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Home My WebLink About20061585.tiff RESOLUTION RE: APPROVE EIGHT NOTIFICATION OF FINANCIAL ASSISTANCE AWARDS FOR LIFE SKILLS PROGRAMS 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 eight Notification of Financial Assistance Awards for Life Skills Programs 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. Victor Cordero 3. Transitions Psychology Group, LLC 4. Lutheran Family Services of Colorado 5. The Jubilee Retreat Center- Lori Kochevar, LLC 6. Alpine Christian Services, Inc. 7. Child Advocacy Resource and Education (Family Advocate Program) 8. Child Advocacy Resource and Education (House-Visitation) 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 eight Notification of Financial Assistance Awards for Life Skills Programs between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County,on behalf of the Department of Social Services, and various providers listed above, be, and hereby are, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said awards. 2006-1585 SS0033 EIGHT NOTIFICATION OF FINANCIAL ASSISTANCE AWARDS FOR LIFE SKILLS PROGRAMS PAGE 2 The above and foregoing Resolution was,on motion duly made and seconded,adopted by the following vote on the 14th day of June, A.D., 2006, nunc pro tuns June 1, 2006. OARD OF COUNTY COMMISSIONERS E' L4 44 LD COUNTY, • LORADO ATTEST: �G"'�"f �/ ` `� . 1 G� =ile, Chair Weld County Clerk to the Bo- `rFr dl,��Ni1avid E. Long, Pro-Tern BY: ti► 1t" 3 _ ' De ty Cler to the Board 4 Willi m H. Jerke APP ASTOF � Robert D. Masddee ty ttorney Glenn Vafa IJ a Date of signature: 1I o1oco 2006-1585 SS0033 a 4;itiss DEPARTMENT OF SOCIAL SERVICES P.O. BOX A GREELEY, CO. 80632 ID Website:www.co.weld.co.us Administration and Public Assistance(970) 352-1551 Fax Number(970) 346-7691 Wie COLORADO MEMORANDUM TO: M.J. Geile, Chair Date: June 1, 2006 Board of County Commissioners a FR: Judy A. Griego, Director, Social Services J C 'L(,1 RE: Notification of Financial Assistance Awar with Various ontractors— Life Skills Programs Enclosed for your approval are Notification of Financial Assistance Awards with Various Contractors for Life Skills Programs. 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 life skills programs to families involved in the child welfare system. 4. The Contractors include: A. Reflections for Youth,Inc. $53.80 hourly rate life skills- visitation $53.80 hourly rate court testimony Parenting Skills/Visitation B. Victor Cordero $110.00 hourly rate life skills - visitation $120.00 hourly rate court testimony Parenting Skills/Visitation C. Transitions Psychology $97.05 hourly rate life skills services Group, LLC $150.00 hourly rate court testimony Life Skills Coaching/Parent- Child Interaction Therapy 2006-1585 MEMORANDUM Page 2 M.J. Geile, Chair, Board of County Commissioners June 1, 2006 D. Lutheran Family Services of $85.91 hourly rate life skills • Colorado $60.00 hourly rate court testimony Parenting Coaches E. Jubilee Retreat Center—Lori $89.00 hourly rate life skills Kochevar LLC $150.00 hourly rate court testimony Parenting SkillsNisitation F. Alpine Christian Services, $35.00 hourly rate staffing Inc. (Lakewood) $35.00 hourly rate visitation $70.00 hourly rate high level treatment TherapyNisitation G. Child Advocacy Resource& $70.48 hourly rate life skills Education (c.a.r.e) $50.00 hourly rate court testimony Family Advocate Program H. Child Advocacy Resource& $42.17 hourly rate visitation Education (c.a.r.e.) $76.01 hourly rate intensive services $34.33 hourly rate transportation Visitation $50.00 hourly rate court testimony If you have any questions,please telephone me at extension 6510. Weld County Department of Social Services Notification of Financial Assistance Award for Families,Youth and Children Commission (Core)Funds Type of Action Contract Award No. X Initial Award 06-CORE-68 Revision (FY-FYC-06005; 06LS13) Contract Award Period Name and Address of Contractor Beginning 06/01/2006 and Reflections for Youth, Inc. Ending 05/31/2007 Lifeskills P. O. Box 1860 Berthoud, CO 80573 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Program offers assistance in parenting skills, Assistance Award is based upon your Request for milestone information, employment,household Proposal (RFP). The RFP specifies the scope of management, finances, relationship building, services and conditions of award. Except where it is education planning, transportation,prevention in conflict with this NOFAA in which case the planning, and overall support to families. NOFAA governs, the RFP upon which this award is Workload of eight families concurrently, for a based is an integral part of the action. total of 16 families per calendar year, with an Special conditions average of 24 weeks of services per family. 1) Reimbursement for the Unit of Services will be based on a monthly rate per child or per family. 2) The monthly rate will be paid for only direct face to Cost Per Unit of Service face contact with the child and/or family or as Hourly Rate Per $53.80 specified in the unit of cost computation. Visitation 3) Unit of service costs cannot exceed the hourly and Treatment Package-Moderate yearly cost per child and/or family. Court Testimony $53.80 4) Payments will only be remitted on cases open with, and referrals made by the Weld County Department of Social Services. 5) Requests for payment must be an original submitted to the Weld County Department of Social Services by the end of the 25Th calendar day following the end Enclosures: of the month of service.The provider must submit X Signed RFP: Exhibit A requests for payment on forms approved by Weld X Supplemental Narrative to RFP: Exhibit B County Department of Social Services. X Recommendation(s) 6) The Contractor will notify the Depar tment of any Conditions of Approval changes in staff at the time of the change. Approvals: Program Official: Q � BM. J. , Chair ByBJud E . Gr'e o, Dir�e,:tor Board of W cIV goynt 8mmissioners Wel ounty Department of Social Services Date: ll 3 LL Date: (o/ IMO aO66- /5/S `>� LS /3 ORIGINAL INVITATION TO BID OFF SYSTEM BID 001-06 (06005-06011 and 006-00,A, B,& C) DATE: March 1, 2006 BID NO: RFP-FYC-06005 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-06005) for:Colorado Family Preservation Act--Life Skills Program Emergency Assistance Program Deadline: March 31, 2006, Friday, 10:00 a.m. The Families, Youth and Children Commission, an advisory commission to 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 Program Act(C.R.S. 26-5.5-101)and Emergency Assistance for Families with Children at Imminent Risk of Out-of-Home Placement Act(C.R.S. 26-5.3-101). The Families, Youth and Children Commission wishes to approve services targeted to run from June 1, 2006, through May 31, 2007, at specific rates for different types of services,the county will authorize approved providers and rates for services only. The Life Skills Program must provide services that focus on teaching life skills, which are designed to improve household management competency,parental competency, family conflict management and effectively access community resources. 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 L L (After receipt of order) BID _ E SIGNED IN INK 1*A iat TYPE RJRINTED SI NATURE VENDOR COL V1 MS cCAct7 t- . d/) I�L (Name) J Handwritte i re By Authorize r 1 Officer or Agent of Vender ADDRESS , pp ,Df �"AQt1(` if LD� C� ° )TITLE t; 1� 1 1 G DATE t3,114(/ ' n PHONE # c_10-0J\ , J� 1/O The above bid is subject to Terms and Conditions as attached hereto and incorporated. Page 1 of 41 Bid 002-05(RFP-FYC-06005) Attached A LIFE SKILLS 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 002-05 (06005) NAME OF AGENCY: 1Lt( CPS 1\)0,1-411 \,01..ADDRESS: .0, \klSh � ov-d 1 CO St'S PHONE: Kq S3., 599D C1T_( 9O\ -ck Uy35_ CONTACT PERSON: J .9 -c.Ufu \ JCY TITLE: 4c-T,(A4..Il\t>Nb1,1.a1tYL, DESCRIPTION OF FAMILY PRESERVATION PROGRAM CATEGORY: The Life Skills Program Category must provide services that focus on teaching life skills designed to facilitate implementation of the case plan by improving household management competency, parental competency,family conflict management, effectively accessing community resources, and encouraging goal setting and pro-social values. 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: 1a 3 ac1sy,f, Name and Si ture of Person Preparing Document Date Judy A. Griego, Director Name and Signature Chief Administrative Officer Applicant Agency Date MANDATORY PROPOSAL REOUIREMENTS For both new bids and renewal bids,please initial to indicate that the following required sections are included in this Proposal for Bid. Project Description Target/Eligibility Populations Types of services Provided Measurable Outcomes Service Objectives Workload Standards Proof of Collaboration Evidenced-based Outcomes Staff Qualifications Unit of Service Rate Computation Billing Process ogram Capacity per Month Certificate of Insurance Assurance Statement Page 29 of 41 03/30/2006 09:39 9706676713 OLSEN PAGE 03 • Bid 002-05(RFP-FYC-06005) A _.. i4Shad A Date of Meeting(s)with Social Services Division Supervisor: /3 96 W Comments by SSD Supervisor: l ba oa. thu_hra 04167 43/7A Name and Signature of SSD Supervisor Date Page 31 of 41 Reflections for Youth, Inc. "Discovering the Power of Positive Choice" Weld County Life Skills Program RFY-FYC-06005 03-30-06 (Services from 06/01/06 through 05/31/07) I. Project Description Title of Project: Life Skills Program Mission and Purpose Reflections for Youth will provide life skills to children and their families which are in crisis and are in an imminent risk of children being removed and placed out of the home. The life skills program will also offer assistance in transitioning a child back into home from placement. Life Skills program will offer assistance in the areas of parenting skills, milestone information, employment, household management, finances, relationship building, education planning,transportation, prevention planning, and overall support to the family. Children who are transitioning home after completion of placement will transaction with an Aftercare Agreement/Plan. The Aftercare Agreement/Plan includes weekly visits for the first two weeks, bi-weekly visits for two weeks, and final visit in a month. If at any time during Aftercare Agreement/Plan the family appears to struggle, a request for an extension will be filed with Weld County. Design All Life Skills visits will occur in the home,unless otherwise determined not safe. If not safe visits will occur in the community or in the office of a Reflections for Youth, Inc. worker. Families will be assessed through the NCFAS-R: North Carolina Family Assessment Scale-Reunification to determine strengths and needs of the family, as well as provide a base line for development and progress through the program. Reflections will provide services for up to 8 families at a time. There may be a potential to serve more families as resources become available. Reflections will provide an average of 2 hours of service per week for an average of 24 weeks. All service providers and supervisors under the umbrella of Reflections for Youth, Inc. meet the requirements as listed in staff manual volume VII section 7.307.17 and section 7.3006 q. The supervisor for the program will also carry a caseload. All Lifeskills Workers and supervisor(s)will either have a master's degree with two years experience or a bachelor's degree with three years experience in the field. In addition, our program also has a staff person with several years experience as a Family Support Worker in Nebraska and as a Case Aide in the Lifeskills Unit at Larimer County. She has an AA degree and is working toward completion of her bachelor's degree. If possible, she would be a wonderful support to our agency and the youth and families of Weld County if she could carry a caseload as well. II. Target/Eligibility Populations Reflections for Youth agrees to work with a total of 8 families at a time with at least one child at risk of out of home placement or transitioning back to the family. Family consolations may include one child age 10 years or older up to an underdetermined number of children in the family. If there are children under 10 in the family Reflections will work with the family. Based on our program description it is our plan to provide all services within an average of 2 hours per week for an average of 24 weeks. Reflections will provide for a total of 16 families per calendar year, with an average of 24 weeks in the Life Skills program. All families will be able to receive bicultural services. Bilingual services can be provided for one family at any given time. Reflections has a contracted interpreter and again the percentage has potential to rise if resources become available. Services will be offered as often as possible on a 24-hour basis to client families living in all parts of Weld County, provided they are within one hour of the city of Loveland. III. Types of services to be provided Mentoring Life Skills Worker will teach and coach all members of the family by role modeling appropriate effective communication skills, household management and finance. The Life Skills worker will set goals each week for the family based the NCFAS-R Assessment. In addition the Life Skills worker will bring related material for the family to go over and discuss. The goals will be worked on with the Life Skills worker and the follow up will be up to the family. This will be one form of measurement for the program. As the program progresses the Life Skills worker will next focus on community resources and connections by finding community centers for the children, finical assistance programs, low-income child care, ect. In addition Life Skills worker will assist the family with appropriate employment,benefits, and educations. Life Skills worker will place emphasis on career goal setting as well establishing healthy connections and relationships. Visitation When Life Skills worker is providing a supervised visit the worker will be observing, listening and documenting the visit. The worker will step in when necessary to role model and teach effective communication. The visit will be documented each time after the visit has taken place. The worker will not be documenting throughout the visit as this may make family uncomfortable and unable to act as normally would. Worker may write down a brief note if needed. After visit worker will call parents to discuss how visit went and will set goals for following visit. Examples of goals could be dinner needs to made for next visit, find out what game the children are fond of and have the game ready, how to effectively use a time out if needed, etc. • Housing Search • Job Search/Financial Planning • Parenting Skills • Housekeeping Skills • Supervise Visits • Therapeutic Intervention Visits • Using Community Resources • Affordable and Appropriate Leisure Activities IV. Measurable Oucomes • The NCFAS-R Assessment tool will be used at initial visits to assess strengths and needs. Goals will be set with family, Life Skills Worker and Life Skills Supervisor. Family's acceptance or resistance to the goals will be one form of measurement and documented in weekly progress notes. • Life Skills program will be considered successful if child remains in home, parents provide a safe environment and parents are employed for a minimum of 12 months after Life Skills services have been provided. • Improvements in parenting, household management, relationships, and finances are observed and self reported by the family. • Family is utilizing the community connections which have been provided through Life Skills worker and goal setting. • NCFAS-R will be completed at end of program to be used as a comparison for the family and measure for the Life Skills Worker. V. Service Objectives Mentoring • Life Skills worker will improve the household management by assisting and role modeling how to clean properly, organize, laundry and an overall schedule for a healthy environment for a child. Worker will connect family with low cost maintenance for the house as well as assistance with community churches and other non-profit organizations in the area. • Life Skills worker will assist with the family budget by researching the family bills and debts, assisting the family by setting a schedule of when bill are due. Prioritizing past due bills. Connecting the family with community churches and non-profit agencies,which help families with scholarships and grants. • Life Skills worker will assist the family in employment search. Worker will help prepare family for employment search by helping find appropriate clothing and conduct mock interviews. • Life Skills worker will assist family budget by researching family income and balance out with needs. Life Skills program will begin a drive for start up items for families such as household products and hygiene products. Woker will connect family with area food banks as well as other community connections that provide assistance with items and scholarships. • Life Skills worker will have an on-going goal of relationship skill building within the family to promote pro-social and healthy communication. Visitation • Worker will observe visits for safety concerns and will document in weekly progress note. • Worker will contact parents by phone after visit to discuss strengths and concerns. • Worker will address concerns and will set goal with parents in order for parent to understand where improvement needs to occur. • Workers will role model by providing structured activities when necessary; follow phone call will address any concerns for lack of structured activity. Goal will be set of expectation of parent to be responsible for a structure activity for all future visits. • Worker will promote pro-social and healthy relationships by stepping in and assisting in the visit when needed and discussing all concerns with parents in follow up phone call Performance Improvement Plan (PIP) The life skills program at Reflections for Youth, Inc. will work to improve outcomes in the Performance Improvement Plan is several key ways. (1) The life skills program will work to provide additional parenting and support skills for the families, with the overall goal of increasing the parents' ability to cope in better, safer and healthier ways with the child(children) and reducing the length of out of home stay or increasing the chances that out-of-home care won't be necessary in the future. (2)Assessment and aftercare support are part of the overall services offered by the life skills program. Reflections will complete needs assessments for the families that are comprehensive enough to identify as many underlying problems as possible and address them as thoroughly as possible over the life of the life skills program contract and contact with the family. (3) A fair amount of the PIP in both the larger categories of Permanency and Child and Family Well- Being discusses the issue of visitation. Reflections will work to insure that visitation between children and their siblings and their mothers and fathers is sufficient enough to meet the needs of the children and the parents. Prior to setting up the visits we will collaborate with the caseworker to insure that the visit is used to focus on issues relevant to the case plan, service delivery and achieving the child's permanency goal. We will also work to make the visits of sufficient quality to promote safety and well-being of the child and enhance the attainment of the case goals. VI. Workload Standards Based on a workload of 8 families at a time, Reflections will provide a minimum of 16 hours per week of lifeskills program support. This equates to 2 hours per week, per family over the course of a six month (24 week) contract. Reflections for Youth will provide a minimum of four to six licensed therapists, master's level counselors with two years experience or bachelor's level counselor with three years experience all working under the umbrella of Reflections for Youth, Inc. Maximum caseload per staff in the program would be four(4); preferred amount would be no more than two (2). Maximum caseload per supervisor would be eight (8) All insurance coverage for Reflections for Youth, Inc. is shown on the enclosed Certificate of Liability Insurance and exceeds the amount requested in the bid proposal. Insurance coverage includes general liability, automobile liability, comp and collision, worker's compensation and employer's liability and professional liability. Weld County has been named as a certificate holder. VII. Proof of Collaboration Reflections for Youth, Inc. currently works in collaboration with the Weld County Department of Social Services to provide residential treatment services, day treatment services, home-based intensive family intervention services and hopefully, lifeskills visitation, mentoring and support services. Our routine collaboration occurs with the caseworker asking for the services, Weld County CORE service caseworker, PRT team as needed and other individual's involved in the child's and/or family's life. If a client is receiving or will receive services from North Range Behavioral Health,we will make every effort to communicate with them regarding therapeutic needs and work to involve them in aftercare planning, including obtaining a release (example attached) and forwarding on a discharge summary including continuing recommendations for the clients served. If needed, referral information for Greeley/Weld Housing Authorities and Employment Services of Weld County is provided. • Phone call messages have been left to the Housing Authority (Marsha)to gain their cooperation in referral process. • Message left for Salvation Army to gain cooperation in referral process in case of emergency housing need. • Provide transportation to and from Housing Authority and other housing options to fill out applications. • Set weekly goals with clients on follow-up with housing applications. Job services/resource provision • Message left with Weld County Employment Office to gain cooperation in referral process; waiting for a call back. • Assistance in job search by looking through newspapers and providing transportation to pick up and turn in applications if necessary. • Picking appropriate and realistic employment options. • Checking into service positions which offer schooling and educational assistance. • Checking into benefits and helping to explain the best options for the individual. • Assisting with resume writing to gain the best possible opportunities. • Assisting clients with mock interviews,to include helping to put together interview outfits. • Set a weekly goal with clients on follow through with applications and resumes. Other referral/resources • Community activities with low or no cost for adults and children. • Low-income child care. CCAP eligible. • Health and Dental providers • Habitat for Humanity for start up items for a home, clothing, etc. VIII. Evidence Based Outcomes Bibliographic Evidenced-Based Information California Youth Connections http://www.calyouthcann.org/ Child Development Institute (research and articles on child development) http://www.childdevclopmentinfo.com Bavolek, Stephen J., PhD The Nurturing Parenting Programs, Washington DC,U.S. Department of Justice Office of Juvenile Justice and Delequincy Prevention, 2000 Beyer, Marty, "Parent-Child Visits as an Opportunity for Change."Prevention Report 1999 #1, National Resource Center for Family Centered Practicepp. 