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Home My WebLink About20061586.tiff RESOLUTION RE: APPROVEFIVE NOTIFICATION OF FINANCIAL ASSISTANCE AWARDS FOR MENTAL HEALTH SERVICES WITH VARIOUS PROVIDERS AND AUTHORIZECHAIRTO 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 five Notification of Financial Assistance Awards for Mental Health Services between the County of Weld,State of Colorado,by and through the Board of County Commissioners of Weld County, on behalf of the Department of Social Services,and various providers, listed below,commencing June 1,2006,and ending May 31,2007, with further terms and conditions being as stated in said awards: 1. Barry Lindstrom, Ph.D., LLC 2. Victor Cordero 3. Jack Gardner, Psychologist 4. Transitions Psychology Group, LLC 5. Individual and Group Therapy Services 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 five Notification of Financial Assistance Awards for Mental Health Services between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Social Services, and various providers listed above, be, and hereby are, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said awards. 2006-1586 SS0033 OP '. SS -7/ 40 FIVE NOTIFICATION OF FINANCIAL ASSISTANCE AWARDS FOR MENTAL HEALTH SERVICES PAGE 2 The above and foregoing Resolution was,on motion duly made and seconded,adopted by the following vote on the 14th day of June, A.D., 2006 nunc pro tunc June 1, 2006. � BOARD OF COUNTY COMMISSIONERS EL4 to ELD COUNTY LORADO ATTEST: Lie/'//� ` ?� 11S2 eile, Chair Weld County Clerk to the B e W sfi �'- 1 ' �'David E. Long, Pro-Tem BY: � t ^fj�1k2C�: r D uty Cle to the Board l Will H. Jerke O AS TO FORM: \ Robert D. Mas oun Atto en Date of signature: to(0(0 2006-1586 SS0033 **CORRECTED** (7e s iall;Nsts DEPARTMENT OF SOCIAL SERVICES P.O. A BOX GREELEY,CO. OX80632A Website:www.co.weld.co.ns Administration and Public Assistance(970)352-1551 Child Support(970)352-6933 O • COLORADO MEMORANDUM TO: M.J. Geile, Chair Date: May 31, 2006 Board of County Commissioners FR: Judy A. Griego, Director, Social Services_#14i4(,L \ RE: Notification of Financial Assistance Awards with Various Contractors— Mental Health Services Enclosed for your approval are Notification of Financial Assistance Awards with Various Contractors for Mental Health Services. The Department and the Families, Youth, and Children (FYC) Commission are recommending approval of these Awards. These Awards were reviewed at the Board's work session of May 24, 2006. The major provisions of these Awards are as follows: 1. The Award period is June 1, 2006 through May 31, 2007. 2. The source of funding is Core Services or Child Welfare Administration. 3. The Contractors will provide mental health services for adults, youth, and children involved in the child welfare system. 4. The Contractors include: A. Barry Lindstrom, Ph.D., LLC $1,800 per episode psychological examination $600 per episode other/termination hearing $900 per episode mental health assessment $2,400 per episode parent-child interaction $600 per episode treatment—low $600 per episode treatment—moderate $600 per episode treatment—high $300 per hour treatment— high $150 per hour care coordination $175 per hour court testimony B. Victor H. Cordero $1,200.00 per episode psychological examination $600.00 per episode other services $1,200.00 per episode parent/child interactional $120.00 hourly rate court testimony 2006-1586 C. Jack J. Gardner $1,300 per episode psychological examination $900.00 per episode other services $1,600 per episode diagnostic services $100.00 hourly rate interactional evaluation $110.00 hourly rate parent/child interactions $150.00 hourly rate court testimony $100.00 hourly rate court preparation $100.00 hourly rate professional consultation $120.00 hourly rate individual counseling $120.00 hourly rate family counseling $100.00 hourly rate court facilitation, mediation, $1,800.00 other services (training) D. Transitions Psychology $282.62 hourly rate psychological examinations Group $110.89 hourly rate mental health assessments $150.00 hourly rate court testimony E. Individual & Group Therapy $39.44 hourly rate treatment package Services $100.00 hourly rate court testimony If you have any questions,please telephone me at extension 6510. Weld County Department of Social Services **C0RRECTED** Notification of Financial Assistance Award for Families,Youth and Children Commission(Core)Funds Type of Action Contract Award No. X Initial Award 06-CORE-55 Revision (RFP-FYC-006-00; 06MH04) Contract Award Period Name and Address of Contractor Beginning 06/01/2006 and Barry Lindstrom,Ph.D., LLC Ending 05/31/2007 Mental Health Services 3211 20 Street,#D Greeley,CO 80634 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Assistance Program provides diagnostic services to assist in the Award is based upon your Request for Proposal(RFP). development of the Department's family services The RFP specifies the scope of services and conditions of plans,and to assess family communication, award. Except where it is in conflict with this NOFAA in functioning and relationships. Monthly average which case the NOFAA governs,the RFP upon which this capacity is 10 open evaluations.Cultural/ethnic needs award is based is an integral part of the action. considered in evaluation process and in making Special conditions treatment recommendations; South Weld County 1) Reimbursement for the Unit of Services will be based on an access. Available for visitations at DSS Del Camino hourly rate per child or per family. or Fort Lupton offices. 2) The hourly rate will be paid for only direct face to face Cost Per Unit of Service contact with the child and/or family,as evidenced by client- Episode Rate Per: signed verification form,and as specified in the unit of cost Psychological Exam(adult or child) $1,800.00 computation. Other Services,(termination hearing), add $600.00 3) Unit of service costs cannot exceed the hourly and yearly Mental Health Assessment(up to 3 hours) $900.00 cost per child and/or family. Treatment Package 4) Payment will only be remitted on cases open with,and (psych eval after assessment),add $900.00 referrals made by the Weld County Department of Social Parent-Child Interactions Services. (first three members) $2,400.00 5) Requests for payment must be an original submitted to the Treatment Package Low Weld County Department of Social Services by the end of (Each additional member), add $600.00 the 25th calendar day following the end of the month of Treatment Package Moderate service.The provider must submit requests for payment on (With evaluation additional testing),add $600.00 forms approved by Weld County Department of Social Treatment Package High Services. (Termination hearings), add $600.00 6) The Contractor will notify the Department of any changes in Hourly Rate Per: staff at the time of the change. Treatment Package High $300.00 Care Coordination $150.00 Hourly Rate per Court Testimony (2 hr Minimum) $175.00 Additional charge for transportation* Enclosures: X Signed RFP: Exhibit A X Supplemental Narrative to RFP: Exhibit B Recommendation(s) X Cond. .ons of Approval Appr Program ffic. 1: a By By M.J.Geile, Chair r� Judy .Grieg irector Board of Weld Co tyL(9trnssioners Weld runty De artment of Social Services Date: Date: l e l ' a/0 C( —�t (91)O6-is86 INVITATION TO BID OFF SYSTEM BID 001-06(06005--06011 and 006-00, A, B,&C) DATE: March 1,2006 BID NO: RFP-FYC-006-00,A, B, & C RETURN BID TO: Pat Persichino, Director of General Services 915 10th Street,P.O. Box 758, Greeley,CO 80632 SUMMARY Request for Proposal (RFP-FYC-006-00,A, B, & C)for: Colorado Family Preservation Act—Mental Health Services Emergency Assistance Program Deadline: March 31, 2006,Friday, 10:00 a.m. The Families, Youth and Children Commission, an advisory commission to Weld County Social Services, announces that competing applications will be accepted for approved providers pursuant to the Board of Weld County Commissioners' authority under the Colorado Family Preservation Act(C.R.S. 26-5.5-101) and Emergency Assistance for Families with Children at Imminent Risk of Out-of-Home Placement Act(C.R.S. 26-5.3-101). The Families, Youth and Children Commission wishes to approve services targeted to run from June 1,2006,through May 31,2007,at specific rates for different types of services. The County will authorize approved providers and rates for services only. The Mental Health Services program provides diagnostic and/or therapeutic services to assist in the development of the family services plan,to assess and/or improve family communication, functioning and relationships. This program announcement consists of five parts, as follows: PART A...Administrative Information PART D...Bidder Response Format PART B...Background,Overview and Goals PART E...Bid Evaluation Process PART C...Statement of Work I�� Delivery Date 313 ° / l J L (After receipt of order) BID al-B1(IGNED IN INK Barry R. Lindstrom, PhD TYPED OR PRINTED SIGNATURE k VENDOR Barry R. Lindstrom, PhD, LLC rZL\-- ^�(Name) Hanwrittentgnature By Authorized Officer or Agent of Vender ADDRESS 3211 20th Street, Suite D TITLE Psychologist GREELEY, CO 80634 DATE 3171. PHONE# 970. 356. 31 00 The above bid is subject to Terms and Conditions as attached hereto and incorporated. Page 1 of 41 Bid 001-06(RFP-FYC-006-00,A,B,& C) Attached A MENTAL HEALTH SERVICES PROGRAM BID PROPOSAL AND REQUEST FOR CONTINUATION OF AWARD UNDER CORE SERVICES FUNDING EMERGENCY ASSISTANCE PROGRAM 2006-2007 BID PROPOSAL APPLICATION PROGRAM FUNDS YEAR 2006-2007 BID 001-06(006-00,A,B,& C) NAMEOFAGENCY: Barry R. Lindstrom, PhD, LLC ADDRESS: 3211 20th Street, Suite D, Greeley, CO 80634 PHONE(g7a 3x6-3100 CONTACTPERSON: BARRY LTNDSTROM, PHD TITLE: psychologist DESCRIPTION OF EMERGENCY ASSISTANCE PROGRAM CATEGORY: The Mental Health Services program provides for"diagnostic,and/or therapeutic services to assist in the development of the family services plan,to assess and/or improve family communication,functioning,and relationships.(Volume VII, 7.303.1,GI" 12-Month approximate Project Dates: _ 12-month contract with actual time lines of: Start June 1,2006 startJune 1 , 2006 End May 31, 2007 End _y 31 , 2007 TITLE OFPROJECT: Individual and Family (Interactional) Psychological Evaluations UAJNI..4_-cA_, Barry R. Lindstrom, PhD March 30, 2006 and Person Preparing Document Date Barry R. Lindstrom, PhD March 30, 2006 Name and Si ature 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. V-Project Description Target/Eligibility Populations 2- Types of services Provided AU Measurable Outcomes (� Service Objectives tt,k- Workload Standards k- Proof of Collaboration tI Evidenced-based Outcomes Staff Qualifications Unit of Service Rate Computation ttL Billing Process � Program Capacity per Month Certificate of Insurance PROP 10 n141 Bid 002-05(RFP-ITYC-06005) . • _.. • Attracted A • Date of Meeting(s)with Social Services Division Supervisor: 31,10(4 Comments by SSD Supervisor: ;-C n•ttic :4Ar% C,. L : .r,A Sac ry c�1�o , w�� r� Clueakio__ Scgnoad on 'MT Iota 4+ .Lam.€uktairen..n S.Nirk-- dL gnu tl.]or-i p1n_v rt tat, o-- ,-toc../c,._LA CW\.� 6244' 41 f Name and Signature SSD • ° Date • • • • • BARRY LINDSTROM, Ph.D., L.L.C- LICENSED CLINICAL PSYCHOLOGIST Page 31 of 41 3211 20TH ST., #D GREELEY, CO 80634 Barry R. Lindstrom, Ph.D., LLC Licensed Clinical Psychologist 3211-20th Street, Suite D Greeley, CO 80634 (970) 356-3100 March 30, 2006 TO: Weld County Department of Social Services RE: OFF SYSTEM BID 001-06 (0600--06001 and 006-00, A, B, &C) Request for Proposal BID NO: RFP-FYC-006-00,A, B,& C for: Colorado Family Preservation Act—Mental Health Services Emergency Assistance Program Project Title: Individual and Family(Interactional)Psychological Evaluations Vendor: Barry R. Lindstrom,Ph.D., LLC; Licensed Clinical Psychologist March 30, 2006 Attached A Page 2 BID 001-06 (RFP-FYC- 006-00, A, B, & C) Program Category: Mental Health Services Emergency Assistance Program Project Title: Individual and Family(Interactional)Psychological Evaluations Vendor: Barry R. Lindstrom,Ph.D., LLC; Licensed Clinical Psychologist L PROJECT DESCRIPTION The proposed project will provide diagnostic services to assist in the development of the Department's family services plans, and to assess family communication, functioning and relationships. This project will provide psychological evaluations for individuals (children, adolescents, and adults)and families(interactional and attachment assessments) as requested by Weld County Department of Social Services(WCDSS)and ordered by Weld County Courts. The goal will be to provide diagnostic information to the Department and Courts for treatment planning in order to meet current permanency planning goals and requirements to prevent out of home placement or provide for the timely reunification of children and families. This project does not provide psychosexual evaluations. Clients will be informed of the nature, scope and procedures of evaluation at the outset and their informed consent obtained in writing. Releases of information will be signed to obtain records from and allow consultation with the Department and all collateral sources and contacts. Evaluations will include clinical interviews, psychological testing, review of case records and consultation with collateral contacts(other involved professionals). Evaluations will be responsive to the context of the referral in the phase of the family's involvement with the Department and court process (initial D&N, progress in treatment, or review of permanency plans and goals)and address all questions outlined in the caseworker's referral (e.g., treatment planning and recommendations, placement and permanency questions). Individual evaluations will assess and summarize individual psychosocial functioning and diagnostic questions raised in the referral,in particular as it relates to issues(child or parent)that support or interfere with parenting or reunificication. Family evaluations will assess and summarize individual child and parent functioning and the attachment relationship and family interaction between family members that support or interfere with parenting or reunificication. All evaluations will be documented in and completed by a written report outlining: the referral questions; brief case history and context; evaluation procedures and findings; and conclusions and recommendations. Evaluation reports will address both strengths or protective factors, and risk factors or problems. Evaluations will be completed in a timely and professional manner following all state, federal and professional(American Psychological Association,APA)regulations and standards regarding confidentiality and professional standards for evaluations. March 30, 2006 Attached A Page 3 BID 001-06 (RFP-FYC- 006-00, A, B, & C) Program Category: Mental Health Services Emergency Assistance Program Project Title: Individual and Family(Interactional)Psychological Evaluations Vendor: Barry R. Lindstrom,Ph.D., LLC; Licensed Clinical Psychologist II. TARGET/ELIGIBILTY POPULATIONS A. Up to fifty(50) evaluations can be completed within the fiscal year depending on the needs of the Department. B. Family evaluations can be for any size family and include members of all ages. Individual evaluations can be for children,adolescents and adults of any age. C. This can include up to fifty(50) family units. D. All evaluations will be conducted in English with attention paid to any cultural or ethnic needs of the clients. E. South Weld County residents can access services through my office. I can be available to observe family interaction/visitations at the DSS Del Camino or Ft. Lupton offices. F. All clients and Department personnel have access to after hours' answering service. Evaluations will be conducted during office hours (8am to 5pm, Mon- Fri). I can also be available to attend evening appointments or Saturday visitations at CARE, LFS, etc. G. Multiple evaluations can be occurring simultaneously within any given month. H. The monthly average capacity is ten open evaluations. I. Each evaluation takes between one and three months from referral to report depending on the clients' availability and willingness. J. Each evaluation averages two hours per week of direct contact. K. Clients'cultural/ethnic background and needs will be considered in the evaluation process and in making relevant treatment recommendations. L. South Weld County residents can access services through my office. I can be available to attend Visitations at the DSS Del Camino or Ft. Lupton offices. March 30, 2006 Attached A Page 4 