8
10.DESCRIBE HOW WELL YOU GET ALONG WITH THIS ADULT FEMALE WHO IS NOT YOUR SISTER.
❑ Well
❑ Fairly well
❑ Poorly
❑ N/A
II.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
O Deceased
O 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
❑ Poorly
❑ N/A
17.ARE YOU LIVING WITH YOUR STEPFATHER?
❑ Yes
❑ No
18.DESCRIBE HOW WELL YOU GET ALONG WITH YOUR STEPFATHER.
❑ Well
O Fairly well
❑ Poorly
❑ N/A
AAMFT Forms Book-III.-8
19.ARE YOU LIVING WITH ANY OTHER ADULT MALES BESIDES BROTHERS?
❑ Yes
D 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
❑ 1
❑ 2
❑ 3
O 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.
I.How often does your family have dinner together?
O Never
❑ 1 to 3 times a week
❑ 4 or more times a week
❑ 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
O Once a week
❑ More than once a week
If you do activities with your family,what are they?
AAMFT Forms Book-III.-8
Section 4:This section talks about some supervision techniques that your parents use.
Please CHECK ONLY ONE OPTION
I.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?
❑ Always
❑ Most of the time
❑ Sometimes
❑ 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
❑ Between 6pm and 8pm
O After 8 pm,but before 10 pm
❑ After 10 pm,but before midnight
O After midnight AAMFT Forms Book-111-8
Section 5:In the following questions more than one answer may apply.
Please CHECK ONLY ONE OPTION. —'
I.How often do you drink alcoholic beverages like beer,wine,mixed drinks,or hard liquor?
❑ never
O once or twice a year
❑ once or twice a month
❑ every weekend
❑ several times a week
O everyday
2.When did you have your last drink of alcohol?
O I.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
0 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
I.WHAT ARE THE AGE DIFFERENCES BETWEEN YOU AND YOUR FRIENDS?
❑ All friends are no more than 2 years or older than you
❑ 1 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-!IL-8
2.HOW MANY FRIENDS ARE INVOLVED IN THE JUVENILE COURT SYSTEM?
0 No friends are involved in the system
❑ 1 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 COMMITTED?
❑ No friends were involved
❑ 1 or more friends were involved
❑ I or more friends were involved in other crimes,but not this one
❑ 1 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
O 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-IIL-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?
❑ None
❑ I
❑ 2
❑ 3
❑ 4 o more
S.WERE YOUR PARENTS NOTIFIED?
❑ Yes
❑ No
6.HOW MANY TIMES WERE YOU IN IN-SCHOOL DETENTION LAST YEAR?
❑ None
❑ I
❑ 2
❑ 3
❑ 4 or more
7.WERE YOUR PARENTS NOTIFIED?
❑ Yes
❑ 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?
❑ None
❑ I
❑ 2
❑ 3
❑ 4 or more
AAMF7'Forms Book-Hi-8
11.WERE YOUR PARENTS NOTIFIED?
❑ Yes
❑ No
12.DO YOU LIKE SCHOOL?
❑ Very much
❑ It is all right
❑ Not at all
13.HOW REGULARLY DO YOU ATTEND SCHOOL?
❑ Everyday
❑ Most days
❑ Only sometimes
❑ 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-HI.-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
❑ Home life is worse
❑ Made no difference to me
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 ALCOHOL/DRUGS?
❑ Yes
❑ No
❑ Does not apply
AAMFT Forms Book-III.-8
•
6.DO OTHER CHILDREN(UNDER IS 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.