1-12 Fahlberg, Vera I. M.D.,A Child's Journey Through Placement, Prospective Press, Indianapolis, IN,1991 Assessment NCFAS-R Attached Request for Renewal Family and#: Caseworker: FSW: Date/Time: Request to Renew Services: At the end of 12 weeks Cooper family continues to struggle with arguing and escalated behavior. The family has utilized FSW to express feelings in a controlled setting; however they have been unable to transfer the skills into the family while unsupervised. The family is showing signs of progress and would greatly benefit from continued support from FSW. FSW observed family needs support with gaining stable employment, and assistance with Finical Planning which has not been addressed as of date due to needed to stabilize relationships as a priority. Monthly Report Family Name/#: Caseworker: FSW: Date/Time: Assessment: Family Jones has been compliant with follow through of goals set for the family. MOC has begun to understand the importance of consistency her children need to include breakfast, clean clothes, and help with homework and family time. FOC continues to need assistance with understanding how to communicate with the children and not giving orders with no relationship building. Family needs continued to need assistance in relationship building, roles of family, limit setting, and organization of house. Treatment Proposal: Continue to work with FSW to ensure family is able to practice new skills under supervision. FOC attends a Parenting Class geared towards Fathers roles on family. Meet with family every other week rather than twice a week to transition the family to working less with FSW and more with each other. FSW worker will have close out session at the end of the 24 weeks and provide the family with a list of community resources should they need them. IX. Staff Qualifications All services provided under the umbrella of Reflections for Youth, Inc. will meet the requirements as listed in Staff Manual volume VII Section 7.303.17 and section 7.3006 q. The supervisor of the program may also carry a caseload. Total number of staff, including supervisor available for the project is between five (5)and seven (7). The supervisor has received the mandated caseworker training and all other staff working within the lifeskills program would be willing to attend the trainings when offered. Base on my limited knowledge, the trainings are county-based and are conducted for counties and CDHS staff. All staff involved directly in the Lifeskills program have knowledge of risk assessment and in some cases very thorough and complete knowledge of risk assessment. All Reflections for Youth, Inc. staff are required to have an annual full-day class on assessing risk and suicide prevention/intervention. X. Unit of Service Rate Computation The hourly unit rate computation is $53.80 per hour for 48 hours of life skills intervention contact(based on two hours per week for a total of 24 weeks). XI. Billing Process Reflections for Youth, Inc's billing process for the life skills program is attached. A fictional monthly billing is attached. XII. Lowest Qualified Bid XIII. Program Capacity By Month The minimum number of clients per contract (based on a 24 week contract)to support the program would be two. Reflections for Youth, Inc. is in the process of providing additional training and support for the life skills program staff from a current Reflections employee that has several years experience as a Family Support Worker in Nebraska and more recently as a Case Aide in the life skills unit of a local county. It is our hope that we will be serving a minimum of four families at a given time throughout the year. The maximum number of families that Reflections can serve per year is 16 (no more that 8 at any given time throughout the year). ATTACHMENTS 1. Consent for Release 2. Consent for Release Minor Child 3. NCFAS-R (Assessment Scale) 4. Computed Unit of Service Rate Computation 5. Sample Billing Process 6. Sample Monthly Report 7. Certificate of Liability Insurance AUTHORIZATION TO RELEASE INFORMATION FORM I• , 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 I• , 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 03/30/2006 09:18 9706676713 OLSEN PAGE 01 • NCFAS R: North Carolina Family Assessment Scale-Reunification for Intensive Family Preservation Services Programs Serving Reunification Cases • Version R2.0 DEF'DHf11ONS - AEnvirumomit — 1.OveraO Clear Strength Mid Raad i=/Adequate. r Mild Moderate Serious Problem Environment S. P. P. +2 +1 0 _, -1 -2 -3 • Refers to family Recta to fat* Refers to family receiving very receiving very high static*minimal law ratings in the following ratings in the following problems Site following areas:housing stability,safety in areas:housing • seas:bounce atab0ity, the comnamity,housing stability;safety in the safety Sate w*y;hw®g habitability, . community,housing habitab.,mcamo'employ, income/ to habitability, linen> R ma food& �p ywd and financial management,food and nutrition, income/employment, median,personal personal hygiene,transportation, • financial management, hygiene,tampon.,& and learning environment. food and nuttition, teaming envt Howeva, personal hygiene, problems do maltreat transportation,and m family's ability to learning environment. f m tiou,&poblas do not neat tobe addressed 2.Rasing Clear Strength Mild BaseMa fMeq uk Mild Moderate Serious Problem Stability S. P. P. +2 +1 0 -1 -2 -3 Refers to family Rotas to&wily Refers to family being occupying the same, experiments=previously threatened with eviction. adequate residence for experiencing minor Unable to meet rent or more than three years. . problems inp®a®g in mortgage obligations on time, if less than three years, to sametesideace,but a at all.Or,family does not move is prompted by a fierily is relatively capable have housing,is living with job change or move to afm etmg financial different relatives or friends,or better housing,etc. Rent/mortgage are paid abl preshouse*is not ent living in a homeless shelter. Family is not satisfied with on time.There are no and faml)'mambas ate living situation. problems meeting not inhibited iptasni g financial obligations of other obligations tae ei rent or mortgage. O problems. 1 The NCFAS-R is a modification of the NCFAS(North Camlata Family Assessment Scale)and is intended for use by fortify preservation services providers workbrg vdthrtteifcation cases.Modifications were made by R.S.Kirk,in collaboration with the National Family Preservation Network(NFFN).Funding provided to NFFN for the modification project Came from the David and Lucile Packard Foundation. The original NCFAS was developed by R.S.Kirk and K.Ashcroft The NCFAS is derived from previous version"based on the Family Assessment Form,developed at the Children's Bureau of Southern California,Michigan's Family Assessment of Needs Form,and four auees0eni inaeummts developed es North Carolina by Raven Rouse(Raleigh),Home Remedies(Morganton),Methodist Home MI Children (Raleigh),and the state Division of Mental Health,Developmental Disabilities and Substance Abuse Services.Special acknowledgments are due to Sandy Slade.and Judith Nelson at the Children's Bureau of Southern California and to researchers Jacquelyn Mecroskey and William Mean.Domain specifications for the original NCFAS were based on the work of Meezan and McCroskey.Domains end subaestes for V ersian 2.0 are based upon reliability and validity testing convicted in the Fan of 1997.The NCFAS-R,Vernon R2.0,is based upon reliability Ind validity testing conducted during 2000-2001.R*V testing is ongoing. (v)See Usa's Guide to the NCFAS,Venice 2.0,for additional intonation on scale construction and paychomenics. 03/30/2006 09:26 9706676713 OLSEN PAGE 14 3.Safety in Clear Sme glh Mild Baseline/Adequate MIM P. Moderate Serious Problem C S. p -+2 +1 0 4 -2 - -3 - Refers to a sak and Refastominor Refers to many disturbances secure neighborhood • disturbances in the such as fights and/or outbursts for the children. neighborhood,but in the neighborhood.The Caregivers can allow di anbercer do not • neighborhood is not safe for children to play outside prevem fnnlynr ben children to play outdoors or without fear.Neighbors and chikken from walk to the bus or to school. look out for each other spending tint outside in Evidence of violence,"boarded (i.e.,neighborhood the commmity. up"or barred windows,gem "watch.") fire,the use of alcohol or drugs, and/or drug"trafficking"in the • neighborhood.Neighbors fearful of"getting involved." Clear Strength Mild Baseline/Adequate Mild Moderate P. Seeing Problem otHourror S. P. +2 +1 0 -1 -2 -3 Refers to family and Reftastoninny! Refers to tmaanitary situations, neighbors problems in the bencinghome home, includingand/or=roaches litter,s clutter, en "warm"Home is very such wt • th =pleasant Food particles arti present clean and neat.Plenty a sow and/or d/o home. of space and privacy 1ecautons 4 atmos unt s and ing food on the Urine- for children.Plenty safety counters tables.of taken(e.g,poisons are mad soaked or stained furniture, furnishings in good ofsightbtd not locked). dirty diapers,dirty dishes, repair.Safety Mnerhahae or precautions are awnbling plaster)maybe animal or hug man feces ec,son th considered andanimal a it n cen on the taken, but floor.Hesitance to sit down or such as the use of enter the home.Nonfunctioning smoke alarms and plumbing,and/or no electricity. dead bolts on outside Many hazards within the reach doors.Poisonous items of children,such as guns, are kept locked and • knives,street drugs,or open out of children's reach. medication and poisons. Plumbing is in good condition. 2 The NCFAS-R is a modification of the NCFAS(North Carolina Family Assessment Scale)and is intended for use by Snub preservation services providers working with reunification cases.Modifications were made by RS.Kirk,in collaboration with the National Family Preservation Network(NFPN).Funding provided to NFPN for the modification project cams nom the David sod Lucile Packard Foundation. The original NCFAS was developed by R.S.Kirk and K.Ashcraft.The NCFAS is derived from previous versions based on the Family Assessment Form,developed at the Children's Bureau of Southern California,Michigan's Family Assessment of Needs Form,and four assessment instruments developed in North Carolina by Haven House(Raleigh),Home Remedies(Morganton),Methodist Home for Children (Raleigh),and the state Division of Mental Health,Developmental Disabilities and Substence Muse Services.Special acknowledgments are due to Sandy Sladen and Judith NEUe%at the Children's Btaesu of Southern California and to researchers Jacquelyn McCroskey and William Mint.Domain specifications far the original NCFAS were based on the work of Meaan and McCloskey.Domains and subscales for Version 2.0 era based upon reliability end validity testing completed io the Fall of 1997.The NCPAS.R,Version 112.0,is based upon reliability and validity testing conducted during 2000-2001.lttev mating is ongoing. (')See Use's Guide to the NCFAS,Vernon 2.0,fur additional mf iaation on scale construction and psychometrics. 03/30/2006 09:18 9706676713 OLSEN PAGE 02 5.Income/ Clear Strength Mild Baseline/Adequate I Mild Moderate P. Serious Problem Empbyrlient , S. _ , P. +2 +1 0 -1 -2 -3 Refers to family Rena to thinly baying Refers to family losing employ. having stable relaively amble eotloy.in for"negative"reasons 2 or employment and the past 12 mos.Brame is more times in the past 12 mo. & income over the past sutc.i tmeeting basic • inability to pay for food, 12 months.More than needs,such as food,rent, housing&/or clothing.Family enough income to pay and clothing Mae ate receives public assist.,and/or for food,housing, soots roomy pitmans, primary caregivers are and/or clothing. such as aedit card debt, unemployed.Money is a major Money is not an issue. but they do not issue.Child support is not paid. Family has money to significantly inhibit fly Public assist.has been meet responsibilities activities arm. canceled.Family does not have and spend on leisure purchase of necessities. money to meet basic needs. activities. 6.Financial Clear Strength Mild Baseline/Adequate Mild ModmteP Serious Problem Management S. P. +2 +1 0 -1 -2 -3 • Refers to family using Refers to fmalyhavmg Refers to family being severely money in a way that debts,but debts are tinder in debt.Family has a history provides benefits control Somepsoblemc within the past year of being financially,and family withbudgeting,but evicted from their home due to has clear spending jrobloon do not prevent bills.Cheat difficulty paying pleas or priorities. fauw*y frufnnteetmg basic bills,and/or bills are paid late. • • Debts are small and needs fafood rent,etc. Chaotic budgeting,and family manageable.There is a is constantly in crisis over planned use of money, money.Frequently broke,due and no back bills. to betting or gambling.No Family is good at bargain hunting. budget plan.Luxuries are bought before necessities. 3 The NCFAS-R is a modification of the NCFAS(North Carolina Family Assessment Scale)and is intended for use by family preservation services providers worldng with reunification cases.Modifications wee made by R.S.Kirk,in collaborate with the National Family Preservation Network(NFPN).Funding provided to NFPN for the modification project came from the David and Lucile Packard Foundation The original NCFAS was developed by R.S.Kirk end K.Ashanti.The NCFAS is derived torn previous veniotu based on the Family Assessment Form,developed al the Children's Bureau of Southern California,Michigan's Family Assessment of Needs Fain,and four uaeannent instruments developed in North Carolinaby Haven Rouse(Raleigh),Nano Remedies(Morganton),Methodist Home for Children (Raleigh),and the state Division of Mental Health,Developmental Disabilities and Substance Abuse Services.Special admowledpnents are due to Sandy Sladen and Judith Nelson at the Children's Bureau of Southern California and to researchers Jacquelyn McCroekey and William Meeran.Domain specifications for the original NCFAS were based on the work of Meccas and McCrosicey.Domains and subscales for Version 2.0 are based upon oliabibty and validity testing completed in the Fall of 1997.7be NCFAS-R,Version R2.0,is based upon reliability and validity testing conducted during 2000-2001.Ray testing is ongoing. ('),See Use's Guide to the NCFAS.Version 2.0,for additional inforrwtiw on scale construction and psychometrics. 03/30/2006 09:26 9706676713 OLSEN PAGE 13 -.7.Food/ Clear Strength Mid Baseline/Adequate Mild Moderate P. Serious Problem Nutrition S. P • 4-2 +1 0 -1 -2 til Refers to caregivers' Panplymxes basic Refers to caregivers'lack of awareness of nutritional nmitionalneeds.Children awareness of nutritional needs needs of children, have access to sufficient including any specialvar of children,including any food,thou special needs.Does not attempt needs.Meets those rodividuelnnk naynot to meet nutritional needs.Does needs.Prepares always be"bahoced." not consider food preparation balanced,nutritious important.Inadequate supply of meals.Ample food food,and/ot inappropriate food. available.Children eat Lots of'5unkk'food consumed. on a regular schedule. Children often go hungry. • Paodrutritlanactively _"mwaDand"by caiegvae. 8.Penonal Oar Strength Mid Baseline/Adequate Mid Moderate P. Sedan Problem Hate S. E +2 +1 0 -1 -2 -3 Refers to children Refers to children Refers to constant appearance looking clean and well occasionally wearing of children as unkempt or dirty. groomed.Children have nyppropriase clodting or Appearance of adults as plenty of clothing, Wearing=kni a unkempt.Noticeable poor appropriate to the However,appearances:, personal'hygiene,obviously season.Adults look espptopriate clothing is poor dental hygiene,and/or clean and well- not causing problems for body odor.Lack of awareness groomed.Adults have the fewilyce children of children or adults of personal plenty of clothing hygiene and • appropriate to the YSigrooming,Dress is season.Awareness of inappropriate to the season. • personal hygiene and grooming.Take pride in themselves. 4 The NCFAS-R is a modification of the Nt:FA5(North Carolina Family T services providers working with reunification cams.Modifications were made RS.Kirk, nd cs intended for use by Nfaationly area Family Preservation Network PundiAby k,in cm he David av with the National Family (as developed g t S. to NFPN h daft.The NCFA project ramp 6op'reve and ed Packard amindation, The aaigiml NCFAS war developed by R S.Kirk sari IC AahcreR.The NCPAS is derived from previous versions based on the Family Assessment Porth,developed at the Children's Bureau of Southern California,Michigan's Family Assessment of Needs Form,and four assessment instruments developed in North Carolina by Haven House(Raleigh),Home Remedies(Morganton),Methodist Home for Children (Raleigh),and the stare Division of Mental Health,Developmental Disabilities and Substance Abuse Services.Special acknowledgments am due to Sandy Sladen end Judith Nelson at the Children's Bureau of Southern California and to researchers Jacquelyn McCroskey mid William Meson.Domain specifications for the original NCPAS were based on the work of Meer=and Mc Domains mid snelia for Version 2,0 are based upon reliability and validity testing completed in the Fall of 1997.The NCFASR,Version P22.0s validity testing conducted during 2000-2001.R&V testing ii ongoing. upon reliability end (')See User's Guide to the NCPAS,Version 2.0,for additional information on scale ccasbuction and psychometrics. 03/30/2006 09:18 9706676713 0LSEN PAGE 03 • 9. a°sp°rta- Clear Strength Mild Baseline/Adequate Mild Medetate P. Sous Problem don S. P. +2 +1 0 1 -2 3 Refers to family Refers to tautly having Refers to family not having having a car,or fsclyxegular access to regular access to a car reliable turn, available rk,increases which or public Occasionally, in inhibits work, • social isolation,and/or limits transportation' ammoniac�na access to serves,and/or Reliable will came a problem fce transportation allows family(e.g,sad prevents regular school t "k8 late attendance. family to meet to terse because of obligations such as difficulties). doctors'visit, • school,or regular work attendance. 10. I ntg— Clear Strength Mid BaetltoeAdequate Mad Moderate P. Serious Problem _Emiren S. P. ••••+2 +1. 0 _l _2 — -3 Refers to caregivers' Res to caegiveas' Refers to caregivers'lack of enthusiasm in teaching occaeirnallypllexangt re attention or hindrance to children.Family has 6x koalas activities. developmental tasks of routine for play and Caregivers do not actively children,and low involvement study.Tint is planned seek out cassia with children's school. for reading,attending invoheaas with child's Caregivers do not value outings,structured school,but make tine education,and are frustrated activities.Caregivers' available as sequested actively involved with and angered• needs. children'sNo • school,and assist learning children with opportunities for learning at developmental tasks. home.Games and toys absee nt Age appropriate games and/or are not age appropriate, and toys are provided, Caregivers are not supportive of and evident in the school personnel,or are home(e.g.school disdainful of public work is displayed). schools/teachers. Caregivers ere supportive of school personnel. 5 The NCFAS-R is a modification of the NCFAS(Norte Carolina Family Assessment Scale)and is lot ided for use by services provider working withreunifiation axes.Modifications were madeRS.Kirk, Nfaational al a Family Preservation Network F bym in collaboration the David av with the iletracµ Packard F u(NFPNe. undina .S.Lil a d K. fhr the T e NCFA deri came from Ore od Lased nFoundation. The original NCFAS was developed by R S.Kirk and K.Ashcroft The NCFAS is derived from previous version based on the Family Ammonia Form,developed at the Children's Bureau of Southern California,Michigan's Panty Assessnrmt of Needs Fora.and four assessment itutrurnaus developed in North Carolina by Haven House(Ukiah),Home Remedies (Raleigh),and the state Division of Mental Health,Developmental Abuse (Morganton),Special Methodist Home for acknowledgments area to Sandy Siaden and Judith Nelson at the Disabilities i Substance Abuse Services.n MeC o key and ndWiliam are due _ Children's Donau of Southern California and to researchers)se Manta are basemain d specification'for the original NCFAS were based on the work of Meeran and McConkey.Jacquelyn rains ad eubacalca icr Version upon reliability end validity tasting completed in the Fall of 1991,The NCFAS-R,Version R2.0,is based upon reliability and validity testing conducted during 2000-200).RAV testing it°Agoina. (')See User's Guide to the NCFAS,Vendor 2.0,for additional information on scale construction and psychometrics. 03/30/2006 09:26 9706676713 OLSEN PAGE 12 • B.Parental Capabilities* Note:This section refers to biological parent(s)if present,or current caregiver(.) 