The URL can be used to link to this page

Browse Search

Home My WebLink About20051643.tiff RESOLUTION RE: APPROVE FIVE NOTIFICATION OF FINANCIAL ASSISTANCE AWARDS FOR MENTAL HEALTH SERVICES WITH VARIOUS PROVIDERS AND AUTHORIZE CHAIR TO SIGN WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, the Board has been presented with five Notification of Financial Assistance Awards for Mental Health Services between the County of Weld,State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Social Services,and various providers, listed below,commencing June 1,2005,and ending May 31,2006, with further terms and conditions being as stated in said awards: 1. Transitions Psychology Group 2. Jack J. Gardner, Psychologist 3. Victor H. Cordero 4. Barry Lindstrom, Ph. D., LLC 5. Individual and Group Therapy Services WHEREAS, after review, the Board deems it advisable to approve said awards, copies of which are attached hereto and incorporated herein by reference. NOW,THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, ex-officio Board of Social Services, that the five Notification of Financial Assistance Awards for Mental Health Services between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Social Services, and various providers listed above, be, and hereby are, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said awards. 2005-1643 SS0032 �`C . SS c6 o2D OSr FIVE NOTIFICATION OF FINANCIAL ASSISTANCE AWARDS FOR MENTAL HEALTH SERVICES PAGE 2 The above and foregoing Resolution was,on motion duly made and seconded,adopted by the following vote on the 6th day of June, A.D., 2005, nunc pro tunc, June 1, 2005. BOARD OF COUNTY COMMISSIONERS p \: EL WELD COUNTY, COLORADO S • 4e/l/GLff t 1861 0, ' William H. Je , Chair lerk to the Board Deputy Clerk to the Board D 'd . Long APP AS T • Robert D. Masde ounty Attorney p�,t,u 8lis Glenn Vaad �' Date of signature: 2a -c970-p 2005-1643 SS0032 DEPARTMENT OF SOCIAL SERVICES ‘H.......) P.O. BOX A 1 GREELEY, CO. 80632 Website:www.co.weld.co.us 1 Administration and Public Assistance(970)352-1551 Child Support(970)352-6933 O MEMORANDUM • TO: William H. Jerke, Chair Date: June 2,2005 COLORADOBoard of County Commissioners FR: Judy A. Griego, Director, Social ServicesJ�f t 11 Li RE: Notification of Financial Assistance Awards for Mental Health Services with Various Providers Enclosed for Board approval are Notification of Financial Assistance Awards (NOFAAs) for Mental Health Services 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 Core Services funding according to the NOFAA and their respective bid proposal for Mental Health Services. These services are for children,youth,and families receiving child welfare services. 3. Providers will be reimbursed according to various rates as provided below: No. Core Services Description of Program/Special Award Amount Contractor Conditions A. Transitions Psychology Comprehensive psychological services $299.26 per hour Group including cognitive,personality, $150 per hour court attention/memory/concentration, testimony achievement/education and adaptive behaviors; specialized assessments for children 0-5 years. Yearly capacity is 129 clients with an average of 8 per month. B. Jack J. Gardner, Program provides screening, evaluations, $1,300 per psych exam Psychologist and other assessments. 6 to 12 evaluations $900 per mental health per month. Maximum capacity is 10 assessment/other families. Incomplete home study is at 3.5 $1,600 per diagnostic hours. Additional home studies will be service billed at$250 per person. $100 per hour therapeutic visitation/treatment package $110 per hour parent-child interactions $160 per hour portal to 2005-1643 -- ---- ---.____. N portal court testimony $110 per hour professional consultation $100 per hour individual counseling $100 per hour family counseling C. Victor II. Cordero Mental health related and psychological $800 per episode/psych evaluation services, including examination psychological evaluations,parent-child $400 per episode/other interactional evaluations, family $1,120 parent/child assessments, and adjunct services that are interactional per linguistically and culturally sensitive. episode Capacity is 8 evaluations per month. $100 per hour court testimony D. Barry Lindstrom Diagnostic services and assessment of $280 per hour treatment family communication,functioning and package relationships. Capacity is 8 evaluations per $150 per hour court month. testimony E. Individual&Group Mental health evaluations, couples and $39.44 per hour Therapy Services family therapy, domestic violence $100 per hour court evaluation&treatment,evaluation and testimony treatment of youth in conflict, and therapy for those involved in D&N cases. Monthly capacity is 12 families. If you have any questions,please contact me at extension 6510. Weld County Department of Social Services Notification of Financial Assistance Award for Families,Youth and Children Commission (Core)Funds Type of Action Contract Award No. X Initial Award 05-CORE-59 Revision (RFP-FYC-006-00) Contract Award Period Name and Address of Contractor Beginning 06/01/2005 and Transitions Psychology Group Ending 05/31/2006 Mental Health Services 804 11th Avenue Greeley,CO 80631 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Provides comprehensive psychological services Assistance Award is based upon your Request for for infants to adults addressing areas including Proposal(RFP). The RFP specifies the scope of cognitive, personality, attention/memory/ services and conditions of award. Except where it is concentration, achievement/educational and in conflict with this NOFAA in which case the adaptive behaviors; specialized arena NOFAA governs, the RFP upon which this award is assessments for children 0-5 years. Bicultural based is an integral part of the action. services and South County services (Del Camino Special conditions &Greeley office)are available. Capacity to 1) Reimbursement for the Unit of Services will be based serve a total of 120 clients,maximum of 12 on an hourly rate per child or per family. clients per month, and average of 8. 2) The hourly rate will be paid for only direct face to face contact with the child and/or family, as Cost Per Unit of Service evidenced by client-signed verification form, and as specified in the unit of cost computation. Hourly Rate per Treatment Package $299.26 3) Unit of service costs cannot exceed the hourly and yearly cost per child and/or family. Hourly Rate per Court Testimony $150.00 4) Payment will only be remitted on cases open with, and referrals made by the Weld County Department of Social Services. Enclosures: 5) Requests for payment must be an original submitted to X Signed RFP: Exhibit A the Weld County Depaitinent of Social Services by the X Supplemental Narrative to RFP: Exhibit B end of the 25th calendar day following the end of the Recommendation(s) month of service. The provider must submit requests X Conditions of Approval for payment on forms approved by Weld County Department of Social Services. 6) The Contractor will notify the Department of any changes in staff at the time of the change. Approvals: Program Official: " v By t?r By William H. Jerke, Chair Jud . Grie o Direct() Board of Weld County Commissioners Weld ounty Department of Social Services Date: 'JUN 0 6 2005 Date: (9/2/q S' moos^ /64/3 • SIGNED RFP: EXHIBIT A INVITATION TO BID BID 002-05 (05005--05011 and 006-00) •DATE: February 16, 2005 BID NO: RFP-FYC-006-00 RETURN BID TO: Pat Persichino,Director of General Services 915 10th Street, P.O. Box 758, Greeley, CO 80632 SUMMARY Request for Proposal (RFP-FYC-006-00) for: Colorado Family Preservation Act—Mental Health Services Emergency Assistance Program 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 under the Colorado Family Preservation Act (C.R.S. 26- 5.5-101) and Emergency Assistance for Families with Children at Imminent Risk of Out-of-Home Placement Act (C.R.S. 26-5.3-101). The Families, Youth and Children Commission wishes to approve services targeted to run from June 1,2005, through May 31, 2006, at specific rates for different types of service. The County will authorize approved vendors and rates for services only. The Mental Health Services program provides diagnostic and/or therapeutic services to assist in the development of the family services plan, to assess and/or improve family communication, functioning and relationships. This program announcement consists of five parts, as follows: PART A...Administrative Information PART D...Bidder Response Format PART B...Background, Overview and Goals PART E...Bid Evaluation Process PART C...Statement of Work Delivery Date (After receipt of order) BID MUST BE SIGNED IN INK cres ,Uor,/ S . Critaci TYPED OR PRINTED SIGNATURE VENDOR Trans PnG`-o ecOy(n..f (Name) 0 andwri n Signature By Authorized Officer or Agent of Vender ADDRESS $0't It*"AvI..r TITLE ca-oti etc-I-oY' Gw.c lel,CX) SO Ca DATE 'S f/o/a PHONE # (`1-4-U) 33 6-11 a3 The above bid is subject to Terms and Conditions as attached hereto and incorporated. Page 1 of 32 • Bid 002-05 (RFP-FYC-006-00) Attached A MENTAL HEALTH SERVICES PROGRAM BID PROPOSAL AND REQUEST FOR CONTINUATION OF AWARD UNDER CORE SERVICES FUNDING EMERGENCY ASSISTANCE PROGRAM 2005-2006 BID PROPOSAL APPLICATION PROGRAM FUNDS YEAR 2005-2006 BID 002-05 (006-00) NAME OF AGENCY: I rob-5,at-- . s r y,s vaaVlnvi G trowyo ADDRESS: $OK Il't"- Avtwvt i Gina.ten 1 CO *ro 6 3/ PHONE flq 33G//y3 CONTACT PERSON: Town:: Ynot-How+r u.1 TITLE: Co- recA wr" DESCRIPTION OF EMERGENCY ASSISTANCE PROGRAM CATEGORY: The Mental Health Services program provides for"diagnostic, and/or therapeutic services to assist in the development of the family services plan, to assess and/or improve family communication, functioning, and relationships. (Volume VII, 7.303.1, G)" 12-Month approximate Project Dates: _ 12-month contract with actual time lines of: Start June 1. 2005 Start End May 31,2006 End TITLE OF PROJECT: /v ddA-1-al 1A414UM Stevca.-5 vs.n % i VDnoo,010-0zw) Mess' n.+ Sou' b4pe IIQ 4I, MIN'LP 1 31It'/0c, Name and Signature of Person Preparing Document Date G--a 340/0,r- NamedSignatar Chief Administrative Officer Applicant Agency Date MANDATORY PROPOSAL REQUIREMENTS For both new bids and renewal bids,please initial to indicate that the following required sections are included in this Proposal for Bid. For renewal bids,please indicate which of the required sections have not changed from Program Fund Year 2004- 2005 to Program Fund year 2005-2006. Indicate No Change from FY 2004-2005 Project Description Target/Eligibility Populations Types of services Provided Measurable Outcomes Service Objectives Workload Standards Staff Qualifications Unit of Service Rate Computation Program Capacity per Month Certificate of Insurance )ate of Meeting(s)with Social Services Division Supervisor: 3/ 2/05— Page 25 of 32 0f • 1O1CSC; .11Ikehd Llig 65(41641 v• id 002-05(RFP-FYC-006-00) Attached A ants by SSD Supervisor: Pi • , I-` L .limit not,# t''it's I bI.Qjnr J ,reA \j1 ' ' A16 ' 40311dt,�ct4-44-`fv( ��revvl. of A ►t,?. ' t ill_ Qiaa4 \ol ' - "r Or 11t?1z)n)-r►,t.Ut Lam. - ►. M {Il ti (Dr -1A s • �� for O—` ,p � C1C, ULNA 'O) - •.J i 1 ell ,f.'. err i a i u ; - 4sLaL i. M nal" -_ a • 6tn 5ttL2 3 an+^ I\,I i, I`tu, . - 1 r aia_ i 5 r0 i t. e • , le ., - —lop ' 14 At Dom, (An ► n. • 0 .0 anti l:. n OVA a to a c'1ft%�• i1 i' tr r JJ � ii / ►1 ri: " s1 1 \ IL / r .' II, Mn 31) o,J • and u' a of SSD Supervisor ll Date 3/9-/O 5 Q o0 ad) LPL ?i,"0 s Mental Health Services 2005-2006 Transitions 1 . ; ♦ . MENTAL HEALTH SERVICES PROGRAM BID CATEGORY ' • •• • • . Psychological Assessment •• i�� •• : 2005 2006••• Transitions Psychology Group, LLC•Da Transitions PSYCHOLOGY GROUP,LLC I. PROJECT DESCRIPTION Transitions Psychology Group, LLC is a private counseling agency with a multidisciplinary team of human service professionals, including a Licensed Psychologist, Nationally Certified School Psychologists and other degreed professionals. Transitions provides superior counseling, assessment, and consultation services to children and families in Northern Colorado. The purpose of the Psychological Assessment Services program, under the Mental Health Services bid category, is to provide comprehensive psychological evaluations to address specific referral questions and produce recommendations to aid the caseworkers and other professionals in treatment planning and coordination. Psychological Assessment Services will serve a variety of clients from infants to adults. Evaluations will be comprehensive and will be able to address a multitude of referral concerns and issues. Assessment can be done in any combination of the following areas: cognitive, personality, attention/memory/concentration, achievement/educational and adaptive behavior. Specialized Arena assessments will be offered for children ages 0-5 years. These tests assess all areas of the child's functioning, including psychological, motor, speech/ language, pre-educational skills, social/emotional, and attention/ concentration/ memory. In addition, the Psychological Assessment Services staff will provide comprehensive, professional and timely written reports. The team of professionals providing these services will regularly consult with the caseworkers before testing to ensure the clarity of referral question. Transitions will maintain contact with social services throughout the assessment process and promptly respond to inquiries. Transitions staff will also meet with the caseworker after the assessments are completed to discuss specific intervention strategies and the most effective and efficient means to address areas of concern identified by the assessments. II. TARGET ELIGIBILITY POPULATIONS Program participants must be referred by the Weld County Department of Social Services. Transitions does not discriminate based on race, color, religion, Mental Health Services 2005-2006 Transitions 2 national origin or sex, in accordance with State and Federal Laws, rules and regulations. Transitions estimates that the Assessment Program will serve 120 clients in the first program year. Of the total number of clients, approximately 60 would be children between the ages of 0-18; the probable number of adults would also be 60. Approximately one quarter, or 30, clients may be from the same family and therefore comprise a family unit. Approximately 60 individuals would receive bicultural services. Transitions does not offer bilingual testing services at this time. Transitions is in the process of recruiting a bilingual person to provide bilingual assessments and may be able to provide these services by the start of the contract on June 1, 2005. Transitions would provide services to approximately 40 South County clients. Transitions staff can generally be reached between the hours of 8am — 6pm Monday thru Friday, as well as evenings and Saturdays by appointment. Twenty-four hour services are not available for this program. This program could serve a maximum of 12 clients per month with an average of 7 clients per month. Time in the program is dependent on the referral question, but would not exceed 12 hours of face-to-face contact. The average stay in the program would be approximately 5 hours over the course of 3 weeks. Transitions offers assessments that are culturally representative of the client base and are standardized on the appropriate population. Services will be provided to South County clients at the Del Camino Department of Social Services and also available at Transitions' Greeley office. III. TYPE OF SERVICES TO BE PROVIDED A. Psychological Evaluation and Assessment Services for Children, Adolescents and Adults. Psychological Evaluation and assessment services consist of screenings, evaluations and other assessment services intended to provide information needed by the staff of social services. Evaluations will be conducted by licensed eligible psychologists who have an earned doctorate (PhD) in the field of psychology and are under the constant supervision of a licensed psychologist. The following procedure will be followed: 1. Referral Consultation- The PhD will meet with the caseworker after receiving the referral to gather background information and to clarify and develop specific referral questions. 2. Intake- The PhD will meet with the client to conduct a thorough clinical interview and sign necessary paperwork including releases of information. Mental Health Services 2005-2006 Transitions 3 3. Information gathering-Transitions will gather collateral information as applicable to the assessment and allowed by the client. The PhD will keep the caseworker apprised of the information gathered and progress of the assessment. 4. Testing- The PhD will determine the appropriate assessment instruments and use a variety of instruments to address the referral questions. These assessments will allow the practitioner to address issues including but not limited to the following: abilities, mental health impairments, parent's ability to recognize and provide a safe environment for children, ability to learn new strategies, most effective way to learn information, ability to adapt and assimilate to one's community, and an individual's ability to concentrate and recall specific information. Assessments will also provide appropriate diagnosis of any learning disabilities, mental health diagnoses and/or other cognitive impairments. A variety of available tests will be considered to evaluate the subject in areas relevant to the referral questions, such as cognitive (Wechsler Adult Intelligence Scale- Third Edition, Wechsler Intelligence Scale for Children- Fourth Edition, Universal Nonverbal Intelligence Test); personality (Minnesota Multiphasic Personality Inventory [MMPI], Minnesota Multiphasic Personality Inventory for Adolescents [MMPI-A], TAT, CAT, Children's Personality Inventory, Trauma Symptom Scale, Draw-A-Person Screening Procedure for Emotional Disturbance, HTP, Kinetic Family Drawing); attention/ memory/ concentration (Wechsler Memory Scale, Cognitive Assessment System, Behavior Assessment System for Children, NEPSY); achievement/ educational (Woodcock-Johnson Tests of Achievement, Wechsler Individual Achievement Test); and adaptive behavior (Vineland, Gilliam Autism Rating Scale (GARS), Gilliam Asperger's Disorder Scale (GADS). 5. Report Results- The PhD will write a comprehensive report that delineates the methods used, contacts made, tests administered, results and recommendations relevant to the referral questions. 6. Final Consultations-The PhD will meet with the client to review the results of the assessment. The PhD will also meet with the caseworker to address initial referral questions and assist with the application of the test results into practical, effective treatment planning. B. Infant/Child Arena Assessments: An arena assessments target children between the ages of 0 — 5 years old to assess their functioning in all areas of development, . Mental Health Services 2005-2006 Transitions 4 including psychological, motor, speech/ language, pre-educational skills, social/emotional, and attention/ concentration/ memory. It is also possible for the assessment team to use arena assessments with older children as well. These types of assessment are particularly relevant to young children as each area is dependent on the other areas for proper development to occur. For example, if a child has difficulty with motor movements, it may be difficult for the child to grasp and reach for toys, which then hampers the child's cognitive development by not being able to explore toys. A child with a speech language delay may have difficulty communicating, which may lead to an increase in behavior problems and may impede social development. Therefore, a comprehensive assessment, which addresses all of these areas, becomes crucial in uncovering the root of a child's difficulty. The assessment results can then lead to targeted interventions which will improve a child's ability to function in a family and community. The following procedure would be used to conduct this type of assessment: 1. Referral Consultation- The PhD will meet with the caseworker after receiving the referral to gather background information and to clarify and develop specific referral questions. 2. Intake- The PhD will meet with the client's primary caregiver to conduct a thorough clinical interview and sign necessary paperwork including releases of information. 3. Testing-The PhD will use a variety of instruments to address the referral questions. Assessment may involve the following areas and may utilize these or similar instruments: cognitive (Wechsler Preschool Primary Scale, Bayley Infant Development Scale, Wechsler Intelligence Scale for Children- Fourth Edition, Universal Nonverbal Intelligence Test); personality (Children's Personality Inventory, Trauma Symptom Scale, Draw-A-Person Screening Procedure for Emotional Disturbance, HTP, Kinetic Family Drawing); attention/ memory/ concentration (Children's Memory Scale, Cognitive Assessment System, Behavior Assessment System for Children, NEPSY); achievement/ educational (Woodcock-Johnson Tests of Achievement, Wechsler Individual Achievement Test); adaptive behavior (Vineland, GADS, GARS, ADOS). In addition, the child's speech/ language abilities would be assessed using developmentally appropriate measures. The child's motor abilities would be assessed by an occupational therapist, and a physical therapist. 