BID 001-06 (RFP-FYC- 006-00, A, B, & C) Program Category: Mental Health Services Emergency Assistance Program Project Title: Individual and Family(Interactional)Psychological Evaluations Vendor: Barry R. Lindstrom,Ph.D., LLC; Licensed Clinical Psychologist III. TYPE OF SERVICES TO BE PROVIDED A. Family/Child/Adolescent Psychological Evaluation/Assessment Services All evaluations will be conducted as efficiently as possible with no unnecessary intrusion, but with an emphasis on gathering sufficient and appropriate clinical data and information to answer the referral questions within the phase of involvement with the Department(e.g., initial assessment and treatment planning vs. reasons for treatment failure or noncompliance, or changes in permanency planning) and as meets court and professional (APA) standards for evaluation. The relative number of individual or family evaluations is dependent upon the needs of the Department. l.a. Family(Interactional)Evaluations include some or all of the following depending on family composition, child's placement and the caseworker's referral questions: Individual Clinical Interview(s)with each family member(1 to 2 hours for each member), Conjoint clinical interviews with all family members(including marital, parent-child, and sibling subsystems as clinically indicated; 3 to 5 hours), Conjoint interview/consultation with child and current caregivers(foster parent,relative etc)if child is in out of home placement at the time of evaluation, Psychological Testing Minnesota Multiphasic Personality Inventory-2 (MMPI-2),Millon Clinical Multiaxial Inventory-III(MCMI-III), Wechsler Abbreviated Scale of Intelligence (WASI), Thematic Apperception Test(TAT),Beck Depression Inventory, Beck Anxiety Inventory, Penn Inventory for PTSD, and Stressful Life Events Questionnaire for each adult family member as clinically indicated(1 to 2 hours each), Standardized Behavioral Assessment(BASC or similar for each child as appropriate, completed by parents, foster parents,teachers as clinically indicated), Review of case records, previous evaluations and treatment records (1 to 2 hours), Collateral contacts/consultation with caseworker, past or current treatment providers, schools etc (1 to 2 hours), Court Facilitator Staffings as requested(1 to 2 hours, during or after evaluation). Individual Psychological Evaluations include some or all of the following depending on referral questions: Individual Clinical Interviews(3 to 5 hours; for child and adolescent clients this will include interview with current caretakers), Psychological Testing to address referral questions regarding personality and intellectual functioning as clinically indicated(e.g.,MMPI-2, MCMI-III, WASI, BASC etc; 1 to 5 hours as needed), Review of case records, previous evaluations and treatment records (1 to 2 hours) Collateral contacts/consultation with caseworker, past or current treatment providers, schools etc (1 to 2 hours), Court Facilitator Staffings as requested(1 to 2 hours, during or after evaluation). March 30, 2006 Attached A Page 5 BID 001-06 (RFP-FYC- 006-00, A, B, & C) Program Category: Mental Health Services Emergency Assistance Program Project Title: Individual and Family(Interactional)Psychological Evaluations Vendor: Barry R. Lindstrom,Ph.D., LLC; Licensed Clinical Psychologist III. TYPE OF SERVICES TO BE PROVIDED (continued) b. Consultation with collateral contacts (e.g., caseworker, past or current treatment providers or evaluators, schools, court facilitator staffings, etc.) will be included as part of each evaluation to meet court and professional standards. c. A written report will be provided to the referring caseworker within thirty(30) days of the completion of the evaluation. This report will summarize the referral questions; brief case history; evaluation course; methods and procedures (including psychological testing, records reviewed and collateral contacts); findings; conclusions and recommendations. Evaluation reports will address both strengths and protective factors and risk factors or problems. d. Individuals and families will be offered a final diagnostic feedback session as part of the evaluation process to discuss test results and the findings and recommendations of the evaluation. Copies of the evaluation will be distributed to appropriate parties by the caseworker or psychologist in keeping with privacy laws, client consent and legal and professional standards. B. Consultation with Caseworkers Consultation with Caseworkers will occur at the time of initial referral,after the first client contact, prior to the completion of the final report and as needed during the course of evaluation to: Assess and address any urgent or emergent recommendations or questions of safety or placement, Gather and share information and findings, Coordinate scheduling of conjoint and child and caregiver interviews, Assist in the preparation of individual and family treatment plans and court updates, Assist in the elaboration and implementation of recommendations, Discuss the clinical rationale for recommendations or decisions, Discuss placement and permanency needs and plans, and As needed or requested by the caseworker or evaluator. C. Court Testimony Expert testimony will be provided as requested by the county attorney regarding the evaluation process, findings and recommendations. This will include preparation,travel and court time out of the office to be billed at the contracted hourly rate (two hours minimum). Court facilitator staffings will be attended as requested and billed at the contracted rate. March 30,2006 Attached A Page 6 BID 001-06(RFP-FYC- 006-00, A,B, & C) Program Category: Mental Health Services Emergency Assistance Program Project Title: Individual and Family(Interactional)Psychological Evaluations Vendor: Barry R. Lindstrom,Ph.D., LLC; Licensed Clinical Psychologist IV. MEASURABLE OUTCOMES A. Evaluations will be completed in a timely manner(one to three months)to meet caseworker requests and scheduled court updates and hearings. Appointments may be scheduled for multiple hours in one day to accommodate psychological testing, and multiple or family interviews to expedite and simplify the evaluation process. Caseworkers will be contacted at each stage of the evaluation for case management and to share initial impressions, findings and any urgent recommendations (see III B above). Any delays in completing the evaluations will be discussed with caseworkers in advance. Any delays due to client non compliance will be discussed and problems resolved with the caseworker. An average of two months from initial referral to completed report is the goal. Individual evaluations can be completed in less time than family evaluations,because of the number of people involved. Where possible, a limited number of previously scheduled visitations(at LFS, CARE, WCDSS)will be utilized as a clinical opportunity to observe and assess family interaction in order to facilitate scheduling, minimize disruption to the clients and caregivers and avoid redundancy. At least one conjoint (family) interview in the office is necessary for a complete and thorough evaluation. Evaluations conducted at the end of the Court process, particularly regarding changes in the permanency plan away from returning home to biological parents, or to address issues between alternative family placements (e.g., adoption by grandparents or foster parents)are by necessity more thorough and lengthy, and therefore more time consuming. B. Dr. Lindstrom is available for face to face or telephone consultation with caseworkers or providers during or after the evaluation(s)to assist in and address questions regarding the implementation of evaluation findings and recommendations. He is also available to attend court facilitator staffings as requested. C. Consultation is available as requested by the caseworker as outlined in III B, above. Consultation with Caseworkers will occur at the time of initial referral, after the first client contact, prior to the completion of the final report and as needed during the course of evaluation, and at least twice a month. D. Telephone calls will be returned by the end of the next business day. Requests for letters or case updates can be completed within a week. E. Evaluation appointments will be coordinated though the office and Department as needed and outlined above. March 30, 2006 Attached A Page 7 BID 001-06 (RFP-FYC- 006-00, A, B, & C) Program Category: Mental Health Services Emergency Assistance Program Project Title: Individual and Family(Interactional)Psychological Evaluations Vendor: Barry R. Lindstrom,Ph.D., LLC; Licensed Clinical Psychologist IV. MEASURABLE OUTCOMES (continued) F. a. All telephone calls or emails will be returned by the end of the next business day. Emergency calls will be returned the same day if identified as such. In an emergency,Dr. Lindstrom can be reached after hours via his answering service. b. Evaluations will be conducted in accordance with professional and legal standards to be acceptable in court in support of any required expert testimony. Dr. Lindstrom is able to be qualified as an Expert witness in accordance with legal statutes. Written reports will clearly outlined,avoid professional jargon, and contain clearly stated and enumerated recommendations. These targets will be reviewed during the evaluation process with each caseworker and discussed quarterly with Department supervisors to ensure that the evaluations and reports are meeting Department and court expectations for content, clarity and timeliness. March 30, 2006 Attached A Page 8 BID 001-06 (RFP-FYC-006-00,A,B, & C) Program Category: Mental Health Services Emergency Assistance Program Project Title: Individual and Family(Interactional)Psychological Evaluations Vendor: Barry R. Lindstrom,Ph.D., LLC; Licensed Clinical Psychologist V. SERVICE OBJECTIVES A. Family and individual evaluations will provide information to assist the Department and the Court in the development of family services plans, and assess family communication, functioning and relationships. This will include family strengths that can be used in treatment planning to address and improve identified weakness and risks to be contained or minimized in order to reduce the need for or length of placement and to meet permanency plan goals for reunification in a developmentally meaningful time frame. Each client will be offered the opportunity for diagnostic feedback and discussion as part of the final interview. This feedback will address both individual(parent and child)and family functioning, strengths and needs. B. In particular, issues of parent-child attachment and parenting skills that promote safety and attachment will be addressed. These include, but are not limited to: affection and nurturance, stimulation and containment, and safety and protection. Individual evaluations will address any mental health issues or obstacles to the individual's successful completion of treatment and permanency or reunification plans. These issues will be addressed in the written report. C. Ideally,the evaluation process will provide clients an experience, in spite of its stressful nature, that will assist them in developing a trusting relationship (therapeutic working alliance) with current or new professionals whose assistance they require. Other involved professionals will be consulted as part of the evaluation and findings shared with them to assist in the development of a therapeutic working alliance and successful treatment outcome(s). Signed releases of information will be obtained for all collateral contacts or sources. D. Evaluation reports will address all questions outlined in the caseworker's referral (e.g.,treatment planning and recommendations, placement and permanency questions) and be responsive to the context of the referral in the phase of the family's involvement with the Department and court process(initial D&N, progress in treatment, or review of permanency plans and goals). When the caseworker's referral includes specific written questions, these will be individually responded to in the Summary and Recommendations section of the evaluation. Evaluation reports will address both strengths or protective factors, and risk factors or problems. March 30, 2006 Attached A Page 9 BID 001-06 (RFP-FYC-006-00, A, B, & C) Program Category: Mental Health Services Emergency Assistance Program Project Title: Individual and Family(Interactional)Psychological Evaluations Vendor: Barry R. Lindstrom, Ph.D., LLC; Licensed Clinical Psychologist E. The"Child and Family Services Review Performance Improvement Plan"(PIP) lists three priorities (p. 13): "More consistent assessments; Permanency Planning, and Family Centered Case Planning,"to address the target areas of"Safety, Permanency and Child and Family Well-Being" (pp 11-12). Individual and Family Interactional Evaluations conducted as part of the present proposal will contribute to the identified need for more consistent and through evaluations and will provide treatment planning recommendations to address all specific referral questions and the general issues of safety, permanency and well-being as appropriate to the case and referral questions. These service objectives will be reviewed quarterly as needed with Department supervisors. March 30, 2006 Attached A Page 10 BID 001-06 (RFP-FYC-006-00, A, B, & C) Program Category: Mental Health Services Emergency Assistance Program Project Title: Individual and Family(Interactional)Psychological Evaluations Vendor: Barry R. Lindstrom,Ph.D., LLC; Licensed Clinical Psychologist VI. WORKLOAD STANDARDS Dr. Lindstrom maintains an independent private practice in the offices of Pathways: Family Wellness Associates. He is incorporated as a Limited Liability Corporation and is its sole employee/member. A. His office hours are Monday to Friday 8am to 5pm. He has an answering service after hours. He can be available on a limited basis in the evenings for appointments or evenings or Saturdays to attend previously scheduled visitation for the purposes of family evaluation. B. He is the only psychologist in his practice conducting these evaluations. C. He can maintain multiple open evaluations at any given time (10 maximum). D. The modality is psychological testing and clinical interviews and consultation. E. He is available 40 hours/week. F. He is the only psychologist in his practice conducting these evaluations. G. Dr. Lindstrom is licensed in Colorado as a Clinical and School Psychologist. He does not have a supervisor or provide clinical supervision to anyone at this time. H. He typically completes three or more of the open evaluations each month. I. Dr. Lindstrom maintains professional liability insurance, automobile insurance and has unemployment and worker's compensation insurance through his LLC. Liability insurance is maintained through Pathways Management, LLC. (See attached copies pages 10 a-e.) March 30, 2006 Attached A Page 11 BID 001-06 (RFP-FYC-006-00, A, B, & C) Program Category: Mental Health Services Emergency Assistance Program Project Title: Individual and Family(Interactional)Psychological Evaluations Vendor: Barry R. Lindstrom,Ph.D., LLC; Licensed Clinical Psychologist VII. PROOF OF COLLABORATION Provide the following evidence of/and description of collaboration processes your agency has established and can provide through your program. A. Letter from a housing referral contact your agency will utilize when the client has an identified housing need; (not applicable) B. Letter from a job services referral contact your agency will be utilizing when the client has an identified employment need; (not applicable) C. Clients will be asked to sign an informed consent for the evaluation and releases of information to the Department, past and present evaluators and treatment providers, and Guardians ad Litem and Attorneys(etc.)as needed to facilitate verbal communication and the review of collateral information as part of the evaluation process. I will also attend Placement Review Team and Court Facilitator Staffings as requested. D. Each evaluation will include a review of relevant Departmental records and history, in addition to consultation with the referring caseworker. Collateral information will be obtained/exchanged with other providers with written permission. This will include, but is not, limited to: mental health and substance abuse treatment providers, other evaluators(e.g., substance abuse,psychosexual evaluations, previous psychological evaluations, home studies, etc.) and attorneys and Guardians ad Litem. I will also attend Placement Review Team and Court Facilitator Staffings as requested. E. I will provide consultation as requested to help in the implementation of my recommendations at the conclusion of the evaluation. F. I will not be providing evaluations for Medicaid funded clients. Note: All evaluations are being provided at the Department's request to meet court ordered treatment plans. As such,they are considered forensic evaluations and not treatment and do not meet the criteria of"medical necessity"to be eligible for reimbursement by an insurance company(pubic or private). March 30,2006 Attached A Page 12 BID 001-06 (RFP-FYC- 006-00, A, B, & C) Program Category: Mental Health Services Emergency Assistance Program Project Title: Individual and Family(Interactional)Psychological Evaluations Vendor: Barry R. Lindstrom, Ph.D., LLC; Licensed Clinical Psychologist VIII. EVIDENCE-BASED OUTCOMES A. Bibliography of research base being utilized for the evaluations. Child Abuse and Neglect Cicchetti,D. (1987). Developmental psychopathology in infancy: Illustration from the study of maltreated youngsters. Journal of Consulting and Clinical Psychology, 55, 6, 837-845. Korfinacher, J. (1999). The Kempe Family Stress Inventory: A review. Child Abuse and Neglect, 24, 1, 129-140. Lindstrom,B. R. (1999). Attachment, separation and abuse outcomes: Influence of Early Life Experience and the Family of Origin. In G. Ryan and Associates, Web of meaning: A developmental-contextual approach in sexual abuse treatment(pp 32-48). Brandon, VT: Safer Society Press. Attachment American Academy of Child and Adolescent Psychiatry(Author)(2005). Practice Parameter for the Assessment and Treatment of Children and Adolescents with Reactive Attachment Disorder of Infancy and Early Childhood Journal of the American Academy of Child and Adolescent Psychiatry(44) 11, 1206-1219. Cassidy,J. & Shaver,P.R., (Eds.)