1.Overall Clear Strength Mid Baseline/adequate Mild Moderate P. Serious Problem Parental S. P Capabilities +2 +1 0 -1 -2 -3 Refers to family Refers to family Refers to family receiving very receiving very high experiencing some low ratings in the following ratings in the following problems inthe folbw'itig areas:supervision of children, areas:supervision of was:supervision of disciplinary practices,provision children,disciplinary children,disciplinary of develop./enrichment practices,provision of practices,provision of opportunities, develop./enrichment develop./enrichment parent(s)'/caregiver(s')mental opportunities, opportunities, health,parent(s')/caregiver(s') parent(s)'/caregiver(V) parent(s)'/caregiver(e) physical health,and mental health, mental health, parent(s')/caregiver(s')use of parent(s'Nca egiver(s') parent(s')/caregiver(s') drugs/alcohol. physical health,and physical health,and • parent(s'ycaregivet(s') parent(e')/caregiver(a') use of drugs/alcohoL use of drugs/alcohol. However,problem;do not pose major difficulties for farmlymembers. • 2.Supeniian Clear Strength Mild BaselindAdequate MM Moderate P. Serious Problem of Children S. P. +2 +1 • 0 -1 -2 -3 Refers to caregivers' Refers to caregiver Refers to caregivers'lack of age provision of age providiogsatisfactory to appt'opria supervision,or any appropriate sapervisionofchild[m, supervision.Limits on activities supervision,such as Some limits set set on of children are not set or set setting limits for activities based on the inconsistently-Little or no activities based on dulld's age.Some consideration given to selecting the child's age.• considenuion given to substitute caregivers(strangers, Caregiver is careful selecting aubstivao known abusers,persona under and attentive to caregivers,and some the influence of drugs,alcohol). child's needs in concern with dtik en's No thought about children's selecting substitute comfort w/the comfort and feeling of security caregivers(baby- caregiver Use a basic w/substitute caregiver. sitter,neighbor). knowledge of location of Children's blends axe not Makes sum children children,and henbane base known,and location of children feel comfortable and knowledge of daldeen's • is not regularly known safe w/substitute friends caregiver,Keeps track of children and knows children' . friends. • 6 The NCFAS-R.is a modification of the NCFAS(North Carolina Family Assessment Seale)and is intended for use by family preservation services providers working with reunification cases.Modifications were made by RS.Kirk,in collaboration with the National Family Preservation Network(NFPN).Funding provided to NPPN for the modification project came from the David and W cile Packard Foundation. The original NCFAS was developed by R S.Kirk aid R Ashcroft The NCFAS is derived from previous versions based on the Family Anessment Form,developed at the Children's Bureau of Southern California,Michigan's Family Assessment of Needs Fan,and four assessment instruments developed in North Carolina by Haven House(Raleigh),Home Remedies(Morganton).Methodist Home for Children (Raleigh),and the state Division of Mental Health,Developmental Disabilities and Substance Abuse Services.Special acknowledgments are due to Sandy Sladen and Judith Nelson at the CMdren's Bureau of Southern COMM.and to researches Jacquelyn McCloskey and William Mersan.Domain specifications for the original NCFAS were based on the work of Ma ran and McCoskey.Domains and subteeles for Version 2.0 ate based upon reliability and validity testing completed in the Fall of 1997.The NCFAS-R,Version k2.0,is based upon reliability and validity testing conducted during 2000-2001,R&V tasting is ongoing. (')See User's Guide to the NCFAS,Version 20,fbc additional information on scale construction and psychometrics. 03/30/2006 09:18 9706676713 OLSEN PAGE 04 • 3.nbcip0aary Clear Strength Mid BaaeLodAdequate Mid Moderate P. Serious Problem Practices S. P. +2 +1 0 4 -2 -3 Refers to caregivers' Refers to caregivers' Refers to caregivers'lack of ability to provide adequate provision of discipline,or past or current age-appropriate,non- discipline and guidance of emotional or physical abuse punitive,consistent children Occasionally referred to as discipline. discipline.Uses discipline isinapµoprist Discipline is excessive, positive to age,too bnsbcctoo punitive,inappropriate to age, reinforcement,and talent,but Scxais eicies inconsistent,and/or absent. tries to educate do not create major Present poor role models. children through problemtbettt en child Caregivers disagree on appropriate oldcaregivers. parenting strategies and present discipline.Presents mixed messages to child. good role model. Caregivers agree on parenting style and support one another. 4.Provide*of Clear Strength Mild Baseline/Adequate Mild Moderate P. Serum Problem Developmental/ S. P. Emtehucnt Opportunities - +2 +1 . 0 -1 -2 -3 Refers to Reims to cmegivers(s)' Refers to caregiver(s)'lack of caregivcaregiver(s) support of opportunities support or over-involvement in encouragement of for children such as sports, opportunities for children such • opportunities such music lessees,& rfeld as sports,music lessons,&/or as sports,music tips,but caregivers are field trips.Caregivers do oat lessons,&/or visits not actively involved or encourage or discourage to museums& we involved sporadically children's involvement in these parks.Caregivers do iaaippottiogthese activities.Conversely, not"push"children activities. caregivers"push"children to to be involved not only be involved but excel Caregivers are in activities,and are demanding actively involved regarding their children's providing progress_ transportation, coaching teams, and/or participating in advisory boards. 7 The NCFAS-R is a modification of the NCFAS(North Carolina Family Assessment Scale)and is intended for use by fondly preservation services providers working with reunifuatlon cases.Modifications was made by RS.Kirk,in collaboration with the National Family Preservation Network(NFPN).Funding provided to NFPN for the modification project came from the David and Lucile Packard Foundation. The original NCFAS was developed by R S.Kirk and K.Ashcan.The NCFAS is derived from previous versivu based on the Family Assessment Form,developed at the Children's Bureau of Southern California,Michigan's Family Assessment of Needs Form,and four assessment instruments developed in North Carolina by Haven House(Raleigh),Home Remedies(Morganton),Methodist Home for Children (Raleigh),and the state Division of Mental Health,Developmental Disabilities and Substance Abuse Services.Special acknowledgments are due to Sandy Sellers and Judith Nelson at the Children's Bureau of Southern California and to rescnchets Jacquelyn McCroekey and William Masan.Domain specifications for the original NCFAS were based on the work of Mean and McCrakey.Danoa is and subecalea for Version 2.0 c based upon reliability and validity testing completed in the Fall of 1997.The NCFAS-IL Version R2.0,is based upon reliability and validity testing conducted during 2000-2001.R&V testing-is ongoing. (a)See user's Guide to the NCFAS,Version 2.0,for additional information on scale construction and psychometrics. 03/30/2006 09:26 9706676713 OLSEN PAGE 11 • 5.Parmt(s')/ (1w Strength Mild Basemte/Miequate Mild Moderate P. Serious Problem aregiver(s') S. p lam®W health +2 +1 0 -1 -2 -3 Refers to caregivers Refers to caregivers' Refers to caregivers'current current(e.g.,positive coned or past metal and/or past mental health self esteem)mental health(e.g.,old problems(e.g.,severe health which positively depression)which depression,bipolar disorder, affects ability to parent occasionally inhibits active psychosis,etc.)that and/or successful categivtr,but does art negatively affect ability to resolution of past m. significantly hinder the parent children.Caregiver health problems(e.g. caregiver's ability to projects personal problems on using success from patent children or other household Overcoming issues to members bolster wanting). • / Clear&ninth Mild Basegne/Adequate Mgd Moderate P. Saloum Problem Caregiver® Health +2 _ +1 0 -1 . -2 -3 Refers to caregivers' Was to orient or past current M a cx pest medical cc ni dicalorbealth history which are caregivers'exercise healhhisttaywhich not mkt.control ad steady impair regimen,etc.)or past provides sot=lea(e.g, medical or healthfrom tn parent.(tea can range overweight caregiver),but from severe astim>o,disbars, history that positively does not poseoajor blindness,heart Fatal;high affects ability to parent obstacles inpaninttg bloodpresone,cmaes,et.) children. abilities. 8 • The NCFAS-R is a modification of the NCFAS(North Carolina Family Assessment Scale)and is intended for use by family preservation rervioa providers working with reunification cases.Modifications were made by R.S.Kirk,in collaboration with the National Family Preservation Network(NPPN),Funding provided to NFPN for the modification project came from the David and Lucile Packard Foundation. The original NCFAS was developed by IC S.Kirk and IC Ashetan.The NCFAS is derived from previous mains based on the Family Assessment Form,developed at the Childrm'e Bureau of Southern California,Michigan's Family Assessment of Needs Form,and four assessment instruments developed in North Carolina by Haven House(Raleigh),Home Remedies(Morganton),Methodist Home for Children (Raleigh),and the state Division of Mental Health,Developmental Disabilities and Substance Abuse Services.Special acknowledgments are due to Sandy Slat and Judith Nelson at the Children's Bureau of Southern California and to researchers Jacquelyn McCloskey and William Meats.Domain specifications for the original NCFAS were based on the work of Meant and McCroskey.Domains and subscales for Version 2.0 an based upon=liability and validity testing completed in the Pall of 1997.The NCFAS-R,Version R2.0,is based upon reliability and validity teeing conducted during 2000-2001.RAV testing is ongoing. (•),5n.Daces Guide to the NCFAS,version 2.0,for additional information on scale construction and monomeric. 03/30/2006 09:18 9706676713 OLSEN PAGE 05 • 7.Patent(s'y Clear Strength Mid Basthnw dequate Mild Moderate P. Serious �(e') S. P. Problem Uge Ihueg' Alcohol +2 +1 0 -1 -2 4 Refers to caregivers' - Refers to caregivers' Refers to caregivers'current current or past use of current or past use of and/or past alcohol/substance drugs/alcohol. • drugs/alcohol;mostly abuse problems that negatively Caregiver does not use uses alcohol affect ability to parent children. drugs/alcohol,or uses appropriately Use of Caregivers'are frequently alcohol appropriately. drugs/alcohol does not unable to care for or supervise Caregiver does not usesivrifxantlylinderthe children due to use of illegal drugs,and caregivers'abilrtyto drugs/alcohol.Caregiver actively discourages supervise a ped projects personal children's'use of chidlffi children or other household s on drugs/alcohol. members. Caregivers'moderate or non-use does not impair ability to parent. • • • • The NCFAS-R is a modification of the NCFAS(North Carolina Family 9 �,i� ovidenwr AssessmentbR.S.Scale)Kirk, end is lab r ti for use by National l Forma yon Pr working with ramification cases.Modifications were made by it .Kirk in collaboration with the National Family Preservation Network(NFPN).Funding provided to NFPN for the modification project came from the David and Lucile Packard Foundation. The anginal NCFAS was developed by R S.Kirk and IC Ashcrat.The NCFAS u derived from previous versions based on the Final' Assessment Fom,,developed at the Cbtldre is Bureau of Southera California,Michigan's Family Assessment of Needs Farm,and four assessment instruments developed to North Carolina by Haven Howe(Raleigh).Home Remedies(Morganton),Methodist Home for Children (Raleigh),nerd the state Division of Mental Health,Developmental Disabilities and Substance Abuse Services.Special acknowledgments to Sandy Sladen and Judith Nelson at the Children's Bureau of Southern California and to ®menb arc due Meagan.Domain specifications for the Noam Jacquelyn Domains M y and William 2.0 are based upon reliability and validity� coat were based on the work The NCFAS-R, and Met]on R2 sbased and nre a i for Version testing testing is in the Fall of 1997.The NCFAS-R Version R2.0,is laced upon reliability and validity teaang conducted during 1000.2001.R&V tgyng ongoing. (e)Sce User's Guide to the NCPAS,Version 2.0.for additional information on scale cons action and psychometrics. 03/30/2006 09:26 9706676713 OLSEN PAGE 10 C.FamilyInteractions Note This section refers to family members living in the same or different households;an overall assessment• • F , Clear Mid Baseline( Adequate Mild Moderate P. Serious Problemamly P. Interned:ow +2 +1 0 -1 -2 -3 Refers to family Refers to family receiving Refers to family receiving very receiving very high ratings of adequat in the low ratings in the following ratings in the following following mac bending areas:bending w/child, areas:bonding w/child, w/child,caommication ' conantmication w/child, cannon.w/child, w/chid,marital marital relationship, . marital relationship, relanontibt,expectations expectations of the child,and expectations of the of IS child and mtmad mutual support. child,&mutual sit, support • 2.BondingClear Strength Mild BasellodAdequate Mid MadesteP Serious Problem w/Child S. P. +2 +1 0 -1 -2 -3 Refers to caregivers' Refers to caregivers' Refers to caregivers'inability to healthy closeness with ability to be close to the form a close relationship with their child,and their child.Caregivers do not their child,and inability to ability to nurture a openly encourage nurture their child.Caregivers child.Caregivers independence for their are resentful,rejecting,or encourage apprap. child,and any not give detached from their child.Also independ.for child,& affection openly to child, refers to caregivers'non- give love and attention }lawgiver,child's needs responsiveness,inappropriate freely to child.They appear to be met. responsiveness,or extreme respond to child's needs . enmeshment with their child. appropriately,and have a sense of attachment to child. 10 The NCFAS-E.is a modification of the NCFAS(North Carolina Family Aaaeurent Seale)and is intended(or use by family preeavadon services providers working with reunification cases.Modifications were made by RS.Kirk,in collaboration with the National Firmly Presavauon Network(NFPN).Funding provided to NFPN for the modification project came from the David and Lucile Packard Foundation. The original NCPAS was developed by R S.Kirk and it Ashcan.lbe NCFAS is derived from previous versions based on the Family Assessment Form,developed at the Children's Bureau of Southern California,Michigan's Family Assessment of Need.Fenn,and four sueunent instruments developed in North Carolina by Raven House(Raleigh),Rome Remedies(MorgantomJ,Methodist Home for Children (Raleigh),and the state Division of Mental Health,Developreetal Disabilities and Substance Abuse Services.Special aclmowledgnena are due to Sandy 5ladeo and Judith Nelson in the Children's Bureau of Southern California and to researchers Jacquelyn McCloskey and William Marro.Domain specifications for the original NCFAS were based on the work of Meeaan and McCloskey.Domains and nubacales for Vernon 2.0 sa based upon reliability and validity tenting completed in the Fall of 1997.The NCFAS-R.Version R2.0,is based upon reliability and validity tuning conducted during 2000-2001.RAY testing is ongoing, (*).See User's Guide to the NCFAS,version 2.0,for additional information on scale construction and psychometrics. 03/30/2006 09:18 9706676713 OLSEN PAGE 06 3.Expectations Clear Strength Mild Baseline/Adequate Mild Moderate P. Serious Problem of the Chad S. P +2 +1 0 -1 -2 -3 Refers to caregivers' Rotas to categiveis' Refers to caregivers'having possessing age expodalicn for 0re child unrealistic and unclear appropriate asmoetlyage-appsopriae. expectations for the child.Do expectations fin the Cmegivas appear to have not tolerate mistakes in the child,and clear mavesage understanding child.Child is expected to take expectations of the of cblldhde elopseeat l on adult responsibilities(i.e., child.Above needs,but this .'parentificd").Or,child is not average smdaetaodiog does not allowed to engage in age- understanding of ward iaeervamoo. appropriate behaviors(e.g. child's development • sports,dating). Little or cognitively, inappropriate understanding of physically,socially, • normal child development and emotionally. 4.Mutual Clear Strength M1td llasein/Adequate Mild Moderate P. Serious Problem Sport S. V. within hin the Family _ +2 +1 0 _l -2 -3 Refers to excellent Refers to good support Refers to poor or lack of mot.A/or'physical" within Poc family.sons emotional support or"physical" support win family. physical support is support among family members. "Physical"support is provided when requested Family does not provide • given when needed, by a fauilynmtbec Most . . transportation,day care,or such as providing day =pests for help from financial assistance when care,transport.,or family members are nit needed.U of finan.help.Family byt membersef�n8each other in the family.Family members appear to help members do not tolerate success each other willingly. by other family members. • . II • The NCFAS-R is a modification of the NCFAS(North Carolina Family h Assessment Scale)and is intended for use by family services provider,working with reunification cues.Modifications were made by R.S.Kirk,in collaboration with the National Family en Pre+m"tion Network(dFPN).Funding provided to NFPN for the modification project tame from the Druid end Lucile Packard Foundation. The original NCFAS was developed by A S.Kirk and IC.Aehcraf.The NCFAS is derived fromprevious undone based on the Family Asaeamnent Form,developed at the Cbildrea's Bureau of Southern California,Micbdgaa's Family Assessment of Needs Foam,and tour assessment instruments developed in North Carolina by Haven House(Raleigh),Home Remedies(Morganton),Methodist Home for Children (Raleigh),and the sate Division of Mental Health,Developmental Disabilities and Substance Abuse Services.Special acknowledgments are due b Seedy Slade=end Judith Nelson at the Children',Bureau of Southern California end to researches Jacquelyn McCroalcey and William Murat.Donato specifications far the original NCFAS were based on the work of Meeran end McCrwkey.Dommauts and subscales for Version 2.0 cm based open reliability and validity testing completed in the Fall of 1997.The NCFAS-R.Version R2.0,is based upon reliability and validity testing conducted during 2000-2001.RRV toting is ongoing (6)See User's Guide to the NCFAS.Version 2.0,Mr additional information on salt cooauuctioa and psychomeoice. 03/30/2006 09:26 9706676713 OLSEN PAGE 09 S Relationship Clear Strength Mild Baseline/Adequate Mid Moderate P. Salons Problem between S. p • Parents/ • Caregivers" +2 +1 0 -1 -2 -3 Rd=to relatiaash p Pets to relationship Refen to lealicmshiP between between categivers as between caregiver&Saxe caregivas as=supportive and sable,consistent, conflicts are evident,but wn1abk.Major occomunication affutouate,aod do not appear to be dithcuklet with evidare of discord, loving.Couple a able • leading to divorce, to comatose clearly or violence,on oraiaodca Divorce, axdamourage each abandoain t.Scar ecah®doianratare abet Couple,n.tmui— minor ditScolt s with not p e�neatsues.Botm betweenarin are from co�cauon but donot pa o c Madan a imPafrdm leaorbtayseaarisecaskend NOTE:This tem may not he applicable Mai cases.21ria would be the case if tbere wine only one caregiver involved,and there is no significant otla .If this is the case,click NAon the fain • 12 The NCFAS-R is a modification of the NCFAS(North Carolina Family Assessment Scale)and is intended for use by family prosevation services providers working with reuni8cadoo can Modifications were made by AS.Bark,in collaboration with the National Family Preservation Network(NFFN).Funding provided to NFPN for the modification project came frost the David and Lucile Packard Foundation. The original NCFAS was developed by A S.Kirk and K.Ashore&The NCFAS is derived front previous versions based on the Family Assessment Form,developed at the Children's Bureau of Southern California,Michigan's Family Aaaeument of Needs Fora and four ucecsment iratmmetts developed in North Carolina by Haven House(Raleigh).Home Remedies(Morganton),Methodist Home for Children (Raleigh),and the state Division of Mental Health,Developmental Disabilities and Substance Abuse Services.Special ackmaMadgsnents arc due to Sandy Slidell and Judith Nelson at the Children's Bureau of Southern California and to researches Ineptly!'McCroskey and William Mean.Domain specidatiom for the original NCFAS were based on the work of Merzen and McCloskey.Domains and subsoil=for Version 2.0 are based upon reliability and validity testing completed in the Fall of 1997.The NCFAS-R,Venion R2.0,is based upon pliability and validity testing conducted during 2000-2001.R&V testing is ongoing. (s)See User's Guide to the NCFAS,Version 2.0,for additional information on scale construction and paychomeb(cs. 03/30/2006 09:18 9706676713 OLSEN PAGE 07 D.Family Safety • Note:This section refers to family members living in the same or different households 1-Overall Clear Strength Mild Bast e/Megaate Mild Moderate P. Serious Problem Family S. P Safety* +2 +1 0 -1 -2 .3 • Refers to families Refers to families Refers to families receiving receiving very high receiving baseline very negative marks in the marks in the following ratings in the following following areas: anas:absence/presence areas: absence/presence of physical of physical abuse of absence/presence of abuse of children, children, physical abuse of • absence/presence of sexual absence/presence of children, abuse of children,' sexual abuse of absence/presence of absence/presence of neglect of children, sexual abuse of children,and absence/presence absence/presence of children, of domestic violence between neglect of children,and absence/presence of parents/caregivers. absence/presence of neglect of children,and domestic violence absence/presence of between domestic violence parents/caregivers. between parents/caregivers. • 2.Abseral Clear Strength Mild ilasetine/Adequate Mild Moderate P. Serious Problem presented' S p PhYlicall above of • children' +2 +1 0 -1 -2 -3 - ' Refers to families in Refers to farina in which Refers to incidents/complaints/ which incid./ physical abuse has rot substantiation of physical eomplaints/substant occurred,or in which abuse by caregivers which have have never occurred,or compiai t5 ode teisub- not been acknowledged or has occurred&family atantialions of abuse by addressed,or have been successfully been caregivers occurred resolved unsatisfactorily. . involved in counseling. but satisfactory progress is Caregivers may be actively Caregivers do not being made through denying substantiated abuse condone violence. counseling or the and/or neglect,or actively • provision of other . resisting intervention. services. • • 13 The NCFAS-R u a modification of the NCFAS(North Carolina Family Anesameat Seale)and is intended for use by family preservation services providers waking with reunification cases.Modifications wee made by R.S.Kirk,ja collaboration with the National Family Preservation Network(NFPN).Funding provided to NFPN for the modification project time from the David and Lucie Packard Foundation. The original NCFAS was developed by R S.Kirk and K.Ashaaft.The NCFAS is delved from previous versions based on the Family Assessment Form,developed at the Children's Bureau of Southern California,Michigan's Family Aesanmeat of Needs Form.and four sue arnent instruments developed in North Carolina by Have,House(Raleigh),Hare Readies(Morganton),Methodist Home for Children (Raleigh),and the state Division of Mental Health,Developmental Disabilities and Substance Abuse Services.Special aclmowiedamarb are due to Sandy Sladen and Judith Nebon at the Children's Bureau of Southern California and to reeeschem Jacquelyn McCloskey and William Meeran.Doran specifications for the original NCFAS wee based on the work of Metzan.and McCrmskey.Domains and aubacaks for Version 2.0 are based upon reliability and validity testing completed in the Fat of 1997.The NCFAS-R.Version R2.0,is based upon reliability and validity testing conducted during 2000.2001.RAY testing is ongoing. (')See Use',Wide to the NCFAS,Version 2.0,for additional information on scale construction and psychometrics. 