4. Report Results- The PhD will write a comprehensive report explaining the test scores and give specific recommendations Mental Health Services 2005-2006 Transitions 5 relevant to the referral question. In addition, the report would record the child's present level of abilities and recommend strategies to overcome any areas of weakness. C. Consultation with Caseworkers The PhD will collaborate with the caseworker throughout the assessment process, beginning with the referral consultation. The PhD will be available to respond to caseworker questions and requests within 24 hours by phone or e-mail. The PhD will work directly with caseworkers to integrate assessment information into the care plans. Reports will be made available to caseworkers and other professionals as dictated by state and the APA ethical guidelines. Transitions will collect information from and provide information to collateral contacts as permitted within these guidelines. The PhD will notify the caseworker of any suicidal ideations, homicidal ideations and any other forms of gross mental impairment. The PhD will work with the caseworker to seek appropriate and immediate interventions. The PhD will work with other clinicians and agencies regarding rationale of recommendations and to determine appropriate level of care. D. Court Testimony The PhD will be available to provide court testimony on current and former clients when given proper notification. IV. MEASURABLE OUTCOMES A. Transitions will complete evaluations not more than 45 days from receiving the referral, providing that the client is cooperative with keeping scheduled appointments. Transitions will track the number of days from the receipt of the referral until the report is submitted. B. The PhD will meet with the caseworker to discuss specific results, recommendations and interventions. The PhD will be available to answer questions within 24 hours of receiving a question. The PhD will document that the pre and post assessment meetings have Mental Health Services 2005-2006 Transitions 6 occurred and track dates of caseworker contacts and Transitions response date. C. The PhD will meet with the caseworker face to face at the beginning of the referral and at the end of the referral and document that these meetings have occurred. They will also initiate and document contact at least weekly with the referring caseworker. In addition, the PhD will be available to respond to caseworker questions within 24 hours of receipt. The PhD will keep track of the number of contacts between caseworker, clients, and other professionals and the timeliness of those contacts. D. The PhD will be available to respond to outpatient program questions within 24 hours by phone or e-mail. The PhD will track these contacts to ensure the timeliness of their response. E. The PhD will recommend therapeutic interventions based on the results of the assessment. The PhD will be available to consult with the caseworker on where to locate such services. F. Transitions will be available for emergency consultations within 24- hour of the request. The PhD will document that emergency contacts are conducted within 24 hours. Psychological evaluations will be comprehensive and thorough, leading to specific recommendations and interventions that will meet court standards. Each assessment will be supervised by a licensed psychologist and internally reviewed before it is submitted. When possible, Transitions staff will utilize existing data and incorporate that information to avoid duplicating services. Transitions will review referrals to assure that FYC resources will not supplant existing and available services in the community. V. SERVICE OBJECTIVES A. Improve family conflict management- Transitions assessment services will provide vital diagnostic information to assist in effective service planning. This will be measured by the inclusion of the results and recommendations section of the reports and documented consultations with caseworkers. B. Improve household management competencies-Transitions PhDs will assist caseworkers in evaluating the capacity of parents to provide a safe household environment for children, including the determination of any gross impairments, suicidal ideation or homicidal ideation. The Mental Health Services 2005-2006 Transitions 7 PhD will discuss competencies with the caseworker and document them in the reports. C. Improve ability to access resources-Transitions will provide comprehensive assessment services that will determine a clients functioning in a variety of areas. The recommendations in the report will identify applicable resources and the resulting diagnoses may qualify clients for new services that the client has not previously been able to access (e.g. social security). VI. WORKLOAD STANDARDS Assessment Services will be provided Monday through Saturday from 8am — 8pm, by appointment and will be scheduled to meet the client's scheduling needs and PhD's availability. Assessment times will vary based on the referral questions but will generally occur over the course of three weeks. There will be a total of three PhDs providing services. Transitions is in the process of recruiting additional assessment personnel, including a bilingual psychologist. Each PhD will have up to five individuals to assess at any given time. Assessment will be comprised of interviews, information gathering, testing, report writing, feedback and consultation. A Licensed Psychologist (LP) will supervise all PhDs. The LP will supervise three PhD's and a maximum of 15 concurrent cases. Transitions will complete up to 12 assessments per month. All providers will maintain professional liability insurance coverage of at least $1,000,000 for each occurrence and $3,000,000 aggregate. VII. STAFF QUALIFICATIONS A. Transitions staff providing direct services meet or exceed the qualifications in Staff Manual VII. All psychological assessment staff have a PhD in the field of psychology. In addition, each staff member has at least three years of professional experience. For the arena assessments, a certified Speech Language Pathologist, Certified Occupational Therapist, Certified Physical Therapist, and Educational Psychologist will also be used to address each area. The Occupational and Physical Therapist will address the motor and adaptive functions. The Speech/ Language Pathologist will assess a child's ability to effectively use expressive and receptive language, and the Educational Psychologist will assess a students academic or pre-academic skills. Mental Health Services 2005-2006 Transitions 8 1. Nicole R. Warnygora, PhD, LPC has been a school psychologist in the Ft. Collins schools for four years, providing assessment and intervention strategies for children in preschool through high school. She has also provided emergency risk assessments and mental status evaluations through the Poudre Valley Health System. Nicole has worked as a licensed professional counselor for several years and has testified as an expert witness in numerous court proceedings. 2. Molly Geil, PhD, Licensed School Psychologist, is an adjunct faculty member at the University of Northern Colorado where she has taught courses in assessment and intervention and supervised doctoral level students. Molly consults internationally as a school psychologist and also worked as a school psychologist in Weld District 6. Molly has testified in court. 3. Charles Howard, PhD, Licensed Psychologist has more than 12 years of experience with assessments, supervision, consultation and court testimony. B. Transitions has two license eligible psychologists contracted to perform assessment services and one supervisor who is a Licensed Psychologist. Transitions also has a Nationally Certified School Psychologist to perform educational assessments and will contract with physical, occupational and speech therapy professionals to perform the other facets of the arena assessments. C. Staff will participate in new caseworker training as applicable. D. All PhDs have training and experience in the area of risk assessment and intervention. I I I I I I I I I I I I I W W ^ N co 0 m a to N a in N _ - coA N O r .- D7 - T (CD W N D) N . V O Lb W CD N 69 a 69 S NM Vi N 9 N CO Y O O ' y t0 CD to O a co to O O V M W CJ p N CD a N N D0) 0) 0)) N T 0 J w S 69 a V3 a » 0 _ / C � W IG re o ^ Ln 0 N O O)ri co- . N N- O O n 0 to 1L S e9 S (9 M 9 S T r 0 0 W 0 a a x a 0 g al In G7 _ K 0 FO m a + U U Q O a K d' Z K U _i W Cr - W Co Q CO Q + } a LL}i W U CO K(7 = 2 U W re w O 0 2 F a O a 0 W Q U a CC O O o r 5O W a Q a in H a U U W N w 1-- O O 0 W m w re a y co F F W U W dO p I N U v U C W F W N W U.K a 0 LLU Co U O Z m O ag W O j O CC O OLL, O U Z m O X a 0 O W a O w O } OU Z U Z rU- Li_o co>- y J } co W ❑ W F O to O a O Q a Q m ¢ CC U Co -J' Z• N z ≥ O U CC O O FO m w OU m p a O o n co } O co co iti - F- O co ¢ a ¢ O co Z O K Z K O U 5 OU is O N co O j g Z 0 J O a _K F 2¢0Lij m ° _ O (p r _, a 0 W W o a OU 0 2 w o F re O 0 o Co 0 0 > o Z I- I- 13 0 F Q 0 F Z 0 0 aQ O O Q m 0 0 W a ('J = _ U _, J X kl 6 qp Fa"a r S Y L'o " Y"rr'-' m88888888888883 w $$8 8 8 o QW O O4i LL f a °TR a 888888888888 !! 8 !2:25,g 8 8 ¢00 S Q 2 »w N w N w N N»»»N„ w » W N 8 jZ$a8 N P i- g 880 lot. 8 is, 8 a aea 3 40 ›. 8$8$ 8880 88888 lic to act. co o N 8 W pw�0 ^' N re o sss$ss83 mss$ amass W ins NwNwNw h$» »�» F a IllLU WIO 4 p 8 fr „co „ „ „ O FO o Q a 630 t 4-3 Xa °O 00000000000000 w00000 20 zzzzzzzzzzzzzz )- zzzzz 4 ySS� °'°'°888883888 8 f;'5 a»Nw»» » »»»» » 8 l w a tiE g 18 . 0 W @E $ 4U E q .1 h 3t , y} y O a't j tS i tt.'S K p ;x 3 u tiAt '^'.. { x N :"^'aS a°d rc `�*,,, y`� a{yk I r'cty u L ,e yp' , . _ mod. 0 x,y �' LL s "b, " �'Y't' U I'�^' t5" v'a 8¢ a � y � � 'F'`-�aS y3El� �V .. p °K''kd 4 . U' C C 4g a C re t'fYn .. "“4",4. 4....7 6 `-�Y i�t�r N U YY C yp a „ c ,4 ci ,M � 45! `➢c.t. 6 abay x..of.,' O W rc � a ,ai�t . ro i �f g�, ix °.� ,��t3'�` U a o ¢ u " P---4,- .. s $ , r P r ' .; W u i Z.2 a d bt y� 46--.)-4-- sv^x '. 3 p - - ti.-' 0 0 W W J b2t' ' it U { 1 k i J _ 4^ y % � Q I a a t,', ays 'P d YS' K W = 0 8 O O O t }' @i � v- a ZQ0 6 F H F S A3 0 F ,,, 0 Q O U 1- uat„ �I U' 0 4-owo.K •y�m t y gy�`�� ':y'. i MF rui+J'nw ..3 sbn7d�r 888 88882' 8888 8 88SS8S moo «»»»»»»»wwwwww »� �»'4 w wwwww W F O Lucos m 0W0 0 *W 1 Sm 88888 8888 8888 8 88°9e °g008 im m�88$$«»w»$$»» '''wwww R $`w w ww w w 0 3 �o� m o ' 8 2zi w' e W � 'YI Y 4. Xwww E € '� i w y 8888 SSS8888S88 8 sgsss88 LL cc aw 0w'°wei $ = x 0 N O I- , H Q owo `° 8 S 8 -ant'' —": ��° !L ^ w x w 6 w Fd r a „r...` z ,- '6' 88SS8888S88888 8 8. 00 S K o .....0.9,2a:22.9, ioo6yow ow000w000wo bow ow»oo h arc ..So ww ww w p z »»ww w w U i- 0 is w • g 200 9 w o f O W z w *'°; swo. E m 2,,1 "' I W �e6 8� wwwwz90 00000000 000ggoo n zzzzzzzzz zzz zz S88S8 .8o88SS22 S8°888» 888 h ,... 8 8 wwww w ww$» i w - w y m g Y, ,,, y 6 w' Vc r,.1 w m bit ,(1,1:'''',-,,' �i . .. M ;IC at 0 3I. * i 4 I hE A' 414iliz .'`.'4444.1 wit'. ay OW,z -r ,}i b� a4 # Y� ii W - ' o,i7 S , ,„ a p, a ' .,k '.::..19 ao rc >₹w r ' 6 � 'W 6 Ostia 4 ` k,;:,:...:.,1-4%-, v s S 8 8LL .- LL LL ua w ly �� ''� 2 z : a o d 6 O $.r Q .A. §'LL w t , n S ., „ko W x V co K n . , a ' wl 4 ,v 0' wO w w "{i w aw w ; g m % r j¢; r .f 0. . y �y""3 o FO rc LL 5S O yYtit SS U x w o .g a a w us yyg V U x i 4 4' _ #'aa a Y , Uy� axS.`}@R .}'3 'k5 ;:x' ' t .`:e� 8 J6 aSii 88888888888888898 O O 8 O O wog U w w w w»»»w s w w»»»» »w a » w on a Jib a O w `a xa <2 , W, <8asassassssssssss s 0j 0.. W (g222222w22»222222 a00 og0w' 8 8 ;lit(es.' w, al w w w w O ' O CO CO 2 I QWq <C f s LL UO <g £ d OLL [t ,a a 888888888888888888 2 8 o a8 0� N 8 8 s X222222»2 »2222»�� C §% , w » w a o ;,- w 0 W re QO > 82 ,, o d` pt' CoF J w'S 888888888888888888 8 X�yypp�2 13, 8 8 8 222228282282220»»$ m `8 2 w g g i m $ p JJ E $ ag2 tr 4` > go 22 w0000000000000000 0 i�zzz zzzzz zzzzzzzz z 20J a - oc E V--q0, n �sf U ¢ t �x S Q Li,{',-'.5 ypyr�"' 55. ?i t.t r' _,5 c CO tit pp LL N� �+ `v. Y„,,,,,-0,,,,,, 3 33 K a 6 LL p6' a A �,'}`!�'.'ya"?' 7,32 dy O Ia 6 O v'5 T113/424'1,6 9 fl1. H T W 6 j vd 1 K0 W 6 e 5.. 4� - 0 F e,µ m W •i }� Istp n i ' a m PA 0 a a O - C '3. '*'fv S.. W a W W J 99 g ..' hS.AtANit �. YI 0 J s O g O O O > K.,..!,*..,,..44 a a a 9wF I- F (9 CNA Healthcare Providers Service u n�O Organization Purchasing Group 1 11 CNA Plaza, • Chicago,IL 60685 C�Serttft �" .catr of ,1neuran.ce Producer Branch Prefix Policy Number Policy Period from: 12:01 AM Standard Time on: 11/14/04 018098 970 HPG 272975956-8 to: 12:01 AM Standard Time on: 11/14/05 Named Insured and Address Program Administrator Healthcare Providers Service Organization NICOLE R WARNYGORA 159 East County Line Road 1800 ANGELO CT Hatboro, PA 19040-1218 FORT COLLINS CO 80528-6375 Medical Specialty: Code: Insurance Provided by Mental Health 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 $6,000,000.00 aggregate Good Samaritan Liability Included above Personal Injury Liability Included above it'I-alplacement 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 I $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 None l None Hired Auto & Non Owned Auto None Fire & Water Legal Liability None None Personal Liability 1 None Total Premium $125.00 Policy forms and endorsements attached at inception QUESTIONS? CALL: 1-800-982-9491 G-144872-A G-145184-A G-121500C G-1215010 G-123846C-05 G-121503C G-147292-A Healthcare Providers Service Organization is a division of Affinity Insurance Services,Inc.;in NY and NH.AIS Affinity Insurance Agency:in MN and OIL.AIS Affinity Insurance Agency.Inc;and in CA.AIS Affinity Insurance Agency,Inc.dba Ann Direct Insurance.administrators License#0795465. Master Policy: 188711433 Keep this document in a safe place. This and � � {� l (/v your cancelled check act as proof of coverage. AY.LtChairman of the Board Secretary 925 XX 0000097-R 04090A RPNNCP 2/04 R7a6NM 042%2 • THE DOCTORS ' COMPANY PROFESSIONAL COUNSELORS PURCHASING GROUP 4/22/04 Mental Health Counselors Professional Liability Policy NOTICE: A SMALLER LIMIT OF LIABILITY APPLIES TO JUDGEMENTS OR SETTLEMENTS WHEN THERE ARE ALLEGATIONS OF SEXUAL MISCONDUCT(SEE THE SPECIAL PROVISION "SEXUAL MISCONDUCT"IN THE POLICY). DECLARATIONS POLICY NO: MHL-5026599 ACCOUNT NO: CO-GEIM235-0 0429116I ITEM ]. NAME AND ADDRESS OF INSURED: ADDITIONAL NAMED INSUREDS: MARY E . GEIL 2357 42ND AVE. PL. GREELEY, CO 80634 ITEM 2. ADDITIONAL INSUREDS: ITEM 3. DESCRIPTION OF BUSINESS Individual-PART TIME ITEM4. POLICY PERIOD: FROM: 04/12/04 TO: 04/12/05 12:01A.M. STANDARD TIME AT THE ADDRESS OF THE INSURED AS STATED HEREIN: ITEM 5. LIMITS OF LIABILITY: S 1 , 000 , 000 EACH WRONGFUL ACT OR SERIES OF CONTINUOUS,REPEATED OR INTERRELATED WRONGFUL ACTS OR OCCURRENCE 3 , 000 , 000 $ AGGREGATE ITEM 6. PREMIUM SCHEDULE: CLASSIFICATION NUMBER RATE ANNUAL PREMIUM SELF EMPLOYED SCHOOL PSYCHOLOGIST 1 179 . 00 179 . 00 TOTAL PREMIUM: 179 . 00 ITEM 7. POLICY FORMS AND ENDORSEMENT ATTACHED TO THIS POLICY: PCPGMHC002 (2/00) PCPGMHC001 (02/00) PCPGMFTMHC101CO 2/00 PCPGMFT-MHC207 (4/03) PCPGMHC2062/00 PCPGMHC201 (2/00) C AUTH IZE, OMPANY REPRESEN ATIVE THIS IS NOT A HILT.. PHEW"'Mt HAS RIPEN PAID. ALLIED HEALTHCARE PROFESSIONAL AND SUPPLEMENTAL LIABILITY INSURANCE POLICY DECLARATIONS RENEWAL DECLARATIONS ATTACH THIS RENEWAL DECLARATIONS TO YOUR EXPIRING POLICY Policy Number: PHCP039718 Philadelphia Indemnity Insurance Company Administered by: CPH &Associates 711 S. Dearborn, Ste. 205 Chicago, IL 60605 Charles A. Howard 804 Eleventh Ave Greeley, CO 80651 Affiliation: NSP Professional Occupation: PSYCHOLOGIST Coverage Term From: (Effective Date) 06/18/04 To: (Expiration Date)06/18/05 at 12:01 a.m. Standard Time at the Insured's Mailing Address shown above. COVERAGE A— PROFESSIONAL LIABILITY LIMITS OF LIABILITY PREMIUM COVERAGE Individual —Each Incident: $1,000,000 $380.00 Aggregate: $3,000,000 Association, Partnership or Corporation—Each N/A Incident: Aggregate: N/A COVERAGE B—SUPPLEMENTAL LIABILITY COVERAGE Each Incident: $1,000,000 Aggregate: $3,000,000 Policy Forms and Endorsement: The expiring policy forms, endorsements and limits of insurance apply to this renewal unless changes are shown on this Renewal Declaration. Premium (including taxes): $380.00 Call the Administrator to Verify Claims History at 1-800-875-1911 23-0 Jamie Maguire, Authorized Representative PHCP-01(3/01 ) Healthcare Providers Service LCNA Organization Purchasing Group Tn C O T Plaza H Chicago,I t 60685 n,.ue<.n Newsier*service uw...r; T.erttf rate of ,:4Jusuran.c.e Producer Branch Prefix Policy Number Policy Period 018098 970 HPG 270170686-8 from: 12:01 AM Standard Time on: 07/04/04 Named Insured and Address to: 12:_01 AM Standard Time on: 07/04/05 Program Administrator GREGORY S CREED Healthcare Providers Service Organization G4 ORYH ACE 159 East County Line Road GREELEY CO 80631-3246 Hatboro, PA 19040-1218 Medical Specialty: Code: Insurance Provided by Clinical Counselor 729% 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 Good Samaritan Liability Included above $6,000,000.00 agareaate • Personal Injury Liability Included above Malplacement Liability Included above B. Coverage Extensions License Protection $5,000.00 per proceeding Defendant Expense Benefit $12,500.00 aggregate Deposition Representation $1,250.00 per deposition $5,000.00 aggregate _ • Assault $2,500.00 aggregate Medical sul Payments $5,000.00 per incident $12,500.00 aggregate First Aid $1,000.00 per person $50,000.00 aggregate $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 Personal Liability T $150,000 sub-limit I $500,000.00 aggregate D. GENERAL LIABILITY Coverage part D. does not apply if Coverage parr C. is made part of this policy. Workplace Liability None Hired Auto & Non Owned Auto Noise None Fire & Water Legal Liability 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-121500C G-121.531C G-123846C-05 G-121503C Healthcare Providers Senice Organization is a di‘isine of Affinity Insurance Services,Inc.:in NY and NH.AIS Affinity Insurance Agency,in MN and OK,AIS Affinity Insurance Agency.Inc.;and in CA AIS Affinity Insurance Agency,Inc dba Aon Direct Insurance Administrators ors License#0795465 Master Policy: 188711433 A.Y.4. Keep this document in a safe place. This and ��-st- ?p,..4-4/AVAA\41- your cancelled check act as proof o£coverage. ill Chairman of the Board Secretary 925 XX 000024c-R n6na7c orWann - 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 Heaithcare Providers Service Organization is a division of Affinity Insurance Services.Inc:in NY and NH.AIS Affinity Insurance Agency;in MN and OK.MS Affinity Insurance Agency.Inc.;and in CA MS Affinity Insurance Agency,Inc.ciba Ann Direct Insurance Administrators License 40'•95465 Master Policy: 188711433 Keep this document in a safe place. This and j w{ your cancelled check act as proof of coverage. 61 Chairman of the Board Secretary 925 XX 0000246—R 040426 RENHCP 2/04 R177HM 04117 NA Healthcare Providers Service Organization Purchasing Group ®HPSO rA Plaza, 1 1,, v 'cago,II.60685 4neurance „..w..Rr.,<r<ns<rk<oT:.y�- Tertificate of Producer Branch Prefix Policy Number Policy Period from: 12:01 AM Standard Time on: 07/04/04 018098 970 HPG 270170798-8 Named Insured and Address Program Administrator Healthcare Providers Service Organization JAMI M0E 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 $6,000.000.00 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 I $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 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 Insurance Services,Inc.;in NY and NH.AIS Affinity Insurance Agency;in MN and OK,AIS Affinity Insurance Agency,Inc.;and in CA.AIS Affinity Insurance Agency,Inc.dba ion Direct Insurance Administrators License d07959G5. Master Policy: 188711433 , Keep this document in a safe place. This and j 20-4/AX\14-- ` your cancelled check act as proof of coverage. A-Y.4 i-P11( Chairman of the Board Secretary 925 XX 0000246-R 040426 RENHCP 2/04 R177HM 04117 SUPPLEMENTAL NARRATIVE TO RFP: EXHIBIT B CONDITIONS • •• 4. • 804 11th Avenue • s • • •ea • Greeley, CO 80631 • •ig y Phone: (970)336-1123 Pi y FAX: (970) 351-0182 • , : Cell: (970) 590-1424 RECEIVED APR 27 115 i Transitions molaOGY QaJP LW Weld County Dept. of Social Judy Griego, Director Clerical Unit s 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, C--.2 Gregory S. Creed, MA, LPC Cc: Jami Moe-Hartman, Co-director, Transitions Psychology Group, LLC i 7 vo • •.•i�! { • 80411'"Avenue FAX •: ••• Greeley, CO 80631 . • y . . Phone(970)336-1123 soot. *= • FAX(970)351-0182 •tea Transitions PSYCHOLOGY G•OOP L C 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. 