1 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
Cl 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-//I-8
Initial Family Evaluation
(completed by therapist)
Date: •
Name or Case#:
I. PRESENTING PROBLEM:What is each family member's view of what is wrong?
IL 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-Lll.-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,cut-offs,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-III.-9
VI.THERAPISTS EVALUATION OF FAMILY AND PROBLEM(S):
Therapist's view of family relationship and difficulties,major triangles,family strengths/weaknes c,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
Date
_ Therapist Signature
AAMFT Forms Book-III-9
Reflections for Youth Academy
"Discovering the power of positive choice"
Monthly Educational Summary
Day Treatment
Student: Reporting Period:
Social Skills Previous Average Current Average
Relates Positively to Staff _
Relates Positively to Peers _
Controls body boundaries
Uses appropriate language
Follows Directions from Staff _
Good Personal Appearance and Hygiene
Appropriate Transportation Behavior
Task Points
Completes Assigned Tasks _
Has Required Class Materials
Participates Positively in Class _
Asks for Assistance when Needed
Homework completed
Utilizes Health Coping Skills
Key: 4:Excellent;3=hood;2=Fair; 1rUnsatisfactory;Orion participatory
Progress toward Individual Goal:
Teachers Signature: bate:
Reflections for Youth, Inc.
Day Treatment Program
Monthly Summary Reporting Period:
Student Name: Facility:
HH#:
DOB: DOP: Caseworker:
Probation:
Axis I Diagnosis:
Previous Point Sheet Avg: Daily Point Sheet Avg:
Educational: See attached Educational Report.
Emotional: Session summaries
Family: See Core Services Option B report if available.
Additional Information:
Updated discharge concerns/recommendations:
Reasons Day Treatment level of care should continue:
Estimated length of day treatment
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Reflections for Youth, Inc.
P.O.Box 1860
Berthoud, CO 80513
970-532-5990
DESCRIPTION OF BILLING PROCESS
DAY TREATMENT
At the end of the month for each student:
1 . Teacher submits a monthly census to financial administrator.
2. Teacher submits a monthly Educational report to financial
administrator.
3. Therapist submits a monthly summary to financial administrator.
4. Financial administrator then transfers information to Weld County billing
sheets and submits all paperwork to Elaine Furister.
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Client$ 24876 REFLFOR
ACORa. CERTIFICATE OF LIABILITY INSURANCE DATE DAM/D/06 D/YYTY)
03/28
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 II
INSURED INSURER A Tudor Insurance Co. 37982
Reflections for Youth,Inc. INSURER B: Great American Insurance Co. 16691
P.O. Box 1860 INSURER C Pinnacol Assurance 10780
Berthoud,CO 80513 INSURER Cr
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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.TFE INSURANCE AFFORDED BY THE POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADM. TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTTXYIVE POLICY EXPIRATION LIMITS
QTR NSR� DATE IMMIDYI , DATE IMMIDWYYI
A GENERAL LIABILITY PG L739507 09/20/05 09/20/06 EACH OCCURRENCE $1,000,000
X DAMAGE TO R COMMERCIAL GENERAL LIABILITY RENTED $50,000
PREMISES RENTED
X I CLAIMS LADE j j OCCUR MED EXP(Any one person) 31,000
PERSONAL&ADV NJURY $1,000,000
GENERAL AGGREGATE 13,000,000
GENT_AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPtOP AGG $1,000,000
—I POLICY F---1 RGT El LOC I .