03/30/2006 09:26 9706676713 OLSEN PAGE 08 3.Miecnxe/ Clear Strength Mold Basdind/Adegnate Mild Moderate P. Serious Problem presence of S. P. sexual abuse of children +2 +1 0 -1 -2 3 Refers to child who has Rees to child who has Refers to child having never experienced never experienced sexual experienced sexual abuse by sexual abuse,and who abuse,hat Snot been others,or child sexually abused has learned about such actively taught concepts others.May be inferred or concepts as"good"and such as"good"or'bad" substantiated.Child has been "bad"touch.Or,a child touch.Or,a child whoa referred for treatment or is m who has experienced been sexually abused,but treatment A judgment is made sexual abuse,sod is is tasking sansfactory regarding unsatisfactory now being"protected." progress in treatment. progress in treatment.Sexual Child is in treatment, abuse is ongoing,or risk of and has been making sexual abuse is high. excellent progress. 4.Alsace Clear Strength Mild Baeeine/Adegtuse Mild Moderate SerioueProblem presence of S. P. emotional abuse of children +2 - +1 0 -1 -2 -3 Refers to child who has Rats to told who has Refers to child having been never been emotionally neverbeen emotionally emotionally abused by others. abused,and who abused.Child basically Child has been referred for exhibits secure feelings, exhibits seam feelings or treatment or is in treatment. and possesses a sense of self-esteem.Ot a child Treatment is judged to be self-worth.Or,a child who has heal eandomlly progressing unsatisfactorily. who has experienced abaved,but is intreatmms Incidents of emotional abuse emotional abuse,and is and is progreasiog have increased,are ongoing,or making excellent satisfactorily risk is high. progress in treatment. 14 ma NCFAS-R is a modification of the NCFAS(North Carolina Family Assessment Seale)and is intended for use by family preaervatton 'evict'provides working with reunification cum.Modifications were made by RS.Kirk,in collaboration with the National Family Preservation Network(NFPN).Funding provided to NFPN for the modification project came from the David and Lucile Packard Foundation. The original NCPAS was developed by R S.Kirk and lL/wheat The NCFAS is derived from previous version based on the Family Assessment Form,developed at the Children's Bureau of Southern California,Michigan's Family Assessment of Needs Form,and foes usearent iuNrumena developed in North Carolina by Haven Rouse(Raleigh),Hone Remedies(Morgmtnn),Methodist Horne for Children (Raleigh),and the state Division of Mental Hearth,Developmental Disabilities and Substance Abuse Serviem.Special acknowledgments are due to Sandy Sladen and Judith Nelson at the Children's Bureau of Southern California and to researchers Jacquelyn McCroskey and William Meeran.Domain specifications for the original NCFAS west based on the work of Megan end McQeskcy.Domains and saw-ales for Version 20 arebud upon reliability and validity testing completed in the Fall of 1997.The NCFAS-R,Version R2.0,is based upon reliability and senility testing conducted doing 2000-2001.Rev testing is ongoing. nSee user's Guide to the NCPAS,Version 2.0,for additional information on scale conanucton and psychometrics. 03/30/2006 09:18 9706676713 OLSEN PAGE 08 S Absence/ Clear Strength Mild Baeelia&Adequate Mild Moderate P. Serious Problem presence of S. P. neglect of children • +2 +1 0 -1 -2 -3 Refers to families in Refers to families in • Refers to incidents/complaints/ which incidents/ incidents/ substantiation of child neglect complaints/substant of eonoplaints/substant.of. by caregivers which have not neglect have never neglect have never been acknowledged or occurred,or have occurred,or have addressed;or have been occurred&outstanding occtaaed but some resolved unsatisfactorily. progress in counseling progress in counseling Caregivers may be actively is made for the family.. is made for the family.. denying substantiated neglect, Caregivers recognize Caregivers usually or actively resisting and are successful in recognize physical, intervention. meeting children's social,and emotional physical,social,and needs of children and emotional needs. meet moat of these needs. 9tienelh Mid AffslusuiftgatgIYI�7d Moderate P. Serious Problem E Sim Nati withers • _ +2 • ++2. p -3 Refers to families in Refers tofano3ee in witch )refers to which violence has tkmlesdc viollox has incidents/complaints/arrests for never occurred between ocamed.but no longer domestic violence.Violence .caregivers,and all ocgas,Family is involvyd Jaetween caregivers negatively family members are in counseling and making ,affects ability to parent and/or encouraged to solve pant proceet Also problems has resulted in nto children. inwhich violence emotional harm to children. Jeonviolentiv."Also pas nova occurred, • refers to families in Dispute°cwt.andfamily which domestic Imakea solve tobleam violence has occurred, Widlgaviolmce. but no longer occurs• due to family's success in counseling.an4 family actively • • discourages vipjence. I NOTE:This item may not be applicable in all eases.This would be hue if there were only is the case,circle NA on the loon one cat-giver involved,and there is m significant other If this 15 The NCFAS-R is a modification of the NCFAS(North Caroline Fatly Asa by S. and is intended for use be feat ionpreaemtion service'providers working with reunification eases,Modifications were made Dy AS.Kirk,in collaboabon with the National Family prnervation Network(NFPN).Funding provided to NFPN for the modification project came from the David and Lucile Packard Foundation The:original NCFAS CF developed by A S.Kirk and K.Asheraft The NCFAS is derived from previous versions based an the Family Assessment Form,developed at the Children's Bureau of Southern California,Michigan's Family Assessment of Needs Form,and Aar assessment inmate:eta developed in North Carolina by Haven House(Raleigh),Home Remedies(Morganton),Methodist Nome for Children (Raleigh), leigh),and the state Division of Mental Health,Developmental Disabilities and Substance Abuse Services.Special acknowledgment:are due to Sandy Sladen and Judith Nelson at the Children's Bureau of Southern California and to researchers Jacquelyn McCloskey and win ton Wean.Domain specification for the original NCPAS were based on the work of Memo:and McCreakey.Domains and subscales for Version • 2.0 ere bated upon reliability and validity sting colleted in the Fall of 1997.The NCFAS-R,Version R2.0,is based upon reliability and validity testing conducted during 2000-2001.kaV testing is ongoing. (:)See User's Guide to the NCPAS,Version 2.0,for additional iafonnadon at scale continence and psychometrics, 03/30/2006 09:26 9706676713 OLSEN PAGE 07 E.Child Well-Bring Note This section pertains to all children in the family.My chrld having problems may affect the whole family system • I.Overall Clear Strength Mild Baidine/Adequate Mild Moderate P. Serious Problem Well-Being S. P +2 +1 0 -1 -2 -3 J Refers to family Rotas to family receiving Refers to family receiving very receiving very high adequate ratings in all of low ratings in the following ratings in the following the areas:child's physical areas:child's physical health, areas:child's physical health,child's mental child's mental health,child's health,child's mental health,rbiild's behavior, behavior,school performance, health,child's behavior, school paio oce, relationship w/caregivers, school perform., relationship w/caregivers, relationship w/siblings, relationship w/ a]aetnebgr w/alb , relationship w/peers, caregivers,relationship relationship w/peers, rootivation/cooperation, w/siblings,relationship mot vadgdcoopaatioo, alcohol/substancc abuse,sexual w/peers,&motivat/ alcobol/subteance,sexual, abuse,and emotional abuse. cooperat&no ratings and eamtional abuse. in:alcohoj/substance, sexual,and emotional abuse areas. 2.Chid(nn's) Clear Strength Mild Baseline/Adequate MIA Moderate P. Serious Problem Mental Health S. k . +2 +1 0 , _I -2 -3 Refers to child's over Rebus to child's having Refers to child's having poor, all,excel.m health good,overall meal overall mental health. Good at.stability heath.Basically good Emotional difficulties. Inability &self concept Able aiotiooat stability.Child to handle stress.Diagnosed w/ to handle stress may lave had episodes of mental illness,and/or other effectively.Child may anxiety.Or,child may emotional disabilities.Child is have mental health have some menial health making unsatisfactory progress issues,but issues that are being • in treatment.Treatment is participates in trtmt, addressed satisfactonly in sporadic,and/or medication is taking medical.,&is tteatoant not taken regularly. • . reeking cicalae pmgcees. 16 The NCFAS-R is a modification of the NCFAS(North Carolina Family Assessmment Scale)and is intended for use by family preservation services providers working with reunification cases.Modifications were made by R.S.Kirk,in collaboradon with the National Family Preservation Network(NFPN').Funding provided to NFPN for the modification project came from the David and Lucile Packard Foundation. The original NCFAS was developed by R S.Kist and K.Ashcraft The NCFAS is derived from previous versions based on the Family Ames:meet Fora,developed at the Children's Bureau of Southern California,Michigan's Family Asterismeat of Needa Form,and four assessment instruments developed in Nardi Carolina by Haven House(Raleigh),Home Remedies(Morganton),Methodist Home for Children (Raleigh),and the state Division of Mental Health,Developmental Disabilities and Substance Abuse Services.Special acknowledgments are due to Sandy Sladen and Judith Nelson at the Children's Bureau of Southern California and to researchers Jacquelyn McCroakey and William Meets.Domain specifications for the original?CPAS were based on the work of Meenn and McCroskey.Domains and subscales for Version 2.0 ate based upon reliability and validity testing completed in the Pall of 1997.The NCFAS-R,Veraion lt2.0,is based upon reliability and . validity testing conducted during 2000-2004.R&V twins is mngding. ('),See User's Guide to the NCFAS,Version 2.0,for additional information on scale construction and psychometrics. 03/30/2006 09:18 9706676713 OLSEN PAGE 09 - 3.Child(ren's) Clear Strength Mid Baseline/Adequate Mild Moderate P. Serious Problem Behavior S. P. +2 +1 0 -1 -2 -3 _ Refers to child being Reim m some problems Refers to problems managing well behaved,and in managing child's child's behavior at home,and/or • there are no behavior,and some in school.Totally discipline problems. discipline problems.Child uncooperative.Refuses to Child viewed as is usually cooperative,has follow mice,or do chores. • cooperative, care di$adtiee in Delinquent and/or highly following rules,and followiog rules or oppositional behaviors. doing chores. completing chores,but Problems w/courts and law problems do not unit enforcement. 4.School Clear Strength Mid Baseline/Adequate Mid Moderate!! Saha Problem Performance S. P. +2 +1 0 -1 -2 -3 • Refers to child having Pt to c]aldhaving Refers to child having poor excellent attend.at good Madam and an attendance at school,a poor school,&an excellent average academic record academic record,and/or many academic record.Child Sane behaviorproblram behavior problems in school. likes school,&/or may be evident inschool Chid professes to hate school, behaves epprapoately is and/or avoids school w/i'lhxsecs or school — hussy. NOTE:This iasnmy not be applicable in all cam This would be true if the child is not of school age.Ins is the case,circle NA ce the foam S.Relaiooship Clear Strength Mid BaseiadAdequate Mid Moderate P. Serious Problem w/Caredvas S. P. • +2 +1 0 -1 -2 -3 Refers to child Refers to child having Refers to discipline and accepting discipline somepob)emsin supervision problems w/child. and supervision. accepting discipline and Lack of open and clear Having open and clear supetvisknA)so,some communication,or no communication w/ problems in conmmnication w/caregivers. caregivers. coneemic tionw/ • cDoes not respectbotmduies,and caregiver%but&Jesn't has an abusive or bast* warrant itvenlion. relalanibip w/caregivea 11 The NCFAS-R is a modification of the NCFAS(North Carolina Family Assessment Scale)and is intended for use by family preservation services providers working with reunification cases.Modifications were made by R.S.Kirk,in collaboration with the National Family Preservation Network(NFPN).Funding provided to NFPN for the modification project came from the David and Lucile Peeked Foundation. The original NCFAS tau developed by R.S.Kirk sad K.Ashcroft The NCFAS S derived from previews versions based on the Fancily Assessment Form,developed at the Children's Bureau of Southern California,Michigan's Family Assessment of Needs Face and four assessment instrument.developed in North Carolina by Haven House(Raleigh),Home Remedies(Morganton),Methodist Home for Children (Raleigh),and the state Division of Mental Health,Developmental Disabilities and Substance Abuse Services.Special actmowledgments are due to Sandy Slade'and Judith Nelson at the Children's Bureau of Southern Calitbmis and to researches Jacquelyn Mccluskey and William Meer.Domain specifications for the miens]NCFAS were based on the work of Meennn and McCroskey.Domains and subsales for Version 2.0 are based upon reliability and validity testing completed in the Fall of 1997.The NCFAS-R Version R2.0,is based upon reliability and validity resting conducted during 2000-2001.RAY testing is ongoing. CISee User's Ouide to the NCFAS,Version 2,0,for additional hifomutim on scale construction and psychometrics. 03/30/2006 09:26 9706676713 OLSEN PAGE 06 6. Relationship Clear Strength Mild BaselmdAdequate Mild Moderate?. . Serious Problem w/Siblings S. P. +2 +1 0 -1 -2 -3 Refers to getting Reims to getting alcmg fin Refers to frequent fights and along well w/ the most pact w/siblings. inability to get along w/ siblings.Help one Some fights occur among siblings.No Support-to or from • another when in !thugs,and siblings do siblings.Intense rivalry, need.Infrequent net play together conflict,and/or scape-goating fights or problems_ frequently Problems of siblings.Fights may result in Stbingsemploy among siblings donut injury,or other behavior may mgeib= merit special Mentim result in emotional damage to • siblings. NOIR Ilia itemrmy not be applicsbk Mail cases.This would be true'fib=se no siblings lithefirmly If ibis is the Cate,ci ccleNAonthefon 7.Relationship ) Clear Strength Mild — RasttMlequate Mild Moderate P. Serious Problem w/Peers S. P. +2 . +1 I 1 -2 -3 Refers to child Reims to child having a Refers to child's inability to having peers as fewpeas as friends.Peas form friendships w/peers,or friends,and peer do not appear to exhibit inability to get along well w/ group appears to be a withofapositiveor peers.Child may have frequent positive influence. negative influence an the fights with peers or avoid peers. Gets along well with dolt Also,child may have peers as peers.Has forging friends,but peer group MO:recoans.May play to be a negative influence, foram sports,or including gangs,or peers pin nod= involved w/drugs,alcohol, school or rhaehrelated and/or delinquent/ dubs or groups. criminal activities. NOTE:This item may not be applicable in all cases.This wotdd be true if there were no peas,due to the age oldie child If this is the case,circle NA ai Ise fain IB The NCPAS-R is a modification of the NCFAS(North Carolina Family Assessment Scale)and is intended for use by family preservation services providers working with reunification case..Modifications were made by R.S.Kirk,in collaboration with the National Family Reaervatioo Network(NFPN).Funding provided to NPPN for the modification project came torn the David and Lucile Packard Foundation. The original NCPAS was developed by R S.Kirk and K.Ashcroft.TheNCFAS is derived from previous versions based on the Family Assessment Farm,developed sr the Children's Bureau of Southern California,Michigan's Family Assessment of Needs Porn,and four assessment instruments developed in North Carolina by Haven House(Raleigh),Home Remedies(Morganton),Methodist Home for Cluldren (Raleigh),and the state Division of Mental Health,Developsve al Disabilities and Substance Abuse Services.Special acknowledgments are due to Sandy Slade and Judith Nelson at the Children's Bureau of Southern California and to researchers Jacquelyn McCloskey and William Massao.Domain specifications for the enthral NCPAS wan based on the weak of Meehan and McCraskey.Domains and subscales for Version 2.0 are based upon reliability and validity tailing completed in the Fall of 1997.The NCPAS-R,Version R2.0,is based upon reliability and validity testing conducted during 2000-2001.R&V testing is ongoing. (')See User's Guide to the NCFAS,Version 2.0,for additional information on scale Construction and psychometrics. 03/30/2006 09:18 9706676713 OLSEN PAGE 10 t Motivation/ Clear Strength. Mid Baseline/Adequate Mild Moderate Serious Problem Cooperate S. P. P. to maintain • the family +2 +1 0 -1 -2 -3 Refers to child being Refers to child's interest in Refers to child's lack of interest interested in staying staying w/ in staying w/family/caregivers. w/ fmtnly/caregivers.(bold is Child is not motivated to change family/caregivers. not observably motivated behaviors and does not want to Child is motivated to to change behaviors and cooperate.Child is against any change behaviors awl cooperate,bitcbldwill intervention or services,or child cooperate. accept intervention or has strong desire to leave family services. for self-serving reasons. 19 The NCFAS-R is a modification of the NCFAS(North Carolina Family Assessment Scale)and is intended for wee by family preservation services providers working withreunification cases.Modifications were made by R.S.Kirk,in collaboration with the Natal Fondly Preservation Network(N)1N).Funding provided to NFPN for the modification project carne from the David and Lucile Packard Foundation. The original NCFAS was developed by ft S.Kirk and K.Ashcroft.The NCFAS is derived from previous versions based on the Family Assessment Form,developed at ire Children's Bureau of Southern California,Michigan's Family Assessment of Needs Form,and four assteemeat instruments developed in North Carolina by Haven House(Raleigh),Home Remedies avforga ston),Methodist Home for Children (Raleigh),and the state Division of Mental Health,Developmental Disabilities and Substance Abuse Services.Spent acknowledgments are due to Sandy Sladen and Judith Nelson at the Children's Bureau of Southern California and to researcher Jacquelyn McCloskey and William ?demon.Domain specifications for the original NCFAS were based on the work of Meezan and McCroakey.Domain.and subecales for Version 2.0 are based upon reliability and validity testing completed in the Fall of 1997.The NCFAS•4,Version R2.0,is based upon reliability and validity testing conducted during 2000-2001.RQV testing is ongoing. (*See User's Guide to the NCFAS.Version 2.0.for additional information on scale construction end psychometrics. 