04/26/2005 11:52 3510182 PAGE 01 ' i•wa `' 804 11th Avenue FAX • . •te Greeley, CO 80631 .21040 y • Phone(970)336-1123 •#O• FAX(9T0)351-0182 • *Le t . Transitions ..,� CROUP.LUC 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 strlcUy 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. £4/26/2005 11:52 3510182 PAGE 02 so -t ► 0 *JO_; 80411t Avenue • Y i y * Greeley, CO 80631 *M 0 .r : - Phone: (070) 33G-1123 • 0 y 4 ` FAX: (970)351-0182 rid v„ Cell: (970)590-1424 •• :4 Transitions � tMc Judy Griego, Director Weld County Department of Social Services PO Box A Greeley, Colorado 80632 April 26, 2005 Re: RFP 04005: Lifeskilis 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: Lifesldlls: 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 8:00AM-12:00Noon with only one therapist available for 04/26/2005 11:52 3510182 PAGE 03 • 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, Gregory S. Creed, MA, LPC Cc: Jami Moe-Hartman, Co-director, Transitions Psychology Group, LLC DEPARTMENT OF SOCIAL SERVICES 61, tts 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 O � April 18,2005 COLORADO Greg Creed,Co-owner Transitions Psychology Group,LLC 80411 Avenue Greeley,CO 80631 Re: RFP 04005: Lifeskills RFP 006-00A:Foster Parent Consultation RIP 006-0OB:Home Study,Relinquishment Coimarling 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, eilt gostr cc: Juan Lopez,Chair,FYC Commission Gloria Romansik,Social Services Administrator Weld County Department of Social Services Notification of Financial Assistance Award for Families,Youth and Children Commission (Core) Funds Type of Action Contract Award No. X Initial Award 05-CORE-56 Revision (RFP-FYC-006-00) Contract Award Period Name and Address of Contractor Beginning 06/01/2005 and Jack J. Gardner, Psychologist Ending 05/31/2006 Mental Health Services 1228 8th Street Greeley,CO 80631 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Program provides screening, evaluations, and Assistance Award is based upon your Request for other assessment services intended to provide Proposal(RFP). The RFP specifies the scope of information needed by Social Services staff. services and conditions of award. Except where it is Capacity is 6-12 evaluations per month,average in conflict with this NOFAA in which case the capacity is 8. Cultural/Ethnically specific NOFAA governs,the RFP upon which this award is services are not available at this time. based is an integral part of the action. Special conditions Cost Per Unit of Service 1) Reimbursement for the Unit of Services will be based Episode Rate Per on an hourly rate per child or per family. Psychological Evaluations 2) The hourly rate will be paid for only direct face to Psychological Exam $1,300.00 face contact with the child and/or family, as Other Services $900.00 evidenced by client-signed verification form, and as Diagnostic Services $1,600.00 specified in the unit of cost computation. Hourly Rate Per 3) Unit of service costs cannot exceed the hourly and Interactional Evaluations yearly cost per child and/or family. Treatment Package $100.00 4) Payment will only be remitted on cases open with,and Parent-Child Interactions $110.00 referrals made by the Weld County Department of Court Testimony $160.00 Social Services. Professional Consultation $110.00 5) Requests for payment must be an original submitted to Individual Counseling $100.00 the Weld County Depaitnient of Social Services by the Family Counseling $100.00 end of the 25th calendar day following the end of the Daily Rate Per month of service. The provider must submit requests Other Services* $1,200.00 for payment on forms approved by Weld County * Child Welfare Administration Funds Department of Social Services. Enclosures: 6) The Contractor will notify the Department of any X Signed RFP: Exhibit A changes in staff at the time of the change. X Supplemental Narrative to RFP: Exhibit B Recommendation(s) X Conditions of Approval Approvals: Program fficiial: By By William H. Jerke, Chair Judy Griego,i3irector Boar of Weld County Commissioners Weld unty Department o Social Services Date: atiN C t , JUJ Date: de0S - 1653 SIGNED RFP: EXHIBIT A INVITATION TO BID BID 002-05 (05005--05011 and 006-00) DATE: February 16,2005 BID NO: RFP-FYC-006-00 RETURN BID TO: Pat Persichino, Director of General Services 915 10th Street,P.O.Box 758,Greeley, CO 80632 SUMMARY Request for Proposal (RFP-FYC-006-00) for: Colorado Family Preservation Act—Mental Health Services Emergency Assistance Program 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 under the Colorado Family Preservation Act(C.R.S. 26- 5.5-101) and Emergency Assistance for Families with Children at Imminent Risk of Out-of-Home Placement Act(C.R.S. 26-5.3-101). The Families,Youth and Children Commission wishes to approve services targeted to"run from June 1,2005,through May 31,2006, at specific rates for different types of service. The County will authorize approved vendors and rates for services only. The Mental Health Services program provides diagnostic and/or therapeutic services to assist in the development of the family services plan,to assess and/or improve family communication, functioning and relationships. This program announcement consists of five parts, as follows: PART A...Administrative Information PART D...Bidder Response Format PART B...Background,Overview and Goals PART E...Bid Evaluation Process PART C...Statement of Work Delivery Date (After receipt of order) BID MUST BE SIGNED IN INK n TYPED OR PRINTED SIGNATURE VENDOR '"e-4 a o �G�N.IC y- (Name) d ' en Signature By Authorized p ffic or Agent of Vender ADDRESS r4t4 r/� ' "� TITLE /Se-`gleg 4 id; f¢ 5/• .'rtc y,f DATE T-/v-as PHONE# 97o- 3i • a - The above bid is subject to Terms and Conditions as attached hereto and incorporated. Page 1 of 32 ' Bid 002-05/RFP-FYC 05005 through 05011 and 006-00 TERMS AND CONDITIONS RFP-FYC-05005 through 05011 and 006-00 1. The Contractor agrees it is an independent contractor and that its officers and employees do not become employees of Weld County,nor are they entitled to any employee benefits as Weld County Employees if this RFP/Bid is accepted by the Board of County Commissioners. 2. Weld County,the Board of County Commissioners of Weld County, its officers and employees, shall not be held liable for injuries or damages caused by any negligent acts or omissions of Contractor or its employees,volunteers, or agents while performing duties as described pursuant to this RFP/Bid. Contractor shall indemnify, defend, and hold harmless Weld County, the Board of County Commissioners of Weld County, its employees,volunteers, and agents. The Contractor shall provide adequate liability and workers' compensation insurance for all its employees, volunteers,and agents engaged in the performance as prescribed under the RFP/Bid. 3. No portion of this Bid shall be deemed to constitute a waiver of any immunities the parties or their officers or employees may possess,nor shall any portion of the RFP/Bid be deemed to have created a duty of care with respect to any persons not a party to this RFP/Bid. 4. No portion of this RFP/Bid shall be deemed to create an obligation on the part of the County of Weld, State of Colorado,to expend funds not otherwise appropriated in each succeeding year. 5. If any section, subsection,paragraph, sentence, clause,or phrase of this RFP/Bid is for any reason held or decided to be unconstitutional, such decision shall not affect the validity of the remaining portions. The parties hereto declare that they would have entered into this RFP/Bid and each and every section, subsection,paragraph, sentence,clause, and phrase thereof irrespective of the fact that any one or more sections, subsections,paragraphs, sentences, clauses, or phrases might be declared to be unconstitutional or invalid. 6. No public official or employee of Weld County, Colorado, and no member of their governing bodies shall have any pecuniary interest,direct or indirect,in the approved RFP/Bid or the proceeds thereof. 7. The Contractor assures that they will comply with the Title VI of the Civil Rights Act of 1986 and that no person shall, on the grounds of race, creed,color, sex, or national origin,be excluded from participation in,be denied the benefits of, or be otherwise subjected to discrimination under an approved RFP/Bid. 8. The Contractor assures that sufficient, auditable, and otherwise adequate records that will provide accurate, current, separate, and complete disclosure of the status of the funds received under the RFP/Bid are maintained for three(3)years or the completion and resolution of an audit. Such records shall be sufficient to allow authorized local, federal, and state auditors and representatives to audit and monitor the Contractor. 9. The Contractor assures that authorized local,federal, and state auditors and representatives shall, during business hours,have access to inspect and copy records, and shall be allowed to monitor Page 2 of 32 • Bid 002-05/RFP-FYC 05005 through 05011 and 006-00 and review through on-site visits, all contract activities, supported with funds under this RFP/Bid to ensure compliance with the terms of this RFP/Bid. Contracting parties agree that monitoring and evaluation of the performance of the RFP/Bid shall be conducted by appropriate funding sources. The results of the monitoring and evaluation activities shall be provided to the appropriate and interested parties. 10. A RFP/Bid which is approved by the Board of County Commissioners of Weld County, shall be binding upon the parties hereto,their successors,heirs, legal representatives, and assigns and shall constitute a contract without further action by the Board. The Contractor or Social Services may not assign any of its rights or obligations hereunder without the prior written consent of both parties. 11. The Contractor assures that it will fully comply with the Weld County Family Preservation Program regulations promulgated, and all other applicable federal and state laws,rules and regulations. The Contractor understands that the source of funds to be used under this RFP/Bid is: Emergency Assistance Program Funds under the Colorado Family Preservation Act 12. The Contractor assures and certifies that it and its principals: a. Are not presently debarred, suspended,proposed for debarment,declared ineligible,or voluntarily excluded from covered transactions by a Federal department or agency; b. Have not,within a three-year period preceding this RFP/Bid,been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public(Federal, state, or local)transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement,theft, forgery,bribery, falsification or destruction of records,making false statements,or receiving stolen property, c. Are not presently indicted for or otherwise criminally or civilly charged by a government entity(federal, state, or local)with commission of any of the offenses enumerated in paragraph 12(b)of this certification; and d. Have not within a three-year period preceding this RFP/Bid,had one or more public transactions(federal, state, or local)terminated for cause or default. 13. The Appearance of Conflict of Interest applies to the relationship of a contractor with Social Services when the contractor also maintains a relationship with a third party and the two relationships are in opposition. In order to create the appearance of a conflict of interest, it is not necessary for the contractor to gain from knowledge of these opposing interests. It is only necessary that the contractor know that the two relationships are in opposition. During the term of this RFP/Bid,if it is approved by the Board of County Commissioners,the contractor shall not enter into any third party relationship that is a conflict of interest or gives the appearance of creating a conflict of interest. Upon learning of an existing appearance of a conflict Page 3 of 32 , Bid 002-05/RFP-FYC 05005 through 05011 and 006-00 •of interest situation,the contractor shall submit to Social Services a full disclosure statement setting forth the details that create the appearance of a conflict of interest. Failure to promptly submit a disclosure statement required by this paragraph shall constitute grounds for Social Services'termination, for cause,of their contract with the contractor. 14. Contractor shall protect the confidentiality of all applicant records and other materials that are maintained in accordance with this RFP/Bid, if it is approved by the Board of County Commissioners. Except for purposes directly connected with the administration of the Emergency Assistance Program,no information about or obtained from any applicant/recipient in possession of Contractor shall be disclosed in a form identifiable with the applicant/recipient or a minor's parent or guardian. Contractor shall have written policies governing access to, duplication and dissemination of, all such information. Contractor shall advise its employees, agents and subcontractors, if any,that they are subject to these confidentiality requirements. Contractor shall provide its employees, agents, and subcontractors,if any,with a copy or written explanation of these confidentiality requirements before access to confidential data is permitted. 15. Proprietary information for the purposes of this contract is information relating to a party's research,development,trade secrets,business affairs,internal operations and management procedures and those of its customers,clients or affiliates,but does not include information(1) lawfully obtained from third parties, (2)that which is in the public domain, or(3)that which is developed independently. Neither Party shall use or disclose directly or indirectly without prior written authorization any proprietary information concerning the other party obtained as a result of an executed contract. Any proprietary information removed from the State's site by the Contractor in the course of providing services under this RFP/l3id will be accorded at least the same precautions as are employed by the Contractor for similar information in the course of its own business. • Page 4 of 32 Bid 002-05/RFP-FYC 05005 through 05011 and 006-00 PART A ADMINISTRATIVE INFORMATION 1. Legislative Authority The Colorado Family Preservation Act and the Emergency Assistance for Families with Children at Imminent Risk of Out-of-Home Placement Act authorize the Board of Weld County Commissioners to expend funds for the development and implementation of alternatives to out-of- home placement of children. 2. Issuing Office This Request for Proposal (RFP)is issued for the Board of Weld County Commissioners by the Director of General Services for the benefit of the Families,Youth and Children Commission. The Director of General Services is the SOLE point of contact concerning this RFP. MI communication must be done through the Director of General Services. 3. Purpose This RFP provides prospective bidders with sufficient information to enable them to prepare and submit proposals for consideration by the Board of County Commissioners of Weld County to satisfy the need for expert assistance in the completion of Families,Youth and Children Commission goals of this RFP. 4. Scope This RFP contains the instructions governing the proposal to be submitted and the material to be included therein;mandatory requirements which must be met to be eligible for consideration; and other requirements to be met by each proposal. Page 5 of 32 Bid 002-05/RFP-FYC 05005 through 05011 and 006-00 2005-2006 • FYC BID PROCESS 5. Schedule of Activities SCHEDULE OF ACTIVITIES DATE(S) ACTIVITIES DESCRIPTION A. Announcement to February 10, 2005, Announcement activities will include: Prospective Bidders through February 13,2005 - a request to all prospective Concerning Request for bidders to pick up a bid Proposal packet(s)on February 16,2005. - a budget estimate - a requirement to all prospective bidders that the bidders must attend a Prospective Bidders Conference on February 16, 2005,or a bidder will not be allowed to compete in Bid No. 002-05 (05005 through 05011 and 006-00.) Activities will include: 1. Sending letters to our current contractors. 2. Advertising the announcement to prospective bidders through newspapers & radio. 3. Releasing a press release. B. Prospective Bidder February 16, 2005 (1:00 The Prospective Bidder Conference will Conference p.m. to 3:00 p.m.) be mandatory and will include: - the RFP Bid Format for renewing current programs approved for FY 2004-2005 - The RFP Bid Format for all new prospective bidders or current providers requesting major changes to programs approved for FY 2004-2005, - an overall description of the RFP process - a release of the RFP Bid Package which will include: A. The RFP Bid Format, B. The latest version of the Colorado Family Page 6 of 32 Bid.002-05/RFP-FYC 05005 through 05011 and 006-00 Preservation Act criteria, . C. An opportunity by Bidders to ask questions about the RFP Bid Package, and D. A listing of Assigned Social Services Division Supervisors. (Each Prospective Bidder will be required to meet with their assigned Social Services Supervisor to discuss the design of their project prior to its formal submission as indicated by the signature of the assigned Social Services Supervisor in the final Bid submittal.) C.K Written Inquiries from February 18, 2005,by 5:00 FYC Bidders p.m. D. Response Conference to February 23, 2005, from The Response Conference to Written Written Inquiries, 1:00 p.m. to 3:00 p.m. Inquiries will be mandatory and will Submitted by FYC include: Bidders - a written response to Written Inquiries Submitted by FYC Bidders - a written response to vendors requesting renewal of FY 2004- 2005 bids - a unit cost description - the evaluation instrument to be used by the FYC to assess the quality of the RFP bids E. FYC Bid meeting(s)with February 17, 2005, Assigned Social Services through March 3,2005 Supervisor F. Submission Deadline March 11. 2005,by 10:00 a.m. according to the Weld County Purchasing Time Clock G. Pre-award Visits March 16 & 17,2005 (Estimates; optional) Page 7 of 32 • • • Bid 002-05/RFP-FYC 05005 through 05011 and 006-00 H. FYC Final Approval of March 18,2005 ' 2005-2007 3-year Plan/programs (estimate) I. Board of Weld County April 27,2005 Commissioner Revised 2005-2007 3-Year Plan/Programs Approval (estimate) J. Colorado Department of May 31,2005 Human Services Revised 3-Year Plan Submission Approval (estimate) K. Contract Finalization May 31, 2005 Approval (estimate) L. A contract period June 1, 2005 —May 31, (estimate)for 12-month 2006 (Emergency programs. Assistance Program Funds) 6. Invitation for Proposals On behalf of the Board of County Commissioners of Weld County,the Families,Youth and Children Commission is hereby contacting prospective bidders who have an interest or are known to do business relevant to this RFP. All interested individuals/firms who were not contacted are invited to submit a proposal in accordance with the policies,procedures and dates set forth herein. In the event of"No Bid", please sign Invitation and Bid page, indicating"No Bid" and return to the Director of General Services. 7. Written Inquiries Prospective bidders may make written inquiries concerning this RFP to obtain clarification on requirements. No inquiries will be accepted after February 18, 2005, 5:00 p.m. Send all inquiries to: Pat Persichino,Director of General Services, Bid 002-05 (05005 through 05011 and 006-00)inquiry. Responses to bidder's inquiries will be made in writing and/or through a response conference by the Families,Youth and Children Commission, on behalf of the Board of County Commissioners,Weld County, on February 23, 2005, from 1:00 p.m.to 3:00 p.m. at the Weld County Department of Social Services, 315B N 11th Avenue, Greeley,Colorado,to all prospective bidders. 8. Modification or Withdrawal of Proposals Proposals may be modified or withdrawn,by the bidder,prior to the established due time and date. 9. Proposal Submission Proposals must be received on or before the time and date indicated in the Schedule of Activities. No proposals will be accepted after this time. Bidders mailing their proposals shall allow sufficient mail delivery time to ensure receipt of their proposals by the time specified. The proposal package shall be Page 8 of 32 Bid 002-05/RFP-FYC 05005 through 05011 and 006-00 delivered or sent by certified mail to: Pat Persichino Director of General Services 915 10th Street P.O.Box 758 Greeley,CO 80632 Bid 002-05 (05005 through 05011 and 006-00) Proposals which are determined to be at variance with this requirement will not be accepted. Six (6) copies(total,including original) of the proposal must be submitted and sealed in a package showing the following information on a white label. Bidder's Name Bid 002-05 (05005 through 05011 and 006-00) Proposal due: March 11,2005; 10:00 a.m. The Invitation and Bid page MUST be signed in ink by the bidder or an officer of the bidder legally authorized to bind the bidder to the proposal. Unsigned proposals will be REJECTED. 10. Late Proposals Late proposals will not be accepted. It is the responsibility of the bidder to ensure that the proposal is received by the Director of General Services on or before the proposal opening date and time. 11. Addendum or Supplement to Request for Proposal In the event that it becomes necessary to revise any part of this RFP, an addendum will be provided to each vendor who received the original RFP at the prospective Bidder Conference of February 16,2005, from 1:00 p.m. to 3:00 p.m. 12. Oral Presentations/Site Visits Bidders may be asked to make oral presentations or to make their facilities available for a site inspection by the Families,Youth and Children Commission evaluation committee. Such presentations and/or site visits will be at the bidder's expense. 13. Acceptance of RFP Terms A proposal submitted in response to this RFP shall constitute a binding offer. Acknowledgment of this condition shall be indicated by the autographic signature of the bidder or an officer of the bidder legally authorized to execute contractual obligations. A submission in response to this RFP acknowledges acceptance by the bidder of all terms and conditions including compensation, set forth herein. A bidder shall identify clearly and thoroughly any variations between its offer and the Families,Youth and Children Commission's RFP. Failure to do so shall be deemed a waiver of any rights to subsequently modify the terms of performance. Page 9 of 32 • Bid 002-05/RFP-FYC 05005 through 05011 and 006-00 14. Protested Solicitations and Awards Any actual or prospective bidder, or contractor who is aggrieved in connection with the solicitation or award of a contract may protest to the Board of County Commissioners of Weld County. The protest shall be submitted in writing within seven working days after such aggrieved person knows or should have known of the facts giving rise thereto. 15. Budgets Proposals MUST include Budget Information, as described under Attachment A of the application. 16. Proprietary/Confidential Information Any restrictions on the use or inspection of material contained within the proposal shall be clearly stated in the proposal itself. Proposals submitted in response to this RFP are subject to the terms of Article 72 Public(open)Records of the Colorado Revised Statutes. 17. RFP Response Material Ownership All materials submitted regarding this RFP becomes the property of the Board of Commissioners of Weld County. Responses may be reviewed by any person after the Letter of Intent has been issued, subject to the terms of Colorado Revised Statutes 24-72-202 through 24-72-206/Public(open)Records. The Board of County Commissioners of Weld County has the right to use any or all information/material presented in reply to the RFP,subject to limitations outlined in Proprietary Information. Disqualification of a bidder does not eliminate this right. 18. Bid Prices Estimated bid prices are not acceptable. 19. Selection Time The Families,Youth and Children Commission,on behalf of the Board of County Commissioners of Weld County,intends to make recommendations concerning proposal selection on or about March 18, 2005. The Board of County Commissioners of Weld County will make the final selection of proposals within two weeks of the Families,Youth and Children Commissions recommendation. Upon selection and approval by the State if appropriate, the Board of County Commissioners of Weld County will issue a Letter of Intent, and a contract must be completed and signed by all parties concerned, on or before the date indicated in Schedule of Activities. The bidder understands that the FYC's final approval of 2005- 2006 programs/plan and the Board of Weld County Commissioners' approval are based on allocations established by the State Department of Human Services. The contract between Social Services and the bidder will be adjusted according to final allocations provided by the State Department of Human Services. These actions may result in modifications to the original approved Bid. If the proposal selection date is not met,through no fault of the Board of County Commissioners of Weld County,the Board of County Commissioners of Weld County may elect to cancel the Letter of Intent and make the award to the next most responsible bidder. Page 10 of 32 Bid 002-05/RFP-FYC 05005 through 05011 and 006-00 20. Award of Contract The award will be made to that bidder whose proposal, conforming to the RFP,will be the most advantageous to Weld County,price and other factors considered. 