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Home My WebLink About20051650.tiff RESOLUTION RE: APPROVE FIVE NOTIFICATION OF FINANCIAL ASSISTANCE AWARDS FOR HOME STUDY, HOME STUDY UPDATES, AND RELINQUISHMENT COUNSELING WITH VARIOUS PROVIDERS AND AUTHORIZE CHAIR TO SIGN WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, the Board has been presented with five Notification of Financial Assistance Awards for Home Study, Home Study Updates,and Relinquishment Counseling 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, 2005, and ending May 31, 2006, with further terms and conditions being as stated in said awards: 1. Transitions Psychology Group, LLC 2. North Colorado Medical Center- Youth Passages 3. Julie Box, Private Practice 4. Alpine Christian Services, Inc. 5. Jubilee Retreat Center- Lori Kochevar, LLC 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 Home Study, Home Study Updates, and Relinquishment Counseling 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. 2005-1650 SS0032 re; SS 06-02/ O.S-- FIVE NOTIFICATION OF FINANCIAL ASSISTANCE AWARDS FOR HOME STUDY, HOME STUDY UPDATES, AND RELINQUISHMENT COUNSELING PAGE 2 The above and foregoing Resolution was,on motion duly made and seconded,adopted by the following vote on the 6th day of June, A.D., 2005, nunc pro tunc, June 1, 2005. EL, BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO 1861 fl; ' S '� William H. Jer , Chair O filer• d �r Clerk to the Board ,`�►q.1N1 ile, Pro- em s Deputy Clerk to he Board 67 D ' E. Long APP A • Robert D. Masde unty tto y ,4 .RdAa ( AL Glenn Vaad Date of signature: ‘ - -z9,% 2005-1650 SS0032 6 cft a DEPARTMENT OF SOCIAL SERVICES P.O. BOX A GREELEY, CO. 80632 Website: www.co.weld.co.us Administration and Public Assistance(970)352-1551 II Child Support(970)352-6933 O MEMORANDUM • TO: William H. Jerke, Chair Date: June 2, 2005 COLORADO Board of County Commissioners FR: Judy A. Griego, Director, Social Services 0 441 RE: Notification of Financial Assistance Awards for Home U QQ Study, Home Study Updates, and Relinquishment Counseling with Various Providers Enclosed for Board approval are Notification of Financial Assistance Awards (NOFAAs) for Home Study,Home Study Updates, and Relinquishment Counseling between the Weld County Department of Social Services and various providers. The NOFAAs are based upon the provider's Request for Proposal, which has been reviewed and approved by the Families,Youth and Children(FYC) Commission. The NOFAAs were reviewed at the Board's Work Session of May 31, 2005. The major provisions of the NOFAA are as follows: 1. The term period is from June 1, 2005 through May 31, 2006. 2. The Department agrees to reimburse providers under Child Welfare Administration funding according to the NOFAA and their respective bid proposal for Home Study, Home Study Updates, and Relinquishment Counseling. These homes studies assess the suitability of foster care and adoptive homes for children in the custody of Social Services. 3. Providers will be reimbursed according to various rates and services as provided below: No. Core Services Description of Program/Special Award Amount Contractor Conditions A. Transitions Psychology Average of 10 families per month for: $1,115 per full home study Group home studies is eight weeks; six weeks for $725 per updated study updates and relinquishment counseling, $111.50 per hour for with an average of two hours per relinquishment participation per week. Incomplete home counseling study is at 3.5 hours. Additional home $150 per hour court studies will be billed at$250 per person. testimony B. NCMC-Youth Passages Maximum capacity is 10 families. $900 per full home study Incomplete home study is at 3.5 hours. (5 interviews) Additional home studies will be billed at $950 per full home study $250 per person. (6 interviews) $1,000 per full home study (7 interviews) 2005-1650 $1,500 per full home study (8 interviews) $2,000 per full home study (9 interviews) $600 per updated study $80 per hour for relinquishment counseling $155 per hour court testimony C. Julie Box,Private Average of 6 weeks for a home study and $850 per full home study Practice two weeks for each parent in (background check) relinquishment counseling. Incomplete $750 per full home study home study is at 3.5 hours at a cost of (no background check) $225. Additional home studies will be $425 per updated study billed at$250 per person. $103.89 per hour for relinquishment counseling D. Alpine Christian Minimum of 16 hours per week per family $1,200 per full home study Services with a maximum of 4 families at a time. $70 per hour for update (Lakewood) Incomplete home study is at 3.5 hours at a done by Alpine— cost of$250. Additional home studies will maximum of$1,000 be billed at$250 per person. $1,200 for update study not done by Alpine E. Jubilee Retreat Center— Average is 6 home studies and 1 $988.17 per full home Lori Kochevar relinquishment counseling per month. study Referrals will be for Foster Parent Home $562.87 per updated study Studies only. Incomplete home study is at $86 per hour court 3.5 hours. Additional home studies will be testimony billed at$250 per person. If you have any questions, please contact me at extension 6510. Weld County Department of Social Services Notification of Financial Assistance Award for Child Welfare Regular Administration Type of Action Contract Award No. X Initial Award 05-HS-0029 Revision (RFP-06-000) Contract Award Period Name and Address of Contractor Beginning 06/01/2005 and Transitions Psychology Group,LLC Ending 05/31/2006 Home Study,Updates,and Relinquishment Counseling 804 11th Avenue Greeley,CO 80631 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Assistance Capacity for three new referrals per month,two new Award is based upon your Request for Proposal(RFP). referrals per month for updates,and four referrals per The RFP specifies the scope of services and conditions of month for relinquishment counseling. Total monthly award. Except where it is in conflict with this NOFAA in capacity is 18 families,with a monthly average of 10 which case the NOFAA governs,the RFP upon which this families.Approximately 100 individuals would award is based is an integral part of the action. receive Bilingual-bicultural services,and an Special conditions estimated 105 individuals would receive services in 1) Reimbursement for the Unit of Service will be based on a South Weld County.The average stay in the program rate per home study;home study update, and is eight weeks for home studies,six weeks for relinquishment counseling session. updates and relinquishment counseling,with an 2) Reimbursement requests must be an original with an average of two hours participation per week. Services original signature from the provider and/or designee. are available in English, Spanish, and Japanese. 3) Reimbursements requests must include the date the home Cost Per Unit of Service study,update,or relinquishment counseling was completed. Rate per Study The request must reflect the referral number assigned to Full Home Study $1,115.00 each home study,the amount billed for each home study, Updated Home Study $725.00 and the month the service was provided. Hourly Rate per 4) Payment will only be remitted on referrals made by Relinquishment Counseling $111.50 the Weld County Department of Social Services. Court Testimony $150.00 5) Requests for payment must be an original submitted to the • The threshold for hours for an incomplete home study Weld County Department of Social Services by the end of will be set at 3.5 hours. the 251°calendar day following the end of the month of • Turnaround time for receipt of the completed home service.The provider must submit requests for payment on study is 6 weeks from the date of receipt of the forms approved by Weld County Department of Social referral. Services. • Additional home studies will be billed at a maximum 6) The Contractor will notify the Department of any changes of$250 per person. in staff at the time of the change. Enclosures: X Signed RFP:Exhibit A X Supplemental Narrative to RFP: Exhibit B Recommendation(s) X Conditions of Approval Approvals: Program Official: By ot-,1/YA,'' By William H.Jerke,Chair Judy . Griego, irector Board of Weld County Commissioners Weld un Department o Social Services Date: JUN 0 6 Zoos Date: t(1 Z'o c •pooS - ( e, SC) SIGNED RFP: EXHIBIT A INVITATION TO BID 0. TE:February 16, 2005 Bid No. 002-05 RFP FYC 006-00B 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 006-00B) for: Adoption, Foster Care, and Expedited Permanency Planning Home Studies, and Relinquishment Counseling Deadline: March 11, 2005,Friday, 10:00 a.m. The Families, Youth and Children Commission, an advisory commission to the Weld County Department of Social Services, announces that competing applications will be accepted for approved vendors pursuant to the Board of Weld County Commissioners' authority pursuant to Colorado Statute and the Weld County Home Rule Charter. The Families, Youth and Children Commission wishes to approve services targeted to run from June 1, 2005,through May 31, 2006, at specific rates for home studies, home study updates, and relinquishment counseling services. The County will authorize approved vendors and rates for services only. 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 GvechovNicS • Cn.c'cl US (After receipt of order) BID MT 1tE SIGNED IN INK TYPED OR PRINTED SIGNATURE VENDOR TrohSid-.w-srse"k•b7 Grout) U-C. (Name) 0 andECgnature By Authorized Officer or Agent of Vender ADDRESS PSI ll'k`'Avcvmwe. TITLE Co 41 r acCev' & \b-). JD' go 63) DATE 3 MMMo 77 PHONE# (99-O) 371.-112-3 The above bid is subject to Terms and Conditions as attached hereto and incorporated. Page 1 of 35 Bid No. 002-05 RFP-FYC-006-00B Attached A .HOME STUDY, UPDATE, & RELINQUISHMENT COUNSELING BID PROPOSAL AND REQUEST FOR CONTINUATION OF AWARD UNDER CHILD WELFARE ADMINISTRATION FUNDING 2005-2006 BID PROPOSAL APPLICATION PROGRAM FUNDS YEAR 2005-2006 Bid 002-05 RFP-FYC-006-00B NAME OF AGENCY: TrG+n$+44 eo..S ps`aCLLIt"n CTr'."f e ' ADDRESS: 2011 tlt" AVt"t t Gr.. *t a , CO V4'31 PHONE: (17o) 336— )3 CONTACT PERSON: Gvci " t S • C rtm4 TITLE: CrA` DESCRIPTION OF HOME STUDY PROGRAM CATEGORY: Adoption, Foster Care, and Expedited Permanency Planning Home Studies in compliance with the uniform format utilized by the State of Colorado Department of Human Services since October 1, 1999 (Attached A). 12-Month approximate Project Dates: 12-month contract with actual time lines of: Start June 1, 2005 Start End May 31,2006 End TITLE OF PROJECT: it ewe s n jaw Ltoe-ftavtyinavl , MA-, (47 , Ix_} Name and Signature of Person Preparing Document Date -vd C <2 —340/05"-- e an ignature ief Administrative Officer Applicant Agency Date MANDATORY PROPOSAL REQUIREMENTS For new and renewal bids,please initial to indicate that the following required sections are included in this Proposal for Bid. For renewal bids,please indicate which of the required sections have not changed from Program Year 2004-2005 to Program Year 2005-2006. `,.g1- Project Description Indicates No Change from 2004-2005 /yl Sample Home Study Project Description T. ,et/Eligibility Populations Sample Home Study ;IV eneral Indicates Target/Eligibility Populations ultural/Eligibility Populations General Types of services provided Cultural/Eligibility Populations Measurable Outcomes _Types of services provided Service Objectives Measurable Outcomes Workload Standards Service Objectives Staff Qualifications Workload Standards Unit of Service Rate Computation Staff Qualifications rogram Capacity per Month _ Unit of Service Rate Computation Certificate of Insurance Program Capacity per Month Page 23 of 35 03/07/2005 NON 09:46 FAX 2002/004 Bid-Number-003-05(RIP- 006---006-009 Attaatil A / Date of Meeting(s)with Social Services Division Supervisor: p/sgC firm, CS Comments by SSD Supervisor: Pie, ale- la #4 eel .L'a /'1_-1- . _ fl4 , Yfltf Name and S' of SS'. .upervisor Date Home Study Program Bid Proposal Transitions Psychology, LLC 1 • 2005-2006 • . • ♦ Home Study, Update and Relinquishment �•� Counseling Bid Proposal • • •• ♦ , 2005-2006 • ♦•� ••. , • a ♦ •Sa ♦ Transitions PSYCHOLOGY GROUP, LLC I. PROJECT DESCRIPTION Transitions Psychology Group, LLC is a private counseling agency consisting of a multidisciplinary team of human service professionals, including Licensed Psychologist and School Psychologist, Licensed Professional Counselors, Licensed Clinical Social Worker and other degreed paraprofessionals. Transitions provides superior counseling, assessment and consultation services to children and families in Northern Colorado. The purpose of the Home Study, Update and Relinquishment Counseling program is to provide quality home assessment and consultation services to expedite permanency placements of children in Weld County. A. Home Study The Home Study segment of the program strives to effectively and efficiently evaluate prospective foster and adoptive homes in order to provide for safe, nurturing environments for children as quickly as possible. A Home Study begins with a referral from a Weld County caseworker. A staff member from Transitions Psychology Group, LLC (hereafter referred to as "Transitions") begins the study by gathering background and reference information. The family is asked to complete an application, self-study forms and a FACES (Family Adaptability and Cohesion Evaluation Scales) assessment form. A Transitions counselor contacts the referred parent in order to schedule a Family Screening. The Family Screening interview is held in the family's home and includes all members of the household. The home, yard and neighborhood are viewed by the Transitions counselor at this time. When the screening process is completed, a second Transitions counselor meets with the prospective foster/adoptive parents for a Family/Parental Unit interview. The joint interview is followed by Individual Interviews of each parent and child in the home, as age appropriate. Both Transitions counselors involved in the interviews with the family then meet with the Transitions supervisor for the Team Consultation. The team identifies further areas to explore and Home Study Program Bid Proposal Transitions Psychology, LLC 2 2005-2006 makes recommendations. The second Transitions counselor meets again with the parental unit to share the results and recommendations in the Final Interview. The information collected is compiled into a written report that follows the State of Colorado format. The written report is submitted to the referring caseworker, along with all of the original self-study, background check and reference materials. B. Update The Update program begins with a review of the previous Home Study. A counselor from Transitions then interviews the Parental Unit to discuss any changes in the family since the previous Home Study; the entire household is included in part of the interview in order to observe current family functioning. Following this interview, the counselor meets individually with the parent(s). C. Relinquishment Counseling The Relinquishment Counseling program consists of two individual sessions with a parent referred by Weld County who is considering relinquishing a child. A minimum of six days will transpire between the two sessions and the sessions will address all of the components of the Weld County Department of Social Services Relinquishment Counseling Outline. II. SAMPLE HOME STUDY See attached copy. III. TARGET/ELIGIBILITY POPULATIONS The Home Study, Update and Relinquishment Counseling Program serves adults of Weld County, who are interested in foster parenting, becoming foster/adoptive parents or relinquishing children. Program participants must be referred by the Weld County Department of Social Services. Transitions does not discriminate based on race, color, religion, national origin or sex, in accordance with State and Federal Laws, rules and regulations. The Transitions program can serve a total of 85 family units, including 60 families for Home Studies, 15 families for Home Study Updates and 10 families for relinquishment counseling. The 85 family units would consist of approximately 320 individuals. Of the 320 individuals, 160 would be children ages 0-18. 100 individuals could receive bilingual • Home Study Program Bid Proposal Transitions Psychology, LLC 3 2005-2006 • services and approximately 105 will receive services in South Weld County. All individuals in the Transitions program can typically access a counselor between 8 AM and 8 PM, Monday through Friday and weekends by appointment. Twenty-four hour services are not provided as part of the Home Study, Update and Relinquishment Counseling Program. The monthly maximum program capacity would be 18 families, with an average of 10 active families each month. The average stay in the program would be eight weeks for Home Studies and six weeks for Updates and Relinquishment Counseling. The average hours per week in the program would be two per family. IV. TYPES OF SERVICES PROVIDED Transitions will provide Home Studies, Updates and Relinquishment Counseling as referred by the Weld County Department of Social Services. These services will not supplant existing services in the community, as these services are not funded by mental health capitation services, ADAD or other funding. A. Home Study 1. Background Checks and References A Transitions staff member contacts the family to collect information for the background checks. The family will be asked to complete an application, release of information, self-study forms and FACES family assessment forms. All adults in the household will be supplied with fingerprint cards to complete the CBI checks (FBI checks will be performed on individuals who have resided in CO for less than two years). Transitions will collect and submit the fingerprint cards, incurring the costs for fingerprint processing for individuals referred by Weld County child protection caseworkers. Prospective foster/adoptive parents will be responsible for their own fingerprint processing cost. Additionally, Transitions will pay for and complete background checks with CoCourts or similar agency to identify criminal, civil, traffic and money offenses cited in the Colorado court system. Transitions will distribute reference forms to up to four references provided by applicants. The reference persons will be provided with a postage paid return envelope in which to return the reference form. Home Study Program Bid Proposal Transitions Psychology, LLC 4 2005-2006 2. Family Screening A counselor from Transitions meets with all the members of the prospective foster family in the family home. The counselor explains the Home Study process, reviews the application and assesses family interactions and functioning. 3. Parental Unit Interview A second counselor from Transitions meets with the prospective parent(s) to review the elements of the self- studies and evaluate the parental unit's ability to function as caretakers of children. This will include a direct assessment of the parents with their children in their home. This interview will occur at least one week after the Family Screening. 4. Family Assessments Transitions uses a family assessment package, which measures the dimensions of cohesion, adaptability, and communication. The package, which includes the FACES, utilizes the self-reports of adult and adolescent family members and the observations of the counselor to assess individual, couple and family functioning. This provides Transitions with an "insider's perspective" as well as a professional perspective of the family. 5. Individual Interviews Following the Parental Unit Interview, in households with more than one parent, each parent will be interviewed individually. These interviews focus on evaluating each parent's general functioning, personal history, views on childrearing and motivation to become a foster parent. An age appropriate, developmentally sensitive interview will also be held with each child residing in the home. The purpose of these interviews will be to assess the probable impact of fostering on the child and explore any child issues that could adversely impact foster children. The location of the individual interviews will be either in the family home or in the Transitions office at the counselor's discretion. 6. Team Consultation After the majority of the information from the Home Study has been compiled, both Transitions counselors involved in • Home Study Program Bid Proposal Transitions Psychology, LLC 5 2005-2006 the Home Study meet with the Transitions supervisor to review the case. The team specifies areas for further exploration, develops conclusions and delineates specific recommendations for the family. 7. Final Interview The parental unit is interviewed again to address the issues identified in the Team Consultation. The counselor will then share some of their perceptions with the family and any recommendations made by the team. 8. Written Report Within six weeks of the receipt of the Home Study request from Weld County, the Transitions counselor will submit a written report to the referring caseworker. The report will follow the State of Colorado format. Included with the report will be the original fingerprint cards, CBI or FBI reports, original written reference forms and copies of the self-studies. After submitting the report, the Transitions counselor will contact the referring caseworker to ensure that the report was received and compiled satisfactorily. B. Update 1. Review of the Initial Home Study A Transitions counselor will review the previous Home Study and/or updates. The counselor will then contact the referring Weld County caseworker in order to determine the focus of the Update. 2. Parental Unit Interview Parent(s) will meet with a Transitions counselor to discuss any changes that have occurred since the last Home Study or Update. Family strengths will be re- evaluated and progress towards improving areas of need identified in the previous study will be determined. 3. Family Interview and Home Inspection At least seven days following the Parental Unit Interview, The Transitions counselor will meet with all members of the household in the family home. The counselor will view the home and observe the interactions among family members. 4. Supervisory Consultation Home Study Program Bid Proposal Transitions Psychology, LLC 6 2005-2006 The Transitions counselor will meet with the Transitions supervisor to discuss the case and develop recommendations. 5. Written Report The Transitions counselor will submit a written report to the referring caseworker within six weeks of the date on which the Update request was received. The report will include specific recommendations regarding the family's ability to provide a safe, nurturing environment for children. C. Relinquishment Counseling 1. Individual Parent Consultation After receiving a referral from a Weld County caseworker, a Transitions counselor will meet with the referred parent to address questions from the Weld County Relinquishment Counseling Outline. 2. Follow-up Consultation and Review At least seven days after the first parent consultation session, the Transitions counselor will again meet with the referred parent to review the previous session, check for understanding and address any further questions the parent may have. The counselor will also provide the parent with referrals and recommendations for other services as deemed appropriate. 3. Written Report The Transitions counselor will provide a written description of the services provided that addresses all of the questions in the Weld County Relinquishment Counseling Outline. It will be submitted to the referring Weld County caseworker within six weeks of the date on which the referral was received. V. MEASURABLE OUTCOMES A. More Expedient Placement of Children Transitions will track the date on which the referrals from the Weld County caseworker are received as well as the date the Transitions reports are submitted to the referring Weld County Caseworker. There will be no more than eight weeks that transpire between the date of the receipt of the ' Home Study Program Bid Proposal Transitions Psychology, LLC 7 2005-2006 referral and the date the report is submitted to the county for Home Studies. Reports for Home Study Updates and Relinquishment Counseling will be submitted within six weeks of the receipt of the referral. If Transitions experiences delays, (e.g. applicants not completing fingerprint cards or applicant vacations), the referring caseworker will be notified and an adjusted time line will be determined. Submitting the vast majority of the reports within the six to eight week time parameters will enable Weld County caseworkers to place children more quickly. To further facilitate caseworkers' decisions regarding placement, Transitions will perform an internal review of each Home Study and Update to ensure that it includes definitive conclusions and specific recommendations regarding the viability of referred families to become foster or adoptive homes. B. Quality Adoptive Home Studies Done in a Timely Manner Transitions' Home Studies, Updates and Relinquishment Counseling, including bilingual services, will be performed only by degreed human service professionals. Transitions counselors possess at least a Master's Degrees in a human service field; most providers are licensed by the State of Colorado as Licensed Professional Counselors (LPC), Licensed School Psychologists or Licensed Clinical Social Workers. Transitions' has two bilingual LPCs contracted to perform home studies. Proof of each counselor's education will be provided to Weld County. The Transitions counselors and the supervisor have also applied for inclusion on the State Vendor List. Transitions uses a multidisciplinary team approach to staff each Home Study before the final report is completed and recommendations are made. This will be measured by at least three members of the Team Consultation, including the initial counselor, the primary counselor and the supervisor, signing off on the final report. Transitions will further ensure quality by performing an internal review of all Home Study, Update and Relinquishment Counseling reports. The reviewer will document that the review has been completed. Transitions will track received dates for Home Study, Update and Relinquishment Counseling requests as well as the submission dates of the corresponding reports. Home Studies will be submitted within eight weeks from the received date; Updates and Relinquishment Counseling reports will be submitted within six weeks from the referral date. C. Number of Acceptable Home Studies Submitted The Transitions counselor submitting the written report will contact the referring Weld County caseworker within one week of the report's submission to ensure that the Home Study, Update or Relinquishment Counseling report was acceptable. Transitions staff will then document the contact in order to track the number of acceptable studies submitted. ' Home Study Program Bid Proposal Transitions Psychology, LLC 8 2005-2006 VI. SERVICE OBJECTIVES A. Provide Quality Home Studies, Updates and Relinquishment Counseling for Adoptive Parents, Foster Parents and Department of Social Services' Clients 1. Transitions Home Studies, Updates and Relinquishment Counseling will be performed only by degreed human service professionals. Proof of each counselor's education will be submitted to Weld County. All of the services provided, including bilingual services, will be performed by Master's level counselors, with the exception of the tasks listed in the Background Check and Reference portion of the home study; these tasks may be performed by paraprofessional staff. 2. A multidisciplinary team approach will be utilized to staff each Home Study referral before the final report is completed and recommendations are made. This will be measured by at least three Team Consultation participants signing the final report: the initial counselor, primary counselor and the supervisor. Updates will be staffed between the primary counselor and the supervisor as documented by both signing the final report. 3. Transitions will perform an internal review of all reports to check for overall quality, writing skills, definitive conclusions and specific recommendations. The reviewer will document in the chart that the review has been completed. 4. The Transitions counselor submitting the Home Study will contact the referring Weld County caseworker to ensure that the Home Study, Update or Relinquishment Counseling report is acceptable. Transitions staff will then document the follow-up contact and track the number of acceptable studies submitted. Home Study Program Bid Proposal Transitions Psychology, LLC 9 • 2005-2006 VII. WORKLOAD STANDARDS A. Number of Hours Per Day, Week or Month Families in the Home Study program will participate for a minimum of one hour per week for a maximum of eight weeks. Update families will participate for a minimum of three hours during the six weeks of service. Weld County clients referred for Relinquishment Counseling will participate for a minimum of two hours during the six weeks of service. B. Number of Individuals Providing the Services Each Home Study will be performed by two individuals: one counselor who conducts the initial Family Screening and another counselor who completes the remaining interviews of the family members and produces the report. A licensed psychologist will also be involved in the Home Study in a supervisory capacity, to assist with the evaluation of the family and recommendations. However, the supervisor will typically not have direct contact with the referred family. Updates will be performed by one counselor, but will also have the Team Consultation component for evaluation and recommendations. Relinquishment counseling will be performed by one Master's level, licensed counselor or social worker. Transitions currently contracts with one PhD, Licensed Psychologist for supervisory services. Three doctoral level staff and five master's level staff are contracted to provide direct services. C. Maximum Caseload Per Worker Each counselor will not carry more than four open Home Studies or Updates at any time. Counselors will not carry more than two Relinquishment Counseling cases at a time. D. Modality of Service Home Studies and Updates will consist of individual, couple and family service modalities with the referred family. Most of the services will be delivered in the family home, with the possible exception of the Individual Interviews, which may be held in the Transitions office. Case management services, case reviews and consultation without the family members present are also included. • Home Study Program Bid Proposal Transitions Psychology, LLC 10 2005-2006 E. Total Number of Hours per DavNVeek/Month Transitions will provide approximately 2 hours of direct services per day, 10 hours per week and 43 hours per month. F. Total Number of Individuals Providing These Services Ten. Transitions has two co-owners, both Licensed Professional Counselors, available to provide these services along with one Licensed Psychologist to provide supervision and case consultation. Three additional master's level licensed professional contractors and three doctoral level contractors are also available. Paraprofessional staff member provides indirect administrative support, including processing fingerprint cards, performing background checks and collecting reference information. G. The Maximum Caseload per Supervisor The Transitions supervisor will not exceed 24 open cases for Home Studies and Updates. H. Insurance Transitions office and co-directors are insured through Healthcare Providers Service Organization Purchasing Group (HPSO). The limits of liability are $1,000,000 per occurrence and $6,000,000 aggregate. Contract staff members maintain their own policies, each with a minimum of$1M/$3M liability. Current contracted staff members are insured through HPSO and the Philadelphia Indemnity Insurance Company. VIII. STAFF QUALIFICATIONS A. All Transitions staff, including supervisors, who are providing direct services have a minimum of a bachelor's degree in a human service field. The supervisor has a Doctorate in psychology and is a Licensed Psychologist. All staff performing Home Studies, Updates and Relinquishment Counseling have at least a Master's degree in a human service field. Most current providers are licensed in State of Colorado as Professional Counselors, Clinical Social Workers, or School Psychologists. Transitions staff have training and expertise in family systems and experience working with social services, foster/adoptive parents and foster/adopted children. The supervisor has had four years of experience performing home assessments. Transitions staff have applied for inclusion on the State of Colorado Department of Human Services Vendor list. ' Home Study Program Bid Proposal Transitions Psychology, LLC 11 2005-2006 B. Transitions has ten staff members, including a supervisor, available for the project. IX. UNIT OF SERVICE RATE COMPUTATION Please see attached budget form. Flat rates are as follows: $1115 for full home study; $725 for update; incomplete home study, update and relinquishment counseling is calculated at the hourly rate of$111.50 for face-to-face contact. Transitions Psychology Group, LLC Sample Home Study Report 2004 Clark 1 *414. -* . HOME STUDY REPORT ' •.•• w • NAME Clark lie R* f y ADDRESS: 513 Walnut St. •'«�� .� Eaton, CO 80543 . PHONE: (970)663-5541 Transitions DATE: 02/26/2004 PSYCHOLOGY GROUP,LLC FULL NAME: Steven B. Clark Rebecca M. Clark DOB: 03/06/1964 01/09/1967 BIRTHPLACE: Longmont, CO Denver, CO OCCUPATION: Pharmaceutical Sales Interpreter/Homemaker MARRIAGE DATE: August 24, 1986 CHILDREN IN THE HOME AGE DOB Michael B. Clark 15 01/17/89 Joshua R. Clark 12 05/23/91 LOG OF CONTACTS 01/15/04 Referral received at Transitions 01/19/04 Initial telephone contact with family 02/03/04 Family Screening in home (Creed), 1.5 hours 02/10/04 Parental Unit Interview in home (Moe-Hartman), 1.25 hours 02/12/04 Individual Interview with Rebecca at Transitions (Moe-Hartman), 1.0 hour 02/17/04 Individual Interview with Steven at Transitions (Moe-Hartman), 1.0 hour 02/19/04 Individual Interviews with Michael & Joshua in home (Moe-Hartman), 1 hr. 02/20/04 Team Consultation, 1 hour (Moe-Hartman, Creed, Howard), 1.0 hour 02/24/04 Final Interview with family in home (Moe-Hartman), 1. hour HISTORY Steven C/ark.: Steven is the second of four boys born to Sandra and Randall Clark. Sandra worked in the medical field as a medical assistant, receptionist and transcriptionist; she also was a homemaker. Randall Clark worked as a farm manager. Both of Steven's parents finished high school; his mother had some post secondary education. Steven describes his early years as "happy" and "busy", with him and his three brothers at home. The brothers are very close in age: all four were born within a 5 1/2 year period. As a young child, Steven remembers his parents hugging each other and the children. Steven reports that his parents' primary discipline strategies were talking and removing privileges. He admits that he and his siblings were occasionally disciplined with spankings, but Steven describes this as a rare occurrence Transitions Psychology Group, LLC Sample Home Study Report 2004 Clark 2 (approximately once a year for him until age 9). In his teen years, he recalls more fighting and resentment in the family. He attributes much of the family strife to his father's extramarital affair. He denies any history of abuse, although acknowledges that he and his younger brothers were often "bullied" by his oldest brother. Steven's parents ended up divorcing when Steven was 16. His father remarried two years later, creating a blended family with his stepmother, stepbrother and stepsister. Although Steven was already 18 when the family blended, he continued to live with his father and stepmother until he married at age 23. Steven describes his stepmother as very encouraging to him. Despite his positive relationship with his mother as a child, he describes his current relationship with her as "distant". He indicates that his mother became very withdrawn and angry after the divorce and their relationship has never fully recovered. His mother has since remarried twice. She has been married to her current husband for about a year and Steven reports that she seems happy again for the first time in many years. Steven remains connected with his father, but admits harboring some resentment about his parents' divorce. Most of Steven's siblings remain in the Longmont area. He states that they get along well with each other and look forward to opportunities to spend time together. Steven attended private school throughout his elementary and junior high school years then transferred to public school for high school. He describes involvement in drama, sports, church youth groups, coaching and speech team. Steven states that he graduate from high school and continued on to college to earn his bachelor's degree. He is currently employed in pharmaceutical sales. Rebecca Clark: Rebecca is the second of two children born to Margaret and Robert Price. She has one brother, David, who is three years older than she. Margaret and Robert are highly educated; each holds master's degrees in health administration according to Rebecca. Rebecca reports that her mother also holds a degree in speech therapy. Margaret is a retired hospital administrator while Robert is a retired insurance executive. Rebecca describes a rather idyllic, "Pollyannaish" childhood. Her family is described as very stable (Rebecca was born and raised in the same house) and loving. Although there were not a lot of physical displays of affection, the family spent time together, showed respect to one another, listened and gave good advice and compliments, according to Rebecca. Rebecca states that her parents relied primarily on natural consequences and restricting her privileges. She adds that incurring their disapproval was usually enough of a deterrent to getting in trouble. She denies any abuse in her childhood. Rebecca's parents have been married for 45 years. When they retired five years ago, they decided to become "snowbirds", splitting their time between Colorado and California. For approximately six months of the year, Rebecca's parents live with her in a lower level apartment in her home. Rebecca describes a close relationship with her brother growing up but reports they do not see as much of each other as adults because they live in different states. They maintain frequent phone contact, according to Rebecca, and enjoy getting together a few times each year. Rebecca is a high school graduate who also has attended two years of college in early childhood education. She currently works as a freelance interpreter for the deaf. She was on staff at a local school district as an interpreter until she was "let go" two months ago. Rebecca cites additional experience, operating home daycares in Colorado and Transitions Psychology Group, LLC Sample Home Study Report 2004 Clark 3 Georgia that accepted special needs children. Rebecca has some serious health issues, including rheumatoid arthritis and Crohn's disease, but reports that they rarely interfere with her daily functioning. She has been pregnant twice and birthed two children. However, she had significant complications during both pregnancies. ADULT GENERAL FUNCTIONING: Steven Clark: Steven describes himself as a "helper" and mediator. He reports that he is generally easy-going and happy, enjoying joking around and laughing. When he loses his temper, he will either shout or sulk. He finds that when he is experiencing high levels of stress he feels very sleepy. He copes by praying and sharing his feelings with people in his support network. Steven indicates that he also tries to eat well and seek out new learning opportunities or challenges. His leisure activities include golfing, cooking and reading historical fiction. He limits television viewing to five hours per week. Steven believes he is good at listening, leading and motivating. He describes himself as friendly, loving, empathetic and funny. He hopes others see him as he sees himself, as a good friend and family man. Rebecca Clark: Rebecca sees herself as a "thinker", enjoying learning new things and being informed. She seems very happy, warm and optimistic. She indicates that she loves to make new friends and nurture close relationships. Rebecca describes losing her temper only with inanimate objects, like the computer. In these situations, she may yell and pound on the desk. When experiencing stress, Rebecca indicates that her most effective coping skill is to go for a walk and pray to "let go and let God". Another coping skill she has in her repertoire is calling a friend or family member to talk. Rebecca uses nutrition and exercise to maintain her health. She also uses chiropractic care and massage therapy when possible. Rebecca likes to relax with meditation, prayer and reading. She also enjoys shopping, spending time with her children and corresponding via e-mail to friends and family. PARENTING-DISCIPLINE Rebecca and Steven both cite that they try to establish clear expectations and boundaries as a proactive parenting technique to avoid problems. They use other controls that are available, such as the time-out service offered by their Internet provider that automatically shuts down after one hour. They indicate, and the children confirm, that they rarely have to implement consequences. Typical behavior issues with these children include avoiding homework or watching too much television or not doing a chore they were asked to do. When such problems occur, they try to use natural consequences (i.e. if you miss your bus, you walk to school and get a tardy slip; if you aren't getting your homework done because you are watching television instead, then no television). Steven admits that he sometimes struggles with giving up this much control, especially when it comes to academics. They have spent a lot of energy trying to get their oldest son to complete homework, but recently have decided to allow their 15-year old son to accept full responsibility for his grades. Because he is failing a Transitions Psychology Group, LLC Sample Home Study Report 2004 Clark 4 class, they have told him that he does not have time to play in his hockey league; he will likely also have to repeat the class. Rebecca and Steven will also take away privileges but report that they never use physical discipline. When they disagree about a discipline strategy, they will use a talking exercise they learned through marriage encounter to discuss it. Both feel confident in their parenting abilities and believe they have developed some "tried and true" methods that they can utilize with other children. PARENTING VALUES & PRACTICE Rebecca and Steven both cite unconditional love as their greatest parenting strength. As a weakness, Steven admits he is overscheduled at times and this detracts from quality time with his children. After consulting her children, Rebecca acknowledges that her greatest weakness as a parent is letting go of her adolescents: they tell her they want more freedom and "their way" more often. Steven and Rebecca both indicate that they verbalize to their children that they love them, listen to them and give them hugs. Rebecca wants her boys to realize their potential and be good husbands and fathers. Steven expects respect, love and a relationship from his sons. Christian values are the center of life in the Clark home. They also acknowledge the importance of education. The Clark children are involved in activities outside the home, including church youth groups, hockey, tennis, basketball and swimming. Rebecca and Steven plan to introduce their foster child as their daughter and have her involved in all aspects of their family life. CHILDREN Michael Clark: Michael is described as "sweet and smart" by his mother and "loving and giving" by his father. He has presented some parenting challenges, as Rebecca and Steven indicate that he is diagnosed with attention deficit hyperactivity disorder. This seems to manifest in academic problems, as Michael reportedly forgets to complete or turn in homework. After several years of attempting different interventions to help Michael cope with the disorder, the Clark's agreed to try medication. Michael has reportedly been on ADHD medication for about one year. Michael enjoys hockey and tennis; he is also involved in youth group. He also is passionate about sailing, an activity that he does with his maternal grandfather. He is described as a popular babysitter in the community; his mother attributes this to his special talent with young children. Joshua Clark: Joshua is described as a leader who is loved by friends and family. Joshua has had some significant health problems, as he was born prematurely, has asthma and sleep apnea. He had to use a ventilator to help him breathe at night for many years and had heart surgery at age 6. In spite of all this, his father states that he "has the best smile". His mother describes him as "touchy-feely", responding to physical displays of affection. Joshua is involved in youth group, hockey, basketball and swimming. Transitions Psychology Group, LLC Sample Home Study Report 2004 Clark 5 Michael and Joshua were both friendly and respectful during the interviews with both counselors. They appear to get along very well and have minimal concerns about sharing a room (i.e. Michael likes the room very dark to sleep while Joshua prefers some light). The family already begins problem solving around this issue during the interview, developing a viable solution quickly. The family has already begun to renovate the boys' outdoor playhouse to provide them with more options for private space when they no longer have their own bedrooms. FAMILY SYSTEM Family Functioning: The Clark's are a Caucasian, middle class family. They seem to have developed some family interests and enjoy spending time together. The family appears to have established some clear role responsibilities, but also indicate they have some flexibility about who does what. The Clark children, ages 15 and 12, have appropriate responsibilities to attend school, complete homework, care for family pets and help parents with household and yard chores. At 15, Michael also has some responsibilities to others outside the family, such as operating the church sound system, babysitting and fundraisers. Rebecca and Steven describe utilizing a joint decision- making process that includes prayer. Steven is reported to have some "veto" power, so is essentially at the top of the family hierarchy. There seems to be an established boundary between the parent and child subsystems that allows the children to have some input into decisions affecting the family with the parents making the final decision. The Clark family tries to maintain family dinners as a consistent arena for communication. They report that disagreements are infrequent, but they try to talk them out when they arise. The Clark family expresses affection towards on another with hugs and saying "I love you". Family Adaptability and Cohesion: Transitions uses the Family Adaptability and Cohesion Scales(FACES)II to assess family functioning. FACES II measures family cohesion (the emotional bonding between family members) and family adaptability(the ability of a marital of family system to change its power structure, role relationships and relationship rules in response to situational and developmental stress. Family cohesion is used to assess emotional bonding, boundaries, coalitions, time, space, friends, decision-making, interests and recreation. Family adaptability is used to assess family power(assertiveness, control and discipline), negotiation style, role relationships and relationship rules. There are four levels of family cohesion: disengaged, separated, connected and enmeshed There are also four levels of family adaptability: rigid, structured, flexible and chaotic. The instrument assesses marital and family times in the sense of extreme types, mid-range types and balanced types. Scores on each scale range from 1-8, with 8 being high. Overall reliability for the scale is.90. The Clark family describes itself as "flexible", with a family adaptability score of six; there was a minimal discrepancy in the individual members' reports on these measures, with each placing the family in the flexible range (a score of 5 or 6). The family members differed on their perception of their family's cohesion. Rebecca scored a 7, indicating that she sees the family as "very connected". Steven and Michael perceive the family as "connected", with scores of 6 and 5 respectively. Joshua's score of 4 'Transitions Psychology Group, LLC Sample Home Study Report 2004 Clark 6 indicates that he views his family as "separated". The family's combined cohesiveness score was a six, defined as "connected", but due to the differences in the individual reports it may not be an accurate reflection of the family. The discrepancies scores between family members ranged from 1.4 to 3.2, with an overall family discrepancy score of 2. This suggests that there are significant differences in the way family members