(1999). Handbook of Attachment: Theory Research and Clinical Applications. London: The Guilford Press. Greenberg, MT.,. Cicchetti,D., & Cummings, E.M., (Eds)(1990). Attachment in the preschool years: Theory, research and intervention. Chicago: University of Chicago Press. Pilowsky, D.J, &Kates, W.G., (1996). Foster Children in Acute Crisis: Assessing Critical Aspects of Attachment. Journal of the American Academy of Child and Adolescent Psychiatry(35) 8, 1095-1097 Family and Culture Aranson-Fontes, L. (2005). Child Abuse and Culture: Working with Diverse Families. New York: Guilford. McGoldrick,M.,Pearce, J.K., &Giordano,J. (Eds.)(1982). Ethnicity and Family Therapy. New York: Guilford Press. March 30,2006 Attached A Page 13 BID 001-06 (RFP-FYC- 006-00, A,B, & C) Program Category: Mental Health Services Emergency Assistance Program Project Title: Individual and Family(Interactional)Psychological Evaluations Vendor: Barry R. Lindstrom,Ph.D., LLC; Licensed Clinical Psychologist IX. EVIDENCE-BASED OUTCOMES (continued) A. Bibliography continued. Psychological Testing and Evaluations Anastasi, A. Psychological Testing. (Current Edition.) New York: McMillan. Graham, J.R. (2000). MMPI-2: Assessing Personality and Psychopathology (Third Edition). New York: Oxford University Press. APA ethics and testing standards Ethical Principles of Psychologists and Code of Conduct. American Psychological Association. Washington DC Specialty Guidelines for the Delivery of Services: Clinical, Counseling, IndustrialOrganizational and School Psychologists. American Psychological Association. Washington DC March 30, 2006 Attached A Page 14 BID 001-06 (RFP-FYC-006-00, A, B, & C) Program Category: Mental Health Services Emergency Assistance Program Project Title: Individual and Family(Interactional)Psychological Evaluations Vendor: Barry R. Lindstrom, Ph.D., LLC; Licensed Clinical Psychologist VIII. EVIDENCE-BASED OUTCOMES (continued) B. This is an example of a typical family evaluation outline (reports are typically 15 to 20 pages): Psychological Evaluation: Family Interactional Assessment Confidential for Professional Use Only Date SUBJECTS: DOB: ; mother Court Case#: IDENTIFICATION AND REFERRAL ... ... .....were referred for a court-ordered interactional assessment with. .by ... ... .....their Weld County Department of Social Services(WCDSS) caseworker. The Core services referral listed the following treatment objectives: Improve parental capabilities currently impaired by family conflict; Develop or increase the ability to recognize, prioritize and meet children's needs, and Improve level of functioning currently impaired by their mental health issues. The present evaluation was requested to provide diagnostic family assessment and treatment recommendations towards the permanency goal of reunification of......... ......with... ... ... ... COURSE OF EVALUATION .were aware that this is a court-ordered evaluation and gave their informed consent in writing. They were compliant in completing all components of the evaluation including signing releases of information to review and speak with collateral sources. SOURCES OF INFORMATION December 7, 2005: Individual clinical interviews with... ... ... ...........completed the Minnesota Multiphasic Personality Inventory-2 (MMPI-2),Millon Clinical Multiaxial Inventory-III(MCMI-III), Wechsler Abbreviated Scale of Intelligence(WASI), Thematic Apperception Test(TAT), Beck Depression Inventory, Beck Anxiety Inventory, Penn Inventory for PTSD, and Stressful Life Events Questionnaire. December 2, 2005 and January 31, 2006: Parent-child interactional clinical interviews with........ . March 30, 2006 Attached A Page 15 BID 001-06 (RFP-FYC-006-00, A, B, & C) Program Category: Mental Health Services Emergency Assistance Program Project Title: Individual and Family(Interactional)Psychological Evaluations Vendor: Barry R. Lindstrom, Ph.D., LLC; Licensed Clinical Psychologist VIII. EVIDENCE-BASED OUTCOMES (continued) B. Family evaluation outline continued January 15, 2006: Conjoint clinical interview of... .....with her current foster parents... .... Behavior Assessment System for Children(BASC) rating scales were completed by...... Review of documentation provided through the Department with. 's written permission including: Family Services Plan Court Updates dated... ....... Consultation with ... ... ... ... .... CLINICAL FINDINGS Individual Adults/children(for each) Psychological Testing Diagnostic Impression(DSM-IV) Axis I: Posttraumatic Stress Disorder, Chronic; Polysubstance Abuse Axis II: Personality Disorder Axis III: In good health Axis IV: Psychosocial Stressors: Legal, family, Axis V: Global Assessment of Functioning: 60 Family Interaction Parent/Child Interaction Marital Relationship Sibling Interaction COLLATERAL INFORMATION SUMMARY AND RECOMMENDATIONS Risk Factors (e.g., The Kempe Family Stress Inventory) Protective Factors Individual and family Strengths and Social Supports March 30, 2006 Attached A Page 16 BID 001-06 (RFP-FYC-006-00, A, B, & C) Program Category: Mental Health Services Emergency Assistance Program Project Title: Individual and Family(Interactional)Psychological Evaluations Vendor: Batty R. Lindstrom, Ph.D., LLC; Licensed Clinical Psychologist VIII. EVIDENCE-BASED OUTCOMES(continued) B. Family evaluation outline continued (Caseworker)requested the present evaluation to provide an assessment of parental and family functioning and address the following questions: 1. What type of bonding do the parent and child exhibit? 2. What positive attributes does the parent bring to the relationship that is beneficial to the child? 3. What are any deficits that the parent brings to the relationship that may need to be addressed? 4. What are the treatment recommendations that would help the parent develop more productive parenting skills? 5. What is your recommendation regarding parenting time? For example: therapeutic, supervised or unsupervised. 6. Are there any protective concerns noted from the evaluation? Therefore, based upon the above evaluation, consultation and review of records,the following recommendations are respectfully made: 1. RE: level and frequency of individual and family therapies and treatment issues/goals, level and frequency of visitation, medication or other evaluations, permanency plan needs or changes... ... 2. Etc These are my opinions and recommendations based upon the above evaluation and my knowledge and experience in the field. I reserve the right to amend these opinions or modify these recommendations if additional information becomes available. Respectfully submitted, Barry R. Lindstrom,Ph.D. Licensed Clinical Psychologist Licensed School Psychologist Original: caseworker(WCDSS) Cc: file Others as listed on signed Releases of Information March 30, 2006 Attached A Page 17 BID 001-06 (RFP-FYC-006-00, A, B, & C) Program Category: Mental Health Services Emergency Assistance Program Project Title: Individual and Family(Interactional)Psychological Evaluations Vendor: Barry R. Lindstrom, Ph.D., LLC; Licensed Clinical Psychologist VIII. EVIDENCE-BASED OUTCOMES(continued) C. Provide a fictional sample of a request to renew services for a client: Barry R. Lindstrom,Ph.D.,LLC Licensed Clinical Psychologist 3211 20th Street, Suite D Greeley,CO 80634 970.356.3100 March 7, 2006 Andrea Shay Weld County Department of Social Services 315N11thAve PO BOX A Greeley CO, 80632 Via E-mail: shayxxah@co.weld.co.us RE: K HH#: End Date: 03/02/06 Caseworker: Karey Montoya Dear Ms. Shay: I am writing to request an extension of my CORE Services contract beyond the above date in order to complete the requested evaluation. I need to meet again with the K family ... ...etc... Please extend the date by 60 days to allow time for additional appointments as needed. Respectfully submitted, Barry R. Lindstrom,PhD Licensed Clinical Psychologist Cc file March 30,2006 Attached A Page 18 BID 001-06 (RFP-FYC- 006-00, A,B, & C) Program Category: Mental Health Services Emergency Assistance Program Project Title: Individual and Family(Interactional)Psychological Evaluations Vendor: Barry R. Lindstrom,Ph.D., LLC; Licensed Clinical Psychologist VIII. EVIDENCE-BASED OUTCOMES(continued) D. Provide a fictional sample of a monthly report(see attached page 18a). IX. STAFF QUALIFICATIONS A. All work will be completed by Barry K Lindstrom,PhD. He is a Licensed Clinical Psychologist and School Psychologist in the state of Colorado. He meets all continuing education requirements to maintain these licenses. B. Dr. Lindstrom is the only employee of Barry R. Lindstrom,PhD; LLC. He contracts with Pathways Management, LLC for office space and secretarial and billing services. He contracts with MKF Billing Services for transcription services. These contracts are HIPAA compliant. C. Dr. Lindstrom has appropriate knowledge and training regarding casework. D. Dr. Lindstrom has knowledge of risk assessment. X. UNIT OF SERVICE RATE COMPUTATION The budget must be submitted in an hourly unit rate cost of direct delivery of services to an individual or family unit. The bidder must address the Unit of Service Rate Computation Calculation as follows on the attached budget(pages 18b-e). See attached budget for per hour rate for direct client contact hours and court testimony. Evaluation: $ 300.00 per hour of direct client service (interviews and psychological testing). Court testimony: $ 175.00 per hour(preparation,travel and testimony; "portal to portal"). 2 hours minimum. Court Facilitation Staffings: $ 150.00 per hour(for staffings after end of evaluation authorization). Family Therapy(office): $ 150.00 per hour(for time limited interventions such as termination visits or brief clinical intervention, with documentation). March 30, 2006 Attached A Page 19 BID 001-06 (RFP-FYC-006-00, A, B, & C) Program Category: Mental Health Services Emergency Assistance Program Project Title: Individual and Family(Interactional)Psychological Evaluations Vendor: Barry R. Lindstrom,Ph.D., LLC; Licensed Clinical Psychologist XI. BILLING PROCESS A. Bills will be submitted to Andrea Shay at the completion of the evaluation including both Departmental paperwork(client signature sheets, authorization for contractual services, and core services request for monthly reimbursement forms)and an invoice. They will be submitted with the evaluation(original or copy)for distribution to the referring caseworker. Clients will sign in at each appointment and these will be matched with the computer billing system and invoice to assure that only direct client contacts are billed. B. Provide a fictional demonstration of a monthly billing(see attached page 19a) MI. LOWEST QUALIFIED BID (For reviewers.) XIII. PROGRAM CAPACITY BY MONTH This program can produce up to five (5) evaluation reports completed per month on average, with up to ten(10) open, ongoing evaluations per month on average. There is no minimum client capacity per month necessary to support this program. c ) ape EVEREST NATIONAL INSURANCE COMPANY F_ VER MENTAL HEALTH PRACTITIONER'S PROFESSIONAL LIABILITY DECLARATIONS OCCURRENCE POLICY Policy Number : 2200006488-051 Renewal of Number: 2200006488-041 Item 1.Named Insured and Mailing Address Broker Name and Address Barry R. Lindstrom and/or Barry Lindstrom PhD LLC ROCKPORT INSURANCE ASSOC 3211 201B St. Suite D P.O. BOX 1809 Greeley,CO 80364 ROCKPORT,TEXAS 78381-1809 1-800423-5344 Item 2.Additional Insureds None Item 3. Policy Period From: 8/1/2005 To: 8/1/2006 at 12:01 A.M.,Standard Time at the insured's mailing address shown above. Item 4. Description of Business: Form of Business: [X] Individual [ ] Partnership [ ]Joint Venture [ ] Limited Liability Company [ ]Trust [ ] Organization, including a Corporation(but not including a Partnership,Joint Venture or Limited liability Company) Business Description: Mental Health Practitioner(s) Item 5. Limits of Insurance and Regulatory Defense Amount $ 3.000.000 AGGREGATE LIMIT $ 1.000.000 EACH WRONGFUL ACT LIMIT $ 1.000.000 EACH OCCURRENCE LIMIT-PREMISES LIABILITY $ 25.000 SEXUAL MISCONDUCT AGGREGATE LIMIT $ 5.000 REGULATORY DEFENSE AMOUNT Item 6. In return for the payment of the premium,and subject to all the terms of this policy,we agree with you to provide the insurance as stated in this policy. Premium Schedule CLASSIFICATION NUMBER RATE ANNUAL PREMIUM D3 1 $900.00 $900.00 Terrorism Insurance $ 0.00 Total Premium $900.00 Item 6. Forms and Endorsements Form(s) and Endorsement(s) made a part of this policy at time of issue: EDEC 134 09 01,EEO 00 507 09 01,EIL 00 515 07 00,IL 00 17 11 98,IL 02 28 07 02,EEO 21 572 02 03 THIS DECLARATIONS,TOGETHER WITH THE COMMON POLICY CONDITIONS AND COVERAGE FORM AND ANY ENDORSEMENT(S), COMPLETE THE ABOVE NUMBERED POLICY. p AUTHORIZED REPRESENTATIVE (or countersignature where applicable) EDEC 134 09 01 Date issued: 7/12/05 • AUTO INSURANCE pit - - COUNTRY Insurance a Financial Services STATEMENT OF RENEWAL COVERAGES AND PREMIUMS/11/ Account Number 0385404-001-00001 Policy Period Beginning NOV 12, 2005 UM/UIM COVERAGE APPLIES. RATING BASED ON THE NUMBER OF RATED DRIVERS. COUNTRY MUTUAL INSURANCE COMPANY - PREFERRED PLAN -POLICY NUMBER A05A6374425 POLICY TERM 6 MONTHS PAYMENT PLAN SEMI-ANNUAL TOTAL POLICY PREMIUM $494.04 VEHICLE VEHICLE, USE AND DRIVER INFORMATION 1983 VOLVO 918796 AUTOMOBILE, WORK UNDER 10, MALE, 30-64 2004 TOYOT 021904 AUTOMOBILE, PLEASURE, FEMALE, 30-64 POLICY COVERAGE LIMITS EACH PERSON EACH OCCURRENCE LIABILITY-BODILY INJURY 250.000 500,000 PROPERTY DAMAGE 100,000 UNINSURED MOTORISTS 250,000 500,000 UNDERINSURED MOTORISTS 250,000 500,000 1983 VOLVO 2004 TOYOT A05A6374425 AO5A8374425 VEHICLE COVERAGE LIMITS COLLISION - ACTUAL CASH VALUE LESS DED * 500 COMPREHENSIVE - ACTUAL CASH VALUE LESS DED * 500 ENDORSEMENTS • AMENDATORY END-CD YES YES PREMIUMS LIABILITY-BODILY INJURY 128.60 128.60 PROPERTY DAMAGE included included UNINSURED MOTORISTS 37.07 37.07 UNDERINSURED MOTORISTS included included COLLISION * 110.67 COMPREHENSIVE * 52.03 AMENDATORY END-CO included included VEHICLE PREMIUM $165.67 $328.37 The VEHICLE PREMIUM has already been changed by the following: DISCOUNTS GOOD DRIVER included included MULTICAR included included AUTO-HOME ADVANTAGE included included TOTAL DISCOUNT -97.74 -221 .40 * Not applicable to this vehicle. - Not applicable to this policy. BARRY LINDSTR0M, Ph,D., L,L,C, LICENSED CLINICAL PSYCHOLOGIST 3211 20TH ST., #D GREELEY, CO 80634 50104C0 (00-03/05) PAGE 1 OF 1 Colorado Department of Labor and Employment,Unemployment Insurance Operations,P.O.Box 8789,Denver,CO 80201-8789 /U C 303-318-9100(Denver-metro area)or 1-800-480-8299(outside Denver-metro area) NOTICE OF EMPLOYER'S TAX RATE Date: 11/30/05 Qualifying Date: 04/01/04 BARRY R LINDSTROM PHD LLC As required by the Colorado Employment Security Act(CESA)8-76-103 3211 W 20TH ST STE D (5).your notice of employer's tax rate is furnished for calendar year 2006. GREELEY CO 80634 In compliance with the Regulations Concerning Employment Security. you must make a written notification of errors found on your rate notice to Unemployment Insurance Operations within 15 calendar days of the mailing date of this notice. You must specify in detail the grounds for requesting a review of your account. The taxable wage base for year 2006 is$10,000. The total combined rate(Item 12) is your calendar year 2006 tax rate. This rate is not. effective until calendar year 2006 howl hail Item 3 IWa4 13=9 5 Account Number Total Tax Paid For All Past Total Benefits Charged For Excess Average Annual Taxable Payroll Periods Through 07-31-2005 All Past Periods Through (Item 2 Minus Item 3) Through 06-30-2005 06-30-2005 617694.00-7 564.00 564.00 15,999 Item 6 Item 7 Irma Ihem9 Item 10 Item 11:: "•hem 12 *Rate Code Percent of Base Tax Rate Base Industry Tax Surcharge Solvency Tax Solvency Tax Total ..:.Excess Rate Surcharge Surcharge Combined Rate Adjustment \\ 4 +4.0 .0170 .0022 .0180 .0060 .0312 *Rate Codes:1-Computed,2-Reimbursable,3-Political Subdivision,4-Unrated Standard,5-Unrated Industry,6-Unrated Computed,7-Urged Freeze ss(Item 7or Item 8)+Item 9+Item 10—Item 11=Item 12 Rate-Computation Formula: The total tax paid(Item 2)minus the total Solvency Tax Surcharge: A tax is assessed, charged, and added to the benefits charged(Item 3)equals the excess(Item 4). The excess(Item 4) standard or computed tax rate when the fund balance on any June 30 is equal divided by the average annual taxable payroll(Item 5)equals the percent of to or less than nine-tenths of one percent of the total wages reported by ratable excess(Item 6). Compare the percent of excess(Item 6)to the rate chart on Colorado employers. The solvency tax surcharge(STS)is in effect for the the reverse side of this form for the year 2006 experience rate(Item 7). 