21. Acceptance of Proposal Content The contents of the proposal (including persons specified to implement the project) of the successful bidder are contractual obligations if the bid is accepted by the Board of County Commissioner of Weld County. 22. Standard Contract The Board of County Commissioners of Weld County reserves the right to incorporate standard state contract provisions into any contract resulting from this RFP (Ref. Special Provisions). 23. RFP Cancellation The Board of County Commissioners of Weld County reserves the right to cancel this Request for Proposal at any time,without penalty. 24. Weld County Ownership of Contract Products/Services Proposals,upon established opening time,become the property of Weld County. All products/services produced in response to the contract resulting from this RFP will be the sole property of Weld County. The contents of the successful bidder's proposal will become contractual obligations. 25. Incurring Costs Weld County is not liable for any costs incurred by bidders in the course of preparing and submitting their bids. 26. Non-Discrimination The bidder shall comply with all applicable state and Federal laws,rules and regulations involving non- discrimination on the basis of race,color,religion,national origin, age or sex. 27. Resection of Proposals The Board of County Commissioners of Weld County reserves the right to reject any or all proposals and to waive informalities and minor irregularities in proposals received and to accept any portion of a proposal or all items proposed if deemed in the best interest of Weld County. 28. Parent Company If a bidder is owned or controlled by a parent company,the name,main office address, and parent company's tax identification number shall be provided in the proposal. Page 11 of 32 • Bid.002-05/RFP-FYC 05005 through 05011 and 006-00 29. Contract Cancellation Weld County reserves the right to cancel, for cause,any contract resulting from this RFP,by providing a timely written notice to the contractor. 30. Non-Collusion The bidder affirms,by signing the Invitation and Bid document, that the proposed bid price has been arrived at independently without collusion, consultation, or communication as to any other bidder or with any competitor; the said bid price was not disclosed by the bidder and was not knowingly discussed prior to the submission,directly or indirectly,to any other bidder or to any competitor; and directly or indirectly,to any other bidder or to any competitor; and no attempt was made by the bidder to induce any other person,partnership or corporation to submit a proposal for restricting competition. 31. Taxes Weld County, as purchaser,is exempt from all Federal taxes under Chapter 32 of the Internal Revenue Code(Registration No. 84-730123K)and from all State and Local Government Use Taxes (Ref. Colorado Revised Statutes Chapter 39-26.114(a).) Seller is hereby notified that when materials are purchased in certain political subdivisions the seller may be required to pay sales tax even though the ultimate product or service is provided to Weld County. This sales tax will not be reimbursed by either Weld County or the State. 32. Assignment Except for Assignment of Antitrust Claims,neither party to any resulting Contract may assign any portion of the RFP/Bid without the prior written consent of the other party. 33. Bid Bond/Security If the specifications contained herein so state, a bid security in the amount equal to 5%of your proposal shall be furnished to Weld County. See 24-105-201,C.R.S. 34. Contractor's Performance and Payment Bonds If the specifications contained herein so state,the contractor will be required to fiunish a performance bond and a labor and material payment bond. A certified or cashier's check or bank money order may be accepted in lieu of the bonds. 35. Insurance If the specifications contained herein so state,the contractor shall procure, at its own expense, and maintain for the duration of the work,the following insurance coverage;Weld County, Colorado,by and through the Board of County Commissioners of Weld County, its employees and agents, shall be named as additional named insured on the insurance. Page 12 of 32 • • Bid.002-05/RFP-FYC 05005 through 05011 and 006-00 A. Standard Workman's Compensation and Employer's Liability. 1) As required by State Statute including occupational disease, covering all employees at work site. B. General Liability(PL&PD)(Minimum). 1) Combined single limit- $500,000 written on an occurrence basis. 2) Any aggregate limit will not be less than$1 million. 3) Contractor must purchase additional insurance if claims reduce the annual aggregate below $500,000. 4) State of Colorado to be named as additional insured on each comprehensive general liability policy. 5) Certificate of insurance to be provided to Weld County and must be attached to the RFP Bid. 6) Insurance shall include provisions preventing cancellation without 60 days prior notice by certified mail to Weld County. C. Automobile Liability(Minimum). 1) Contractor to carry a minimum of$500,000 combined single limit auto insurance. D. Additional coverage may be required in specific solicitations. For any insurances that are required by this RFP, a completed Standard Certificate of Insurance Form shall be provided to Weld County by the potential contractor prior to the start of any contract. 36. Indemnification To the extent authorized by law,the contractor shall indemnify, save and hold harmless Weld County,its employees and agents, against any and all claims,damages,liability and court awards including costs, expenses, and attorney fees incurred as a result of any act or omission by the contractor, or its employees, agents, subcontractors, or assignees pursuant to the terms of this contract. 37. Venue The laws of the State of Colorado Weld County shall govern in connection with the formation, performance and the legal enforcement of any resulting contract. Further, the provisions of Title 24, C.R.S. as amended, Article 101 and through 112, and rules adopted to implement the statutes,govern this procurement. 38. Certifications The Bidder certifies that it has currently in effect, all necessary licenses, approvals, insurance, etc. required to properly provide the services and/or supplies covered by its bid. Page 13 of 32 • Bid 002-05/RFP-FYC 05005 through 05011 and 006-00 PART B BACKGROUND,OVERVIEW,AND GOALS Under C.R.S. 26-5.5-101 (Colorado Family Preservation Act) and C.R.S. 26-5.3-101 (Emergency Assistance for Families with Children at Imminent Risk of Out of Home Placement Act),the State of Colorado,through the Board of Weld County Commissioners,funds the Weld County Department of Social Services through an Emergency Assistance Program and State funds. The Colorado Preservation Act is a program that focuses on family strengths by directing intensive and time limited services to families to protect children, to prevent placement, and to reunify children and their families. The definition is based upon the following elements: A. Directed toward families B. Focused on family strengths C. Protects children D. Prevents placement or reunifies children and their families E. Time limited F. Families must be receptive to the services;however, exceptions shall be made for families who are court ordered. G. Intervention occurs at critical points. The Colorado Family Preservation Act is composed of several services that all share common purposes and elements. The Colorado Family Preservation Act has two primary goals: 1)prevent imminent placement of children; and/or 2)reunify children in placement with their families. A. For purposes of the Colorado Family Preservation Act,imminent placement is defined to mean that without intervention, a child will be placed out of the home immediately. B. For purposes of the Colorado Family Preservation Act to "reunify with their family" or"to return to their own home"is defined to mean to return to the home of a parent, adoptive placement, independent living placement, foster-adoption placement, or to live with a relative if the case plan is for the child to remain with the relative on a permanent basis. To assist the Board of Weld County Commissioners in the effective use of these funds,the Board of Weld County Commissioners appointed Weld County's Families,Youth and Children Commission to: A. Annually prepare a plan for the provision of Colorado Family Preservation Act Services. The primary Page 14 of 32 • • Bid 002-05/RFP-FYC 05005 through 05011 and 006-00 goals under the plan shall be to prevent imminent placement of children out of the home and to reunite • children who have been placed out of the home. B. Review, on an ongoing basis,the effectiveness of programs within Weld County which are designed to prevent or reduce placement and report its findings to the Board of Weld County Commissioners annually. The Families,Youth and Children Commission is pursuing contractors who demonstrate the capability of meeting the FYC's goals and objectives, and will adhere to Colorado Family Preservation Act eligibility guidelines. Any public or private agency,non-profit,private for profit or community based organization(CBO)or business may receive funding;however, support and commitment to the project being proposed must be demonstrated by other appropriate local agencies and organizations in order to receive favorable consideration for funding. Page 15 of 32 Bid 002-05/RFP-FYC 05005 through 05011 and 006-00 PART C STATEMENT OF WORK Program Requirements A. OUT-OF-HOME PLACEMENT CRITERIA Not every child/youth at risk needs out-of-home placement. These criteria are designed to provide a decision making model to assist in determining whether Core Services Program services and/or out-of-home placement are indicated. All three criteria must be met. Criterion#1: The child/youth may be at imminent risk of out-of-home placement(as defined in 26-5.3-103(2), C.R.S.)because one or more of the following conditions exist: 1. abandonment by or incarceration of parents/relatives/caretakers; 2. abuse/neglect-as defined in the Children's Code; 3. domestic violence-as defined in Section 18-6-800.3,C.R.S. 4. conditions that exist to such a degree for either the child or caretaker so that the caretaker is unable to care for the child. a. substance abuse; drug-exposed infants b. mental illness c. disability d. physical illness e. homelessness 5. beyond control of parents; 6. danger to self, others, or community; 7. infant or young child of teen parent in placement; 8. delinquency-adjudicated delinquent meeting current out-of-home placement criteria written pursuant to Section 19-1-103(2), C.R.S.; 9. Relinquishment or termination of parental rights; 10. child/youth returning home from out-of-home placement or moving to less restrictive level-of-care(LOC). Criterion#2:Before considering placement, an assessment is completed to determine the level of risk. If assessment of risk determines that the child is at imminent risk of out-of-home placement,then child/family strengths are determined, and the appropriate services and/or community supports (reasonable efforts)needed to address the existing Criterion#1 Page 16 of 32 Bid 002-05/RFP-FYC 05005 through 05011 and 006-00 conditions are identified. When these services are not immediately available, or are absent, unsuccessful, or exhausted,placement in the Core Services Program and/or out-of-home may be considered. Reasonable efforts include the intervention strategies and advocacy efforts used: 1. to identify/locate appropriate parent/relative/caretakers if necessary to prevent out-of- home placement; 2. to assess the parent/relative/caretaker's ability to protect children; 3. to assist the parent/relative/caretaker and/or child/youth in accessing and utilizing the identified services to address the presenting conditions. Criterion 3: When placement is the best choice of available options/alternatives at this time to reduce risk to the child/youth while continuing reasonable efforts to resolve the conditions which led to imminent risk,then,placement in the Core Services Program and/or out-of-home may occur. B. The Core Services Program has two primary goals: 1)prevent imminent placement of children; and/or 2)reunify children in placement and their families. 1. For purposes of the Core Services Program, imminent placement is defined to mean that without intervention, a child will be placed out of the home immediately. 2. For purposes of the Core Services Program to"reunify with their family"or"to return to their own home"is defined to mean to return to the home of the parent, adoptive placement, guardianship,independent living placement, foster-adoption placement,or to live with a relative if the case plan is for the child to remain with the relative on a permanent basis. C. Proposals receiving consideration under this RFP must provide services in Weld County. D. Creative and innovative model programs which lead to the reduction of foster care costs and avoid duplication will be encouraged. II. Fiscal Provision A. Applicants must complete all budget forms specified within the application kit. B. Funding shall be under a 12-month estimated contract from June 1, 2005,through May 31, 2006. C. The Contractor shall make provisions for an independent financial audit to be performed annually. To the maximum practicable extent,the audit shall identify, examine, and report the income and expenditures specific to operation of the State-funded program or services. One copy of the audit Page 17 of 32 Bid 002-05/RFP-FYC 05005 through 05011 and 006-00 • report,together with associated special reports and the management letter, if any, shall be furnished to Board of County Commissioners no later than September 30th each year. III. Standards of Responsibility A. The bidder selected, as a result of this RFP,must be responsible for all program costs including personnel, operating,travel, equipment, audit, and capital items. Bidders must have available the necessary financial,material, equipment, facility, and personnel resources and expertise, or the ability to obtain them since no start-up funds will be made available. All contracts are set up so as to reimburse the contractor for allowable expenses as budgeted. B. The bidding agency must be able to document a satisfactory record of program performance, financial solvency, and a satisfactory record of integrity. C. The bidding agency must be a not-for-profit organization incorporated as 501(c)(3) agency. Agencies in the process of applying for 501(c)(3)status must be fully incorporated by contract start date. Private for profit business and local and state units of government are also eligible to bid for funds. D. The RFP must reflect the appropriate time limits of the program needed to reduce risk and enhance the safety of the subject children.The RFP should reflect the precise number of sessions needed for the program to be effective,the number of sessions per week,and the cost for each session. The RFP should also reflect an average cost per family and number of sessions needed. E. The RFP must reflect a process to eliminate renewals or reduce the cost of the program should it have to be reinstated. Preference will be given to programs that incorporate a step-down plan, such as(a) fewer sessions per week or per month after intensive sessions in the first part of the program,(b)transition to ending of services or support services from bidders agency,or (c)transition to another agency. F. All renewal requests must be in writing and reflect cause for renewal. Renewal requests must be submitted to the Department of Social Services 60 days prior to the end of the original service date. Social Services will reserve the right to request a meeting on any request the Department needs clarified. A renewal will be based on whether or not the children still meet placement criteria. A renewal request for additional hours would be considered if there is evidence that there are still steps being actively taken to reunify the family, or to lower the risk of out-of-home placement, and progress is being made as the result of the provider's service. The caseworker and provider shall provide information regarding this need to the program area supervisor who will make the final decision regarding the approval of this renewal. G. The RFP must include the program design that reflects the maximum number of hours in the three stages of the program: start up;middle, and end of services. No service fees will be paid for any programs that exceed these measurements per month. Page 18 of 32 Bid 002-05/RFP-FYC 05005 through 05011 and 006-00 I3. In the RFP process, approved contractors for Program Year 2004-2005,must submit a letter • for all clients who are to be carried over into Core Services Program Year 2005-2006 justifying the carryover by June 1,2005,the start of the Core Services program year. The letter should be sent to the current caseworker,Ms. Elaine Furister, CPS/CAP, Core Services Specialist, and the program area supervisor. I. The contractor must agree to: 1. Be available for court testimony when given proper notification, and such testimony is included in the rates provided under the approved rate for services over the term of the contract. Court testimony includes preparation of and actual court testimony. 2. Provide written recommendations or action plan in the client's primary language for all monolingual clients. A copy of the recommendations or action plan should be sent to Ms.Elaine Furister,CPS/CAP, Core Services Specialist,at Weld County Department of Social Services,P.O. Box A, 315 N 11 Avenue, Greeley, CO, 80632. 3. Provide a case management plan on each referred family within 30 days of the date the Contractor received the referral. The case management plan will be monitored and modified monthly to measure progress toward goals. Copies of the case management plan must be sent to the caseworker,program area supervisor, and Ms. Elaine Furister, CPS/CAP, Core Services Specialist, at Weld County Department of Social Services,P. O. Box A, 315 B N 11 Avenue, Greeley, Colorado, 80632. The case management plan, at minimum,will include goals,timelines,and measurement of success. 4. Provide a monthly client progress report as above within twenty-five(25)working days immediately after the month of service. The monthly progress report must be attached to the monthly billing for payment to be honored.Failure to submit such monthly reports will result in delays or forfeiture of payment. Monthly Reports-will be submitted no later than twenty-five(25)working days past the end of the month of service. It is expected, at a minimum,these reports will reflect: -presenting problem(s)of the client/family, - specific services provided, -extent of client(s)participation and commitment to program, - client(s)progress to date, - anticipated discharge date. 5. Report to Social Services a monthly brief report on the status of the program as prescribed by Social Services; 6. Submit a final narrative summary of program outcomes to Social Services within 30 days after the completion date; 7. Report expenditures and case disbursement at agreed upon times. Page 19 of 32 Bid 002-05/RFP-FYC 05005 through 05011 and 006-00 8. Submit monthly FYC completed billing forms to Ms. Elaine Furister, CPS/CAP, Core Services Specialist, on or about the 10th day of the month after the month the services were provided. All billings must e date-stamped by the Department by the 25th day of the month following service to be eligible for reimbursement. Billings received and date-stamped after the 25th day of the month will not be honored and may result in forfeiture of billed fees. 9. The provider shall submit signed, original billing forms,including all documentation required to verify services provided during the service month. The completed billing forms must be received by the Department no later than the 25th day of the month following the dates of service. No billing forms or documentation will be accepted by the Department for processing after the 25t day following the service month.All items submitted after this date shall be returned to the provider unpaid. Further,the Department will not consider payments that were originally reviewed as deficient in documentation for future reimbursement. The Department will determine billed services not eligible for payment by identifying conflicts in the following: a. Details provided in client referrals and renewals, including approved hours, days,or episodes of service,begin and end dates of service,client name, and Case ID. b. Details in supporting documentation provided by the Provider and submitted with the original bill, including,but not limited to, original signed client verifications,time of service and hours of service provided, and names of clients receiving the services. c. Details provided in the current approved contract and Notification of Financial Assistance, including,but not limited to unit of service,cost per unit of service, and Special Conditions, as stated in the Notification of Financial Assistance. The above items,9a,b, and c,will supersede all requests from providers for review of billing errors. Items submitted for billing will be processed according to the criteria established by the above documentation. An Administrative fee may be assessed to all fees reimbursed through County only funding. Such fees include,but are not limited to,those service fees previously billed and determined by the Department to be not eligible for payment. 10. Work with family to prepare to pay for services beyond established time frame. A complete and timely billing form is identified by and must include the following elements. (See Attachment A of the Request for Proposal): Page 20 of 32 Bid`002-05/RFP-FYC 05005 through 05011 and 006-00 a. The billing must be an original billing signed by the provider and/or designee. b. The billing must include all forms designed for Core Services reimbursement and approved by the Department of Social Services; Core Services Authorization of Funds,Project Report,Update Report, and signed client verifications for each client serviced during the billing period. c. A service summary must be provided by the provider for clients who have active referrals during the billing month in order to direct issues to the caseworker and court. 1) Core Services Authorization forms must be submitted completely filled in with an original signature from the provider and/or designee. 