perceive their family. Adult Relationships/Marriage: Steven and Rebecca Clark married on August 24, 1986, when Steven was 23-years old and Rebecca 19. The couple has been married for more than 17 years and describes their marriage as "strong". Both are committed to the relationship, identifying that their marriage and friendship is one of the most important things in their life. They state that they "make a conscious decision to love each other everyday, no matter what". Steven and Rebecca have been involved in Worldwide Marriage Encounter for the last five years. Currently, they serve as group leaders in the Rocky Mountain Region, facilitating two to three encounter weekends each year. They believe these experiences have improved their relationship, as they get regular opportunities to work on their relationship and develop skills to help them in their everyday life. One skill they report using frequently, "dialogue", involves each member writing on a topic of their choice then sharing it with the other person. This skill is utilized both as a connecting activity as well as a way to settle disagreements. As their children get older and more independent, Steven and Rebecca have found that they have more "couple" time. Most Friday evenings are designated as "date night": the children spend time at a friend's house and Rebecca and Steven go out to dinner or spend a quiet evening at home. Both see the primary weakness of their marriage as their tendency to get too busy to focus on it, forgetting to be playful and romantic. They recognize that an infant foster child will introduce new challenges to their relationship, especially finding time for the couple to be alone together. However, they believe loving the child together will be another way to enhance their relationship and expect the experience of foster parenting to be very fulfilling. FAMILY SUPPORT NETWORK Rebecca and Steven appear to have a large support network. Rebecca's parents, and Robert Harrison, live in the lower level apartment of the family home for approximately six months of the year (they spend the colder months in California). During the time they are living together, the families mutually support one another. For example, Rebecca cooks meals for both families and her mother does the laundry. The Clark's also have a year-round support network of friends, family and church members. Steven's father and stepmother, along with two of his brothers and his stepbrother, all live nearby in Longmont, Colorado. Steven and Rebecca report that they have several "couple friends" that they like to spend time with and can call on for support. They are already working to develop the more "specialized" support network they will need as foster parents: they have friends and Windsor and Steven's stepbrother in Longmont Transitions Psychology Group, LLC Sample Home Study Report 2004 Clark 7 who are all foster parents and can provide respite care; they also have two college students who they say are willing to help out. DEMOGRAPHICS Steven is employed as a pharmaceutical salesperson, with reported earnings of $47,000 each year. Rebecca supplements the family income with freelance interpreting; her anticipated earnings are about $12,000 per year. The Clark's reside in the upper level of a home in Eaton. They have three bedrooms and two bathrooms in their living space. Their living, dining and kitchen areas are spacious with a great view of the mountains. The basement of their home serves as a separate residence for Rebecca's parents during the warmer months. Her parents have their own bedroom, living area, kitchenette, walkout door and screened in patio area. Each family owns their part of the home separately, but at this time there is no physical barrier between the two residences. A stairway effectively divides the two spaces and family members have arranged to "knock on the wall" as they are coming up or down the stairs to warn that they are coming to the other person's home. They are willing to install a locked door at the base of the stairs if needed. The Clark home sits on 2.5 acres that backs up to farmland. On their property are a barn and a "playhouse"—a kid's retreat area complete with heat, television and video games. The current renovations will add a loft to the play space. The home also has an attached garage. The Clarks' neighborhood primarily consists of middle income, single-family homes with some acreage. However, new housing developments are bringing more diverse people and multi-family dwellings into the area. BIRTH FAMILY Rebecca and Steven both acknowledge some negative feelings about parents who maltreat their children. Steven indicates that he would deal with this through prayer for the parents. Rebecca realizes that the parents have their own histories and maybe are "not as far on the walk" as she is. She states that she cannot blame them for not being as far along in their "journey with Christ" as she is and admits that she too would likely make similar poor choices (i.e. substance abuse) if she shared the same negative life experiences. The Clark's believe in open adoptions, as they believe that birth parents need reassurance, through seeing their child healthy and happy, to know they made the right choice. They also believe children have the right to know about their birth heritage. Rebecca and Steven both would try to help foster children cope with birth family issues through love, acceptance and age-appropriate discussions. Rebecca has had some experiences with foster children through her work in schools and through her extended family. She does not see any differences in the children themselves, although she has noted some who have experienced such difficulties to be more resilient. The Clark's have experienced diversity where they lived, worked and studied in Denver and Georgia. They see themselves as accepting of all people; they would consider a foster child of any race. As parents of two boys and coming from families in which they were raised with only brothers, Rebecca and Steven express a strong preference to parent a girl. They are especially interested in infants, but would accept a child under age two. Transitions Psychology Group, LLC Sample Home Study Report 2004 Clark 8 The Clark's, especially Rebecca, have extensive experience working with special needs children. Over the last 20 years, Rebecca has worked in the schools with children who are autistic, deaf or had auditory processing issues. She is fluent in sign language. In her home daycares, she has worked with children who had Attention Deficit Hyperactivity Disorder, various developmental delays, Cerebral Palsy, Downs Syndrome and hearing impairments. Steven has been involved with the daycare children on a more limited basis, but also has the experience of parenting his own "special needs" children. The Clark's oldest son is reportedly diagnosed with Attention Deficit Hyperactivity Disorder and their younger son has had a series of medical issues. They are willing to consider caring for an infant with special medical, physical or emotional needs. FOSTER/ADOPTIVE FAMILY PREPARATION Steven and Rebecca both feel prepared to foster a child. They have been considering foster/adopting a little girl for the last 13 years and have had numerous discussions on the subject over the years. They have taken care of numerous children, including those with special needs, as a daycare home. Steven and Rebecca express the willingness to seek out cultural opportunities for a foster child of a different race or background than they. However, due to the intensity of their involvement with their church, they would not be able to exclude foster children from their religious activities. Rebecca and Steven plan to introduce their foster child as their daughter and part of their family. They are confident that they can meet the multiple needs of another child in their home. The Clark children express excitement about having a "little sister". They are open to having another child in the home, as long as it is an infant or toddler. Apparently, the family had a negative experience several years ago with an older exchange student, who stayed with the family for a couple weeks and was very mean and aggressive to the Clark children. MOTIVATION/COMMITMENT Rebecca had had a difficult pregnancy with her first son so the couple decided they would try to adopt their next child. They gave up hope after losing four possible adoptive placements (the birth parents decided to keep their babies). They decided to try pregnancy again, but this time it was even more difficult for Rebecca. Rebecca and Steven had another son, born prematurely with significant medical issues, and decided that another pregnancy was not an option, even though both still wanted a daughter. They decided to do foster care, but remain open to considering adoption if appropriate. Rebecca and Steven seem to be trying to protect themselves from experiencing additional losses and disappointments by setting themselves up for foster placements instead of planning to adopt at the outset. They are primarily interested in fostering one infant girl, but would consider a sibling group of two very young girls (both under age three). Steven and Rebecca believe they have been "called by God "to be foster parents at this time and plan to continue this venture "as long as they feel God leading us". Steven indicates that this could mean a long-term, possibly lifetime, commitment. Rebecca states that she will follow through with any child God sends her way as long as Transitions Psychology Group, LLC Sample Home Study Report 2004 Clark 9 the child needs the placement. The Clark children seem to have invested in foster care as the whole family's mission. Religion supplies strong motivation for this family, but alternately could provide a convenient "out" if things are not working for them. INTERVENTION Rebecca and Steven both indicate a willingness to participate in foster parenting consultation services. However, they seem very confident in their own knowledge, abilities and beliefs so may struggle with accepting others' advice or opinions. The family seems to have a general understanding of confidentiality issues, as they have dealt with this on some level because of Rebecca's role as an interpreter. RESOURCES NEEDED TO SUPPORT THE PLACEMENT The Clark's indicate that they already have respite care (Steven's stepbrother and sister-in-law are reportedly licensed foster parents through Boulder County) and babysitters available. They will need weekend respite care at least three times per year in order to continue with their Marriage Encounter activities. Rebecca is employed outside the home as an interpreter, but is only doing this on an on-call basis at this time. Thus, the Clark's do not plan to have their foster child in daycare but may utilize some babysitting so Rebecca can continue working (she typically works only two hours at a time, once or twice per week). Although Steven reports that his income supports the family and Rebecca's income is for "extras", there may be some financial motivation to provide foster care following Rebecca's job loss. They will be dependent on social services for foster care monies, respite care costs and medical insurance for the foster child. TRAINING Steven and Rebecca report that they have already completed their foster parent core training and are planning to start their consultation groups this month. Additionally, Rebecca states that she studied child development and educational psychology in college that she has supplemented with many other parenting workshops since that time. Steven and Rebecca both have the experience of parenting their own children, one with emotional/behavioral needs and another with medical needs. They also have cared for a variety of special needs children through Rebecca's role as a daycare provider. The Clark's do not appear to need any additional parent training at this time. Some training regarding working within the social services system may be helpful, if it has not already occurred. Rebecca was "let go" from her job as an interpreter, purportedly due to a conflict with her supervisor about how to deal with a child with whom she was working. This suggests she could potentially have problems with caseworkers if she disagrees with their decisions about children placed in her care. The Clark's may also need some training specific to the special needs of the child placed in their care, especially if it is not a special need that they have dealt with in the past. Transitions Psychology Group, LLC Sample Home Study Report 2004 Clark 10 CONCLUSIONS/RECOMMENDATIONS The Clark's appear to be a very stable, loving family. They have strong moral convictions and a large support network. They see foster parenting as their"family mission", believing they have been called by God to contribute in this way. Rebecca Clark reports specific experience in child development and extensive experience working with children with a variety of special needs over the last 15 years. Both Rebecca and Steven have experience parenting their own children, who also have special needs, through infancy and childhood. At 15 and 12, the Clark children are at an age where they are appropriately trying to separate more from their parents and become more independent, so minimal jealousy of the child is anticipated. Rebecca and Steven indicate that they have parenting skills and "room in our hearts" for another child. The Clark's are specific in their desire to parent an infant girl but are willing to care for children with special needs, whether those needs are medical, physical, emotional or some combination thereof. They may also consider adoption if the child's needs are not too severe (i.e. they would not want to assume responsibility for a child that could never reach an age of independence and would always need assistive care). They have had considerable exposure to people of different races and an interest in seeking out different cultural and ethnic opportunities, so seem to be suitable placement for a child of any race. Although they are open to a sibling group of infant/toddler girls, this may be too taxing for the family initially, especially if one or both children have medical or emotional issues. Rebecca has significant health problems (Crohn's disease and rheumatoid arthritis) that could be exacerbated by the stress of caring for a child. However, she seems to have the necessary lifestyle management, coping skills and supports to prevent this from happening. Rebecca and Steven seem to have some rigidity in their beliefs and could potentially disagree with caseworkers about a child's care. Nonetheless, they seem to realize that agency requirements are "part of the deal" for providing foster care and express a willingness to accept these conditions. Transitions Psychology Group, LLC Sample Home Study Report 2004 Clark 11 Primary Counselor: Jami Moe-Hartman, MA, LPC Date Intake Counselor: Gregory S. 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' O O O < N U o • Healthcare Providers Service HAOrganization Purchasing Group ®HPSO NA Plaza, r+ 41-mural-we Il 60685Ce tificate of Producer Branch Prefix Policy Number Policy Period from: 12:01 AM Standard Time on: 07/04/04 018098 970 HPG 270170798-8 to: 12:01 AM Standard Time on: 07/04/05 Named Insured and Address Program Administrator Healthcare Providers Service Organization JAMI MOE HARTMAN 159 East County Line Road 804 11TH AVE Hatboro, PA 19040-1218 GREELEY CO 80631-3246 Medical Specialty: Code: Insurance Provided by Clinical Counselor 72990 American Casualty Co. of Reading, PA CNA Plaza 26S Chicago, IL 60685 COVERAGE PARTS •LIMITS OF LIABILITY A. PROFESSIONAL LIABILITY Professional Liability $1,000,000.00 each claim $6.000 X04.00 _aggregate Good Samaritan Liability Included above Personal Injury Liability Included above Malplacement Liability Included above B. Coverage Extensions License Protection $5,000.00 per proceeding $12.500.00 aggregate_ Defendant Expense Benefit $5,000.00 aggregate Deposition Representation $1,250.00 per deposition $2,500.00 aggregate Assault $5,000.00 per incident $12,500.00 aggregate Medical Payments $1,000.00 per person $50,000.00 aggregate First Aid $1,250.00 aggregate Damage to Property of Others $250.00 per incident $5,000.00 aggregate C. WORKPLACE LIABILITY Coverage part C. does not apply if Coverage part D. is made part of this policy. Workplace Liability Included in A. Professional Liability Limit shown above Fire and Water Legal Liability Included above subject to $150,000 sub-limit Personal Liability $500,000.00 aaareaate D. GENERAL LIABILITY Coverage part D. does not apply if Coverage part C. is made part of this policy. Workplace Liability None None Hired Auto & Non Owned Auto None Fire & Water Legal Liability None None Personal Liability I None Total Premium $125.00 Policy forms and endorsements attached at inception QUESTIONS? CALL: 1-800-982-9491 G-144872-A G-144959-A G-121500C G-121501C G-123846C-05 G-121503C Healthcare Providers Service Organization is a division of Affinity Insur:wce Services,Inc:in NY and NH.AIS Affinity Insurance Agency,in MN and Oi.,AIS Affinity Insurance Agency.Inc.;and in CA.PUS Affinity Insurance Agency,Inc.dba Aon Direct Insurance Admirusuators License#0/95165. Master Policy: 188711433 20-44)11A)44 Keep this document in a safe place. This and your cancelled check act as proof of coverage. Chairman of the Board Secretary 925 XX 0000246-R 040426 RENHCP 2/04 R177HM 04117 Healthcare Providers Service Organization Purchasing Group oHPSO • NA Plaza 1 11 Chisago,IL 60685 Certificate of 4Incurance .. ..no..�... ...�,�y.,..,,�. Producer Branch Prefix Policy Number Policy Period from: 12:01 AM Standard Time on: 07/04/04 018098 970 HPG 270170686-8 Named Insured and Address t° 12:01 AM Standard Time on: 07/04/05 Program Administrator GREGORY S CREED Healthcare Providers Service Organization 804 11TH AVECR 159 East County Line Road GREELEY CO 80631-3246 Hatboro, PA 19040-1218 Medical Specialty: Code: Clinical Counselor Insurance Provided by 72990 American Casualty Co. of Reading, PA COVERAGE PARTS CNA Plaza 26S Chicago, IL 60685 LIMITS OF LIABILITY A. PROFESSIONAL LIABILITY Professional Liabilit 1 000 000.00 each claim Good Samaritan Liability 6 000 00 Q Included above Personal Injury Liability Included above Malplacement Liability Included above B. Coverage Extensions License Protection 5 000.00 per roceedin Defendant Expense Benefit $12,500.00 aggregate Deposition Representation $5,000.00 aggregate $1,250.00 per deposition $2,500.00 aggregate Assault $5,000.00 Medical Payments per incident $12,500.00 aggregate First Aid $1,000.00 per person $50,000.00 ag gregate Damage to Property of Others $1,250.00 aggregate $250.00 per incident $5,000.00 aggregate C. WORKPLACE LIABILITY Coverage part C. does not apply if Coverage part D. is made part of this policy. Workplace Liability Included in A. Professional Liability Limit shown above Fire and Water Legal Liability Included above subject to _ Personal Liability r $150,000 sub-limit l $500,000.00 aggregate D. GENERAL LIABILITY Coverage part D. does not apply if Coverage part C. is made part of this policy. Workplace Liability Hired Auto & Non Owned Auto None None Fire & Water Legal Liability None None None Personal Liability None Total Premium $125.00 Policy forms and endorsements attached at inception QUESTIONS? CALL: 1-800-982-9491 G-144872-A G-144959-A G-1215000 G-1215010 G-123846C-05 G-121503C Healthcare Prmndets Semce Organization is a anision of Affueiry Insnnwce Services.Inc.:in NY and NH.AIS Affinity Insurance Agency;in SIN and(7K.AIS Affinity Insurance Agency.Inc.;and in CA.AIS.Affwry Instuance Agency,Inc.dba Aon Direct Insurance Administrators License»0795,165 21 ,44/1AX4N-.9 Master Policy: 188711433 64--Y4 /1/4k..44.- Keep this document in a safe place. This and your cancelled check act as proof of coverage. tit Chairman of the Board Secretary 925 XX 0000245-R l4l474 otorsu(to o,n,. ........... ... ..— SUPPLEMENTAL NARRATIVE TO RFP: EXHIBIT B CONDITIONS • • • • f 80411"Avenue ' • • y • Greeley,CO 80631 •0 r _ Phone: (970)336-1123 ••• y { FAX: (970)351-0182 • ! Cell: (970)590-1424• RECEIVED APR 27 2005 Transitions MCHCOLOCt Oar,LIZ WeldSociCounty l Se Dept. of Judy Griego, Director Clerical Unit Weld County Department of Social Services APR 2 7 2005 PO Box A Greeley, Colorado 80632 April 26, 2005 Re: RFP 04005: Lifeskills RFP 006-00A: Foster Parent Consultation RFP 006-00B: Home Study, Relinquishment Counseling RFP 006-00: Mental Health Services Dear Ms. Griego, Transitions Psychology Group, LLC, is pleased to confirm our acceptance of the bids for PY 2005-2006 with the attached conditions as follows: • RFP 006-00A: Foster Parent Consultation. CONFIRMED. • RFP 006-00B: Home Study, Relinquishment Counseling. CONFIRMED with conditions: Condition #1: The threshold for hours for an incomplete home study will be set at 3.5 hours. Additional home studies will be billed at a maximum of$250 per person Condition #2: It has been mutually decided that the turnaround time for receipt of the completed home study by the Department is set at six weeks form the date of receipt of the referral. • RFP 04005: Lifeskills: CONFIRMED with the condition: Condition: Transitions has the following capacity to provide after-hours visitation: Monday-Friday evenings times from 5:00-8:OOPM with the maximum of two simultaneous sessions in any given time slot. Saturdays 8:00AM-12:00Noon with only one therapist available for services. • RFP 006-00: Mental Health Services: CONFIRMED with the condition: Condition: Reports will be provided to the Department no later than 90 days from the beginning date of services. In the event the report is not received within the required time frame, services will not be eligible for payment. We look forward to another successful year of serving Weld County residents and Social Services agencies. Please feel free to call me on my cell phone, 590- 1424, or at the office, 336-1123, with any questions. Thank you. Sincerely, ifiron-11 C----e Gregory S. Creed, MA, LPC Cc: Jami Moe-Hartman, Co-director, Transitions Psychology Group, LLC •*f + - 80411"'Avenue FAX . : •• • Greeley,CO 80631 * •• . * •• Phone(970)336-1123 • •4! ' : FAX(970)351 0182 •• + . U. 4. • Transitions PSYCHOLOGY GROUPUt TO: Elaine Furister, CPS/CAP FAX 970-346-7698 FROM: Gregory S. Creed, MA, LPC DATE: 4/26/05 RE: Confirmation Letter to Judy Griego PAGES: 3 COMMENTS: Please accept this letter of confirmation for the 2005-2006 Bid process. Thanks for going over the conditions with me, Elaine. You are always such a big help. Please confirm that you have received this FAX by calling me at 590-1424. Then I can rest assured. CONFIDENTIAL The information contained in this facsimile message is privileged and confidential information intended for the use of the individual or entity named above. If the reader of this message is not the intended recipient or the employee or agent responsible to delver it to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If you have received this fax in error, please immediately notify us by telephone and return the original message to us at the above address via the U.S. Postal Service. Thank you. ;. . 04 w ''. - 80411v.Avenue FAX ea, 4. Greeley,CO 80631 ,,•#y -+ . ? Phone(970)336-1123 ! e .j. ,�ti FAX(970)351.0182 10 sv,p . Transitions ►IVOIOLOGY CROUP LW TO: Elaine Furister, CPS/CAP FAX 970-346-7698 FROM: Gregory S. Creed, MA, LPC DATE: 4/26/05 RE: Confirmation Letter to Judy Griego PAGES: 3 COMMENTS: Please accept this letter of confirmation for the 2005-2006 Bid process. Thanks for going over the conditions with me, Elaine. You are always such a big help. Please confirm that you have received this FAX by calling me at 590-1424. Then I can rest assured. CONFIDENTIAL The information contained in this facsimile message Is privileged and confidential information intended for the use of the individual or entity named above. If the reader of this message is not the intended recipient or the employee or agent responsible to delver it to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If you have received this fax In error, please immediately notify us by telephone and return the original message to us at the above address via Lhe U.S. Postal Service. Thank you. A e S • s.'� '480411i°Avenue • ♦• +•• • Greeley,CO 80631 ' Swipe Phone;(970) 336-1123 I:00 -} 4 ; FAX: (970)351-0182 ! Cell:(970)590-1424 Transitions . OCt .et Judy Griego, Director Weld County Department of Social Services PO Box A Greeley, Colorado 80632 April 26, 2005 Re: RFP 04005: Lifeskills RFP 006-00A: Foster Parent Consultation RFP 006-00B: Home Study, Relinquishment Counseling RFP 006-00: Mental Health Services Dear Ms. Griego, Transitions Psychology Group, LLC, is pleased to confirm our acceptance of the bids for PY 2005-2006 with the attached conditions as follows: • RFP 006-00A; Foster Parent Consultation. CONFIRMED. • RFP 006-00B: Home Study, Relinquishment Counseling. CONFIRMED with conditions: Condition #1: The threshold for hours for an incomplete home study will be set at 3.5 hours. Additional home studies will be billed at a maximum of$250 per person Condition #2: It has been mutually decided that the turnaround time for receipt of the completed home study by the Department is set at six weeks form the date of receipt of the referral. • RFP 04005: Lifeskills: CONFIRMED with the condition: Condition: Transitions has the following capacity to provide after-hours visitation: Monday-Friday evenings times from 5:00-8:00PM with the maximum of two simultaneous sessions in any given time slot. Saturdays 5:00AM-12:00N0on with only one therapist available for r services. • RFP 006-00: Mental Health Services: CONFIRMED with the condition: Condition: Reports will be provided to the Department no later than 90 days from the beginning date of services. In the event the report is not received within the required time frame, services will not be eligible for payment We look forward to another successful year of serving Weld County residents and Social Services agencies. Please feel free to call me on my cell phone, 590- 1424, or at the office, 336-1123, with any questions. Thank you. Sincerely, Q �' it,�-�(�I• ""---mot r G'Z-_ � V Gregory S. Creed, MA, LPC Cc: Jami Moe-Hartman, Co-director, Transitions Psychology Group, LLC a DEPARTMENT OF SOCIAL SERVICES P.O. A BOX GREELEY,CO. OX a3/4 • Website:www.co.weld.co.us ' Administration and Public Assistance(970)352-1551 Child Support(970)352-6933 110 € April 18,2005 COLORADO Greg Creed,Co-owner Transitions Psychology Group,LLC 804 11 Avenue Greeley,CO 80631 Re: RFP 04005: Lifeskills RFP 006-00A:Foster Parent Consultation RFP 006-00B:Home Study,Relinquishment Counseling RFP 006-00 Mental Health Services Dear Mr.Creed: The purpose of this letter is to outline the results of the Bid process for PY 2005-2006 and to request written confirmation from you by Wednesday,April 27,2005. A. Results of the Bid Process for PY 2005-2006 • The Families,Youth and Children(FYC)Commission recommended approval of RPF 006- 00A,Foster Parent Consultation for inclusion on our vendor list. • The Families,Youth and Children(FYC)Commission recommended approval of Bid#006- 00,Home Studies and Relinquishment Counseling for inclusion on our vendor list,attaching the following conditions for all Home Study providers. Condition#1: The threshold for hours for an incomplete home study will be set at 3.5 hours. Additional home studies will be billed at a maximum of$250 per person. Condition#2: It has been mutually decided that the turnaround time for receipt of the completed home study by the Department is set at six weeks from the date of receipt of the referral. • The Families,Youth and Children(FYC)Commission recommended approval of Bid #05005,Lifeskills, for inclusion on our vendor list,attaching the following condition for all Lifeskills program providers. Condition: All providers must define their capacity to do after-hours visitation. Page 2 Transitions Psychology Group/Results of RFP Process for 2005-2006 • The Families,Youth and Children(FYC)Commission recommended approval Bid#006-00 Mental Health Services for inclusion on our vendor list,attaching the following condition for all Mental Health Services providers. Condition: It is a requirement that provider reports be received no later than 90 days from the beginning date of services.In the event the report is not received within the required time frame, services will not be eligible for payment. B. Required Response by FYC Bidders Concerning FYC Commission Conditions: All conditions will be incorporated as part of your Bid and Notification of Financial Assistance Award(NOFAA).If you do not accept the condition(s),you will not be authorized as a vendor unless the FYC Commission and the Weld County Department of Social Services accept your mitigating circumstances.If you do not accept the condition,you must provide in writing reasons why.A meeting will be arranged to discuss your response.Your response to the above conditions will be incorporated in the Bid and Notification of Financial Assistance Award. The Weld County Department of Social Services is requesting your written response to the FYC Commission's conditions.Please respond in writing to Gloria Romansik,Weld County Department of Social Services,P.O.Box A,Greeley,CO, 80632,by Wednesday,April 27,2005,close of business. If you have questions concerning the above,please call Gloria Romansik at 352.1551,extension 6230. Sincerely, ego, for cc: Juan Lopez,Chair,FYC Commission Gloria Romansik, Social Services Administrator Weld County Department of Social Services Notification of Financial Assistance Award for Child Welfare Regular Administration Funds Type of Action Contact Award No. X Initial Award 05-HS-0030 Revision (RFP-006-00B) Contract Award Period Name and Address of Contractor Beginning 06/01/2005 and North Colorado Medical Center-Youth Passages Ending 05/31/2006 Home Studies,Home Study Updates,and Relinquishment Counseling 928 12 Street Greeley,CO 80631 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Assistance The total number of client family units to be served in Award is based upon your Request for Proposal(RFP). this program is 72.This is estimated at six The RFP specifies the scope of services and conditions of evaluations per month for 12 months. Subtotal of award. Except where it is in conflict with this NOFAA in individuals who receive Bilingual/bicultural services which case the NOFAA governs,the RFP upon which this is 36;subtotal of individuals who receive South award is based is an integral part of the action. county services is 36.The monthly maximum Special conditions capacity is 10 client family units. 1) Reimbursement for the Unit of Service will be based on a Cost Per Unit of Service rate per home study;home study update, and Hourly Rate Per relinquishment counseling session. Relinquishment Counseling $ 80.00 2) Reimbursement requests must be an original with an Rate per Study original signature from the provider and/or designee. Full Home Study(5 interviews) $900.00 3) Reimbursements requests must include the date the home Full Home Study(6 interviews) $950.00 study,update,or relinquishment counseling was completed. Full Home Study(7 interviews) $1,000.00 The request must reflect the referral number assigned to Full Home Study(8 interviews) $1,500.00 each home study,the amount billed for each home study, Full Home Study(9 interviews) $2,000.00 and the month the service was provided. Home Study Update $600.00 4) Payment will only be remitted on referrals made by Court Testimony $155.00 the Weld County Department of Social Services. • The threshold for hours for an incomplete home study 5) Requests for payment must be an original submitted to the will be set at 3.5 hours. Weld County Department of Social Services by the end of • Turnaround time for receipt of the completed home the 25th calendar day following the end of the month of study is 6 weeks from the date of receipt of the service.The provider must submit requests for payment on referral. forms approved by Weld County Department of Social • Additional home studies will be billed at a maximum Services. of$250 per person. 6) The Contractor will notify the Department of any changes Unit of Service Based on Approved Plan in staff at the time of the change. Enclosures: X Signed RFP:Exhibit A X Supplemental Narrative to RFP: Exhibit B Recommendation(s) X Conditions of Approval ApBy '5/Awe ProBy gram fficial: William H. Jerke, Chair Judy .Griego, irector Board 3f Wel,coy, {gommissioners Weld unty Department of Social Services Date: U LUU Date: (n /Z /O S ; - ( SO • SIGNED RFP: EXHIBIT A INVITATION TO BID DATE:February 16, 2005 Bid No. 002-05 RFP FYC 006-00B 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 006-00B) for: Adoption, Foster Care, and Expedited Permanency Planning Home Studies, and Relinquishment Counseling Deadline: March 11,2005, Friday, 10:00 a.m. The Families, Youth and Children Commission, an advisory commission to the Weld County Department of Social Services, announces that competing applications will be accepted for approved vendors pursuant to the Board of Weld County Commissioners' authority pursuant to Colorado Statute and the Weld County Home Rule Charter. The Families,Youth and Children Commission wishes to approve services targeted to run from June 1, 2005,through May 31, 2006, at specific rates for home studies, home study updates, and relinquishment counseling services. The County will authorize approved vendors and rates for services only. This program announcement consists of five parts, as follows: PART A...Administrative Information PART D...Bidder Response Format PART B...Background, Overview and Goals PART E...Bid Evaluation Process PART C...Statement of Work Delivery Date (After receipt of order) BID MUST BE SIGNED IN INK G t7 1.4.4..0-A TYPED OR PRINTED SIGNATURE VENDOR North Colorado Medical Center (Name) Handwritten Signature By Authorized Officer or Agent of Vender ADDRESS 1801 16th Street ITILE CEO Greeley, CO 80631 DATE 3Mbl-- PHONE# (970) 352 -4121 The above bid is subject to Terms and Conditions as attached hereto and incorporated. Page 1 of 35 Bid No. 002-05 RFP-FYC-006-00B Attached A HOME STUDY,UPDATE, &RELINQUISHMENT COUNSELING BID PROPOSAL AND REQUEST FOR CONTINUATION OF AWARD UNDER CHILD WELFARE ADMINISTRATION FUNDING 2005-2006 BID PROPOSAL APPLICATION PROGRAM FUNDS YEAR 2005-2006 Bid 002-05 RFP-FYC-006-00B NAME OF AGENCY: North Colorado Medical Center ADDRESS: 1801 16'h Street,Greeley CO 80631 PHONE: (970)352-1056 CONTACT PERSON: Karen Nicholson TITLE: Outpatient Services Coordinator DESCRIPTION OF HOME STUDY PROGRAM CATEGORY: Adoption,Foster Care,and Expedited Permanency Planning Home Studies in compliance with the uniform format utilized by the State of Colorado Department of Human Services since October 1, 1999(Attached A). 12-Month approximate Project Dates: 12-month contract with actual time lines of: Start June 1,2005 Start_6/1/05 End May 31,2006 End _5/31/06 1'11_LE OF PROJECT: Youth P sages David Rastatter C. 3)�DPC Name an ignature of Person Preparing Document Date/ Name and Signature Chief Administrative Officer Applicant Agency Date MANDATORY PROPOSAL REQUIREMENTS For new and renewal bids,please initial to indicate that the following required sections are included in this Proposal for Bid. For renewal bids,please indicate which of the required sections have not changed from Program Year 2004-2005 to Program Year 2005-2006. x Project Description Indicates No Change from 2004-2005 x Sample Home Study _Project Description x Target/Eligibility Populations _Sample Home Study x General Indicate _ Target/Eligibility Populations x Cultural/Eligibility Populations _General x Types of services provided Cultural/Eligibility Populations x Measurable Outcomes _Types of services provided x Service Objectives _ Measurable Outcomes x Workload Standards _ Service Objectives x Staff Qualifications _ Workload Standards x Unit of Service Rate Computation _ Staff Qualifications x Program Capacity per Month _ Unit of Service Rate Computation _x Certificate of Insurance _ Program Capacity per Month Page 23 of 35 Bid No. 002-05 RFP-FYC-006-00B Attached A Program Category Home Study,Update, and Relinquishment Counseling Project Title Youth Passages Vendor_North Colorado Medical Center PROJECT DESCRIPTION Provide a brief,one-page description of the project. II. SAMPLE HOME STUDY Provide a fictitious home study written using the State format. III. TARGET/ELIGIBILITY POPULATIONS Provide a one page brief description of the proposed target/eligibility populations. At a minimum your description must address: A. Total number of clients to be served. B. Total individual clients and the children's ages. C. Total family units. D. Sub-total of individuals who will receive bicultural/bilingual services. E. Sub-total of individuals who will receive services in South Weld County: F. Sub-total of Individuals who will have access to 24-hour service. G. The monthly maximum program capacity. H. The monthly average capacity. I. Average stay in the program (weeks). J. Average hours per week in the program. W. TYPE OF SERVICES TO BE PROVIDED Provide a two-page description of the types of services to be provided. Please address if your project will provide the service minimums as follows: A. Home Studies, Updates, and Relinquishment Counseling as referred by the Weld County Department of Social Services. Provide your quantitative measures as they directly relate to each service. At a minimum, include a number to be served in each service component. Describe your internal process to assure that FYC resources will not supplant existing and available services in the community; e.g. mental health capitation services, ADAD, and professional services otherwise funded. Page 25 of 35 I. PROJECT DESCRIPTION Youth Passages has been an FYC provider for ten years. Throughout that time we have provided high quality intensive treatment to youths experiencing significant emotional, behavioral, psychiatric, educational, interpersonal, familial and chemical dependency problems. Treatment modalities that we specialize in include: milieu, individual, group, experiential, behavioral and family therapy. Our family therapy program, which addresses issues specific to traditional, blended, adoptive and foster families, is one of the strengths of our service delivery system. Youth Passages staff possesses specific expertise in effectively evaluating family systems and living situations. This information is utilized to formulate treatment interventions and court recommendations. We feel this skill base will be an asset in working with the type of families referred for Home Studies, Home Study Updates and Relinquishment Counseling. The Youth Passages Home Study, Home Study Update and Relinquishment Counseling program (HSRC) will meet or exceed all fifteen specific reporting requirements specified for Home Studies and Relinquishment Counseling as outlined in Off-System Bid No. 010-03 FRP-FYC-06-000. The primary therapist who will complete these evaluations is a Licensed Marriage and Family Therapist who has previous employment experience as a social services caseworker. This supervisor will also supervise all home studies completed by master's level therapists at Youth Passages. If the need arises we can assign a Licensed Master's Level bilingual therapist who has successfully provided FYC services to the department. To ensure high quality service delivery Youth Passages staff will attend all related mandatory training offered by Weld County Department of Social Services. 1 II. SAMPLE HOME STUDY Client Name: CarinM Matthew M Date of Birth: 2/24/1994 4/1/1999 Legal Guardian: Weld County Department of Social Services Case Worker: Dave C. PO Box A Greeley, Co 80632 (970) 352-1551 ext. #4 People interviewed: Name: Bob Lucy Date of birth: 1/23/1964 12/8/1966 Relationship to children Family friend Family friend Address: 1640 Pond Drive Boulder, Colorado 80637 Phone #: home (303) 377-6767 work (303) 377-2999 (Bob) Cell (303) 217-4455 (Lucy) Interview dates: May 14, 2003 and May 21, 2003 PURPOSE OF THE HOME STUDY This home study was requested by Weld County DSS to determine if Bob and Lucy, long-time friends to the M. family, can provide a stable, nurturing long-term placement for Carin and Matthew. There are currently no known, family members who are available to provide long-term care for these children. 2 FAMILY HISTORY Bob descends from a Norwegian farming family from Sioux Falls, S. D. His family consisted of one older sister and one younger brother. Bob's birth and childhood development were unremarkable. He reached his childhood milestones as appropriate, as did his siblings. Bob's health was good; he had chicken pox at age 4, broke his arm falling from a tractor at age 8, and had his tonsils out when he was 11. Bob completed high school and then attended college in Vermillion, S.D. where he earned a bachelor's degree in Business. As a high-school student Bob wrestled and played football. He was a fairly popular student but chose to spend time with a small group of friends. Bob reports that he and his family got along well. His parents were devoted Lutherans and held to fairly traditional, conservative values. The family attended church together each Sunday and participated regularly in church activities. Due to this influence Bob was a fairly "normal" kid who only drank beer occasionally after a football game and never tried drugs. Bob related well to both his brother and sister and reported only the typical sibling rivalry between them. Bob's dad was the disciplinarian, and his mom was the homemaker. According to Bob it took only a few spankings at the hand of his dad for him to understand his behavior had consequences. In the times when discipline was needed Bob would lose privileges and have to do extra chores around the farm. At age 10 Bob's grandmother was in an accident and died. This was a very difficult loss for the entire family and Bob and his family spent 3-4 evenings at the home of the senior pastor, "processing" the death of his grandmother. This is the closest thing to counseling Bob experienced in his youth. In College Bob met Lucy. They began to date his junior year and were engaged two years later. They married after Bob graduated, and Lucy was a junior. 3 Lucy descends from an American father and a Spanish mother. She and her younger sister grew up in Boulder, Colorado. The family moved three rimes when Lucy was young, but they always remained in the city of Boulder. Her family regularly attended a charismatic church since the time she was 7 years old. Lucy's birth and childhood development were unremarkable, and she reached childhood milestones at appropriate ages. Her sister, Pam, however, was born with a disease similar to Cerebral Palsy. She suffered minimal brain damage due to complications during her birth. As a result, Pam required extensive home health medical care which was provided by her family and a hired home-health care agency. Lucy spent many hours caring for Pam, and though she does not resent this Lucy definitely believes she missed out on a lot of social activities by staying home with Pam. Lucy's health was generally good and she experienced common childhood illnesses, including croup, chicken pox, and pinkeye. Lucy did experience earaches as a toddler and as a result had tubes put in her ears. At age 14 she had her appendix removed. Lucy graduated from high school with honors, and moved to Vermillion to attend college. Her desire to move out of state was motivated in part by the desire to be free from caring for her sister. Lucy studied business and completed her degree in four years. Her junior year in college she married Bob, and he worked while she completed her senior year. Lucy reports that her family was very close, partially due to the need they had to care for Pam. They were strong participants in the Assemblies of God church and often attended church together, taking Pain in her wheel chair. Though Lucy's faith provided strength to her, it also created frustration because she hoped God would heal Pam. Lucy's disillusionment and confusion about this led her to step away from her faith when she moved away to college. While Lucy has no history of alcohol use she does admit to smoking pot off and on in high school. She reports it was only recreational use and stopped smoking when she married Bob. 4 Lucy was compliant with her parent's rules and reports that discipline consisted of being grounded from the phone or the car, and "being talked to" by both of her parents together. After Lucy completed her college degree she and Bob moved to Boulder and opened a restaurant. They managed the business together and were very successful with their first restaurant. Bob decided to open a second restaurant in Longmont. Even though the prospects appeared good early on they had to close the restaurant within two years of opening. Their perspective on the closing was optimistic since their first restaurant continued to do very good business. In 1996 Bob was forced to close the restaurant due to re-zoning by the city of Boulder. He pursued legal action against the city to prohibit the closure but was unsuccessful. The legal and the emotional cost to Bob and Lucy was high and it created tremendous stress on their marriage. As a result they chose to see a marriage therapist for 4 months as they attempted to deal with the stress of losing a business they loved. They felt the counseling was very helpful and effective. Bob and Lucy have no biological children. After trying to conceive for 2 years without success they decided to seek the help of an infertility specialist. The trials were not successful and because the cost was very prohibitive Bob and Lucy were not able to repeat the procedures. The grief that accompanied their infertility was the most difficult for Lucy and she admits that she has some residual anger at God for this. As a result they decided they wanted to adopt children, or become foster parents. Both see the opportunity to care for Carin and Matthew as the perfect opportunity. GENERAL FUNCTIONING During a business workshop in. 1998 Bob was given the Myers-Briggs Type Indicator (MBTI). His report indicated he was an ISTJ, introvert, sensing, thinking,judging. After reviewing the results Bob agreed that the indicator was accurate. To summarize here, Bob is an introvert who gains energy from being alone more than with groups. He has strong friendships with 2-3 other 5 men, and his wife and believes he is self-disclosing with all of them, Lucy the most. He prefers to look at situations by paying attention to the information present in front of him, and tends to be logical when making decisions. He is a very driven man who likes new challenges and believes it is important to finish what he starts. Because Bob is logical and detail oriented he tends to overlook emotions. He admits that he prefers not to spend a lot of time worrying about something, or getting upset about things. Instead, he thinks them through and tries to fix them. Bob's communication is "short and sweet", communicating only the minimal amount of information necessary in a conversation. Lucy has not taken the MBTI assessment, but in comparing herself to Bob she believes she is also an introvert, preferring quiet time and her own space, but also enjoys going out with friends or other couples more than Bob. Lucy prefers to look at situations by paying attention to the information present in front of her. She diverts from Bob by making decisions primarily based on her values and how she feels about the situation. Lucy reports she is less driven than Bob, and though she likes to do good work, she is much more relaxed about schedules and details. Both Bob and Lucy believe they are good communicators, including when they are angry. Lucy will cry more often when angry and Bob rarely cries about anything. He admits that at times he is not aware of his own emotions and it takes a number of conversations with Lucy for him to get at "the whys" of what may be bothering him. PARENTING - DISCIPLINE Both Bob and Lucy agree that discipline is an important component of parenting. They want to be "a united front" as they teach and discipline Cann and Matthew and agree that they will share the responsibility equally. Both agree that their hopes and expectations in this area are purely conjecture since they have never had children. They have read books (Parenting with Love and Logic and Boundaries with Kids) and feel this has given them a strong starting point. Yet they also realize most of the immediate active parenting will have to come from Lucy since Bob will be at work full-time. They also believe that the exact 6 consequences for misbehavior may depend on the differences between Carin and Matthew, including their age difference. They agree that they favor taking away privileges, adding chores and possibly utilizing time-out fo:r Matthew. Both state they will not employ corporal punishment. Bob and Lucy believe the point of discipline is to teach and help a child grow, not just to punish. They both admit to being a little nervous to see how this plays out "in real life" once the children move in. Currently there is no plan to use day care. PARENTING- VALUES AND PRACTICE Bob and Lucy have compiled a list of what they consider the "family non- negotiables". They want Carin and Matthew to be well provided for (i.e. clothes, toys, etc...) but state they will be cautious about being too excessive in this area. School attendance is required, and they would like to see both kids maintain at least a "B" average. Extra-curricular activities will be encouraged. A daily chore list will be established, at age-appropriate levels, and both kids will earn allowance. A portion of their allowance will be put into a savings account. The family will have family meetings once a week to talk about how everybody is doing, and to plan activities together. The family will attend church together most Sundays. Both kids will be provided the opportunity to participate in 2-3 activities per year, such as swimming lessons or soccer, so they are exposed to various activities and skills. Depending on the disposition regarding Carin and Matthew's parents, Bob and Lucy are hoping to eventually adopt the children. With this in mind, and due to the history of abuse perpetrated on the children by their biological parents, it is Bob and Lucy's preference that the parents have no contact with Carin and Matthew. They will, however, abide by the court rulings on this matter. 