2006 rate year in compliance with CESA 8-76-102(5Xa). In 2006 the STS will be in its third incremental year. Base Tax Rate: The base tax rate (Item 7) will be a computed rate, an unrated-standard rate.or an unrated-computed rate. See definitions for tax- Solvency Tax Surcharge Adjustment: In accordance with House Bill 05- rate codes on Form UITR-7r,Tax-Rate Codes. 1208.effective for rate year 2006.the solvency tax surcharge yearly increment is credited back to employers as an adjustment(Item 11). If the limit on Base Industry Rate: Construction-industry employers, newly subject to solvency tax is reached,the adjustment(Item 11)may be less than the 2006 paying unemployment insurance taxes on or after January 1.2002,will be yearly increment(see RATE CHART on reverse side). assigned an average rate based on the industrial classification in compliance with CESA 8-76-103(3XaXIB)(E). Negative Balance: The amount of benefits charged exceeded the amount of taxes paid(Items 2 and 3). Therefore.the excess and percent of excess are Tax Surcharge: A tax is charged to all employers with a computed rate and negative figures.and the negative-excess table applies. benefits charged to their account over $100 for the last three fiscal years immediately preceding the computation date. This also applies to all newly Delinquent Penalty: Employers with delinquent taxes on June 30 of each subject employers who are not eligible for a computed rate. Effective calendar year shall have a penalty computed equal to the taxes due or 1 percent of the year 2000.the annual surcharge tax rate shall be established at 0.22 percent taxable wages in the previous calendar year.whichever is less. In compliance (0.0022). with CESA 8-79-104(1)(c).this penalty shall be payable in four quarterly payments during the current calendar year. 22869 / YOUR COMPUTED PENALTY FOR TAXES DELINQUENT ON JUNE 30, 2005 IS $ I•00 UITR-7(R 10/2005) --._. ,(Od PINN/1/�^COL 7501E Lowry Blvd Denver,CO 80230-7006 ASSURANCE www.pinnacol.com POLICY INFORMATION PAGE POLICY #: 3217113 POLICY TYPE: ADVANCE Date: May 2, 2005 ITEM 1. POLICYHOLDER: PATHWAYS MANAGEMENT, LLC PATHWAYS 3211 20TH ST. STE D GREELEY CO 80634 ST / 7.00 ITEM 2. POLICY PERIOD: FROM 05/01/2005 TO 05/01/2006 12:01 A.M.MOUNTAIN STANDARD TIME. ITEM 3. A. Workers'Compensation Insurance: Part One of the policy applies to the workers' compensation law of the states listed here: COLORADO B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3 A. The limits of our liability under part two are: BODILY INJURY BY ACCIDENT $100,000 EACH ACCIDENT • BODILY INJURY BY DISEASE $100,000 EACH EMPLOYEE BODILY INJURY BY DISEASE $500,000 POLICY LIMIT C. Other States Insurance: Part Three of the policy applies to the states,if any,listed here: NONE (Please contact Pinnacol Assurance for information on coverage outside the state of Colorado) D. This policy includes the attached endorsements and schedules: 0404 Premium Credit Addendum ITEM 4. We will determine the premium for this policy by our manuals of rules,classifications, rates and rating plans. All information required below is subject to verification and change by audit. The statements of estimated advanced premium are also a part of this policy. BARRY LINDSTROM, Ph.D., L.C.C. 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I § I UCENSED PSYCHOLOGIST n a | i f \ ® @B2IBHST #D , | GREEL� CO 80634 | 1 I PP $ $ | ` § a 0 e �| . . . . ■ ,| §1| . / /2 to en 8888Sa.8a-.,a8 , . 8888888 . ■,Saa,2■a■a»;; a e;ag»aS ■ 0 �k ■, §E| §|§ gaggga|||§§!|| | ggaggg| a , r §■! E§t, : / IA ||||2||||||||| 8 |||;||| | w |eUr ||| / 8882888888.... R .■8,. 8 § §|g f|aga■■a■■■■■■ $ |■#.k,| § 2 k Ng! ! ga . | |§ J g 2 7 |I ! B |§ e1=;22;9e22,,2 !922!2 1 888888888888■■ ; 8 8 8 ! | §■agaaaga22a22 g | § .| ■2 & & '!K | c |. . !_ § • } � ` I I / E \ § ■ ' • 0 \ § o \ / § E 8 I ° § § § | : | | § ° BARRY LINDSTROM, Ph.D., L.L.C. Si . ! . | 0 | LICENSED CLINICALPSYCHOLOGIST §` | » I ° r 3211 20TH a, ■D rE I GREELEY, CO 80634 | z II 5 | \ / ( !} } I 12 / . • ` p / »e 9 § 4O }° 0 §! gagaaa!||||||||||| a 8 a § !| ! Ig f. Co ■■5222222888888888 8 $ ■ aaal;aagaga»aagaaa s a a § § � O § '1 ko� § r 88888888$$$$$g$R $s 5 8 8 o 05! sagasa#■■gagassaas ■ g ■ @ § §§ I a ■ o o §\ ■a■■■a■■■8■■■a■■ns ■ ■ ■ ` !■ ! #■■§!■r»aa»;as»as, ! | [ 7 || ! | | ) .--;--- - - , j§ I §| ||||||| 7P § §\ ] 22222@22222292@292 f 5$,«558 8 8 28 8 UIR ! ! O &;;.,U, & | & | ` 6 | 8 | ! 5 § | | ! k | I ! `2. ( u; oCLINICAL kYGOBLGo2 i 2 ° B cE� �Er \off\ )!| ! || 2 8400 !11| 111 § | § 602292!!!| ! O ! r 3211 20th Street,Suite D / y 4 Greeley, CO 80634 BARRY LINDSTROM, Ph.D., I.L.C. (970)356-3100 LICENSED CLINICAL PSYCHOLOGIST 3211 20TH ST., #D GREELEY, CO. 80634. Weld County Department Social Service Statement Date....,: 02/21/2006 Attn: Elaine Furister Page Number • 01 P.O. Box A aJ Greeley, CO 80632 Account Number : 694 Patient Name • Lt • STATEMENT FOR PROFESSIONAL SERVICES CHARGES OR PAYMENTS AFTER ABOVE STATEMENT DATE WILL APPEAR ON YOUR NEXT STATEMENT —ID:694 L -- - 12/21/2005 EVALUATION 1 HOUR, Barry R. Lindstrom, Ph.D., charge 280.00 01/06/2006 EVALUATION 1 HOUR,Bany R. Lindstrom, Ph.D.,charge 280.00 01/09/2006 EVALUATION 1 HOUR, Barry R. Lindstrom, Ph.D.,cha 280.00 01/11/2006 EVALUATION 1 HOUR, Barry R. Lindstrom, Ph.D., a 28 01/20/2006 EVALUATION 3 HOURS, Barry R. Linds , Ph. .,charge 0.00 02/06/2006 EVALUATION 2 HOURS, Barry R. tinc3or . Ph. arge 560.00 77 L----=====--===--==---====— < PLEASE REMIT PAYMENT PROMPTLY> - • 0.00 2 520.00 0.00 0.00 2,520.00 0.00 2,520.00 ` 1680.00 0.00 0.00 0.00 0.00 0.00 Return this portion with your payment 694 - - - 02/21/2006 1520.00 Please make check payable to: Pathways 3211 20th Street, Suite D Greeley, CO 80634 (970) 356-3100 WE ACCEPT CASH, CHECK, MASTERCARD and VISA FOR QUESTONS ON YOUR ACCOUNT CALL JOLENE AT(970)356-3100 EXHIBIT B SUPPLEMENTAL NARRATIVE TO RFP Barry R. Lindstrom, Ph.D., LLC Licensed Clinical Psychologist 3211-20th Street, Suite D Greeley, CO 80634 (970) 356-3100 May 22,2006 Gloria Romansik Weld County Department of Social Services PO Box A Greeley, CO 80632 RE: Bid# 06MH04 (RFP 006-00)Mental Health Services Dear Ms. Romansik: I am writing to respond to the May 15, 2006 letter I received via fax on May 18, 2006 from Judy A. Griego, Director. I am looking forward to another year of working with the Department providing psychological evaluations. I am willing to address the conditions outlined as discussed below. I have spoken with Andrea Shay about them and will work with her until these are completed. 1. To further define the service objectives outlined in my proposal for evaluations, I will personalize these areas in my evaluation report for each client/family. I will offer specific individual feedback in the last appointment with the client if they want and in collaboration with the referring caseworker and other involved professionals. 2. I will discuss a"per evaluation"rate further with Ms. Shay. I would prefer to continue to charge per hour as before and have already set up multiple office procedures for tracking and evaluating this process. I believe this is the most accurate and fair system and allows me to prioritize Department referrals to complete evaluations and reports in a thorough, timely and efficient manner. Family(interactional)assessments vary considerably in size and scope. I often receive referrals for large, complex, multigenerational family systems. For example, I am completing a family evaluation with three adults and five children in three different foster homes. I have just begun an evaluation including three grandparents and two parents in addition to the children. I am willing to discuss a "tiered" rate system that reflects the number of adults and children in the family and whether the children are placed outside of the home. Often the caseworkers request a combination of family and individual psychological evaluations. Also, evaluations that are being prepared for testimony at termination trial • May 22, 2006 RE: Bid# 06MH04(RFP 006-00)Mental Health Services Response letter Page 2 must be more thorough and lengthy than evaluations that are helping develop initial treatment plans or placement recommendations. I will discuss this further with Ms. Shay to finalize this and assist her in the preparation of referrals. 3. I will seek"collaboration"letters to the agencies mentioned, and appreciate Ms. Shay's assistance in providing contacts to facilitate this process. I should be able to have them within two weeks. If not, I will inform her Medicaid does not pay for this type of evaluation,and Ms. Shay informs me that the Department does not have a contact for them at NRBH. If I recommend further treatment in my evaluations,and the clients have Medicaid I would be happy to help facilitate referrals to NRBH as needed. I will assist clients with the telephone number and making direct contact for the referral as needed. It is my understanding from Ms. Shay that the caseworkers forward my reports and recommendations as appropriate. If not, I will have clients sign a release of information so that I may do so. 4. I did include a court testimony rate of$175/hour in my bid. This is in section X, Unit of Service Rate Computation, on page 18 of my proposal(see attached). I also included my calculated hourly rate for evaluations and an hourly rate for court facilitator staffing and family therapy. I will bill at these rates, not my previous rate. There was not, however, a line for court testimony on the computerized budget spreadsheets I received from the Department as there was last year. This may have contributed to the reviewers' oversight. Please let me know if I should be in contact with anyone other than Ms. Shay or yourself. In the interim I trust that we will be able to continue our longstanding collaboration to meet your clients' needs. Respectfully, � 2 () h Barry R. Lindstrom,PhD Licensed Clinical Psychologist Cc Andrea Shay encl marcn it),auub Attached A Page 18 BID 001-06(RFP-FYC-006-00,A,B,&C) Program Category: Mental Health Services Emergency Assistance Program Project Title: Individual and Family(Interactional)Psychological Evaluations Vendor: Barry R. Lindstrom,Ph.D., LLC; Licensed Clinical Psychologist VIII. EVIDENCE-BASED OUTCOMES(continued) D. Provide a fictional sample of a monthly report(see attached page 18a). IX. STAFF QUALIFICATIONS A. All work will be completed by Barry IL Lindstrom,PhD. He is a Licensed Clinical Psychologist and School Psychologist in the state of Colorado. He meets all continuing education requirements to maintain these licenses. B. Dr. Lindstrom is the only employee of Barry R. Lindstrom,PhD; LLC. He contracts with Pathways Management LLC for office space and secretarial and billing services. He contracts with MKF Billing Services for transcription services. These contracts are HIPAA compliant. C. Dr. Lindstrom has appropriate knowledge and training regarding casework D. Dr. Lindstrom has knowledge of risk accecsment. X. UNIT OF SERVICE RATE COMPUTATION The budget must be submitted in an hourly unit rate cost of direct delivery of services to an individual or family unit. The bidder must address the Unit of Service Rate Computation Calculation as follows on the attached budget(pages 18b-e). See attached budget for per hour rate for direct client contact hours and court testimony. Evaluation: $300.00 per hour of direct client service (interviews and psychological testing). Court testimony: $ 175.00 per hour(preparation,travel and testimony; "portal to portal"). 2 hours minimum. Court Facilitation Staffings: $ 150.00 per hour(for staffmgs after end of evaluation authorization). Family Therapy(office): $ 150.00 per hour(for time limited interventions such as termination visits or brief clinical intervention, with documentation). • a ris DEPARTMENT OF SOCIAL SERVICES P.O. BOX A GREELEY, CO. 80632 Website:www.co.weld.co.us 'D Administration and Public Assistance(970)352-1551 Child Support(970)352-6933 WI C May 15, 2006 COLORADO Barry Lindstrom, Ph. D.,L.L.C. Licensed Clinical Psychologist 3211 20 Street#D Greeley, CO 80634 Re: Bid#06MH04 (RFP 006-00)Mental Health Services Dear Dr. Lindstrom: 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 06MH04 (006-00), Mental Health, for inclusion on our vendor list, attaching the following conditions and compliance item. Your bid scored 92 points out of 100. Condition: You must further define the service objectives by explaining how issues will be addressed. Condition: The bidder will work with the Weld County DSS Business Office to set a rate per episode for completed evaluations. Compliance Item: You must provide the required letters under the Collaboration Section from Weld County/Greeley Housing Authority, employment/training partners, and other partners as identified in the bidder's assessment of needs. You must identify the process you will utilize to facilitate Medicaid eligible clients receiving mental health services at North Range Behavioral Health. Hourly Rate for Court Testimony: You did not provide a rate for court testimony. For bidders carrying over services to 2006, the Department will use last year's court testimony hourly rate. The rate for court testimony will be billed at is $150 per hour. B. Required Response by FYC Bidders Concerning FYC Commission Conditions: All conditions will be incorporated as part of your Bid and Notification of Financial Assistance Award(NOFAA). If you do not accept the condition(s), you will not be authorized as a vendor unless the FYC Commission and the Weld County Department of Social Services accept your mitigating circumstances. If you do not accept the condition, you must provide in writing reasons why. A meeting will be arranged to discuss your response. Your response to the above conditions will be incorporated in the Bid and Notification of Financial Assistance Award. Page 2 Lindstrom/Results of RFP Process PY 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, J d A. Gri go,Dir r cc: Juan Lopez, Chair,FYC Commission Gloria Romansik, Social Services Administrator Weld County Department of Social Services Notification of Financial Assistance Award for Families,Youth and Children Commission(Core)Funds Type of Action Contract Award No. X Initial Award 06-CORE-57 Revision (RFP-FYC-006-00; 06MH05) Contract Award Period Name and Address of Contractor Beginning 06/01/2006 and Victor H. Cordero Ending 05/31/2007 Mental Health Services 2828 Speer, Unit 118 Denver, CO 80211 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Program provides mental health, family/parent