2) Project reports must include the client's full name,Weld County Case ID, Weld County Refe,nal number,hours served,hourly rate, and total billed for the month the service was provided. 3) Verification forms must include the client's original signature at the time of service, date of service,hours served, Case ID and Core service referral number. Payment through Core Services Program funds will be made only for direct client contact with the appropriate identifying client signature included on the verification form. 11. Will develop and utilize evaluation tools(pre and post assessment test instruments)to collect necessary data in cooperation with Social Services staff to monitor effectiveness of program; 12. Will meet with Social Services FPP Supervisor quarterly(more if needed)to review program usage and effectiveness to discuss necessary improvements to better serve families or increase referrals; 13. Be available to meet with DSS staff to explain program,time lines of response to referrals and answer questions to enhance program. 14. Be available for the Families,Youth and Children Commission review and attendance at the FYC meetings. Page 21 of 32 • Bid 002-05/RFP-FYC 05005 through 05011 and 006-00 PART D BIDDER RESPONSE FORMAT INFORMATION TO BE INCLUDED IN PROPOSALS The following requirements exist which must be met by all proposals submitted. It is required that bidders address the proposal requirements in the following format and use the exact replication of forms included in the attachments to these guidelines. Failure of the bidder to provide all information requested in this RFP may result in disqualification of the proposal. A. Invitation for Bid The Invitation for Bid page must be signed in ink by the bidder or an officer of the bidder legally authorized to bind the bidder to the proposal. Unsigned proposals will be rejected. This should be the first page of the document. The Invitation and Bid page should be signed for the bid proposal submitted. B. Cover Page This page must follow the Invitation to Bid page in the document. Proposals must contain an original copy with original signatures, and six copies of the proposal (Attachment A). C. Program Narrative The body of the proposal must clearly and concisely describe the overall plan for the program. However,the bidder must use the prescribed form(excluding charts and attachments). However, the only attachments to the proposal must be those specifically related to the project: 1. Project Description (5 points) The overall mission,purpose, and design of the project should be described in this section. 2. Target/Eligibility Population (15 points) A profile of clients to be served including such factors as age; number of clients to be served, and duration of time to be served. The Bidder must address both Part C, statement of work and the target/eligibility populations Section for the Core Services Program. A. Quality of General Description (5 points) B. Ability to Provide Ethnically/Culturally Appropriate Services (10 points) 3. Types of Services Provided (15 Points) Service components should be described in this section. Services should be based on the needs of clients, the community,the Colorado Family Preservation Act(C.R.S. 26-5.5-101) and Emergency Assistance for Families with children at Imminent Risk of Out-of-Home Placement Act(C.R.S. 26-5.3-101). Services description must address the Types of Services Provided section for the Colorado Family Preservation Act. A copy of the Bidder's Certificate of Insurance must be attached to the RFP. Page 22 of 32 Bid'002-05/RFP-FYC 05005 through 05011 and 006-00 4. Measurable Outcomes (10 Points) A list of measurable outcomes of the Family Preservation Program is to be addressed as required the Measurable Outcomes Section. The Bidder must address what methods the Bidder will use to measure, evaluate, and monitor the outcomes. 5. Service Objectives (10 Points) The Service Objectives Section provides for service objectives as developed by the FYC and the Bidder. The Bidder must address what methods the Bidder will use to measure, evaluate, and monitor the objectives. 6. Workload Standards (5 Points) The Bidder must address the workload standards as described in the Workload Standards Section. 7. Staff Qualifications (10 Points) The Bidder must address the Staff Qualifications Section as required by the FYC. 8. Unit of Service Rate Computation (10 Points) The budget must be submitted in an hourly unit rate cost of direct delivery of services to a individual or family unit. The Bidder must address the Unit of Service Rate Computation Section of the Family Preservation Program. 9. Lowest Qualified Bid(s) (15 Points) 10. Program Capacity by Month (5 Points) A description of maximum and minimum client capacity per month necessary to support program. Page 23 of 32 PART E EVALUATION PROCESS A. An evaluation committee composed of Families,Youth and Children Commission members,except those FYC members who have submitted proposals for consideration under RFP-FYC-05005 through 05011,and 006-00,will judge the merit of proposals received in accordance with the general criteria defined in the RFP and the adequacy and completeness of the proposal. In addition to the evaluation committee's independent reviews,the evaluation committee will obtain: 1. Independent reviews from representatives from the Colorado Department of Human Services and the Weld County Department of Social Services who will judge the merit of proposals received in accordance with the general criteria defined in the RFP and the adequacy of the proposal. 2. Any performance reports submitted by the FYC Commission in accordance with criteria defined by the FYC. The recommendations of this committee will be forwarded to the Board of Weld County Commissioners. The Board of Weld County Commissioners will make the final approval of providers and/or revisions to the 2005-2007 Core Services Plan. Failure of the bidder to provide any information requested in the RFP may result in disqualification of the proposal and shall be the responsibility of the bidding individual or firm. The sole objective of the evaluation committee will be to recommend the bidder whose proposal is most responsive to Weld County's needs while within the available resources. The specifications within the RFP represent the minimum performance necessary for response. B. Evaluation Criteria Mandatory Proposal requirements include: 1. Project Description (5 Points) 2. Target/Eligibility Populations ( 15 Points) A. General (5 Points) B. Cultural/Eligibility Populations (10 Points) 3. Type of Service Provided (15 Points) 4. Measurable Outcomes (10 Points) 5. Service Objectives (10 Points) 6. Workload Standards (5 Points) 7. Staff Qualifications (10 Points) 8. Unit of Service Rate Computation (10 Points) 9. Lowest Qualified Bid(s) (15 Points) 9. Program Capacity by Month (5 Points) Total Points 100 The proposal must obtain minimum points of 75%of total possible points to be considered for funding. Attachments A. Colorado Family Preservation Act Bid Proposal Page 24 of 32 Bid 092-05(RFP-FYC-006-00) Attached A MENTAL HEALTH SERVICES PROGRAM BID PROPOSAL AND REQUEST FOR CONTINUATION OF AWARD UNDER CORE SERVICES FUNDING EMERGENCY ASSISTANCE PROGRAM 2005-2006 BID PROPOSAL APPLICATION PROGRAM FUNDS YEAR 2005-2006 /pJ BID 002-05 (006-00) NAME OF AGENCY: S0-c-k $• (rev tPh ati �ti2-R-1-f e0A-of n *fir" )•u6 t-aI ADDRESS: 1 a 2 $ 5 4 S-6. j , r 2eQ-e� CO 6o 31 PHONE(77p) 3 S 6 8V Z- S UX CONTACT PERSON: 7.4, TITLE: DESCRIPTION OF EMERGENCY ASSISTANCE PROGRAM CATEGORY: The Mental Health Services program provides for"diagnostic,and/or therapeutic services to assist in the development of the family services plan.to assess and/or improve family communication,functioning,and relationships. (Volume VII.7.303.1,G)" 12-Month approximate Project Dates: _ 12-month contract with actual time lines of: Start June 1,2005 Start End May 31,2006 p End TITLE OF PROJECT: /93 oltst C 4( o.e-v u n.. cam j Ja a ecLrdQ-✓ d - 7- QS Name and Signature of Person Pr?m g ument Date Af///A Name and Signature Chief Administrative Officer Applicant Agency Date MANDATORY PROPOSAL REQUIREMENTS For both new bids and renewal bids,please initial to indicate that the following required sections are included in this Proposal for Bid.For renewal bids,please indicate which of the required sections have not changed from Program Fund Year 2004- 2005 to Program Fund year 2005-2006. Indicate No Change from FY 2004-2005 Project Description Target/Eligibility Populations Types of services Provided Measurable Outcomes Service Objectives Workload Standards Staff Qualifications Unit of Service Rate Computation Program Capacity per Month Certificate oflnsurance Date of Meeting(s)with Social Services Division Supervisor: 3-?- Oira Page 25 of 32 Bid 002-05 (RFP-FYC-006-00) Attached A Comments by SSD Supervisor: Name and Signature of SSD Supervisor Date Page 26 of 32 • Bid 002-05(RFP-FYC-006-00) Attached A Program Category Mental Health Services Program Bid Category Project Title r is ie,r0•cos, Vendor 7<c%..T• P,4 r cht t' I. PROJECT DESCRIPTION Provide a brief one-page description of the project. H. TARGET/ELIGIBILITY POPULATIONS Provide a one page brief description of the proposed target/eligibility populations. At a minimum your description must address: A. Total number of clients to be served. B. Total individual clients and the children's ages. C. Total family units. D. Sub-total of individuals who will receive bicultural/bilingual services. E. Sub-total of individuals who will receive services in South Weld County. F. Sub-total of Individuals who will have access to 24-hour service. G. The monthly maximum program capacity. H. The monthly average capacity. I. Average stay in the program(weeks). J. Average hours per week in the program. K. Cultural/Ethnically Specific Services L. Service to South Weld County Clients III. 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. Family/Child/Adolescent Psychological Evaluation/Assessment Services 1. Screening, evaluations, and other assessment services intended to provide information needed by the staff of Social Services. a. Evaluation procedures designed to produce useful responses to specific referral questions mutually developed by the licensed or licensed eligible psychologist and Social Services' caseworker assigned to the case. For purposes of this RFP, a licensed eligible psychologist is defined as an academically qualified, (post doctorate) candidate for licensure under the constant supervision of a licensed clinical psychologist. b. Collaboration with contacts prior to the completion of the evaluation. c. Written report upon completion of the assessment. The report must clearly state Page 27 of 32 • • Rid 002-05 (RFP-FYC-006-00) Attached A methods used, contacts made,tests administered,results and recommendations • relevant to the referral questions. d. Make available the content of the assessment to the family and other relevant parties, subject to the American Psychological Association ethical standards and other legal considerations. B. Consultation with Caseworkers 1. Consultation with caseworkers of Social Services regarding the integration of assessment results into the overall care plans for children, adolescents, and families. (This may include issues pertaining to the evaluation of suicidal clients and the need for in-patient placement or other levels of intervention.) 2. Assist in obtaining feedback from agency clinicians regarding the rationale for decision on these issues. C. Court Testimony 1. Be available for court testimony when given proper notification for clients with open or closed cases. 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. IV. MEASURABLE OUTCOMES Provide a two-page description of your expected measurable outcomes of the project. Address the following measurable outcomes: A. Program design will shorten time required to obtain evaluation results following a Social Services referral. B. Provided services will increase the Social Service staff access to the evaluation practitioner when questions about implementation of evaluation results occur. C. Frequency of contacts between the evaluation practitioner and Social Services staff D. Timeliness of responses from outpatient programs. E. Coordination of therapeutic interventions between your agency and Social Services. F. Explain how your agency will provide the following specific outcomes: a. Emergency consultations will occur within 24 hours of request; b. Psychological evaluations will have clear recommendations and methods that will be accepted by the court. Describe your quantitative measures: Also, describe the methods you will use to measure, evaluate, and monitor each quantitative measure. Page 28 of 32 . Bid 002-05(RFP-FYC-006-00) Attached A V. SERVICE OBJECTIVES Provide a one-page description of your expected service objectives and quantitative measures. Address, at a minimum,the following ways the project will: A. Improve Family Conflict Management—Diagnostic and/or therapeutic services to assist in the development of the family services plan,to assess and/or improve family communication, functioning and relationships. B. Improve Household Management Competency-capacity of parents to provide a safe household environment for their children by addressing safety issues and protection of children. C. Improve Ability to Access Resources- services shall assist parents in learning to obtain help from other sources in the community and within the local, state, and federal governments. Describe the methods you will use to measure, evaluate, and monitor each service objective. VI. WORKLOAD STANDARDS Provide a one-page description of the project's workload standards and quantitative measures. Address, at a minimum,the following areas: A. Number of hours per day,week or month B. Number of individuals providing the services. C. Maximum caseload per worker. D. Modality of treatment. E. Total number of hours per day/week/month. F. Total number of individuals providing these services. G. The maximum caseload per supervisor. H. The number of assessments completed per month. I. Insurance. VII. STAFF QUALIFICATIONS Provide a one-page description of staff qualifications and address, at a minimum,the following: A. Will your staff; including supervisors,who are providing direct services have the minimum qualifications in education and experience in Staff Manual Volume VII, Section 7.303.17, and Section 7.0006,Q, Colorado Department of Human Services? Describe. B. Total number of staff, including supervisors, as defined in Staff Manual Volume VII, Section 7.303.17, and Section 7.0006, Q, Colorado Department of Human Services. C. Will your staff have received mandated new caseworker training? D. Will your staff have knowledge in risk assessment? Page 29 of 32 ,Bid 002-05(RFP-FYC-006-00) Attached A VIII. Unit of Service Rate Computation The budget form is to be used to provide detailed explanation of the hourly or daily rate your organization will charge the Core Services Program for the services offered in this Request for Proposal. This rate may only be used to bill the Weld County Department of Social Services for direct, face-to-face services provided to clients referred by the Department. Requests for payment based on units of service such as telephone calls,no shows,travel time,mileage reimbursement, preparation,documentation, and other costs not involving direct face-to-face services will not be honored. Likewise,bills must be for hours or days of direct services to the client,regardless of the number of staff involved in providing those services. Therefore,it is imperative that this rate be sufficient to cover all costs associated with this client, regardless of the number of staff involved in providing these services. The rate for court testimony includes preparation of and actual court testimony during the term of this contract.Pease list your requested rate for court testimony separate from your direct hourly rate for client services. There are two different ways to fill out the budget form. The budget can either be done manually or by computer. Regarding the manual budget, all areas that are required to be filled in are highlighted. The computerized budget is less work due to predefined calculations,but does require Microsoft Excel for Weld County's predefined budget. There are highlighted areas on the computerized budget that are required to be filled in as well. There are disks available that have this predefined budget on it. Firms can also design its own budget form on a spreadsheet,but at minimum,it must have all of the columns that are on the manual or computerized budget. Explanations on how to fill out the budget form are provided below and on the following pages. (A) This is an estimate of the total hours or days of direct, face-to-face services each client will receive from the time he or she enters the program until completing the program. On the manual budget,the only place to put this number is on the Program Budget worksheet. The computerized budget requires this number to be entered on the Direct Service Cost worksheet only. Once filled in there,this number is populated throughout the entire budget. (B) This is an estimate of the number of clients who will be served during the period from June 1, 2005,through May 31, 2004. On the manual budget,the only place to put this number is on the Program Budget worksheet. The computerized budget requires this number to be entered on the Direct Service Cost worksheet only. Once filled in there,this number is populated throughout the entire budget. (C) This is the total number of hours or days per client multiplied by the total number of clients to be served for(B). On the manual budget,this will have to be calculated manually on the Program Budget worksheet. The computerized budget will automatically calculate this then populated throughout the entire budget. (D) This is calculated by taking the total direct service costs(E)and dividing it by the total number of hours in(C). On the manual budget,this will have to be calculated manually. The computerized budget will automatically do this calculation for you. Page 30 of 32 , Bid 002-05(RFP-FYC-006-00) Attached A (E)This number represents the salary and benefits that your organization pays its direct service providers plus any costs which are directly attributable to the face-to-face session with the client. On the manual budget,all areas that are highlighted on the Direct Service Costs worksheet must be filled out according the descriptions. The Grand Total Direct Service Costs must be then carried over to the Program Budget worksheet. The computerized budget, once all of the highlighted areas are filled in, it will automatically carry the total over to the Program Budget worksheet. (F) This represents the salary and benefits of direct service, supervisory, and clerical personnel which are not incurred in providing direct, face-to-face service to the client,but can be allocated to this program for time spent on the program for activities such as travel,phone conversations,no- shows, discussions with involved parties,meeting preparation, and report completion. On the manual budget, all areas that are highlighted on the Admin Costs Non-Face-to-Face worksheet must be filled out according to the descriptions. The Grand Total Direct Service Costs Not-Face-To-Face must be carried over to the Program Budget worksheet. The computerized budget, once all of the highlighted areas are filled in on the Admin Costs Non-Face-to Face worksheet,it will automatically carry the total over to the Program Budget worksheet. (G)This represents the agency overhead costs, such as rent,utilities, supplies,postage,travel reimbursement,telephone charges,equipment, depreciation, data processing,interest, and taxes which are not incurred in providing direct, face-to-face service to the client,but can be allocated to this program for time spent on the program for activities such as travel,phone conversations,no- shows, discussions with involved parties,meeting preparation, and report completion. On the manual budget, all highlighted areas on the Overhead Costs and Profits worksheet must be completed according to the descriptions. The Total Overhead Costs must be carried over to the Program Budget worksheet. The computerized budget, once all of the highlighted areas are filled,will automatically carry over to the Program Budget worksheet. (H) This represents the total of all direct face-to-face costs, admin direct non face-to-face costs, and overhead costs. On the manual budget,this will have to be manually calculated by adding these three total costs together. The computerized budget does it automatically. (I) This represents the total amount of profit your firms expects to realize as a result of operating this program. Any difference between lines(H)and(J)must be substantiated by an amount indicated on this line. The manual budget,this amount will be entered on the Overhead Costs and Profit worksheet and then have to be carried over to the Program Budget worksheet. The computerized budget, once it is filled in on the Overhead Costs worksheet, it will then automatically be carried over to the Program Budget worksheet. (J) This represents the total costs and profits added together. This is(H) and(I). On the manual budget, it will have to be calculated manually on the Program Budget worksheet. The computerized budget will automatically calculate it on the Program Budget worksheet. (K)This represents the total hours or days of direct service for the year. This is(C) above. On the manual budget,you will have to carry this number down from(C). On the computerized budget, it is automatically carried down. Page 31 of 32 , Bid 002-05(RFP-FYC-006-00) Attached A (L)This is the actual direct, face-to-face hourly or daily rate at which you will be requesting payment for the services provided under the conditions of this Request for Proposal. This amount cannot be more then what is charged to the general public or collected from insurance providers. On the manual budget,this amount must be calculated by taking the total costs and profits (J) and dividing it by the total hours or days of direct service for the year(C or K). The computerized budget automatically calculates this total. All providers who receive a NOFAA must also submit a certified computation of the organization's actual expenditures for the approved Core Service program by January 31, 2006, for a six-month period from June 1, 2005,to November 30,2005. The actual expenditures must be submitted in the same format as the budget was prepared. The certification language must be the same as on the Computerized Actual Expenditures worksheet. The document must be signed by the Chief Executive Officer or the authorized officer of the bidder in order for it to be considered certified. The use of the actual program expenditures is to insure that the direct, face-to-face hours/daily rate is comparable to the budget computation. The actual numbers will be taken into consideration for the 2006-2007 Request for Proposal for that specific program. Page 32 of 32 5310.213(2/79) COLORADO STATE DEPARTMENT OF SOCIAL SERVICES AUTHORIZATION FOR CONTItACTURAL SERVICES 1. WELD COUNTY DATE: 2. Name of Provider 3. Address 4. City, State, Zip THE DESCRIBED SERVICE IS AUTHORIZED FOR THE CLIENT INDICATED: 5. Name of Client Household# Cat. Cat.Grp. 6. Description Sv.Code 7.APPROVAL: Caceworker Date Co.Director or Supervisor 8.TO BE COMPLETED BY PROVIDER DATE OF SERVICE CHARGES$ I CERTIFY THE SERVICE AUTHORIZED WAS PROVIDED ON THE DATE INDICATED AND THE CHARGES ARE MADE PURSUANT TO A BONA FIDE CONTRACT BETWEEN ME AND THE COUNTY DEPARTMENT OF SOCIAL SERVICES INDICATED. Provider Signature Date Prepare in Triplicate,Original and One copy to Provider,One Copy for Pending File. Completed Provider's Forms-Original to County Finance Office-Copy to Case Record \ •. \ / } r s / # 00 t) § § 7 U t °O. ea 0 . 