7 CHILDREN Bob and Lucy have no children. FAMILY SYSTEM Family Functioning Based partially on his Norwegian/Lutheran upbringing Bob brings the following dynamics to his relationships with others. He tends to have strong opinions and often will share them in a diplomatic, confident manner. Bob knows clearly what he expects with, and from, others and rarely deviates from his own rules. He professes that overall his thinking is black and white, right or wrong. When he makes a decision it is most often with strong conviction and he stands by his decisions. Because of this it can be difficult to change his opinion and doing so requires a thorough explanation and discussion of the issue. Early on in their marriage Bob rarely changed his opinions, but over the years he has "softened" and will listen to others (Lucy and co-workers) as they express differing opinions. Bob acknowledges that he is more willing to change his mind now than when he was younger. Generally Bob holds to what he describes as a "traditional line" when it comes to rules and values, and anticipates that will remain the same when he cares for Carin and Matthew. The influence of Lucy's Hispanic heritage is exemplified through her core family values. Lucy's parents taught her to respect and love her family and honor her parents. The one striking divergence from traditional Hispanic values is that her parents raised her in a home where parents shared equal roles in the family. Her church background encompassed strong evangelical values, with tolerance for differences in others, and some flexibility with rules. Lucy is quite verbal and will process her thoughts out loud with whomever she is talking. She often solicits the thoughts and opinions of others when it comes to making a decision, yet is very clear within herself about what she wants. 8 • • Bob and Lucy are openly affectionate with each other (this can be uncomfortable for Bob), and Lucy openly hugs other friends and co- workers. In terms of affection, both of them agreed that they want to openly demonstrate care and respect for each other in front of the children. It is their hope that Carin and Matthew will learn how to care for and respect others and appropriately express these feelings. Lucy travels to Longmont every other week to visit with her sister Pam, who is being cared for in an assisted living facility. Though she acknowledges feeling an obligation to do this, she willingly visits Pam and notes that it is so much easier now than when she was caring for Pam on a daily basis. Lucy would like to bring Carin and Matthew with her occasionally so that they can learn to socialize with, and even help care for, people with handicaps. Bob and Lucy feel that their marriage is stronger at present than it ever has been. Both believe they have adequately grieved their inability to have biological children and Lucy i.s able to express this tearfully, but with resolve. Lucy believes there will always be some degree of sorrow over the fact that she herself could not carry and birth a baby. FAMILY SUPPORT NETWORK Bob and Lucy appear to have a strong support network. Both are active in church social activities as their schedules permit. Lucy is in a women's bible study and Bob participates in a men's accountability group that meets every other Tuesday morning. Bob feels close friendship with his assistant manager at the restaurant, as well as a few other friends. Bob's family continues to live in South Dakota and they have expressed an excitement for Bob and Lucy regarding caring for Carin and Matthew. The hope of Bob's family is that they can all spend time together in the summer and every Thanksgiving when his family travels to Colorado for the holiday. Lucy's family supports her wishes to care for the kids, and Lucy's parents are very excited about the prospect of becoming grandparents. 9 • DEMOGRAPHICS Home Bob and Lucy live in a 4-bedroom ranch-style home east of Boulder. Their home rests on 2 acres of land, with a front and back yard, and a small field behind the back yard. Their neighborhood is older, and there is ample space between homes. Because they have lived in the home for 12 years they know all of their neighbors, and have met the children in three homes on their street. Two of the neighbors have children close in age to Carin and/or Matthew. Financial status For the tax year 2002 Bob and Lucy's gross income was $68,000. They anticipate a similar income in 2003 from their restaurant. They have limited investments in mutual funds and stocks. In February 2003 they refinanced their home on a 15-year loan. Bob and Lucy took out a small home-equity loan when they refinanced so that they can buy furniture for both of the kids' rooms and pay for clothes and other essentials. They own both of their cars, and have an outstanding credit card debt of $650.00. Once the children live in their home they will be added to Bob's current health insurance plan. In their estimation they believe they will be able to provide for a family of four financially without too much problem. BIRTH FAMILY Bob and Lucy have been friends with Carin and Matthew's parents for 6 years. They have been aware of the problems in the home and have been there on a number of occasions to support and encourage Jim and Barb. As the situation became more unstable in the home Lucy did try and offer counsel, especially to Barb, but felt she was rebuffed. Bob became angry 10 and began to detach from Jim, primarily, in his words, because it did not do any good to try and help. In 2001 Bob and Lucy offered to care for the children for the summer so that Jim and Barb could get the help they needed without having to worry about caring for Carin and Matthew. Barb seemed appreciative of the offer, but declined. To date there is tension between the couples, and because it is the hope of Bob and Lucy to adopt they would like to have contact with the children discontinued, "at least until the kids are settled in with us". FOSTER/ADOPTIVE FAMILY PREPARATION Bob and Lucy have attended the county foster parent trainings and have completed the home licensing process. They attended a "Growing Kids God's Way" series at their neighbor's church, and though they agreed to many of the principles they disagreed with what they felt were "rigid behavioral expectations". Bob and Lucy plan to attend a different parenting series in the future. Bob and Lucy are unsure of how to deal with visitation from Carin and Matthew's grandparents. They do not wish to isolate the children from family members who love them, yet they want to protect the kids from potential indirect harm of mom and dad. On this issue Bob and Lucy would like outside counsel that incorporates the children's wishes. MOTIVATION/COMMITMENT Bob and Lucy express a high level of motivation to care for Carin and Matthew. Their motivation is evidenced by reading books to strengthen their parenting skills, discovering who the neighborhood children are for possible friendships with Carin and Matthew, financial preparation to 'make rooms' for the kids, and completing all necessary licensing requirements to date. Bob and Lucy have longed to be parents for many years. They have an established relationship with the kids, and have shown a high level of care and concern about their welfare for 6 years. Lucy admits her longing for children feels a little more urgent due to their inability to have children. 11 They agree they do not know all there is to know about parenting, but, as all parents do, they will learn as they go. Bob and Lucy are financially stable and possess a strong support network through their faith community and other friendships that will be a benefit to them as foster/adoptive parents. They feel a slight apprehension about the adjustment from having a lot of personal freedom to, at all times, considering the needs of a 9 year old and a 4 year old. INTERVENTION Bob and Lucy have agreed that they are open to seeking help from outside resources when necessary. When pressed by this evaluator Bob admitted he would be slower to seek help than Lucy, but that he would never oppose help if Lucy or he really believed it was needed. TRAINING/RESOURCES Bob and Lucy have attended and completed all required DSS and licensing classes. They completed one parenting class and are waiting to hear from the Rocky Mountain Marriage and Family Institute about an up-coming parenting class for families with special needs, i.e. abuse, adoption, behavior concerns. OBSERVATIONS Based on the home study the undersigned submits the following observations: 1. The home and neighborhood are safe and appropriate for Carin and Matthew. 2. The financial status of Bob and Lucy is adequate to provide for Carin and Matthew. 3. The expressed level of acceptance and excitement of the extended family to include Carin and Matthew in their family is high. 4. The support system for Bob and Lucy is strong. 5. Bob and Lucy are very motivated and committed to caring for Carin and Matthew. 12 6. The tension between Bob and Lucy and Jim and Barb does create concerns. 7. Bob and Lucy do not yet understand the process of terminating parental rights. 8. Bob's stoic nature and preference not to express emotion may create difficulty for him to express empathy towards the children. 9. The emotional roller coaster of infertility and the longing within Lucy to care for these children may contribute to her being an enabling or permissive parent. RECOMMENDATIONS Based on the home study, the undersigned recommends the following: 1. Bob and Lucy should be considered as a viable foster/adoption home for Carin and Matthew. 2. Bob and Lucy need information from DSS about the relinquishment process and a written plan regarding visitation between Jim and Barb and Carin and Matthew. 3. Parental visitation should be limited and supervised. 4. Bob and Lucy need counsel from DSS regarding grandparent visitation, both now and in the future, if parental rights are terminated. 5. Carin and Matthew should participate in therapy with a skilled play therapist that specializes in the treatment of domestic violence. Evaluator Date 13 IV. TYPE OF SERVICES TO BE PROVIDED The Youth Passages Home Study, Home Study Update and Relinquishment Counseling program (HSRC) will meet or exceed all fifteen specific reporting requirements specified for Home Studies and Relinquishment Counseling as outlined in Off-System Bid No. 010-03 FRP-FYC-06-000. The primary therapist who will supervise these evaluations is a Licensed Marital and Family Therapist who has previous employment experience as a social services caseworker. If the need arises we can assign a Licensed Master's Level bilingual therapist who has successfully provided FYC services to the department, as well as a Licensed Professional Counselor. To ensure high quality service delivery Youth Passages staff will attend all related mandatory training offered by Weld County Department of Social Services. Quantitative Measures A. 100% of clients referred by Weld County Department of Social Services for a Home Study or Home Study Update will be fully evaluated on the fifteen specific reporting requirements specified for Home Studies as outlined in Off-System Bid No. 010-03 FRP- FYC-06-000. The background checks will be completed and the written report submitted to Weld County Department of Social Services within six weeks of our receipt of the referral. B. 100% of clients referred by Weld County Department of Social Services for Relinquishment Counseling will be fully evaluated on their understanding of the fifteen specific categories specified for Relinquishment Counseling as outlined in Off-System Bid No. 010-03 FRP-FYC-06-000. The written report will be submitted to Weld County Department of Social Services within the 14 individualized timeframe specified for each case. North Colorado PsychCare/Family Recovery Center deals daily with patient funding issues which include mental health capitation, ADAD and private insurance. We will not utilize FYC funds when other payer sources are available. V. MEASURABLE OUTCOMES A. 100% of our home studies and relinquishment counseling cases will be completed within the timeframe specified by the department. Our timeliness will positively impact the mandate to place children in an expedient manner. B. 100% of our home studies will consist of high quality clinical evaluations. 100% of our reports will be well written and submitted to the department within the timelines outlined in Off- System Bid No. 010-03 FRP-FYC-06-000. C. 100% of our submitted home studies will be defined by the department as acceptable. We will ensure quality reports by presenting them for internal clinical review by supervisors prior to submitting them to Weld County Department of Social Services. VI. SERVICE OBJECTIVES Youth Passages will ensure the provision of quality home studies, updates and relinquishment counseling for Adoptive, Foster Parents and Department of Social Services clients by hiring only highly qualified and well trained licensed Master's Level therapists. These therapists will receive ongoing clinical supervision and their reports will be reviewed by a supervisor prior to submission to the department. 100% of our home studies, updates and relinquishment counseling reports for Adoptive, Foster Parents and Department of Social Services clients will consist of high quality clinical evaluations. 100% of our reports will be well written, address the mandated evaluation topics and submitted to the department within the timelines outlined in Off-System Bid No. 010-03 FRP-FYC-06-000. 15 VII. WORKLOAD STANDARDS A. The person providing this service for North Colorado PsychCare will be a full time, or part time, therapist who will not work more than 12 hours per day, 40 hours per week, or 173 (on average) per month. One bilingual Master's Level therapist will be available to assist on special needs or high census periods. B. 2 C. Maximum caseload per therapist - 6 D. The treatment modality will vary depending upon the requested service. All submitted reports will meet standards outlined in Off- System Bid No. 010-03 FRP-FYC-06-000. E. Total Number of Hours of Service - 2-4 hours per day on days clients are seen 4-8 hours per week 16-32 hours per month F. Total number of individuals providing these services- 1 full time, or part time, therapist. 1 bilingual therapist available for special needs cases or high census periods G. Maximum caseload per supervisor -.15 H. Insurance - See attached certificate of insurance 16 VIII. STAFF QUALIFICATIONS A. The Behavioral Health Therapist(s) providing services will have a minimum of a Master's Degree in psychology, counseling, social work or a related field, possess a current Colorado licensure, or be supervised by a therapist with current Colorado licensure, and will be listed on the State of Colorado Department of Human Services vendor list, having applied for inclusion.. B. Two staff members will be available for the direct service phase of this project with one additional staff member providing supervision. 17 VERIFICATION OF COVERAGE ISSUE DATE: Jan. 14, 2005 Issuer.Banner Health This verification of coverage is issued as a matter of information only,and does not extend or alter the coverage carried by Banner Health. COVERED PARTY COMPANIES PROVIDING COVERAGE COMPANY BANNER HEALTH LETTER A SAMARITAN INSURANCE FUNDING,LTD. 1441 N.12TH STREET COMPANY PHOENIX, AZ 85006 - LtI I ER El COMPANY LETTER C COMPANY LETTER D COVERAGES THIS IS TO CERTIFY THAT THE INSURANCE COVERAGE LISTED BELOW IS CARRIED BY THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS VERIFICATION OF COVERAGE MAY BE ISSUED OR MAY PERTAIN,THE COVERAGE DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF THE POLICIES OF INSURANCE CARRIED BY BANNER HEALTH. CO LTR TYPE OF INSURANCE POLICY NUMBER/OLICY EFFECTIVE DATE POLICY EXP.DATE LIMITS A HOSPITAL PROFESSIONAL& SIFL2005 01/01/05 01/01/06 PL EACH LOSS $10,000,000 GENERAL LABILITY GL EACH LOSS $10,000,000 GL AGGREGATE $10,000,000 HOSPITAL PROFESSIONAL HPL EACH LOSS $ UABIUTY HPL AGGREGATE $ HOSPITAL PROFESSIONAL HPL EACH LOSS $ LIABILITY HPL AGGREGATE $ MEDICAL PROFESSIONAL PER MEDICAL INCIDENT $ LIABILITY ANNUAL AGGREGATE• $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM WORKER'S COMPENSATION STATUTORY LIMITS $ AND EMPLOYER'S UABIUTY $ EMPLOYER'S LIABILITY COMMENTS. BANNER HEALTH HAS ARRANGED TO HAVE COVERAGE EXTENDED TO NORTH COLORADO MEDICAL CENTER. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED OR MATERIALLY TO WHOM IT MAY CONCERN CHANGED BEFORE THE EXPIRATION DATE,BANNER HEALTH WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER,BUT FAILURE TO MAIL SUCH NOQRCE SHALL IMPOSE NO LIABILITY OF ANY KIND UPON BANNER HEALTH.ITS II1fJRERS OR THEIR AGENTS OR REPRESENTATIVES. 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BOX A GREELEY, CO. 80632 Website:www.co.weld.co.us ' Administration and Public Assistance(970)352-1551 Child Support(970)352-6933 O • COLORADO April 18,2005 Gene O'Hara North Colorado Medical Center 1801 16th Street Greeley,CO 80631 Re: RFP 05010: Option B,Home Based Services RFP 05006:Day Treatment RFP 006-00:Home Studies,Relinquishment Counseling Dear Mr.O'Hara: The purpose of this letter is to outline the results of the Bid process for PY 2005-2006 and to request written information or confirmation from you by Wednesday,April 27,2005. A. Results of the Bid Process for PY 2005-2006 • The Families,Youth and Children(FYC)Commission recommended approval of the bids listed below for inclusion on our vendor list. 1. RFP 05010: Option B,Home Based Services 2. RFP 05006:Day Treatment • The Families,Youth and Children(FYC)Commission recommended approval of the bid, RFP 006-00B,Home Study.Updates.Relinquishment Counseling,for inclusion on our vendor list,attaching the following conditions for all Home Study providers. Condition#1:The threshold for hours for an incomplete home study will be set at 3.5 hours. Additional home studies will be billed at a maximum of$250 per person. Condition#2: It has been mutually decided that the turnaround time for receipt of the completed home study by the Department is set at six weeks from the date of receipt of the referral. 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 North Colorado Medical Center/Results of Bid Process for PY 2005-2006 The Weld County Department of Social Services is requesting your written response to the FYC Commission's condition.Please respond in writing to Gloria Romansik,Weld County Department of Social Services,P.O.Box A,Greeley,CO, 80632,by Wednesday,April 27, 2005,close of business. If you have questions concerning the above,please call Gloria Romansik at 352.1551,extension 6230. Sincerely, J A. ego, for cc: Juan Lopez,Chair,FYC Commission Gloria Romansik, Social Services Administrator Home Study Home Study Update ML Relinquishment 1:1 2005 Number of Statistic: Hours/Casa Cases Home Study 15 50 Home Study Update 8 15 ML Relinquishment 1:1 3 7 Total Cases 72 1872 • Revenue Per Case Home Study 5 Interviews $ 900 $ 36,000 Home Study 6th interview $ 950 $ 2,850 Home Study 7th interview $ 1,000 $ 4,000 Home Study 8th interview $ 1,500 $ 4,500 Home Study 9th interview $ 2,000 Home Study Update $ 600 $ 9,000 ML Relinquishment 1:1 $ 80 $ 560 Gross Revenue $ 56,910 Deductions: No Shows $ 1,000 Net Revenue $ 55,910 Expenses: Salary-ML therapist $ 44,460 Salary Clinical Coordinator $ 543 Other(BA,Reimb,MR,etc) $ 262 Sub Total Salaries with benefits $ 45,265 Non-Salary expense: Mileage $ 3,000 Background Checks $60ea $ 9,000 Supplies $ 750 Sub Total Non-Salary $ 12,750 Total Expense $ 58,015 Contribution Margin $ (2,105) SUPPLEMENTAL NARRATIVE TO RFP: EXHIBIT B CONDITIONS Kirk Lei. t: DEPARTMENT OF SOCIAL SERVICES P.O. BOX A GREELEY, CO. 80632 Website:www.co.weld.co.us ' Administration and Public Assistance(970)352-1551 Child Support(970)352-6933 • COLORADO April 18,2005 Gene O'Hara North Colorado Medical Center 1801 16th Street Greeley,CO 80631 Re: RFP 05010:Option B,Home Based Services RFP 05006:Day Treatment RFP 006-00: Home Studies,Relinquishment Counseling Dear Mr. O'Hara: The purpose of this letter is to outline the results of the Bid process for PY 2005-2006 and to request written information or confirmation from you by Wednesday,April 27,2005. A. Results of the Bid Process for IW 2005-2006 • The Families,Youth and Children(FYC)Commission recommended approval of the bids listed below for inclusion on our vendor list. 1. RFP 05010: Option B,Home Based Services 2. RFP 05006:Day Treatment • The Families,Youth and Children(FYC)Commission recommended approval of the bid, RFP 006-00B,Home Study,Updates,Relinquishment Counseling, for inclusion on our vendor list,attaching the following conditions for all Home Study providers. Condition#1: The threshold for hours for an incomplete home study will be set at 3.5 hours. Additional home studies will be billed at a maximum of$250 per person. Condition#2: It has been mutually decided that the turnaround time for receipt of the completed home study by the Department is set at six weeks from the date of receipt of the referral. 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 North Colorado Medical Center/Results of Bid Process for PY 2005-2006 The Weld County Department of Social Services is requesting your written response to the FYC Commission's condition.Please respond in writing to Gloria Romansik,Weld County Department of Social Services,P.O.Box A, Greeley,CO, 80632,by Wednesday,April 27, 2005,close of business. If you have questions concerning the above,please call Gloria Romansik at 352.1551,extension 6230. Sincerely, J A. 'ego, . for cc: Juan Lopez,Chair,FYC Commission Gloria Romansik, Social Services Administrator Page 2 North Colorado Medical Center/Results of Bid Process for PY 2005-2006 The Weld County Department of Social Services is requesting your written response to the FYC Commission's condition.Please respond in writing to Gloria Romansik,Weld County Department of Social Services,P.O.Box A,Greeley,CO, 80632,by Wednesday,April 27, 2005,close of business. If you have questions concerning the above,please call Gloria Romansik at 352.1551,extension 6230. Sincerely, J A. ego, ' for cc: Juan Lopez,Chair,FYC Commission Gloria Romansik, Social Services Administrator Weld County Department of Social Services Notification of Financial Assistance Award for Child Welfare Regular Administration&EPP Funds Type of Action Contract Award No. X Initial Award 05-CPS-31 Revision (RFP-006-00B) Contract Award Period Name and Address of Contractor Beginning 06/01/2005 and Julie Box,Private Practice. Ending 05/31/2006 Home Studies,Updates, Relinquishment Counseling 1702 68t Avenue Greeley, CO 80634 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Home study format is based on 20 hours of Assistance Award is based upon your Request for work. Relinquishment counseling for a Proposal (RFP). The RFP specifies the scope of maximum of 4 hours per parent. Program services and conditions of award. Except where it is capacity is 36 home studies or updates per year in conflict with this NOFAA in which case the and 24 individuals receiving relinquishment NOFAA governs, the RFP upon which this award is counseling per year.The average stay is based is an integral part of the action. expected to be 6 weeks for a home study, and Special conditions two weeks for each parent in relinquishment 1) Reimbursement for the Unit of Service will be based counseling. Bilingual-bicultural services on a rate per home study; home study update, and available through subcontract. relinquishment counseling session. 2) Reimbursement requests must be an original with an Cost Per Unit of Service original signature from the provider and/or designee. Hourly Rate per Relinquishment Counseling $103.89 3) Reimbursements requests must include the date the Full Home Study with Background Check* $850.00 home study, update, or relinquishment counseling was Full Home Study(No Background Check)* $750.00 completed.The request must reflect the referral Updated Home Study $425.00 number assigned to each home study,the amount Home Study(3.5 Hour Minimum Direct Face- billed for each home study,and the month the service to-Face Contact) Cancellation by DSS $225.00 was provided. Additional Fee per Additional Adults in 4) Payment will only be remitted on referrals made by Household per Home Study* $250.00 the Weld County Department of Social Services. 5) Requests for payment must be an original submitted to the Weld County Department of Social Services by the end of the 25th calendar day following the end Enclosures: of the month of service. The provider must submit X Signed RFP:Exhibit A requests for payment on forms approved by Weld X Supplemental Narrative to RFP: Exhibit B County Department of Social Services. Recommendation(s) 6) The Contractor will notify the Department of any X Conditions of Approval changes in staff at the time of the change. Approvals: Program Official: By ' t /{'^^^ By i7 William H. Jerke, Chair Judy GriegooDirector ktit Board of Weld Count Commissioners Weld ounty Department olll. Social Services Date: JUN 0 6 200 Date: 0 S c2CC,S - / 6S0 SIGNED RFP-EXHIBIT A • INVITATION TO BID DATE:February 16, 2005 Bid No. 002-05 RFP FYC 006-00B 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 006-00B) for: Adoption, Foster Care, and Expedited Permanency Planning Home Studies, and Relinquishment Counseling Deadline: March 11, 2005,Friday, 10:00 a.m. The Families,Youth and Children Commission, an advisory commission to the Weld County Department of Social Services, announces that competing applications will be accepted for approved vendors pursuant to the Board of Weld County Commissioners' authority pursuant to Colorado Statute and the Weld County Home Rule Charter. The Families,Youth and Children Commission wishes to approve services targeted to run from June 1, 2005,through May 31, 2006, at specific rates for home studies,home study updates, and relinquishment counseling services. The County will authorize approved vendors and rates for services only. 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 O 3.c9 E OS - (After receipt of order) BID MUST BE SIGNED IN INK P>0X TYPED OR PRINTED SIGNATURE . ,t J lilt L'� VENDOR tE oX — - - - (Name) • : .dwri en Signature By Authorized O t c- •r Agent of Vender ADDRESS (101 (DO //n�ret TITLE C.re-ek-e ("o 51.0(Q2)c . DATE PHONE# an0. . ty7( — The above bid is subject to Terms and Conditions as attached hereto and incorporated. Page 1 of 35 Bid No. 002-05 RFP-FYC-006-00B Attached A • HOME STUDY, UPDATE, & RELINQUISHMENT COUNSELING BID PROPOSAL AND REQUEST FOR CONTINUATION OF AWARD UNDER CHILD WELFARE ADMINISTRATION FUNDING 2005-2006 BID PROPOSAL APPLICATION PROGRAM FUNDS YEAR 2005-2006 Bid 00:2-05 RFP-FYC-006-00B NAME OF AGENCY: -v_lUdI�aO1 ADDRESS: Viol (o Ati'e- (2 reel-el �t0 X()/a34 PHONE: (y7c) 3eL -1 q71 CONTACT PERSON: U-�to aox / TITLE: LO 5W DESCRIPTION OF HOME STUDY PROGRAM CATEGORY: Adoption,Foster Care,and Expedited Permanency Planning Home Studies in compliance with the uniform format utilized by the State of Colorado Department of Human Services since October 1, 1999(Attached A). 12-Month approximate Project Dates: 12-month contract with actual time lines of: Start June 1,2005 Start.—Lunt l ? LOo5 End May 31,2006 End Mo A. 11 Zoo(0 T F PROJECT: tAtAt O' �-�Vtie,, et vAeo-u .Lve,ie„ N. - . d .ignature of Person Preparing Document Date Name . . Signature Chief Administrative Officer Applicant Agency Date MANDATORY PROPOSAL REOUIREMENTS For new and renewal bids,please initial to indicate that the following required sections are included in this Proposal for Bid. For renewal bids,please indicate which of the required sections have not changed from Program Year 2004-2005 to Program Year 2005-2006. Project Description Indicates No Change from 2004-2005 Sample Home Study Project Description Target/Eligibility Populations Sample Home Study G _General Indicates Target/Eligibility Populations cC3Q Cultural/Eligibility Populations General ypes of services provided Cultural/Eligibility Populations Measurable Outcomes of services provided Service Objectives Measurable Outcomes Workload Standards Service Objectives Staff Qualifications Workload Standards Unit of Service Rate Computation Staff Qualifications Program Capacity per Month Unit of Service Rate Computation Certificate of Insurance Program Capacity per Month Page 23 of 35 Bid No. 002-05 RFP-FYC-006-00B Attached A Date of Meeting(s)with Social Services Division Supervisor: E Q P Comments by SSD Supervisor: 0. 63ep._ arr./44,4.a datheae__ Name and Signature SSD • .- 'sor Date Page 24 of 35 June 2005 Off-System Bid 002-05 RFP FYC 006-006 Home Studies, Relinquishment Counseling Julie Box, LCSW I. PROJECT DESCRIPTION Julie Box(Bidder) is a Licensed Clinical Social Worker offering a wide range of services to children, families and adults. Bidder has been providing human services to the Northern Colorado area since 1986. During the past 18 years, Bidder has provided services as a counselor, a caseworker and a therapist in the field of child welfare. Bidder has provided services to all individuals without consideration of religious beliefs, race, ethnicity, sex or economic status. For the past three years, Bidder has been providing home study and relinquishment counseling services to the Weld County Department of Social Services as well as through this Bidder's employer, Lutheran Family Services, a non-profit agency. Bidder uses the Foster Family Assessment System developed by ACTION for Child Protection. A written, narrative home study will be provided to the Weld County Department of Social Services. Bidder is currently on the state vendor list for adoptive home study providers. Additionally, Bidder has the experience and expertise to provide relinquishment counseling in a timely fashion. II. SAMPLE HOME STUDY A sample home study is attached to this proposal. 111. TARGET/ELIGIBILITY POPULATIONS: The population to be served under this contract includes: families who wish to adopt children from the Weld County Department of Social Services; relinquishment counseling for parents who are considering relinquishing children and applicants for foster care certification. Bidder has been providing home study services to Weld County for the past three years through Lutheran Family Services and has never turned down a referral. At 20 hours per home study, Bidder would be able to complete 3 home studies per month. Home studies are given ten hours of direct service and ten hours indirect service. Bidder is cross-trained to provide a variety of clinical services including therapy,clinical case management, relinquishment counseling or home studies. The following numbers reflect a case load of 3 home studies per month: A. Total Number of Clients to be served: Each home study is'worth'20 hours and will be spread over a six-week period of time. Bidder estimates she could complete 36 home studies per year. Relinquishment counseling will be provided on an hourly basis. Bidder estimates the relinquishment counseling takes an average of four hours of direct service per person. Bidder estimates she could counsel 24 Individuals per year. B. Total Individual clients and the children's ages. The number of individuals and ages of children is completely dependent on the demographics of the families referred for services. Bidder does not limit services to families with children of specific ages. C. Total family units. Bidder estimates she could complete 36 home studies per year. D. Subtotal of individuals who will receive biculturaVbilingual services Unfortunately, Bidder is not bilingual; however, Bidder would be able to contract with a qualified Spanish speaking clinician to complete home studies as referred. Bidder would not refuse any bicultural services. E. Subtotal of individuals who will receive services in South Weld County. Bidder does not limit her services to specific geographical areas so Bidder will provide services in the Southern part of Weld County as they are referred. F. The monthly maximum program capacity. Bidder estimates she could complete 3 home studies every month. G. The monthly average capacity. Bidder estimates she can manage the volume of home studies as Bidder has done so this past year. At the present rate of referral, Bidder would plan to complete 3 home studies per month. H. Average stay in the program (weeks) Bidder's goal is to complete home studies within six weeks of implementation of the home study. Bidder is estimating that relinquishment counseling averages 2 weeks. I. Average hours per week in the program. Families who are having a home study completed will average 3-4 hours of direct service per week, for 3 weeks. Individuals receiving relinquishment-counseling services will average 1 hour per week of direct service. IV. TYPES OF SERVICES TO BE PROVIDED Adoption and Foster Care Home Studies Bidder uses the Foster Family Assessment(FFA)System developed by ACTION for Child Protection. This is the format that was taught in state sponsored training. That format is the format used in the fictitious home study submitted with this bid. A narrative home study is produced using the FFA system. These home studies are'adoptive quality'and meet the state prescribed format There is no difference between adoption,foster care or kinship care home studies. Bidder is currently on the state vendor list for adoptive home study providers. Home study updates will be completed using the FFA System and there will be a reduced fee charged. The following background checks will be completed by Bidder unless otherwise indicated on the referral: 1 Fingerprints sent to CBI on Weld County Department of Social Services fingerprint cards, results will be returned directly by CBI to the Weld County DSS. Bidder will collect and submit the fingerprint cards after the Weld County Department of Social Services has distributed the cards. Bidder will cover the fee for the submission of these cards. If the applicant has lived in the state for less than two years, an FBI search will be requested. Bidder will cover this additional fee. 2 Department of Motor Vehicles(results returned to Bidder). 3 Local county DSS search for open or past cases (results returned to Bidder). 4 Four reference questionnaires will be sent out with a SASE (results returned to Bidder). 5 Local police department (results returned to Bidder). 6 Central Registry will be completed by the referring caseworker through the Trails system at the Weld County Department of Social Services. All original background check information will be forwarded to the Weld County DSS with the written home study. A copy will be retained in Bidder's files. Bidder has all of the forms and processes in place necessary to complete these background checks. Additionally, Bidder can provide a safety inspection of the home, if requested, at no additional fee to the county. Relinquishment Counseling Services Relinquishment counseling services will be provided to all adult individuals referred for this service by the Weld County Department of Social Services as well as to their children age 12 and older. Services will be provided individually and Bidder will submit a written report and the appropriate affidavits. V. MEASURABLE OUTCOMES The goal for each home study referral is to complete a comprehensive,written home study within six weeks of initiation of the home study. The outcome will be measured through timely submission of the home study to the referring caseworker. Bidder will also track the number of home studies referred that Bidder did not accept and the number of home studies referred and subsequently cancelled by the department The Foster Family Assessment(FFA)System provides a rating system used to measure the risk of the placement in an applicant foster family or adoption of a child in any given home. Relinquishment counseling referrals will be tracked and measured in the same way as home studies. VI. SERVICE OBJECTIVES The service objectives are the same as the measurable outcomes,that is: the completion of quality home studies, updates and relinquishment counseling services in a timely manner. All home studies will be completed using the state endorsed FFA System. VII. WORKLOAD STANDARDS Please see the previous section"TargeUEligibility Populations"for a detailed explanation of Bidder's workload standards. In summary, Bidder intends to devote 20 hours per week to completing the home studies referred. Half of Bidder's time will be in Direct Service hours and half in Indirect Service hours. The requested minimum standards for insurance have been met and documentation provided. VIII. STAFF QUALIFICATIONS Bidder has a bachelors degree in Psychology(BA), a Masters degree in Social Work(MSW)and is a Licensed Clinical Social Worker(LCSW)since January 21, 2003(license number. 992996). Please see the attached copy of Bidder's license. Bidder secures a minimum of 32 hours per year of continuing education training. IX. COMPUTATION OF DIRECT SERVICE RATE Please refer to the attached budget for computation of direct service rate. This hourly rate is what Bidder will charge for each hour of direct service of relinquishment counseling provided. 850 Home studies are charged at a flat rate: for a fulllhome study without background check:me study with background check: $750 for an updated home study: $425 This fee includes the background check and all necessary interviews for a two-parent family. The assessment of additional adults living in the home will necessitate an additional fee of$200 per adult. Bidder would like to propose a flat fee of$225 for any home study that was initiated and where Bidder provided a minimum of 3 hours of direct,face-to-face contact, and the home study was subsequently cancelled by the Weld County DSS or the family. X. PROGRAM CAPACITY BY MONTH As outlined in this proposal, Bidder's capacity is based on a direct/indirect service ratio. Bidder estimates that her monthly capacity is 3 home studies and 2 individuals needing relinquishment counseling per month. FAMILY ASSESSMENT AND UPDATE INITIAL ASSESSMENT: DATE: February 28, 2004 RE-CER I IFICATTON: DATE: N/A Family Name: Bob and Jane Doe Clinician Name: Julie Box, LCSW Parent Force 1. History Element: Social History/Background Check, Character and Suitability (Adults) What is the parents' childhood and adult history? Consider the individual's cultural context in your description. When updating or re-certifying, describe new or significant information that indicates a change from previous assessment. Specific areas include: personal history of abuse, marriages, divorces, births, deaths; issues of grief and loss, employment; education; physical/mental health; childbearing or infertility; arrests or legal encounters; relationships (including other races/cultures); number and type of foster/adoptive placements (CPS, Juvenile Justice, other); placement success or disruption; other information. Mr. and Mrs. Doe are requesting they be considered as a foster/adoptive family through the Weld County Department of Social Services for children, three to four-years-old They stated they would accept a child of either gender and they would accept a child of any race, culture or religion. Parent III: Jane Doe Jane Doe was born on November 12, 1966, in Chicago, Illinois,to Sally and Ralph Doodle. She has one full-brother and one half-brother. Her older, full-brother, Doug Doodle, is 45 years old, living in Chicago and divorced with two children. Her younger, half-brother, Brian Doodle, is 25 years old, living in California and married with two children. Both of her parents currently live in the Chicago area. Mrs. Doe reported that her parents divorced when she was two-years-old. She stated that they divorced because her father had an affair. Mrs. Doe stated, "I didn't know about the affair until I was an adult. I heard about it from a neighbor who my mom had confided in. It helped me understand a lot benuse my parents never fought and I was really confused about the divorce." Mrs. Doe and her brother,Doug,remained with their mother. Their tither remained in the area and she had semi-regular contact with her father. Mrs. Doe's father was in construction and her mother was a secretary. Mrs. Doe reported that when she was seven or eight years old,her mother's boyfriend, Paul, moved in with them. Her mother and Paul married when Mrs. Doe was twelve-years-old. When asked about her relationship with her stepfather,Mrs. Doe replied, "We didn't get along very well. We didn't bicker but I didn't care for him. I kept my distance because he was physically inappropriate. There was never any rape or anything like that, but some physical touching and verbally sexual comments. I told mom after a long time,probably about ten, but he talked his way out of that one. I told my mom again when I was about sixteen; it had been progressing, becoming more emotionally traumatic for me, so I finally told her again. She left me out of the loop when she divorced him but I found out that was the reason." Mrs. Doe went on to add that it was a huge relief to have Paul gone and she was fine after he left. She stated that she had told her older brother what happened after Paul left and her brother was very angry. Mrs. Doe stated that she asked her brother not to tell their father because she was afraid of what her father would do. She said she never told her younger brother what his father had done because she didn't want to hurt him. Mrs. Doe's mother never remarried. Mrs. Doe reported that she is very close to her mother. Mrs. Doe stated that her father married two more times after her parents'divorce. He married Connie, who had a son from a previous relationship,when Mrs. Doe was three-years-old. Her father and Connie never had any children together. They divorced when Mrs. Doe was fourteen- years-old and he married Pam when Mrs. Doe was fifteen. They did not have any children and they divorced when Mrs. Doe was 19. Mrs. Doe stated that she is not close to her father. When Mrs. Doe was fourteen-years-old,she and her family moved to North Hollywood, California. When asked why they moved, Mrs. Doe replied, "Paul had been there and liked it there and thought it would be a better place for Brian. Mom was okay with it. Doug stayed in Chicago; he was eighteen and already had a work and a serious girlfriend. I was dead set against moving. I had just graduated eighth grade and had gone through the process to go to another school and be on the volleyball team and then we had to move. It was probably my most traumatic experience. I didn't want to leave my grandparents (maternal)and Doug." When asked how she handled her feelings of loss, Mrs. Doe responded, "I kind of withdrew. I was never an angry or aggressive child and I just stayed in my room. I was really shy my first year of school there. I pretty much kept to myself. Eventually I adjusted. My grandparents would pay for me to go back to Chicago every summer for about six weeks and that helped a lot." Mrs. Doe was asked to talk about her childhood memories. She said, "Mainly positive,mostly because of my mom's family. I have awesome, awesome grandparents and an uncle who tried to step in and fill dad's shoes. I remember spending almost every weekend at my grandparents. They lived out in the suburbs and I really enjoyed it. Doug went too until he was thirteen or fourteen. That's where I got my example of wonderful,healthy relationships. Ifs probably where I learned that this is the way ifs supposed to be." When asked if she ever told her grandparents about her stepfather's behavior, Mrs. Doe became very teary-eyed and replied, "I feel very protective of them and I knew it would have hurt them and maybe I was afraid they'd look badly on my mom and I didn't want that. They take things in and they're hurt very easily when their family is hurt. Then when he was gone the problem was gone so I never brought it up. I haven't told anyone in my family except my mother and my older brother. I feel very,very blessed and very lucky it wasn't worse. I have friends who have been through much worse and it's awful." When asked if she has any anger toward her mother for not responding the first time she told her, Mrs. Doe replied, "Yes, mainly while it was still going on after I told her and she believed him. I've never talked to her about it as an adult. One of the traits of my family is not to talk about things. I had to learn to communicate. I learned with Dan. I told him,but I don't want to hurt someone in my family or anger someone." Regarding grief and loss issues,Mrs. Doe said, "The move to California; I was at that selfish age where you're focused inward. I guess loss issues are the family and school and my brother, leaving him behind. We were actually closer at that age." As reported earlier,Mrs. Doe reported that she handled her losses by isolating herself. Mrs. Doe stated that she has never been physically abused. She added, "I don't think I was ever even spanked." Regarding sexual abuse, Mrs. Doe stated that she has never suffered sexual abuse other than the reported incidents with her stepfather,which occurred over approximately eight years. She added, "It didn't affect any of my relationships with any of the men in my life." Mrs. Doe stated that she has never suffered from neglect. When asked how she was disciplined, Mrs. Doe responded, "Honestly, I was a pretty good kid. My brother had the role of being in trouble all the time. I remember not getting home for dinner on time and I might get grounded for a day or two." Mrs. Doe reported that there were no substance abuse or domestic violence issues in her home. She said there were no problems with gambling or pornography either. She added, "My dad went to jail in 1990. I haven't spoken to him since then,he's removed all contact from my brother and I. He was there for five or six years for running a Meth lab with his stepbrother. I don't remember ever seeing him drink,he was always sober. My mom said he never used drugs. It was pretty much a shock when this happened." Mrs. Doe reported no personal history of substance abuse, domestic violence,gambling or pornography issues. Mrs. Doe reported attending Kindergarten through the eighth grade in Chicago. She then attended ninth through twelfth grade in.North Hollywood, California. She graduated from high school in 1984. Mrs. Doe stated that she then attended one year of junior college at Valley Community College and then received her AA degree in Interior Design from the Fashion Institute of Design and Merchandizing in 1988. Mrs. Doe stated that she liked school. She said, "I was in volleyball in elementary school and in California I got into music. I got into the Madrigal Group, a more formal choir. You travel more and do more performances outside of school. My major in high school was art and music. I loved being part of the [Madrigal] group. It was a huge self-esteem booster. I had a lot of good friends in high school. High school was fun for me. I really enjoyed being there." Mrs. Doe reported that she started dating when she was 19 years old. She stated, "No one sticks out" Mrs. Doe related that she met her husband,Bob Doe,at her best friend's wedding. She stated, "We started dating when I was 21 and dated for one year. We were engaged for a year and married on July 14, 1990." Mr. and Mrs. Doe have two children,Taylor,twelve-years-old,and Matthew, six-years-old. Mrs. Doe reported this is her only marriage and she has no other children. Regarding her employment, Mrs. Doe stated, "I was 18 and I worked for a florist in California. I was there almost a year and we got held up and I thought"no"and left. I went to Price Club, like a Sam's,as a cashier. I was there approximately two and a half years. I finished college and went to a designer center; Pacific Designer Center. They had showrooms for designers and I worked in the furniture showroom but I got laid off after six months. Then I went to a design firm, California Business Interiors,CBI, and was there for two years. Then