B AUTOMOBILE LIABILITY CAP5154804 09/20/05 ' 09/20/06 COMBINED SINGLE LIMIT
X ANY AUTO (Es Accident) 31,000,000
ALL OWNED AUTOS BODILY NARY
SCHEDUL ED AUTOS (Pet won)
X HIRED AUTOS BODILY INJURY
X NON OWAIED AUTOS (Peracademe) 1
PROPERTY DAMAGE
(Per Accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC ,3
AUTO ONLY: AGE $
EXCESSAIMBREL LA LIABILITY EACH OCCURRENCE 3
IOCCUR CLAIMS MADE AGGREGATE 1
DEDUCTIBLE 1
RETENTION $ $
C WORKERS COMPEPISATIONANO 4085090 10/01/05 10101/06 X IToaYiuilrs1
EMPLOYERS'LIABILITY
ANY PROP RETOR/PARTNERIEXECLITIVE E.L.EACH ACCIDENT3100,000
OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $100,000
H yes, PROVISIONS under
SPECIAL PROVISIONS below E.L.DISFJISE-POIICY LIMIT $500,000
A OTHER professional PGL739507 09/20/05 09/20/06 $1,000,000 per incident
Claims Made Policy $3,000,000 Aggregate
DESCRPTION Of OPERATIONS I LOCATIONS I VEHICLES/EXCLUSIONS ADDED SY ENDORSEMENT!SPECIAL PROVISIONS
REVISED CERTIFICATE'THIS CERTIFICATE SUPERSEDES ANY ISSUED THIS POLICY 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 INSURER WILL ENDEAVOR TO MAIL +e_ DAYS WRITTEN
Services NOTICE 70 THE CERTIFICATE HOLDER NAMED TO THE LEFT.anT FAILURE TO DO SO SHALL
P.O.Box A 315 North 11th AVE. IMPOSE NO OBLIGATION OR LABILITY Of ANY KIND UPON THE INSURER,ITS AGENTS OR
Greeley CO 80632 REPRESENTATIVES.
Greeley,CO 80632 AUTHORIZED REPRESENTATIVE
ACORD 25(2001108)1 of 3 ItS285755/M285753 L IR E ACORD CORPORATION 1988
..o.e. .,,..i.000 ♦ive; •,•.r re TO, Jett V 1-970-472-1736 Page, 003
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED,the pollcy(les)must be endorsed. A statement
on this certificate does not confer rights to the certificate holder In lieu of such endorsement(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 #5285155/M285753
uu�ae J/6J/dUV0 net 4,e, rn Toe Jett W 1-970-472-1736 Page: 004
sicetitintiedfrontpagelyHHHHHHHHHHHHh
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 masons
approved by the Commissioner of Insurance
•
AMS 25.3(2001108) 3 of 3 #S285755/M285753
EXHIBIT B
SUPPLEMENTAL NARRATIVE TO RFP
May 23 06 09:33p Jeff and Carol Johnson 970-472-1736 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:61119),01/447
TO: writh W ie,
FROM:)-4-1b4 JIB- Smv \SiC
RE: brit Iq fl I. — l53'1a- c3`A %mass i
COMMENTS:
CA-u- >. tpU EcrA
--ut s
O IN► 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 privileged confidential,and exempt from disclosure under applicable low. If the reader of
this facsimile is not the intended recipient nor the employee or agent responsible fa delivering the facsimile to
the intended recipient,you are hereby notified that any dissemination,distribution.or copying of this
communication is strictly prohibited. If you have received this communication in error.please notify us
immediately by telephone and return the original message to us at the above address via the U.S.Postal
Service. Thank you.
May 23 06 09:34p Jeff 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 affercare 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
May 23 06 09:34p Jeff and Carol 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 dearly 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 jeff@reflectionsforyouth.orq if
you have any questions or need further clarification. Thank you.
Sincer I ,c�
Jeff J. Jo nson, L C
Executive Director
May 23 06 09:34p Jeff and Carol 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
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 I.E.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 place 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/ciedits 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 23 06 09:34p Jeff and Carol Johnson 970-472-1736
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
schooUdistrict 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 fnctioning. 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 mariner. 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
a
DEPARTMENT OF SOCIAL SERVICES
P.O. A BOX
GREELEY,CO. 80632A
Webslte:www.co.weld.co.us
' Administration and Public Assistance(970)352-1551
Child Support(970)352-6933
C.
COLORADO
May 15, 2006
Jeffery Johnson, Executive Director
Reflections for Youth
204 W County Road 10.5, P 0 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 providc the rcquired 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. 'ego, Di for
cc: Juan Lopez, Chair, FYC Commission
Gloria Romansik, Social Services Administrator
Hello