03/30/2006 09:26 9706676713 OLSEN PAGE 05 F Caregiver/Child Ambivalence 1.overall Clear Strength Mild BaselitWAdequete Mad Moderate P. Serious Problem Caregiver/ S. P. Chad Anthividenee +2 +1 0 -1 -2 -3 Both child(ren)and Both child(ren)and Children)and/or caregiver(s) caregiver(s)are eager caregiver(s)say they express serious reservations to reunite,as want to be together; about being together,either due evidenced by both one or both maybe to fear of future harm,strong verbal and behavioral apprehensive or negative affect by one or both expression of desire to nervous about reunion, parties towards the other, be together.Family but that apprehension previous history of 1 s wrval of receives mild to clear is determined to be due this or other child(ren),and or strength rating on the to uncertainty about prior failed reunification efforts. items in this domain: capability rather than Generally problematic or some Parent/Caregiver competition for strongly negative ratings on the Ambivalence Towards affection,substantive items comprising this domain: Child,Child inability to parent,or Parent/Caregiver Ambivalence Ambivalence Towards significant unresolved Towards Child,Child Parent/Caregiver, treatment issues.Some Ambivalence Towards Ambivalence mild problems may be Parent/Caregiver,Ambivalence Exhibited by present on the items Exhibited by Substitute Care Substitute Care comprising this Provider,Disrupted Provider,Disrupted . domain,but family is Attachment,Pre-Reunification Attachment,Pre- working to resolve House Visitations Reunification Home those issues. s Visitations. • 20 The NCFAS-R is a modification of the NCFAS(North Carolina Family Assessment Scale)and is intended for use by family preservation services providers working with reunification caeca.Modifications were made by KS.Kirk,in collaboration with the National Family Preservation Network Q.JFPN).Funding provided toNFPN for the modification project came from the David and Lucile Packard Foundation. The original NCFAS was developed by R S.Kirk and K.AshrnA The NCFAS is derived from previous versions based on the Family Assessment Form,developed at the Children's Bureau of Southern California,Michigan's Family Anerement of Needs Form,and four wetsment instruments developed in North Carolina by Haven House(Raleigh),Home Remedies(Morgantan),Methodist Home for Children (Raleigh),and the state Division of Mental Health,Developmental Disabilities and Substance Abuse Services.Special acknowledgments art due to Sandy Medea and Judith Nelson at the Children's Bureau of Southern California and to researchers Jacquelyn McCloskey and William Meezan Domain specifications for the original NCFAS were based on the work of Menem and McCloskey.Domains and subscales for Version 2.0 ere based upon reliability and validity testng completed in the Fall of 1997.The NCFAS-R,Version R2.0,is based upon reliability and validity testing conducted during 2000-2001.RSV testing is ongoing. (')Set Use's Guide to the NCFAS,Vendee 2.0,for additional information on seal*construction and psychometrics. OLSEN PAGE 11 03/30/2006 09:18 9706676713• 2.Parent/ Clear Strength Mid Baseline/Adequate Mild Moderate P. Serious Problem Caregiver S. E • Ambivalence Towards Child +2 , . +1 0 4 -2 -3 Caregiver responds Caregiver generally Caregiver purposefully appropriately to child, responds appropriately abused/neglected child in the both verbally and non- to child,but may pan;expresses disaffection verbally.Caregiver harbor some towards child;associates receptive and resentment or negative feelings towards child responsive to services occasional feeling of with negative feelings towards designed to support intrusion or excessive child's other caregiver; reunification by • demands by child. originally requested removal of bringing the caregiver Caregiver accepts some child Caregiver claims not to and child closer responsibility for understand child,fails to together;is willing to family difficulties respond to child appropriately attend to child's needs leading to removal and or responds very before their own. is malting progress in inappropriately;expresses Caregiver this area.Generally disillusionment with child,feels acknowledges and positive feelings anger or a sense of violence accepts responsibility towards child,but may towards child,and/or resents for roll in family need ongoing support child's interference with difficulties leading to or additional services caregiver's own life. Caregiver removal. after reunification- blames child for family difficulties leading up to removal;caregiver has refused to respond to services intended to achieve reunification. 21 The NCFAS-p.is a modification of the NCFAS(North Carolina Family Assessment Scale)and is intended for use by family services providers working with reunification cases.Modifications were made by R.S.Kirk,in collaboration with the NationalF preservation Family Preservation Network(NFP?1).Funding provided to NFFN for the modification project came from the David and Lucile Packard Foundation. The oulgnnai NCFAS was developed by R.S.Kirk and K.Ashcroft.The NCFAS is derived from previous versions based on the Family Assessment Form,developed at the Children's Bureau of Southern California,Michigan's Family Assessment of Needs Forth,and four assessment instrument,developed hi North Cant=s by Haven House(Raleigh),Home Remedies(Morganton),Methodist Home for(bildree (Raleigh),and the sate Division of Mental Health,Developmental Disabilities and Substance Abuse Services.Special acknowledgments are due to Sandy Sladen and Judith Nelson at the Children's Bureau of Southern California and to researchers chers Jacquelyn McCloskey and William Means.Dorman specifications for the original NC FAS were based on the work of Means and McCloskey.Domains and subscaks for Version 2.0 are bailed upon reliability and validity testing completed in the Fall of 1997.The NCFAS-R,Venires R2.0,is band upon reliability and validity testing conducted during 2000-2001.R@V testing is ongoing. (•)gee User's Guide to the NCFAS,Version 2.0,for additional information on scale coosnvction and psychometrics. , 03/7,0/2006 09:26 9706676713 OLSEN PAGE 04 • 3.Chad Clear Strength MM HasebewAdegturte Mild Moderate P. Serious Problem AmMvNmee S. • p. Towards . Caregiver +2 +1 0 -1 -2 -3 Child's very t ortable Cbnld is generally Child is fearful of caregiver, mpreemce of caregiver, cdmafatabk in caregiver's Child experienced serious expresses love kr prmmce,but may=pod physical ox emotional harm caregiver ChM responds fearfully or withdraw if prior to removal and holda appgorstaly to=viva caregiver becomes angry caregiver responsible(verbally alit,expressions of a if faualy tensions arise. or behaviorally).As appropriate lave,sad exercising of Oateatlyiespande to age,child verbally or cntgivertespoimbslities ap xxIpriatelyao caregiver otherwise expresses fear, (limit setting,discipline). eta,but may resist mistrust,anger or feelings of ABapropioatetoage, aiegiver setSgor violence towards caregiver, child adiibia a desire to discipline.Does riot feels that caregiver'limits an live with c regive; always acknowledge too strict,is embarrassed by acknowledges and caregiver authority a caregiver;states that he/she will accept"anyresponsibility reapmobaldy.Chgd not stay with caregiver to work chid had for flintily earpesxe a desire to be out problem's that may arise in difficulties leadiogto with caregivexbut the future. removal;has responded ogresses some to and edged in =avatars abort team=or services caregivers desire to be intended to effect with child Gild is ramification scawhertxmPoctedby desire to realm home, leaving behind feelings of security a txmfort afforded during period of a bstmge care. 22 The NCFAS-R is a modification of the NCFAS(North Carolina Family Assessment Scale)and is intended for use by family preservation smites provides wooing with reunification cases.Modifications were made by RS.Kirk,in collaboration with the National Family Preservation Network(NFFN).Funding provided to NFPN for the modification project came from the David and Lucile Packard Foundation. The original NCFAS was developed by R S.Kirk and K Ashaail.The NCFAS is derived from previous versions based on the Family Assessment Form,developed at the Children's Bureau of Southern California,Michigan's Family Asaeaswant of Needs Form,and four assessment instruments developed in North Carolina by Haven House(Raleigh),Home Remedies(Morganton),Methodist Home for Children (Raleigh),and the state Division of Mental Health,Developmental Disabilities and Substance Abuse Services.Special acknowledgments are due ter Sandy Maiden and Judith Nelson at the Children's Bureau of Souther°California and to researches Jacquelyn McCroskey and William Meehan.Domain specifications for the original NCFAS were based on the work of Meehan and McCroskey.Domains and subscalea for Version 2.0 ere based upon reliability and validity testa completed in the Fall of 1997.The NCFAS-R,Version R2 O,is based upon rehabiliry and validity eating conducted doing 2000-2001.RIV testing is ongoing. (Ike User's Ouide to the NCFAS,Version 2.0,for additional inhumation on scale canstuction and psychometrics. 03/30/2006 09:18 9706676713 OLSEN PAGE 12 4.arm Clear Strength Mid Baseline/Adequate Mild Moderate P. Serious Problem . • Exhrbleed by S. P. Substitute Care Provider/ +2 +1 0 -1 -2 -3 Substitute care Substitute care Substitute care provider provider has always provider understands opposes reunification;threatens expected policy on reunification, or has taken legal steps to block reunification to but has bonded with reunification;strongly views occur;supports . child and is caregiver as flawed or unworthy ramification experiencing feelings of return of child;has philosophically;is of separation/loss.As provided/promoted different willing to work with age appropriate,child socio-economic environment and/or be a resource feels or behaves with (e.g.,food,clothing,play items, far caregiver to reciprocity.Substitute recreation)for child and uses achieve successful care provider expresses that difference to sabotage reunification. some reservations reunification efforts.Substitute about caregivers ability care provider has denigrated to adequately care for caregiver to child,actively child,but is willing to expressed view of caregiver's give caregiver a fair inability to resume chance at resuming roll parental/caregiver roll. _ as caregiver -- 5.Disrupted Clear Strength Mild Baadiote/Adequate Mild Moderate P. Serious Problem Attachment S. P +2 +1 0 -1 -2 -3 Both caregiver and Child and/or caregiver Child or caregiver or both child long to resume acknowledge that express marked feelings of lost intimate family . separation has been attachment to the other.Period relationship.As age painflil and have of separation has been very appropriate,each worked/are working to long,and/or child was removed acknowledges the repair relationship. at very young age and has strengths and Relationship• develaped/aged/boodedin limitations of the other, reparations includes relation to persons other than • and is willing/eager to couseling or other the caregiver.Child is at a resume relationship treatment regarding markedly different stage of with accommodation In development and age- development(particularly for limitations. . appropriate older children)than when expectations,to effect removal from caregiver • reconnection between • occurred.Caregiver may have child and caregiver. bad another child or joined another family unit and has transferred affection/attention to other persons. • The NCFAS-R is a rmdificaton of the NCFAS(North Carolina FamilyAssessment rby LS. in ointend%for naebe NatiyFmisl preservation services providers working with reunification cases.Modifications were made by R.S.Kirk, coUaboation with the National Family Fresavation Network(NPPN).Funding provided to NFPN for the modification project came from the David and Lucile Packard Foundation. The original NCFAS was developed by R.S.Kirk and K.Ashcroft.The NCFAS is derived from previous versions based on the Family Assessment Form,developed at the Children's Bureau of Southern California„Michigan's Family Asaee meat of Needs Form,and four assessment instruments developed in North Carolina by Haven House(Raleigh),Home Remedies(Morganton),Methodist Home for Children (Raleigh),end the Stitt Division of Mental Health,Developmental Disabilities and Substance Abuse Services.Special aclmowledgramtts are due to Study Sedan and Tudith Nelsen at the Children's Bureau of Southern California and to researchers lacquetyn McCloskey and William Meer.Domain specifications for the original NCFAS were based on the work of Meeaan and McCloakey.Donning' and subecales for Version 2.0 are based upon reliability and validity testing completed in the Pall of 1997.The NCFAS-R,Version R2.0,is based upon reliability and validity testing conducted during 2000-2001.R&V testing is ongoing. ('),ee User's Guide to the NCFAS,Version 2.0,for additional information on scale wnanuction and psychometrics. 03/30/2006 09:26 9706676713 OLSEN PAGE 03 6.Pre- Gear Strength Mid Base inadequate Mild Moderate P. Serious Problem reunification S. P. Home VbidtUom +2 +1 0 -1 -2 -3 Both caregiver and Caregiver and child(as Caregiver has not participated child(as age age appropriate)are satisfactorily in scheduled home appropriate)exhibit working out issues and visits;has missed visits,failed positive anticipation of re-establishing roles to supervise child adequately home visits.Caregiver during home during visits;has requested plans activities or visitations.Some minor early termination of visits,has special time together incidents may arise,but allowed family issues to with child,and executes caregiver discusses escalate into incidents of high those plans.Home them with service tension or even suspected visitations have provider and uses them abuse/neglect of child.Child progressed well in as opportunity to learn has requested early termination terms of increasing more and prepare for of visits,has refused to stay frequency and duration next visit Child and/or with caregiver,has reported and decreasing caregiver complete maltreatment(substantiated or necessary supervision. visits with minor not)at hands of caregiver Visitations are incident- reservations about during visitations. free;childand caregiver longer tam express sadness/sorrow reunification,but • that visitation period continue to work to ends. resolve differences or issues. Note:Although"Intake"ratings are always important on this subscale,"Closure"ratings may not be appropriate in all cases, depending largely on the reunification model employed and the timing of the assessment. • 24 The NCFAS-R is a modification of the NCFAS(North Carolina Family Assessment Scale)and is intended for use by family preservation services providers working with reunification corn.Modifications was made by R.S.Kirk,in collaboration with the National Family Preservation Network(NFPN).Finding provided to NPPN for the modification project came from the David and Lucile Packard Foundation. The origin]NCFAS wes developed by It S.Kirk and R.Ashes([.The NCFAS is derived from previous versions based on the Family Assessment Form,developed at the Children's Bureau of Southern California,Michigen's Pettily Assessment of Needs Fong and four assessment insnuntents developed in North Carolina by Haven House(Raleigh),Home Remedies(Morganton),Methodist Home for Children (Raleigh),and the state Division of Mental Health,Developmental Disabilitiea and Substance Abuse Services.Special acknowledgments are due to Sandy Stirlen and Judith Nelson at the Children's Bureau of Southern Cahfomia and to reaearchen Jacquelyn McCroskey and William Mann.Domain specifications for the original NCFAS WWI based on the work of Maeaan and McCroskey.Domains and subacala for Version 2.0 are based upon reliability and validity testing completed to the Fall of 1997.The NCFAS-R,Version R2.0,1s based upon reliability and validity testing conducted during 2000-2001.R&V testing is ongoing. (o)See User's Guide to the NCFAS,Vaaion 2.0,for additional information on scale construction and peycbonwtics. 03/30/2006 09:18 9706676713 OLSEN PAGE 13 • G.Readiness for Reunification • 1.Overall Clear Strength Mild BasellnelAdequate • Mild Moderate P. Serious Problem Readiness for S. P. Reunification • +2 +1 0 -1 -2 -3 •Family has made Family has made some Family clearly not ready for substantial progress on progress on return of child due to family practical/ practical/logistical/ chaos,unsatisfactory or high- logistical/legal issues legal issues,and is risk living situations or since removal,and is. moving in the right dangerous or illegal family ready to have child direction.Some issues lifestyles.Little ear no progress returned permanently. may remain,but are not made on the issues leading to Family generally viewed as sufficiently removal;Family embroiled in receives mild-to clear- serious to prevent . contests with the law and with strength ratings on the ' reunification. authority figures in general. items associated with Additional services Family receives numerous this domain:Resolution may be necessary to problem ratings on items in this of Significant CPS Risk continue progress on domain. Factors;Completion of outstanding or Case Service Plans; unresolved issues. Resolution of Legal Some mild problem Issues;Parent/Caregiver ratings may be evident • Understanding of Child on domain items,but Treatment Needs; family is making Established Back-Up progress on those Supports and/or Service items. Plans . . 25 The NCFAS-R is a modification of the NCFAS(North Carotin Family Assessment Scale)and is intended for use by family preservation service providers working with reunification easy.Modifications were made by RS.Kirk,in collaboration with the National Family Preservation Network(NFPN).Funding provided in NFFN for the modification project cairn from the David and Lucile Packard Foundation. The original NCFAS was developed by R S.Kirk and K.Aetiersft-The NCFAS is derived from previous versions based on the Family Assessment Perm,developed at the Children's Bureau of Southern California,Michigan's Family Aasesansemt of Needs Fern,and four assessment tenements developed in North Carolina by Haven House(Raleigh),Home Remedies(Morganton),Methodist Home for Children (Raleigh),and the state Division of Mental Health.Dsalopmatal Disabilities end Substance Abuse Services.Special acknowledgments are due to Sandy Sladen and Judith Nelson at the Children's Bureau of Southern California and to researchers reequebn McCreary and William Mewrn.Domain specifications for the original NCFAS were based on the work of Menem and McC7oskey,Domains and subacala for Version 2.0 are based upon reliability and validity testing completed in the Fell of 1997.The NCFAS-R,Version R2.0,is based upon reliability and validity teasing conducted during 2000-2001.RAN'toting is ongoing. MS=User's Ouide to the NCFAS,Version 2.0,for additional infbr nation on scale construction and psychometrics. 03/30/2006 09:26 9706676713 OLSEN PAGE 02 • • 2.Baclullon Clear Strength Mild Baseline/Adequate Mild Moderate P. Serious Problem of Significant S. P. CPS Risk • • Factor — +2 +1 0 -1 -2 -3 Cmegiva has addicted Caregiver hes made Caregiver has maintained 'yore-potent"weds of substantial progress destuclive,abusive,or finody(transportation, towmdsreeohffieaofrisk inappropriate relationships with housing,employment, thetas that kdeiremawnL other aduda(apeapetator)a has income,supervision,et). Scam issues amain established new suchrelacamehp(s) Ifeplaoptiate,perpelme r unresolved,bitireproted, in child absence.Caegiveahas has been removed tom sodptogrees continues to Ailed toaddteaepe-polentneeda fa ilybyremaaimg be made.Caregiver thatplace thusly mar Minor caregiver Caregiver has acSnowledges old accepts stenor treatofle s'intervmuat reconnectedhvrog iespaossbilityfor such as c aliaseduseofdrugs, envaaanenttoaffoed cmtexdwork onthose alcohol,or engaginginpagd0.itiaf, Fellation and me of issues. or uncial lifestyle,et). bald 3Completion Clear Strength Mad Baseline/Adequate Mild Moderate P. Sabo Problem of Case S. P. Service Pien • +2 +1 0 -1 -2 -3 Caregiver has Caregiver has completed Caregiver strongly denies need for successfully completed required services at last seances,is oppositional b receipt of required services and/or to the mina tequadby services,has Medtopaticipace • voluntary services(eep. cotat ark aatahoritative meaningfully arcomplete xequited • alcohoVdrug abuse, service plan Caregiver services.Ossetianrepeatedly anger management, can vabalizeknowledge exhibits behaviors Miner the crisis management, about Mist focus of service plan,and/or flaunts commnications)and beSvin/ablliües,but has nooconplimceto aerate provider; has demonstrated newly not necessarily or ofrss in witty.Caregiver acquired skills/abilities. deraonetattdd same blames ohm,including service • . Caregiver appears Caregiver tray deny pavvidas,"dre system",amdt gratified by new having needed sae of the parma(s)or child for problems and skills/abilities,and owned service,ha in defense of on appears to have admowledges benefits of internalized change. sane of the services. Caregiver is approachable and • receptive to the idea of ongoing services,and is eager or willing to • participate. 26 The NCFAS-R is a modification of the NCFAS(North Carolina Family Assessment Scale)and is intended for use by family preservation service providers working with reunification cases.Modifications were made by R.S.Kirk,in collaboration with the National Family Preservation Network(NFFN),Funding provided to NFPN for the modification project carne from the David and Lucile Paeland Foundation. The original NCFAS was developed by A S.Kids and K Ashcraft The NCFAS is derived from previous veniona based on the Family Assessment Fora,developed at the Children's Bureau of Southern California,Michigan's Family Asseumamt of Needs Font,,and tout masers instruments developed in North Carolina by Haven House(Raleigh),Home Remedies(Morganton),Methodist Home for Children (Raleigh),and the state Division of Mental Health,Developmental Disabilities and Substance Abuse Services.Special acknowledgments are due en Sandy Slade end Judith Nelson at the Cbfldrm'a Bureau of Southern California and to researchers Jacquelyn McCroskey and William Masan.Domain specifications for the original NCFAS were based on the work of Meemn and McCroskey.Domains and subacalea for Version 2.0 are based upon reliability and validity testing completed in the Fall of 1997.The NCFAS-R,Veuion R2.0,is belied upon reliability and validity katirig conducted during 2000-2001.RRV testing is ongoing. (')See User's Guide to the NCFAS,Version 2.0,for additional intnntetioa on scale construction and psychometrics. 