Assistance Award is based upon your Request for interactional, and psychological evaluation Proposal (RFP). The RFP specifies the scope of services to children, adults,and families. services and conditions of award. Except where it is Specific services include psychological in conflict with this NOFAA in which case the evaluations and parent-child interactional NOFAA governs,the RFP upon which this award is evaluations, family assessments, and adjunct based is an integral part of the action. therapeutic services to include family and Special conditions individual therapy. Services are linguistically 1) Reimbursement for the Unit of Services will be based (Latino, Hispanic, Bilingual/Spanish) and on an hourly rate per child or per family. culturally sensitive. South County services 2) The hourly rate will be paid for only direct face to available in Firestone, Frederick,Ft. Lupton, face contact with the child and/or family, as including South Weld Annex or WCDSS Ft. evidenced by client-signed verification form, and as Lupton offices. Maximum monthly capacity for specified in the unit of cost computation. psychological evaluations per month is five; 3) Unit of service costs cannot exceed the hourly and maximum number of Parent-child Interactional yearly cost per child and/or family. Evaluations per month is four. 4) Payment will only be remitted on cases open with,and Cost Per Unit of Service referrals made by the Weld County Department of Social Services. Rate per Episode 5) Requests for payment must be an original submitted to Psychological Exam $1,200.00 the Weld County Department of Social Services by the Other Services $600.00 end of the 25th calendar day following the end of the Parent-Child Interactional $1,200.00 month of service. The provider must submit requests for payment on forms approved by Weld County Hourly Rate per Court Testimony $ 120.00 Department of Social Services. Enclosures: 6) The Contractor will notify the Department of any X Signed RFP: Exhibit A changes in staff at the time of the change. X Supplemental Narrative to RFP: Exhibit B Recommendation(s) X Cond ions of Approval App als: /- Progra O icialf (hit)By /C i By /leyM. J. Ceile, Chair Jud . Grie o, Direc Board of eldl oountyOcommissioners Wel o epartmefnt of Social Services Date: LUU Date: 5 3 V/° a5 -Z586 Jri M14 INVITATION TO BID OFF SYSTEM BID 001-06 (06005--06011 and 006-00, A, B, & C) DATE: March 1, 2006 BID NO: RFP-FYC-006-00, A, B, & C RETURN BID TO: Pat Persichino, Director of General Services 915 10th Street, P.O. Box 758, Greeley, CO 80632 SUMMARY Request for Proposal (RFP-FYC-006-00, A, B, 8,1C) for: Colorado Family Preservation Act—Mental Health Services Emergency Assistance Program Deadline: March 31, 2006, Friday, 10:00 a.m. The Families, Youth and Children Commission, an advisory commission to Weld County Social Services, announces that competing applications will be accepted for approved providers pursuant to the Board of Weld County Commissioners' authority under the Colorado Family Preservation Act (C.R.S. 26-5.5-101) and Emergency Assistance for Families with Children at Imminent Risk of Out-of-Home Placement Act (C.R.S. 26-5.3-101). The Families, Youth and Children Commission wishes to approve services targeted to run from June 1, 2006, through May 31, 2007, at specific rates for different types of services. The County will authorize approved providers and rates for services only. The Mental Health Services program provides diagnostic and/or therapeutic services to assist in the development of the family services plan, to assess and/or improve family communication, functioning and relationships. This program announcement consists of five parts, as follows: PART A...Administrative Information PART D...Bidder Response Format PART B...Background, Overview and Goals PART E...Bid Evaluation Process PART C...Statement of Work Delivery Date IN IS1 O b \,}.(After receipt of order) ,BrID MUST BE SIGNED IN INK VICToR h . CORbeRo TYPED OR PRINTED SIGNATURE VENDOR 1 itibf\ i1.Co{gDeRot ISyD. . a3.1UJ?5 - (Name) Handwritten Signature By Authorized e Officer or Agent of Vender ADDRESS a8o1� S?CER �)� TITLE\Rec-vczR -Mt=k. uER \ Co coal a DATE ?\j2..M/OCo PHONE # 30-3 - t-1 5 5 -(2tc18O The above bid is subject to Terms and Conditions as attached hereto and incorporated. Page 1 of 41 t Bid 001-06 (RFP-FYC-006-00, A, B, & C) Attached A MENTAL HEALTH SERVICES PROGRAM BID PROPOSAL AND REQUEST FOR CONTINUATION OF AWARD UNDER CORE SERVICES FUNDING EMERGENCY ASSISTANCE PROGRAM 2006-2007 BID PROPOSAL APPLICATION PROGRAM FUNDS YEAR 2006-2007 \I 1 ' BID 001-06 (006-00,O,A, B, & C) NAME OF AGENCY: V (CtOR t T _ (1,o RDERO l l�Sy�, )• C , ADDRESS: aaaB Specs Blvd, l Ur\icr 118 .DE/uvEg, co 8oal ) PHONE() U55 -9ti8t-> CONTACT PERSON: Y iQtt , CoR-DEe2 d TITLE:-DI FSEC-TO4 DESCRIPTION OF EMERGENCY ASSISTANCE PROGRAM CATEGORY: The Mental Health Services program provides for "diagnostic, and/or therapeutic services to assist in the development of the family services plan, to assess and/or improve family communication, functioning, and relationships. (Volume VII, 7.303.1, G)" 12-Month approximate Project Dates: _ 12-month contract with actual time lines of: Start June 1, 2006 Start End May 31, 2007 End TITLE OF PROJECT: CA ekiniC t-t-e t.2fl-k SEKVIQ1=S V;etoR LaDeig / men 1-lQmastms' 3 agM6 Name and Signature of P rson Preparing Document Date `L4 14,&oFiZO)?srD./ Y R —ci.e.thzsr I 3Jas )e co 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 7Target/Eligibility Populations Types of services Provided 7 Measurable Outcomes Service Objectives Workload Standards /Proof of Collaboration /Evidenced-based Outcomes z Staff Qualifications i Unit of Service Rate Computation Z. Billing Process Program Capacity per Month Certificate of Insurance Date of Meeting(s) with Social Services Division Supervisor: 3 I1 o cp C Page 29 of 41 Bid 002-05 (RFP-FYC-06005) Attached A Date of Meeting(s)with Social Services Division Supervisor: St I o f U n Comments by SSD Supervisor: . '3- 1O—DLp 40 6-Csc 7- , g M QK aS1 /7\ C��l.n� \C�n,-\c� t f.Z QC�,�t�Y t Q �'�(\Ole �`S- v\OAi.ar m O✓ � cow P c't bid Ls--R ,(moo r1 c � ec lrZ;\S{lA A � O l n �! 60 ' 2 11) 51 , 0/0(0 Name and Signature of S Su "sor Date Page 31 of 41 Victor H. Cordero, Psy.D. Mental Health Services, RFP-FYC-006-00 Bid 001-06 (RFP-FYC-006-00) Category: Mental Health Services Program Project Title: Psychological Evaluation, Parent-Child Assessment & Therapeutic Services Vendor: Victor H. Cordero, Psy.D. 1 Victor H. Cordero, Psy.D. Mental Health Services, RFP-FYC-006-00 I. PROJECT DESCRIPTION This project is designed to provide mental health, family/parent-interactional, and psychological evaluation services to children, adolescents, adults, and families involved with Weld County Department of Social Services. The project will strive to provide the highest levels of competence in the execution of all evaluation, therapeutic, and skills building services, and in contributions to Family Service Plan development. Services will be provided in a context that is congruent with the highest ethical standards and accepted practices in the field of clinical psychology. Services will also be linguistically (bilingual/Spanish) and culturally sensitive as a means of providing the most effective psychological evaluations and parent-child interactional evaluations. Recommendations, approach, and clinical conceptualization will specifically account for the culturally, linguistically, and socioeconomically diverse populations to be served. Specific services available will include: psychological evaluations, parent-child interactional evaluations, family assessments, and adjunct therapeutic services to include family and individual therapy. 2 Victor H. Cordero, Psy.D. Mental Health Services, RFP-FYC-006-00 II. TARGET/ELIGIBILITY POPULATIONS A. Total Number of Clients to be served: 60 B. Total individual clients and the children's ages: age range from newborn children through young adult. C. Total Family Units: 60 D. Sub-total of individuals who will receive bicultural/bilingual services: At least 60%. Fluent Spanish speaker and culturally competent psychologist will provide such services. E. Sub-total of individual who will receive services in South Weld County: Up to 40%. (more if need dictates) F. Subtotal of individuals who will have access to 24-hour service: 100% G. Monthly maximum program capacity: 9 evaluations H. Monthly average capacity of assessments: 5 I. Average stay in the program: 3 months J. Average hours per week in the program: 10 hours K. Cultural/ethnically specific services: Latino, Hispanic, Bilingual/Spanish, Immigrant L. Service to South Weld Count Clients: Services available in Firestone, Frederick, Ft. Lupton area. Clients can be seen at South Weld County Annex (Del Camino) or WCDSS Ft. Lupton offices (or in Longmont) if requested by The Department and/or client. 3 Victor H. Cordero, Psy.D. Mental Health Services, RFP-FYC-006-00 III. TYPE OF SERVICES TO BE PROVIDED A. Family/adult/child/adolescent psychological evaluation & assessment services 1. Psychological evaluation, screening, and other assessment services are intended to provide clinical information requested by Social. Services will include/incorporate the following: a. Evaluation procedures, reports and recommendations will be designed to produce useful responses to specific referral questions developed in collaboration with WCDSS caseworkers. A licensed psychologist or qualified candidate for licensure under supervision by a licensed clinical psychologist will complete all evaluations. b. Evaluators will make all reasonable efforts to collaborate with case related contacts prior to the completion of the evaluation either by personal contact, telephone contact, or via written report. c. Evaluation reports will clearly state methods utilized, contacts made, tests administered, and results and recommendations relevant to the referral question. d. Evaluation and assessment content will be made available to the family or other relevant parties and will comply with the ethical standards and practice of the American Psychological Association and/or other legal considerations. B. Parent-Child Interactional evaluations a. Evaluation procedures, reports and recommendations will be designed to produce useful responses to specific referral questions and from arising clinical issues as observed by the evaluator. A licensed psychologist or qualified candidate for licensure under supervision by a licensed clinical psychologist will complete all evaluations. b. Evaluators will make all reasonable efforts to collaborate with case related contacts prior to the completion of the evaluation either by personal contact, telephone contact, or via written reports. 4 Victor H. Cordero, Psy.D. Mental Health Services, RFP-FYC-006-00 c. Evaluation reports will clearly state methods utilized, contacts made, tests administered, and results and recommendations relevant to the referral question. d. Evaluation and assessment content will be made available to the family or other relevant parties and will comply with the ethical standards and practice of the American Psychological Association and/or other legal considerations. C. Individual & Family Therapy Services (adjunct services) a. Therapeutic services will be designed to address the needs of The Department, or referral request, in line with the best interests of the children or family involved. b. Therapeutic services will be congruent with recommendations stemming from referral sources, or other evaluation procedures previously performed. D. Consultation with Caseworkers 1. Evaluators will consult with Social Service caseworkers regarding the integration of assessment results into the overall care plans for the child, adolescent, adult, or family involved. These will include critical issues pertaining to assessment of suicidality, residential placement, or other levels of needed intervention. 2. Evaluators will assist in obtaining feedback from agency clinicians regarding the rationale for decisions on these issues when required. E. Court Testimony Evaluators will make all reasonable efforts to be available for court testimony when given proper notification for clients with open or closed cases. 5 Victor H. Cordero, Psy.D. Mental Health Services, RFP-FYC-006-00 IV. MEASURABLE OUTCOMES A. Program Design: Steps to reduce turn around time for evaluation results following referral. -Pre-selected appointment times will be available specifically for WCDSS clients. -Provider will utilize a dictation service to significantly improve report generation and delivery within two weeks of final face to face client contact. -Provider will deliver appointment times within days, to no more than three weeks post referral delivery. B. Ease of Access to Provider: -Provider will be available directly by office phone, voicemail, e-mail, and cellular phone. -Calls will be returned within one to two business days for non-urgent matters and as soon as is possible for urgent matters. C. Frequency of Contact between provider and WCDSS staff will be consistent, ongoing, and of sufficient frequency to ensure quality of service delivery. D. Outpatient programs will adhere to all of the latter conditions regarding timeliness. E. Coordination of therapeutic interventions between the provider and WCDSS will be assured via consistent communication, a team management approach, and frequent case status exchange. F. Specific Outcomes a. Emergency consultations will occur within 24 business hours. b. Psychological evaluation recommendations will include recommendations which are practical to the child protection field, are realistic and obtainable, and are documentable in terms of progress and outcomes. Documents will consider their potential presentation to the Court as a means of assuring acceptability. 6 Victor H. Cordero, Psy.D. Mental Health Services, REP-FYC-006-00 V. SERVICE OBJECTIVES • Services of the project will improve family conflict management by providing clear diagnostic guidance and effective therapeutic recommendations/services to assist in the development or improvement of the Family Services Plan, to assess and improve family communication, improve parenting skills, and to improve functioning of familial relationships. Services will improve household management competency in families by providing parents and caregivers insight, education, and guidance, in regards to safety of the household and the protection of children. Evaluations will provide families with noted areas of deficiency or concern in a language they can comprehend. Services shall assist parents in identifying and accessing assistance from other community based resources within local, state, and federal governments when applicable. These will include referral services, written materials, or contact information for such services at all levels of government. Specific referral issues will be addressed by means of solution focused, and WCDSS referral question relevant recommendations and case conceptualizations. Each of the objectives will be measured via direct observation, client feedback, and direct feedback from social workers to occur on an ongoing basis. Formal pre & post-assessment measures will also be utilized in quantifying the efficacy of interventions/recommendations when therapeutic. 