00 . : In } $/( \ k \ \ t Co 5 ® n wo ( }] \) . 0 ) b0 � � e® - - \) 5! § I z;, g ) / § a \= ) , % 7 ■ . tee, o g ° 08 °a ) § • - » _ } ) » § 0 \ } \ / / , N a jk u ° 1BE / ) , = « A44 \/ ) ) 0 } o ) \ C \ 0 ? \ ( 2 4o 0 ) § ) [ 3 m ® F4 �� 0U « A2 / \{ 24 U P. \) F ] ) ? \ ) a7 U � ` . . /) \ C Ca ) ) \ Ut ® {} \ { / ) \ / 0 ) m a A w 0 54y U W .°a O u y .o co o 5 o rn o V O4° W N O M ° O d > o wUQ U m Ca "'. ° d X v p- N 5 • NR. o O a 6 m N a U .5 o n v tiocv> x u., E Uon ca o W 2 u 2 N ci 0 U 2 � x' ow o - N ' M O ° F 0Manc vU in r t0 «� WW O X G O m [ F •0 � Ou u � 4O y g 0. H q w - >-., uz o w °,' otb0 o o a x m V 2 as w ° . x 5 m 'al 0 q O Q p 0 0 5 Y 6 U oo Um� u °a O pH gcso "' t a w 0 5 ° `5 ti o ] U 0 ac w q o 0 U W o U 00 g 3 VJ u .. q o o o U M, o xAw U v U0 ° x N >4 ow .B E. d too w .o o U C 0 H a A w a � .� y o w p., c° Tn c N O N O 0o al /-� Y W r0 O .44 W Qt oI,p � a ° b r. Y `" a O 0 ° � " ° K o o oq {4 42 .2 1 < al a O m 4 R W .0 vb o � U § 0 .F o w O y .� z m t xa g 0 a HF U w LEY32 �; •,�. anP, • �E: . ,vim• • B' • • �, r �'. Bid Proposal: Weld DSS March 2005 I. For several years I have provided a variety of psychological services to the department in the following modalities: • Psychological Evaluations (Standard, 1 party) • Psychological Evaluations (Standard, additional parties) • Psychological Evaluations (Sexual Specific, 1 party) • Interactional Evaluations (at DSS) • Interactional Evaluations (Home Visits) • Court Testimony • Court Preparation • Consultation • Training • Individual Therapy • Family Therapy • Court Facilitation, Mediation, or Staffing • No Shows (Client Terminated after 3 no shows). II. TARGET/ELIGIBILITY POPULATIONS a. I complete between 55 and 100 evaluations per year. I see from 1 to 10 clients in therapy per year. I usually complete 2 trainings per year. I attend approximately 25 mediation sessions per year. I consult with the department on cases approximately 25 times per year. I testify in court approximately 20 times per year. b. The total number of clients is the number of evaluations completed plus a few added family members. The children's ages are between newborn and eighteen years old. c. The total number of family units is somewhat less than the total number of total evaluations as I sometimes see both mother and father. d. I do not provide bilingual services. I am bicultural (Hispanic culture). I don't have any idea the number of persons who come to me who are of a specific ethnicity. e. I have been asked to serve some clients from south county. I estimate I see between 10 and 20% of the total number of evaluations from south county. f. I do not provide 24 hour access to any clients. g. I can complete between 6 and 12 evaluations per month depending on the complexity of the cases and the timely attendance of the clients. h. The monthly average capacity is 8 evaluations per month. i, Average time from start to finish of an evaluation is between 4 to 12 weeks. j. This is Not Applicable • k. There are no Cultural/Ethnically Specific Services I. See "e" above. III. TYPES OF SERVICES TO BE PROVIDED See the list of services above. Because I am a private practitioner, I was not able to utilize the software that was available to determine fees. I estimated my non-billable costs and adjusted my previous rates accordingly. FEES: • Psychological Evaluations (Standard, 1 party) $1300.00 • Psychological Evaluations (Standard, additional parties) add $900.00/ea. • Psychological Evaluations (Sexual Specific, 1 party) $1600.00 • Interactional Evaluations (at DSS) $100.00/hr • Interactional Evaluations (Home Visits) $110.00/hr • Portal to Portal • Testimony $160.00/hr • Portal to Portal • Court Preparation $00.00/hr • Consultation $110.00/hr • Training $1200.00/day • Individual Therapy $100.00/hr • Family Therapy $100.00/hr • Court Facilitation, Mediation, or Staffing $ 0.00/hr • No Shows (Client Terminated after 3 no shows) $0.00.hr IV. MEASUABLE OUTCOMES A) I do not anticipate there will be much of a change in the time it takes to get evaluations from start to finish. I obviously do them as quickly as possible as my livelihood is directly tied to completion of each evaluation. Each piece of work must be of top notch quality and internally consistent to withstand the rigors of Bid Proposal Greeley Counseling Center 3/9/05 Pavel nfd court review and review by second opinions. Each report must be valuable to the caseworker for treatment planning. B) There will be no change in availability of services. I try to answer all calls the day they are received and certainly within 24 hours. C) The frequency of contacts depend on the complexity of the case. We call each other as much as necessary. D) N/A E) I discuss my interventions regularly in the few instances when I have been asked to do therapy. I also communicate via letters and written reports. F) As noted elsewhere, I do not provide 24 hour emergency service. I will respond to caseworker's calls as soon as possible and usually within 24 hours. My evaluations have been well received by the courts in the past several years. I continue on-going training to provide the best reports possible. I also know the limits of my competency and refer the case workers to other practitioners as needed. I do not use quantitative measures. I rarely know the outcome of my work as I rarely have contact with the clients or caseworkers when an evaluation is complete. I seek informal feedback from caseworkers but have no formal method for garnering information. For psychotherapy I usually adopt a humanistic/behavioral model that looks to changes in frequency, duration and magnitude of both positive and negative behaviors. I often rely on the subjective reports of the client and family as well as the reports of the caseworker to determine if the client is changing. V. SERVICE OBJECTIVES I attempt to provide practical information regarding the client's personality structure, risk profiles, diagnosis, strengths, and weaknesses for the caseworker to use in planning needed interventions and assessing progress. I recommend different kinds of therapy but rarely provide the therapy myself. If often provide the court and attorney's with information to plan for the child's placement. I do not primarily address ways parents can find or utilize community resources. VI. WORKLOAD STANDARDS This section does not seem to apply to the solo practitioner like myself, but rather to an agency. I work 40+ hours a week. I am the only one providing the evaluations. I sometimes work with specific individuals and families who have behavioral or sexual dysfunctions, as I have specialized training in these areas. I complete six to twelve evaluations per month depending on the complexity of the cases. I have a 1/3 million dollar malpractice insurance policy. VII. STAFF QUALIFICATIONS I have a Psy.D. I am a licensed psychologist. I do not have a supervisor, nor do I provide supervision. I have knowledge of risk assessment in the areas of homicide, suicide, violent behavior, sexual assault/abuse, self-injury, and Bid Proposal Greeley Counseling Center 3/9/05 Pnoo i nrd likelihood to benefit from treatment. I don't think new caseworker training is relevant to my work. Bid Proposal Greeley Counseling Center 3/9/05 Penn d nfd • • td 002-05 (RFP-FYC-006-00) Attached A tints SSD inun th5401 4i5 M0MI habit_Irn5 PIVAI. cvny Pe witty-whims Ji-tv vitt- N-arol S unikiadej5 a /5 VIA4i insb, lam, Vi s i•}irJ, axis n Aar0n Grp51tA araP.uA c 5 3 3 is Ira and Sir .ture of SSD Supervisor Date I Pave 96 of 3') EXECUTIVE RISK SPECIALTY CO. 3/11/04 - A PSYCHOLOGISTS PROFESSIONAL LIABILITY POLICY • THIS IS A CLAIMS MADE POLICY-PLEASE READ CAREFULLY *** RENEWAL *** NOTICE:A LOWER LIMIT OF LIABILITY APPLIES TO JUDGEMENTS OR SETTLEMENTS WHEN THERE ARE ALLEGATIONS OF SEXUAL MISCONDUCT(SEE THE SPECIAL PROVISION"SEXUAL MISCONDUCT" IN THE POLICY). DECLARATIONS POLICYNO: 008-1755292 ACCOUNT NO: CO-GREE631-0 0314607B ITEM I. (a)NAME AND ADDRESS OF INSURED: ITEM ]. (b)ADDITIONAL NAMED INSUREDS: JACK J. GARDNER, PSY.D. GREELEY COUNSELING CENTER, P.C. 1228 8TH STREET GREELEY, CO 80631 TYPE OF ORG: PROFESSIONAL CORPORATION ITEM 2, ADDITIONAL INSUREDS: BOULDER COUNTY RISK MANAGEMENT DIVISION P.O. BOX 471 BOULDER, CO 80306 ITEMS. POLICY PERIOD: FROM: 04/01/04 TO: 04/01/05 12:01A.M.STANDARD TIME AT THE ADDRESS OF THE INSURED AS STATED HEREIN: ITEM 4. LIMITS OF LIABILITY: (a)$ 1 , 000 , 000 EACH WRONGFUL ACT OR SERIES OF CONTINUOUS,REPEATED OR INTERRELATED WRONGFUL ACTS OR OCCURRENCE (b)$ 5, 000 DEFENSE REIMBURSEMENT (c)$ 3 , 000, 000 AGGREGATE ITEM 5. PREMIUM SCHEDULE: CLASSIFICATION NUMBER RATE ANNUAL PREMIUM 1ST PSYCHOLOGIST 1 1191 . 00 1, 191 . 00 DEFENSE LIMIT . 00 ADDITIONAL INSUREDS 1 50 . 00 SURPLUS LINES TAX 1 37 . 23 INSPECTION FEE 1 1 .24 ITEM6. RETROACTIVE DATE: 04/01/92 TOTAL PREMIUM: 1, 279 . 47 ITEM 7. EXTENDED REPORTING PERIOD ADDITIONAL PREMIUM(if exercised):$ 2, 239. 33 NO DISCOUNT INCLUDED ITEM 8. POLICY FORMS AND ENDORSEMENTS ATTACHED TO THIS POLICY B22138 (7/95 ED. ) B22137 THIS IS NOT A BILL.PREMIUM HAS BEEN PAID. AUT RIZED COMPANY REPRE NTATIVE APA77/1WOC) - • AMERICAN FAMILY MUTUAL INSURANCE COMPANY MADISON, WISCONSIN 53783-0001 • BUSINESSOWNERS POLICY POLICY NUMBER DECLARATIONS 05XD106901 NAMED JACK J GARDNER INSURED DBA GREELEY CONSELING MAILING 1228 8TH ST ADDRESS GREELEY, CO 80631-3216 POLICY PERIOD FROM 11-01-2004 TO 11-01-2005 12:01 A.M. Standard Time at your mailing address shown above. FORM OF BUSINESS INDIVIDUAL In return for the payment of the premium, and subject to all the terms of this policy, we agree with you to provide the insurance as stated in this policy. SECTION I PROPERTY ALL PROPERTY COVERAGES ARE SUBJECT TO THE FOLLOWING: COVERED CAUSES OF LOSS SPECIAL - RISK OF DIRECT PHYSICAL LOSS • COVERAGE PROVIDED INSURANCE AT THE FOLLOWING DESCRIBED PREMISES ONLY FOR COVERAGES FOR WHICH A LIMIT OF INSURANCE IS SHOWN UNLESS COVERAGE IS PROVIDED BY AN ENDORSEMENT. DESCRIPTION OF PREMISES PREMISES NO. 0001 BUILDING NO. 001 LOCATION 1228 8TH ST GREELEY, CO 80631-3216 OCCUPANCY PSYCHOLOGIST OFFICE CONSTRUCTION FRAME YEAR BUILT 1902 COMMERCIAL BUILDING CONSTRUCTION COST INDEX LEVEL 261 POLICY PROPERTY DEDUCTIBLE $250 OTHER PROPERTY DEDUCTIBLE(S) OPTIONAL COVERAGE/GLASS DEDUCTIBLE $500 • COVERAGE LIMIT OF INSURANCE PREMIUM ru BUILDING $131,018 $367.00 o REPLACEMENT COST a a a ADDITIONAL COVERAGE LIMIT OF INSURANCE PREMIUM o BUSINESS INCOME ACTUAL LOSS SUSTAINED INCLUDED a a OPTIONAL COVERAGES LIMIT OF INSURANCE PREMIUM rq a AGENT 020-311 PHONE PAGE 0001 LI, BRENT W FRIESTH 303-449-9595 BRANCH CRW024 RENW 2595 CANYON BLVD STE 250 ENTRY DATE 08-05-2004 BOULDER, CO 80302-6744 BP AF 01 01 99 INSURED Stack No.15141 AMERICAN FAMILY MUTUAL INSURANCE COMPANY MADISON, WISCONSIN 53783-0001 • BUSINESSOWNERS POLICY POLICY NUMBER DECLARATIONS 05XD106901 • MONEY AND SECURITIES $15.00 INSIDE THE PREMISES $10,000 INCLUDED OUTSIDE THE PREMISES $5,000 INCLUDED Property forms and endorsements applying to this premises and made part of this policy at time of issue: Any endorsement followed by a state abbreviation will only apply to coverages within this state. BP 84 11 07 98 MORTGAGEHOLDER LOAN NO. 9011629 & 9011630 PREMISE NO. BUILDING NO. BANK OF CHOICE 0001 001 3635 23RD AVE EVANS, CO 80620-1725 TOTAL ADVANCE PROPERTY PREMIUM $382.00 Property forms and endorsements applying to all premises and made part of this policy at time of issue: Any endorsement followed by a state abbreviation will only apply to coverages within this state. BP 05 76 11 02 BP 83 01 07 98 BP 83 02 05 00 BP 85 11 05 00 SECTION II LIABILITY AND MEDICAL EXPENSES Except for Damage To Premises Rented To You, each paid claim for the following coverages reduces the amount of insurance we provide during the applicable annual period. Please refer to Section II Liability in the BUSINESSOWNERS COVERAGE FORM and any attached endorsements. COVERAGE LIMIT OF INSURANCE LIABILITY AND MEDICAL EXPENSES $1,000,000 MEDICAL EXPENSES -ANY ONE PERSON $5,000 DAMAGE TO PREMISES RENTED TO YOU $50,000 LOCATION PREMIUM BASIS ADVANCE PREMIUM Li) PREMISES NO. 0001 BUILDING NO. 001 m 2000 SQUARE FOOTAGE $48.00 0 TOTAL ADVANCE BUSINESS LIABILITY PREMIUM $48.00 Liability forms and endorsements applying to all premises and made part of this policy at time of issue: o Any endorsement followed by a state abbreviation will only apply to coverages within this state. o BP 04 17 07 02 BP 04 39 07 02 BP 04 54 07 02 BP 04 93 07 02 o BP 05 77 11 02 BP 10 05 07 02 BP 84 24 07 02 BP 85 05 07 9800 BP 85 10 07 98 BP 85 12 10 01 IL 75 26 10 01 • rl 0 0 0 0 a- 0 a AGENT 020-311 PHONE PAGE 0002 BRENT W FRIESTH 303-449-9595 BRANCH CRW024 RENW 0 2595 CANYON BLVD STE 250 ENTRY DATE 08-05-2004 BOULDER, CO 80302-6744 BP AF 01 01 99 INSURED stock No.15141 AMERICAN FAMILY MUTUAL INSURANCE COMPANY V V V V V vv MADISON, WISCONSIN 53783-0001 BUSINESSOWNERS POLICY POLICY NUMBER DECLARATIONS 05XD106901 TOTAL ADVANCE BUSINESS PREMIUM $430.00 This premium may be subject to adjustment. Forms and endorsements applying to property and liability at all premises and made part of this policy at time of issue: Any endorsement followed by a state abbreviation will only apply to coverages within this state. BP IN 01 07 02 BP 00 03 07 02 BP 01 81 07 02 BP 05 01 07 02 BP 05 15 01 03 BP 05 33 11 02 BP 05 40 12 02 BP 80 01 07 98 AUTHORIZED A14.-JQ /y��'^��'o;144 COUNTERSIGNED REPRESENTATIVE LICENSED RESIDENT AGENT ul m m 0 L m C s 0 0 C C C 0 C C C C C C C o- C X AGENT 020-311 PHONE PAGE 0003 BRENT W FRIESTH 303-449-9595 BRANCH CRW024 RENW 2595 CANYON BLVD STE 250 ENTRY DATE 08-05-2004 BOULDER, CO 80302-6744 BP AF 01 01 9! INSURED Stock xo.15141 SUPPLEMENTAL NARRATIVE TO RFP: EXHIBIT B CONDITIONS 7, �y 1 • 31' FAX TO: Gxoni A ROM it c I )(,___ From: 3-FlcgL. 3 , 611 )jt)ia PS7 . U. Number of Pages: This message contains confidential information intended for a specific individual and purpose, and is protected by law. If you are not the intended recipient, you should destroy this message. Any disclosure, copying, or distribution of this message, or the taking of any action based on it, is strictly prohibited. SZ�S )y54' TO 39Vd Sad 9L8SESE0L6 SE:TO SOOL/9L/bO t 3„,„ - =t, qq ... .. . „, April 26,2005 Gloria Romasik, PO Box A Greeley,CO 80632 RE: Bid Proposal Dear Ms. Romansik, It is my intention to finish each evaluation within 90 days in almost every case. I agree to either furnish the department a report within 90 days of commencing work or a letter indicating extenuating circumstances forcing a delay. Occasionally clients do not come for appointments which delays the completion of their work. I do not feel payment should be withheld if the client is forcing the delay and if an evaluation is prepared or in process. Sincerely, ardh /?17 ck J. G er,Psy.D. icensed Psychologist Z0 39Vd Sad SLBSESEOL6 SE:TO S00Z/9Z/70 esestot DEPARTMENT OF SOCIAL SERVICES Ø \IT GREELEY, CO. 80632 Website:www.co.weld.co.us Administration and Public Assistance(970)352-1551 Child Support(970)352-6933 O • April 18,2005 COLORADO Jack J.Gardner,Psychologist. Greeley Counseling Program 1228 8 Street Greeley, CO 80631 Re: RFP 006-00 Mental Health Services Dear Dr. Gardner: 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 Bid 006-00, Mental Health,for inclusion on our vendor list,attaching the following condition for all Mental Health 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, J A. (to,D' for cc: Juan Lopez,Chair,FYC Commission Gloria Romansik, Social Services Administrate Weld County Department of Social Services Notification of Financial Assistance Award for Families,Youth and Children Commission (Core)Funds Type of Action Contract Award No. X Initial Award 05-CORE-57 Revision (RFP-FYC-006-00) Contract Award Period Name and Address of Contractor Beginning 06/01/2005 and Victor H. Cordero Ending 05/31/2006 Mental Health Services 2828 Speer, Unit 118 Denver, CO 80211 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Program provides mental health related and Assistance Award is based upon your Request for psychological evaluation services, including Proposal (RFP). The RFP specifies the scope of psychological evaluations,parent-child interact- services and conditions of award. Except where it is ional evaluations, family assessments,and in conflict with this NOFAA in which case the adjunct services to include family and individual NOFAA governs,the RFP upon which this award is therapy for adults, adolescents, families, and based is an integral part of the action. children involved with the Department. Services Special conditions are linguistically(Latino,Hispanic, 1) Reimbursement for the Unit of Services will be based Bilingual/Spanish) and culturally sensitive. on an hourly rate per child or per family. South County services available in Firestone, 2) The hourly rate will be paid for only direct face to Frederick,Ft. Lupton, including South Weld face contact with the child and/or family, as Annex or WCDSS Ft. Lupton offices.Maximum evidenced by client-signed verification form, and as monthly capacity is 8 evaluations, with average specified in the unit of cost computation. monthly capacity of 4. 3) Unit of service costs cannot exceed the hourly and yearly cost per child and/or family. Cost Per Unit of Service 4) Payment will only be remitted on cases open with, and referrals made by the Weld County Department of Rate per Episode Social Services. Psychological Exam $800.00 5) Requests for payment must be an original submitted to Other Services $400.00 the Weld County Department of Social Services by the Parent-Child Interactional $1,120.00 end of the 25th calendar day following the end of the month of service. The provider must submit requests Hourly Rate per Court Testimony $ 100.00 for payment on forms approved by Weld County Enclosures: Department of Social Services. X Signed RFP: Exhibit A 6) The Contractor will notify the Department of any X Supplemental Narrative to RFP: Exhibit B changes in staff at the time of the change. Recommendation(s) X Conditions of Approval Approvals: Program Official: By J i" BY William H. Jerke, Chair Judy riego,, irector Board of Weld County Commissioners Weld C ty Department of Social Services Date: !JUN Q 6 II Date: Q3— —/tog3 SIGNED RFP: EXHIBIT A INVITATION TO BID BID 002-05 (05005-05011 and 006-00) DATE: February 16,,2005 BID NO: RFP-FYC-006-00 RETURN BID TO: Pat Persichino,Director of General Services 915 10th Street,P.O.Box 758,Greeley, CO 80632 SUMMARY Request for Proposal (RFP-FYC-006-00) for: Colorado Family Preservation Act—Mental Health Services Emergency Assistance Program 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 under the Colorado Family Preservation Act(C.R.S. 26- 5.5-101) and Emergency Assistance for Families with Children at Imminent Risk of Out-of-Home Placement Act(C.R.S. 26-5.3-101). The Families, Youth and Children Commission wishes to approve services targeted to run from June 1,2005,through May 31,2006, at specific rates for different types of service. The County will authorize approved vendors and rates for services only. The Mental Health Services program provides diagnostic and/or therapeutic services to assist in the development of the family services plan,to assess and/or improve family communication, functioning and relationships. This program announcement consists of five parts, as follows: PART A...Administrative Information PART D...Bidder Response Format PART B...Background,Overview and Goals PART E...Bid Evaluation Process PART C...Statement of Work {� Delivery Date 3/405 IIO5 (After receipt of order) BID MUST BE SIGNED IN INK Mi rcp \4, ccCMERo PSyJX TYPED OR PRINTED SIGNATURE VENDOR ` 1e:1OR \ , CoRbERO (Name) Handwritten Signature By Authorized tea S c:ER (.ht + i1 3 Officer or Agent of Vender ADDRESS -Devjveis 1QO 8 TITLE�eRECTo2 DATE 'Wit / e:35 PHONE# 3t-s3-`15S -`19Sa The above bid is subject to Terms and Conditions as attached hereto and incorporated. Page 1 of 32 ' Bid 002-05 (RFP-FYC-006-00) Attached A MENTAL HEALTH SERVICES PROGRAM BID PROPOSAL AND REQUEST FOR CONTINUATION OF AWARD UNDER CORE SERVICES FUNDING EMERGENCY ASSISTANCE PROGRAM 2005-2006 BID PROPOSAL APPLICATION PROGRAM FUNDS YEAR 2005-2006 �I `'fit, BID 002-05 (006-00) ^� \TAME OF AGENCY: \1Q-1'0R �C� R eve 1 Ps-yap , ADDRESS: oZ$ eQ SLVa, , ytier tl$ , yeR , CtO �Do� t1 PHONE CPI 45 5— y c ` CONTACT PERSON: J 1 C-le Z (lOg Pat) TITLE:e31)1(Z ea-ez, DESCRIPTION OF EMERGENCY ASSISTANCE PROGRAM CATEGORY: The Mental Health Services program provides for"diagnostic,and/or therapeutic services to assist in the development of the family services plan,to assess and/or improve family communication,functioning,and relationships. (Volume VII,7303.1,G)" 12-Month approximate Project Dates: 12-month contract with actual time lines of: Start June 1,2005 Start End May 31,2006 End A TITLE OF PROJECT:�c� n3r c�% Ev�ws4rranl L1 Age►ut-CL .D FFSSeSS i+te� Arvb TtteRaveLreic 5EikutcEs • Name and Signature of Person Preparing Document Date Name and Signature Chief Administrative Officer Applicant Agency Date MANDATORY PROPOSAL REQUIREMENTS For both new bids and renewal bids,please initial to indicate that the following required sections are included in this Proposal for Bid.For renewal bids,please indicate which of the required sections have not changed from Program Fund Year 2004- 2005 to Program Fund year 2005-2006. Indicate No Change from FY 2004-2005 ✓ Project Description V Target/Eligibility Populations V Types of services Provided Measurable Outcomes Service Objectives 7 Workload Standards —7 Staff Qualifications ✓J Unit of Service Rate Computation Program Capacity per Month V Certificate of Insurance Date of Meeting(s)with Social Services Division Supervisor: 34 405 Page 25 of 32 Victor H. Cordero,Psy.D. Mental Health Services, RFP-FYC-006-00 Bid 002-05 (RFP-FYC-006-00) Category: Mental Health Services Program Project Title: Psychological Evaluation, Parent-Child Assessment & Therapeutic Services Vendor: Victor H. Cordero, Psy.D. 1 Victor H. Cordero, Psy.D. Mental Health Services, RFP-FYC-006-00 I.PROJECT DESCRIPTION This project is designed to provide mental health related and psychological evaluation services to adults,adolescents,adults,families,and children involved with Weld County Department of Social Services. The project will strive to provide the highest levels of competence in the execution of all evaluation, therapeutic,and skills building services. These services will be provided in a context that is congruent with ethical standards and practices in the field of psychology. Services will also be linguistically (bilingual/Spanish)and culturally sensitive as a means of providing the most effective psychological evaluations and parent-child evaluations. Recommendations,approach, and clinical conceptualization will account for the culturally,linguistically, and socioeconomically diverse population to be served. Specific services available will include: psychological evaluations,parent-child interactional evaluations,family assessments, and adjunct services to include family and individual therapy. 