I worked at Kraft General Foods as an administrator for two years and then we moved to Ault(Colorado)in 1991. Then we moved to Windsor(Colorado) in'93 or'94. I worked for Bataa Oil for four years in administration. I was licensed for home day care for five years in Weld County." Currently, Mrs. Doe is the office manager for the Doe's construction business. When asked about her beliefs about people of differing races,cultures and religions,Mrs. Doe replied, "In Windsor there's not a huge variety. I have Hispanic and Caucasian friends. Most of our friends are from our church family. It's all Caucasian in our immediate neighborhood. I have friends in California that are Caucasian and Hispanic. I'm very accepting of differences. I grew up in Chicago where ifs very racially and culturally mixed. It's new to me to be out here without other races. I usually base people on their actions." Mrs. Doe reported that her physical health is "excellent." She and her husband recently completed physicals. Regarding her mental health, Mrs. Doe stated, "I think excellent." She reported that she has never been diagnosed with any mental health disorders. When asked if she's ever been arrested, Mrs. Doe replied, "No." She stated that she has had two traffic tickets but has never had a DUI. Mrs. Doe stated that she has never fostered children in her home in any state. Rating: _3.5_ Parent#2: Bob Doe Bob Doe was born on October 19, 1962, in Whitter,a suburb of Los Angeles, California,to Sue and Robert Doe. He has three full siblings and one half-sister. His full siblings are: Judy Loop, 44 years old,living in Idaho,married with children;Mike Doe,42 years old, living in California, divorced with one child and Karen Roberts, 36 years old, living in California,married with children. His half-sister, Susan Soel, is 35 years old,lives in California, and is married with two children. Currently his parents are divorced and living in California. When asked how old he was when his parents divorced,Mr. Doe replied, "I'm guessing five." He remained with his mother,as did his siblings. Mr. Doe reported that he continued to have contact with his father after the divorce. He stated, "It wasn't like today where you get visitation rights. We saw him once a month when he'd drop off the check. He moved near us when I was twelve and we could ride our bikes to see him." His mother worked at school as a teacher's aide and his father worked for the phone company. Mr. Doe said his mother never remarried. He stated, "She was going to many Sonny but he split town. I was about ten and they'd dated for a few years. I really liked him. We never found out why he left." When asked if his father ever remarried, Mr. Doe replied, "I think he married Marie. I think he married her when I was six or seven." He stated that his parents divorced because his father"cheated"on his mother with Marie who was their babysitter. When asked if he knew his half-sister, Susan,growing up,Mr. Doe responded, "Not really. When we were younger 1:knew her but when we became teens she went to a different school." When asked if he knew the reason his parents divorced,Mr. Doe said, "Not then,she(Susan)was the same age as my sister so when I was older, I figured it out." Mr. Doe's father left Marie and has been living with a woman, Mary, for the past eighteen years. Mr. Doe stated that his relationship with his mother when he was a child was "good." He stated that he was"closer to mom" than his:father. He said his relationship with his father was "good, but I didn't see him that much." Growing up, Mr. Doe reported that his relationship with his sister,Judy,was "good." He added 'We bad a good family, it didn't seem terrible." Regarding his relationship with his brother,Mike,Mr.Doe stated, "It was good'tit we were teenagers and then we kinda went our separate ways." Mr. Doe reported that he was "Closest to Karen growing up,we were the last two in the house." Currently, Mr. Doe said that he is close to his father. He stated, "My relationship with my mother is good,but I'm closer to my dad now. She still drinks beer." When asked about his current relationship with his siblings,Mr. Doe replied, "It's good with everyone except my brother. it's not that it's bad, we just don't really talk. I see my family about once a year. We try to have family reunions. Sometimes mom or dad will come to visit." When asked how he was disciplined as a child,Mr.Doe responded, "I don't really remember. I never got spanked. My mom yelled and threatened to call our dad over and if she ever did he'd come over and give us a talk. Same as we got older,we got yelled at and lectured to." Regarding substance abuse issues in his family,Mr.Doe stated, "I remember her(mother)drinking beer. I remember she'd always get really sad. She was never abusive. I don't think she ever blacked out." He reported that his mother never used any drugs and that there was never any domestic violence,no gambling issues or any pornography issues with either parent. He stated that his father would drink but he never saw him drunk or using any drugs. Mr. Doe stated that he was never physically or sexually abused. When asked if he was neglected,Mr. Doe replied, "No, not in the sense of being left alone or no food. Not having dad there at special events and stuff was hard sometimes." Mr. Doe was asked to discuss his childhood memories. He responded, "Mainly good. We had a single mom with four kids but she took us camping and fishing. Dad helped out financially. We were poor but we managed. Dad took us fishing. Like I said, it was hard sometimes,dad not being at basketball games and stuff." When asked about grief and loss issues, Mr. Doe stated, "None really." When asked about his father not being around for special events, Mr. Doe replied, "I'm not sure." He added, "I've had relatives die; my grandfathers and grandmothers and my great-grandmother. To be honest,I always felt weird because I wasn't bawling,but I wasn't close to them. With my dad's side,they disconnected after the divorce." Mr. Doe reported that he attended Kindergarten through twelfth grade in Whitler. He stated that he graduated from high school in 1980. When asked how he felt about school,Mr. Doe replied, "I always knew I wasn't going to go to college. Not because of financial reasons, it just wasn't my thing. I think I enjoyed school." He reported that he was not involved in any sports or other activities at school. He said he enjoyed shop;welding,and didn't like English or Algebra. Mr. Doe said he liked to surf. After graduation,he stated that he went through an apprenticeship program for carpenters through the local junior college. He stated that he worked at a hardware store from age fifteen to seventeen. He reported that he then worked at a"drive through dairy where you could drive up to the dairy and get your dairy products" for approximately two years. He then worked at carpentry through a union for twelve years. Mr. Doe stated that he then moved to Colorado and worked subcontracting carpentry work through a construction company. Currently he owns his own construction company. Mr. Doe reported that he started dating when he was approximately sixteen. When asked to discuss his relationships, Mr. Doe replied, "I dated Lisa for eight years and then we went our separate ways. I wanted to get married and she didn't,I guess." He then said he met his wife, Donna Young, at a wedding. Mr. Doe reported that they dated for approximately two years and married on July 14, 1990. Mr. and Mrs. Doe have two children,Taylor,twelve-years-old, and Matthew, six-years-old. Mr. Doe reported that his son stuttered from the three to four-years-old. He added, "He went to speech therapy at school,we didn't make a big deal of it and it just kind of went away." Mr. Doe reported that this is his only marriage and he has no other children. Mr. Doe stated that his physical health is"excellent." He said his mental health is"Fine,as far as I know." He reported that he has never been in therapy,has never been diagnosed with any mental health disorders and he has never been on any psychotropic medications. Mr. Doe stated that he has no infertility issues. He said that, after their two children were born,he had a vasectomy. Mr.Doe stated that he has never been arrested and the only legal encounters he has ever had were speeding tickets or minor accidents. When asked if he has ever received a DUI,Mr. Doe stated, "No." When asked is he has any substance abuse history,Mr. Doe replied, "I did. I think I was an alcoholic for about eighteen years. I've been clean for the past five years." When asked why he stopped abusing alcohol, Mr. Doe stated, "I just knew it wasn't right." He reported that he has no domestic violence issues and no issues with gambling or pornography. Regarding his attitude toward other rafts, cultures or religions,Mr. Doe stated, "I'm comfortable with others and have friends of other races. I don't like racism and I'm not tolerant of racial remarks. I would say something." Mr. Doe reported that he has never fostered children in any state. Rating:_3 Parent Force 2. Adult General Functioning Element: Character and Suitability How does the adult function with respect to daily management and general adaptation? When updating or re-certifying, describe new or significant information that indicates a change from the previous assessment Specific areas include: previous emotional problems, mental illnesses, substance abuse issues, or marital/relationship problems that may have an impact on a child(ren); problem solving capacity/history, response/reaction to stress, ability to communicate, styles of communication, cognitive functioning; ability to make judgments/decisions and capacity to/history of follow through; use of defense mechanisms; levels of self-esteem; awareness of own capabilities and limitations; ability to control emotions; adaptation to infertility (if appropriate); levels of impulse control; expression of emotions/frelings/general temperament; attitudes towards people of similar/different races, cultures, religions; attitudes toward and response to sexual contact between children;homophobia. Parent#1: Jane Doe As previously reported,Mrs.Doe reported no prior emotional problems,no mental health issues or any substance abuse issues. Mrs. Doe stated that she has no marital issues that may have a negative impact on children in her home. When asked about her problem solving ability,Mrs. Doe replied, "Pm pretty good with emotional or personal problem solving. I'm getting better as Pm getting older. I don't get too worked up. It depends on the situation,we pretty much use each other as a sounding board and that helps. We usually talk things through pretty much in depth." Mrs. Doe was asked to discuss how she handles stress. She responded, "I usually talk to Dan if something's really bugging me, or I talk to someone. I vent and get it all out and that helps. Recently,Pm reading a book,Don't Sweat The Small Stuff And It's All Small Stuff,and ifs really good." Mrs. Doe said she's "pretty good" at communicating. Regarding her history of follow through,Mrs. Doe stated, "I think we're pretty good. Sometimes we'll get overwhelmed with things at church,but with the majority of decisions we always follow through." When asked about her self-esteem,Mrs.Doe responded, "I think it's pretty good. I think with body image you go back and forth about that, as a woman. On my abilities to do things it goes back and forth. It could be better maybe." Mrs. Doe was asked to list her strengths. She replied, "I think Pm a good listener. I think I have a kind heart. I think Pm always willing o and learn in all areas of my life and definitely my faith is very strong." Regarding weaknesses areas she would like to work on,Mrs. Doe said,"Probably those brief moments of self-doubt and letting things overwhelm me. Patience,I think you can always use more patience." Regarding her ability to control her emotions,Mrs. Doe stated, "Oh,I cry on the drop of a hat, I have no control. I can control things like anger and frustration but I cry when I'm happy and when I'm sad." When asked about her ability to express her emotions, Mrs. Doe responded, "I think I usually let people know when I'm angry, in a nice way. It's another thing I'm working on as I get older." Mrs. Doe reported that she is "in the middle" in terms of her impulse control. She added, "It depends on what I'm dealing with; like, lets go somewhere,okay,but with something major that would affect our lives I'm not impulsive." When making decisions, Mrs. Doe stated that she and her husband discuss the issue and then make decisions. When asked about her attitude toward and her response to sexual contact between children, Mrs. Doe replied, "I would definitely be shocked at first. I think I'm knowledgeable enough to know the child is probably acting out something. I would seek out help to deal with it. It's one of my major concerns. My children are quite sheltered and I do feel quite protective but I will work with whatever does come up." Regarding her beliefs about homosexuality,Mrs. Doe stated, "I don't judge them for it. I don't agree with it because of my faith. We've had homosexual friends and I don't judge them,I just don't agree with it." Rating:_3.5 Parent#2: Bob Doe As previously reported,Mr. Doe reported no prior emotional problems and no mental health issues. He previously discussed his substance abuse issues,stating he has not been drinking for the past five years. Mr.Doe stated that he has no marital issues that may have a negative impact on children in his home. He stated that he is good at problem solving. When asked how he handles stress,Mr. Doe replied,I usually just try to get over it. I just sit down,try to calm down and tell myself it's not worth it." When asked about his decision-making abilities,Mr. Doe said(laughing), "I ask her if it's okay. Really, if it's a major one we always talk about it. If it's a new tool,I just get it. It's something she's always understood,with my work I need the tools." Regarding his history of following through on decisions, Mr. Doe stated, "I don't always follow through with some ideas,but typically once I get into something I get every magazine on the topic and I go over it and go for it." Mr. Doe reported that his self-esteem is "good." He added, "It probably comes from my work,I really like my work." Regarding his strengths,Mr. Doe stated, "Fm honest, I don't mind talking to my wife, I'm a good carpenter and Pm a good dad. I'm a goof(with the children)." Remaining calm and realizing little stuff doesn't matter were the areas he stated he would like to improve. He added, "I'm trying to read more and listen to more motivational type stuff." Mr. Doe reported that he is"pretty good" at controlling his emotions. He stated, "The kids know when I'm angry,the way I talk to them or raise my voice." Regarding his ability to express his emotions,Mr. Doe stated, "I typically let people know verbally or with body language and actions." Mr. Doe stated that he is not impulsive, "unless it's a tool." Mr. Doe was asked to discuss his attitude toward and his response to sexual contact between children. He responded, "My response would be shock. I'd obviously tell them to stop,call you and ask,'Okay,now what?' I don't think I would be angry. Obviously something's wrong here and I'd need to figure it out probably." Regarding his attitude toward homosexual people, Mr. Doe stated, "I don't agree with it but it's none of my business. It's their lifestyle I guess,whatever." Rating:_3_ Parent Force 3. Parenting — Discipline Element: What are the disciplinary approaches used by the potential foster or adoptive parent, including the typical context? When updating or re-certifying, describe new or significant information that indicates a change from the previous assessment Specific areas include: view of the role of discipline (teaching, punishment, safety, etc.); parenting practices in the family in terms of expectations, frustrations, supervision, and disciplinary approaches. Specifically include discipline used with their own children, grandchildren, daycare,etc.;other information. Parent#1: Jane Doe Mrs. Doe was asked to discuss her view of the role of discipline. She replied, "The basic reason is that kids need to know right from wrong and they have to take responsibility for their actions. We all have to follow guidelines and rules. Discipline helps them to realize that was not okay, teaching them that what they did was not okay." When asked what she expects of herself as a foster parent,Mrs.Doe responded, "To be accepting and loving and nurturing. To be open minded and flexible. To provide a sale haven and a sense of security." When asked what she expects of the foster children, Mrs. Doe stated, "I don't know that I have expectations. I guess I hope that they will,over time,accept the kindness and accept the love. I hope they become accepting of us and trust us." Regarding what frustrates her as a parent, Mrs.Doe stated, "When you don't have the answers to solve their problems. Like the button pushing problem with my son,trying to get across to him something is wrong with this. He says, 'Okay'and then turns around and does the same thing. I get frustrated thinking,'What can I do that's going to get through to this child?'" Mrs. Doe reported that both she and her husband would be responsible for supervising any foster children. Regarding discipline,Mrs. Doe reported that she and her husband have spanked their son. She stated, 'We don't spank our son often. I don't think he's been spanked in quite awhile,but we have in the past." Mrs. Doe was informed that corporal punishment is not allowed with foster children. When asked how she intends to discipline foster children,Mrs. Doe replied, "Taking away privileges, sending them to their rooms unless they think ifs fun. We might cancel plans for doing something fun depending on how serious it is." Rating: _3_ Parent#2: Bob Doe When asked how he views the role of discipline,Mr. Doe responded, "To show them right from wrong. To make them realize there's consequences for actions." Regarding his expectations of himself as a foster parent,Mr. Doe stated, "My main goal is to show them a loving family and make them laugh. To prove that there's love out there." When asked what he expects of foster children, Mr. Doe said, "I have no idea." Mr. Doe was asked what he finds frustrating about parenting. He replied, "Getting through to them. Sometimes I think I expect too much for their age." Regarding supervision,Mr. Doe said, "At home,both of us,for church,both of us and everybody there." When asked how he disciplines his children and how he will discipline a foster child,Mr. Doe responded, 'Typically, time-outs. Matt sometimes will get a swat on the butt with a hand. I threaten. With foster kids, time-outs and loss of privileges." Mr. Doe was infon tid that he is not allowed to use corporal punishment with foster children. Rating: 3 Parent Force 4. Parenting — General Element: What are the overall, typical, pervasive parenting practices used by the applicant?Do not include discipline. When updating or recertifying, describe new or significant information that indicates a change from the previous assessment. Specific areas include: knowledge of child development and expectations of children, parenting/child rearing practices in the family in terms of sensitivity, concern, provision of basics; comfort with parent role; ability to parent transracial/transcultaral child(ren) or with special needs and/or disabilities; school attendance of all children; parent's school involvement; bonding; dress, hygiene, general appearance of children; parent's ability to meet children's emotional needs (time alone with parent, etc.); checking with county departments for any reports of child maltreatment and investigations; other information. Parent#1: Jane Doe Mrs. Doe was asked about her knowkxlge of child development. She stated,"It's about average,I did child care for about five years with different aged kids. I guess it's average to slightly above, at least up to that twelve-year-old stage." Mrs. Doe reported that she has no concerns about her ability to provide senility or the basics for any child. Regarding her comfort with the role of foster parent,Mrs. Doe said, "It's unlike anything we've ever done but we're pretty open and affectionate with lithe children." Mrs.Doe stated that she doesn't have any concerns about the race, culture or religion of a child. Regarding children with special needs or disabilities,Mrs. Doe stated, "We've discussed it somewhat. I don't think we feel equipped to handle anything major,like Autism,but anything developmental,like speech issues,we're okay. Part of it is we're doing all of this to expand our family and to give a child a family but not to sacrifice our family while doing it." When asked about her participation in the child's schooling,Mrs.Doe replied, "We both Mrth pretty s Doe much do it. I do the majority of it,all the daytime stuff,he comes to the evenings." reported that her children are bonded to her. She added, 'There's a lot of physical contact, holding hands,hugging and reassuring them that we love them. I understand that attachment disordered kids aren't going to want the hugs and stuff. I think it's important to be honestly interested in what they're doing. That shows them in a non-physical way you care." Mrs. Doe reported that she thinks hygiene and physical appearance are important. She stated, "Hygiene is a health issue. I'm kinda.anal about clothes matching but I'm getting better. We do censor as our daughter gets older,no belly shirts or short shorts that we feel are inappropriate." Mrs. Doe was asked how she intends to meet her own children's emotional needs. She responded, "What we do already,try to take time with them. He'll take Man and go do something and Taylor and I will have a girl's day out. We try to have a fun day with them, let them pick what they want to do, spend one-on-one time with them. It would be the same with a foster child. We'd talk about it with them too. They understand a foster child might need more understanding and take more time, but if they feel they're being pushed aside come and tell us." The Weld County Department of Social Services is completing the background checks on Mrs. Doe. This clinician has not seen the results of this background check. Mrs. Doe reported that she has never been accused,investigated or convicted of child maltreatment. Rating:_3.5 Parent#2: Bob Doe Mr. Doe was asked about his knowledge of child development He stated, "On a scale of one to ten? I'd say a five. I think I always expect them to act older than they are. I realize this by reading books or seeing something on television." Mr. Doe stated that he has no concerns about being sensitive to children or providing the basics for them. When asked about his comfort with the role of foster parent,Mr. Doe said, "Yeah,I'll be comfortable." Mr. Doe stated that he isn't concerned about the race,culture or religion of a foster child. Mr. Doe reported that he doesn't attend PTA meetings at school but he attends the school conferences, open houses and the"beginning of the year stuff." He added, "I attend their activities and coached T-ball." Mr. Doe stated that his children are bonded to him and he thinks a foster child will start bonding, "When.they start feeling they can trust you. I don't know how it works." Regarding meeting his children's emotional needs,Mr. Doe stated, "I've thought about it. I don't know if we'll need to take them aside and do date nights." Mr. Doe reported that he believes hygiene and physical appearance are important. The Weld County Department of Social Services is completing the background checks on Mr. Doe. This clinician has not seen the results of this background check. Mr. Doe reported that he has never been accuser' investigated or convicted of child maltreatment. Rating:_3 Child Force Child 1: Name Taylor Doe Age_12 (enter"0"if no child exists.) 5. Child Functioning Element: Social History/Background (Child) How does the child function on a daily basis? When re-licensing, describe significant information that indicates a change from the previous assessment. Specific areas include: Parents' Own Children in Placement, Other Children in the Home Age Appropriate, general temperament, expressions of emotions/feelings, typical behaviors, presence and level of peer relationships, school performance, known mental health disorders including substance abuse (organic/inorganic); issues of independence/dependence; issues related to racial/cultural identity;other information. Taylor Doe presented as a friendly, pleasant twelve-year-old girl. She was attentive and articulate during the individual interview. Taylor was asked if her parents had talked to her about why this clinician was there. She replied, "That we're going to adopt and we need to be interviewed so they know if we're a great family or not." Regarding how she feels about adopting a child,Taylor said, "I'm excited." She was asked how she thinks she will handle jealousy issues. Taylor responded, "I don't know really,I'm not sure." Taylor reported that her parents,her brother,Matt, and she live in their home. When asked how she thinks a foster child might feel,Taylor said, "Scared,not knowing what would happen next." She was then asked what she thinks she would have to offer a foster child. Taylor replied, "Comfort it and tell it it's okay and you'll be fine. Be nice and care for them." Taylor reported that she would expect the foster child to"be respectful and nice" in return. When asked for her opinion on parents who mistreat their children,Taylor responded, "I think it's just wrong and no child should be treated like that." When asked what she thinks a foster child might think about her,Taylor said, "I don't know. Maybe they'd try to work harder. Maybe they might think, 'She's the birth child so I have to work harder so they might respect me.'" Regarding what her family does together,Taylor stated, "Sometimes we go camping and fishing. We'll have a movie night and stuff like that." When asked what movies they watch,Taylor replied, "Most,like, cartoons. My mom likes classical stuff and I started liking it so I like that stuff too." Taylor was asked how she gets along with her brother. She responded, "Sometimes we'll be like best friends and stuff and sometimes we're hie enemies and stuff but I think we've gotten a lot better." Regarding how she gets along with her mother,Taylor said, "Fine,I think we have a good relationship. We have a girl's day and go to the mall the whole day. Just me and her." When asked how she gets along with her father,Taylor stated, "Fine,sometimes we get in little arguments, but most of the time he's fun. I like when he wrestles us." Taylor was asked how she gets along with her peers. She replied, "Good,I get along with them pretty much because they're my age and they like to do what I like. Not a lot of arguments." She stated that she gets along with younger children. Taylor added,"Most I like to baby-sit sometimes. I like little kids,they're cute and fun." Taylor reported that she doesn't know many older kids. Regarding her extended fmmily,Taylor stated, "I have family in California,Illinois and Chicago. I don't get to see them much. We mostly go to California in the summer. Last summer we went to Chicago for my grandpa's 90th birthday." For fium,Taylor stated, "I like to do gymnastics. I like to draw and color and play on the computer." Regarding clubs or organizations,Taylor said, "I'm in Youth Group at church(United Methodist Church). I like it a lot. Some of my friends are there from school." Taylor reported her hobbies as collecting"porcelain dolls and snow globes mostly." Taylor reported that she is in the sixth grade at Windsor Middle School. She added, "I have lots of friends. Two really best friends,Priscilla and Meagan. I like science because I've always loved science. I like experiments and doing new things and I like my teacher. He picks on me but it's fun. I don't like math, probably'cause Pm not good at it." Taylor reported that she plays with her friends everyday at school. She added, "I get to see Meagan every Saturday'cause she's in gymnastics too. Every once in awhile I have a sleep over. We switch off at each other's house." Taylor was asked to list two or three things she likes about herself. She replied, "I like my hair 'cause not a lot of people have red hair. I like being athletic and I think Pm nice. Most people say I'm really nice, it makes me feel really good." When asked to list two or three things she doesn't like about herself,Taylor said, "I would like to believe in myself more. Thais really all." When she is mad,Taylor reported she will, "Sometimes just go to my room and be by myself for a minute. That's all I really need, or read a book." Taylor reported that,when she is sad,she would do the"same thing,I just go in my room to have some quiet time to myself." When she is happy, Taylor said, "I'm all hyper,I never stop talking. I talk really loud and never stop talking. My parents say I get annoying." Taylor reported that when her mother is mad, "She'll kinda just tell us what we did wrong and sometimes send us to our room and sometimes her voice will get a little louder,but not too much." When her father becomes angry,Taylor said, "He gives us this long lecture and sometimes he yells when he's really mad." When asked what she does to make her parents angry,Taylor stated, "I usually do something to my brother or not listen or not do the dishes when I'm supposed to or argue'with whichever one's getting mad at me." Taylor was asked to list any chores she is responsible for. She responded, "I have to clean my hamster cage,do the dishes, clean my room,pick up the dog poop and dump the trash in the office's." Taylor reported that her family shows they care for one another by hugging. She added, "Mom comes and hugs us and says'I love you.' We get along really good and have a fun time." When asked who gives orders in the home,Taylor replied, "Mostly my dad." When orders aren't followed, Taylor said, 'We get in trouble." Taylor was asked which parent she is most like. She stated, "My dad because,like,we're both funny. Sometimes he'll say something and I'll have this really good comeback and well both wrestle." Taylor reported that the rules in her home are, "Usually we have to eat what's on the table,no playing ball or gymnastics in the house,clean up when you're told to and don't leave trash on the floor." Taylor reported that she feels safe in her home. When asked if she would like to add anything to this report,Taylor replied, "I just think we're a really good, caring and loving family and we're all really excited about it." Rating: 4_ Child Force Child 2: Name Matthew Doe Age_6 (enter"0"if no child exists.) 5. Child Functioning Element: Social History/Background (Child) How does the child function on a daily basis? When re-licensing, describe significant information that indicates a change from the previous assessment. Specific areas include: Parents' Own Children in Placement, Other Children in the Home Age Appropriate, general temperament, expressions of emotions/feelings, typical behaviors, presence and level of peer relationships, school performance, known mental health disorders including substance abuse (organic/inorganic); issues of independence/dependence; issues related to racial/cultural identity; other information. Matthew Doe presented as a typically shy, quiet six-year-old boy. He was able to make good eye contact and smiled shyly at this clinician during the individual interview. When asked if his parents had talked to him about why this clinician was there,Matthew said, "A little,there are lots of kids in foster care." When asked how he feels about a foster child living in his home, Matthew replied, "Good. I kinda want a brother that's four." Matthew was asked to list the people who live with him. He stated, "Taylor,Dan,Donna and that's all." When asked if he calls his parents "Dan"and"Donna",Matthew said, "No,mom and dad." Matthew reported that he thinks a foster child might feel "embarrassed"about being in foster care. When asked what his family does together, Matthew responded, "Puzzles,games,video games and watch TV." Matthew said he feels "bad and sad" about parents who hurt their children. Regarding how he gets along with his sister,Matthew stated, "Pretty good. If I go in her room, she tells on me and sometimes I get spanked and sent to my room." He reported that he gets along"good"with his parents. When asked what his favorite thing is about his mother,Matthew said, 'The food that she makes." He said his favorite thing about his father is, "That he likes building things with me." Matthew was asked about his grandparents,aunts and uncles. He stated, "My grandparents live far,some of them live in California Aunts and uncles live far away too." Regarding what he likes to do for fun,Matthew stated, "Sometimes just watch TV and do puzzles. I like hockey and baseball. I'm in T-ball. I'm thinking about doing soccer." he said he likes to watch movies like"S/rrek Finding Nemo and Jurassic Park." Matthew reported that his hobby is collecting rocks. When asked how often he plays with his friends,Matthew replied, "Probably like,the most I play at school with them. I play kick-ball at school. I got hit in the face with the ball twice,it didn't hurt." Matthew reported that he is in the first grade at Brandview Elementary School, "right up the street." When asked what he hies to do at school,Matthew said, "Probably recess. I don't like to do homework or spelling tests." Matthew was asked to list two or three things he likes about himself. He stated, "I don't say bad words. I be nice to other people and I'm a good friend." When asked if there's anything he doesn't like about himself,Matthew said, "No." Matthew said when he gets mad he gets "angry,it's not good. I just get really mad." When he is sad, Matthew stated, "I cry and if it's my family,when somebody says something bad to me,it hurts my feelings." Matthew reported that,when he is happy,he does "nice things to people." When asked if he laughs and dances around,Matthew laughed and shook his head. When asked what happens when his mother is mad,Matthew responded, "She sends me to my room. I know her face,how it looks when she's mad and she has a very angry voice and she grounds me from the video games and stuff." When his father is mad,Matthew said, "He spanks me and he sends me to my room and does the same thing as mom." When asked why his parents get mad at him,Matthew replied, "Not being nice to Taylor." Matthew was asked if he has any chores he's responsible for. He responded, 'Take out the trash, empty all the trash cans, clean up the backyard,that's really all." When asked if he earns an allowance, Matthew stated, "Yes,two dollars and two quarters. One dollar's for my savings,one dollar's for my wallet and I keep the two quarters." When asked who gives orders in his home, Matthew said. "Mom and dad." If orders aren't followed,Matthew reported, "We get in trouble." Matthew was then asked to list the rules in his home. He replied, "Be nice to Taylor and do the things you're asked to do." When Matthew was asked if he would like to add anything else,he stated, "They don't smoke, they don't drink,they don't go to drug parties,they don't do any drugs at all." When asked where he learned about drugs, Matthew stated, "From my dad. He used to drink before me and Taylor were born and he stopped." Rating:_3.5 Family Force 6. Family Functioning Element: Current Status of the Family, Family System, Lifestyle How does the family function, communicate and interact? Consider the family's cultural context as you describe family functioning. When updating or re-certifying, describe new or significant information that indicates a change from the previous assessment Specific areas include: family structure and flexibility; clarity of roles and boundaries (including roles children), who is in charge, how family decisions are reached,the level and type of conununication used, the presence and use of affection, marital issues, unresolved infertility issues of couple (if appropriate), presence/absence of family violence, open/closed to trans-racialtrans-cultural/religiious experiences; general feelings/climate within the family; other information. Mr. and Mrs. Doe were asked to describe their family structure. Mrs. Doe replied, "I think we're in the middle. Structure for school days but flexible for the weekends." Mrs. Doe reported that the roles in the family are clear. She stated, "For the most part, I'd say so. I think the kids know it's pretty much equal. My daughter is a little bit of a mother hen. He's (Mr. Doe) the player, the playful one. We both put them to bed and say prayers." Mr. Doe reported that he is responsible "firr taking out the trash and if things are broken, I fix them." Mrs. Doe stated that her responsibilities include, "Most of the transporting to school, gymnastics and doctors appointments. I do the cooking and I primarily help with the homework." Mr. and Mrs. Doe reported that they are both in charge. They stated that they make decisions together. Mrs. Doe stated, "We make decisions a lot of times as a family. We discuss it and come up with the best solution. With something small we let the kids help decide." Regarding communication skills, Mrs. Doe said, "It's very good. We talk a lot, our daughter talks a lot. She opens up and talks about friends at school and who's doing what and then she'll go to her dad and tell him what's going on." Mr. Doe added, "I tell her that's the problem with cell phones; I call and tell her what's going on so I don't have anything to talk about at night." Mr. Doe reported that family members show affection with "hugs, kisses and play wrestling." Mrs. Doe added, "We talk to them and tell them that we're proud of them and say 'I love you.'" Mr. and Mrs. Doe stated they have no marital issues. Mr. Doe stated, 'We can both be stubborn but it's not necessarily an issue." The Doe's reported no infertility issues. They stated there is no violence in their home. Mr. and Mrs. Doe reported that they are open to accepting children of other races, cultures or religions. Mrs. Doe stated, 'We're open. I guess it would be hard if a child came in saying 'I'm Buddhist'or Muslim. It would be difficult." Rating: _3.5_ Family Force 7. Family Support Network Element: Child Safety and Well-Being, Availability of Support System. What is the quality of supportive relationships (formal and informal) outside the home? Consider the family's cultural context as you describe their support network When updating or re-certifying, describe new or significant information that indicates a change from the previous assessment. Specific areas include: nature of extended family support; support of unrelated persons (friends, confidantes); involvement/support of organizations, clubs, churches, agencies; involvement/support of neighbors,business and social associates;other information. Mr. and Mrs. Doe were asked to discuss their extended support system. Mrs. Doe replied, "Definitely our church family, it's small so everybody knows everybody. Our Pastor's daughter just adopted from a foster/adopt situation and she encouraged us to adopt. All of our family is out of state." Mr. Doe added, "That's our main friends." Mr. and Mrs. Doe stated that they attend the First United Methodist Church. Mr. Doe reported that they belong to the Business Network International group as well as belonging to the Chamber of Commerce. Mrs. Doe attends the PTAC and PAC meetings at her children's schools. She stated that she also volunteers at school two mornings a week. They do not belong to any other organizations„groups or clubs. Rating:_3_ Family Force 8. Demographic Element: Finances, Home Safety Inspection, Employment, Community Makeup What are the demographics of the family?Consider the family's cultural context as you describe demographics. When updating or re-certifying, describe new or significant information that indicates a change from the previous assessment Specific areas include: economic resources; employment home (additions/remodeling with square footage); neighborhood and community (include racial/cultural/religious integration); health problems; financial self-sufficiency; stresses related to demographics and how handled (e.g., medical, bankruptcy, family moves, household members leaving); other information. Mr. and Mrs. Doe own their own business; D. Doe Construction Company. Mr. Doe stated that he has been self-employed for ten years. He generally works Monday through Friday, nine to ten hours per day. Mrs. Doe works on their books, appointments and payroll from home. She stated, "I don't budget my time. I pretty much work when the kids are in school." She volunteers at her children's schools on Tuesday and Thursday mornings, generally until noon. They estimated their yearly income at$95,000.00. They reported that they receive no other income. The Doe's own their home and have lived there for four years. They reported that they have been in Windsor, Colorado, for nine years, living for one year in Ault, Colorado. The home is a ranch style home with a finished basement. The square footage on the main floor is 1565 square feet and the basement is 1300 square feet. On the main floor there are three bedrooms, two bathrooms, a kitchen with dining area, a living room and laundry room. The basement has one bedroom, one bathroom, a family room, office and a general play area. Their house payment is $1,235.00 per month. The only other large payment they reported is on their Suburban; $400.00 per month. There is a park across the street and another park with playground equipment approximately two miles away. The closest hospitals are in Greeley, Colorado, or Ft. Collins, Colorado. There are two medical clinics in Windsor with 'Urgent Care available until 8:00pm. Brandview Elementary is six blocks away and the junior high school and high school are approximately one mile away. Mr. and Mrs. Doe described their immediate neighborhood as having middle aged neighbors with teens. There are also older couples and younger people with no children. Mrs. Doe reported that the community is "98% Caucasian." Mrs. Doe stated that she and her husband just completed their physical exams and they are both.in"excellent"physical health. When asked if they have any stress over finances, Mrs. Doe replied, "Nothing on-going. Every once in awhile we get stressed from running our own business." They stated that they have never filed for bankruptcy,don't intend to remodel their home and there are no moves planned. Rating:_3.5_ Birth Family Force 9. Viewpoint of Birth Parents Element: How do the parents view child maltreatment, parents who maltreat their child(ren), parents who place their children in foster care, and parents whose children are placed by a court in foster care? When updating or re-certifying, describe new or significant information that is a change from the previous assessment and examine the attitude toward the birth family and understanding/support of positive relationships and/or memories of birth family. Specific areas include: training completed or needed concerning the parent's viewpoint of birth parents when updating or re-certifying, contact with birth parents and learning gained from the experience; general learning regarding birth parents; other information. Parent#1: Jane Doe Mrs. Doe was asked how she views parents who maltreat their children. She responded, "I think they definitely need guidance and help. It angers me that people have kids who shouldn't and others who should can't have them. I wish they could reach out and get help before it gets out of hand." Regarding parents who place their children voluntarily,Mrs. Doe stated, "I give them a lot of credit. That takes an awful lot of courage. They're trying to do what's best for their child in most cases. Hopefully they're not just giving up on the kids." When asked for her viewpoint on the courts removing the children,Mrs. Doe replied, "I think there was obviously a problem, something not right. I feel bad for the family,but worse for the kids who had to be in a situation that's not healthy for them." Mrs. Doe has not had any formal training on the viewpoint of the birth family. She reported that they were supposed to start the CORE training program through the Weld County Department of Social Services in January of 2004 but they got"bumped." Mrs. Doe stated that they are to begin their CORE training in February of 2004. Rating: 3.5_ Parent 112: Bob Doe Mr. Doe stated that his viewpoint on birth parents is that"It's sad that you need to take a test to get a drivers license but anyone can get together and have kids. It's upsetting,hearing all the trauma about these kids. I wish they could be more educated about the amount of damage they do to the kids." When asked for his viewpoint on parents who voluntarily place their children, Mr.Doe replied, "I think it's gotta be hard on them and their whole family but they're looking out for the best interest of their child. They're looking for help and will hopefully get it." Regarding his viewpoint on the court placing children,Mr.Doe stated, "I think I would have to assume that most of the time the court has to intervene is because there has been some kind of substance abuse and then the parents sober up and find out they've lost their kids. I feel sorry for them." Mr. Doe has not had any formal training on the viewpoint of the birth family. He reported that they were supposed to start the CORE training program through the Weld County Department of Social Services in January of 2004 but they got"bumped." Mr. Doe stated that they are to begin their CORE training in February of 2004. Rating:_3.5_ Birth Family Force 10. Viewpoint of Foster Children Element: How does the parent view children placed in foster care? Any differences in view based on type/age/race/culture/religion of the child? When updating or re-certifying describe new or significant information that indicates a change from the previous assessment Specific areas include: feelings toward and treatment of foster children (general, and specific to their foster children, if updating or re-certifying); training completed or needed concerning parent's viewpoint of foster children; when updating or re-certifying, consider presentation of children to community(sensitivity,advocacy); other information. Parent#1: Jane Doe • Mrs.Doe was asked for her viewpoint on children in foster care. She replied, "I feel they're pretty fragile. They need to be treated with a lot of compassion and understanding. They need to be treated like your own kids but with more sensitivity. You may not know what they've gone through. I want to show them a positive family life and that not all are like they've been exposed to so far." When asked if there is any difference in how a foster child of a differing race, culture or religion should be treated,Mrs. Doe responded, "Not as far as how I would treat them,no. As far as adoption,we don't feel we could meet the needs of an African American child culturally living where we do." Mrs. Doe has not had any formal training on the viewpoint of foster children. She reported that they were supposed to start the CORE training program through the Weld County Department of Social Services in January of 2004 but they got"bumped." Mrs. Doe stated that they are to begin their CORE training in February of 2004. Rating:_3.5_ Parent#2: Bob Doe Regarding his viewpoint on foster children, Mr. Doe stated, "I feel they've been let down. I feel they've probably got a real aching in their heart to have a real family." When asked if there is any difference in how a foster child of a differing race, culture or religion should be treated, Mr. Doe responded, "No, it wouldn't matter." Mr. Doe has not had any formal training on the viewpoint of foster children. He reported that they were supposed to start the CORE training program through the Weld County Department of Social Services in January of 2004 but they got"bumped." Mr.Doe stated that they are to begin their CORE training in February of 2004. Rating:_3_ Foster Family Force 11. Preparation Element: How prepared is the family for adoption/fostering?How able is the family to provide children with relevant racial, cultural, and religious experiences?Include issues related to visitation with birth relatives and reunification as appropriate. When updating or re-certifying, describe new or significant information that indicates a change from the previous assessment. Specific areas include: family's own children's current view of fostering, including jealousy issues; parents' specific capabilities as related to foster parenting; training completed or needed concerning impact of fostering/adoption; when re-licensing consider effects of foster parading on extended family; attachment to foster children, and feelings about foster children who may have left the home; other information. When asked how prepared they think they are to provide foster care, Mrs.Doe stated, "He's kind of anxious. He thinks he's too old." Mr. Doe stated, "When we do this,we're looking for a child who's already been given up." Mrs.Doe