03/30/2006 09:18 9706676713 OLSEN PAGE 14 4. Clem Strength Mild BaseW ere 44 goate Mild Moderate P. Serious Probkmt Resolution S. P. of Legal lima +2 +1 0 -1 -2 J -3 Caregiver has pursued • Caregiver is engaged in In spite of restraining order, legal remedies or of resolving reso caregiver continues to maintain accepted legal services destructive or dangerous issues thamay affect to resolve specific ability to provide steady relationship with other adult(s); issues of a legal nature, competent care.Spa caregiver has chosen to legally including obtaining issues are still not oppose authority domestic violence compleielyreaohed,Gar rob tyininiteanlow re probability of rgwinning"and is straining order, ca sgiver is engaged more expending energy on losing resolving legal charges process of resolution,with legal conflicts rather than resulting from appropriate and realistic abuse/neglect annotations.Caregiver expending energy on becoming allegations.If axresisted to is a caregiver.mor competent,caring receiving Caregiver has serious appropriate,paternity legal assistance when it is legal charges pending that may has been established F neoeaeay.Nat ofibe result in incarceration or other and child support is unresolved issues is biely serious impediment to future being provided.Other io cause firmly chaos or care-giving. • . legalcriminal temoval or caregiver is difficulties being unsuccessfullyresolved. experienced by caregiver that may affect future ability to parent or provide care have been resolved(e.g. • pending eviction, . pending criminal court cases). • • • 27 The NCFAS-R is a modification of the NCFAS(North Carolina Family Assessment Scale)and is intended for use by family preservation services providers working with reunification cues.Modifications were made by RS.Itirk,in collaboration with the National Family Preservation Network(NFPN).Funding provided to NFPN for the modification project came from the David and Lucile Packard Foundation. The original NCFAS was developed by R S.Kirk and R.AsheraR The NCFAS is derived from previous version based or the Farmly Assessment Farm,developed at dm Children's Bureau of Southern California,Michigan's Funny Assessment of Needs Form,and four assessment instruments developed in North Carolina by Haven House(Raleigh),Home Remedies(Morganton).Methodist Home for Children (Raleigh),and the state Division of Mental Health Developmental Di.abitilies and Substance Abuse Services.Special acknowledgments are due to Sandy Slider and Judith Nelson at the Children's Bureau of Southern California and to researchers Jacquelyn MeCroskey and William Meezan.Domain specifications for the original NCFAS were based on the work of Mean and MeCroskey.Domains and subscales fbr Vernon 2.0 are based upon reliability and validity testing completed in the Fall of 1997.The NCFAS-R,Version 112.0,is based upon reliability and validity testing conducted during 2000.2001.RBV testing is ongoing. (•),See User's Guide to the NCFAS,Version 2.0,for additional information on scale construction and psychometrics. , 03/,30/2006 09:26 9706676713 OLSEN PAGE 01 5.Parent/ Clear Strength Mild BasebnWAdequate Mid Moderate P. SlaiomProblem Caregiver s. p. undanaging of Chilly .. Ttaamueat ' Needs +2 +1 g -1 -2 -3 -Caregiver has Caregiver is fairly Caregiver blames child for completed education or knowledgeable of cognitive or developmental counseling on child- treatment provided to disabilities,hold child centered issues and child during period of responsible for progress that emdastands what to out-of-home care,and may not be attainable. expect from child,as seems to tmderstaad Caregiver views normal child ago appropriate, treatment goals. developmental processes as including possible Caregiver may tut deliberately oppositional to to different developmental understand completely caregiver authority or lack or stage of child than prior the potential future to removal(e.g., respect.Caregiver unwilling to treatment needs of engage in discussion of child's puberty).If child has child but professes to experiences in institutional or cognitive or support future closed facility care,and expects developmental treatment if needed, child to return"fixed"or cured. disabilities,caregiver Caregiver may not Caregiver denies need for or knows what to expect fully understand opposes medications or ongoing and has service plans in cognitive/development psychological or medical place to help child al disabilities of child, services. develop.If child is but is willing to accept coming out of outside assistance,if institution or closed needed.Caregiver may treatment facility, not fully understand • . caregiver is aware of • medication regime°, and supportive of but is willing to treatment goals and is administer medication ' prepared to support and to allow child to future treatment, have access to ongoing psychological services. Note:This sub-scale may also be used to assess Chud'k knowledge of Parent's treatment needs, being returned to aThough less common a child may be family in which one or more caregivers have ongoing treatmem needs, and the child's understanding and cooperation,if not participation,may be important to successful reunification.To use the sub-scale to assess"Child's Understanding of Caregiver's Treatment Needs"simply substitute"child"and"caregiver"in the text of the definitions. • • 25 The NCFAS-R is a modification oftne NCFAS(North Gran Faintly.ssessrn at Scale)and is Wended for use by fatly preservation services providers wonting with reunification cases.Modifications went made by R.S.Kirk,in collaboration with the National Family Preservation Network(Nf bQ.Funding provided to NFPN for the modification project came foam the David and Lucile Packard Foundation, 1M nigkW NCFAS was developed by R S.Kirk and K Atria The NCFAS is delved from previous vnraicas based on the Family Msasment Form.developed at the Cbildrre's Bureau of Southern California,Michigan's Family Assessment of Needs Pam,and fax essamaat irummenn developed in North Carolina by Haven House(Raleigh),Home Remedies(Morganton),Methodist Home for Children (Raleigh),and the state Division of Mental Henn,Developmental Disabilities and Runtime Abuse Services.Special stowledpeents are due to Study Maslen and Judith Nelson at the Guinea's Bureau of Southern Catofomia and.b researchers Jacquelyn McConkey and William Mean.Domain specifications for the original NCFAS were based on the work of Meemh and McConkey.Domains sad rubscales for Version 2.0 ins based upon reliability and validity Tang completed to Sc Fan of 1997.The NCFAS-R,Version R2.0,is based upon reliability and validity testing conducted during 2000-2001.Ray opting is ongoing. ( )See Use's Guide to the NCFAS,Wotan 2.0,for additional infomation on sale construction and psychaMnu. 03/10/2006 09:18 9706676713 OLSEN PAGE 15 • • 6. Clear Strength Mild BasSne/Adequate Mid Moderate P. Serious Problem Fatablished S. P Back-Up Supports or Sava Pram +2 +1 0 — -1 -2 3 — Caregiver has Caregiver has some Caregiver has constructed no established slishelaae�and plans in place to plans or ineffective plans for back-up plans provide basic child care and supervision. supervision of child,for supervision of child or Caregiver opposes outside accessing emergency to access services on provision of services(e.g., family services,for emergency basis. refuses to to requests respite if needed. Caregiver has respondby g) Caregiver has plans for minimum so�� Ca echoer for parrot position, accessing social Y with regard to publicly oppositional support.Caregiver with regard to publicly services,mental health does not oppose health, provided social services.mental services or law education or health services, enforcement,if needed. socialzation efforts onpsychological Friends and family those services and has for not engaged post- available for are child�� services fairly passive,relying reunification support.Caregiver social/emotional • on external sources rem mains estranged from family support.Plans and such as school system and/or rema socially isolated mechanisms are in and emergency medical and therefore without social or place to provide health care. emotional care,education and age- support should a crisis or need for assistance . appropriate socialization of child. a °" • 29 The NCFAS-R is a modification of the NCPAS(Noah Carolina Family Assessment Scale)and is intended for use by family preservation service providers working with reunification cases.Modifications were made by R.S.Kirk,in collaboration with the National Family Preservation Network(NFPN).Funding provided to NFPN for the modification project came from the David and Lucile Packard Foundation. The original NCFAS was developed by R.S.Kirk and K.Ashcan.The NCFAS is derived from previous versions based on the Partly Assessment Penm,developed at the Children's Bureau of Southern California,Michigan's Family Assessment of Needs Porto,and four awenment msaumenr developed in Ninth Carolina by Henn Rouse(Raleigh),Home Remedies(Mammon).Methodist Home for Children (Raleigh),and the state Division of Mental Health,Developmental Disabilities and Substance Abuse Services.Special acsmowledgmmv are due to Sandy Sladen and Judith Nelson at the Children's Bureau of Southern California and to researchers Jacquelyn McCroakey and William Meese.Domain specifications for the original NCFAS were based on the work of Meezan and McCYoskey.Domains and subecges for Version 2.0 are based upon reliability and validity testing completed in the Fah of 1997.The NCFAS-R.Version R2.0,is based upon reliability and validity testing conducted during 2000-2001.R&V testing is ongoing. 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Imo a a. kt o - o CO 888888888888888888 8 8 8 OW ■#g;■&a#aaat5-45 # & & & O 8 8 @ uj 04 ) E| X o k)CO au- 11 8I 8 8 8 888888888888888888 8 8 8 ) 7§ ! ! « ! ) � ( s| |||§ ]2 !■„ C/ § . 0§ »;;; 0000000000000 zzzzzzzzzzzzz § , 8888 — 8 Mo |#| a � 0 a ; a ; | co a Ix 0. §09 2w | a e # | | ; | ( § 141 � Si8$ li | | . 0. k / § 2I|!| § 00 Reflections for Youth, Inc. P.O.Box 1860 Berthoud, CO 80513 970-532-5990 (p); 970-472-1736 (f) LIFE SKILLS SAMPLE BILLING PROCESS 1. The life skills practitioner will give a monthly summary to the financial administrator at the end of each month. Each summary will include the date of each session, the length of each session and a summary of each session. At the end of the monthly summary there will be a grand total of face-to-face hours for the month. 2. The life skills practitioner will give a signed client verification form to the financial administrator at the end of each month. The total number of hours signed will match the total number of hours on the monthly summary. 3. The financial administrator will input the monthly totals onto the Weld County billing forms and submit them to Elaine Furister. Reflections for Youth, Inc. P.O.Box 1860 LIFE SKILLS ASSISTANCE REPORT Berthoud, CO 80513 Client Name HH# Date Family Members present. Session summary. Time Date Family Members present. Session summary. Time Date Family Members present. Session summary. Time Date Family Members present. Session summary. Time Total # of hours: 1 . fa ov b -a O 0o S w u O .nO4 $ >; ..co 4 = .9 O 0 ... U O .0d En a, .a Vi Q U -4-8 04 0 CIS Q Q II 4.4 o 0 W U C., w .E E O O a w � CL) 'S0 - g . w S '� 0 w g. En b �, o O O O N u •B O4 A o '. U U O �GI O a... 4. 0 IA A g cog W . CEI .b U Con O = a F A ai `, 0 a+ U o o ' ,o o a O~ R. 4) a) ►�- ohoch CZ 4,O a) }. 3 w s y t'l t0 133A • a) T cc � a O bi • •E N0 > �' a En o L7 a Y Y 0 VI . ›" � a F. �� 0. 0 .) 0a2 m O N AG Gt. 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P.O.Box 469025 Denver.CO 80248-9025 INSURERS AFFORDING COVERAGE. NAIC s MIMEO INSURER A: Tudor Insurance Co. 37982 Reflections for Youth,Inc. INSURER a Groat American insurance Co. 18891 P.O.Box 1660 INSURER a Pinnacol Assurance 10780 Berthoud,CO 80513 INSURER 0: INSURER E COVERAGES . -•---- .._. C....:::::';:rill?:C 6E4754 ISSUED TO THE INsURED NAMED ABOVE FOR TI-E POLICY P134100 INDICATED-NOTW!THSTANDPIG - - .• »ni4Y CONTRACTOR OTHER DOCUfd1ENT vYI INi RESPECT TO WHICH TJ{IS CERTF1CATE MAY BE tSSUED OR : t_4-. --.:a ; r'.E SNIiiAAIJ AFFORDED BY THE POLICES DESCRIBED HEREII'i IS SUBJECT TO AU-THE TERMS.EXCLUSIONS AND COMMONS OF SUCH (( 'A.r.,FL.:, ,-.a?' L1AIE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAD CLAIMS. BM3fTTaNM I S..,....w.N .... -- ---..vow: . 1 r I i IM..eiR.aa..rw•... Ir i. .r.ailairi i t:T•b.'LiiT'3 1.-z;:.::::-_-z. •= .� i�»;. .c_�_ • ...�a�s, i tX- ator r,mt. ...e...... I I 1 tr'o:.L:F Tn.TQ.7n �' I I 1 Ixl ctanmw.oi!Amer.—. OCCUR I 1 I I.�..�..,,__ — — . •: T 1 1 I I I I I I —.—, ...,... _ t - _ ` 1 1 BOP FRAI,AGGREGATE 33,M0.000 I I I e jm.AGGREGATE uwT APPLIES PUN:I I • i Fit0DIJCTS-COMPtt r AG& 31.000.000 1 I......A_._L. _F Pi"x:r/- I err 1 {.:x: 1. . I-. �... ..._ ` I _ . _ 4 e i iAUT 1T PNOPALIEMAear f'rS1548fJ4 illVl12D7IS )Q9/7p11IP+ ? i • — I 1 N AMTAUTOfIA.rTIIG I I :TKaki.,LIRA: 61.000.000 11] I I I-1 I I I I tl' Y I t - 1 I I f---1-•- ___...... ._..._ I I MILV INJURY X mon-creisom Autos [fiw I= , 1 1 1 1 - 1 I I I-. .. I I 1 GARAGE LAM M!!ITY I AUTOO$O.11 d.EA ACCIDENT I$ H I I f I 01100t THAN " 't' 1 1 I I ' 1 I _ - .__.._.. " ""Aso I I i Ir EXCESSA7/IBRELLALIABILITY EACH OCCURRENCE $ IOcclrt n CLAIMSAIDE AGGREGATE--.--, $ I I I�-yI DEDUCTIBI.F I I f I $ I 1-1 RE-rerstnle $ $ C MORRETtscOIIPENSATION AND 4085090 110/01/05 10/01/08 IX ' Yrc sTATRt I EMMOYERA-L'A RILNT/ IORYIIM{T$ r3T I ANY PRORRIETIRUPARTAtER/EXEOITIVE I i 1 i E.L.EACH ACCIDENT I$100,000 I IN,PICER/NEMBER EXCLUDED'? E.L_DISEASE-FA EMPLOYEE ;100,000 rsov"�+o,s e.tu. _ ea..DISEASE-EA EM LIMO s300,000 A O1t4 orofR ional PGL739507 �I MINIMS noPa1►/rrt c1 AIM Alan T,n.i n+3rig..v 1 �^z Palley ..3,000,1n0 la ;a .,a T1F avairrION OF nPERATIOM9 I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PNDV1.IONS Tai_ITICa.ri CgT1Cil�/a'PC>•TLIiS I+COTICT/�A Y !?F CIIRCCCr" c .V!!`y f� • `:.lr Yu..-..�..r.w. i!i 111 'CLAP= POUCY 4.' The following are Additional insureds as respects General Liability only I :u Li,•:.t.:4-at Coviv ;fie might apply accardir►0 to the policy terms, !. 446•,“r';.;__s%trtt4 Desscriptlorrs) 1 CERTIFICATE HOLDER _ CANCELLATION I .. T i I I tlr1VULO AAIY Dr 1 NE ABOVE DEDCRS)£D POLICIES BE CANCELLED BEFORE THE EXPIRAThiN 1 J INNL T.-MIS TT-+$,oapt.3r:•11-. .-.,-. f1 V 'tE TY REDY.HIETA'R$h 11113/737 WILL ENDEAVOR TO RAIL ��. DAIC^ .^.'.' I Services I NOTICE TO 701€CERTNVCATE MOLDER MAYEO TO TOIL 1£FT.OJT FAMINE TO 00 SO OHMI 1 1".U.MX A 315?Jort?T 11th AV1. IIFAFti;'3E NO OBLIGATION OR UARfLITT OF ANY RIND UPON'INC NIRIRTFN_RA*IMO"AR I 1 rt?,NIcry rn oro.7.1 I - 1 1 Gt'aGley,CO 80632 J.ITOORLTEa.:.rW:.E::6:,;:.i. ACO W 25 i2;'01iitir't i uU eS283- 55iN72657a3 L IR v AuUHHU LAIR FORAT VON 1986 I I Paget 003 IMPORTANT If the certificate holder Is an ADDMONAL INSURED,the policy(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 potties 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(2007/08) 2 of 3 #5285755/M285753 Page: 003 , A • IMPORTANT If the certificate holder Is an ADDRIONAL INSURED,the policy(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 potties 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 253(2001/08) 2 of 3 MII285755/M285753 EXHIBIT B SUPPLEMENTAL NARRATIVE TO RFP Me, 23 06 09:33p Jeff and Carol Johnson 970-472-1736 p.1 FAX TRANSMISSION REFLECTIONS FOR YOUTH, Inc. 'Discovering the Power of Positive Choke" P.O. Box 1860 Berthoud, CO 80513 (970) 532-5990 (p) (970) 472-1736 (f) DATE:5'/J rc , TO: FROM:).W}cl,r )cttpcoo l ll'L RE: 44-tit Ufl ��C COMMENTS: C k 4u rv-As %ilk& Q_IN 1 L�Totaf 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 privfeged,confidential,and exempt from disclosure under applicable law. If the reader of this facsimile is not the intended recipient nor the employee or agent responsible for the intended recipient,you are hereby firing the facsimile to communication is strictly you hove received ve dissemination,atian,communication disMbufloe,or please of nthis otify prohibited. If have received this 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 Lorimer County. She has attended all of the trainings and is very knowledgeable in the subject. Thirdly, the level of service provided will be dependent upon the referral. Lastly, we are able to travel to South Weld County. Our hope would be to stay within a 30 mile (one way) radius of the city of Berthoud. In terms of court testimony I would request the same amount for all court testimony by representatives of our agency. This amount is $80.00 per hour. As it relates to Day Treatment (RFP# 06006), as discussed in section III. E. "Assessment and plan to meet the needs of child and family", all youth served through Reflections for Youth, Inc. Day Treatment will have a school/therapeutic services aftercare plan upon discharge. The therapist, teacher and family will begin to work on the plan at least 60 days prior to the youth's projected discharge date. The plan will include but is not limited to educational needs, resources and recommendations, therapeutic needs, resources and recommendations and any follow-up or referrals needed prior to discharge. Home-based services can be 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 Ill. 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 LPL 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 dicruss aftercare and what services are needed. Needed services can include individual therapy, family therapy, drug and alcohol therapy, community-based NA/AA, mental health/psychiatric through North Range Behavioral Health or similar provider. Individual therapy,family therapy and home-based services can be provided by RFY is necessary at discharge and if so desired. 3. A date for discharge will be set by the team of people involved with the student's case plan. If the student is a non-GED student, Reflections for Youth, Inc. will advocate for a date that least upsets the transition back to public school. Students can lose valuable clock hours/credits if expected to return to public school in the middle of a semester or academic quarter. 4. A key area that will be addressed throughout the course of placement but certainly during a transition meeting is student progress. For special education students this will be a discussion of the I.E.P. goals and objectives and outcomes. Teachers will be able to give the receiving school information regarding the progress students made towards achieving their I.E.P. goals and their present level of functioning. Teachers and clinicians will also report on effective behavioral and academic interventions and modifications used within the classroom and throughout the day treatment day. 8 May 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 I: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 41;ics DEPARTMENT OF SOCIAL SERVICES P.O. A BOX GREELEY,CO. OX80632A Webslte:www.co.weld.co.us ' Administration and Public Assistants(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 O Box 1860 Berthoud, CO 80513 Re: Bid 06OPB05 Option B Bid 06DT03 Day Treatment Bid 06LS13 Lifeskills Dear Mr. Johnson: The purpose of this letter is to outline the results of the Core Bid process for PY 2006-2007 and to request written information or confirmation from you by Monday, May 22, 2006. Results of the Bid Process for PY 2006-2007 A. The Families, Youth and Children(FYC) Commission recommended approval of your RFP# 06010, (Bid# 06OPB05) Option B-Intensive Home Based Therapy for inclusion on our vendor list. The score given to your bid was 95. The FYC Commission attached the following recommendation to this bid. Recommendation: You must clarify that you provide Bilingual services. Hourly Rate for Court Testimony: You did not provide a rate for court testimony. For bidders carrying over services to 2006, the Department will use last year's court testimony hourly rate. The rate for court testimony will be billed at is $80 per hour. B. The Families, Youth and Children(FYC) Commission recommended approval of your RFP# 06005, (Bid# 06LS13) Lifeskills, for inclusion on our vendor list. The score given to your bid was 90. The FYC Commission attached the following recommendation to this bid. Page 2 Reflections for Youth/Results of RFP Process for PY 2006-2007 Recommendation: • You must clarify in writing that you will be providing transportation at$30 an hour. • You must provide details of staff qualifications. • You must clarify that the level of service provided is dependent on the referral. • There is no information included on your bid about travel to South County. Hourly Rate for Court Testimony: You did not provide a rate for court testimony. For new bidders, the Department will use your requested hourly rate. The rate for court testimony will be billed at is $53.80 per hour. C. The Families, Youth and Children(FYC) Commission recommended approval of your RFP#06006, (Bid# 06DT03) Day Treatment for inclusion on our vendor list. The score given to your bid was 90. The FYC Commission attached the following recommendation to this bid. Recommendation: You must clarify and define the youth's after care and transition back to the school system. Hourly Rate for Court Testimony: You did not provide a rate for court testimony. For bidders carrying over services to 2006, the Department will use last year's court testimony hourly rate. The rate for court testimony will be billed at is $80 per hour. Compliance Item: For all of the above bids, you must provide the required letters under the Collaboration Section from Weld County/Greeley Housing Authority, employment/training partners, and other partners as identified in the bidder's assessment of needs. You must identify the process you will utilize to facilitate Medicaid eligible clients receiving mental health services at North Range Behavioral Health. Required Response by FYC Bidders Concerning FYC Commission Recommendations: You are requested to review the FYC Commission recommendations and to: 1. accept the recommendation(s) as written by the FYC Commission; or 2. request alternatives to the FYC Commission's recommendation(s); or 3. not accept the recommendation(s) of the FYC Commission. Page 3 Reflections for Youth/Results of RFP Process for PY 2006-2007 Please provide in writing how you will incorporate the recommendation(s) into your bid. If you do not accept the recommendation,please provide written reasons why. All approved recommendations under the NOFAA will be monitored and evaluated by the FYC Commission. The Weld County Department of Social Services is requesting your written response to the FYC Commission's recommendations. Please respond in writing to Gloria Romansik, Weld County Department of Social Services, P.O. Box A, Greeley, CO, 80632, by Monday, May 22, 2006, close of business. You may fax your response to us at 970.346.7698. If you have questions concerning the above, please call Gloria Romansik, 970.352.1551 extension 6230. Sincerely, et' J y A. 'ego,Di for cc: Juan Lopez, Chair, FYC Commission Gloria Romansik, Social Services Administrator Weld County Department of Social Services Notification of Financial Assistance Award for Families,Youth and Children Commission (Core)Funds Type of Action Contract Award No. X Initial Award FY06 06-CORE-65 Revision (RFP-FYC-06005; 06LS08) Contract Award Period Name and Address of Contractor Beginning 06/01/2006 and Victor H. Cordero Ending 05/31/2007 Lifeskills 2828 Speer,Unit 118 Denver, CO 80211 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Assistance Program is designed to provide culturally and Award is based upon your Request for Proposal (RFP). linguistically competent mentoring,visitation, The RFP specifies the scope of services and conditions therapeutic visitation, and parenting instruction of award. Except where it is in conflict with this to parents involved with Weld County NOFAA in which case the NOFAA governs, the RFP Department of Social Services. Total number of upon which this award is based is an integral part of the clients to be served is 30,monthly average action. capacity 5 on going family units, average stay in the program is 12 weeks, average hours per Special conditions week per client/family unit is 4 hours per week. 1) Reimbursement for the Unit of Services will be based Latino,Hispanic, Bilingual Spanish. on a monthly rate per child or per family. 