2 Victor H. Cordero,Psy.D. Mental Health Services, RFP-FYC-006-00 II.TARGET/ELIGIBILITY POPULATIONS A. Total Number of Clients to be served: 55 B. Total individual clients and the children's ages: 55 clients,age range from elementary school age children,through geriatric C. Total Family Units: 55 D. Sub-total of individuals who will receive bicultural/bilingual services: 60% E. Sub-total of individual who will receive services in South Weld County: 40% F. Subtotal of individuals who will have access to 24-hour service: 100% G. Monthly maximum program capacity: 8 evaluations H. Monthly average capacity: 4 evaluations I. Average stay in the program: 3 months J. Average hours per week in the program: 7 hours K. CulturaVethnically specific services: Latino, Hispanic,Bilingual/Spanish L. Service to South Weld Count Clients: Services available in Firestone, Frederick,Ft.Lupton area, including South Weld County Annex or WCDSS Ft.Lupton offices if requested by The Department. 3 Victor H. Cordero,Psy.D. Mental Health Services, RFP-FYC-006-00 III.TYPE OF SERVICES TO BE PROVIDED A. Family/adult/child/adolescent psychological evaluation & assessment services 1. Psychological evaluation services are intended to provide clinical information requested by Social Services and will include/incorporate the following: a. Evaluation procedures, reports and recommendations will be designed to produce useful responses to specific referral questions. A licensed psychologist or qualified candidate for licensure under supervision by a licensed clinical psychologist will complete all evaluations. b. Evaluators will make all reasonable efforts to collaborate with case related contacts prior to the completion of the evaluation either by personal contact,telephone contact,or via written report. c. Evaluation reports will clearly state methods utilized,contacts made,tests administered,and results and recommendations relevant to the referral question. d. Evaluation and assessment content will be made available to the family or other relevant parties and will comply with the ethical standards and practice of the American Psychological Association and/or other legal considerations. B. Parent-Child Interactional evaluations a. Evaluation procedures, reports and recommendations will be designed to produce useful responses to specific referral questions and from arising clinical issues as observed by the evaluator. A licensed psychologist or qualified candidate for licensure under supervision by a licensed clinical psychologist will complete all evaluations. b. Evaluators will make all reasonable efforts to collaborate with case related contacts prior to the completion of the evaluation either by personal contact,telephone contact,or via written reports. c. Evaluation reports will clearly state methods utilized,contacts made,tests administered, and results and recommendations relevant to the referral question. 4 Victor H. Cordero,Psy.D. Mental Health Services, RFP-FYC-006-00 C.Individual & Family Therapy Services (adjunct services) a. Therapeutic services will be designed to address the needs of The Department,or referral request,in line with the best interests of the children or family involved. b. Therapeutic services will be congruent with recommendations stemming from referral sources,or other evaluation procedures previously performed. D. Consultation with Caseworkers 1. Evaluators will consult with Social Service caseworkers regarding the integration of assessment results into the overall care plans for the child, adolescent,adult,or family involved. 2. Evaluators will assist in obtaining feedback from agency clinicians regarding the rationale for decisions on these issues when required. E. Court Testimony Evaluators will make all reasonable efforts to be available for court testimony when given proper notification for clients with open or closed cases. 5 Victor H. Cordero,Psy.D. Mental Health Services, RFP-FYC-006-00 IV.MEASURABLE OUTCOMES A. This program will shorten the time required to obtain evaluation results after a referral is made by means of an accessible referral line and allotted appointment times with the evaluator. B. Social Service staff will have ease of access to the practitioner/clinician by means of a direct phone line, mobile telephone,or other device which will result in a response as soon as is reasonably possible. C. Frequency of contact between the practitioner/clinician and Social Service staff will be defined by the needs of the case and the needs of the referring staff member. D. Timeliness of responses will be pursued as a high priority as will client scheduling. E. Coordination of assessment and therapeutic services between the practitioner/clinician and Social services will be ongoing. F. This program will provide emergency consultations within 24 hours of such request or will make all efforts to assure this outcome. Evaluation results will demonstrate clear recommendations and utilize methods that will be accepted by the court,and which are reasonable. Quantitative measures to be utilized will be based on direct caseworker feedback regarding timeliness,usefulness,and professionalism of reports. 6 Victor H. Cordero,Psy.D. Mental Health Services, RFP-FYC-006-00 V.SERVICE OBJECTIVES Services of the project will improve family conflict management by providing clear diagnostic guidance and effective therapeutic reconunendations/services to assist in the development of the family services plan, to assess and improve family communication,improve parenting skills,and to improve functioning of familial relationships. Services will improve household management competency in families by providing parents and caregivers insight,education, and guidance,in regards to safety of the household and the protection of children. Services shall assist parents in identifying and accessing assistance from other community based resources within local,state,and federal governments when applicable. Each of the latter objectives will be measured via direct observation, client feedback,and direct feedback from social workers to occur on a quarterly basis. 7 Victor H. Cordero, Psy.D. Mental Health Services, RFP-FYC-006-00 VI.WORKLOAD STANDARDS The program will provide a minimum of 25 hours per week of clinical services,to include up to three practitioners/clinicians providing these services. The maximum caseload per worker on evaluations will be 4 clients per week. Modality of treatment interventions will be individual or family. Maximum caseload per supervisor will be 4 cases of evaluation per week, and 10 cases of individual/family therapeutic services. The number of assessments per month will be a maximum of eight. Insurance: Attached 8 Victor H. Cordero,Psy.D. • Mental Health Services, RFP-FYC-006-00 VII.STAFF QUALIFICATIONS A. All staff providing direct services will have at least the minimum qualifications in education and experience. Psychologists and clinicians will be licensed in the state of Colorado,be eligible for licensure,or evidence competence in the area of service. All non- licensed clinicians will be directly supervised by a licensed clinical psychologist and the psychologist will supervise and sign off on all documents provided to Social Services. B. Total staff number: 3 C. Staff will receive and comply with any training required by Social Services. D. All staff have knowledge in risk assessment. E. Staff providing bilingual (Spanish)services will demonstrate adequate levels of fluency in both linguistic competencies,and in cultural competencies. 9 id 002-05(RFP-FYC-006-00) Attached A ents by SSD Supervisor. Lb' nLn--or�ta `s��;;�-k�� pp '1 mm1lt. lv��n Vrta-e _ ""off�c ` e4- R i s ( PUf MQi L y'�Vat • Dr , (ora to W\Il (cM AL1 -b € je-A . IV1�Gc�Libf1�, cij\ad\n ffuaQ ,Arr C` (AkftsiaQ2-- it 63 K h� P� (�-oov�d► ��R ttput ��\licg..ta4 can t N- a 3' ( u, cif�. 14 Lao cvt\li cl L -Q.van it. y.1C 0' 1J C l i s and t11,4 (toms )etl (&r Qxt.t 4,04114, (nr ev (.vzn> d-- • joJo lie and Sign of SSD Supervisor Date Pavr 96 of 19 Q \ , _ _ _ _ _ _ k ( b ) 2 N tilN 07 \60 \ \ / Q \ N N 2 , W3 69 49 69 a 11: LO frl % N .a U) 00 10 Wl C9 r Wl 103 49 fl 69 69 5 0 -J \ ! Co ( R R co } } J \ a \ , } ) k [ 2 a _03 / 0 H z = 0 a ° _ ) a. CC } CO 2ili 0 0 ( E ° ± W 0 0 ) + 2 - 5 ) § § G ° / § \ \ 0 e e ) § S ° < ° a \ ± LU 3 = 0 k � § 2 § ( o § b E 0 0 0 o i [ \ 0 0 \ \ S < o L Sa 2 0 ) ± 0 ± o S § 0 E ] ± E E ± m 9 H Z § w w > ) § ( § \ G Z CC w % E ° S k \ J \ R § # a m or e m p m o t w< a / ± / § > ) < § p } \ oo / < o < + cc m o 0 _ « w z c \ e § n § l- i a c z 0 # S > o 0 P 0 0 = m e = _ 2 m ( LU o D § E § ( § o \ } ° § ' a o = a_ § e . ! < < < e < 2 ± k a k cc C H H H 0 H .e W H ; e e ( $ _ a_ H p H 0 H a 0 R a p H m H S < = 0 0 LU U- 0 = _ - Y u I... 0000 V 000 000 0690000069000000 0000069 w g2a y 6 O y i w w 0 0 9 o !IIM ' S g 0 I mPJth m '� f yo 88"88888888888 2 888888 O w o o w w w w w w w a a a w 882222 5Z= yaw w w w w w x 0 it,zmo '21 &i t w ' fit- w y m m m ry ry r 82888888888888 2 888888 0m 000000000000 0 000000 0 Li) re 0 U00004.04.49690.9494949 w »w w w w a <w ry cii y 2 w w w F O =ayIllw ..„ e itc n {E qjjpjjpj sii i 8888888888888 88p8888 8 y m 0 m m 0 y 8 Qm 0 0 w m 0 re zuo 2....."....»... w h w w w w5 w a ya x O 5, 4 ye N a 6 L b.b ..N1 io-a 4 . �.,GCA� v � I S,. m 5j:3 (C„t`.a w f N O Q . U o wwww0000000000 ww0000 W DO „.„zzz222Z222 >>2222 a a W r5 000000www I: I;IIE ' m "o H H w o a 0 _ g ry W �A aN® }AFC .} #v F t '.-51.7. .t y .. t iittKO, a r LL 95i Y '_1 4 W lm xr '4 E in, M 4 jn, _'" iii Q2 W ~ *x r' - A O p m .wieel,1 L ry % `p!3'i 1 'i W• C7 a,: E 3Q a p A a"'-, i r,, w z a. 2 p It 5e ".f E• i� ' 0 f t O W K p F M ,�4_ E i f 3i.u"" r 8 K a a i ,S yx e� a of p G w w +k,: .. a 7 n o N J Wci- U tix r""c 0 W K ' O it r y w �.f n a H• CO N re O i Co xJl� m a la Z w mQ a �" r t ,43 r g r S J J p _It r r Pfrv+ :-< w W 5 W H< Q m . W y e o 8 ,xOO ww««««ww««d w HO ww w w««««ww « 5=� a a W_ F F w O m f Oi-OE F dx :t � � 1 a' 4 x.. Nya zo 0 f w " .r ii w X w 1 U v # S A 5 F 88 88888888888 8888888 a pp-0.a....0.0OO O0 woeze, 0«aN « U� NWHHW N JQa a w N y 1 s',; L7, « i- 0 gg o up F F ,jA 6 �, d 1 } 4! _ }M 0 LLO a FL N $ rt « I- �0p88O8888888888 8888880 ^w wooa w3 H O«N«is N«N N W 49 49« K W M H W U 0 5z0 " " h ztf, -w « 47, I- 0 w z s z „'9 iii. ::2114110,44. :n O qn E‘2 ta, a$:r. i Rig. y' N 0 w X o u 5 I,? ^< 8888888 ^a � pppp pp a «zirj o o N N o a M 2 w w 19 N«M 0 «K"W; O N a it = « « w w « i- 0 w w z Y a ,' -v n seq .x x _-.* XNM1 N Ir "{ 5 1 K ) 7� LwZ IT o w w F U o� www0000000000o w00000 LL °0 aaaZZZZZ22222Z aZZZZZ Z a 2 ,i e m p np p op 0 0 0 0 0 o 0 0 p op o oo !g'��5i' e trp '"O "Osaasaa WKNiAww m N c -:$ "- UF Oc ww « " 5 Z m Xii d9 Q m A fitx.. ' r G Q ef*. k- � yi.y a 4 D O W iili.:3 g ,K. 0tt '' .a tq!Est W - a '` ' . c“it; Y } M !-�• , einWlinagn frtkeyla 7.K W �$t!-:1kMT1 p f5te ymj Kw' 4 w z 0 o w tp t �„: a> sin tni 8 F -,w o 0 U a $ y o z co G. 6- 6 p d. 4rys !kV, � U i w a 4" Ix' l ,I, g g ,fit F o O O O w Cn LL t - -4{ - O O A U— w J W J d d X`} . « V « Fy S G N u F a£attain <igzla .. i i tl .:SO w m h LL,.'` ' !tifi T 4.,; 1. ow F, ,»it:u u • w w re { nt 1 � w " K t F o o i '7`1 f. �a c o n`i,� 4x 0 O 4d 1ak `' e t 't.0 0 a a a » Lan £ a w w04,741,0M:<'M a 1 n F F F +Rn r.fit.. . . ::4 F ., Y �_'rF O La b ~ 0 00 I °°°"""888888882.p p p p p p8 co wUK W gassz;n Hw WNgHHH HHN H . N w < o0 r o -Ira.W K H H N 0 < W, o UO ,fit d''�Sl3>. I ". `' �k!'§r .�#`i E JJO. e i �d oos 8°Sp88p8p88888p88.p0p0p800 0 0 P N H K H H N 0 N N H H H N H N W d W 0 =K U H O. H N Hf w w J W < I_ > Oaa y 12 O. << 8828 2e WUK 002 2 ry e s oes 00 ssssssssss w < oa O - 0 8 8 O r W 6 N N w 0 H N N a re 5 CO O 0re rc #a'a Y` "''F 5 t'b Z _ C v b:d t ....., I. < o�a 888 e F w U 6' .................w w Y 10 a 0O i O H H w w w U ID -i n > '^ w "�' G < WOF a < a> W ...so it C .k '� .FY x 80 www000000000000000 0 »>zzzzzzzzzzzzzzz z O O otilE`tppyy a v ,,,,,,ttt hex rt gA Fa'k Y „s� C F a, xf 4 M i... N W (7 ₹ 4 IZ . Ai.. u O W f C Y �C6 S` N 4 tt -I o- 1*: u o a a r C O re El a feu a D '' �� %'T' o u a W 8 *Pribvtr A ' +� "t 1 . 4` w w O re 6o W i ' i 3ly�Afis &I,-."qga a w re Y }sir t] S' iW N U_ < W y. W,p�{- Y i RY 4 ryx r O Q u < w w p n` C R j S asklx Ns.₹ yvi. O Q O O F f a W ga ₹ WA t AN,i 8 O 8 < to O Account Number: CO CORV 2130 Date: 11/04/04 Initials: JMULLIN CERTIFICATE OF INSURANCE EXECUTIVE RISK SPECIALTY CO. C/O: American Professional Agency, Inc. 95 Broadway, Amityville, NY 11701 This is to certify that the insurance policies specified below have been issued by the company indicated above to the insured named herein and that, subject to their provisions and conditions, such policies afford the coverages indicated insofar as such coverages apply to the occupation or business of the Named insured(s) as stated. THIS CERTIFICATE OF INSURANCE NEITHER AFFIRMATIVELY NOR NEGATIVELY AMENDS, EXTENDS OR ALTERS THE COVERAGE(S) AFFORDED BY THE POLICY(IES) LISTED ON THIS CERTIFICATE. Name and Address of Insured: Additional Named Insureds: VICTOR H. CORDERO, PSY.D 2828 SPEER SUITE 118 DENVER, CO 80211 Type of Work Covered: PROFESSIONAL PSYCHOLOGIST Location of Operations: N/A (If different than address listed above) Claim History: Policy Effective Expiration Limits of Coverages Number Date Date Liability PROFESSIONAL/ 1,000,000 LIABILITY 008-1764838 10/01/04 10/01/05 3,000,000 NOTICE OF CANCELLATION WILL ONLY BE GIVEN TO THE FIRST NAMED INSURED ON THIS POLICY AND HE OR SHE SHALL ACT ON BEHALF OF ALL INSUREDS WITH RESPECT TO GIVING OR RECEIVING NOTICE OF CANCELLATION. Comments: This Certificate Issued to: y - Name: VICTOR H. CORDERO, PSY.D 2828 SPEER Address: SUITE 118 DENVER, CO 80211 Au orized Representative SUPPLEMENTAL NARRATIVE TO RFP: EXHIBIT B CONDITIONS From the office of: 2828 Speer Blvd.,Unit 118 Victor H. Cordero, 1'sy.11.,P.C. Denver, CU 80211 1 irPnsed Clinical Psychologist Office (3031 455-9480 Fax(303)651-3773 rt4r; SCHEDULE Effective Junel,2005 -June 30, 2006 Wei a RE: Mental Health Services RFP 006-00 Sow atncy 0 RE: Lifeskills RFP 05005 C/ep,eel Ser. etc° op i/n!t s APR Service Fee d 7 2p0S English,Bilingual and Spanish Assessment& Evaluation Services: Psychological Evaluation $800 Intellectual/Cognitive Test in Addition to Above $400 (I.Q./intellectual,cognitive assessment) Parent-Child Interactional Evaluation $1,120 (Comprehensive evaluation of parenting capacity including in-vivo observation, videotaped observation on multiple visits with full report and recommendations) Offense Specific Evaluation $1,200 Supervised/therapeutic Visitation $85/clinical hour (Therapeutic visits at WCDSS offices, therapist office, or WCDSS satellite offices North and South Weld County. Available for after hours by appointment and weekends by appointment). Individual Therapy $85/clinical hour Family Therapy $100/clinical hour Anger Management Group(Spanish) $50/Group dAO it j‘iirii DEPARTMENT OF SOCIAL SERVICES P.O. BOX dillit GREELEY, CO. 80632 Website:www.coweld.co.us Administration and Public Assistance(970)352.1551 Child Support(970)352-6933 I e IIII iv • April 18,2005 Victor H.Cordero Psy.D. 2828 Speer,Unit 118 Denver,CO 80211 Re: RFP 006-00 Mental Health Services RFP 05005 Lifeskills Dear Dr.Cordero: 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 l • The Families,Youth and Children(FYC)Commission recommendedapproval of Bid 006-00, Mental Health,for inclusion on our vendor list,attaching the following conditions.Condition#1 is applicable for all Mental Health providers,while Condition#2 is specific to your Mental Health program. Condition#1: 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 Condition#2: Please clarify your rate for services,assuring that the cost of service is for client contact only. • The Families,Youth and Children(FYC)Commission recommended approval of Bid 05005, Lifeskills,for inclusion on our vendor list,attaching the following conditions for all Lifeskillss providers. Condition:All providers must define their capacity to do after-hours visitation. Required Response by FYC Bidders Concerning FYC Commission Conditions: All conditions will be incorporated as part ofyour Bid and Notification of Financial Assistance Award (N0FAA).If you do not accept the condition(s),you will not be authorised as a vendor unless the FYC Commission and the Weld County Department of Social Services accept your mitigating circumstances.If you do not accept the condition,you must provide in writing reasons why.A meeting will be arranged to discuss your response.Your response to the above conditions will be incorporated in the Bid and Notification of Financial Assistance Award. Page 2 Victor H.Cordero/Results of Bid Process 2005-2006 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 3521551,extension 6230. Sincerely, Oglo, c ---4411Altri cc Juan Lopez,Chair,FYC Commission Gloria Romansik,Social Services Administrator Weld County Department of Social Services Notification of Financial Assistance Award for Families,Youth and Children Commission (Core)Funds Type of Action Contract Award No. X Initial Award 05-CORE-55 Revision (RFP-FYC-006-00) Contract Award Period Name and Address of Contractor Beginning 06/01/2005 and Barry Lindstrom, Ph. D., LLC Ending 05/31/2006 Mental Health Services 3211 20 Street,#D Greeley, CO 80634 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Program provides diagnostic services to assist in Assistance Award is based upon your Request for the development of the Department's family Proposal (RFP). The RFP specifies the scope of services plans, and to assess family services and conditions of award. Except where it is communication, functioning and relationships. in conflict with this NOFAA in which case the Monthly average capacity is 8 open evaluations. NOFAA governs,the RFP upon which this award is Cultural/ethnic needs considered in evaluation based is an integral part of the action. process and in making treatment Special conditions recommendations; South Weld County access. 1) Reimbursement for the Unit of Services will be based Available for visitations at DSS Del Camino or on an hourly rate per child or per family. Fort Lupton offices. 2) The hourly rate will be paid for only direct face to face contact with the child and/or family, as Cost Per Unit of Service evidenced by client-signed verification form, and as specified in the unit of cost computation. Hourly Rate Per $280.00 3) Unit of service costs cannot exceed the hourly and Psychological Exam yearly cost per child and/or family. Parent-Child Interactional 4) Payment will only be remitted on cases open with,and Professional Consultation referrals made by the Weld County Department of Social Services. Hourly Rate per Court Testimony $ 150.00 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 of the Enclosures: month of service. The provider must submit requests X Signed RFP: Exhibit A for payment on forms approved by Weld County X Supplemental Narrative to RFP: Exhibit B 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 J A tA— By William H. Jerke,Chair Judy eg , irector Board of Weld County Commissioners Weld unty Department of Social Services Date: JUN 0 6 2005 Date: G9/ 2,/ Oc SIGNED RFP: EXHIBIT A INVITATION TO BID BID 002-05 (05005-05011 and 006-00) - - • DATE: February 16, 2005 BID NO: RFP-FYC-006-00 RETURN BID TO: Pat Persichino,Director of General Services 915 10th Street,P.O.Box 758,Greeley, CO 80632 SUMMARY Request for Proposal(RFP-FYC-006-00) for: Colorado Family Preservation Act—Mental Health Services Emergency Assistance Program 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 under the Colorado Family Preservation Act(C.R.S.26- 5.5-101) and Emergency Assistance for Families with Children at Imminent Risk of Out-of-Home Placement Act(C.R.S. 26-5.3-101). The Families,Youth and Children Commission wishes to approve services targeted to run from June 1,2005,through May 31,2006, at specific rates for different types of service. The County will authorize approved vendors and rates for services only. The Mental Health Services program provides diagnostic and/or therapeutic services to assist in the development of the family services plan,to assess and/or improve family communication, functioning and relationships. This program announcement consists of five parts,as follows: PART A...Administrative Information PART D...Bidder Response Format PART B...Background,Overview and Goals PART E...Bid Evaluation Process PART C...Statement of Work Delivery Date ---31 \ %-or ST t7 (After receipt of order) MU SIGNED IN INK TYPED OR PRINTED SIGNATURE VENDOR � � (Name) Handwri 'Si ture By Authorised � ) 8� BARRY LINDSTROM, Ph.D., L.L.C. Officer or Agent of Vender LICENSED CLINICAL PSYCHOLOGIST ADDRESS 3211 20TH ST., #D TITLE a, 0 4' 41'\'- GREELEY, CO 80C34 DATE '3_ / PHONE# q7 0 3,16- lI 00 The above bid is subject to Terms and Conditions as attached hereto and incorporated. Page 1 of 32 . Bid 002-05 (RFP-FYC-006-00) Attached A MENTAL HEALTH SERVICES PROGRAM BID PROPOSAL AND REQUEST FOR CONTINUATION OF AWARD UNDER CORE SERVICES FUNDING EMERGENCY ASSISTANCE PROGRAM 2005-2006 BID PROPOSAL APPLICATION PROGRAM FUNDS YEAR 2005-2006 BID 002-05(006-00) NAME OF AGENCY: Barry R. Lindstrom, Ph.D. ,LLC ADDRESS: 3211 20th Street, Suite D, Greeley, CO 80634 PHONE(97C 356-3100 CONTACT PERSON: Barry T,i ndstrnm, Phi) TITLE: psychologist DESCRIPTION OF EMERGENCY ASSISTANCE PROGRAM CATEGORY: The Mental Health Services program provides for"diagnostic,and/or therapeutic services to assist in the development of the family services plan,to assess and/or improve family communication,functioning,and relationships.