added, "I think we're willing to go through whatever training and classes we need. Are we prepared today? It depends on the child and if we can keep the child. I'm worried about our youngest child's reaction. I've tried to address jealousy issues with our youngest. His biggest concern is not being the youngest. We know we have a choice in which kids to take. Our twelve-year-old is asking when do we get a child. She's very eager. She dotes on little ones. We're worried she might ignore Matt,we'll watch for this." Mr. and Mrs. Doe stated they only want a child who is available for adoption. When asked if they would consider taking a child on the verge of availability,Mrs. Doe replied, "Were wary of bringing a child in the home and becoming attached. We've discussed it a lot, if a child returns home it's God's intention the child return." Mr. Doe added, "I think in our hearts we'd say yes." The Doe's have not had any formal training on fostering children. They reported that they were supposed to start the CORE training program through the Weld County Department of Social Services in January of 2004 but they got"bumped." They are to begin their CORE training in February of 2004. Rating:_3_ Foster/Adoptive Family Force 12. Motivational Commitment Element: Motivation for a Child What is the nature and level of motivation and commitment demonstrated by the family?Include infertility issues as appropriate. When updating or re-certifying, describe new or significant information that indicates a change from the previous assessment. Specific areas include:basis/reasons for motivation/commitment(e.g., status,financial. emotional,adoption,own needs, service to community. etc.);other information. The Doe's were asked about their motivation in foster/adopting a child. Mrs.Doe replied, "We've been talking about it for three:years. I really would like another child,even before we were married we talked about it" Mr. Doe added, "To help a child. We decided a long time ago to have two and if we wanted more to adopt." Mr. and Mrs. Doe stated they do not wish to adopt for financial reasons. Rating: _3.5 Intervention Force 13. Family Response Element: Relationship with County Department of Human Services, Agency How capable are the potential parents to use agency involvement and to seek help on their own?Include willingness offamily to seek cross-cultural models and experiences. When re-certifying, describe new or significant information that indicates a change from the previous assessment. Specific areas include: communication with agency staff; relationship with agency staff (includes willingness to receive consultation/advice); relationship with other professionals; ability to share information; ability to keep information confidential; ability to keep schedules and appointments; willingness to be involved with birth family (as appropriate); resourcefulness in pursuit of services; willingness to provide transportation; participation in foster/adoptive parent activities (e.g., newsletter, foster parent association/support groups, parties/picnics, assist with trainings, provide/use respite care); other information. When updating or re-certifying also consider preparation of foster children for removal from home (includes gathering belongings, handling good byes). Indicate summary of training attended since last certification. Also identify any rule/contract violations and corrective/action plan if appropriate. Mrs. Doe stated that her communication so far with the Weld County Department of Social Services has been"very comfortable,they're easy to talk to and answered questions honestly." The Doe's stated they have no concerns about their ability to communicate appropriately with other professionals. Mr. Doe added, '"We'll just eavesdrop and learn." Regarding sharing information with appropriate people, Mrs. Doe stated, "I would assume the more information we give them,the better they can help." Neither of the Doe's felt keeping confidentiality would be an issue for them. They stated that providing transportation would be no problem as Mrs. Doe works from home and can set her own hours. When asked about their willingness to be involved with the birth family, Mrs. Doe replied, "To the extent it needs to be,like at visitation. I can handle being polite." Regarding their interest in participating in foster/adoptive activities,Mrs.Doe stated, "Fm assuming I'd want to do a support group with foster/adoptive parents." The Doe's have not had any formal training on fostering children. They reported that they were supposed to start the CORE training program through the Weld County Department of Social Services in January of 2004 but they got"bumped." They are to begin their CORE training in February of 2004. Rating: _3_ Intervention Force 14. Resource Element: Availability of Support Systems What are the resources, external to the family, which support the placement(s)?Includes ongoing training services and support groups. When updating or re-certifying, describe new or significant information that indicates a change from the previous assessment. Specific areas include:the availability of support to the family 24 hours a day, including agency/staff resources; other information. The Doe's were informed that the Weld County Department of Social Services provides support 24 hours a day, seven days a week through caseworkers and an emergency duty worker evenings, weekends and on holidays. They were given the phone number to Greeley Dispatch to contact the emergency duty worker at need and given instructions on how to call. Rating:_4 PARENT FORCE CHILD FORCE FAMILY FORCE BIRTH FAMILY FOSTER FAMILY INTERVENTION FoRCE FORCE FORCE History _3_ Child FundParent 3.5 Family Fund. 3.5 Viewpoint 3.5 Preparation _3_ Family _3_ Adult general _3_ Family.Support 3 Viewpoint Child _3_ Motivation 3.5 Resource Parenting Dcp_3_ Demograpic 3.5 Parenting Gen 3 Conclusion 1. Add the ratings entered above in the 14 elements _45.5 (If no child in home, score"0" on"Child Functioning in the Child Force) 2. Based on the rating in#1,identity the presence of positive parenting/effective family functioning or the likelihood of disruption: (48 to 56) a. p Very positive family finting and apparent risk here to be no The presence of positive parenting and effective family functioning are apparent. conditions of risk which exist the parents capability to care for children is adequate.Based on appropriate matching,a child will likely be/is enhanced by this placement Indications are that a placement will be/is secure,productive and stable. b. Generally positive family ifield/Minimal risk (37 to 47)_X Generally,there is evidence of positive parenting and effective family functioning.There are indications that there is a balance between the capacity,conditions,and needs of the family and the needs of the child.There are minimal risks present the family is aware of and willing to address the areas of risk.Consideration should be given to continued matching of the drills and abilities of the family with the needs of the child in order to insure that the child will continue to be enhanced by the placement c. Somewhat positive family field/Low risk (22 to 36.5) Although there is evidence of positive parenting and effective family functioning,there is an indication that the child may not braefit/be benefiting from this placement and the placement may be problematic.Them may be an imbalance between the capacity,conditions,and needs of the family and the needs of the child. Consideration should be given to the most pronounced risks and how manageable or adjustable they are. Documentation in the case record as to these risks needs to be clear.When updating or recertifying,a support/action plan should be entered into with the foster family in order to manage the most pronounced risk elements,if they are considered serious enough to address. d. Negative family field/Moderate risk (11 to 21.5) Enough negative influences have been identified within the field so that there is a threat that the child will suffer/is suffering directly from this placement and the placement may disrupt There is an imbalance between the capacity,conditions,and needs of the home and the needs of the child.Analysis of the most concerning risks needs to occur.Clear documentation of these risks is imperative. If a placement exists when updating or re-certifying,it is recommended that consideration be given to removing the children from the home and that the family not be approved for any future placements. e. Very negative family field/Significant to High Risk...(0 to 10.5) It is probable that the child will suffer/is suffering directly from this placement and the placement will disrupt Continued or future placements of a child could result in some form of maltreatment to the child.The agency needs to inform the family of the areas of risk influences.All risk influences need to be documented in the case record.It is recommended that if a placement exists,the child should be removed from the home. The home should not be approved for any future placements.If ANY children reside in this family, consideration should be given to making a referral for a CPS assessment. Evaluation and Decision: Based upon all materials, interviews,and use of this system,the conclusion of the assessment X or re-assessment is as follows: A. Provide a general summary of the strengths and weaknesses of the family, indicating any categories within the field which raise concerns regarding the ability of the family to parent children who may be or are now placed in the home.Address the significance of any support plan that has been offered with regard to certification or re-certification of the family. Mr. and Mrs. Doe appear to be a very caring, supportive couple. They have two children of their own who appear to be well adjusted and bonded in a healthy manner to their parents. The Doe's own their own business,which they have been successful running for the past ten years. They receive a great deal of support from their church,although it is slightly concerning that this is the only area of support they were able to identify. They have never fostered before and are therefore somewhat naive regarding children involved in the child welfare system. However,they are both intelligent,caring people who are motivated to learn more and help a child. They have both expressed an interest in understanding the needs of these children and an enjoyment in learning. The Doe's stated that,although they would not be comfortable with a child with severe developmental issues,they are willing to take a child with special needs and minor disabilities. B..Indicate your judgement as to the type of child(ren) that should be considered for this family When updating or re-certifying, consider: with which type of child does the family excel? With which type of child does the family provide adequate care? Which type of child likely does not benefit from placement in this family?Describe children in terms of age, race, sex and general functioning. Dependent upon the results of the background cheek this clinician would recommend this family as acceptable applicants for the foster/adoption of a child aged three to four years. Either gender is acceptable to this couple. Although the Doe's stated that they would accept a child of any race, culture or religion,Mrs. Doe expresses some concern about being able to meet the cultural needs of an African American child in the Windsor area. She also expressed some doubt as to her level of comfort should a child be of the Buddhist or Muslim religion's. This should be considered when deciding on a child to be placed in the Doe home. Julie Box,LCSW Date Julie Box, LCSW 1702 68 Ave Greeley, CO 80634 970.302.1471 (cell) 970.339.9036(fax) February 24, 2005 Weld County Department of Social Services P.O. Box A Greeley, CO 80632 Re: Bid No. 002-05 RFP FYC 006-00B: Home Studies and Relinquishment Counseling The purpose of this letter is to assure the Department that this provider, Julie Box, LCSW,agrees to notify the Department immediately of any change in staff at the time of the change. �rely, : Lffsv✓ J ie : • , LCSW P' _ 'tactics AMERICAN' HOMt ASSUKANa.c a,u. THIS IS A CLAIMS MADE POLICY PLEASE READ CAREFUL_ /13/05 SOCIAL WORKER PROFESSIONAL LIABILITY POLICY *** RENEWAL *** NO:MISCONDUCT TCS: LOWER ER LIMIT F UABILITY PROVISIONLIBSXTOL JUDGMENTS MISME OR S STETTLEMENTS E EMENTPOLICY)S WHEN THERE ARE ALLEGATIONS OF SEXUAL HE DECLARATIONS DLIACCOUNT NO: CO—BOXJl70-0 04269745 EM 1.Y(a)N NAME AND A D252 ITEM 1.(b)ADDITIONAL NAMED INSUREDS: EM 1. AND ADDRESS OF INSURED: JULIENNE E. 80X 1702 68TH AVENUE GREELEY. CO 80634 TYPE OF ORG: INDIVIDUAL BEM 2. ADDITIONAL INSUREDS: STATE OF COLORADO/THE WELD CNTY• DEPT. OF S.S. P.O. BOX A GREELEY. CO 80631 TEM 3. POLICY PERIOD: FROM: 02/20/05 TO: 02/20/06 12:01 A.M.STANDARD TIME AT THE ADDRESS OF THE INSURED AS STATED HEREIN: 1.000.000 EACH WRONGFUL ACT OR SERIES OF CONTINUOUS.REPEATED rEM 4. LIMITS OF LIABILITY: (a)$ OR INTERRELATED WRONGFUL ACTS OR OCCURRENCE (b)$ 1.000.000 AGGREGATE (c)$ 5.000 DEFENSE REIMBURSEMENT TEM 5. PREMIUM SCHEDULE: CLASSIFICATION NUMBER RATE ANNUAL PREMIUM PROFESSIONALS I. 102.00 102.00 DEFENSE LIMIT .00 ADDITIONAL INSUREDS 1 20.00 20.00 TEM 6. RETROACTIVE DATE: 02/20/04 TOTAL PREMIUM: 122.00 TEM 7. EXTENDED REPORTING PERIOD ADDITIONAL PREMIUM(If exercised):$ 122.00 TEM 8. POLICY NFOR7Mr�S AND ENDORSEMENTS )RM N6585 %TFllggg{SICSY.(7/96) 52134 10/91 66053 '97 83191 ( 10/03) 3. Is there concern for maltreatment or likelihood of maltreatment in this home? Yes No X If yes,identify decisions and actions concerning responsibility to refer for a Child Protection assessment: 4. Is there a concern for disruption/likelihood for disruption in the potential foster/adoptive home? Yes No_X_ If this foster/adoptive applicant family is currently providing foster care, does the family require agency support to strengthen skills/abilities to remain a foster family? Yes No N/A X_ If the foster/adoptive applicant family is not providing foster care, are there decisions and actions that can be taken to prevent future disruptions and strengthen the family? Yes No_X_ If the answer to any of the above questions is "Yes," complete the Action/Support Plan designed to remedy the disruptive condition(s) or to strengthen the family's skills/abilities. STATE OF COLORADO DEPARTMENT OF REGULATORY AGENCIES DIVISION OF REGISTRATIONS SOCIAL WORK EXAMINERS BOARD ACTIVE // LCSW a-anc al.� ett„-e_ 992996 07/01/2003 06/30/2005 DIRECTOR DIVISION OF REGISTRATIONS NUMBER ISSUED EXPIRES JULIENNE ELISE BOX, M.S.W. 3800 AUTOMATION WAY SUITE 200 FT COLLINS CO 80525 LICE E'S SIGNATURE ( / ! ) )� • 01. 1 . ]j §] � ' ! 8 } / } 1111 1,4 / ] | ! ! § / _ ) ; ! ! : / | 6 § } ; ! § § § ; ) | ) ) [ [ ] ( § ( A8 . [ § ] | ! 98id r Co . ! § florwnr.ar 8 $ $ $ � ` : . $ $ « : : : § Z ) / f \ ( ( / • 0 88888888888888 8 sasssa s a 88889998899988 989889 8 8 FOI � 88888888888888 8 888888 8 8 3�8 88888989898888 8 888898 8 8 LL 88888888888888 8 888888 8 8 8288882888888g g 888888 8 8 n � a o,. • 88888888888888 8 88888 8 8 14;': 88888888888888 8 888888 8 8 A<w O oa 8 1 . 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';e 2 6 p O2 rag aaaaaaaaaaaaaaaaaa a 8 u m O J O a°a < og as au xf fi ooa O 8$888$ 8$8$888 8888 8 8 0 < Q00 aaaaRaaaaRaaaaaaaR R a a O W rc j x a 0mo 00 Jp <o N Z 888888888888888888 O88O88O8O8O88O aRaa aaaasaaaaaaasa a a a a o 0 V O W x 0 < W O F O 40 00 Oa JO N i r 886 aaaaaaaaaaaaaasaaa a a a 00 Va 0 j x a < W o 0 1 au uo • Ore Ja - ooh 8$$$$0$$$$ $$8$8$$ aou aaaaaaaaaaaRaaaaaa a a a 1 o u o 8 ow ! o a 02 eg aO orc py ja - oo� 5 888888888888888888 8 8 0 80 "'2222»2»2212aaaaaaa E w w w J a N w I O 40 saaaa0g$gaa$' 00 oa <O e� 0.000000000. to W W W W W W W W W W W WOO 0 0 0 0 W ) - >-)- >- >- >- >- »�y 2 2 2 2 2 Z N $(($�� $y$yy,Q8�Q88Q r8rii Q$Qfigg${{gy�p$p`` $ fr NUOAsiNN Ni4 NY{p OM w O N O O r F ¢ $ o n a i I @= u o a. d o 4 0 o rc < O N N (/ F O 2d K m a 0 a V O n bi V O < N a J J J a} O 8 W C ,F w u u x O a o N o �g g � rc 0 o tip ' cT� .A n r g 0 0 0 a m u _ a SUPPLEMENTAL NARRATIVE TO RFP: EXHIBIT B CONDITIONS RECEIVED APR 2 5 2005 April 25, 2005 Gloria Romansik Weld County Department of Social Services P.O. Box A Greeley, CO 80632 Re: Response to FYC Commission's recommendation re: RFP 006-00B: Home Studies and Relinquishment Counseling Dear Ms. Romansik, I am writing in response to the results of the Bid process for PY 2005-2006 and to confirm the information you requested. A. Results of the Bid Process for PY 2005-2006 • Condition#1: I agree to the condition that the threshold for hours for an incomplete home study will be 3.5 hours. I also agree that,for every additional adult in the home, past the two"parental"figures will be billed at a maximum of$250.00 per additional adult. Condition#2: I also agree that the turnaround time for receipt of the home study by the Department is set at six weeks from the date of receipt of the referral. • Unit of Service Rate Computation: Full home study with a background check: $850.00 Full home study without a background check: $750.00 Updated home study: $425.00 Additional adults beyond the parental figures: $250.00 Incomplete home study,beyond 3.5 hours of face-to-face direct contact: $225.00 Relinquishment Counseling: $250.00 flat rate. Thank you for the opportunity to work with the Department. If you have any further questions,please contact me at 970.302.1471. inc ely, (� Julie B ix, LCSW rivat; Practice a. • DEPARTMENT OF SOCIAL SERVICES P.O. BOX A GREELEY, CO. 80632 Website:www.co.weld.co.us Administration and Public Assistance(970)352-1551 fip Child Support(970)352-6933 'Hue April18, 2005 COLORADO Julie Box,Private Practice 1702 68 Avenue Greeley, CO 80634 Re: RFP 006-00B: Home Studies and Relinquishment Counseling Dear Ms.Box: The purpose of this letter is to outline the results of the Bid process for PY 2005-2006 and to request written information or confirmation from you by Wednesday,April 27, 2005. A. Results of the Bid Process for PY 2005-2006 • The Families,Youth and Children(FYC) Commission recommended approval of the bid,RFP 006-00B,Adoption,Foster Care, and Expedited Permanency Planning Home Studies,Relinquishment Counseling, for inclusion on our vendor list, attaching the following conditions for all Home Study and Relinquishment Counseling providers. Condition#1: The threshold for hours for an incomplete home study will be set at 3.5 hours. Additional home studies will be billed at a maximum of$250 per person. Condition#2: It has been mutually decided that the turnaround time for receipt of the completed home study by the Department is set at six weeks from the date of receipt of the referral. • Unit of Service Rate Computation: You are requested to respond in writing with a per episode rate for home study. B. Required Response by FYC Bidders Concerning FYC Commission Conditions: All conditions will be incorporated as part of your RFP 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 RFP Bid and Notification of Financial Assistance Award. • • Page 2 Julie Box,Private Practice/Results of Bid Process for PY 2005-2006 The Weld County Department of Social Services is requesting your written response to the FYC Commission's condition and request for episode rate. Please respond in writing to Gloria Romansik,Weld County Department of Social Services,P.O. Box A, Greeley, CO, 80632,by Wednesday,April 27,2005, close of business. If you have questions concerning the above,please call Gloria Romansik, 970.352.1551, extension 6230. Sincerely, y4iego,Qr cc: Juan Lopez, Chair,FYC Commission Gloria Romansik, Social Services Administrator Weld County Department of Social Services Notification of Financial Assistance Award for Child Welfare Regular Administration Type of Action Contract Award No. X Initial Award 05-CPS-48 Revision (RFP-006-00B) Contract Award Period Name and Address of Contractor Beginning 06/01/2005 and Alpine Christian Services,Inc. Ending 05/31/2006 Home Study and Home Study Updates 1200 S Wadsworth Blvd,#300 Lakewood,CO 80232 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Assistance Provision of a minimum of 16 hours of service per Award is based upon your Request for Proposal(RFP). week per family with a maximum of 4 families at any The RFP specifies the scope of services and conditions of one time.Maximum caseload per worker is 12 award. Except where it is in conflict with this NOFAA in families,including referrals from other county which case the NOFAA governs,the RFP upon which this departments of Social Services. Travel time for each award is based is an integral part of the action. home study will be from 15 minutes to a maximum of Special conditions 3 %2 hours round trip from office location, 1200 S. 1) Reimbursement for the Unit of Service will be based on a Wadsworth Blvd.,Lakewood,Colorado.Additional rate per home study;home study update, and times will normally occur once per family in duration relinquishment counseling session. of total time provided.All other face-to-face time 2) Reimbursement requests must be an original with an will be held at 1200 S.Wadsworth Blvd.,#300, original signature from the provider and/or designee. Lakewood,Colorado,or at a designation agreed upon 3) Reimbursements requests must include the date the home by relevant parties. study,update, or relinquishment counseling was completed. Cost Per Unit of Service The request must reflect the referral number assigned to Rate per Study each home study,the amount billed for each home study, Incomplete Home Study $250.00 and the month the service was provided. Full Home Study $1,200.00 4) Payment will only be remitted on referrals made by Hourly Rate per the Weld County Department of Social Services. Home Study Updates 5) Requests for payment must be an original submitted to the Home Study Previously Completed by CFS,up to a Weld County Department of Social Services by the end of maximum of$1,000.00 $70.00 the 25th calendar day following the end of the month of Home Study Previously service.The provider must submit requests for payment on Completed by other provider $1,200.00 forms approved by Weld County Department of Social • The threshold for hours for an incomplete home study Services. will be set at 3.5 hours. 6) The Contractor will notify the Department of any changes • Turnaround time for receipt of the completed home in staff at the time of the change. study is 6 weeks from the date of receipt of the referral. • Additional home studies will be billed at a maximum of$250 per person. Enclosures: X Signed RFP:Exhibit A X Supplemental Narrative to RFP: Exhibit B Recommendation(s) X Conditions of Approval Approvals: Program fficial: By A--‘,. V // AveBy William H. Jerke, Chair Judy . Griego, irector Board dU o.£ �flu> ommissioners Weld unty Department of ocial S rvices Date: Date: (cif Z,1 Or Joos- ( 65c SIGNED RFP: EXHIBIT A B%4-Pi 006 OOC) Attached-A Date of Meeting(s)with Social Services Division Supervisor comments by SSD Supervisor. ,,� �l�-mac-- a9%, D� `� /tart O377 7, /`7�9 of deli /Wed a cc � �-(�- d4 f y p2 / a* , TL v n n d lc a `-ci.e.it -, c Istr trata wean 7Pant 403,-,a, Name and rgnature ofeS �/`e ^ Datj/ `S e Page 25 or 7 INVITATION.TO,BID A , 1 • _ — DATE:February 16, 2005 Bid No. 002-05 RFP FYC 006-00B ETURN BID TO: Pat Persichino, Director of General Services 915 10th Street, P.O. Box 758, Greeley, CO 80632 - SUMMARY Request for Proposal (RFP-FYC 006-00B) for: Adoption, Foster Care, and Expedited Pemianenev Planning Home Snidie , and Relinquishment Counseling Deadline: March 11, 2005, Friday, 10:00 a.m. The Families, Youth and Children Commission, an advisory commission to the Weld County Department of Social Services, announces that competing applications will be accepted for approved vendors pursuant to the Board of Weld County Commissioners' authority pursuant to Colorado Statute and the Weld County Home Rule Charter. The Families, Youth and Children Commission wishes to approve services targeted to ran from June 1, 200e), through May 31, 2006, at specific rates for home studies_ home study updates. and relinquishment counseling services. The County will authorize approved vendors and rates for services only. This program announcement consists of five parts, as follows: PART A kdministrative information PART D...Bidder Response Format PART B Background, Overview and Goals PART E...Bid Evaluation Process PART C Statement of Work ;!� ._:live.;;Date M h 11 200s it - (After receipt of order) BID MUST BE SIGNED IN INK Ron Fritts-6h e TYPED OR PRINTED SIGNATURE VENDOR Alpine Christian Services , Inc . — (Name) Handwritten Signature By Authorized Officer or Agent of Vender dba Colorado Family Services ADDRESS 1200 S Wadsworth Blvd , #300 TITLE Executive Director Lakewood , CO 80232 DATE May 11 , 2005 PHONE# 303/935-3199 — The above bid is subject to Terms and Conditions as attached hereto and incorporated. Page 1 of 35 b INVITATION TO BID DATE:FObruary 16, 2005 Bid No. 002-05 RFP FYC 006-00B ETURN BID TO: Pat Persichino, Director of General Services 915 10th Street, P.O. Box 758, Greeley, CO 80632 SUMMARY Request for Proposal (RFP-FYC 006-00B) for: Adoption, Foster Care, and Expedited Permanency Planning HomeStudieg, and Relinquishment Counseling Deadline: March 11, 2005, Friday, 10:00 a.m. The Families, Youth and Children Commission, an advisory commission to the Weld County Department of Social Services, announces that competing applications will be accepted for approved vendors pursuant to the Board of Weld County Commissioners' authority pursuant to Colorado Statute and the Weld County Home Rule Charter. The Families, Youth and Children Commission wishes to approve services targeted to run than j ure 1. 200 , through May 31, 2006, at specific rates for home studies, home study updates, and r elinglistanent counseling services. The County will authorize approved vendors and rates for services only. This program announcement consists of five parts, as follows: PART A_.Administrative information PART D...Bidder Response Format FART B...Background, Overview and Goals PART E...Bid Evaluation Process PART C...Statement of Work ?_live:-, Date March 11 , 2005 (After receipt of order) BID BE SIGNED IN INK Ron Fritecha TYPED OR PRINTED SIGNATURE VFNDOB. Alpine Christian Services , Inc . (Name) andwritten Signature By Authorized Officer or Agent of Vender dba Colorado Family Services ;yDDRESS1200 S Wadsworth Blvd , #300 TITLE Executive Director Lakewood , CO 80232 DATE May 11 , 2005 PHONE # 303/935-3199 The above bid is subject to Terms and Conditions as attached hereto and incorporated. Page 1 of 35 4e. t ° Attached A Bid No. 002-05 RFP-FYC-006-00B HOME STUDY,UPDATE, &RELINQUISHMENT COUNSELING BID PROPOSAL AND • • REQUEST FOR CONTINUATION OF AWARD UNDER CHILD WELFARE ADMINISTRATION FUNDING 2005-2006 BID PROPOSAL APPLICATION PROGRAM FUNDS YEAR 2005-2006 Bid.002-05 RFP-FYC-006-00B NAME OFAGENCY: apine Christian Sarvlrps , Inc . dba Colorado Family Services ADDRESS: 1200 S Wadsworth Blvd . , #300 PHONE_(3pj 935`3199 Lakewood , CO 80232 CONTACT PERSON: Ron Fritsche TITLE: Executive Director DESCRIPTION OF HOME STUDY PROGRAM CATEGORY: Adoption, Foster Care, and Expedited Permanency Planning Home Studies in compliance with the uniform format utilized by the State of Colorado Department of Human Services since October 1, 1999(Attached A). 12-Month approximate Project Dates: 12-month contract with actual time lines of: Start June 1,2005 Start End May 31, 2006 End TITLE OF PROJECT: Writing o Home Studies by CFS Ron Fritsche March 11 , 2005 Name and Signature of Person Preparing Document Date -JMa.r_ch--5,-1005-..—._.- Name and S mature Chief Administrative Officer Applicant Agency Date MANDATORY PROPOSAL REQUIREMENTS For new and renewal bids,please initial to indicate that the following required sections are included in this Proposal for Bid. For renewal bids,please indicate which of the required sections have not changed from Program Year 2004-2005 to Program Year 2005-2006. RDF Project Description Indicates No Change from 2004-2005 RDF Sample Home Study Project Description RDF Target/Eligibility Populations Sample Home Study RDF General Indicates Target/Eligibility Populations RDF Cultural/Eligibility Populations General RDF Types of services provided Cultural/Eligibility Populations R 11FF Measurable Outcomes Types of services provided RDF— Service Objectives Measurable Outcomes R DF Workload Standards Service Objectives RDF-Staff Qualifications Workload Standards R H Unit of Service Rate Computation Staff Qualifications RDF Program Capacity per Month Unit of Service Rate Computation RDF Certificate of Insurance Program Capacity per Month Page 23 of 35 I Bib No. 002-05 RFP-FYC-006-00B • Attached A Date of Meeting(s)with Social Services Division Supervisor: C,....ments by SSD Supervisor: David Aldrich met_with me over the phone about the RFP for Colorado Family Services for Home Studies . He gave me information that should be include and is herewith incorporated into the bid . He stated that he would fax me a state— ment confirming our conversation but failed to do so . I called Mr . Aldrich on both March 9, 2005 and March 10 , 2005 and each time left a message requesting he fax the statement we had discussed . ( zlX5 Name and Signature e: SST) Supervisor - Date Page 24 of 35 t 4{ COLORADO FAMILY SERVICES, INC. t1I Nitf A division of Alpine Christian Services,Inc ! _ March 11,2005 Pat Persichino Director of General Services 915 10th Street P.O. Box 758 Greeley,CO 80732 RE: Bid 002-05 RIP-FYC-006-00B Dear Pat Persichino: Colorado Family Services does hereby submit the enclosed bid for your consideration. We are bidding on providing Home Studies as outlined in the packet. Sincerely, Ron Fritsche,MA Executive Director 1200 South Wadsworth Boulevard,Suite#300•Lakewood,Colorado 80232 Phone: 303.935.3199•Fax: 303.935.3181•Toll free:888.223.0786 Colorado Family Services • • A Division or Alpine Christian Services PROJECT DESCRIPTION Alpine Christian Services,Incorporated, doing business as Colorado Family Services (CFS),submits this project description for Home Studies. Included are the overall mission, purpose and design. The Employer Identification Number is 84-1365958 CFS will provide services to Weld County Department of Social Services(WCDSS) during the fiscal year June 1,2005 to May 31, 2006. CFS will write Home Studies,Expedited Permanency Planning Home Studies, Home Study Updates, Court Ordered and Incomplete Home Studies(the latter sometimes required by or to WCDSS). Our Denver office is located at 1200 South Wadsworth Blvd, Suite#300,Lakewood,Colorado 80232-5434. The telephone is 303.935.3199, the fax is 303.935.3181. Our e-mail address is coloradoservices@gwest.net. Home Study Mission,Purpose and Design 1. CFS receives referral from WCDSS. Therapist consults with caseworker or referring agent and they discuss information about the family,focusing on the specifics needed of this home. We will concentrate on any available background checks or concerns, family history, history of DSS involvement(if any) in home, safety issues,caseworker concerns regarding family, parenting ability and contact information. Caseworker defines the type of study needed. 2. CFS staff and parent arrange for the first joint interview session, usually at the CFS office. We discuss parent's motivation and review application packet. Packet contains the following materials that parents need to complete: Application(2 parts: general information and autobiography for each caretaker in the home, signature is required)and health evaluation for all household members. Also we need background checks including fingerprinting, (required for every member of the household who is 18 and older),documents for CBI/FBI, (FBI search is required for individuals who have lived in Colorado less than two years). The Background Inquiry Form from the Office of Performance Improvement, (the former Registry of Child Protection)and payment for background checks are also required. They need to sign the child abuse reporting form,release of information and discipline agreement; complete and record on proper form a fire and tornado drill;and include names and full addresses of references. Also they will need to attend Core Training if they intend to foster(our Agency offers 16 hours of core training for$47 per person, with a minimum of 12 people, price includes Core Training Manual). Also CPR and First Aid are required if they are not currently certified(we offer it for $45 per person, with a minimum of 10 participants,which excludes manuals, available for$15). For foster care they will post emergency telephone numbers, household rules and emergency evacuation plan and having children's rights available. Prospective foster parents must also provide a copy of each driver's license,auto and homeowner or renter's insurance; pet inoculations; and proof of income. Finally,they sign that they have reviewed the Colorado Department of Human Services Rules and Regulations and WCDSS policies and procedures. 3. After packet is returned to our office we arrange for visit to home for second joint interview and individual interview to determine appropriateness of it for the placement of children and/or adolescents. We complete on-site home inspection and provide copy to parents so they can correct deficiencies. We then schedule third joint interview and inspection follow-up. 4. CFS will then assess, review,complete and send in the Home Study to WCDSS. 1 3/9/05 Colorado Family Services A Division of Alpine Christian Services SAMPLE HOME STUDY Enclosed is a Home Study completed using the state format. 2 3/9/05 FOSTER HOME STUDY FOR Blaise and Mary e IDENTIFYING INFORMATION Foster Parent 1 (Primary Caretaker) Foster Parent 2 (,econdary Caretaker) Mary Elle Balazs laise) Laszlo DOB, ager:1111 44 years old 53 years old Ethnicity: Caucasian Caucasian Address 4890 S. Phone: 303 670 (home) istureen, CO 80439 303 670 t +:'c!ai r aver! Jefferson County 303 941 Mary's cell) Email: Blaise no.com Children Living in the Home Mario /86 17 years Sala /89 15 years Angelica 8/90 13 years • Glorianna /93 10 years Josiah 26/95 8 years Graciella /99 4 years Elijah 21/02 19 mos Date of Home Study: June 17, 2t A. SOCIAL HISTORY/BACKGROUND Foster Parent 1 - Mar Significant Events in Her Family Background Mary is the youngest of six children born to her parents. who remained married to each _ , u .ti! her ..'1 ccr'c death til co:2 She grew up in a suburban area of v p&s 4sq.eXaS. e said she has wonderful memories of those years. Mary remembered her mother, w o was her primary caretaker, as cheerful and positive and as someone she could confide in. They have always had a wonderful relationship and that closeness continues today although they live miles apart. Mary described her father as friendly and personable. She said she was able to confide in him also although she f loser to her mother. She said that she respected and honored him. His passing in 2 s one of the most significant events in her life. COLORADO FAMILY SERVICES, INC. 1200 South Wadsworth Boulevard, Suite 1)300• Lakewood,Colorado 802.2_ Phone: 303.935-3199 • Toll Free: 888.223.0786 • Fax: 303.935.3181 4 FOSTER HOME STUDY Blaise and Mary; Mary said she was lucky to also develop close relationships with other important people during her childhood. She named her grandparents, her priest and her godmother as adults who had a significant influence on her in her early years. Mary has four older brothers and one older sister who passed away in 14She said that although there was quite an age difference among her and her siblings, they all had good, typical sibling relationships. Her sister's death, from complications of diabetes was another very significant event in Mary's life. Mary graduated from high school in nd earned a Bachelor's of Music Edu- cation degree from So ate Universe y. She was a student when she first met Blaise, who was a grad en a he same school. He graduated and moved out of state and it was not until years later that they met again and married. • Knowledge and Capacity to Care for Children Mary and Blaise have been foster parents for several years. They hove both completed extensive training in working with the special needs children in foster care. She also took col- lege courses in child development and other courses related to children in the educational set- ting. She continues to take classes for lay counselors offered by her church. In addition to raising her children, Mary has worked with children all through her adult life. She taught in public school, has done foster care, provided day care and respite care and worked in a private setting caring for children and adults with Down's Syndrome. Ability to Maintain Long Term Relationships Mary maintains frequent contact with several of her friends from college. They talk often on the phone and get together whenever they can. She also talks frequently with her mother and brothers who all live out of state. Ability to Deal with Life Changes Including Issues of Grief and Loss • Mary appears to be an optimistic and compassionate person. She said she has experi- enced some very painful events in her life but that she has learned and healed from them. She understands the grief process and said she allows herself to go through the feelings and stages without worrying about whether she is "doing it right." She said that Blaise is her greatest sup- port curing difficult times. Mary understands that she will most likely become very attached to the foster children placed in their home. She said she expects to feel the loss when the children leave, but that she will be comforted knowing that the children will be in God's hands. Foster Parent 2 - Blaise Significant Events in His Family Background �i Blaise is the youngest of four children born to his parents. He was born in Hungary and his family moved to the United States when Blaise was eight years old. e re- membered being very poor when he lived in E e said.that often his parents went without food so that the children could eat. Once the family settled in Ne they became ' FOSTER HOME STUDY Blaise and Mm) more prosperous with his father working as a banker. Blaise said that both of his parents took responsibility for taking care of him and his siblings. He remembered his mother as a strong yet warm person. He was able to confide in her and said that his relationship with his mother has • always been a good one. He described his father as "a nice guy." Blaise said he was closer to his father and said that he was able to confide in him. His father died in 1997 and Blaise de- scribed the loss as a significant event in his life. Blaise said that, in addition to his parents, his pastor had a substantial influence on his life. He said the pastor took the time to be an attentive mentor to him. Blaise has two older sisters and one older brother. He described his relationships with his siblings as "normal and close." The talk on the phone and visit as often as they can. He attended boarding schools and', and graduated from high school in N- He earned a bachelor's tit and a eree physics at�S - university. Blaise served in the military from 19 9 Me participat ac- - tive comsat and received an honorable discharge. • He was married twice before his current marriage to Mary. He said that he learned from both marriages to marry someone with whom he had common values, beliefs and goals. He said that Mary is very different from his previous wives because she is tolerant and loving. They have much in common and they both expect this marriage to last forever. Knowledge and Capacity to Care for Children Blaise has had extensive training in caring for special needs children in his role as a fos- ter parent. In addition, he has taken college courses in counseling. He has also had the expe- rience of raising, with Mary, his seven children." Mary described Blaise as an excellent father. Ability to Maintain Long Term Relationships Blaise cherishes the long term marriage he shares with Mary. He also maintains fre- quent contact with his siblings and mother, although they all live far away. Ability to Deal with Life Changes Including Issues of Grief and Loss Blaise said the death of his father was the most significant event in his life, other than his marriage to Mary. He said that he understands that time heals the grief associated with loss and that he looked to Mary for emotional support. He believes he will be able to handle the in- evitable sadness associated with saying goodbye to foster children with whom he has bonded. Others Living in the Home Mary and Blaise have seven children, all of whom still live in the home. They lead a busy life and are involved in and very supportive of their children's various talents and interests. Marica, 17 years old, attended Mchools and has been home-schooled. She loves to perform on stage, singing in chora roups and opera productions. She was thrilled to have the chance to tour with the Co ers. Marica described her home environment as structured and loving and said tha s e is happy to see her parents getting back into foster parenting because they like it so much. -3- 1 FOSTER HOME STUDY Blaise and Mare Isaiah, 15 years old, is active in a variety of sports and also in theirganization. He is also very involved in the performing arts. He has been singing with the Evergree t' d 1. • le for four years, has performed in children's theater groups both at church an,: e community. He has attended public school and is currently being home-schooled. Isaiah is very supportive of his parents' being foster parents because he knows they enjoy it. Angelica, 13 years old, enjoys dancing, performing in plays and singing in groups. She also likes being involved in church youth activities and she enjoys going camping with her fam- ily. At home she always has craft projects in progress. She is currently being home-schooled and described her home atmosphere as "loving, cozy and nice." She thinks it would "be awe- some if we could take care of a baby." Glorianna. 