2) The monthly rate will be paid for only direct face-to- Cost Per Unit of Service face contact with the child and/or family or as specified Hourly Rate Per $110.00 in the unit of cost computation. Treatment Package-Intensive 3) Unit of service costs cannot exceed the hourly and Treatment Package-Moderate yearly cost per child and/or family. Aftercare-Low - 4) Payments will only be remitted on cases open with, and Court Testimony $120.00 referrals made by the Weld County Department of Social Services. 5) Requests for payment must be an original submitted to Enclosures: the Weld County Department of Social Services by the X Signed RFP: Exhibit A end of the 25th calendar day following the end of the X Supplemental Narrative to RFP: Exhibit B month of service. The provider must submit requests for Recommendation(s) payment on forms approved by Weld County X Conditions of Approval Department of Social Services. 6) The Contractor will notify the Department of any changes in staff at the time of the change. Approvals: Program Official: By .J. eile, Chair By Board of Weld Count/commissioners Ju . Gn go,Direc or Date: JUN 14 ZOOID We Cou pep ar ent of Social Services Date: t I o aOo6-/S85 o LS 0 ? • INVITATION TO BID OFF SYSTEM BID 001-06 (06005-06011 and 006-00, A, B, & C) = DATE: March 1, 2006 BID NO: RFP-FYC-06005 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-06005) for:Colorado Family Preservation Act--Life Skills Program Emergency Assistance Program Deadline: March 31, 2006, Friday, 10:00 a.m. The Families, Youth and Children Commission, an advisory commission to 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 Program Act (C.R.S. 26-5.5-101) and Emergency Assistance for Families with Children at Imminent Risk of Out-of-Home Placement Act (C.R.S. 26-5.3-101). The Families, Youth and Children Commission wishes to approve services targeted to run from June 1, 2006, through May 31, 2007, at specific rates for different types of services, the county will authorize approved providers and rates for services only. The Life Skills Program must provide services that focus on teaching life skills, which are designed to improve household management competency, parental competency, family conflict management and effectively access community resources. This program announcement consists of five parts, as follows: PART A...Administrative Information PART O...Bidder Response Format PART B...Background, Overview and Goals PART E...Bid Evaluation Process PART C...Statement `of Work tit ` (1, n Delivery Date 131 )O Co Y ¶itY\,\-?•LA'\& (After receipt of order) BID MUST BE SIGNED IN INK X ICToR N . CORDER() \ TYPED OR PRINTED SIGNATURE VENDOR `tlett* \\-- \De o VAS-1-1 . Cr0/Ol4l�lT,V Jj�a (Name) el Handwritten Signature By Authorized •a8 a$ SQe0R u k— k(O Officer or Agent of Vender ADDRESS t3ENUE&Ic-O Baal) TITLE`Dtrec-c'DR DATE 3 lag It 6 PHONE# `,7i6rS X56 -9y �3o The above bid is subject to Terms and Conditions as attached hereto and incorporated. Page 1 of 41 Bid 002-05 (RFP-FYC-06005) Attached A LIFE SKILLS 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 \r BID 002-05 (06005) • NAME OF AGENCY: `I IC1 4 ' �bRDeI�o 1 PsYD )�•e ADDRESS: 2E SpgiR 81-vd. / Uvv7± tt% Dengue( t C0�°Zl ) PHONE: 3 c33 -tts 55-c19 CONTACT PERSON: IC1OR Go RIDER CD TITLE: 'T9tt-rt9 DESCRIPTION OF FAMILY PRESERVATION PROGRAM CATEGORY: The Life Skills Program Category must provide services that focus on teaching life skills designed to facilitate implementation of the case plan by improving household management competency,parental competency,family conflict management, effectively accessing community resources,and encouraging goal setting and pro-social values. 12-Month approximate Project Dates: _ 12-month contract with actual time lines of: Start .Lune 1.2006 Start End May 31, 2007 End �o TITLE OF PROJECT: LcESKAIS VPICMORiY0 /1�is'IATr�1 tetior E{. CPRpE2° / tc n.4k. 3 WI it" Name and Signature of Person Preparing Document Date ludy A.Griego, Director 3'2'9 1 O (o Name and Signature Chief Administrative Officer Applicant Agency Date MANDATORY PROPOSAL REQUIREMENTS For both new bids and renewal bids,please initial to indicate that the following required sections are included in this Proposal for Bid. Project Description Target/Eligibility Populations . Types of services Provided 7 Measurable Outcomes / Service Objectives / Workload Standards / Proof of Collaboration / Evidenced-based Outcomes 7 Staff Qualifications Unit of Service Rate Computation / Billing Process / Program Capacity per Month Certificate of Insurance Assurance Statement Page 29 of 41 Bid 002-05(RFP-FYC-06005) Attgched A Date of Meeting(s)with Social Services Division Supervisor.$/4 /6 Comments by SSD Supervisor: 7 U ao G'-CJ,f et ile6 wml r 3/o -‘, Name and Signature of SSD Supervisor Date Page 31 of 41 Victor H. Cordero,Psy.D. Life Skills RFP-FYC 06005 Bid 002-05 (RFP-FYC-06005) Category: Life Skills Project Title: Mentoring, Visitation, Therapeutic Visitations Vendor: Victor H. Cordero, Psy.D. 1 Victor H. Cordero,Psy.D. Life Skills RFP-FYC 06005 I. PROJECT DESCRIPTION This project is designed to provide culturally and linguistically competent mentoring, visitation, therapeutic visitation, and parenting instruction to parents involved with Weld County Department of Social Services. The project will provide highest levels of competence in the execution of all services and provide parenting time visitation in a context that is congruent with ethical standards. The program is designed with the goals of optimizing parental strengths, enhance parent-child bonds, modifying negative parenting behaviors, and providing interventions that are best suited to each family's individual needs. Observational, in-vivo, didactic, experiental and video format will be utilized to optimize appropriate and healthy parenting skills and increase positive family dynamics. 2 Victor H.Cordero,Psy.D. Life Skills RFP-FYC 06005 II. TARGET/ELIGIBILITY POPULATIONS A. Total Number of Clients to be served: 30 minimum B. Total individual clients and the children's ages: 30 clients minimum, infant, elementary school age, and adolescence. C. Total Family Units: 10 minimum D. Sub-total of individuals who will receive bicultural/bilingual services: 60% E. Sub-total of individuals who will receive services in South Weld County:30% F. Monthly maximum program capacity: 10 family units G. Monthly average capacity: 5 ongoing family units H. Average stay in the program: 12 weeks I. Average hours per week in the program: 4 hours per client/family unit J. Cultural/ethnically specific services: Latino, Hispanic, Bilingual/Spanish K. Service to South Weld Count Clients: Services available in Firestone, Frederick, Ft. Lupton area. 3 Victor H. Cordero,Psy.D. Life Skills RFP-FYC 06005 III. TYPES OF SERVICES TO BE PROVIDED A. Visitation: Parenting instruction, therapeutic visitation, and parenting assessment 1. All spectrum of parenting related interventions are intended to provide parents the environment, and interventions necessary to reach the general goal of improving parenting related behaviors and preserving the potential for unrestricted parenting or reunification. a. Instruction and parenting supervision will be designed to produce useful parenting related changes which will teach and model adequate or ideal parenting skills, teach relational skills, encourage goal setting and pro-social values, and plan structured activities in visitation to help achieve the objectives of the treatment plan. b. Clinicians will monitor parent/child interactions for physical and emotional safety issues, and document clinical observations. Clinicians will make all reasonable efforts to collaborate and communicate with Social Workers by personal contact, telephone contact, or via written report. c. Reports will clearly state methods utilized, contacts made, concerns, results and recommendations relevant to the reason for referral. d. Feedback will be made regularly available to the parents or other relevant parties in congruence with ethical standards and practice. e. Techniques utilized will be varied and tailored to the parent/families individual needs, to include specific modifications on the length of visits, mode of intervention, mode of feedback/rehearsal, and manner of presenting didactic information to the parent/family. 4 Victor H. Cordero,Psy.D. Life Skills RFP-FYC 06005 IV. MEASURABLE OUTCOMES Improvement of household management competency and parental competency will be measured by pre and post assessment instruments and documented behaviorally based observation and assessment. Parents and families will be encouraged and will be expected to identify, utilize, and build relationships with additional resources in the community at all levels of government. Families and participants receiving Life Skills interventions will receive quality and effective services such that they will remain intact six months post discharge and will display improved competency as well as a reduction in overall risk. All measures will be assessed via pre and post assessment utilizing instruments designed to assess parent-child relationships, family functioning, and risk/abuse/neglect potential. 5 Victor H. Cordero,Psy.D. Life Skills RFP-FYC 06005 V. SERVICE OBJECTIVES Mentoring The primary objectives of this program are to provide sound, ethical, practical, effective, bilingual, and culturally competent interventions to improve/enhance parenting skills and family interactions. Improvements in the areas of parent-child dynamics, child management, safety issues, bonding and attachment, emotional growth, and general parent-child/family communication are anticipated The program will provide parents with an improved capacity for household management, evidenced by parents providing a safe household environment for their children through competent cleaning and maintenance of the home, budgeting, responsible purchasing, and appropriate leisure activities. Parental competency will improve by means of increasing the parents use of adaptive strategies, establishing and maintaining appropriate relationships with their children, and by providing care, nutrition, hygiene, discipline, protection, instruction, and appropriate supervision. Parents and families will also enhance their capacity to function as an independent goal setting mechanism, espousing prosocial values. Visitation Parents will improve parenting skills, parent-child interactions and relationship skills through documentation of structured activities as a means of achieving the objective of the treatment plan. Parents/families will improve goal setting abilities and improve the behavioral manifestation of pro-social values. 6 Victor H. Cordero,Psy.D. Life Skills RFP-FYC 06005 Mentoring & Visitation Services Families will improve in their ability to access resources by means of acquiring this knowledge and competency through education. Services shall be directly related to the referral issues specified by WCDSS and will incorporate a solution focused approach. Families will complete pre and post intervention assessments which will be utilized to assess levels of integration and behavioral competency of the desired parenting, family dynamic, and life skill related behaviors. Service objectives will be measured and evaluated by: direct behavioral observation, incident report frequency, and pre/post assessments of functioning. 7 Victor H. Cordero,Psy.D. Life Skills RFP-FYC 06005 VL WORKLOAD STANDARDS The program will provide 10 hours per week, to include up to three clinicians providing these services. The maximum caseload per worker will be 4 ongoing clients per week. Modality of treatment interventions will be in-vivo parenting instruction or mentoring at the clinicians office, visitation center, or The Department, including Greeley, Ft. Lupton, and South Weld County Annex offices on request. Maximum caseload per supervisor will be 5 ongoing and active cases. 8 Victor H. Cordero,Psy.D. Life Skills RFP-FYC 06005 VII. PROOF OF COLLABORATION A. Housing Referral Contacts: Weld Housing Authority Public Housing/Tax Credit Housing/Housing Rehabilitation Program 315 N. 11th Ave.,Bldg. B Greeley, CO 80632 Marsha Gringstead —970-346-7660 Yvonne Benavides— Section 8 Catholic Charities Northern—Plaza del Sol/Plaza del Milagro 2500 1g Ave. Greeley, CO 80631 John Moore—970-378-1171 Island Grove Village Apartments 119 14'"Ave. Greeley, CO 80631 Craig Allen -970-356-2808 B. Job Service Referrals: Rocky Mountain SER/Jobs for Progress 822 7`" St. Suite 12 Greeley, CO 80631 Alvina Derrera—970-353-9251 Dislocated Worker Program 1551 n. 17th Greeley, CO 80632 Walter Speckman—970-3535-3800 Weld Human Services Employment First Dora Lara—970-353-3800 C. Methods to assure collaboration: 1) Obtain releases of information at the time services are rendered 2) D. Routine collaborative communications: 1. Provider will be available for meetings at any designated office with any/all members of the treatment/management team and/or family members. 9 Victor H. Cordero,Psy.D. Life Skills RFP-FYC 06005 E. Collaborative efforts for step down: Provider shall identify and make appropriate referral and transition to step-down agency once services are no longer provided by this provider. F. North Range Behavioral Health Provider is Medicaid eligible. 10 Victor H. Cordero,Psy.D. Life Skills RFP-FYC 06005 VIII. EVIDENCE BASED OUTCOMES A. Bibliographic information: (see attached bibliography) B. Fictional sample of assessment (see attached) C. Fictional sample of monthly report(see attached) 11 Victor H. Cordero,Psy.D. Life Skills RFP-FYC 06005 IX. STAFF QUALIFICATIONS A. All staff providing direct services will have at least the minimum qualifications in education and experience to provide competent and ethical services. Psychologists will be licensed in the state of Colorado, be eligible for licensure, or evidence competence in the area of service delivery. All non-licensed clinicians will be directly supervised by a licensed clinical psychologist and the psychologist will sign off on all documents provided to Social Services. B. Total staff number available: Up to 3 C. Staff will receive and comply with any training required by Social Services and with expected professional development in the field. D. All staff will have knowledge in risk assessment. E. Staff providing bilingual (Spanish) services will demonstrate adequate levels of linguistic and cultural fluency. 12 Victor H. Cordero,Psy.D. Life Skills RFP-FYC 06005 X. UNIT OF SERVICE RATE COMPUTATION See attached budget sheet 13 Victor H. Cordero,Psy.D. Life Skills RFP-FYC 06005 XL BILLING PROCESS A. Description of Billing Process Narrative: As a general rule, billing for services occurs after product (report, monthly summary, progress notes, etc.) are delivered to WCDSS and/or referring caseworker. Billing involves completion and delivery of the following: signed client verification form, copy of report/summary and recommendations, request for payment authorization form and/or project report form, and authorization for contractual services form. All with original signatures when required. Billing will be delivered by deadline of the month following completion of services. B. Fictional Sample of Monthly Billing See Attached Sample 14 Victor H. Cordero,Psy.D. Life Skills RFP-FYC 06005 XII. LOWEST QUALIFIED BID(S) See attached budget sheets 15 F. - In .O 8 § a a § a \ © 7 §; - - en \ B� CD C ! a 0. m m •f \ 49 # a 1.41 \ m - 49 / 2 ` S { 4- a \ 2 \ 5 - ; @ a w @ \ § § f § on , ( & � , F § 7 I- 2 b " 0 2 E § ■ % / \ \ tij w 0 / o o g y — » < a § § [ 2 E 7 ( o w 5 § + _ w < a s co cc e 2 - 5 u. § CO § 2 ( 2 / § § re F- 0 —ce � o0 0 cc a §w k a k 3 ( ( § k § § o 0 0 g & = e E h . @ \ c o < o 103 CO o � co o O w w co 0 § > 8 / ) 2& 2 ) o = co 0 Cl) § CO — § o - ) CO§ § » § § & § § k d < [ ( r § § " it w - w co § 1- § cc wa ce \ ca m \ § /111 k < § E Cr- \ § ( [ k CO [ k ( CO / [ 2 ) < A /$ § CC M WI- 0 CO cc § Ct Win I CO D CC O CO 2 = o = I a § $ e ± S 2 § g [ • k / / -J co -J § 3 -J k / k � ( § . E 0 0 0 OO 2 < > p < 0 R & R OO ! < CO 0 OWL!. o r _ Y g 8888888888$888 8 888888 8 8 ||f 8288882882888g / $gage; f | ( O '■,| , " ! ! n § 4 ; | \PiaI ! ■ ■ ■ 'I 88;88888888888 n 888884 8 n 8 ||7 agngaggggasag | !!aa»g | \ 0 ; ; » „• | " 8 § 0 *5 8 , tE , # ! • i . |,g 88888888828888 / 888888 8 7 P| ■ a ■ ■,| z - | § § *5 8 8 §o| ( ! 88888888888888 8 888888 8 8 i , 888228288888 r882288 ■ ■ |; (n2 ; »g . . „* ! g 8 § ■ || g - § 8 ) ■ ; 2 o §§ FM222222,,,, ,§2222 W $8288888888$88 8 $$ 8 8 © li- . t§I|gggaag;»„ ; i| § § I- ■� 6 " ! k |E !§k# f!.1 4§., . ; ||E 8888 ik § � . 0- 0 . It Lail 0 2 0 _ E | E | _ � � ) of Ili | E \_ a a - a , ___: | p § § . - /▪ 0 -�\k\ 2 )/ § 0 r 88888888888888 8 8888888 8 ,§ gagaaagggggga. g as;=a.a e ) � 0 `ii | anX 2 ° `r 88888888888.8 ^ $888888 R 88 aa■a■a;a;a,.■a § mgaa„e , gelI a a ` ° a /28 : ; 8 S \ • / g 84-888888888888 ® as#„as 6- )-22 ■§;;;ga&a;;;aa § ;;gaga; ! a!/ a a a 0.8 § 8 8.8 § § k | IV ! ®at : . 28888888888888 , 8888888 k ,aaseaa;aaaae. , �aa;a;t4 # a,= ; - a ; ! ILI Veil % \ - ® | •§ k ) � k ( ® ) §| !,.zzzzzzzzzzz , zzzz a ` - 6'10;88.8888888S 8 w $ m § !|| n7aea;.aaasae = . # ! o ■ &a; & - • i ec f|[ )§ h !!§ sk 0 0 $ } ■ k ■ -at• ) z � k � < - & CC | § k 0 i ) E . of al § § ) i #�- z▪ z �'F � , . 8 888 or § - . ) kkk \\ k 0 - o § �E 888888888888888888 8 8 8 as■n;;aagaaa.a.a#k s g 2 K \| ( a ; |- ' §, §/ ; 888888888888888888 • $ $ ®■ "122 "Sa;aaa»ag ; a ; k �| a a .7. - , k| |;f eNry ;k ■ ■ 88888888888888$888 $ 8 $ § §I § , a a §■laga;aaaasaaaa», | g § x || r - a ' ` ` i §& 2 r §l 888 � §| 660 § $$$$888$88888888$8 8 8 8 $ \ ° || 4 #!■»k■gsgaagak■■,a # a , az. .. a a a 2° w ||§ 2 Co 0 §% 4@§§222222222222222 I ■r ■S8 8 $ § |§ | | i | a | I ■ ! z i & § & o o g to 0 ) | k 22 | . zz i0 � \ ) � g � §|\/ ,4 ,48 - RED R § § • EVIDENCE BASED OUTCOMES ATTACHMENTS FOR SECTION VIII Bibliographic information Fictional sample of assessment Fictional sample of monthly report BIBLIOGRAPHY SAMPLE FAMILY THERAPY/VISITATION RELATED Dolam Y 2003 Solution-focused Brief Therapy: Its Effective Use in Agency Settings Te iPichot Haworth Press Berg I K George E 1992 Family Preservation A Brief Therapy Workbook BT Press Berg, I.K., & Kelly, S. 2000 Building Solutions in Child Protective Services. W.W. Norton&Company,. Berg I K 1994 Family Based Services A Solution Focused Approach WW Norton Furman B Ahola T 2001 Hosting Therapeutic Conversation BT Press Gabel, Stewart. 1992. Behavioral Problems in Sons of Incarcerated or Otherwise Absent Fathers: The Issue of Separation. Family Process 31 (September) : 303-314. Kuehl B 1995 The Solution Orientated Genogram; A Collaborrative Approach Journal of Marital and Family Therapy Vol 21 No 3 239-250 Lee, M. Y. (1997). A study of solution-focused brief family therapy: Outcomes and issues. The American Journal of Family Therapy, 25, 3-17. Wright, Lois, and Cynthia Seymour. 2000. Working with Children and Families Separated by Incarceration: A Handbook for Child Welfare Agencies. Washington, D.C.: Child Welfare League of America Press. Children/Visitation From the office of: 2828 Speer Blvd., Unit 118 Victor H. Cordero, Psy.D., P.C. Denver, CO 80211 Licensed Clinical Psychologist Office (303) 455-9480 Fax (303) 651-3773 Impressions Summary Report Supervised Visitation 01/11/2006 Regarding a Children: A,B, C,D, E Visiting Parents: Y & Z WCDSS Case Worker: Billy Jean HH#: 12345 Date Range of Summary: 10/19/2004 - 01/11/2005 Number of Supervised Visits Included in this Summary: 12 Duration of Visitation Time, per episode: 2 Hours Observations & Narrative of Impressions: Supervised visitations are notable for various factors, both positive and negative. These will be discussed as they relate to the original reason for referral, WCDSS concerns, and issues identified during supervised visitation time. This summary is intended to provide succinct observations of notable negative dynamics requiring further attention only and will be noted as these are relevant to each of the children. A This clinician has consistently observed A in the parent role during visits. The latter can present as positive given her age and status in the family, and as such, reflects caring behaviors, nurturing behaviors and episodes of providing guidance to her younger siblings. A can demonstrate a connectedness to her siblings which reflects a high level of care and protectiveness of them. Unfortunately, she has been placed in this situation artificially and may become overwhelmed with these demands when one considers she is also facing the challenges of essentially, single motherhood and is struggling with the issues of blurred boundaries in her family of origin. This clinician observed a concerning trend by A to verbally externalize her anger and frustration toward her circumstance, and her mother during visits in short bursts. As such, these instances of inappropriate comments suggest A continues to experience emotional upset at her situation and parents. B_ B evidences various behaviors suggesting the presence of resiliency and potential. He is clearly familiar with the problematic dynamics of his family, yet functions most often as the logical, and calming force in contrast to A's more emotional approach. As with A, B also evidences a tendency toward functioning in the parental role toward his siblings, though to lesser degrees as he often waxes and wanes between the parentified older brother, and a more domineering and critical teenager in his verbalizations toward them. 1 ChildrenNisitation Fortunately, B most often shuts down or calms situations which raise emotional levels between family members and A in particular. It should be noted that one consistent pattern which surfaced and is noted above is that of A and B's tendency toward the"parent role". While they clearly appear to be familiar with these demands in the household, their maturational levels and skills often results in what appears to this psychologist to be a somewhat cutting and cruel mode of intervention with their siblings. Of most importance is the relative absence of the grandparents clear assertion of themselves in the adult and essential parent role (thus eliminating A and B's need to intervene). Examples of the latter include that of allowing the older siblings to institute verbal disciplinary action as the grandparents observe. While in some instances this is appropriate, often potentially hurtful words and intervention styles utilizing insults or derogatory terms