7 Victor H. Cordero, Psy.D. Mental Health Services, RFP-FYC-006-00 VI. WORKLOAD STANDARDS The program will provide a minimum of 25 hours per week of clinical evaluation services, to include up to three practitioners/clinicians providing these services. The maximum ongoing caseload per worker on active/non-complete evaluations will be 4 clients per week. The number of non-complete assessments per month will be a maximum of nine. Modality of treatment interventions will be individual or family. Maximum caseload per supervisor will be 4 cases of evaluation per week, and 10 cases of individual/family therapeutic services. Insurance: see attached 8 Victor H. Cordero, Psy.D. Mental Health Services, RFP-FYC-006-00 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 1st Ave. Greeley, CO 80631 John Moore—970-378-1171 Island Grove Village Apartments 119 14th Ave. Greeley, CO 80631 Craig Allen -970-356-2808 B. Job Service Referrals: Rocky Mountain SER/Jobs for Progress 822 7th 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. Mental Health Services, RFP-FYC-006-00 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. Mental Health Services, RFP-FYC-006-00 VIII. EVIDENCE BASED OUTCOMES A. Bibliographic Information (see attached sample bibliography) B. Fictional sample of assessment (see attached sample evaluation) C. Fictional sample of request to renew services (n/a) D. Fictional sample of monthly report (see attached) 11 Victor H. Cordero, Psy.D. Mental Health Services, RFP-FYC-006-00 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. Mental Health Services, RFP-FYC-006-00 X. UNIT OF SERVICE RATE COMPUTATION (See attached budget forms) 13 Victor H. Cordero, Psy.D. Mental Health Services, RFP-FYC-006-00 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. Mental Health Services, RFP-FYC-006-00 XII. LOWEST QUALIFIED BID (See budget sheets) 15 Victor H. Cordero, Psy.D. Mental Health Services, RFP-FYC-006-00 XIH. PROGRAM CAPACITY BY MONTH a. Minimum number of psychological evaluations per month: 3 b. Maximum number of psychological evaluations per month: 5 c. Minimum number of Parent-Child Interactional Evaluations per month: 2 d. Maximum number of Parent-Child Interactional Evaluations per month:4 16 SAMPLE BIBLIOGRAPHY PSYCHOLOGICAL ASSESSMENT ETHNIC/MINORITY ISSUES IN COUNSELING BIBLIOGRAPHIC INFORMATION American Psychological Association. (1985).Standards for educational and psychological testing. Washington,DC: Author. Altarriba,J., and Bauer,L.M. Counseling the Hispanic client: Cuban Americans, Mexican Americans, and Puerto Ricans. Journal of Counseling& Development 76(4):389-396, 1998. Cuellar,I., and Gonzalez,G. Cultural identity description and cultural formulation for Hispanics. In: Dana,R.H., ed. Handbook of Cross-Cultural and Multicultural Personality Assessment. Mahwah, NJ: Lawrence Erlbaum Associates,2000. pp. 605- 621. Cueller,I. Cross-cultural clinical psychological assessment of Hispanic Americans. Journal of Personality Assessment 70(1):71-86, 1998. Garcia,J.G.,and Zea,M.C., eds. Psychological Interventions and Research with Latino Populations. Boston: Allyn & Bacon, 1996. CEMA/CPTA Collaboration Project on Relevant Literature Addressing Testing and Assessment of Cultural, Ethnic,and Linguistically Diverse Populations Bibliography Altus,W. D. (1945). Racial and bilingual group differences in predictability and in mean aptitude test scores in an Army special training center. Psychology Bulletin, 42, 310- 320. Altus,W. D. (1949).The Mexican American: The survival of a culture. The Journal of Social Psychology, 29, 211-220. American Educational Research Association,American Psychological Association, The National Council on Measurement in Education. (1985). Standards for educational and psychological testing.Washington DC: American Psychological Association. American Psychological Association. (1991). Guidelines for providers of psychological services to ethnic, linguistic, and culturally diverse populations. Washington DC: Author. Ammons, R. B. &Aguero,A. (1950).The full-range picture vocabulary test: WI. Results for a Spanish American school-age population.Journal of Social Psychology, 32, 3- 10. Anderson, N. E., Jenkins,F. F., & Miller, K. E. (1996). NAEP inclusion criteria and testing accommodations:Findings from the NAEP 1995 field test in mathematics. Princeton, NJ: Educational Testing Service. Anderson, N. E. & Olson,J. (1996). Puerto Rico assessment of educational progress: 1994 PRAEP Technical Report. Princeton,NJ: Educational Testing Service. Arias, B. (1986). The education of Hispanic Americans: A challenge for the future. American Journal of Education, 95. Armour-Thomas, E.A. (1992). Intellectual assessment of children from culturally diverse backgrounds. School Psychology Review, 21, 552-565. Armour-Thomas, E. & Goupaul-McNicol, S. (1997).The bio-ecological approach to cognitive assessment. Cultural Diversity and Mental Health, 3, 131-141. Arreola v. Santa Ana Board of Education (1968). No. 160-577. Arsenian,S. (1945). Bilingualism in the post-war world. Psychological Bulletin, 42, 65-86. Levin. A.B. (2000). Comment.: Child witnesses of domestic violence: I low should judges apply the best interest of the child standard in custody and visitation cases involving domestic violence? The Regents of the University of Californ.in CCL,I Law Review, 17 UCLA Lain Rericw (Review 813). Levin. A. & dills. I.. G. (2003). Fighting for child custody when domestic violence is at issue: Survey of state laws. Social (Fork, /8(4). 163(8) Macdonald, (1999). A I ieu From the Bench. 1(1). The Par and Bench Visitation Report. Winter. The Clearinghouse on Supervised Visitation. Florida State University. Tallahassee. FL, 2-3. Magen, R. II. (1999). in the best interests of battered women: Reconceptualizing allegations of failure to protect. Child Maltreatment, -1(2), 127-135. Magen, H. 11.. Conroy. K.. & Del Tufo. A. (2000). Domestic violence in child welfare preventative services: Results from and intake screening questionnaire. Children and Youth Service Review, 22(3/4). 251-274. Marsh. K. (2000). The services. New York Society For Prevention Of Cruelty 7'o Children Professionals'Handbook On ProridingSupervised Fisitation, A.Reiniger Ed.). 31-35. Mechanic. NI. B.. Uhlmansiek. NI. II.. Weaver, T. L.. Renick, P. A. (200.2). The impact of severe stalking experienced by acutely battered women: An examination of violence. psychological symptoms and strategic responding. 1 iolence and Victims, /5(4). 443-458. Meier. J S. (2003). Symposium: Domestic violence. child custody. and child protection: Understanding judicial resistance and imagining the solutions. .lmeri:can ('nirersity -Journal of (lender, Social Policy & the Lain. Mills. L. G.. Friend, Colleen. C.. Kathryn, Fleck-Henderson. A., Krug, S.. Magen. R. II.. el al. (2000). Child protection and domestic violence: Training practice. and policy issues. Children and Youths Service Hewlett', 22(5). 315-332. Mitchell. I).. & Carbon. S. B. (2002). Article: Firearms and domestic violence: A primer for judges. ,tmerican -Judges .association Court Review, 39 Court Review 32-49. Morris. IL dr. (200:3). Florida College of Advanced Judicial Studies: Unified Family Court. Clearwater, Florida Murphy. J.C. (2003). Symposium: Engaging with the slate: The growing reliance on lawyers and judges to protect battered women. American I'nirersity .Journal of Gender, Social Policy & the Law, 11, 499-521. Nadkarni. L., & Shaw, B. Z. (2002). Making a difference: Tools to help judges support the healing of children exposed to domestic violence. _American -Judges Association Court Review, 39 Court Rei'teu 24-35. National Coalition Against Domestic Violence (NCADV). retrieved from www.ncadv.org/problem/ barriers.htm. last viewed. August 21, 2004. National Institute on Drug Abuse. at http://www.nida.nih.gov/NIDA-Notes/NNVolI7N1/ Childhood.html National Council of Juvenile & Family Court Judges Family Violence Department (1999). Effecter(' Intervention In Domestic I iolence & Child Maltreatment Cases: Guidelines for Policy and Practice, Reno. NV. New. M. d.C.. Stevenson. 1.. & Skuse. 1). (1999). Characteristics of mothers of boys who sexually abuse. Child Maltreatment, 1(1). 21-31. 181 FICTIONAL SAMPLES OF ASSESSMENT & REPORT (Pertaining to Evidence Based Outcomes Section, VIII) Evaluation Monthly Report X Confidential Psychological Evaluation From the office of: 2828 Speer Blvd., Unit 118 Victor H. Cordero, Psy.D., P.C. Denver, Colorado 80211 Licensed Clinical Psychologist Office (303) 455-9480 Clinical & Forensic Psychology Fax (303) 651-3773 Confidential Psychological Evaluation Client: X DOB: November 30, 1979 Date of Evaluation: 10/24/2004 Case #: 09JV 1234567 Reason for Referral Ms. X was referred to undergo a psychological evaluation by XXDepartment of Human Services Case Worker, MM. Specifically this evaluation was requested in order to assist in determining Ms. X's emotional and psychological functioning as these are related to Ms. X's capacity to appropriately function in the parenting role. Techniques Utilized The Personality Assessment Inventory (PM) Millon Clinic Multiaxial Inventory-III (MCMI-III) The Parenting Stress Index (PSI) The Beck Depression Inventory-II (BDI-II) The Beck Anxiety Inventory (BAI) Incomplete Sentences Blank Clinical Interview Mental Status Examination Psychosocial History Interview Review of Records/Collateral Contacts XX Department of Human Services Records MM, XXHS, Personal Communication Conclusions and recommendations are based on the above sources of data only. Information or disclosures not provided to this evaluator may, or may not impact the findings of this evaluation. Brief Relevant Background Family, Relationships and Early History Ms. X is originally from the state of Durango, Mexico. She reports she was born and raised in a rural small town atmosphere. She also spent approximately eight years of her childhood living in small city, but returned to the more rural environment at about ten years of age. Ms. X has resided in the United States for approximately four years and her husband has resided in the United States for approximately five years. She states her future plans are to return to Mexico with her children once the current XXHS case is resolved. Ms. X describes the motivation for 1 X Confidential Psychological Evaluation these plans include the presence of too much pressure due to lifestyle requirements in the United States. She specified that life in the United States requires that both parents work. Consequent to the latter, she is not able to provide enough time and care for her children due to work related demands. In terms of relationship history, Ms. X described having been involved in a cohabitating relationship for approximately two months at the age of fifteen. She alleges this relationship terminated quickly as the man was physically aggressive and violent toward her. Ms. X described, "he would hit me a lot and I was not allowed to go out with him or look at other people." At the age of 18, she married her current husband and they have been involved in a common-law marriage for approximately eight years. The couple have four children from this union, ages, seven, six, three and two. Her children are currently placed with her siblings. Ms. X reports the six-year-old child was raised by her mother as she left the boy with her when they immigrated to the United States when the child was one year of age. Ms. X emotionally recalled that when she sent for the child to be sent to her in the United States, her family did not want to return him. With regard to the quality of the relationship with her current husband, Ms. X described it as "supportive." She alleges, however, her husband is not happy with her not wanting to dress up or go out during the current Human Services case as he perceives her to be somewhat depressed. However, she reports she has great difficulty experiencing enjoyment without her children. In regards to Ms. X's childhood and adolescence, she reports having spent a large portion of childhood without her father present. She states her father spent large amounts of time in the United States providing financial support for her and her family in Mexico. She recalled one incidence of a five year span in which she did not see her father. Ms. X's perception of her family of origin as a child is that she was not treated equally to the remaining children. She describes some difficulties in that time span which reflected an older male sibling who abused alcohol and received much of the family's attention due to this condition. She described having a lot of"hand-me-down" clothing and perceiving that her family did not love her as they did the rest of her siblings. Though as an adult, she now looks back and realizes her at-risk brother required more attention than she did, as she was a low-demand child. In regards to difficult childhood experiences, Ms. X emotionally and tearfully described having experienced sexual abuse by her grandfather at the age of five. She recalled her parents did not believe her at that time, until she was admitted to a hospital due to "feeling bad, difficulty walking and bleeding in the genital area." She reports that during the sexual assault she broke a bottle on the perpetrator's head and blankly recalled, "I remember this like it happened yesterday." She states she recalls thinking she would never marry anyone again for fear that "this would happen again." Ms. X went on to say, she recalled that on her grandfather's deathbed, he asked to see her in order to ask forgiveness. However, Ms. X reports she could not bring herself to see him or forgive him. She states this experience is one reason why her girls are not allowed out of the home. In addition, she also stated she was regularly physically abused by her older brother and that her mother was not able to control this sibling. Prior to the sexual abuse, Ms. X recalled being "a happy and singing girl." After the sexual assault, Ms. X states she changed drastically. Specifically, she reports she no longer trusted anyone, felt guilty for anything that went wrong 2 X Confidential Psychological Evaluation and perceived the whole incident was her fault. She states that while her mother was a good person, her mother was unable to protect her. She reports that consequent to the latter, she moved in with a godmother for some time. She recalled that a significant reason why she moved in with a man at 15 years of age as noted above, was to leave the house, "so that my brother would not hit me any more." Ms. Xis one of eight siblings and currently she reports she gets along well with all of her siblings except for one. All of her siblings reside in the United States, with the exception of one and her parents who continue to reside in Mexico. Ms. X described current relationships with these extended family members by stating that they engage in frequent family gatherings and that their is supportive relatedness between them. According to her, her family greatly supports her in the current case. She alleges that they inform her was careless in her supervision of the children, but that she has to demonstrate to the Department that she is responsible and can get ahead in life. Educational History Ms. X reports she completed eight years of formal schooling in Mexico. According to her, she discontinued her schooling secondary to getting married at the age of 15. Ms. X alleges that while she did not require special education instruction and denied a formal learning disability, she would experience difficulty in learning based on "memory problems." At the times of this evaluation Ms. X was engaged in English instruction classes on a one-time per week basis. Vocational History At the time of this evaluation, Ms. X was not employed. She recalled that her last period of employment was in March, where she was employed for approximately five months in a restaurant/bar. She reports she left this position secondary to a difficult work schedule, which required her to be there from 8:00 p.m. until 2:00 a.m. Ms. X alleges that this schedule left her "sleepy" and therefore perceived she could not care for her children adequately. Prior to that position, she was also employed for approximately one year in three other restaurants as a waitress. In Mexico, Ms. X was not employed on a regular basis. Ms. X reports her husband is currently employed as a roofer. Medical History According to Ms. X, she has experienced what she termed "two small strokes". One allegedly occurred approximately one month prior to this evaluation and the other approximately two years ago. She alleges that these incidents were minor and she has no ongoing weakness, paralysis or other cognitive problems consequent to these events. However, she does complain of increased headaches since these occurred. Ms. X alleges she has ongoing medical checkups for this condition and is ingesting only over the counter pain medication. She reports she was told by medical professionals that she needed to "take care of herself and not stress out." Formal records to verify Ms. X's report of her medical condition were not made available to this evaluator and are worth pursuing to assure no significant or relevant conditions are present. At the time of this evaluation, she was no ingesting any prescribed medications. 