10 years old, likes to sing and play a variety of spo She loves it that her parents take the family lots of places and said they "went to Ne wo times." She said they have a fun time in their house and that she can tell her mom is "mad when she makes that • face and then she scrunched up her face and laughed)." Glorianna is being home-schooled and said she feeis good about having foster children in their home. Josiah, 8 years old, loves to play any kind of sport or outdoor game. His parents de- scribed him as fun-loving, giving, happy and funny. He is currently home-schooled and said he feels okay about having foster children in the home. Graciella, 4 years old, is curious, active and happy, according to her parents. She has recently been diagnosed with pervasive developmental disorder and her parents are actively learning about how best to meet her special needs. Elijah, 22 months, is the baby. He is a busy, curious and even-tempered child. B. CURRENT STATUS OF THE FAMILY Marital Relationship Mary and Blaise have been married since 11laise described Mary as "tolerant and loving." He said they are compatible in many ways including their commitment to their family and to their faith. Blaise said his marriage completely fills his life with satisfaction. Mary described Blaise as strong and personable. They are compatible in their values about raising children and religion. Mary said that the marriage gives her the satisfaction of be- ing in a relationship that grows deeper all the time. Blaise and Mary seemed relaxed and confident in each other's presence. They laughed at each other's little jokes, encouraged each other to share personal information in the interview and seemed supportive of each other in every way. They have a loving relationship based on mutual respect, recognition of each other's strengths and their shared goals for their individual and family growth. Interrelationships with Significant Persons Outside the Nuclear Family Mary and Blaise said they have not experienced anyone interfering or attempting to put undi influence ;c their lives. They both said they have long-term friendships with the people -4- e FOSTER HOME STUDY Blaise and Mary.. they work with and the people in their church. They are quite involved with their children's ac- tivities and with activities at church but also seem to be able to maintain healthy boundaries. They are careful to arrange for both personal and couple time. Lifestyle Changes Blaise and Mary agreed that over the years, the births of their children have brought on- going changes to their family. They also both lost their fathers recently in the last few years and, most recently, their family dog died. They said that these changes are part of living and that they face challenges together and with the help of their faith. Mary and Blaise have carefully considered the changes that welcoming foster children into their home would bring to their life. Their previous experiences as foster parents were posi- tive and rewarding. Because they enjoy a high energy and activity level, they believe that hav- ing foster children again would simply expand the number of children in the home. They said- they would be busier with appointments and the paperwork required of foster parents. They recognize that they will need to carefully observe the interactions between their children and the new children, and they are ready to help everyone make necessary adjustments. Mary and Blaise seem to have a realistic view of the responsibilities involved and the effort it takes to blend new children into the family. They enjoy being a family with children and they know they have what it takes to care for foster children. They both have a history of coping well with change as evidenced by their ability to take action to move forward despite disappointments and losses. They believe their home is filled with the love, fun, acceptance and security a traumatized child would need. Methods of Decision-Making Mary and Blaise agree that they share decision-making responsibilities equally. They listen to the children's point of view on issues involving them and then decide, as the parents, how to handle situations. They work from their individual strengths to make decisions that are fair and work for the family's benefit. In their experience, they share the same values and have been able to come together to make even the most difficult decisions. Blaise and Mary are deeply devoted Chris- tians and they believe that prayer also helps them with difficult decisions. They work together to handle family responsibilities such as housekeeping and yard work. They share responsibil- ity for financial decisions and caring for the children. They have developed a system that works for them yet they are flexible enough to make changes as the need arises. Parenting/Child Rearing Practices Including Discipline (include beliefs on corporal punish- ment) Blaise and Mary said their children have brought incredible joy to the family. They have reasonable expectations for their children such as being honest, doing their best in school and being considerate of others. They are teaching their children the importance of serving God to the best of their abilities. They have a simple structure in place to help the children v.'ork on goals and to recognize the small steps of progress toward those goals. -5- I ( FOSTER HOME STUDY . Blaise and Mara Neither Mary nor Blaise has ever used physical punishment with their children. They believe it does damage to the heart and soul_ They believe children should be disciplined with respect. They do not use threatening, belittling or shaming behavior such as having a child stand in the corner. They try to-immediately address misbehaving situations and both of them are comfortable setting limits and consequences. Discipline strategies include removing the child from the stressful situation and offering alternatives. They work hard to motivate their children to want to do the right thing. If neces- sary they will remove privileges or decrease allowances. They try to instill compassion for oth- ers by helping the child see how their behavior affects others. Neither Blaise nor Mary were physically abused in their families of origin, and they share the conviction that children learn best through loving, supportive and consistent expectations and limits. They believe that disci- pline means teaching and that it is important to set a good example through their own behavior. They recognize that encouragement is usually more effective than imposing negative conse- quences. They are in agreement about how to implement discipline strategies with foster chil- dren. Mary and Blaise understand the concept of allowing children to experience the natural and logical consequences of their negative behavior. However, they will always be there as a safety net for the children to protect them from harm. In general, they agree on discipline strategies and privately discuss options when they are not in agreement. The are an • intelligent, compassionate couple who possess effective parenting skills. They e open to working with team membersto fine-tune their knowledge and skills to meet special needs of individual children. Knowledge of Nutrition The enjoy eating a variety of healthy foods. Mary said she has done extensive research and make a real effort to serve a tasty and varied menu. The family prefers rice and soy milk but Mary said she would provide regular milk if the foster child prefers it. They both understand that a person cannot "live on junk food alone." They allow themselves and the chil- dren some treats but are careful to maintain a well-rounded diet. Religion Mary and Blaise attend weekly services at t ommunity Church, a non-denominational Christian church. The whole fame y participates in various group activities there. Blaise and Mary hope that foster children would be able to attend church with them. However, they understand the state's restrictions about requiring foster children to attend church. If it makes sense, they would arrange for the children to attend a church of their choice or they would make other arrangements for the children. They would accept guidance from the county Case Worker and the Colorado Family Services Case Manager regarding this issue. Finances (Include description of their jobs, income) Blaise and Mary own a residential and commercial plumbing company. He likes meet- ing and working with people but is less enthusiastic about the hard work sometimes involved. He usually works a regular Monday through Friday, 40-hour week. Mary also works with the business and does volunteer work in the community. She is a stay-at-home mother whose -6- FOSTER HOME STUDY Blaise and Mary family responsibilities keep her as busy as a full-time job. Mary takes primary responsibility for scheduling and participating in the children's appointments and various other commitments. With notice, either of them can adjust their schedules if necessary. Family's Ability to Meet Financial Responsibility Their total monthly income from employment is approximately $3400. Blaise also re- ceives approximately $1000 per month in military disability payments. Their monthly expenses are approximateiy $2800. Mary and Blaise own their car and the home in which they live. They do not have ex- tensive liabilities and have demonstrated the ability to adequately manage their finances. They understand that the payments they receive for the foster children are meant to meet the child's needs and are not to be considered as income. Extended Family (Are they supportive of the decision to do foster care or adopt?) Although both of their families live out of state, telaported that their extended family memoers are 100% supportive of their plan to become foster parents. They have a net • - work of friends in the Evergreen area and several people have offered to help Blaise and Mary in any way they can. Their church family has a reputation in the community of welcoming foster children and encouraging foster parents in their work. The are obviously proud and competent parents. The children are cheerful, active and secure' emselves. The family is excited about the prospect of welcoming more - children into their home. Childcare Plan in the Event of Emergency and/or When Parents are Away from Home (In- clude hours that they work) Blaise works a regular workweek. Mary works at home and is generally responsible for the day-to-day care of the children. There are several Colorado Family Services foster families in the area who are willing to work together with other foster parents as respite providers and information resources. Assessment of the Family's Interest and Ability to Meet the Special Needs of a Child Blaise and Mary have indicated that they are willing to accept children who have been physically and emotionally abused and who have been neglected. They are also willing to ac- cept children who have had prenatal drug exposure. They understand that there may be some long-term developmental problems with these children and are willing to accept the risks. They would consider accepting children with certain medical conditions. Blaise and Mary are mature and thoughtful people who are accepting of the many be- haviors common in foster and adoptive children. They are confident in their ability to care for foster children. They have demonstrated their ability to meet the special needs of foster chil- dren. They are willing to put their energy and talents into fostering and are excited about get- ting involved as foster parents again -7- • FOSTER HOME STUDY Blaise and Mary Family Strengths Including Individual and Family Strengths and Self-esteem Blaise said he is proud of his educational achievements, the success of his business and the happiness of his family. He gets most pleasure from his family and his relationships with other people. His goals for the future include growing the business. Blaise said the big- gest risk he took was leaving his extended family and moving with Mary to Colorado. He said the outcome of taking the risk was positive and he learned that hard work and determination pay off. Blaise is a confident man who has planned well for his family's future. Mary was an accomplished musician in high school as the first chair player in the orchestra. She said the experience taught her the value of discipline in accom- plishing her goals. As an adult, she is proud of her knowledge in early childhood education and nutrition and in her physical fitness. Goals accomplished include teaching and raising their chil- dren and the successful business she shares with Blaise. Her goals for the future include be- coming a missionary with Blaise in Mozambique. Mary said that giving her sister a kidney was tnc biggest risk she took in her life and that, thankfully, the result proved to be very positive. Mary is satisfied with.her personal life, her financial stability and her relationship with Blaise and the children. She is a woman who takes pride in her successes as a wife and mother. She finds satisfaction in creating a loving, safe and fun home environment Mary and Blaise are both positive and enthusiastic people with goals and hopes for their future. They describe their family as one that has fun talking and sharing their hopes and dreams with each other. Their strengths as a family include their family relationships, their indi- vidual and family stability, their faith and their commitment to each other. C. MOTIVATION FOR A CHILD Applicants Attitude Toward Foster Care Mary and Blaise understand that children come into foster care for a variety of reasons. They feel compassion for natural parents who are not able to care for their children. However, their focus is on the well-being of the children, believing that the children have the right to a safe. stable family life. They want to share their fun and loving home environment with a child in need. They think that it will be fairly easy to add one or two more to the children they have. They believe that welcoming a foster child into their home will add to the peace and satisfaction they already have in their marriage. Attitude of Other Adults Living in the Home No other adults live in the home. Attitude of Children Living in the Home The children all seem to welcome the idea of having additional children in their family. -8- , e FOSTER HOME STUDY Blaise and Mare Physical, Mental and Emotional Capability of the Applicant Both Mary and Blaise deny having any physical, mental or emotional disability that would interfere with caring for foster children. More discussion is included in following,sections of the home study. Ability of Family to Adjust to Foster Children Mary and Blaise agreed that adding more children in their home is a natural extension of their commitment to family. They believe that having foster children will increase the level of activity, sharing and caring that already exists in their home. They have discussed both the re- wards and challenges of fostering. They appear to have a realistic view of the joys and difficul- ties they could face. There confident that, with the support of the Colorado Family Services Case Manager and their church family and friends, they will be able to make neces- sary adjustments. Ability to Meet Child's Physical and Emotional Needs The Makamily is a warm and accepting family. They have the energy, commitment - to and interest in working with the child's treatment team to focus on meeting the individual needs of the children. Types of Children Family Wants Placed in the Home The eefers placement of one or two children, male or female of any ethnicity. They prefer children aged newborn to four years old and are willing to accept sibling groups. They are interested in long-term placements and are very willing to consider foster adopt placements. D. TRANSRACIAL AND TRANSCULTURAL ASSESSMENT Willingness to Take Children from a Different Ethnic or Cultural Background Mary and Blaise have discussed the idea of accepting a child from a different ethnic background into their family. They have also talked with their friends and extended family members about the idea. They believe they have the heart and ability to parent children who are of a different ethnicity. They have friends of African American and Hispanic ethnicity. Mary grew up in south Texas and said she is very familiar with the Hispanic customs and culture. The mountain community in which they live is home to primarily Caucasian families. Willingness and Ability to Preserve Continuity of the Child's Ethnic and Cultural Back- ground Mary and Blaise have an understanding of the need to fully support a child's ethnic and cultural identity. They are willing and able to learn about and implement strategies to assist the child in maintaining a strong connection to their ethnic and cultural heritage. • 9_ • • FOSTER HOME STUDY • • Blaise and Mary Suitability to Care for Children of Different Races Blaise and Mary are both Caucasian. They are eager to learn about the culture of a child from a different ethnic background who might be placed with them. They would be fully involved in sharing in the child's culture and in encouraging the child to learn about and em- brace their ethnic and cultural identity. They have friends of different ethnicities and have al- ready asked for their support if needed. They also agreed that they would accept guidance from the case worker and Colorado Family Services Case Manager in seeking appropriate re- sources to meet the child's and their family's needs in this area. E. CHILD SAFETY AND WELL-BEING • History of Abuse of Adults and Children Living In the Home Mary„ t d Blaise denied experiencing any abuse as a child. Both said that, as they look • back, the discipline given by their parents was appropriate. They lost privileges or were told to • think about what they could have done differently. Neither was involved in any serious negative behaviors as children or youth No one in their families abused alcohol or drugs or suffered from mental illness. None of their children has been involved in child abuse investigations. Have Any of The Applicant's Children Been Placed in Out of Home Care? No. Knowledge of Child Development Both have had years of training and experience as foster parents, in addition to raising their own seven children. Blaise has taken college level counseling courses. Mary taught in public school. Their children are engaged, confident and talented people. The Faragos are proud of their child rearing skills, and their emotionally healthy children are evidence of their dedication and success as parents. Coping Skills for Dealing for Dealing with Anger, Frustration and Provocation From Chil- dren and Ability to Maintain Control When Angry Blaise and Mary sometimes feel stressed when their children misbehave. However, - they talk things out and work together to set limits and discipline measures. They said they do not really argue about anything. When they have a disagreement, they talk "forever," until they work out a solution that works for both of them. Sometimes they take a "time-out" by separating themselves from the situation and thinking quietly about what the real goals are. The references for the al are unanimous in their descriptions of Blaise and Mary as people who deal well with the provocative and manipulative behavior of others. They are consistently described as people who do not become easily angered or frustrated. Blaise is said to consider things carefully before acting. Mary is described as patient and firmly loving. Both were praised for their consistent ability to remain calm, caring and firm when children are misbehaving. They do not appear to be the kind of people who will engage in power struggles -10- FOSTER HOME STUDY Blaise and Mary with children and they seem able to avoid controlling and critical behaviors. They both have a generally positive outlook on life and on the expected behaviors of foster children. They do not appear to be impulsive or judgmental and they say they are each other's best support. Capacity for Compassion and Empathy Both Blaise and Mary are able to express affection and compassion. All of their refer- ences clearly admire them for their warmth and compassionate natures. They are both de- scribed as having more heart and compassion than average. Mary said she really tries to un- derstand the feelings of others and Blaise said the key is to be willing to spend time listening to others. Neither seems to view withholding attention and affection as a way to control children. Ability to Separate Own Needs and Perceptions from Those of Others The understand the need to occasionally take time away from family responsi- bilities as a way of keeping their relationship strong. They have several friends who are certi- fied foster parents and who have offered to baby sit foster children so that they can occasion- ally spend some time away from the home. Mary and Blaise agreed they do not feel over- whelmed by the responsibilities of daily life and are able to set limits on the demands of others. Availability of Support Systems Mary and Blaise have close relationships with both their family and long-term friends. Although their families live out-of-state, they talk on the phone frequently. Several of their friends have stated their commitment to provide both tangible and emotional support to the .as they meet the challenges of becoming a family with foster children. There are also other foster parents in the community available to provide respite for longer breaks. F. CHILDREN WITH SPECIAL NEEDS AND/OR DISABILITIES Interest, Preparation and Willingness to Care For Children with Disabilities Mary and Blaise appear to understand that there are special needs common in the type • of children who will be placed with them. They would consider children with physical and/or mental disabilities. Mary has experience working with developmentally and physically disabled people. They believe that their family strengths and commitment will help them to meet the challenges of caring for children with disabilities. They are thoughtful and intelligent people who are willing to put their energy and talents into learning about and providing for children's special needs. Assessment of How It Will Impact the Family There will be a period of adjustment as Mary and Blaise settle new children into their home. They are excited and optimistic at this time. They also appear to have realistic expecta- tions about the changes that will follow. They have a strong partnering relationship and have the emotional resources and support system in place to help with the expected adjustments. -II_ FOSTER HOME STUDY • Blaise and Mary G. RELATIONSHIP WITH THE COUNTY DEPARTMENT AND CFS Mary and Blaise have been flexible and interested as they moved through the certifica- tion process. They complied with all requests for information, thoughtfully participated in core training and in other trainings with current foster parents. They have shown enthusiasm, com- mitment, humor and honesty in their interactions with the Colorado Family Services staff and foster fami'ies H. EMOTIONAL, MENTAL, SUBSTANCE ABUSE AND MARITAL OR RELATIONSHIP ISSUES (include results form the MMPI and conclusions from interviews Blaise and Mary each completed the MMPI as part of the screening process. Neither had any scores significantly outside of the average range. This pattern would suggest that they are stable in their personality structures. Neither has any history of substance abuse, mental - - illness, family violence or law enforcement involvement. Their family histories are also unre- markable. In interviews, they appear forthright and honest. They appear emotionally healthy, both as individuals and in their marital and parenting relationships. MEDICAL RECORDS Mary's doctor described her health as good and said there are no emotional or physical factors that should be considered if care is given to unrelated children. She does not need to be seen again for three years. Blaise's doctor said his health is good and said he does not have any physical or emo- tional factors that should be considered if care is given to unrelated children. He does not need to be seen again for three years. The children were found to be in good health and their immunizations are current. J. STAFF MEMBER No one in this family is an employee or board member of Colorado Family Services. -12- FOSTER HOME STUDY Blaise and Mary K. WILLINGNESS TO ADOPT Are They Able to Have Children? Mary and Blaise have seven children and are able to have more children. However, they have chosen to add more children to their family through fostering and/or adoption. Do They Want to Adopt? Yes. They are willing to accept foster children or foster adopt placements. They are very open to the idea of adopting foster children who are a good fit for their family. How Much Risk are They Willing To Take if They Want to Adopt? They understand the concept of legal risk and are willing to accept children at any level of legal risk. L. HOME Mary and Blaise live in a spacious home in a quiet, mountain community outside the town of Evergreen. The home has a large backyard that backs to a protected forest area. The main floor has a large, eat-in kitchen, living room, dining room, family room, laundry room, workshop, two bedrooms and one full bathroom. The upper half story has four bedrooms, a den and a full bath. Second upper half story has the master bedroom and bath. They have four dogs and four cats whose immunizations are current. The administer all rabies shots to their animals. The home meets all safety requirements fora amily foster home. M. COMMUNITY The home is located in Jefferson County. The community is about 30 miles west of Denver. The nearest hospital is within 30 miles of the home. There are several doctors and dentists in the area who provide services for Medicaid recipients. Therapy and medication management is available through community mental health providers. There are numerous recreational, cultural and educational resources available in the Evergreen area and in Denver. The community is served by Jefferson County Schools. including Wilmot Elementary, Ever- green Middle and Evergreen High Schools. -13- FOSTER HOME STUDY Blaise and Manimilli N. BACKGROUND CHECKS CBI And or FBI Checks Both have lived in Colorado for more than three years. The CBI background check did not reveal any arrests or convictions. Central Registry Check The Central Registry background checks did not report any involvement in child abuse investigations. Check with Other Agencies Theastated they have been previously certified foster parents with Jefferson County. New Horizons and Whole Family. The background check with Colorado Department of Human Services and Jefferson County revealed incomplete information about previous certifi- cation. However, none of the information that was available was negative. The child place- ment agent;es are no longer in operation and, therefore, we are not able to obtain references. . O. EVALUATION Blaise and Mary are stable, caring, responsible people who enjoy their role as parents. The have demonstrated the ability to maintain their composure in difficult situations. The have strong family values and are faithful Christians. They have seven biological children and have been reported by longtime friends to be firm, loving and attentive parents. They consider their relationship and the well-being of their children as their highest priorities. They are enthusiastic and confident about their ability to work well with both foster children and with the professionals involved on the treatment team. They have demonstrated their capabilities as foster parents over the years. They are very willing to consider the placement of legal risk foster children and would consider adoption if the child is a good fit for their family. Blaise and Mar have both the qualifications and commitment necessary for cer- tification as foster parents. P. RECOMMENDATIONS Should the Applicant(s) be Certified as Foster Parents? Thillailkamiy should be certified. They have met all requirements and, in the course of this assessment, were found to be emotionally and physically stable. competent and committed to becoming foster or adoptive parents. - -14- FOSTER HOME STUDY Blaise and Mary Children Recommended for Placement in the Home The ve the space for one or two foster children. They would work well with a young sibling group. ey are primarily interested in working with young children, newborn to four years old. They feel comfortable accepting children of any ethnicity. They are prepared to accept children who have been abused and/or neglected. They will accept drug and alcohol exposed children and children with certain medical problems. The CPA should carefully assess potential placements for risk factors due to the presence of young biological children in the home. -15- FOSTER HOME STUDY Blaise and Melilla Written by: Reviewed and Approved by: / 7 c�'"�;-�_ 11 u�^,� l�:3i.. .� Charlotte Allen. MSW Date Ron Fritsche, MA Date Placement Supervisor Executive Director Reviewed and Approved by: Byrn Davis Date Program Director -16- • • Colorado Family Services A Division of Alpine Christian Services TARGET/ELIGIBILITY POPULATION Colorado Family Services(CFS) will provide Home Studies to the Weld County Department of Social Services(WCDSS). WCDSS will contact CFS at 303.935.3199 to request the provision of a Home Study,Expedited Permanency Planning Home Study, Home Study Updates, Court Ordered and partial Home Studies. The families needing the services will normally be in southern Weld County, Denver-Boulder or the Colorado Springs area. CFS will provide the services described above for a maximum number of four families per eight week time period. For the purposes of defining our target, it is assumed that each family will have an average of four children living within the home. In the course of each week,CFS will provide up to 10 hours of services each week. It is expected that most Home Studies will be completed within 4 to 8 weeks. However,this time frame is dependent upon the families submitting the necessary paperwork we provide them in a timely fashion. The maximum time we will normally take is 12 weeks,thus paperwork must be completed promptly. If appropriate, up to eight children under the age of 18, including biological, adopted and foster children may live in a targeted family. This may be subject to other conditions such as size of home, income level and other mitigating factors. CFS's staff is well experienced in multicultural issues, with each staff person averaging over fifteen years of experience in child welfare and social services. Therefore we are adept at providing home studies for the general as well as multicultural populations. Each of CFS's staff members has worked with multicultural issues as we have many foster homes that are bilingual and/or multicultural. Typically we find that the vast majority of clients speak English. For those who do not, within the family unit there is usually someone who can translate. We have the ability to provide services on a bicultural/bilingual basis. It is anticipated that approximately 25% or 10 family units will have one or more members who are monolingual in a language other than English. We will provide services to these families by using translators whenever needed. CFS currently has 24-hour service available by telephone. After normal business hours this service is available to those clients referred by Weld County for Home Studies only if a . genuine emergency exists. After business hours,calls will be received and appropriately handled in all cases. All such cases will be managed through phone contact and appropriate steps will be taken to successful manage each individual situation. On occasions that a family seeking to place a child needs to contact CFS due to an emergency/crisis only messages can be left. Those calls will be returned the next business day. As part of the initial contact the adults of the family will be given information on basic standards and expectations during the services. Also, the Agency expects that all appointments be kept if they are not canceled 24 hours in advance. CFS will provide adoption, foster care,and expedited permanency planning according to the above and part C, statement of work. This includes checking with the Department of Motor Vehicles, local county DSS search for open cases, and checks with local police and/or sheriff department. 3 3/9/05 Colorado Family Services A Division of Alpine Christian Services TYPES OF SERVICES TO BE PROVIDED Colorado Family Services(CFS) will provide services consisting of Home Studies, Expedited Permanency Planning Home Studies,Home Study Updates, Court Ordered and Incomplete Home Studies for Weld County Department of Social Services(WCDSS). CFS will start by determining the qualifications of the prospective home including background checks, psychological profile, financial background and similar information that already may be available through WCDSS or other sources. Next, CFS will, through initial contact with a family seeking to place a child from WCDSS, make clear to that family what is to be accomplished. Initial contacts will be by phone and so a mailing address is necessary to communicate with each prospective home. In the initial conversations the social worker from CFS will inform the adults(including all residents of the home that are 18 years of age and older) of each document to be sent to them and cover their needed actions for each of the documents. If background checks have not been provided to CFS, Agency staff will call the adults of the family back within 5 business days to make sure this process is underway. (Background checks are an essential first step in determining the feasibility of an approved Home Study). Once this step is completed and the paperwork has been received by the prospective home, our staff will, answer any questions and develop a timeline for the timely completion of the Home Study. The adults will be told that if they have questions regarding the paperwork or concerns about whether to continue the process they need to discuss this with WCDSS and/or CFS. Within the initial mailing or meeting the forms that family members need to filled out will be include: the application forms and documents for CBI/FBI,the Background Inquiry Form from the Office of Performance Improvement,Employment Affairs Division Health Evaluations (formerly the Registry of Child Protection). Also they sign the Agreement to Abide by Colorado Rules and Regulations and WCDSS Policies and Procedures,Department of Motor Vehicle Forms, Authorization for Release of Information and any other forms that may be required by the state or county. All background checks will be paid for by the families seeking to be licensed for the placement of children in their home. The family assessment process includes obtaining information in the following areas: Social HistoryBackground of all those living in the home, Current Status of the Family (Family System/Lifestyle), and Motivation for a Child. Also, Transracial and Transcultural Assessment, Child Safety and Well-Being, Children with Special Needs and/or Disabilities, Relationship with the WCDSS, Documentation of any previous emotional problems,mental illnesses, substance abuse issues, or relevant maritaUrelationship problems, medical records, and evaluation of each applicant's knowledge and ability to care for children. Each of the sections will seek to draw out indicators of strengths and weaknesses in the individuals and family system. Once the paperwork has been completed and filed with CFS,the social worker will travel to the family's home and conduct an interview. This interview will be completed in the proper sequence after the social worker has had the opportunity to review all paperwork. At this time, the CFS social worker and adults will agree upon when subsequent meetings will take place. Within each section and in the conversations between all family members and the social worker an effort will be made to reveal legal, medical and psychological issues/problems. Normally, none of the discovered issues/problems will be immediately taken as reason to terminate the Home Study process. If CFS discovers a valid reason or reasons that we would not 4 3/9/05 • Colorado Family Services A Division of Alpine Christian Services recommend the family for approval, appropriate steps will be taken with WCDSS to determine what the next step should be. In some court or other legal cases the Home Study will be completed anyway, in others it may not be necessary to continue. The procedure to follow in such cases will be mutually decided. If the study does not go forward during this initial phase, $250 will be paid by WCDSS to CFS for the time and effort provided up to that point. If the time involved in the Home Study exceed 3.5 hours of our time, WCDSS will pay $70/hour for the time spent by CFS. If a problem surfaces that does not necessarily prohibit the family from being approved, the adults may be informed that additional information must be obtained. These may include(but are not necessarily confined)to: seeking additional legal/court records and intensive interviewing with the appropriate family member(s). If it is helpful and agreed upon as necessary, psychological testing,such as the Minnesota Multiphasic Personality Inventory may be administered to family members to determine the appropriateness of placing children in the home. Information gathered through forms filled out by family members, conversations the social worker holds with family members and family systems, documents gained through requests to CBI, FBI, Social Services of any appropriate county, medical information, financial information and as well as other information will be used to complete the assessment. A narrative report will then be completed that summarizes and evaluates the information obtained and lists characteristics of the child(ren) for which the home is approved. Once the Home Study is completed, it will be sent to WCDSS. Our services are based on the client needs as well as the good of the community in providing out of home placements. The Colorado Children's Code and other similar considerations require the standards cited above as the needs and general welfare of children and adolescents are considered. State and federal legislation, state rules and regulations and county policies and procedures will guide the framework for all children that are served by this bid. 5 3/9/05 Colorado Family Services A Division of Alpine Christian Services MEASURABLE OUTCOMES Colorado Family Services (CFS) will provide the Weld County Department of Social Services(WCDSS)with the following information: The Home Study will contain the following information: Social History/Background of all those living in the home, Current Status of the Family (Family System/Lifestyle),Motivation for a Child, Transracial and Transcultural Assessment. Also,Child Safety and Well-Being, Children with Special Needs and/or Disabilities,Relationship with the WCDSS,Documentation of any previous emotional problems, mental illnesses, substance abuse issues, or relevant marital/relationship problems,medical records, and evaluation of each applicant's knowledge and ability to care for children. A narrative report will then be completed that summarizes and evaluates the information obtained and lists the characteristics of the child(ren) for which the home is approved. Information about each individual's family of origin, educational background, medical history, employment and financial history(as appropriate), history of and exposure to abuse and neglect (if any), conflict and problem resolution histories and other pertinent information needed to establish the appropriateness of the family to place children in the home. It is important to determine the family's reaction to the possibility of placing children in their home as they go through this process. If doubts are raised by the family or others regarding the appropriateness of the family to provide care for non-biological children; CFS will discuss this with WCDSS and provide information along with appropriate recommendations in order to make the best-informed decision that is possible. It is important at each stage of the assessment to determine the prospective family's motivation for wanting to have children placed in their home. We will make every effort to take these factors into account before making our final recommendations. The conclusion of the Home Study will clearly state a recommendation to place children or not place children in the home. The document will bring concise summaries of each part of the home study in relevance to the placement process. The recommendation will not have been covered with the family seeking to place children in their home. It is the responsibility of WCDSS to make the final decision regarding the suitability of placing children in the home. We plan on providing these services in order to place children more rapidly. CFS provides quality adoptive home studies in a timely manner and realizes that the number of acceptable studies submitted influences the quality of life for abused and neglected children. We will measure our success by the number of acceptable home studies divided by the number of qualified applicants referred to us. Suggestions will be made to improve the outcomes on an as needed basis.. 6 3/9/05 • Colorado Family Services A Division of Alpine Christian Services SERVICE OBJECTIVES The objective of Colorado Family Services(CFS) is to effectively work with a family seeking to place a child from Weld County Department of Social Services(WCDSS)in generating a Home Study. The Home Study is to concisely draw together all needed familial information to assist WCDSS in effectively accomplishing the following steps: A. Basic information of familial system B. Identification of the strengths and weaknesses of the familial system C. Identification of issues and problems that could necessitate stopping the placement process. D. The above information is to be given to the assigned caseworker with WCDHS. Consultations with that caseworker will be provided as needed. CFS will provide quality home studies at a reasonable cost. The cost per successful placement will be factored in as a component of what encompasses success. The number of qualified homes referred to us will also be taken into account. 7 3/9/05 • Colorado Family Services A Division of Alpine Christian Services WORKLOAD STANDARDS Colorado Family Services(CFS) will provide a minimum of 3 hours up to a maximum of 16 hours of service per week per family with a maximum of 4 families at any one time that may be seeking to place children in their home. CFS will have up to 3 individuals providing direct services, under the direction of the Clinical Supervisor, Dave Felker,LCSW. The maximum caseload per worker is 12 families on the caseload, including those referred from other county departments of social services. Treatment will not be provided to prospective foster or adoptive homes, as the purpose is to provide a Home Study to Weld County Department of Social Services. If treatment is needed before certification,this will be discussed with WCDSS. Each family engaged in a Home Study will require a minimum of 3 to a maximum of 12 hours of face-to-face and phone conversations. Services for each family will be engaged in across an average of 6-8 weeks. Service will also vary across the number of families engaged in the placement process each week from 0-4. Should the Agency become engaged in a set of 4 families it would require an avenge of 16 hours per week over an 8 week time period. It is possible that some overlap may occur, especially if WCDSS is under court-ordered time restrictions. In this case, it is possible that the time required would range up to 16 hours. Hours in excess of this amount will be dealt with as needed. Assessments and the development of narrative reports will normally be included in the suggested maximum of 16 hours/week. It is estimated that it will take between 8 and 15 hours of assessment and report writing to complete the Home Study. CFS will have a total of 4 individuals providing services, including the supervisor. The supervisor's maximum caseload is 36 (12 cases each for the 3 CFS Case Manger who provide direct services). At this time CFS has only 4 professionals, so there is only one supervisor. Travel time for each study will be from 15 minutes to a maximum of 3-V2 hours round trip from the office 1200 S. Wadsworth Blvd., Lakewood, Colorado. These additional times will normally occur once per family in the duration of the total time provided by CFS. All other face- to-face time will be held at 1200 S. Wadsworth Blvd., #300 Lakewood Colorado, or at a place designated and agreed upon by the relevant parties. This may include office space available in Aurora, southeast Denver or Colorado Springs. CFS has and will continue to provide adequate liability and workers' compensation insurance for all its employees, volunteers, and agents engaged in the performance as prescribed under the RFPBid. 8 3/9/05 • Colorado Family Services A Division of Alpine Christian Services STAFF QUALIFICATIONS Colorado Family Services(CFS) has four professionals who will provide the needed services: Charlotte Allen,MSW and Lynn Davis BSW will do most of the assessments and write the narrative. Together they have written dozens of home studies over a period of almost thirty years. Ron Fritsche,MA will provide administration, support, generate home studies when Charlotte and Lynn are full and serve as the main editor. Dave Felker, LCSW will supervise the provision of these services. All four of the individuals listed above meet the minimum qualifications in education and experience described in Staff Manual Volume VII, especially as it relates to writing Home Studies. We work for a private child placement agency and each person meets the necessary qualifications listed in Volume VII for the type of work we do. Combined,these four professionals have over sixty years of relevant experience in social work and child welfare. Copies of resumes and licensure are enclosed. CFS is licensed by the Colorado Department of Human Services(CDHS)as a child placement agency and has the ability to certify foster homes. In addition CDHS has approved CFS to write Home Studies. 9 3/9/05 RESUME David E. Felker,LCSW 5665 S.Bannock,#201 Littleton,CO 80120 720.283.7712 Licensure: Licensed Clinical Social Worker since 1989 (CO#989410) Work Experience: Colorado Family Services/Alpine Christian Services, 1200 S. Wadsworth, Suite 300,Lakewood 80232. (303)935-3199. Clinical Supervisor(9/02 to present)volunteer Executive Dir. -Ron Fritsche, MA Clinical Supervisor(11/94 to 5/01)part-time Executive Dir.- Ron Fritsche, MA * Participated in the startup of this agency as the clinical supervisor * Participate in weekly staffing. * Supervise ongoing clinical care of the foster children: * Actively work with CEO in conflict resolutions * Participate in conflict resolutions in foster homes * Interviewed potential foster parents * Developed policies and procedures with CEO. PacifiCare Behavioral Health, 7887 Bellview Ave., Suite 825 Englewood,CO 80111. (303)714-1000 Case Manager III(11/97 to 5/99) Supervisor-Jennifer Elpers, LCSW * Assessment and direction of care for individuals in various stages of crisis * Worked with the mental health professionals to access services within PBHI for their clients * Conferred with the treating professional(s)to sort out and reinforce the direction of care * Frequently sought by other case managers and customer service personnel to determine: which professionals would best fit the customers needs, what emergent services were needed, and to access psychological testing Merit Behavioral Care, Inc 7400 E Orchard Rd., Suite 2500, Englewood,CO 80110. (303)689-9230. Acute Care Crisis Clinician(8-95 to 11/97) Supervisor- Bob Eckles, LCSW MBHI's contract was not renewed by PacifiCare and I transitional to PacfiCare Behavioral Health,Inc. * Brief interventions in crises, assessing for level of care and/or inpatient management * Crisis intervention were done in: hospitals,emergency rooms, and doctor's offices * Focused on coordinating services to gain access to best help the client * As needed mental health holds were signed by this professional Mental Health Corporation of Denver, 1733 Vine, Denver,CO 80206. (303)377-4300. Psychotherapist(2-93 to 8-95) Supervisor-Faye Copenhaver, MS, RN * Conducted initial assessments for intake and assignment of appropriate services * Actively participated in the emergency services(72 hr holds) * Supervised unlicensed professionals as they sought licensing * Participated in problem solving within the intake and emergency department * Interacted with staff and psychiatrists in hospitals The Men's Center, 4293 Kipling,#190, Wheat Ridge, CO 80033. (303)420-7322 Psychotherapist(2-93 to 3-96)part-time Director- Gil Milburn-Westfall, Psy.D. * Intakes on perpetrators of domestic violence * Facilitated group treatment of domestic violence * Interacted with the county's person managing treatment of domestic violence perpetrators David Felker, LCSW, 709 Clarkson, Denver, CO. Sole Proprietor Psychotherapist(3-92 to 1-93) * Provided individual, family and group psychotherapy * Focused on family issues and domestic violence. • * Developed a group that worked through relational issues. Christian Counseling Services, 6909 Holly Cir., #360,Englewood,CO. 80111. (303)773-9791. Psychotherapist(3-90 to 2-92) Director/Owner-Jim Collins, Ed.D. Dr. Collins began to sell-off the agency, which prompted my seeking new employment * Delivered individual, and family psychotherapy * Dealt with multiple emergency mental health cases * Participated in the hospitalization of those clients who were an immanent danger to themselves or others CarePsychCenter, Humana Hospital, Mountain View&CompCare Inc. 9191 Grant St.,Thornton, CO 80229 (303)450-4500. The position ended as CarePsychCenter ceased connection with Humana Hospital, Mountain View. Case Manager(2-89 to 1-90) Program Director-Darrel Misgen, III, MA It Provided case management on an Acute Care psychiatric floor in a Med/Surg hospital. * Social assessments, individual and group therapy,discharge planning and transitional care. * Earned an LCSW during this time * Began doing emergency assessments and care as a licensed clinical social worker. Contemporary Learning,Inc., 11350 W. 72°°P1.,Arvada,CO 80005 (303)422-9283. Instructor(8-25-1989 and 9-29-1989) * Taught two 6.5 hour continuing education courses in these topic areas * Intimate domestic violence * Adolescent behavior: drug abuse and sexuality Brandon Center,Volunteers of America, 1865 Lorimer St., Denver, CO 80202 (303)620-9190. This position was taken to both gain income while seeking a clinical position and a great exposure to emergency work was gained that I had not yet seen. Counselor(5-88 to 2-89) Clinical Supervisor- Mark Annas, ACSW * Intake of victims of domestic violence *Group psychotherapy * Crisis calls taken during each work period Dallas Christian College, 2700 Christian Parkway, Dallas,Texas 75234. Associate Professor(1-86 to 6-86)part-time * Taught developmental psychology * Developed the semester course Magnolia Psychiatric Center, 1065 W. Magnolia, Fort Worth,TX 76104(817)926-5747. Left this agency because ex-wife wanted to return to Colorado Director of Social Services(8-85 to 1-88)Centers for Psychiatry and Psy holoy,g 3 300 00t Burgos,Joyce Fort Worth,TX 76116 (817)560-2256. Medical c Henan MD *Participated in the initial setup of the center for the urgent partial hospitalization care of children and adolescents * Conducted individual, family and group therapy * Produced social histories * Coordinated Medical Records and Utilization Review * Twice participated in the preparation of the facility for JCAHO audit and supervised staff. Clinical Assistant(3-86 to 11-86) Psychiatric Institute of Fort Worth, PO Box 69, Fort Worth,TX 76101 (817)335-4040. Medical Director-Heman Burgos,MD * Compiled clinical information for psychiatrists to guide treatment * Interacted with the treating psychiatrist to develop aftercare * Wrote reports to insurance companies * Assisted in utilization review. 2 David Felker,LCSW • Social Worker(8-85 to 8-86) Medical Director-Heman Burgos, MD * Case management * Individual, family and group therapy * Social histories * Hospital liaison. New Life Children's Home,Route 3 Box 274, Burleson,TX 76028. Social Worker(1-85 to 8-85) Medical Director-Heman Burgos, MD * Case management * Intake interviews * Interfacing with local and state social service agencies * Individual counseling and developed treatment plans Vernon Grounds Counseling Center, 8000 E. Girard Ave.,N.Tower, Suite 601, Denver, CO 80231(303)755-2880. Social Worker(8-84 to 12-84) * Individual and family therapy * Crisis intervention * Social histories Family Counseling Service,Youth for Christ, 1400 S. Emerson, Denver,CO 80210. Social Worker(6-82 to 8-84) Program Director-Luis Villarreal, LCSW * Individual and family therapy * Crisis intervention * Social histories * Interfaced with schools and government agencies,public relations * Designed new framework for Family Counseling Service Education: Graduate School of Social Work, University of Texas at Arlington, Box 9088, UTA Station, Arlington, TX 76019. *Twelve hours were earned toward a Ph.D. in clinical/research social work. (1986- 1987) * Focused on research and statistics Graduate School of Social Work,University of Denver,University Park,Denver, CO 80210. * MSW earned(1980- 1982) * Focused on the clinical track emphasis in family treatment. * Intern Supervisors: Thomas Cimack,MA, 1980-1981 & Luis Villareal, MSW 1981-1982. Nebraska Christian College, 1800 Syracuse,Norfolk, NE 68701. * BA in Pastoral Ministries earned(1975 - 1979) * Preached at area churches as needed * Directed 4 plays for the college Hospital Affiliation: University of Colorado Health Sciences Center, Campus Box C290,4200 E. 9th Ave., Denver, CO, 80262 (303)315-7565 & Fax(303)315-8494 Non-Medical Affiliate Staff(12/96 to present): Individual, Family&Group Therapy In association with Merit Behavioral Care Hospitalized individuals requiring immediate care for suicidal, homicidal, and grave disability Followed and participated in the individuals care during their brief hospitalization Participated in treatment planning sessions on the unit At discharge, aftercare was developed with the patient. David Felker,LCSW 3 Followed the individual's aftercare for at least a week to make sure the process was working. Porter Care Adventist Hospital, 2525 S. Downing St., Denver,CO 80210-5876 (303) 778-1955 Non-Medical Affiliate Staff(11/95 to 12/97): Individual, Family, &Group Therapy. In association with Merit Behavioral Care Hospitalized individuals requiring immediate care for suicidal,homicidal,and grave disability Followed and participated in the individuals care during their brief hospitalization Participated in treatment planning sessions on the unit At discharge, aftercare was developed with the patient. Followed the individual's aftercare for at least a week to make sure the process was working. Columbia HealthOne, 3398 S. Pearl St., Englewood, CO 80110 (303)788-8856 Non-Medical Affiliate Staff(10/95 to 12/97): Individual, Family, &Group Therapy. In association with Merit Behavioral Care Hospitalized individuals requiring immediate care for suicidal,homicidal, and grave disability Followed and participated in the individuals care during their brief hospitalization Participated in treatment planning sessions on the unit At discharge, aftercare was developed with the patient. Followed the individual's aftercare for at least a week to make sure the process was working West Pines Psychiatric Hospital, 3300 Lutheran Parkway, Arvada,CO 80033 (303)2394000. Non-Medical Affiliate Staff(6-89 9/91): Individual, Family&Group Therapy Hospitalized individuals from private practice needing immediate and emergent care Followed and participated in the individuals care during their brief hospitalization Participated in treatment planning sessions on the unit At discharge,this professional reassumed the treatment of the individual Psychiatric Institute of Fort Worth, PO Box 69, Fort Worth, TX 76101 (817)335-4040 Non-Medical Affiliate Staff(3-86 to 11-86): Individual, Family&Group Therapy In association with Magnolia Psychiatric Center Participated in group psychotherapy sessions Documentation of treatment process was done regularly Participated in treatment planning sessions on the unit David Felker,LCSW 4 (-- STATE OF COLORADO I Department of Regulatory Agencies Division of Registrations PRINTED ON SECURE PAPER CTIVE .I LICENSED CLINICAL SOCIAL WORKER 0302005 0610 07/012003 Number Issue Date Expires I David Ernest Felker 1. 