are implemented by these older siblings. C "C 's" behaviors and dynamics manifest in two distinct modes. On the one hand, she can present as a silly, talkative and jovial girl, giggling frequently and discussing appropriate family matters. On the other, a drastically different presentation can be observed and manifests as a sullen girl apparently yearning for attention which is most often not provided during these episodes. Interestingly, when C presents in this negative manner, she is most often ignored, as if the family perceives this dynamic as a normal episode. However, she has been observed to at times spend the entire two hour session without much interaction and appearing sad, with no effective attempts by family members to connect with her. As such, she is also the most frequent target of the older siblings verbal negativity and derogatory interactions which appear hurtful to her but again, receive no intervention from the grandparents. D&E These two young boys are discussed in combination consequent to the large similarities in their presentation and lack of overtly salient issues during visits. Interestingly however, during the last two visits, in which the older siblings were not present, these boys evidenced more age appropriate play, verbalizations, and affect. They appeared more relaxed and content, and were able to assert themselves in the attention they sometimes lacked when the older siblings are present. While the etiology for this observation is uncertain, the discrepancy in this behavior is apparent. Additional Observations & Impressions During one visit in which biological mother was present, an interesting dynamic surfaced and reflected what may represent less than ideal functioning between adults. The particular incident, while isolated, appears relevant given past issues of concern in family boundaries. Specifically, this incident involves E becoming upset, requiring biological mother to soothe and coax him from behind a sofa. While her intervention was felt to be highly appropriate in manner and approach, grandmother intervened with negative comments about no longer coming to visits if the child was upset, and later stating that the mother"babied" the children too much. While this may reflect differences in 2 Children/Visitation preferred parenting style, the discrepancy is significant and is suggestive of potential covert contention between these adults and is thus worthy of verification. In addition, it is worth noting the potentially confusing and uncomfortable repercussions of the children's biological mother with the children's great great grandfather. This point it noted again in light of the ill feeling projected by A in response to this circumstance and the likely trickle down this situation has on the siblings as well. It would appear that the latter circumstance has not been addressed or resolved effectively, if this is possible. In light of the above areas of concern and potential barriers to healthy family functioning, it is important to identify dynamics in this family from a strength based perspective as well. There is clearly a great deal of affective connection between siblings and adults. In addition, as noted above, siblings evidence a good capacity for caring behaviors when they choose to implement these, including expressions of affection, and a protectiveness of each other that is robust. The commitment to the family system is greater than individual relationships and as such, can be utilized as a culture based catalyst for change and positive growth during future therapeutic interventions. It is also evident that the grandparents are clearly committed to these children and their struggles in the past may in part reflect their strife to function as grandparents rather than authoritative parents. The struggle from this psychologist's perspective does not rest on whether or not the family and grandparents have the resources to implement change, as the potential is present, but whether family members will choose to adapt in the interests of a future healthy, and unified family system. General impressions, based only on the information made available to this psychologist and these twelve visitation sessions, identify the following as primary areas of ongoing concern and needed improvement. 1) blurred generational boundaries, 2) parentified behaviors in the children, 3) limits in empathy and poor communication between family members, and 4) maladaptive reactions to a surely confusing and upsetting home situation. As such, this psychologist perceives that the following interventions are warranted. Recommendations This psychologist recommends that the current supervised visitation format be modified to a therapeutic visitation format. Goals to incorporate would include but are not limited to the following: Improve the family's insight regarding unhealthy or hurtful dynamics and interactions(both verbal & behavioral) Improve the family's insight specific to the issue of the current blurred generational boundaries and the impact on family functioning. Improve the clarity of generational boundaries via interventions. Identify and clarify family member roles. 3 ChildrenNisitation Improve the qualitative nature of family communication and relatedness. Ideally therapeutic visitations should be complemented with family therapy sessions with the adults involved as necessary to address adult only themes and discussions, or to address issues between certain identified family members. Efforts to assure that C is receiving consistent therapeutic sessions on an individual basis should be pursued. Professionals involved should assess whether or not the remaining children may benefit from individual, short term counseling(depending on their coping to date)to assist in adjusting and integrating the dynamics which will be discussed in therapeutic visitation. This psychologist perceives that at this point in time, there remains potential for reunification in some form and that efforts to implement higher level therapeutic interventions with the family is warranted. Please contact this evaluator with further questions or clarifications. Victor H. Cordero, Psy.D. Licensed Clinical Psychologist 4 X family Visitation January 2005 From the office of 2828 Speer Blvd., Unit 118 Victor H. Cordero, Psy.D., P.C. Denver, CO 80211 Licensed Clinical Psychologist Office (303) 455-9480 Fax (303) 651-3773 Impressions Summary Report Supervised Visitation January, 2005 Regarding X Children: A, B,C,D, E Visiting Biological Father: Z WCDSS Case Worker: Billy Jean HH#: 12345 Date Range of Summary: 01/25/2005 Number of Supervised Visits Included in this Summary: 1 Duration of Visitation Time, per episode: 1 Hours Observations & Narrative of Impressions: This is the first visitation with father alone at WCDSS visitation. A made a homemade meal for the visit and all siblings are excited about the food. Father asks the children about school informally. D& E begin to ask dad about what they want to do when they go home. Father responds, "yeah but it might be some time". B asks father where he is staying and a questionable conversation about past episodes of dad his losing his license and a time when the children's mother was hiding in the back of a car from police ensues. Other questionable themes are observed throughout the session including episodes of past legal involvement, unhealthy lifestyle etc. Father's relatedness appears more peer like in content and style. Interestingly, the relationship appear mutual as A in particular speaks to father in a peer tone when upset. She raises her voice to him and give commands without recognition of the normally expected boundaries. These dynamics appear to reflect the norm in this family. This was the only contact with this family this month. Please contact this evaluator with further questions or clarifications. Victor H. Cordero, Psy.D. Licensed Clinical Psychologist 1 SAMPLE MONTHLY BILLING (pertaining to section XI) 5310.213(2/79) COLORADO STATE DEPARTMENT OF SOCIAL SERVICES AUTHORIZATION FOR CONTRACTURAL SERVICES 1. WELD COUNTY DATE: 3 J ZS ) O 6 2. R A . QC)RD€0 B1 ' ) r Q . Name of Provider 1�7� 3. a az 8 S?EER 151_J . , At 1 i Address---m CO g©a\ 1 el e=.frvuE-i2, a. City, State, Zip THE DESCRIBED SERVICE IS AUTHORIZED FOR THE CLIENT INDICATED: 5. —3".: O-E- prA'NN41c Name of Client Household# Cat. Cat Grp. \� \Z3�1S 6. Y 151-1 -tt0V3 Description Sv.Code 7.APPROVAL: NG C 3(-24.c 1 Z3 Caseworker Date Co.Director or Supervisor 8.TO BE COMPLETED BY PROVIDER DATE OF SERVICE 2, i I S ` 2- I - a i) 2 / Z"S- CHARGES$ 3 3 n I CERTIFY THE SERVICE AUTHORIZED WAS PROVIDED ON THE DATE INDICATED AND THE CHARGES ARE MADE PURSUANT TO A BONA FIDE CONTRACT BETWEEN ME AND THE COUNTY DEPARTMENT OF SOCIAL SERVICES INDICA R1b\IA 4 eQ,,,,-,,cs :I-0 Provider Signature Iate-3/2,040 6 Prepare in Triplicate,Original and One copy to Provider,One Copy for Pending File. Completed Provider's Forms-Original to County Finance Office-Copy to Case Record • oa NP, u m to -n y o u Z a a o 2 0 :aaaiw E % v OS 44:'3 % M C oo m es O u q % % a Q a PE Z E o C rnn CUw E x N u T`Si: rp a m 00 V Ta el :16 T a Hp� % O o u . W U v d4 0 % o �aj u W U Ta W Or 44 S 0 0 N w' A N F ,� x u o ,..-.1 WA `^ a o a 0 • 0 rasa :4_.; Or, m 0 a o 0 0 o a ' 4:• F «, Upgs P4 Y..' — u u0• 8' 4.) - 0 � tiia � 3wF 2 a tea WU a O9. 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C/O: American Professional Agency, Inc. 95 Broadway, Amityville, NY 11701 This is to certify that the insurance policies specified below have been issued by the company indicated above to the insured named herein and that, subject to their provisions and conditions, such policies afford the coverages indicated insofar as such coverages apply to the occupation or business of the Named insured(s) as stated. THIS CERTIFICATE OF INSURANCE NEITHER AFFIRMATIVELY NOR NEGATIVELY AMENDS, EXTENDS OR ALTERS THE COVERAGE(S) AFFORDED BY THE POLICY(IES) LISTED ON THIS CERTIFICATE. Name and Address of Insured: Additional Named Insureds : VICTOR H. CORDERO, PSY.D 2828 SPEER SUITE 118 DENVER•, CO 80211 p Type of Work Covered: PROFESSIONAL PSYCHOLOGIST Location of Operations : N/A (If different than address listed above) Claim History: Policy Effective Expiration Limits of Coverages Number Date Date Liability PROFESSIONAL/ 1, 000,000 LIABILITY 008-1764838 10/01/04 10/01/05 3, 000, 000 NOTICE OF CANCELLATION WILL ONLY BE GIVEN TO THE FIRST NAMED INSURED ON THIS POLICY AND HE OR SHE SHALL ACT ON BEHALF OF ALL INSUREDS WITH RESPECT TO GIVING OR RECEIVING NOTICE OF CANCELLATION. Comments : This Certificate Issued to: Name: VICTOR H. CORDERO, PSY.D 2828 SPEER Address: SUITE 118 T` DENVER, CO 80211 Au orized Representative • ` S i yy�,> N A .....:..-.. CC : . X1'6 w P EXHIBIT B SUPPLEMENTAL NARRATIVE TO RFP • 05/22/2006 10:45 3036513773 DR. V.H. C0RDER0 PAGE 01/06 Victor H.Cordero,Psv.D. From the office of: 2828 Speer Blvd.,unit 118 Victor H.Cordero,Psy.D.,P.C. Denver,CO 80211 Licensed Clinical Psychologist Office (303)455-9480 Fax(303)651-3773 May 19,2006 Weld County Department of Social Services ATTN: Gloria Romansik RE: Bid 06M1105 (RFP 006-00)Mental Health Services Bid 06LS08 (RFP 05005)Lifeskills I have initiated the process of obtaining the additional information or documents as requested to complete the RFP's identified above. I have made contact with the agencies identified to provide collaborative services as well and anticipate receiving these letters promptly. I can enclose one letter from the housing authority,though I noticed both my last name and degrees are incorrect I will include a corrected copy as soon as possible. I have included the other condition/compliance items requested in other areas of the RFP in this transmission. I hope these suffice and would be happy to correct or provide addendums if these are not complete. Thank you. Sincerely, Victor H. Corriere,Psy.D. Licensed Clinical Psychologist • 05/22/2006 10:45 3036513773 DR. V.H. CORDERO PAGE 02/06 RE: Bid 06M1105 (RFP 006-00) Requested Conditiops: Provide clarification of licensing of professionals conducting psychological and other evaluations under the bid proposal. Response:Evaluations will be completed and signed by a licensed clinical professional. At this time, a licensed clinical psychologist will provide such services. 05/22/2006 10:45 3036513773 DR. V.El. CORDERO PAGE 03/06 RE: Bid 06LS08 (RFT 06005) Requested Condition Identify staff qualifications Note: At this time,there is only one staff member(licensed clinical psychologist). However, below are the qualifications which will be required to engage in future employment with this agency. Any staff providing such services will be qualified by means of competence,and experience working with children and families. Staff members will have a clinical background and will receive ongoing supervision from a licensed clinical psychologist. These staff members backgrounds will reflect obtained degrees in psychology,behavioral health,and mental health. Training and education will be commensurate with job demands. Work experience and education will specifically reflect mental health and visitation experience, family therapy, child development and child therapeutic services. High emphasis for any staff member will be plarpd on ethical and competent delivery of services. 05/22/2006 10:45 3036513773 DR. V.H. CORDERO PAGE 04/06 RE: Bid 06MH05(Mental Health)&Bid 06L808 (lifesltills) Requested Compliance Item Letters to provide proof of collaboration with County Housing and Employment Training. Housing Authority: Obtained and attached letter,though a minor solution needs to be made and will resubmit with accurate information. Employment Services:Have made contact with Ted Long regarding the collaboration letter. I anticipate receiving this letter shortly and will forward it as soon as it is obtained. 05/22/2006 10:45 3036513773 DR. V.H. CORDERO PAGE 05/06 RE: Bid 06MH0S(Mental Health)& Bid 06LS08(lifesldlls) Requested Compliance Item Facilitation of Medicaid eligible client's capacity to receive mental health related services at North Range Behavioral Health. Medicaid Eligible clients requiring additional mental health related services will begin steps to initiate securement of such services. Protocol: -Clients will be provided with all contact information for NRBH. -Clients will have the option of signing a release of information to facilitate exchange of data and referral information with NRBH. -If a release is obtained, a formal referral for services can be transmitted via fax, mail,and/or by means of a telephone communication with NRBH case manager. -When possible, a first appointment will be scheduled(if available from NRBH) and will be provided to the client This information will also be relayed to the WCDSS caseworker to assist in follow-up. 05/22/2006 10:45 3036513773 DR. V.H. C0RDER0 PAGE 06/06 05/18/2006 10:43 FAX 670 346 7690 GREELEY/VELD HSR AUTH hgooz/vvz Rt3REELEY/ WELD HOUSING AUTftORI7IeS lit P.Q. Box 1.30 sh Greeley, Colorado 80632.0130 (970) 353-7437 May 19,2006 (970) 3537463 Fax (800) 859-2656 TTY Relay Victor Cotdcia,MA.,LPC 2828 Speer Blvd.Unit 118 Denver,CO 80201 Dear Mr.Cordcio: As a Housing Authority we would be glad to accept any appropriate referrals for clients needing our services from your office. if you sine awarded a contract to work with Weld County clients we will be agreeable to enter into a Memorandum of Understanding concerning the services provided by each agency. If you have any questions please contra me at(970)353-7437 ext 103 Sincerely, C G_e—e r Thomas Teixeira Executive Director iniHousing Authority of the city of Oveerey • Weir,County Housing Authority 905 6th Steel • Greeley, Colorado ,"�: 05/22/2006 13:15 3036513773 DR. V.H. CORDERO PAGE 01/03 Mf5 _ ...... __..... . .._..... From the office of: 2828 Speer Blvd., Unit 118 Victor H. Cordero,Psy.D.,P.C. Denver,CO 80211 Licensed Clinical Psychologist Office (303)455-9480 Fax(303)651-3773 Note: The material contained in this transmittal is confidential intended for the use and viewing of the below mentioned individual/agency only. If this transmission is received in error,please call the number above. Thank you. May 22,2006 Pages including cover page:3 Weld County Department of Social Services ATTN: Gloria Romansik RE: Bid 06MH05 (RFP 006-00)Mental Health Sex-vices Bid 06L508 (RFP 05005)Lifeskills I've just received the letter of collaboration from Employment Services and have included it with this transmission. I believer you have all documents requested from the RFP panel. Please contact me with any questions or clarifications. Jtoc4 . dr:� Victor H. Cordero,Psy.D. Licensed Clinical Psychologist • 05/22/2006 13:15 3036513773 DR. V.H. C0RDER0 PAGE 02/03 Sent by: HUMAN SERVICES 19703563975; 05/22/2006 2:54PM; @291; Page 2/3 (0‘ DEPARTMENT OF HUMAN SERVICES EMPLOYMENT SERVICES OF WELD COUNTY 1651 NORTH 17TH AVENUE PO BOX 1805 GREELEY.CO 80952 are)359.3800 FAX{970)359-3975 COLORADO May 22,2006 Victor H.Cordaro,Pay.D. PIC. Employment Services of Welt,County is providing you this letter outlining the areas of collaboration when a client you serve undei CORE service funds is identified as having an employment need. The collaborative areas were developed from your responses contenting the parameters you felt were practical,based upon the services you intend to provide. Victor H.Cordaro,Fsy.D.Pt.is proposing services to work with adolescents and families for psychological evaluations, child interaction evaluations,visitation,and family therapy services. It is unlutown if these service-4 have a direct relationship to employment,however,the following outlines the plan for referrals}when,or if,they arise: Case management Dr.Cord4ro agrees to provide ease management for families that may require the parent or youth to seek emplabenent For these individuals,Dr.Cordaro agrees to make a referral to Employment Services of Well County. Referral process,. For individuals identified as having employment needs,Dr.Cordaro will refer the Sian to Employment Servio4s of Weld County and will send an email to Employment Services,alder the attention of Linda Perez,stating that the client was referred.Dr.Cordaro agrees to forward the email within five business data of making the retinal. Follow UP: Dr.Cordaro williemail a follow-up concerning the referral made to Employment Services of Weld County to business days after sending the initial email. Employment Services of Weld County will email Dr.Cordea+h if the client does not contact us,and agrees to discuss the matter with the client at their next viMit. Dr.Cordaro will provide a written email of that discussion to the attention of Linda Perez within five bu31ness days. Cross timing: If new staff ate hired by Dr.Cordaro,they will be made aware of this collaborative arrangement and will be provided training concerning the employment and training services offered by Employment Services of Welb County. • 05/22/2006 13:15 3036513773 DR. V.H. CORDERO PAGE 03/03 • Sent by: HUMAN SERVICES 18709563875; 05/22/2006 2:54PM; 4281; Page 3/3 Sir collaborative areas: A$this time there are no additional collaborative efforts with Employment Services_ As additional areas of collaboration arise,Dr,Cordero agrees to include them in the Memorandum of Understanding discussions to be completed by February 1.2007. Employment Services will mid with Dr.Cordero in July 2Q06 to initiate the collaborative Memorandum of Understanding process once bids for CORE services are completed and accepted. Sincerely, f C((14-11:::6:--1,.Perm Director Employment Services of Weld County • 4 , { { } rs a DEPARTMENT OF SOCIAL SERVICES P.O. BOX A GREELEY, CO.80632 Website:www.co.weld.co.us ig - Administration and Public Assistance(970)352-1551 Child Support(970)352-6933 WI C. COLORADO May 15, 2006 Victor H. Cordero Psy.D. 2828 Speer, Unit 118 Denver, CO 80211 Re: Bid 06MH05 (RFP 006-00)Mental Health Services Bid 06LS08 (RFP 05005)Lifeskills Dear Dr. Cordero: The purpose of this letter is to outline the results of the Bid process for PY 2006-2007 and to request written confirmation from you by Monday, May 22,2006. A. Results of the Bid Process for PY 2006-2007 • The Families,Youth and Children(FYC)Commission recommended approval of Bid 06MH05 (RFP 006-00),Mental Health, for inclusion on our vendor list,attaching the following conditions. Your bid scored 98 points out of 100. Condition: You must clarify that only licensed professionals are to be involved in the completion of evaluations.Professionals can sign off on other medical health services,but the actual work performed is to be done by a Licensed Ph. D. or Psy. D. • The Families,Youth and Children(FYC) Commission recommended approval of Bid 06LS08 (RFP 06005), Lifeskills, for inclusion on our vendor list attaching the following condition. Your bid scored 92 out of 100. Condition: You must identify your staffs' qualifications. Compliance Item: For Bid 06MH05 (Mental Health)and Bid 06LS08 (Lifeskills)you must provide the required letters under the Collaboration Section from Weld County/Greeley Housing Authority, employment/training partners, and other partners as identified in the bidder's assessment of needs. You must identify the process you will utilize to facilitate Medicaid eligible clients receiving mental health services at North Range Behavior Health. Required Response by FYC Bidders Concerning FYC Commission Conditions: All conditions will be incorporated as part of your Bid and Notification of Financial Assistance Award (NOFAA). If you do not accept the condition(s),you will not be authorized as a vendor unless the FYC Commission and the Weld County Department of Social Services accept your mitigating circumstances. If you do not accept the condition,you must provide in writing reasons why. A meeting will be arranged to discuss your response. Your response to the above conditions will be incorporated in the Bid and Notification of Financial Assistance Award. Page 2 Victor H. Cordero/Results of Bid Process 2006-2007 The Weld County Department of Social Services is requesting your written response to the FYC Commission's conditions.Please respond in writing to Gloria Romansik,Weld County Department of Social Services,P.O.Box A,Greeley, CO, 80632,by Monday, May 22,2006,close of business.You may fax your response to us at 970.346.7698. If you have questions concerning the above,please call Gloria Romansik at 352.1551,extension 6230. Sincerely, Jo A. 'e o,Direct cc: Juan Lopez, Chair,FYC Commission Gloria Romansik, Social Services Administrator Hello