3 X Confidential Psychological Evaluation Mental Health and Psychiatric History At the time of this evaluation, Ms. X reports having had no prior contact with a mental health related provider. She reports having no knowledge of ever being diagnosed with a mental health related condition and denies a family history of mental illness. In terms of current functioning, Ms. X does report having experienced what she termed a"serious depression" after the removal of her children. She described this incident as being "locked in" her room and not ingesting significant amounts of nutrition for a period of approximately one month. Additional symptomatology not related to the current XXHS case also stems from Ms. X's reports of ongoing emotional difficulties stemming from childhood sexual abuse at the hands of her grandfather. She also claims ongoing resentment and upset due to perceptions of a lack of support and caring behaviors from her family of origin as a minor. Criminal History According to Ms. X, beyond police contact and charges stemming from the current child abuse/neglect case she has no other prior criminal record. No records to contradict Ms. X's report were provided to this evaluator. Drug and Alcohol History According to Ms. X, she does not ingest alcohol or illegal drugs. No records to the contrary were provided to this evaluator. XXHS Concerns According to XXHS, primary concerns stem from Ms. X's questionable supervision of the children, and her capacity to recognize the potential for harm during episodes of unsupervised time. In addition, as of the writing of this report, caseworker reports indicate that while Ms. X has completed a parenting course, she has not followed through with prior referrals for therapy/counseling. In addition to Department concerns regarding questionable supervision and minimizing of the potential harm to the children, caseworker noted the presence of childhood sexual abuse and whether or not this impacted Ms. X's current mental health state. Client Perspective of XXHS According to Ms. X, her perspective of The Department's concerns them from their allegations of poor supervision of her children. In addition, she reported she has been accused of medical neglect of one of her children who was suffering from some form of vaginal infection, stating she was accused of not attending to this medical condition promptly. In regards to these reports from the Department, Ms. X stated that in fact the girls had been left unattended on the first occasion. She admitted that at the time, she perceived that the six-year-old child was able to adequately supervise the other children for a brief period of time. She reports that her assumption about her children's safety stemmed from her ordering the child not to open the door, touch the stove or other instructions which she perceived the child would be able to comply with during mother's absence. She states she only left them for brief amounts of time, and specified she would leave the home to a location one to two blocks away. The second removal concerns, again stemmed from the Department finding the children alone and unsupervised. Ms. X, 4 X Confidential Psychological Evaluation however, recalls that on this particular incident she left the girls in the upstairs portion of the home where they rent a basement. She alleges her understanding of what occurred is that the children went downstairs to the basement and were there alone when the Department made a visit. Ms. X states she trusted in her neighbor (the upstairs resident) to have kept an eye on the girls and not allow them to be unsupervised. However, she admitted that it was her mistake as she should have just taken the girls with her. In regard to the allegation of possible medical neglect, Ms. X reported her understanding was that the appointment to treat the child's condition was not a two-day away medical appointment as claimed by XXHS, but rather was a six-week appointment. She alleges she had paper proof of this more extended appointment. When discussing the Department's concerns regarding inadequate supervision of the girls, Ms. X stated she now realized she was completely in the wrong and that her perceptions of the girls' ability to supervise themselves was mistaken. She stated, "I realized anything could have happened, the stove, hot water, a stranger..." She went on to say that she feels badly as in the event of an emergency, "it could have been bad." She perceived that this mistaken mentality stems in part from "how it was in Mexico". When asked to clarify, she related that she perceived outright dangers were not as readily present in Mexico and that customs and beliefs regarding such child rearing behaviors were more tolerated. Mental Status Examination and Behavioral Observations Ms. X arrived for her appointment session on time. She presented as a neatly dressed young woman and hygiene is unremarkable. Ms. X appears her stated age and responds to all questions that were asked of her in a cooperative manner. Psychomotor activities are mildly decreased and Ms. X is noted to sit in a fairly rigid posture. No other specific mannerism or gestures are noted during the evaluation session. No gross evidence of distractibility or exaggerated self-absorption is noted. Speech is unremarkable in terms of volume and rate. Mood is mild to moderately dysthymic and affect is largely decreased in range. Ms. X presents with episodes of weeping when discussing her children's removal and some aspects of her history as well. No episodes of uncontrolled lability are noted at any point of the evaluation session. She does not demonstrate episodes of irritability or hostility regardless of topic of discussion. Per Ms. X's report, sleep patterns are improved toward more normal levels. She describes frequent crying spells when discussing her children with others. Ms. X perceives herself to be more motivated and looking forward to the future in contrast to the beginning weeks of this case. Ms. X is fully oriented at the time of this evaluation. Simple tasks of memory and concentration are performed adequately. Thought processes are logical, coherent and goal-directed. No delusional thought content was noted. Ms. X does not evidence signs or symptoms suggesting hallucinations and there is no evidence of a thought disorder. Ms. X denies suicidal and homicidal ideation. 5 X Confidential Psychological Evaluation Results and Impressions Intellectual and Cognitive Assessment Ms. X does not present with gross evidence of significant organic dysfunction based on clinical interview, mental status examination, and psychosocial interview. Informal estimation of intellectual functioning was felt to fall within the average range based on vocabulary, comprehension, abstract reasoning, fund of information and educational attainment. No concerns or reports of intellectual cognitive difficulties were reported by any available source. In light of these results, there appear to be no cognitive or intellectual deficits present which should significantly and specifically interfere with Ms. X's capacity to modulate behavior, modulate emotional expressiveness, appreciate right from wrong, or benefit from therapeutic interventions designed to improve parenting skills. Consequently, limits to or inefficiencies in general parenting skills, if identified, are felt to stem from dynamics in the realms of parenting skills deficits and/or other areas of emotional/psychological functioning. Emotional and Personality Assessment On the PAI, an instrument utilized to generate hypotheses about an individual's characterological and emotional functioning, Ms. X's response profile was determined to be valid. Ms. X's profile on this particular instrument reflected a fairly elevated profile, with notable clinically elevated scores on multiple scales. Generally speaking, the most notable clinical scale elevations suggest that Ms. X is currently experiencing multiple symptoms of anxiety related problems. The pervasiveness of her symptom endorsement would suggest she is experiencing high levels of anxiety, worry and tension to a point where it may interfere with her ability to carry out day-to- day roles and which suggests she may experience episodes of overwhelming emotional discomfort. In addition, less intense, but nonetheless present, symptom endorsement suggesting mild to moderate levels of dysphoria and despondency were also present. A notable result, particularly given Ms. X's biographical information, is an elevated profile on the anxiety related subscales which would suggest that she continues to experience difficulties with a traumatic event of the past. While the specific etiology of this event is not noted, the traumatic event continues to cause her distress and recurrent anxiety. This result would be congruent with Ms. X's self report of ongoing emotional difficulties stemming from childhood sexual abuse. From an interpersonal perspective, Ms. X's profile would suggest that at this point in time, she perceives her environment in fairly distrustful and suspicious manners. She likely perceives herself to be largely misunderstood and may be perceived by others as unattached, impulsive or irritable at times. On the treatment scales profile, Ms. X's item endorsement would suggest she is currently experiencing high levels of stress consequent to some major life area. This level of stress causes her high levels of worry, rumination and anxiety. Ms. X's profile also identifies that she currently acknowledges major difficulties in functioning and perceives herself to be in high need of help to resolve these current difficulties. On the MCMI-III, a measure utilized in conjunction with additional data to generate hypotheses about an individual's emotional functioning and potential negative characterological conditions, Ms. X's response was valid. Generally speaking, Ms. X's profile identifies clinically significant elevations on scales, which as noted above, suggest the presence of high levels of anxiety, tension and worry. In addition, elevated levels of suspicion, distress, and vigilance toward others 6 X Confidential Psychological Evaluation and the environment were also present. Ms. X's profile on this instrument also suggests a propensity toward negativity and perceptions of herself as a victim of circumstance. Interpersonally, these results identify Ms. X as not highly prone toward increased levels of interpersonal contact and connectedness, preferring smaller circles of support and a reserved lifestyle. The PSI is a measure which assesses potential stressors in the parent-child relationship. Ms. X's profile on this particular instrument was valid. This instrument distinguishes between those characteristics or dynamics in the child which the parent perceives contributes to stressful dynamics from those characteristics or dynamics the parent perceives are inherent to the parent themselves. On the child domain, Ms. X's profile identified clinical elevations on two of the six scales. Clinical elevations on the Adaptability Scale are associated with characteristics that challenge the parent by virtue of the child's alleged inability to adjust changes in his or her physical or social environment. Examples of such difficulties include the inability to change from one task to another without upset, over reaction to changes, avoidance of strangers, and difficulty calming after upset. Demandingess Scale elevations are produced when the parent experiences the child as placing many demands upon her. These demands may come from various sources, including crying, clingy behavior, frequent requests for help or a high frequency of minor problem behaviors. Young parents tend earn somewhat elevated scores on this subscale, as do parents of children who are very dependent or who have failed to successfully negotiate the task of individualization. On the Parental Domain of the PSI, Ms. X's profile identified clinical elevations on two of seven scales. High scores on one scale, the Depression Scale, are suggestive of the presence of significant depressive symptoms in the parent. Some items relate to guilt or unhappy feelings, which may correspond to dissatisfaction with the self and life circumstance and not necessarily to a clinical depression. Generally speaking, high scores on this subscale suggest the parent may find it difficult to mobilize the psychic and physical energy needed to fulfill parenting responsibilities. Withdrawal and an inability to act with assertiveness and authority toward parenting may manifest when such scale elevations are observed. The second scale was sub-clinical but elevated relative to the remaining scales nonetheless. This scale, the Competence Scale, suggests there are a number of factors which the parent perceives are lacking such as practical child development knowledge or a limited range of child management skills. Parents who find the role of parent not as reinforcing as they had expected, also evidence elevations on this scale due to feelings of being overwhelmed. The hypotheses generated by the PSI should be verified by means of direct observation of parent- child dynamics and relatedness. Two screening instruments utilized for depression and anxiety symptoms resulted in various endorsements in both of these areas of functioning. A depression inventory results corresponded to moderate levels of symptom endorsement with particular emphasis on those aspects of depression considered more cognitive in nature. The later include a higher endorsement of symptoms such as self-criticism, self-loathing and feelings of guilt. Similarly, the anxiety screening inventory resulted in milder levels of anxiety with particular emphasis on those aspects of anxiety considered more cognitive, such as worry about the future, fears that the worst will happen, followed by more physiological aspects of anxiety such as feelings of tension, 7 X Confidential Psychological Evaluation nervousness, difficulty breathing and weakness. A simple projective instrument did not identify bizarre or distorted themes or thought processes. Diagnostic Impressions AXIS I Anxiety Disorder, Not Otherwise Specified Traits of Posttraumatic Stress Syndrome (PTSD) Depressive Disorder, Not Otherwise Specified, mild Neglect of Child AXIS II Deferred AXIS III Chronic headaches per client report Unclear report per client of what is described as"mini strokes", mild, no alleged ongoing significant problems per client report (no documentation to verify) AXIS IV XXHS Involvement, removal of children AXIS V Current GAF: 60 Summary and Clinical Impressions Ms. X presents as a 55 year old Spanish speaking young woman, currently referred for psychological evaluation consequent to distinct episodes of inappropriate supervision of her children. This evaluation identifies that Ms. X is not limited by intellectual or cognitive abilities, and therefore, possesses and adequate cognitive capacity to appreciate the potentially harmful nature of her actions and to benefit from interventions which might be implemented in order to improve her functioning in the general area of parenting skills. In regards to personality and emotional-behavioral functioning, Ms. X currently endorses various signs and symptoms suggestive of an anxiety related disorder foremost and secondarily, demonstrates lesser, yet impacting, symptoms of a depressive disorder. With regard to the anxiety related difficulties, these appear to be largely chronic in nature and most likely stem from Ms. X's ongoing difficulties with early childhood sexual abuse. As the sexual abuse was allegedly committed by a now deceased grandfather, the familial connections to not only the perpetrator, but more importantly to re-exposure of linked traumatic stimuli are likely present. The most specific and detailed symptoms as described in testing and corroborated by Ms. X's self report, include intrusive recollections of the abuse, episodes of emotional numbing or lability, as well as nightmares and ongoing subtle resentment toward parental figures. It would appear the current trauma of having her children removed also potentially triggered this prior a X Confidential Psychological Evaluation experience of trauma-based symptoms, though these appear to have diminished in recent months, per her own report. With regard to depressive symptoms, Ms. X's presentation and item endorsement would suggest milder levels of difficulty, though these do appear to impact her interpersonal and familial functioning to some degree. Her experience and symptom complaints will fluctuate depending on circumstance. Consequently, at this point in time, Ms. X would benefit from both therapeutic and pharmacological consideration as a means of improving overall mood and familial functioning. With regard to Ms. X's instances of lacking parental supervision and errors of judgment with regard to the care taking of her children, it would appear these actions on her behalf were not malicious or of ill intent. Rather, these do appear to reflect not only life circumstance (i.e. the unavailability of proper childcare), but also distinct errors of insight,judgment, and distorted attitudes toward expected norms for parenting. In addition, an initially decreased level of appreciation for the potential risks involved was present. Her emotional status as reflected in anxiety/depressive symptoms is also a potential contributor with regard to the possible influence of lacking motivation, diminished capacity to prioritize, diminished concentration, and perhaps a diminished capacity to plan ahead and invest appropriately in her children's emotional well being. As such, episodes of parenting skills deficits appear to be amenable to a skills enhancement approach and prognosis is considered positive with respect to this specific area of functioning if she can demonstrate full accountability and recognition of the risky nature of her actions and seek assistance for her emotional well being. With regard to emotional/psychological constraints, Ms. X's motivation for treatment will be important to gauge. This assessment clearly identifies that she is emotionally impacted by difficult, historical events in her life. High investment in exploring these issues may prove fruitful to her personally, but may also provide insight as to other emotional contributions to maladjustment in the family, will improve self insight, and may identify other catalysts for the observed neglectful parenting behaviors. Recommendations Ms. X should be referred to undergo a medication evaluation to assess the appropriateness of pharmacological agents with respect to her anxiety and depressive symptoms. Ms. X would benefit from a referral to individual therapy. The specific areas or goals to address in this setting include, but are not limited to the following: - Assist Ms. X in positive coping and adaptation to the current Human Service case. - Assist Ms. X in exploring and appropriately processing childhood sexual abuse issues, particularly as these affect current levels of emotional and interpersonal well being, availability to her children, and personal decisions. -Assess and assist Ms. X in identifying those areas of functioning that interfered with optimal parenting and supervision/caretaking of her children as identified by Human Services. 