1 1. LITTLETON,CO 80120 .I eUo: __. - Si nature LYNN DAVIS 3636 South Depew Street, #10• Lakewood, CO 80235 Evening 303 986-0754• Cell 303 229-3964 cyran99@netzero.com OBJECTIVE To obtain a social work position in child welfare so that I could use my expertise in human relations, business administration or social work. RELATED Colorado Family Services (A Child Placement Agency) EXPERIENCE Lakewood, Colorado, 1996-2004 Position: Program Director Duties • Case managed foster homes • Assisted with certifying foster parents • Designed and maintained web site(www.alpinechristianservice.org) • Composed monthly newsletters and company brochures • Composed and maintained policies and procedures • Taught core training and on-going training to foster parents and biological parents • Trainer for CPR and First Aid • Wrote home studies • Demonstrates excellent computer skills • Keeps files up to date RELATED Founder and Executive Director for Bibles for Jails Project, Inc., VOLUNTEER WORK Small group leader at Bear Valley Church. Approximately 20 people attend the group. I EXPERIENCE organize and lead the planning meetings EDUCATION Bachelor's Degree in Social Work, Emphasis in Child Welfare expected in May 2005 Metropolitan State College of Denver, Denver Colorado Major Grade Point Average: 4.0/4.0 Overall Grade Point Average: 3.9/4.0 Phi Alpha Social Work Honor Society Associates of Science Degree in Business Administration, Red Rocks Community College, Golden, CO Red Rocks Community College Honor Roll Three Year Diploma in Interior Design International Institute of Interior Design, Washington, D. C. Charlotte Allen, MSW P.O. Box 40443 Denver, CO 80204 Home Telephone: 303 388-0769 Cell Phone: 720 371-3269 EDUCATION: Master of Social Work (August 1992) University of South Carolina, College of Social Work Columbia, South Carolina B.A. Sociology/Applied Social Relations (December 1983) Eastern Connecticut State University Willimantic, Connecticut CLINICAL, CASE MANAGEMENT AND SUPERVISORY EXPERIENCE: 4/02 - present Placement Supervisor Colorado Family Services, Denver, Colorado Supervise this Child Placement Agency's Case Managers. Developed and maintained a quality assurance plan to comply with state regulations. Providing therapy to abused and neglected foster children. Work closely with the Executive Director to develop and implement diverse programs to serve children and families. 2101 -4/02 Placement Supervisor Creative Beginnings, Inc., Denver, Colorado Supervised Case Managers who work with special needs children placed in agency osier homes. Participated in case staffings, cowl hearings and Foster Care Reviews. completed new foster parent home studies. Worked with the Executive Director to develop and initiate quality assurance protocols. Provided child-centered therapy and family therapy tor children placed with the agency. 8/99 -7/00 Treatment Director- Charleston Division Specialized Alternatives for Families and Youth, Inc, Charleston, SC Responsible for the overall operation of the Charleston Division office of a national child placement agency. Supervised the clinical and case management services provided by four social workers and two support staff. Responsible for implementation of quality control measures, outcome achievement,treatment planning, staff and foster parent training, crisis resolution and the day-to day management of the division. Developed cooperative working network within the community and participated fully in corporate activities on a regional, state and national level. • Charlotte Allen, MSW Page 2 1997 -1999 Private Practice in Clinical Social Work and Adoptive Services Charleston, South Carolina Provided individual non-directive, child-centered play therapy and family education and therapy services. Completed adoption home studies and court reports, including consultation services in securing relinquishments. 6/98 -8/99 Program Coordinator Reid House Adoption Center, Charleston, South Carolina Supervised staff members in the development and implementation of adoptive recruitment initiatives and strategies. Responsible for monitoring compliance protocols and for reporting inter-agency and government grant information. 1996 -1998 Adoption Specialist South Carolina Department of Social Services, Charleston, SC Case management duties for special needs children in varied foster care programs, with a focus on achieving the permanency plan of adoption. Provided assessment, education and counseling for children and their perspective adoptive families. 1993 -1996 Social Worker Human Service Associates, Charleston, South Carolina Provided full clinical support and case management services to youth, foster care providers and prospective adoptive parents in therapeutic foster care setting. Trained, supervised and offered counseling support to therapeutic foster parents. 1993 Family Therapist Charter Hospital of Charleston, Charleston, South Carolina Completed psychosocial assessments, developed and implemented family therapy treatment plans for children and adolescent psychiatric patients in an in-patient environment 1986 - 1993 Victim Service Coordinator People Against Rape, Charleston, South Carolina Provided assessment, counseling and advocacy services to victims of sexual assault, adult survivors of childhood sexual abuse and their families. References provided upon request. • RON FRITSCHE 7499 South Teller Street • Littleton, Colorado 80128 . 303/972-7035 Education M.A. —University of Colorado, Counseling & Guidance, 1976 B.A. — Rockmont College, Music, 1970 Summary of Experience Executive Director - Colorado Family Services. I have worked in this field since 1992; starting CFS in 1994. The main office is located in Lakewood, with a satellite office in Colorado Springs. The Agency has quality homes and staff and is financially stable. As a private, Christian, non-profit agency we work with people to help them improve their family relationships and dynamics. Two years ago, we started Alpine Visiting Center in Lakewood. This is a place for families that are experiencing tough times to meet with each other. We provide monitored visits, therapeutic visits and child exchanges in addition to other similar services available. Prior to my present work in social services, I worked from1978 to 1994 in private vocational rehabilitation work in Minnesota and Colorado. In the process, I worked with hundreds of clients, and facilitated many as they returned to work. I developed vocational rehabilitation plans, worked with employers to find jobs for injured workers, and provided related services. In addition, I worked as the Director of Admissions for Rockmont College, Lakewood, Colorado; and Sioux Falls College, Sioux, South Dakota from 1972 to 1978. In this capacity I gained extensive experience in administration of non-profit institutions, which was helpful preparation for my present position. Other jobs have included psychological consultant for Head Start and Lecturer in Psychology at three colleges and universities. Assets Energetic... .articulate... .innovative...creative...entrepreneurial. I have the necessary resources to provide services for children, adolescents and adults. • Colorado Family Services A Division of Alpine Christian Services UNIT OF SERVICE RATE COMPUTATION The Unit of Service Rate Computation sheets are enclosed. This includes Program Budgets, Administrative Costs Non-Direct,Direct Services and Overhead Costs and Profits. Note Row L on the Program Budgets. It states that our costs for Home Studies is $1234.79 per study(episode). Note that the rate we are charging for new Home Studies is only$1200. In the event that a Home Study is not completed, a fee of$250/Home Study will be assessed for any work performed, up to and including 3.5 hours of work or less. If the number of hours we devote to preparing a Home Study exceeds 3.5 hours,WCDSS will be billed at the rate of $70/hour up to the maximum charge of$1200. Also,the fee for Home Study updates is $1200 for a revision of one that we have not previously done. If it were an update on one of our previous Home Studies provided to WCDSS, we will charge only$70/hour up to a maximum of $1000(this would be if there were major changes in the status of a home). 10 3/9/05 f m $ @m § ° ■ R § 82822 § ) aa % 3r }\ \ ■ © @ § 9k § k co § � ogrWr 2 $2 � R § O 1rt CD l - _ n 2 o ■ .18 % 8882 4 i \ kKk� Co aR § 4O 69 § ) k • @78 § goA f CO21- ooj � % \7k� k 69 CO twtk k § mm a ) a f aa CD -▪ ; WE _ . (5 § » . k ) / ' & a � ® ® n aaka ! § ) � (0822 = > #Q • � F00 co o2 o. kpka § } @ / FE ! .o8 w � 16 on a@ - e � E0Z2° 3 §O \ ) kk � FA >. _ f }03 E ± (§$ � 7t { \a] 0 ; � 0 —0 - 0 a' sto ® }/ ) tit4 [ } § §§ & � - - © ca « sfkegin a 82iaa #R- 2a3 (A § . < \2olf # ) #fkk \ $ 13 ; U fdfEaEfg 0 To a O.a k § ) 0f--< § k ) k aaidd d » = s u2 � 40°i } \ | 2k ! E I } / § , } 0 | CO /(o & { Q 7.• ® ■ ) & } !, b� PI CV § 2 § & )"5 k g K 0 ° & 2 0 J of a ) § k - c 2 2 a < 0 - \ 03• t E• f _ . \ ( a. 0 \ �k r. 0 GI O o. it ; ! 2 2 a Q. kz k 02 !` ^|1® | §|I eE § ! K 1 {/ ---- ! - e,„_ ; % 2228$$85 $ 8$ 8 !. ■!i« . ■E , | I| ___- � \§! .,'A'A ! 8888 8 2§ $ MR " ^ ligi - " - a sat** !■§ , a , !! 8885 $ $ $ O• f UU R;1:1--- - ` k ) ! ! ;0 ttgitg g,g a ;!& ■) |(k| i` m■!■ in "- '® ®!!K %t§ ---- ;_ ■!!§ |% O. 3.‹. .. !2! II!! `• ■ 111 f ` fl | ;;!- ! . , ! I $ kl \ k j ! ! \|3# 2 2 !|_# ; . #99@aa ##@ m ! ! e-=mz &§"` #s# !li ; wa;k[# ;a; § \ko2 M ! |■|■§;|;■■■ | E eka°sa $$ , g ? §#k§©k ! k©!!& rq i 5 20 ! f !■!■■■!!■K! amaR# %@# k E ■■§t©\a—.112 o . 1a82 a % ° ` - a ; f «#m#-■#m!m■ \ ! #aa\§\(##|| $ - ! )&k� ;.§&#} Ft a |, • . - - o mi ga |t § ! k ■;■K«■;gm■q 3 ! § | sss88$$8$$$ $ ` '”EnA#KRR# - Et ,aa,[s;«;a= § t | I ! { . # i ye} E / 1| . tEI { I! k| § s|\{ |k & 6 402\7|||m»m !!! Colorado Family Services A Division of Alpine Christian Services PROGRAM CAPACITY BY MONTH The maximum client capacity (Home Studies) per month necessary to support this program is 3, the minimum number of Home Studies isl per month. II 3/9/05 . I i.COf D,. CERTIFICATE OF LIABILITY INSURANCE ..._ __4 /'' '.i'Et ONLY AND SICATE CO NFE`S RSSNOED AS A RIGHTS MATTER THE INFORMATION CERTIFICATE • HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Gaeddert Insurance Agency iINSURERS AFFORDING COVERAGE LiQ�wge�19b6r�QZIp2 4 ,NsuaER A. Western World Ins ,RSVAED _ - Colorado Family Services INSURERS _ Alpine Christian Services INSURER C: 1200 So Wadsworth Bid Suite 300 iINSUREAO: , Lakewood, CO 80232 IINSUAER E: COVERAGES ` THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE F^P.l'4-i'"m'1,'�:T°r"'.'' ••_ I^ATED R • NOTWHSTANDING ANY REQUIREMENT,TERM OR CONDITION Of ANY CONTRACT OR OTHER DOCUMENT WITH F'•CS%r'-C' :'J +''r"'`�•' ,.L `- '•'I"`.'`'il MAY BE ISSUED OR I.AY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE.TERL''S.E.%CLUE 7r`S AND CONDITIONS Of SUCH POLICIES AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS _ -- ►OLICY ETFECfiVE•►oocv gY E.eina YI0N own i.i`_a TYPE OT,NtURANCE I 'DUCE NUIPPEA . DAM mr.1'DDIYYI DATI lk.'1)01YI 11R (ACIIOCGURRfrJCF i$ 1,000,000 _GENERAL.LIABILITY L X ,ccAim ciAL GENER;L V+•G•,,TY ! NTP0835062 10-29-04 110-29—OS •c,AE DAb7AC-E to^t 7 fro s 50.000 fOtED ExP(An,c^a pa,ta,i t 5 A QOQ,.. CLA�nt5 SAAUC % •occ'n I - :a ►E NSOI:A:a AUV wJURY i s 1,000.000 r--.�._.__ ^- --..-. -_•. , GENERAL AGGaf G+tTE '$ 2,000,000 •oROOUC'S.CO O,OP AOG,t inClr �L eE•S'i`3''•[V!7'T AP ,iF •A. cc I 1.000.000 y 0. '-='-'c• ;r CT Ix AVTOM06,LE UAOlI Il♦ C Acc.o v 6tNGLE ln-T!T E iSa u[Otroi ....--i.---- _-_� ANi AV.° • -.. . __ i i '.BOOBY INJURY E -. :A_1 OWNED AUTOP I I ` (PO'WWI) I SCHEDULED AUTOS I I I (I I soo' ,NA/RY ptnFD AUTOS ' ,(Par*WOW) t k I !NON OKNEO AUTOS j PAOPERTY DAMAGE I$ ,--L i i AUI()ONO-EA ACCIDENT_I t '.�.,LRAOL UAHtLITY • .• 1 I r- F„A0C $ •ANY AU1C ` I I OTTER THAN i , I AUTO ONLY AGG!f IA5ILfY _ EXCESS I I I AOOREGAIE _..'t • _. .. AGiE,7-,D': EK' SEATO. ZT.; T9a,Lx 1•, E% . wOhr ERc tOV'FNSa110•.A,.7 . '-..�-- _�___.. I f►'tZOYIR: lutRrtY E.l.E�:•'ACCIOiNT I E_L_DISEAS_E•E_A E_A!LOYEE 3ii : E.l DISEASE•PO.ICY DM.S 'OTHE A ' i , ptYCLU ADO0OIAY EMIORSf.MENT:6PI C.AlPROx'S+ORS • • • INTUn::,RtALETIE[ COt4CELLATIO.OE , Colorado Dept. of Hyman Services S nOULU[.':,W Yr't o.L L[c_RiL!,D►JL,�,(S fit G,:CF l l EO f[•Oct Ml[/a,4aTF 6771 T»t.143, T.': VW-W.: “.5:1,f I.Knt IKJLAYDA TO VEAL L-_ D[YS YarrrL• ?..,71,7L10 1Pt ct,T ', 'It .0 hr.I•I1,10 T7t LEIT.ti JT fA,IUA:TO O^_SC V.&1.4._ I. :.i'. a7 0.•X.,•. o' it.- .7.,or A. K,'::•two,:THE,KSU,E4 fIS ►C7'.TS Ot. .r :_t t'1f 1. 7 I L C-COE..'CC,nL•iJI,E1)04:ES' Colorado Family Services A Division of Alpine Christian Services ASSURANCE STATEMENT This is an assurance that all of the information contained in this bid is to the best of my belief true and contains no purposeful omissions. Ron Fritsche,MA,Executive Director May 11,2005 12 3/9/05 SUPPLEMENTAL NARRATIVE TO RFP: EXHIBIT B CONDITIONS ,1/44.00 COLORADO FAMILY SERVICES, INC. 0 NIAVir # A division of Alpine Christian Services,Inc. rr cf April 26, 2005 Dept' CO' 'Services Weis ociaC1e�icel on%t � Gloria Romansik Weld County Department of Social Services APR 2' 1 q 2005 c'y P.O. Box A Greeley, CO 80632 Dear Ms. Romansik, We received the bid approval letter for RFP 05005: Lifeskills and for RFP 006-00B: Home Studies and Relinquishment Counseling. We are excited at the opportunity to work as a vendor with your agency. In response to the Commission's request that our agency comply with specific conditions, we submit the following: RFP 05055: Lifeskills #1 Our staff will work closely with the visiting parent(s) and the custodial or foster parent(s) to coordinate the supervised/therapeutic visits. If evening or weekend appointments are necessary in order for the visits to take place, our staff will arrange appointments during those times. #2 We will use pre- and post tests to assess risk for measurable outcomes in order to increase the validity of the written reports. We are currently developing the assessment tools and will have them ready to use by June 1, 2005. #3 Any decrease in the level of supervision and/or service will ultimately be decided by the Weld County Case Worker who is managing the family's case. We will use a risk and safety assessment tool (currently under development), to guide our recommendations. #4 The duration of services generally runs from six to twelve months. Services will end sooner only at the direction of the Weld County Case Worker. RFP 006-00B: Home Studies #1 Incomplete home studies will be billed at an hourly rate of$70.00 per hour, not to exceed 3.5 hours. 1200 South Wadsworth Boulevard,Suite#300•Lakewood,Colorado 80232 Phone:303.935.3199•Fax: 303.935.3181 •Toll free:888.223.0786 e'^ For each additional adult residing in the home, other than the mother and father, $250.00 will be billed in addition to the regular home study fee. #2 We understand that completed home studies are due six weeks from the date of referral. Weld County DSS understands that there may be a delay in completion due to delays in the receipt of required paperwork from the family being studied. When this occurs, Colorado Family Services and Weld County DSS will discuss, and come to agreement on, the expected due date for the home study. We look forward to working with your staff and your families. Please contact me if there are further questions. Sincerely, Ron Fritsche, M.A. Executive Director Apr 26 05 12: 58p Lynn Davis 303 935-3181 p. 1 Or COLORADO FAMILY SERVICES, INC. fax To: Gloria Romansik S. a- - a Company or Agency: Weld Co. DSS Date: April 26, 2005 Fax Number: 970 346-7698 From: Ron Fritsche, M.A. Executive Director Number of Pages: including cover sheet Subject: Response to bid proposal Gloria— An original will follow by mail. Thank you for your assistance. Please call me if you have any further questions. THIS IS CONFIDENTIAL INFORMATION THAT IS FOR THE ABOVE-NAMED PERSON ONLY. IF THIS PERSON IS NOT AVAILABLE, OR IF THERE ARE ANY PROBLEMS WITH THIS TRANSMISSION, PLEASE CONTACT CHARLOTTE ALLEN IMMEDIATELY AT 303/935-3199 1200 South Wadsworth Boulevard, Suite 300• Lakewood, Colorado 80232• Phone:303/935-3199 Fax: 303/935-3181 • Toll free: 888/223-0786 • E-mail:kidsQalpinechrisfianservice.org Apr 26 05 12: 59p Lynn Davis 303 935-3181 p• e t COLORADO FAMILY SERVICES, INC. A division of Alpine Christian Services,Inc. ti April 26, 2005 Gloria Romansik Weld County Department of Social Services P.O. Box A Greeley, CO 80632 Dear Ms. Romansik, We received the bid approval letter for RFP 05005: Lifeskills and for RFP 006-00B: Home Studies and Relinquishment Counseling. We are excited at the opportunity to work as a vendor with your agency. In response to the Commission's request that our agency comply with specific conditions, we submit the following: RFP 05055: Lifeskills #1 Our staff will work closely with the visiting parent(s) and the custodial or foster parent(s) to coordinate the supervised/therapeutic visits. If evening or weekend appointments are necessary in order for the visits to take place, our staff will arrange appointments during those times. #2 We will use pre-and post tests to assess risk for measurable outcomes in order to increase the validity of the written reports. We are currently developing the assessment tools and will have them ready to use by June 1, 2005. #3 Any decrease in the level of supervision and/or service will ultimately be decided by the Weld County Case Worker who is managing the family's case. We will use a risk and safety assessment tool (currently under development), to guide our recommendations. #4 The duration of services generally runs from six to twelve months. Services will end sooner only at the direction of the Weld County Case Worker. RFP 006-00B: Home Studies #1 incomplete home studies will be billed at an hourly rate of$70.00 per hour, not to exceed 3.5 hours. 1200 South Wadsworth Boulevard,Suite#300•Lakewood,Colorado 80232 Phone:303.935.3199•Far 303.935.3181 •Toll free:888.223.0786 Rpr 26 05 12: 59p Lynn Davis aua U4b-aiai p• a For each additional adult residing in the home, other than the mother and father, $250.00 will be billed in addition to the regular home study fee. #2 We understand that completed home studies are due six weeks from the date of referral. Weld County DSS understands that there may be a delay in completion due to delays in the receipt of required paperwork from the family being studied. When this occurs, Colorado Family Services and Weld County DSS will discuss, and come to agreement on, the expected due date for the home study. We look forward to working with your staff and your families. Please contact me if there are further questions. Sincerely, Ron Fritsche, M.A. Executive Director DEPARTMENT OF SOCIAL SERVICES P.O. OXA GREELEY, CO. 80632 pit itWebsite:www.eo.weld.co.us o i Administration and Public Assistance(970)352-1551 Child Support(970)352-6933lir V J.tO L DO April 18,2005 Ron Fritsche,Executive Director Alpine Christian Services,Inc.,DBA Colorado Family Services 1200 S Wadsworth Blvd.,#300 Lakewood,CO 80232 Re: RFP 05005:I,ifeskills RFP 006-00B:Home Studies and Relinquishment Counseling Dear Mr.Fritschec The purpose of this letter is to outline the results of the Bid process for PY 2005-2006 and to request written confirmation from you by Wednesday,April 27,2005. A. Results of the Bid Process for PY 2005-200f • The Families,Youth and Children(FYC)Commission recommended approval of the bid,RFP 05005, Lifeskills for inclusion on our vendor list with the following conditions:Condition#1 is applicable to all Lifeskills providers,while Condition#2,#3,and#4 are specific to your program. Condition#1: All providers must define their capacity to do after-hours visitation: Condition#2 Throughout the fiscal year,the provider shall utilize pre and posttests to assess risk for measurable outcomes in order to increase the validity of written reports: Condition#3: Please clarify under the"Service Objectives"section of the bid how you will assess safety in order to decrease the level of service for the visit Condition#4: Discuss sentence one under"Measurable Outcomes"the statement"At the end, . . .for at least three months,or as agreed upon with the caseworker."The statement is unclear because the durations for most client services are from six to 12 months. • The Families,Youth and Children(FYC)Commission recommended approval of the bid,006-00B, Home Studies and Relinquishment Counseling for inclusion on our vendor list,attaching the conditions below for all Home Study and Relinquishment providers. Condition#1r The threshold for hours for an incomplete home study will be set at 3.5 hours. Additional home studies will be billed at a maximum of$250 per person. Page 2 Alpine Christian Services/Results of Bid Process 2005-2006 Condition#2: It has been mutually decided that the turnaround time for receipt of the completed home study by the Department is set at six weeks from the date of receipt of the referral. B. Required Response by FYC Bidders Concerning FYC Commission Conditions. 1. FYC Commission Conditions: All conditions will be incorporated as part of your Bid and Notification of Financial Assistance Award(NOFAA).If you do not accept the condition(s),you will not be authorized as a vendor unless the FYC Commission and the Weld County Department of Social Services accept your mitigating circumstances.If you do not accept the condition,you must provide in writing reasons why.A meeting will be arranged to discuss your response.Your response to the above conditions will be incorporated in the Bid and Notification of Financial Assistance Award. The Weld County Department of Social Services is requesting your written response to the FYC Commission's conditions.Please respond in writing to Gloria Romansik,Weld County Department of Social Services,P.O.Box A,Greeley,CO, 80632,by Wednesday,April 27,2005,close of business. If you have questions concerning the above,please call Gloria Romansik at 352.1551,extension 6230. Sincerely, ego cc Juan Lopez,Chair,FYC Commission Gloria Romansik,Social Services Administra Weld County Department of Social Services Notification of Financial Assistance Award for Child Welfare Regular Administration Funds Type of Action Contract Award No. X Initial Award 05-CPS-32 Revision (RFP-006-00B) Contract Award Period Name and Address of Contractor Beginning 06/01/2005 and Jubilee Retreat Center-Lori Kochevar,LLC. Ending 05/31/2006 Home Studies,Updates,Relinquishment Counseling 810 12 Street Greeley,CO 80631 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Assistance Home study format is based on testing,3 joint Award is based upon your Request for Proposal(RFP). interviews with a couple, 1 individual interview with The RFP specifies the scope of services and conditions of each adult member in household and an award. Except where it is in conflict with this NOFAA in age/developmentally appropriate interview with all which case the NOFAA governs,the RFP upon which this children residing in the home.For single applicants,a award is based is an integral part of the action. minimum of 3 interviews will be required.Home Special conditions study updates as requested by foster parent 1) Reimbursement for the Unit of Service will be based on a coordinators.Relinquishment Counseling to follow rate per home study;home study update,and State outline.Monthly average capacity is 6 home relinquishment counseling session. studies and 1 unit relinquishment counseling.The 2) Reimbursement requests must be an original with an average stay in the program is 6 weeks, average hours original signature from the provider and/or designee. per week in the program is 4.Bilingual-bicultural 3) Reimbursements requests must include the date the home services available through current staff. study,update, or relinquishment counseling was completed. Cost Per Unit of Service The request must reflect the referral number assigned to Rate per Study each home study,the amount billed for each home study, Full Home Study* $988.17 and the month the service was provided. Updated Home Study $562.87 4) Payment will only be remitted on referrals made by Additional Adult-Home Study $250.00 the Weld County Department of Social Services. Court Testimony $86.00 5) Requests for payment must be an original submitted to the *Referrals will be for Foster Parent Home Studies Weld County Department of Social Services by the end of only. the 25th calendar day following the end of the month of • The threshold for hours for an incomplete home study service.The provider must submit requests for payment on will be set at 3.5 hours. forms approved by Weld County Department of Social • Turnaround time for receipt of the completed home Services. study is 6 weeks from the date of receipt of the 6) The Contractor will notify the Department of any changes referral. in staff at the time of the change. • Additional home studies will be billed at a maximum of$250 per person. Enclosures: X Signed RFP:Exhibit A X Supplemental Narrative to RFP: Exhibit B _ Recommendation(s) X Conditions of Approval ByprovaJs;n.y ). ^i By ProBr qt �Jal l/C ( William H. Jerke, Chair Jud-{/A.Griego,Director Board of Weld County Commissioners Welt-Coup D4artment of Social Services Date: JUN 0 6 2005 Date: 2� 0S" mss - ( & c° A SIGNED RFP: EXHIBIT A 1 Bid No. 002-05 RFP-FYC-006-00B Attached A • HOME STUDY,UPDATE, & RELINQUISHMENT COUNSELING BID PROPOSAL AND REQUEST FOR CONTINUATION OF AWARD UNDER CHILD WELFARE ADMINISTRATION FUNDING 2005-2006 BID PROPOSAL APPLICATION PROGRAM FUNDS YEAR 2005-2006 //�� /��Bidd 002-05 RFP-FYC�-,006 J-00B , NAME OF AGENCY: (dJJ)L12az cant, Q ADDRESS: 210 1 raU+1' PHONE: 1 �74 s a 927.3 CONTACT PERSON: i.42) Y>0GAO, 'vl TITLE: 0 G/' /L, DESCRIPTION OF HOME STUDY PROGRAM CATEGORY: Adoption,Foster Care,and Expedited Permanency Planning Home Studies in compliance with the uniform format utilized by the State of Colorado Department of Human Services since October 1, 1999(Attached A). 12-Month approximate Project Dates: 12-month contract with actual time lines of: Start June 1,2005 • Start End May 31,2006 (� End TITL F PROJECT:: 42,Yrl) Studs T ccp rri 3' I I [JCS ao-).(� Nam and Signature of Person Preparing Document Date Name and Signature Chief Administrative Officer Applicant Agency Date MANDATORY PROPOSAL REOUIREMENTS For new and renewal bids,please initial to indicate that the following required sections are included in this Proposal for Bid. For renewal bids,please indicate which of the required sections have not changed from Program Year 2004-2005 to Program Year 2005-2006. o5C Project Description Indicates No Change from 2004-2005 At. Sample Home Study ... 1-Project Description Xi? Target/Eligibility Populations Sample Home Study General Indicates Target/Eligibility Populations tC,Cultural/Eligibility Populations General Types of services provided &C-eultura]Eligibility Populations hC Measurable Outcomes Types of services provided Service Objectives Measurable Outcomes Workload Standards ervice Objectives A' Staff Qualifications Workload Standards _ StaffQualifications C//, IT LM SA''`P SAW ;�. Unit of Service Rate Computation CI""�' Program Capacity per Month AK Unit of Service Rate Computation Certificate of Insurance gc-Program Capacity per Month Page 23 of 35 INVITATION TO BID DATE:February 16, 2005 Bid No. 002-05 RFP FYC 006-00B 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 006-008) for: Adoption, Foster Care, and Expedited Permanency Planning Home Studies,and Relinquishment Counseling Deadline: March 11, 2005,Friday, 10:00 a.m. The Families,Youth and Children Commission, an advisory commission to the Weld County Department of Social Services, announces that competing applications will be accepted for approved vendors pursuant to the Board of Weld County Commissioners' authority pursuant to Colorado Statute and the Weld County Home Rule Charter. The Families,Youth and Children Commission wishes to approve services targeted to run from June 1, 2005,through May 31,2006, at specific rates for home studies,home study updates, and relinquishment counseling services. The County will authorize approved vendors and rates for services only. This program announcement consists of five parts, as follows: PART A...Administrative Information PART D...Bidder Response Format PART B...Background, Overview and Goals PART E...Bid Evaluation Process PART C...Statement of Work Delivery Date (After receipt of order) BID MUST BE SIGNED IN INK 1--CA'; !c(rj,&Lo.r MS tPC— TYPED OR PRINTED SIGNATURE VENDOR Qttk b lQ4i ja KMec M UL ame) a Han$$written Signature By Authorized Officer or Agent of "Vender ADDRESS 2/0 ( a Sit- tt !TILE O J2F& Gl 13 66 3) DATE PHONE# O/7 O ."is t — R 73 The above bid is subject to Terms and Conditions as attached hereto and incorporated. Marna 1 of 2c gaCkf Bid Number 002-05(RFP-FYC 006-00C) Attached A Date of Meeting(s)with Social Services Division Supervisor. Comments by SSD Supervisor: a,4 4z ; C. cciiet ,start-fre 4.2 949#4 :r olarde) c--- N 6ihaAnd Signature of SSD Date Page 25 of 34 Staff Qualifications A. All the providers exceed the minimum qualifications needed for both education and experience. All providers have their Master's Degree in Counseling or Registered Nursing Degree. In addition, the therapists have between 8-20 years a piece providing services for families. See Resumes in Appendix B. B. Staff available for this project consists of five experienced specialists that have a s'_ii'tar core value of clinical excellence. We believe in providing strength- based, services that empower the families we serve. Another strength of our staff is our diverse areas of specialties. • Lori Kochevar a licensed professional counselor has extensive experience and training in providing services and supervision using the family preservation model. She has been working in the field for over twenty years and has been in child welfare for the last ten of those. She has specialized training in substance abuse, attachment and bonding, trauma, grief, and domestic violence. In the last fifteen years Lori has developed and facilitated multiple training's that emphasize experiential learning opportunities. Many of these training's were developed specifically for foster parents, while others were created for families, school personnel, and service providers across the state. • Heidi Friese has a master's degree that includes specialization in public child welfare, as part of government efforts to improve the foster care system, and trauma counseling. She has over ten years of experience in child welfare, as well as over fifteen years experience working with children. As a caseworker in Milwaukee County's child welfare system, Heidi worked in the foster care (carrying foster child and birth parent cases), family reunification (intensive service provision to foster children and birth parents to reunify birth families), and adoption units. In recent years, she has been the Child Placement Supervisor for the Institute for Attachment and Child Development, specializes in the treatment of foster children with attachment issues using Love and Logic. Heidi has also provided outpatient and intensive therapy, as well as in- home therapy, including Wraparound. • Bill George has a master's degree in counseling from the University of Northern Colorado. He has over twenty years of experience in the field and is certified in many areas of practice. He has specialized training in individual and group services as a member of a psychiatric crisis team, drug and alcohol counselor, medical social worker, and vocational rehabilitation specialist. He is a Certified Alcohol and Drug Counselor in the State of Colorado, level III 15 and an Expert Witness. Most recently he became certified as a Disability Management Specialist and has provided evaluations, vocational testing and assessments for the Department of Veteran Affairs. He is currently taking additional training on therapeutic attachment and bonding issues. • Ellenor Dominguez has a master's degree in counseling and is bilingual in Spanish. She has eight years of experience with Weld County Social Services, and is well respected by her colleagues. Last year, she received the prestigious title of caseworker of the year. She received her Master's degree from the University of Northern Colorado. Over the last ten years Ellenor, has worked as a caseworker III, Case aid, Supervisor, and lead Counselor at a Women's Place, and Migrant Outreach Coordinator. She has extensive experience with mono-lingual families in the community and community resources. She is currently taking additional training on therapeutic attachment and bonding issues. • Lisa Downs is a licensed professional counselor and a registered play therapist. She received her Master's degree from the University of Northern Colorado. She has experience working with children and families in both the mental health and school setting. Her expertises are working with families that have been affected by drug or alcohol addiction, play therapy, and women's issues. Along with being skilled trainers, due to our extensive background as caseworkers and therapists we are knowledgeable of the systems (i.e... biological families, social services, mental health services, legal services, etc...) that foster parents need to interface with as advocates for the children that are placed with them. • 16 Appendix B LORI KOCHEVAR, M.S., L.P.C. 2118 19th Avenue Greeley, CO 80631 (970) 353-6568 EDUCATION: University of Southern Mississippi, M.S. Counseling Psychology, Cumulative GPA 3.8 - - University of Northern Colorado, B.A. Pre-Professional Psychology, Cumulative GPA 3.5 PROFESSIONAL EXPERIENCE: 5/95 - PRIVATE PRACTICE THERAPIST, STRETCHING OUR STRENGTHS Serve others through a creative process that stretches participants strengths and provides an environment for authentic healing. Facilitate opportunity for individuals, families, and groups to participate in body centered spiritually based psychotherapy. Interpersonal dynamic facilitation for community development, team building, stress reduction, anger management, parenting, and personal effectiveness are available. 5/95 - 9/96 DIRECTOR, VALLEY COMMUNITY FUND Serve and manage Board of Directors to strengthen the internal structure of the agency to increase fundraising capabilities. Responsibilities include: access state, government, and businesses to participate in payroll deduction, grant writing, marketing, coordination of special events and community trainings, and disbursement of funds. 5/'92 - 5/95 FAMILY PRESERVATION SPECIALIST, SAN LUIS VALLEY MENTAL HEALTH CENTER Provide intensive home-based treatment for famUies that are at risk of having youth removed from the home. Intervention emphasizing strength-based approaches, including psychotherapy, skill bulking (parenting, communication, anger control, problem-solving, etc.), educational support, and assistance in obtaining support for concrete needs. Management duties: public relations, supervise students, hire staff, and provide training for staff and community. 3/92 - 5/95 WILDERNESS THERAPIST, SAN LUIS VALLEY MENTAL HEALTH CENTER Provide intensive tent-based treatment for youth ages 8-17. Facilitate opportunities for young people to learn skills in leadership, team work, decision making, dealing with stress, facing fears, and building responsibility. Use outdoor challenge course experience such as rafting, badcpadung, mountaineering, and rock climbing to provide skills based learning opportunities. 5/89 - 5/91 CONSULTANT, GRADUATE ASSISTANT, UNIVERSITY AFFLILIATED PROGRAM, UNIVERISTY OF SOUTHERN • - MISSISSIPPI Participating in an interdisciplinary team that provides assistance for community-based child care centers who serve children with disabilities and their families. Responsibilities include: Grant writing, development and presentation of awareness training, assessment of teaming.environment and handicapping conditions. Provide consultation for teachers and parents using a coaching model, skills- based training, and evaluation of improvement. 1/89 - 5/89 TEACHING ASSISTANT, UNIVERSITY OF NORTHERN COLORADO Teach skills for report writing and use of computer programs, PC Write and Labstat. Teach weekly labs and grade lab reports. 4/86 - 9/89 RECREATION SUPERVISION, BOYS AND GIRLS CLUB OF GREELEY Providing guidance and support for at-risk youth, fundraising, program planning, facilitate teenage drug and pregnancy prevention program, family and community involvement, organization and supervision of field , and participation in local and national staff development INVOLVEMENT: FOUNDER, BOARD MEMBER, BOYS AND GIRLS CLUB OF • ALAMOSA Spearhead community organization to obtain Boys and Girls Club. Orsianize fundraising, board development, marketing, and regional and national networking. MEMBER, SAN LUIS VALLEY COALITION FOR YOUTH SERVICES . Member of steering committee and chairperson of the multicultural task force. • CONFERENCES: SPIRITUAL 2000 Hakomi Training 11/05/99 Mariane Williamson - Enchanted Love 10/22-24/99 Shapeshiifting: Shamanic Trarformation 1999 Women Who Run With the Wolves - Jungian 10/5-17/99 Phoenix Rising: Yoga Therapy Levels 1 and 2 09/24-26/99 Energy Medicine - Donna Eden 08/19/99 James Redfield -The Celestine Prophecy 08/14/99 Ruth and Naomi - Women's Partnerships • 04/24/99 Substanability and Spirituality 04/23/99 lime, Money and the Meaning of Life 03/19/99 Gandhi's Search for Meaning 1023/98 Spirituality and Religion 06/06/98 Tying it all Together- Biblical Overview 03/28/99 Transformation- Job of the Old Testament 03/06/98 Matthew Fox- Spirituality of Compassion 11/6-9/97 Common Boundaries: Joy of Creation 07/10-13/97 Body and Soul Conference 04/26/97 Day of Prayer 04/19/97 Contemplative Living 1997 Catholic Biblical School 11/6-10/96 Common Boundaries: Intentional Living 1993-1995 Creative Process COMMUNITY DEVELOPMENT 1/7-8/00 Foster Parent Core Training 10/30/99 Matrix Leadership 10/21-22/96 Working as Partners with Managed Care 04/02-05/95 Leadership for Executive Directors 03/29/95 - Fundsaving Workshop Fall 1995 Leading Edge/Business 02/09-13/95 Challenge by Choice: Ropes Course 05/20-22/94 Organizational Conflict Management: CSAP 05/06/94 CPR and First Aid Certification 02/01-/4/94 Multicultural Conference 11/30/93 Exploring Multiculturalism Within 10/13/93 Conflict Mediation Training 08/11-14/92 Multicultural Training: CSAP 05/12-26/89 Women as Leaders FAMILIES 06/4-6/99 Passionate Marriage • 10/15-19/98 Marriage and Family Conference 05/16-17/98 Relationship Enhancement 12/08-9/97 Family Group Decision Making 10/06/97 Family Group Decision Making 05/2-3/97 Marriage and Family 9/15-16/94 Family Preservation - Supervision 07/20/94 Jim Fay Parenting 07/13/94 Family Sculpting 4/26-27/93 Family Sculpting Spring 1993 Redirecting Chidren's Behavior 02/06/93 Meaningful Family Comunication 07/070-8/92 Active Parenting 03/16-19/92 Famiy Preservation Training 09/20-21/90 Parents and Professionals United CHILDREN AND ADOLESCENTS 09/10/99 Testifying in Child Abuse Caes 07/12/99 Firestarting - Prevention and Intervention 01/29/99 Play Therapy 12/11/98 Attachment Disorders 10/18/97 Art Therapy for Children 04/04/97 Attachment Disorder 10/11-13/96 International Play Therapy Conference 07/8-9/94 Play Therapy 09/26/93 Traumatic Stress Reactins in Children 03/11-14/93 Child Adolescent Conference Spring 1993 Play Therapy Class 02/16-17/91 Strategic Therapy for Adolescence 10/11-13/90 C.H.A.D.D. Conference on ADHD 05/30-6/1/90 Early Intervention 12/05/89 Play Assessment TRAUMA AND GRIEF REACTIONS - 12/03/99 Jurisprudence Workshop 06/25/99 Molecule of Emotions 04/09/99 Depression and Anxiety 05/19/97 Cuitixal Grief 09/14-16/95- Annual Hospice Conference 04/14/94 Empowering Resistive Client II 06/09/93 Empowering Resistive Clients 09/17-.19/92 Annual Mental Health Conference SUBSTANCE ABUSE AND DOMESTIC VIOLENCE 10/14/98 Working with Aggression in group Therapy 09/23/97 Domestuc Violence 09/17/97 Substsance Abuse 05/16-17/94 FPS - Motivational Interviewing - Jill Kenney 05/3-14/94 Teen Baseline TOF - Drug Prevention 10/5-9/93 Baseline TOF- Drug Prevention 04/23-24/92 Domestic Violence Conference • San Luis Valley Comprehensive Community Mental Health Center CONIC OFFICE ADMIN AND CLINIC OFFICE 1015 FOURTH STREET CLINIC OFFICE 522 ALAMOSA AVENUE ALAMOSA,CO 81101 402 FOURTH STREET ALAMOSA.CO 81101 TDD 719-589-3671 MONTE VISTA, CO 81 144 719-589-3673 719-589-3671 719-852-5186 FAX 719-589-1521 FAX 719-589-9136 FAX 719-852-3043 August 6, 1996 26041 Woodland Ave. Esparto, CA 95627 Dear Colleagues: I have worked very closely with Lori in the Family Preservation program. Lori has been a wonderful asset to this program and to all her colleagues at Mental Health. More importantly, her dedicated and skillful service to our clients has greatly benefitted many SLV families. Lori's skills are numerous. She is well organized and very conscientious. She has excellent speaking and writing skills. Her forte is her ability to work with all kinds of people, and work through difficult interpersonal situations. Lori has consistently impressed me with her resilience and problem solving skills in dealing with some of the most chaotic and resistive families. In working with these families, Lori has also come to know the needs of SLV families and has become an expert in resources that are available throughout the Valley. She has worked in every county in the Valley. Despite carrying a full caseload of challenging cases, Lori took "time off" for herself by making solid contributions to other programs. I was amazed to see Lori doing good work for such things as the Mental Health Center's Wilderness Program, the Boys and Girls Club of Alamosa, the Multicultural Awareness Committee and the Drug and Alcohol Baseline program. She attended trainings in all of these programs and then consistently returned to share her expertise and take responsible roles in each, and handling the mix of responsibilities effectively. Lori has a strong philosophical commitment to the empowerment of the oppressed. Lori will direct people toward healthy, fun relationships. Lori will earn the confidence of the people with whom she works: staff, clients, and community leaders. I highly recommend her. Sincerely, ''AA Atfl Offering Comprehensive Mental Health Care for The Entire Son Luis Volley Heidi S. Friese, LCSW Experience Kinder Kounseling September 2003 to present Therapist, Owner Providing therapy to children, adolescents, adults, couples, and families. Specializing in work with adoption, trauma, and Attachment Disorder. Institute for Attachment and Child Development August 2002 to present Therapist, Training Coordinator Child Placement Supervisor, Clinical Services Manager Providing outpatient and intensive therapy to children and families. Coordinate workshops, conferences, and Therapist Training Program both on site as well as throughout the country. Recruitment, initial licensure, training, and maintenance of licensure for agency therapeutic foster homes. Responding to initial and ongoing queries from potential clients and referral sources, assessment of potential clients, as well as coordination of intake process. Executive administrative responsibility when Clinical and Executive Directors absent. Specializing in work with Attachment Disorder. Child and Family Therapeutic Systems November 1997 to August 2002 Child and Family Therapist Provide outpatient and in-home therapy to individuals, couples, families, and groups. Specializing in work with children, teenagers, trauma, and attachment problems. Children's Service Society of Wisconsin April 2000 to October 2000 Second team member Provide in-home therapy for children, teenagers, and their families. Client referrals primarily received form public child welfare system. Milwaukee County Department of Human Services, Youth Services Division March 1995 to April 2000 Human Service Worker, Child Welfare Experienced in Adoption, Foster Care, and Family Reunification. Assess and supervise family situations to protect the best interest of children. References available upon request Heidi S. Friese, LCSW (nee Wilmanns) 901 Granite Court, Longmont, Colorado 80501 home 303-684-6847; cell 303-921-2173 Objective To obtain a position as a therapist, utilizing my skills and knowledge to promote personal growth of others. Professional Qualifications Clinical Social Worker license granted by the State of Colorado, Department of Regulatory Agencies, on May 30, 2003. Clinical Social Worker license granted by the State of Wisconsin, Department of Regulation and Licensing, on February 27, 2003. Advanced Practice Social Worker certification granted by the State of Wisconsin, Department of Regulation and Licensing, on December 17, 1999. Masters of Social Work conferred on August 9, 1997, by the University of Wisconsin—Milwaukee. Completed the Trauma Counseling Program, Child Welfare Training Program, Marriage and Family Therapy curriculum, field experience in public child welfare. Initiation into Upsilon Chapter of Alpha Delta Mu National Social Work Honor Society on December 8, 1996. Bachelor of Arts in Psychology conferred in May of 1991 by the University of Wisconsin—Milwaukee. Maintain a Strengths Perspective Approach with colleagues and clients. Communicate eloquently with professionals and clients, including those resistant to intervention. Proficient in handling the complexities of case management, including multifaceted ongoing assessments, problem resolution, crisis intervention, court appearances, knowledge of state statutes, case documentation, visitation scheduling, and referrals and coordination of services. Strong background in childcare, complete with lapsed state certification. Consistently maintain a professional demeanor. Member of the National Association of Social Workers. References Beverly Baker White, M.A., LPC Clinical Supervisor and colleague through the Institute for Attachment and Child Development 8094 South Trinchera Peak Littleton, Colorado 80127 303-9-4-3012 Forrest Lien, LCSW Clinical Director and colleague at the Institute for Attachment and Child Development 5911 South Middlefield Road, #102 Littleton, Colorado 80123 303-904-0038 Jennifer Lant, MSW Coworker with the Milwaukee County Department of Human Services, Child Welfare Division 10267 Glassboro Court Las Vegas, Nevada 89123 702-205-9538 Lawrence Gross, MSW Coworker with the Milwaukee County Department of Human Services, Child Welfare Division 18685 Centennial Street Hesperia, California 92345 760-617-7831 Paul Krepel, CICSW, MFT Clinical Supervisor and Owner of Child and Family Therapeutic Systems 4848 South 76 Street Milwaukee, Wisconsin 53220 414-325-7741 William(Bill)E.George 4909 30th St. Greeley, CO 80634 Home Ph. (970)339-9328 Cell Ph. (970)371-2220 E-mail bgeorgel6©comcastnet O6lective To work as a health care professional where I can utilize my skills in counseling, case management, and health care coordination. Relevant Skills Clinical Knowledge& Practice: • Unique ability to communicate with people in stressful situations, establish trust, and facilitate positive change. • Have counseled adults in both outpatient and inpatient settings. Over six years of experience in group and individual therapy. Experience in mental health and substance abuse assessments with adults and adolescents. Identification of appropriate diagnoses using ICD-9 and DSM IV-TR. • Over ten years of case management experience coordinating patient focused outcomes. Excellent problem resolution skills through face to face intervention or telephone. The ability to gather and synthesize sensitive information from people with varied backgrounds. • Experience in home visits to clients for vocational/medial disability evaluations. • Expertise in medical and psychiatric utilization review. A unique blend of clinical background including mental health, substance abuse, vocational rehabilitation counseling or consultation and disability management. Administrative&Organizational Strengths: • In a director-level position, made policy decisions, delegated work, handled problems, oversaw budget,and represented interests for a non-profit organization. • Proven skills in classifying and organizing information, allowing for quick access to needed facts and resources. • Implemented new treatment curriculum for a non-profit agency. • Possess broad computer background in database administration, Microsoft Word and Internet. Background in Employee Relations&Training: • Completed graduate-level training in counselingfinterpersonal communications. • For more than five years, have provided employee relations counseling and support to team members. • Skilled in creating a confidential environment, sharing company-policy information, coaching employees on options, and operating within established guidelines. • Provided ongoing training and support to team members regarding procedures, policies, and computer tools. • Have completed extensive course work addressing personality and leaming styles, and the development of effective training methods and curricula. Skills in Management&Supervision: • Supervised seven highly-skilled case management professionals, providing guidance, monitoring work quality and deadlines, and overseeing reporting and administrative activities. • Supervised three counselors and provided clinical supervision of two hundred clients for an outpatient alcohol/drug treatment program. • Have consistently received positive feedback for managerial and administrative work performed. Comment from previous supervisor. "He is not afraid to face a challenge, and works as a team player. He had a good grasp on the business end, and follows up every step of the way." • Excellent oral/written communication abilities, especially for status reports, business correspondence,etc. Comments from a provider.'He was kind, direct,thorough and respectful? Benefits Knowledge: • Knowledge of COBRA, HIPAA,Workers'Compensation, labor acts, and discrimination policies. • Extensive background in benefits claims handling, including serving as a liaison between the plan participant, the insurance provider, and other related parties. • Highly accomplished at managing enormous amounts of data: Was responsible for knowing the details for more than 30 different benefit insurance plans, as well as monitoring eligibility status for thousands of plan participants. • Accomplished negotiator. Coordinated treatment with various providers, insurance companies. Arranged costs and pricing with a range of service providers, including home health care, skilled nursing facilities, rehabilitation centers, and hospitals. Work History: 2003- Present Vocational/Medical Genex-Denver, CO Case Manager 2001 -2002 Medical Case Manager Sedgwick CMS-Denver, CO 2000-2001 Clinical Director Mile High Council on Alcoholism and Drug Abuse- 1994-2001 On-call Therapist Longmont United Hospital-Longmont, CO 1994-2000 Health Management Zenith Administrators-Westminster, CO Coordinator 1987-1993 Supervisor Intracorp-Denver, CO (Also held positions as Psychiatric Case Coordinator and Rehabilitation Specialist at Intracorp) 1983- 1987 Therapist Island Grove Regional Treatment Center- Greeley, CO t980-1983 Psychiatric Team Assistant North Colorado Medical Center-Greeley, CO Education: University of Northern Colorado, MA, Psychology, Counseling&Guidance with emphasis in Agency Counseling, 1984 University of Northem Colorado, B.A., Psychology, 1980 Certifications: Certified Case Manager, Certified Disability Management Specialist Alcohol and Drug Counselor,Level III PROFESSIONAL AND PERSONAL REFERENCES William E. George 4909 30th St. Greeley, Colorado 80634 Home (970)339-9328 Work(970)339-3427 Professional References: Ellen Goren,Vocational Rehabilitation Counselor 16739 E. Arkansas Dr. Aurora, CO 80017 (303) 369-8884 Mary Anderson, Previous Supervisor 19053 E. Low Dr. Aurora, CO 80015 (303) 287-3748 Joan Lee, Previous Supervisor 915 W. 44th Loveland, CO 80538 (970)635-9679 Cathleen Cundell, Previous Supervisor Longmont United Hospital-ATS 1331 Linden St. Longmont, Colorado 80501 (303) 651-5388 DiAnn Kalvels, Previous Supervisor 1090 Birch St. Broomfield,CO 80020 (303)469-9917 Anne Hazelton,MD,MSPH 11453 E. Orchard Place Englewood, CO 80111 (303) 587-7879 Personal References: Jackie Moore-Davis 4464 Pioneer Dr. Greeley, Colorado 80634 (970) 381-3559 ELLENOR DOMINGUEZ 720 26 Avenue,Greeley, Colorado 80634 (970)392-2653 OBJECTIVE Seeking a challenging and rewarding position performing Home Studies and utilizing my bi-lingual educational background to assist clients in the bonding process with the children. OVERVIEW OF CAPABILITIES Offering a Masters degree and more than nine years of experience on positions requiring the following abilities: Interpersonal Relationships Crisis Intervention Individual and Group Counseling Report Preparation Advocacy Assessment Understand and work closely with community referral agencies Establish and maintain productive rapport with people of all Backgrounds and socioeconomic levels Communicate clearly and concisely; speak fluent Spanish Poscecs sound judgment and excellent decision-making skills Work efficiently and under pressure; good coping skills • EDUCATION UNIVERSITY OF NORTHERN COLORADO, Greeley, CO • Master of Arts Degree in Rehabilitation Counseling(1995) Bachelor of Arts Degree in Psychology(1990) EMPLOYMENT SOCIAL SERVICES, Greeley,CO 1/98-1/05 Caseworker III Create client treatment plans and monitor client progress Visit clients monthly to ensure safety and well being of children • Work closely with attorneys and the legal community Document client progress and distribute reports to appropriate Individuals ' Utilize the TRAILS computer system to document case information accurately SOCIAL SERVICES, Greeley,CO 1/98- 7/99 Case Service Aide Supervise child/parent visitations to ensure appropriate and safe Environment for children Document and report findings to case workers;testify in court Regarding home visit observations Work closely with foster parents to coordinate visits and transportation ELLENOR DOMINGUEZ Page 2 EMPLOYMENT(cont.) A WOMAN'S PLACE,Greeley,CO 10/95-1-98 • Lead Counselor/Supervisor Evaluate, provide individual and crisis counseling, and serve as advocate for women and children victims of domestic violence Establish and maintain effective working relationships with community referral agencies resulting in a more effective assistance program Successfully initiated new counseling program for Spanish speaking sector Facilitate Spanish-speaking support groups Oversee daily operations, scheduling, and safe-house coverage Developed record-keeping forms used for reporting to Social Services CATHALIC CHARITIES,Greeley,CO 5/93-10/95 Migrant Outreach Coordinator Visited homes and labor camps throughout Weld County, providing supportive services COLORADO EASTER SEALS, Denver,CO 4/94-11-94 Migrant Coordinator • Participated in highly successful pilot program developed to work with migrant workers with disabilities Assessed needs, provided tefeitals to community agencies and served as advocate for migrant farm workers with disabilities Served as agency representative throughout Colorado Print Date: 01/18/0 5 • HEALTHCARE PROVIDERS . ® SERVICE ORGANIZATION PURCHASING GROUP CERTIFICATE OF INSURANCE -73-f-ticr .-* '� Thf4�1" ,rte 018098 970 HPG 0273177648 from:12:01 AM Standard lime on:02/26/05 to: 12:01 AM Standard Time on: re 2. 06 Lori Kochevar MS LPC LLC Healthcare Providers Service Organization 810 12th Street 159 East County Line Road Greeley, CO 80631-4022 Hatboro, PA 19040-1218 Medical Specialty: Code: Clinical Counselor Firm 72990 American Casualty Co. of Reading, PA CNA Plaza 26S Chicago, IL 60685 „ x .=•�:zn..,..W ..,. . ....._..,. _.�. .. . v,a.,.....a ..,.,,..,_..k..w_..,s,,,.,...tea.-�.i,.t>.......a..__. _, ..,._�. .,.oti.:.a.._..... A. PROFESSIONAL LIABILITY Professional Liability(PL) $ 1,000,000 each claim $ 6,000,000 aggregate Good Samaritan Liability included above -ersona njury iael rty included above y a p acemen is et included above B. COVERAGE EXTENSIONS: License Protection $ 10,000 per proceeding $ 25,000 aggregate Defendant Expense Benefit is, sgma r' $ 10,000 aggregate Deposition Representation $ 10,000 aggregate Assault $ 10,000 per incident $ 25,000 aggregate Medical Payments $ 2,000 r person $ 100,000 aggregate First Aid . - ' $ 2,500 aggregate Damage to Property of Others $ 2,500 per incident $ 10,000 aggregate C. WORKPLACE LIABILITY coverage van c.Workplace Liability does net apply if Coverage pen D.General Liability is made pen of this policy. Workplace Liability none Fire&Water Legal Liability none Personal Liability none D. GENERAL LIABILITY . Coverage part D.General Liability does not apply if Coverage pan C.Workplace Liability is made pan of this policy. General Liability(GL) $1,000,000 each occurrence $1,000,000 aggregate Hired Auto&Non Owned Auto included in (9L limit above Fire&Water Legal Liability included in GL limit above subject to $250,000 sub-limit Personal Liability ,£ none Total Premium: $ 673 . 00 QUESTIONS?CALL: 1-888-288-3534 u:.,......,,,,..:.e.,..sa..,..:......mewd b:.da..,.. G-121500-C G-121501-C G-145184-A G-147292-A G-144872-A G-123846-005 G-121504-C G-123827-B G-141239-A Master Policy#188711433 Keep this document in a safe place. ft and proof of payment are evidence of your insurance coverage. $62A-4/A Chairman of the Board Secretary ® HEALTHCARE PROVIDERS GENERAL LIABILITY COVERAGE PART ENDORSEMENT Additional Insured General Liability In consideration of the premium paid. and subject to the General Liability limit of liability shown on the certificate of insurance, it is agreed that the GENERAL LIABILITY COVERAGE PART Is amended as follows: The person or entity named below(the"additional insured"is an insured under this Coverage Part but only as respects its liability arising out of named insured's operations, or premises owned by or rented • by the named insured and solely to the extent that: • 1. a general liability claim is made against the named insured and the additional insured;and 2. in any ensuing litigation arising out of such claim,the named insured and the additional insured remain as co-defendants. In no event is there any coverage provided under this policy for an occurrence that is the direct liability of the additional insured. Additional Insured: State of Colorado do Weld County Social Svs. PO Box A Creeley,CO 80634 This endorsement is a part of your policy and takes effect on the effective date of your policy, unless another effective date is shown below. All other provisions of the policy remain unchanged. Must Be Completed Compete Only When This Endorsement Is Not Prepared with the Policy ENDT. NO. POLICY NO. ISSUED TO $is Not to be Effective with the Policy ENDORSEMENT EFFECTIVE DATE • 01 j 0273177648 Lad KochevarMS LPC LLC 2/26/2005 6-123527-B(07/2001) Page 1 of I TOTAL P.03 Appendix C \ ( § _ , (O - s 7 ; ( $ \ \ a ) ° 5 k i 2 ■ & a ; & ) , , ) } } f \ \ / / i 8 ■ $ ® ` ` ~ ~ } # z I } . ~ k ) ` ; § \ ` 2 @ g - •- ® ° oi of ■ _ ( 2 } k i In oa ° . 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The focus of this program is to teach parents how to create an emotionally safe and secure environment for their children in the home. The goal of this program is to keep children with their biological parents. Design: This program will provide supervised visitation for the family during the time the bonding specialist is working with them. Starting this year, we have the expertise on staff to serve children up to age twelve. It has become clear over the last ten years of this program that bonding and attachment work for older children is greatly needed. When parents are unaware of how to set significant structure and firm boundaries with children that have attachment issues they are more likely to fail in their attempts to reunify with their children. It is paramount that these parents be given direct training, modeling and coaching on how to address the specific needs of the older child in need of bonding work. In addition, due to an increase in staff availability we will be able to provide services for more bi and mono-lingual families. While in the past we have used interpreters and had limited clinical time from a bilingual therapist, we now have the capacity to serve this need. Providing services in the most comfortable language for the clients greatly increases its effectiveness. All other aspects of the program will remain the same using the design and assessment tools that have evolved over the last ten years of providing this service. The program provides modeling of how to build nurturing relationships with the family during visitation in the home or at the Department of Social Services. The program is designed to assess the response of the parent to the child and the child's response to the parent. Assessment will include the parent's commitment and ability to make changes in parenting which will enhance the emotional relationship. From this assessment, a Case Management Plan for intervention will be developed which addresses the strengths and deficiencies of the relationship. This program is based on a strength-based family preservation model of service. This program offers information, education and modeling of behaviors that promote bonding, to assist the parent in strengthening the relationship with their children. Other topics regarding parenting and children (including discipline, growth and development, health and safety) will be addressed during the sessions. Establishing a strong emotional parent-child relationship will be the underlying foundation for teaching other child related issues. Why Services are Important: Bonding is a deep and lasting relationship which develops between the caregiver and the child during the first two years of life. The strength of this bond has a profound affect on every aspect of the child's nature. The child, who develops a strong sense of nurturing from his mother, will develop: a sense of trust, a good self-esteem, positive reciprocal interaction with others and an ability to function as a healthy adult. hi addition, an adult who had a positive bonding experience with his mother will be able to establish an emotionally healthy foundation for his own children. A child who does not experience the development of a strong bond with the parent will be prone to difficulties with relationships, antisocial behavior and learning difficulties. When these children grow up, they are often unable to regulate their emotions or their behavior. Any event that separates the child from the mother either physically or emotionally during the first three years of life, places the child at risk for inadequate bonding. Lack of bonding in a parent-child relationship can occur for several reasons. Children who experience frequent moves within a foster care system become resistive to bonding. When the mother experiences a high level of stress during pregnancy, suffers from depression 2 or is involved in substance abuse, she may not be emotionally available to nurture the child. Domestic violence may cause a child to develop fear and distrust of the parent making bonding difficult. Children who experience abuse/neglect are at high risk for bonding difficulties. Children who are not well bonded do not learn to trust. They have a difficult time building strong meaningful relationships throughout life. This may be reflected in early childhood through angry, defiant and controlling behavior. The child may also have difficulty dealing with authority figures throughout his life. The lack of a strong parent-child bond may also interfere with the child's learning ability. These children may have difficulty focusing in the classroom. They are often emotionally and developmentally delayed. Due to the impact inadequate bonding may have on the future of the child and our society, it is imperative that intervention begin as early as possible in the child's life. TARGET/ELIGIBILITY POPULATION A. Total Number of clients to be served: The program will serve a total of 60 families during the twelve-month period. Each bonding specialist will serve eight to ten families at one given time period. Each family will receive 24 hours of one-on-one supervised visitation with the bonding specialist. This would provide 27 hours of intervention with families per week, 120 hours per month. Total number of client hours provided per year would be 1440 hours. B. Total number of clients and ages: Based on the approximation that the average family is made up of four children and one parent, the total number of clients for the year could be 240 clients. Focus will be on children whose ages are birth to twelve years of age. When the family includes older children, they will be included in the family intervention C. Total number of families served: A total of 60 families will be served during the year. C. Sub-total of individuals who will receive bilingual/ bicultural services: All services provided would be in a manner that is sensitive 3 to the family's culture of origin. The program manager and specialists have extensive training in cultural competency issues. Lori Kochevar chaired the multicultural task force that successfully implemented multicultural training throughout the San Luis Valley. Becky McMahan has worked with families from various cultural roots. She has a sense of respect for the family's cultural beliefs and practices. Ellenor Dominguez a bicultural bilingual provider will be available for any Spanish speaking families. Due to our experience in bicultural settings, all individuals in our program will receive bicultural services. E. Sub-total of individuals who will receive services in South County: The program could serve three to four families in South County during a given time period. Based on referrals in past years, this would be an adequate estimate. Services will be provided for families where they reside as determined by Social Services. F. The monthly maximum program capacity: If needed, we could expand the number of hours we are available for services to 35 hours per week, which would make available 140 hours per month. G. The monthly average capacity: The monthly average capacity of this program is six to eight families. II. Average stay in the program: The average stay in the program would be six months. It is felt that clients have adequate opportunity to make positive changes in parenting styles in that period of time. I. Average hours per week in program: Initially, each family would receive services two hours per week, unless a different number of hours is requested by the caseworker for clinical reasons. After the first twelve weeks, sessions will decrease as recommended by the treatment team. Number of hours of service and length of service vary according to the individual family situation. 4 SERVICES TO BE PROVIDED A. Through mentoring, the program will address the following areas: 1. Teach, model and coach adaptive strategies: The bonding specialist will teach through use of visual aides, demonstration and verbal interaction with the parent and child. She will use demonstration of bonding behaviors. She will guide the parent and child through activities that utilize bonding skills and encourage a positive emotional interaction between the parent and child. She will support the parent with encouragement and recognition of positive changes. 2. Model and influence parenting practices: During the visits with the parent and child,the bonding specialist will influence and direct parenting practices through education of the parent. The parent will be given opportunity to gain increased awareness of the child's developmental level and have a better understanding of expectations which are appropriate to the child's age. The bonding specialist will have opportunity to model for and guide the parent during the visitation. 3. Teach relational skills: The parent will receive information and guidance regarding nurturing behaviors which, when put into practice, will enhance relationships. The bonding specialist will guide and support the parent as she makes efforts to utilize new skills. Just as the mother has difficulty in her attempts to make changes in her parenting and bonding behaviors,the poorly bonded child struggles to respond to those changes. This can be discouraging to the parent who will be offered support and encouragement. 4. Teach household management, including prioritizing, finances, cleaning, and leisure activities: The program will address everyday living concerns faced by the family through observation and initial assessment. The bonding specialist will address issues such as the safety and health of the family as related to hygiene and care of the living quarters. The bonding specialist will increase the parent's awareness of the importance 5 of structure and consistency in the home routine for the children and the parent. This will be a process of education presented through verbal and written materials. 5. Actively help to establish community connections and resources: the bonding specialists are well informed about community resources. She will be able to direct the client to resources as needed and to assist with accessing those resources. This would include offering the information to the client, setting up an initial appointment, and possibly meeting the parent at a designated appointment as a support person. This could also include guiding the parent to Play Groups or other activities that would offer opportunities for social interaction for the child and parent. A Resource Guide will be used in the intervention with the family. (Appendix A) 6. Encourage goal setting and pro-social values: When working with the family in the above areas, the bonding specialist will assist the parent in developing goals that the parent recognizes as important to the welfare of the child and the family. Goals will be developed with the parent and put into writing, to be reviewed periodically together. Through this experience, it is hoped that the client would develop a greater awareness of how to function successfully in society. B. Visitation: 1. Monitor parent-child interactions for physical and emotional safety: Supervised visitation by the bonding specialist will be made in the home of the client, our home setting for visitation, or in a location designated by the Department of Social Services. During the visitation, the bonding specialist will be attentive to the interactions between the child and parent. She will guide, direct and model behavior with the parent and child as a means of increasing parent awareness regarding ways to provide an emotionally and physically safe environment. 6 2. Document clinical observations: The bonding specialist will utilize The Family Visitation Evaluation Form (Appendix A), developed specifically for the program, to document clinical observations made during the visitation. The form will be filled out at the time of the visit or prior to the following visit. The client receives a copy and is asked to review it with the bonding specialist at the end of the visit or at the beginning of the visit. The parent is the asked to sign the form. This allows the client written feedback from each visit. The parent and caseworker receive a copy and the bonding specialist keeps one copy for her records. The bonding specialist keeps her own notes in addition for each visit and from these submits a monthly report to the caseworker, the supervisor of Life Skills Programs and a billing person. 3. Strategize for teaching and modeling parenting skills: Demonstration is most often the most effective strategy for increasing parent awareness and teaching new skills. As events unfold during a visit, it is effective to be able to point out emotional or physical safety concerns as the issues arise. It is also effective to offer support and positive feedback to the parent and the child as positive events occur during the visit. It is through this process of redirecting and recognition of a parent's efforts that the she begins to understand her own sense of success. 4. Teach relational skills: Parents will be educated through visual aides and verbal information about bonding and ways the parent can enhance the relationship with the child. During visitation, the bonding specialist will point out behaviors of the child which relate to an insecure bond and direct the parent to tools she can use to offer the child more emotional support. The bonding specialist will also use demonstration and modeling to assist the parent's understanding of her child's needs and healthy responses to those needs. 5. Encourage goal setting and pro-social values: During the visitation, much of the focus will be on the emotional interactions between parent and child. As the parent comes to a better understanding of her child's needs and how her own 7 behaviors affect the child, she will be better able to focus on her own goals. The bonding specialist will work with the parent to develop goals that are within the parent's understanding. Those goals will be reviewed with the client periodically and enhanced or changed as the parent progresses. Through the increased awareness of her responsibility as a parent and her self- discipline in changing parenting patterns, she may develop a greater awareness of social values that allow her to function more successfully in society. 6. Plan structured activities in visitation to help achieve the objectives of the treatment plan: The bonding specialist will plan and implement activities that will enhance the interactions between parent and child. The focus of these activities is to encourage the basic modes of emotional connection; holding, touching, rocking, eye contact, talking, pleasant facial expression and feeding. This would include demonstration of various activities that encourage those behaviors. Activities such as peek-a-boo, looking in the mirror and rolling the ball back and forth (which encourage eye contact)will be demonstrated. Parents will also be encouraged to read books to the child to encourage closeness. Emphasis will be placed on assisting parent's response to the child's behavior through modeling and guiding at the time of the behavior. Through these interactions, the bonding specialist will be able to offer education and demonstration to increase the parent's awareness of appropriate expectation of the child at his current developmental stage. Other activities would be to practice making physical contact and face-to-face posturing. Activities will be practiced according to the age of the child and the parent/child relationship at a particular point in the intervention. MEASURABLE OUTCOMES At the time the family is accepted into the bonding program, bonding will be assessed through observation and through use of a Bonding Assessment Tool, which is based on input from the parent and parent-child interaction (Appendix A). This will include assessment of the level of bonding the child has experienced and identify behaviors that indicate areas of concern. The bonding specialist will discuss concerns with the parent and develop a 8 Case Management Plan. This will be an outcomes-based plan that will be shared and reviewed periodically with the parent. A. After involvement in this program the parent will be able to provide a safe secure home for the children. This includes health, safety, and provision for every day needs. The parent will have: • Resources to provide for the child's basic needs, such as adequate housing and resources for providing food and clothing on a consistent reliable basis. • Increased awareness of daily planning for the child's needs and providing a stable environment by establishing routines around mealtime, after school activities, bath time and bedtime. • Increased understanding of the nutritional needs of the family and a means of providing for those needs. • Increased awareness of the exposure of the children to health and safety risks when the home is not well maintained. • The ability to focus spending on the basic needs of the family as a priority over other expenditures. B. After involvement in this program parents will be able to realize increased competency in their parenting. Parent will demonstrate through her behaviors: • Increased awareness of the emotional needs of the child and demonstrate nurturing behaviors meant to enhance their bonding. • Increased demonstration of nurturing behaviors in parent-child interactions. • Increased awareness of the emotional and physical developmental age of the child and responses that are fitting for that child. • Increased knowledge and understanding of child's behavior as related to bonding issues. 9 • Increased use of discipline measures that are effective (not damaging to the relationship) and is consistent in the use of those measures. After involvement in this program, the child will: • Indicate through his behavior that he has an increased sense of security and trust in the parent. • Demonstrate an increased emotional bond with the parent. • Behave appropriately in social situations. • Begin top progress developmentally with expected achievement. C. After involvement in the program the parent will have increased ability to access resources in the community independently in order to better meet the needs of the child and family. • This program will empower the parent to access community resources by providing information and initial support and guidance. The parent will have an increased knowledge of resources available and show confidence in seeking out resources independently, making appointments, keeping appointments and following up with services. D. Parents who complete the program will obtain higher skill and competency levels in order to provide the child with a safe, secure home. The Parent will provide the nurturing needed to enhance the child's sense of security. Parents will be able to identify factors that have a positive affect on family unity and security. In order to keep the family together after six months from discharge, the parent will: • Be able to prioritize the needs of the children over the parent's own needs. • Will recognize and have ways of meeting their own needs. • Maintain awareness of enhanced family relationships and continue to utilize skills gained during the program. • Have in place identified and used sources of support in the community. • Be aware of the need for continued focus on and attention to the emotional needs of the child. 10 E. Families who participate in the program will develop skills and awareness that will increase their competency as parents. Increased competency will be measured through documentation occurring at each visit through use of an outcomes-based Case Management Plan developed at the time of entry into the program. Risk factors will be identified at the time the initial plan is written. This will be reviewed with the parent and updated as goals are met and as changes occur in the parent-child relationship. SERVICE OBJECTIVES The program has the following service objectives: MENTORING: A. Improvement of household management competencies: It is imperative that parents understand and show competence in the practice of keeping a clean, well-maintained home for the health and safety of the children. It is expected that parents will manage the household finances in a manner that allows for the children to be nutritionally healthy, clean, and adequately dressed. It is expected that the parents will consider the child's health and emotional safety when planning leisure activities for themselves and the children as they develop increased awareness of health and safety issues. Included in household management is the parent's ability to maintain structure and consistency in the child's life in the home. This objective will be measured through the parent's ability to reach specific goals as defined in the Case Management Plan relating to household concerns. B. Improve parental competency: • Parents will have the capacity to provide a safe environment for the children, both physically and emotionally. Parents will show competency in being able to protect and keep the child safe. Parents must be aware of the need for structure in the home in order to enhance the child's security. 11 • Parents will indicate through their behavior, their understanding of bonding and nurturing behavior that serves to enhance the child's sense of security. It is crucial to the well being of the child that the parent be able to continue to utilize strategies to maintain and enhance the relationship. • The child will show in his responses to the parent that he feels safe and secure. • Parents will demonstrate their understanding and their ability to utilize parenting techniques that are effective and emotionally healthy for the child. This includes use of adaptive strategies for discipline and behavior management, offering age- appropriate activities, and conveying expectations that are age- appropriate. • Parents will recognize the importance of being a dependable caretaker for the child. It is necessary to the well-being and emotional growth of the child that the parent be both emotionally and physically available to the child in a consistent manner. The parent must understand that this is the foundation for building and maintaining trust. • Parents will acknowledge their responsibility for providing a healthy diet for the children. They must offer the child healthy and adequate food. • It is important that the parent take responsibility for attending to the child's hygiene. The parent must guide the child in hygiene issues and model good practices. This includes basic everyday hygiene, such as bathing, hand washing, changing clothes and care of teeth. The parent must make every effort to provide the necessary tools for practicing good hygiene. This service objective will be measured through use of the Case Management Plan objectives (the use of a pre and post assessment tool) and the Family visitation evaluation form. C. Improve ability to access community connections and resources: • After being in this program, parents will have information regarding resources in the community and an understanding of how to access them. Parents will be empowered to make the necessary steps to resolve their concerns. This objective will 12 be measured with use of Case Management Plan objectives and the parent's demonstration of utilizing resources independently, making and keeping appointments. (Resource List, Appendix A) D. Improve goal setting and pro-social values: • Parents will experience a sense of success, as they are able to utilize new skills and achieve goals set early in the program. With that sense of success, the parent will realize the value of goal setting and be able to apply it to other areas of life. This objective will be measured through use of Case Management Plan anticipated outcomes and observation which indicate the parent's use of goal setting. VISITATION: A. Improve parenting skills, parent/child interactions and relational skills for physical and emotional safety throughout structured activities in, and documentation of, visitations to achieve the objectives of the treatment plan: • The parent will show increased ability to put into practice the skills that are demonstrated during the visitation and will use the skills independently, without the continued guidance of the bonding specialist. • The parent will have an understanding of ways to make an emotional connection with the child. It is crucial for the emotional health of the child that the parent be committed to that emotional connection. • The child will show positive response to the parent's efforts to make emotional connection. • The parent will demonstrate her capacity to protect the child from physical harm. She will take the initiative to set limits and follow through in order to protect the child. These objectives will be measured and progress documented in face-to-face visitation with the family. 13 WORKLOAD STANDARDS A. Number hours per day, week or month: The program has the capacity to serve up to 60 families. The bonding specialists would spend up to 27 hours a week providing services. Henceforth, 27 hours a week x 52 weeks, provides 1440 client hours a year. B. Staff: There are three bonding specialists and a program supervisor. Lori Kochevar M.S., L.C.P., LLC will serve as the program supervisor for Becky McMahan R.N, Bill George M.A, Heidi Friese L.C.S.W., Ellenor Dominguez M.A., and Lisa Downs M.A., L.P.C. All providers have extensive experience in Family Services and Attachment and Bonding as documented in the attached resumes C. Caseload: The caseload will be between 2-10 families per bonding specialist. The caseload of each specialist will depend on matching specific needs of the referred family with the area of specialty of the bonding specialist. D. Modality of treatment will be supervised visitation that provides a psycho-education regarding of attachment and bonding. Referral and linking services will be provided. E. Hours: Total number of clinical hours devoted to this program equals 6 hours a day, 27 hours a week, and 108 hours a month. F. Staff: The providers are supported by part time bookkeeping and clerical staff. G. Supervisor: This contract would be supervised part time by Lori Kochevar M.S., L.P.C., who will monitor the program compliance and clinical excellence. H. Insurance: Lori Kochevar M.S., L.P.C., LLC carries one million three million-liability on the company and each one of the independent contractors connected to this bid. In addition, Lori Kochevar M.S., L.P.C., LLC carries a general liability policy related to accident or injury on the premises. The State of Colorado is named 14 as an additional insured on this policy. Each individual provider also carries one million three million-liability insurance. Both the general and group liability coverage's are attached. All specialists providing services are self-employed and choose to be exempt from workman's compensation and Employer's liability insurance. 15 Appendix C VISITATION FORMAT Visit I: - Intake form - Family concerns indicator—parent take home and return at next visit - ROI - Explain to parent the purpose of the Bonding Program - Introduce the basic elements of bonding—needs of the child - Parent responses that encourage or enhance closeness Visit 2: - Review parent concern indicator with the parent - Parent Questionnaire—age appropriate Individual visit - Bonding assessment with parent - Pre and post parent assessment - Discuss G&D per age of child Visit 3: - Share strengths and concerns with parent - Develop interventions with parent input - Limit setting and structure - Need vs.want The following visits will focus on addressing concerns from above assessment and observation. Format for these visits will be developed to meet the individual needs,level of understanding and progress of each family. Written materials will be provided related to various issues after discussion and at a level of understanding of the parent. Observation: Attachment Interaction Mastery Social support 5/20/03 FAMILY VISITATION EVALUATION FORM Name: Date: Location: Greetings: Good-byes: • • Activities: Planned_ Spontaneous_ Age Appropriate Interactions: Initiated bv: Parent Child • • Touch Holding___ Eye contact Voice_ Smile • Description of Interactions: • Limit Setting, Discipline: Food Offered: • Strengths: Suggestions: Did interactions or activities relied feedback given last visit? : • Parent: Bonding Nurse: ORIGINAL-TO CLIENT YELLOW COPY-RN • PINK COPY-CASE WORKER ilk 02/1)I MlwPfikvbMCMahanga ilyvisiulionewlwlionform RESOURCE LIST BONDING PROGRAM 810-126 Street—Greeley,CO 88631 Plume(970-352-8879 HEALTH Monfort Children's Clinic 100 N. 111 Avenue (970)352-8898 Sunrise Community Health Center 1028 5th Avenue (970)353-9403 Urgent Care 1900 16th Street (970)3531661 NCMC 1801 16th Street (970)3524121 North Colorado Family Medicine 1600 23*Avenue (970)353-2424 Scheduling 346-2818 Quick Care 2928 W. 10th Avenue (970)351-8181 Weld County Department of Public Health 1555 N. 17th Avenue (970)304-6420 Family Connects 2985 W.29th ST. #A (970)330-3842 North Range Behavioral Health 1306 11th Avenue (970)346-1166 CLOTHING 353-3686 Church Women United 1030 11th Avenue (970)353-7144 Salvation Army 1119 6th Avenue (970)353-1444 Adventist Community Services 612-2Y"Ave (970)356-3740 Budget Baby Shop 130111'"Avenue (970)351-8427 Life and Light Community Church 110 N.25th Avenue (970)353-3451 Baby Stuff and More 2126 9th Street (970)353-2229 DENTAL CARE Monfort Children's Clinic 100 N. 11th Avenue (970)3528898 Sunrise 10285th Avenue (970)353-9403 FOOD WIC 1028 5m avenue (970)353-9403 Weld Food Bank 104 11th Avenue (970)356-2199 Share Colorado 1311- 11th Avenue (970)353-6433 Salvation Soup Kitchen 1119 6th Street (970)353-1441 Supplemental Foods 104 11th Avenue (970)356-2199 PARENTING CLASSES CARE 3700 Golden Street,Evans (970)3566751 ROUSING Greeley Housing Authority 315 N 11th Avenue (970)352-1551 ext.6541 Hudson Housing Authority 1151 Main/Hudson 1-303-536-4501 Ft.Lupton Housing Authority 400 2°a Street/Ft Lupton 1-303-857-4400 RENT/DEPOSITE ASSISTANCE Catholic Charities Noi drum 2500 1"Avenue Bldg C-B (970)353-6433 Mi Casa Tu Casa 1311 3*Street (970)352-6417 Salvation Army 1119 6th Street (970)353-1441 SHELTERS 1202 6*Street (970)352-3215 Greeley Transitional House Guadalupe Center 1516 n�25*Avenue (970)353-372 A Women's Place 1327 2 Avenue (970)356-4 A Room At the Inn 1213 5Th Avenue (970)378-0100 MEDICAID/CHP+APPLICATION Weld County Department of Public Health 1555 N. 17*Ave. (970)304 6420 Department of Social Services 315 N. l la'Avenue (970) 352-1551 PRE AND POST BONDING ASSESSMENT Child Parent Date: Date: Check: Avoids eye contact Resists being-held-stiffens body, Pulls away from touch Does not respond to mothers voice-avoids, ignores Resists feeding when mother holds bottle- prefers —— propped bottle Somber, sad expression, withdrawn Lack of responsive smile Prefers to play away from mom, does not check in with mom periodically Decreased stranger awareness, prefers others to mom Eating problems, gorging, refusal, FT Destructive of own or others property, frequently breaks own toys / High pain tolerance, self-abusing behaviors /— Clingy, whiney, fussy baby, hard to console Defiant, resistive behavior / Manipulative Senseless lying Hyperactive behavior, unable to be still or to focus, /_ Sullen, quiet and withdrawn / Frequent tantrums, often lasting for unusually long — time _/ Developmental delays, learning, speech, motor _/ Speech delays or speech is difficult to understand _/ Hurtful to others or animals PRE AND POST ASSESSMENT Bonding Program Name: Date: Date: 1. Parents will be able to show improved competency in parenting practices. • Increased awareness of the emotional needs of the children. • Increased understanding of bonding and how poor bonding affects the child • Increased positive responses to the child • Increased ability to interact with the child in a manner which enhances bonding • Increased awareness of the developmental age of the child and practice age appropriate expectations. • Child will show increased response to the parent. • Child will show increased respect for the parent • Increased understanding of punishment vs. discipline • Increased ability to utilize discipline measures which are not emotionally detrimental to the children 2. Parents will develop a greater understanding of the components that are necessary to insure a lasting family relationship. • Increased ability to place the children a position of high priority in the home. • Increased ability to continue to utilize the parental and relationship skills learned in the program. • Increased ability to recognize and meet own needs. • Increased ability to maintain sources of support in the community for self and children. • Increased awareness of the ongoing emotional needs of the children. 3. Parents will be able to improve household management competency as measured by a pre and post assessment of skills needed to maintain a safe and secure home. • Increased resources to provide for the family needs • Improved ability to maintain a clean,healthy environment • Increased ability to provide structure and consistency in the home structure the home • Increased awareness of the nutritional nents of the children • Increased awareness of health and safety risks in the home • Increased ability to keep the child safe 4. Increased ability to utilize resources available in the community. • Increased knowledge of community resources. • Increased understanding of how to access services. • Increased confidence in seeking services. • 5. The child will: • Indicate through his behavior, that he has increased sense of security with the parent. • Demonstrate increased emotional bond with the parent. • Behave appropriately in social interactions. • Begin to progress developmentally with expected achievement. The items checked above indicate areas of concern. A circled item indicates improvement. Parent: Bonding Specialist: Date: 2 N C. N •0 E 1Y. •t in v n C L Q ., O c ° 0 0 °'n ° '� $ y ❑ c o — p >. C c. c c el0 m E .p o N . O O O O >. a- U O 3 w U h B .2 vi L 0U in N v -0 -0 ... d J 4- tr d N c L CO C.-. y .. g O a >, e c c c ?, a x E v E i- v O C y. N 9 C 17 0 -p w N C al C C y > IC C N —gra -F N d •. N {co � '8 tic C la N C IA 'O T U E .C a≥,..-. U = y 1- 0.U > .C in 4to yay G c 0 N N O 7i id • 3 U ! Y is - Y L a > c C '9 U Op 6.' O Y14 U G ... £ 14 O co -" w U O 5 o u .... 0_ a = Ci.3 O. > N O i0 ,. X s N N C C >. N .C O Q. = c0 w -. 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C C c o ] \ C 7tn \ ba v. - - § ] \ 2 § \ - 7 / � 8 ' % ) § C3 Ca 2 \ 7 $t2 C2 \ •=C �/ , oe 2o00 kn - . / � / ! tIl in- Q \ / \ /) � � j /\ La r2 2 § \ tk ) - = � k \ ) � ° ° B % / fof2G ® ' ` CO ) --fl ! . 9 » . 031-“C ® e , 7E \ \ & ] ECO e 2 15 oo z - LI r a : o.o ) / \ \ _ \ 17� ) 7 2 - / ) \ , f c• ` - - G0 o c > 3S ) ._ 32 ) �E gg ° § \ , . 0 . _ a \ \ // \ ° � � \ c ! ! 7 » u � ej 42 03 a • - } \ / 1O. ) § j ; E ] /\ , / - 2 fiS. _ _ a = 7 - \ • ) § ` ] � ] � / \\ ( \ / ) ) � o 0 \\d � ( 3 (g } _ , . 99 f ( . {/ \ [ K ej � ft. 0 73 O . $ } §\ -43 § / & / / 2 § ate \ � . - ) /\ § SUPPLEMENTAL NARRATIVE TO RFP: EXHIBIT B CONDITIONS Lori Kochevar,MS LPC 810 12th Street Greeley Co 80631 Weld County Dept. of Socia. Services Clerical Unit Weld County DSS PO Box A APR 2 5 2005 Greeley Co 80631 Re: RFP 04005; Lifeskills Re: RFP 006-00c: Foster Parent Consultation Re: RFP 006-00a: Foster Parent Training Re: RFP 006-00: Home Study Dear Ms. Griego, This letter serves as written confirmation that I received the results of the Bid process for the 2005-2006. I am in agreement with the Commission's conditions with the following clarifications. The following is the response requested by the conditions for the RFP 05005, Lifeskills. Condition 1: Definition of our capacity to do after-hour visits. We will have the capacity to see clients after 4 and on Saturdays as deemed appropriate by caseworker and or client request. Appropriateness will be measured by safety concerns for the children. The following is the response requested by the conditions for the RFP 006-00 Home Studies. Condition 1: The threshold for hours for an incomplete home study will be set at 3.5 hours at our hourly rate of$85. Additional adults in the home were a home study is being completed will be billed at$250. Thank you for this opportunity to again serve the families of Weld County. Please let me know if you are in need of any further clarification. Sincerely, Lori Kochevar M.S. LPC a. ret DEPARTMENT OF SOCIAL SERVICES P.O.BOX A GREELEY, CO. 80632 Website:www.co.weld.co.us Administration and Public Assistance(970)352-1551 ' Child Support(970)352-6933 Dc COLORADO April 18,2005 Lori Kochevar MS LPC The Jubilee Center for Families 810 12th Street Greeley,CO 80631 Re: RFP 05005:Lifeskills RFP 006-00C:Foster Parent Consultation RFP 006-00A:Foster Parent Training RFP 006-00:Home Study,Relinquishment Counseling Dear Ms.Kochevar: The purpose of this letter is to outline the results of the Bid process for PY 2005-2006 and to request written confirmation from you by Wednesday,April 27,2005. A. Results of the Bid Process for PY 2005-2006 • The Families,Youth and Children(FYC)Commission recommended approval of the bids below for inclusion on our vendor list. 1. 006-00A Foster Parent Training 2. 006-00C Foster Parent Consultation • The Families,Youth and Children(FYC)Commission recommended approval of the bid, RFP 05005 Lifeskills,for inclusion on our vendor list,attaching the following condition for all Lifeskills providers. Condition: All providers must define their capacity to do after-hours visitation. • The Families,Youth and Children(FYC)Commission recommended approval of the bid, RFP 006-00 Home Studies,Updates,and Relinquishment Counseling,for inclusion on our vendor list,attaching the following conditions for all Home Study providers. Condition#1: The threshold for hours for an incomplete home study will be set at 3.5 hours. Additional home studies will be billed at a maximum of$250 per person. Condition#2: It has been mutually decided that the turnaround time for receipt of the completed home study by the Department is set at six weeks from the date of receipt of the referral. Page 2 Lori Kochevar,LLC,Results of Bid Process 2005/2006 B. Required Response by FYC Bidden Concerning FYC Commission Conditions: All conditions will be incorporated as part of your Bid and Notification of Financial Assistance Award(NOFAA).If you do not accept the condition(s),you will not be authorized as a vendor unless the FYC Commission and the Weld County Department of Social Services accept your mitigating circumstances.If you do not accept the condition,you must provide in writing reasons why.A meeting will be arranged to discuss your response.Your response to the above conditions will be incorporated in the Bid and Notification of Financial Assistance Award. The Weld County Department of Social Services is requesting your written response to the FYC Commission's conditions.Please respond in writing to Gloria Romansik,Weld County Department of Social Services,P.O.Box A,Greeley,CO,80632,by Wednesday,April 27,2005,close of business. If you have questions concerning the above,please call Gloria Romansik at 352.1551,extension 6230. Sincerely, J A. ' go, ' r cc: Juan Lopez,Chair,FYC Commission Gloria Romansik, Social Services Administrator Hello