9 X Confidential Psychological Evaluation - Monitor Ms. X's mood and coping to include self harm monitoring. Efforts to assure Ms. X has complied and has obtained adequate levels of progress in all Department interventions requested to date, should be pursued. Given the findings of this evaluation, this evaluator would recommend that informal assessment of Ms. X's interactions with her children take place. If concerns are identified, a formal parent- child interactional or other visitation time assessment should take place to specify areas of need. If interactions and relatedness between mother and children are adequate, primary focus on skills building and individual therapy/medication evaluation should suffice. Ms. X's motivation and compliance with the family service plan will be an important indicator of her ability to prioritize and place her children's needs in the forefront. As such, inability to demonstrate appropriate compliance and progress in all the above would raise concern as to her internal resources and motivation at this point in time. Ms. X should demonstrate the ability to provide for the physical, educational, health, and nutritional needs of her children. This mother will require linguistically and culturally competent service providers as a means of increasing probability of success. Efforts to assure mother is pursuing medical care for herself with regard to her complaints of a "mini stroke" should be pursued. Verification of her alleged MRI and other laboratory exams should be pursued despite lack of overt symptomatology. Please contact this evaluator with any further questions or clarifications regarding the evaluation of Ms. X. Victor H. Cordero, Psy.D. Licensed Clinical Psychologist Bilingual Evaluator 10 X Family From the office of: 2828 Speer Blvd., Ste. 118 Victor H. Cordero, Psy.D., P.C. Denver, CO 80211 Licensed Clinical Psychologist Office (303) 455-9480 Fax (303) 651-3773 Treatment Summary Brief Family Therapy Client(s) MOTHER OF CHIILDREN Ms. X DOB: 01/01/1971 Age: 30 Children: A Age 12 B Age 11 C Age 8 D Age 3 Span of Treatment: 10/12/2005 -01/31/2006 Format: Biweekly, In-Home Total Number of Sessions Completed: 6 Reason for Referral & Brief Background Information: This family was originally referred by X Department of Human Services Caseworker, MM to undergo 6-8 sessions of brief individual family therapy. The goal of the therapy was to assure that the family members were adequately coping with recent instabilities including housing, financial, separation of parents, and chronic exposure to significant domestic violence in the home by their father in years past. Mental health evaluations were previously performed on all family members and a brief number of sessions were recommended to follow-up and assure adequate family functioning prior to closing this case. Impressions of Family Member Dynamics & Coping The family was seen in different constellations of family members to increase observation of differing family dynamics and intensity of services per single visit. All family members will be discussed in relation to the larger family system. Most notable in A, the oldest child, was his emerging adolescence and mother's reaction to this developmental stage. Therapy sessions were utilized to assist mother in recognizing A's experience of the previous domestic violence and how his role as her "protector" at that time, has now changed to more expected and developmentally appropriate levels since father is no longer involved. Mother was counseled regarding appropriate expectations of his behavior and how A should not be allowed to re-engage in a parentified role. A himself was allowed to discuss his feelings in terms of the previous 1 X Family domestic violence he witnessed. Recommendations to mother included enrolling him in a"big-brother" or mentorship type program, or school based extracurricular activities as A needs a place to grow both in terms of self-esteem, and socially. B is the"brain" in this family system and her role in this family manifests as a passive, obedient, and quiet girl. In contrast C, is spunky and playful. These girls seem to balance each other out and formed a close dyad during family sessions. They were generally smiley, happy, and despite their different communication styles, did not have difficulties in expressing relief of their "new life" without violence in the home. The girls were able to communicate their needs to mother and both displayed age appropriate behaviors during all sessions. No regression or anxiety related behaviors were observed in these two young girls. D is the youngest child and presents as mother's greatest challenge. This is a very active little boy who requires frequent structuring, direction, and limit setting. He was too young developmentally to be greatly impacted by father's violence and thus, his "hyper" state is likely to reflect other etiology. It was recommended to mother that she look into enrolling D in a school based program or preschool program next year. This would hopefully assist in providing a more structured learning environment for D as well as give mother respite. Despite high activity and rambunctious behavior, D did not present with concerning aggression or other indices of poor adaptation or emotional difficulties. Mother continues to present with resilience, although, she does lack some direction in terms of"life ambition". It may be that stepping out of the domestic violence "cycle" appears to have left her with uncertainties in regards to what her role is beyond that of "mother" to four children. In part, recommending that D be enrolled in school would also provide mother the opportunity to increase her social support system, which is somewhat lacking. Additionally, seeking employment of some type was highly recommended as there was a sense that mother's activities outside the home were very limited. Generally speaking, mother's coping was adequate and it is felt that with some direction and prompting, she is capable of directing more energy toward self-care in terms of activities which will build her esteem and personal identity such as employment and a social life. Conclusions As previous mental health evaluations of these family members suggested, this family's coping and adaptation to past instability is surprisingly positive. Brief family therapy sessions revealed high amounts of resiliency in this family and problems in functioning, if identified, are not felt to reflect ongoing difficulties in adjustment to previous circumstance or reason for XXHS involvement. It appears that now that many of the previous pressures have been minimized (housing, financial, father's violence), the children's personal identities are emerging and all are regaining developmentally appropriate attitudes and behaviors. Mother has also begun to experience some cognitive discomfort in terms of her role beyond "mother" and while this provides for some frustration on her part, it is felt to be a healthy response. Most notable in all family members, the older children in particular, is a common sense of relief and a maturity in 2 X Family terms of their thoughts and feelings about their father. While all displayed an appropriate emotional connection to him, they also expressed no desire for his presence as their perspective on the unchanging nature of his aggression toward their mother is fairly realistic. Overall, this family's manner of coping and dealing with difficult circumstance in the past appears positive. All family members have utilized their resources in terms of moving on and appear to be settling into their"new" family roles appropriately. It is hoped that mother will accept the recommendation that she begin to emerge, as her children have emerged, into new roles and activities. She is in the initial stages of this change and hopefully, exploring occupational and social activities will impact her in a positive way and reflect on her children. If this family can maintain the cohesion that has been displayed throughout this ordeal, indicators for a positive outcome, with time, remain. Thank you for the opportunity to work with this family. Please contact me with any further questions or follow-up concerns. Victor H. Cordero, Psy.D. Licensed Clinical Psychologist 3 SAMPLE FICTIONAL MONTHLY BILLING (From section XI) • 5310.213(2/79) COLORADO STATE DEPARTMENT OF SOCIAL SERVICES AUTHORIZATION FOR CONTRACTURAL SERVICES 1. WELD COUNTY DATE: in A RCN 3 I l ?c C7 L 2. 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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 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 DENVER, CO 80211 Au orized Representative • t W(6 { •• W � ,W�j 1= • EXHIBIT B SUPPLEMENTAL NARRATIVE TO RFP 05/22/2006 10:45 3036513773 DR. V.H. CORDERO PAGE 02/06 RE: Bid 06M1105 (RIP 006-00) Requested Conditions: 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.H. CORDERO PAGE 03/06 RE: Bid 06L508 (RFP 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 Lxpciience, family therapy, child development and child therapeutic services. High emphasis for any staff member will be plarM on ethical and competent delivery of services. 05/22/2006 10:45 3036513773 DR. V.H. CORDERO PAGE 04/06 RE: Bid 06M1105 (Mental Health)&Bid 06LS08 (lifeskills) Requested Compliance Item Letters to provide proof of collaboration with County Housing and Employment Training. Housing Authority: Obtained and attached letter,though a minor correction needs to be made and will resubmit with accurate information Employment Services:Have merle 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 06MH05(Mental Health)& Bid 06LS08 (lifeskills) Requested Compliance Item Facilitation of Medicaid eligible client's raparity 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. CORDERO PAGE 06/06 05/18/2006 10:43 FAX 870 346 7690 GREELEY/WELD HS8 AUTH 1®0V2/VVZ GREELEY/ WELD HOUSING ,AUTUORITIeS P.Q. box 1.30 iiii No Qreeley, Colorado 80632-0130 (970) 353 7437 May 19,2006 (970) 5537463 Pax (800) 659-2656 771'Relay Victor Cordeia,MA,LPG 2828 Speer Blvd Unit 118 Denver.Co 80201 Dear Mr.Cordele: As a Housing Authority we would be glad to accept any appropriate referrals for clients needing our services from your office. If you ire awarded a contract to work with Weld County clients we will be agreeable to otter Into a Menaorandmn of Understanding concerning the services provided by each agency. If you have any questions please cent=me at(970)353-7437 ext 103 Sincerely, C a.. Thomas Teixeira Executive Director Housing Authonty of the City of Greeley - V/eta County Housing Authorityth 903 6th Steel • Greeley, Colorado a"""�.." 05/22/2006 10:45 3036513773 DR. V.H. C0RDER0 PAGE 01/06 Victor H.Cordaro,Psy.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 19,20% Weld County Department of Social Services ATTN: Gloria Romansik RE:Bid 06M1105 (RFP 006-00)Mental Health Services Bid 06LS08 (RFP 05005)Lifesidals 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, n- " \LASH \ "t . snc—rg-iQ— Victor H. Cordaro,Psy.D. Licensed Clinical Psychologist 05/22/2006 13:15 3036513773 DR. V.H. CORDERO PAGE 01/03 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 Rowansik RE: Bid 06MH05 (RFP 006-00)Mental Health Services Bid 06LS08 (REP 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. 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 18703583975; 05/22/2008 2:54PM; 5291; Page 2/3 DEPARTMENT OF HUMAN SERVICES EMPLOYMENT SERVICES OF WELD COUNTY 1561 NORTH 17TH AVENUE PO BOX 1805 GREELEY,CO 80832 (970)359.3800 FAX(970)3563975 COLORADO May 22,2006 Victor H. Cordaro,Pay.D. PIC. Employment Services of Weill County is providing you this letter outlining the areas of collaboration when a client you serve uncial CORE service funds is identified as having an employment need. The collaborative areas were developed from your responses concerning the parameters you felt were practical,based upon the set tees you intend to provide. Victor H.Cordaro,Psy.D.P.E.is proposing services to work with adolescents and families for psychological evaluations,parent/child interaction evaluations,visitation,and family therapy services. It is unknown if these servil have a direct relationship to employment,however,the following outlines the plan for referrals!when,or if,they arise: Case management: Dr.Cordtmi agrees to provide case management for families that may require the parent or youth to seek emplcifmtent. For these individuals,Dr.Cordaro agrees to make a referral to Employment Services of Wel$County. i Referral process; For indlvidbrals identified as having employment needs,Dr.Cordaro will refer the client to Employment Servio+of Weld County and will send an email to Employment Services,under the attention of Linda Perez,ringing that the client was referred.Dr.Cordero agrees to forward the email within five business daps of making the re&aal. 1 Follow tan: Dr. Cordero williemail a follow-up concerning the referral made to Employment Services of Weld County 10 business days after sending the initial email. Employment Services of Weld County will entail Dr.Corder if the client does not contact us,and agrees to discuss the matter with rho client at their next visit. Dr.Cordaro win provide a written entail of that discussion to the attention of Linda Perez within five business days. Cross training: if new staff ale hired by Dr.Cordaro,they will be made aware of this collaborative arrangement and will be provided training concerning the employment and trewnlrog services offered by Employment Services of Well County. 05/22/2006 13:15 3036513773 DR. V.H. CORDERO PAGE 03/03 Sent by: HUMAN SERVICES 10703503975; 05/22/2008 2:54PM; #291; Pape 3/S • weer collaborative areas: Al this time there are no additional collaborative effor is 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 mkt with Dr.Cordero in July 2006 to initiate the collaborative Memorandum of Understanding process once bids for CORE services are completed and accepted. Sincerely, L.Perez Director Employment Services of Weld County • • } a DEPARTMENT OF SOCIAL SERVICES P.O. A BOX GREELEY, CO. OX Website:www.co.weld.co.us ' Administration and Public Assistance(970)352-1551 Child Support(970)352-6933 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, Ju A. 'e o,Direct cc: Juan Lopez, Chair,FYC Commission Gloria Romansik, Social Services Administrator Hello