(Volume VII,7.303.1,G)" 12-Month approximate Project Dates: _ 12-month contact with actual time lines of: Start June 1,2005 Start June 1 , 2005 End May 31,2006 End May 31 , 2006 TITLE OF PROJECT: Individual and Family Psychological Evaluations , g,,, 7.At� t Barry R. Lindstrom, PhD March 10, 2005 Name and Signature f Person Preparing Document Date ��, j Barry R. Lindstrom, PhD March 10, 2006 Nine and S ature Chief Administrative Officer Applicant Agency Date 1j PP g MANDATORY PROPOSAL REOUIREMENTS For both new bids and renewal bids,please initial to indicate that the following required sections are included in this Proposal for Bid.For renewal bids,please indicate which of the required sections have not changed from Program Fund Year 2004- 2005 to Program Fund year 2005-2006. Indicate No Change from FY tit/ Project Description t Target/Eligibility Populations Types of services Provided Measurable Outcomes Service Objectives Workload Standards ' Staff Qualifications i Unit of Service Rate Computation ' Program Capacity per Month u Certificate of Insurance Date of Meeting(s)with Social Services Division Supervisor: March 2, 2005 Page 25 of 32 id 002-05 (RFP-FYC-006-00) Attached A ents by SSD Supervisor. • Linos xY\ Oncf -? Me+ 4\6rnoinim(3)aks `tv5 bid ?oc-id lot aW -b save igof-l-h SoU coi(Au) Lt U -a \oisull-\ndm@ �lahoo c AL, 34ns n d y •tune of SSD Supervisor Date LLL Barry R. Lindstrom, Ph.D., LLC Licensed Clinical Psychologist 3211-20th Street, Suite D Greeley, CO 80634 (970) 356-3100 March 11,2005 TO: Weld County Department of Social Services RE: Request for Proposal (RFP-FYC-006-00)for: Colorado Family Preservation Act— Mental Health Services Emergency Assistance Program Project Title: Individual and Family Psychological Evaluations Vendor: Barry R. Lindstrom,Ph.D., LLC; Licensed Clinical Psychologist March 11,2005 Attached A Page 2 Bid 002-05 (RFP-FYC-006-00)Mental Health Services Emergency Assistance Program Project Title: Individual and Family Psychological Evaluations Vendor: Barry R. Lindstrom,Ph.D., LLC;Licensed Clinical Psychologist I. PROJECT DESCRIPTION The proposed project will provide diagnostic services to assist in the development of the Department's family services plans,and to assess family communication, functioning and relationships. This project will provide mental health(psychological)evaluations for individuals (children, adolescents,and adults) and families(interactional and attachment assessments)as requested by Weld County Department of Social Services(WCDSS)and ordered by Weld County Courts. The goal will be to provide diagnostic information to the Department and Courts for treatment planning in order to meet current permanency planning goals and requirements to prevent out of home placement or provide for the timely reunification of children and families. This project does not provide psychosexual evaluations. Clients will be informed of the nature, scope and procedures of evaluation at the outset and their informed consent obtained in writing. Releases of information will be signed to obtain records from and consultation with the Department and all collateral sources and contacts. Evaluations will include clinical interviews, psychological testing,review of case records and consultation with collateral contacts(other involved professionals). Evaluations will be responsive to the context of the referral in the phase of the family's involvement with the Department and court process(initial D&N,progress in treatment, or review of permanency plans and goals)and address all questions outlined in the caseworker's referral (e.g.,treatment planning and recommendations,placement and permanency questions). Individual evaluations will assess and summarize individual psychosocial functioning and diagnostic questions raised in the referral,in particular as it relates to issues(child or parent)that support or interfere with parenting or reunificication. Family evaluations will assess and summarize individual child and parent functioning and the attachment relationship and family interaction between family members that support or interfere with parenting or reunificication. All evaluations will be documented in and completed by a written report outlining:the referral questions;brief case history and context; evaluation procedures and findings; and conclusions and recommendations. Evaluation reports will address both strengths or protective factors,and risk factors or problems. Evaluations will be completed in a timely and professional manner following all state, federal and professional (American Psychological Association,APA)regulations and standards regarding confidentiality and professional standards for evaluations. March 11,2005 Attached A Page 3 Bid 002-05 (RFP-FYC-006-00)Mental Health Services Emergency Assistance Program Project Tide: Individual and Family Psychological Evaluations Vendor: Barry R. Lindstrom,Ph.D., LLC;Licensed Clinical Psychologist II TARGET/ELIGIBILTY POPULATIONS A. Up to fifty (50)evaluations can be completed within the fiscal year depending on the needs of the Department. B. Family evaluations can be for any size family and include members of all ages. Individual evaluations can be for children, adolescents and adults of any age. C. This can include up to fifty(50) family units. D. All evaluations will be conducted in English with attention paid to any cultural or ethnic needs of the clients. E. South Weld County residents can access services through my office. I can be available to observe family interaction/visitations at the DSS Del Camino or Ft. Lupton offices. F. All clients and Department personnel have access to after hour's answering service. Evaluations will be conducted during office hours(8am to 5pm, Mon- Fri). I can also be available to attend evening or Saturday visitations at CARE, LFS,etc. G. Multiple evaluations can be occurring simultaneously within any given month. H. The monthly average capacity is eight open evaluations. I. Each evaluation takes between one and three months from referral to report depending on the clients' availability and willingness. J. Each evaluation averages two hours per week of direct contact. K. Clients' cultural/etimic background and needs will be considered in the evaluation process and in making relevant treatment recommendations. L. South Weld County residents can access services through my office. I can be available to attend Visitations at the DSS Del Camino or Ft. Lupton offices. March 11,2005 Attached A Page 4 Bid 002-05(RFP-FYC-006-00)Mental Health Services Emergency Assistance Program Project Title: Individual and Family Psychological Evaluations Vendor: Barry R. Lindstrom,Ph.D., LLC; Licensed Clinical Psychologist III TYPE OF SERVICES TO BE PROVIDED A. Family/Child/Adolescent Psychological Evaluation/Assessment Services All evaluations will be conducted as efficiently as possible with no unnecessary intrusion, but with an emphasis on gathering sufficient and appropriate clinical data and information to answer the referral questions within the phase of involvement with the Department(e.g.,initial assessment and treatment planning vs. reasons for treatment failure or noncompliance or changes in permanency planning)and as meets court and professional(APA) standards for evaluation. The relative number of individual or family evaluations is dependent upon the needs of the Department. 1.a. Family(Interactional)Evaluations include some or all of the following depending on family composition, child's placement and the caseworker's referral questions: Individual Clinical Interview(s)with each family member(1 to 2 hours for each member), Conjoint clinical interviews with all family members(including marital,parent child, and sibling subsystems as clinically indicated; 3 to 5 hours), Conjoint interview/consultation with child and current caregivers(foster parent,relative etc)if child is in out of home placement at the time of evaluation, Psychological Testing(MMPI-2, and/or MCMI-III) for each adult family member as clinically indicated(1 to 2 hours each), Standardized Behavioral Assessment(BASC or similar for each child as appropriate, completed by parents, foster parents,teachers as clinically indicated), Review of case records,previous evaluations and treatment records(1 to 2 hours), Collateral contacts/consultation with caseworker,past or current treatment providers, schools etc(1 to 2 hours), Court Facilitator Staffings as requested (1 to 2 hours,during or after evaluation). Individual Psychological Evaluations include some or all of the following depending on referral questions: Individual Clinical Interviews(3 to 5 hours;for child and adolescent clients this will include interview with current caretakers), Psychological Testing to address referral questions regarding personality and intellectual functioning as clinically indicated(e.g.,MMPI-2, MCMI-III, WASI, BASC etc; 1 to 5 hours as needed), Review of case records,previous evaluations and treatment records(1 to 2 hours) Collateral contacts/consultation with caseworker,past or current treatment providers, schools etc (1 to 2 hours), Court Facilitator Staffings as requested(1 to 2 hours,during or after evaluation). March 11,2005 Attached A Page 5 Bid 002-05(RFP-FYC-006-00)Mental Health Services Emergency Assistance Program Project Title: Individual and Family Psychological Evaluations Vendor: Barry It. Lindstrom, Ph.D.,LLC;Licensed Clinical Psychologist III TYPE OF SERVICES TO BE PROVIDED (continued) b. Consultation with collateral contacts (e.g.,caseworker,past or current treatment providers or evaluators, schools,court facilitator staffmgs, etc.)will be included as part of each evaluation to meet court and professional standards. c. A written report will be provided to the referring caseworker within thirty(30) days of the completion of the evaluation. This report will summarize the referral questions;brief case history; evaluation course;methods and procedures (including psychological testing,records reviewed and collateral contacts); findings;conclusions and recommendations. Evaluation reports will address both strengths and protective factors and risk factors or problems. d. Individuals and families will be offered a final diagnostic feedback session as part of the evaluation process to discuss test results and the findings and recommendations of the evaluation. B. Consultation with Caseworkers Consultation with Caseworkers will occur at the time of initial referral,after the first client contact,prior to the completion of the final icpurt and as needed during the course of evaluation to: Assess and address any urgent or emergent recommendations or questions of safety or placement, Gather and share information and findings, Coordinate scheduling of conjoint and child and caregiver interviews, Assist in the preparation of individual and family treatment plans and court updates, Assist in the elaboration and implementation of recommendations, Discuss the clinical rationale for recommendations or decisions, Discuss placement and permanency needs and plans,and As needed or requested by the caseworker or evaluator. C. Court Testimony Expert testimony will be provided as requested by the county attorney regarding the evaluation process,findings and recommendations. This will include preparation,travel and court time out of the office to be billed at the contracted hourly rate(two hours minimum). All evaluations are being provided at the Department's request to meet court ordered treatment plans. As such,they are considered forensic evaluations and not treatment and do not meet the criteria of"medical necessity"to be eligible for reimbursement by any insurance company (pubic or private)or other sources of funding. March 11,2005 Attached A Page 6 Bid 002-05(RFP-FYC-006-00)Mental Health Services Emergency Assistance Program Project Title: Individual and Family Psychological Evaluations Vendor: Barry R.Lindstrom,Ph.D.,LLC;Licensed Clinical Psychologist IV. MEASURABLE OUTCOMES A. Evaluations will be completed in a timely manner(one to three months)to meet caseworker requests and scheduled court uplistes and hearings. Caseworkers will be contacted at each stage of the evaluation for case management and to share initial impressions,findings and any urgent recommendations (see III B above). Any delays in completing the evaluations will be discussed with caseworkers in advance. Any delays due to client non compliance will be discussed and problem solved with the caseworker. An average of two months from initial referral to completed report is the goal. Individual evaluations can be completed in less time than family evaluations,because of the number of people involved. Where possible,a limited number of previously scheduled visitations (at LFS, CARE,WCDSS)will be utilized as a clinical opportunity to observe and assess family interaction in order to facilitate scheduling,minimize disruption to the clients and caregivers and avoid redundancy. At least one conjoint(family) interview in the office is necessary for a complete and thorough evaluation. Evaluations conducted at the end of the Court process,particularly regarding changes in the permanency plan away from returning home to biological parents, or to address issues between alternative family placements(e.g., adoption by grandparents or foster parents)are by necessity more thorough and lengthy, and therefore more time consuming. B. Dr. Lindstrom is available for face to face or telephone consultation with caseworkers or providers during or after the evaluation(s)to assist in and address questions regarding the implementation of evaluation findings and recommendations. He is also available to attend court facilitator staffrngs as requested. C. Consultation is available as requested by the caseworker as outlined in III B, above. Contact will occur at each stage of the evaluation,and at least twice a month. D. Telephone calls will be returned by the end of the next business day. Requests for letters or case updates can be completed within a week. E. Evaluation appointments will be coordinated though the office and Department as needed and outlined above. Appointments may be scheduled for multiple hours in one day to accommodate psychological testing, and multiple or family interviews to expedite and simplify the evaluation process. March 11,2005 Attached A Page 7 Bid 002-05(RFP-FYC-006-00)Mental Health Services Emergency Assistance Program Project Title: Individual and Family Psychological Evaluations Vendor: Barry R. Lindstrom,Ph.D.,LLC;Licensed Clinical Psychologist IV MEASURABLE OUTCOMES (continued) F. a. All telephone calls will be returned by the end of the next business day. Emergency calls will be returned the same day if identified as such. Dr. Lindstrom is available after hours via an answering service. b. Evaluations will be conducted in accordance with professional and legal standards to be acceptable in court in support of any required expert testimony. Dr. Lindstrom is able to be qualified as an Expert witness in accordance with legal statutes. Written reports will clearly outlined, avoid professional jargon, and contain clearly enumerated recommendations. These targets will be reviewed during the evaluation process with each caseworker and discussed quarterly with Department supervisors to ensure that the evaluations and reports are meeting Department expectations for content,clarity and timeliness. March 11,2005 Attached A Page 8 Bid 002-05(RFP-FYC-006-00)Mental Health Services Emergency Assistance Program Project Title: Individual and Family Psychological Evaluations Vendor: Barry R. Lindstrom,Ph.D.,LLC; Licensed Clinical Psychologist V. SERVICE OBJECTIVES A. Family and individual evaluations will provide information to the family,the Department and the Court about family strengths that can be used in treatment planning to address and improve identified weakness and risks to be contained or minimized in order to reduce the need for or length of placement and to meet permanency plan goals for reunification in a developmentally meaningful time frame. Each client will be offered the opportunity for diagnostic feedback and discussion as part of the final interview. This feedback will address both individual (parent and child) and family functioning,strengths and needs. B. In particular, issues of parent-child attachment and parenting skills that promote safety and attachment will be addressed. These include,but are not limited to: affection and nurturance, stimulation and containment, and safety and protection. Individual evaluations will address any mental health issues or obstacles to the individual's successful completion of treatment and permanency or reunification plans. These issues will be addressed in the written report. C. Ideally,the evaluation process will provide clients an experience, in spite of its stressful nature,that will assist them in developing a trusting relationship(therapeutic working alliance)with current or new professionals whose assistance they require. Other involved professionals will be consulted as part of the evaluation and findings shared with them to assist in the development of a therapeutic working alliance and successful treatment outcome(s). Signed releases of information will be obtained for all collateral contacts or sources. These service objectives will be reviewed quarterly with Department supervisors. March 11,2005 Attached A Page 9 Bid 002-05(RFP-FYC-006-00)Mental Health Services Emergency Assistance Program Project Title: Individual and Family Psychological Evaluations Vendor: Barry R.Lindstrom,Ph.D.,LLC; Licensed Clinical Psychologist VI WORKLOAD STANDARDS Dr. Lindstrom maintains an independent private practice in the offices of Pathways: Family Wellness Associates. He is incorporated as a Limited Liability Corporation and is its sole employee/member. A. His office hours are Monday to Friday 8am to 5pm. He has an answering service after hours. He can be available on a limited basis in the evenings,or Saturday to attend previously scheduled visitation for the purposes of family evaluation. B. He is the only psychologist in his practice conducting these evaluations. C. He can maintain multiple open evaluations at any given time(10 maximum). D. The modality is psychological testing and clinical interviews. E. He is available 40 hours/week. F. He is the only psychologist in his practice conducting these evaluations. G. Dr. Lindstrom is licensed in Colorado as a Clinical and School Psychologist. He does not have a supervisor or provide clinical supervision to anyone at this time. H. He typically completes two to three of the open evaluations each month. I. Dr. Lindstrom maintains professional liability insurance, automobile insurance and has unemployment and worker's compensation insurance through his LLC. Liability insurance is maintained through Pathways Management,LLC. March 11, 2005 Attached A Page 10 Bid 002-05 (RFP-FYC-006-00)Mental Health Services Emergency Assistance Program Project Title: Individual and Family Psychological Evaluations Vendor: Barry R. Lindstrom,Ph.D., LLC; Licensed Clinical Psychologist VII STAFF QUALIFICATIONS A. All work will be completed by Barry R. Lindstrom,PhD. He is a Licensed Clinical Psychologist and School Psychologist in the state of Colorado. He meets all continuing education requirements to maintain these licenses. B. Dr. Lindstrom is the only staff member of Barry R. Lindstrom, PhD; LLC. He contracts with Pathways Management, LLC for office space and secretarial and billing services. He contracts with MKF Billing Services for transcription services. These contracts are HIPAA compliant. C. Dr. Lindstrom has appropriate knowledge and training regarding casework. D. Dr. Lindstrom has knowledge of risk assessment. VIII Unit of Service Rate Computation See attached budget for per hour rate for direct client contact hours and court testimony. Evaluation: $ 280.00 per hour of direct client service. Court testimony: $ 150.00 per hour DX Lowest Qualified Bid For reviewers. X PROGRAM CAPACITY PER MONTH Up to five(5) evaluation reports completed per month on average. Up to eight(8)open, ongoing evaluations per month on average. | 6/7R 0 Ccc C)CC Co 0 13 § § = co @ 2 ° ` - fa 69 ES r e ° � ® ) _ r < § § § E 0 Lu Z X 0 x cc o § » ) § ) § 0 CD § § 0 0 & U. O N rz b O ® 2 / } m m § 2 ( o E $ G re La I- § 0 § S. O § § 0 G § CC U. 0 § / ) § a a. O 0 $ O & » 0- 0 O , co 0 0 c o 0_ 0 w 2 0 R 2 Ill LU m \ @ 5 CO S CO r z -I p § § § § w O 2 J E 0 0 z < ) z g a- 0 § 0 ° E ( p § % 0 E /0 m w ■ C6 o > o < - co E w < ° 2 00 CO ° 0 ( § k r § 2 § z a z et 0 0 R 0 0 0 J ® 0 0 k = w D i & U co o I 0 CO § 9 0 0 b 0 § § 0 0 ? X ,.., o I- 0 / k / ( k § § / / k / � § - 0 0 0 0 0 0 0 0 > O Z O O < o 0 O. I- w F- O w < O w < e e < 0 0 O U u o = _ -, Y WZ2 o ' f O Q . F F K U Ola 0 Wd C I- oo pp O o o pp N r co an' W 22222222 ONS$ K a 0 J p a' 0U q Q W or = d r n d Cl m W Z 5 0 C c iH'O 20Q re _oo u.20 u. N2 ~ Opa 0= J C O F- 0 0 0 0 0000 000000 0 0 0 0 0 } y N J O W W Waal W M V)He H ES V) 0 0C Z W O 0 o O �Oy �u, 0 CC W ,may W a a W S a M N c CC CO J en C 7 0 x 19 I- '.1 COCO f O N0 M Flea > v g O 2 2 O IL WO 01 o �' v°D O O. 4 S N Z; W 2 ✓ o re 00V W0000000000000 S 8 W dO TZZZZZZZZZZZZZ TT CO H a IIIO S =A O as W W aaaaa Vi fO9OMNa re O a C 0 D ~ 0Ca X • W ^ La C 2 a 2305 • ¶ 4 .4- X DI sW S o zs � 2 m a ▪ OC CU S C • 1 a 0— re 0 o s O IL d f CC *a / a 8 0° cc 0 rc 0 cc 0 a o a ILI = W K W K W O 1.1 0 O a. .� r. W v0i 0 w 0 g 0 0 Q W a cc o w 0 co O , i K w 5 CC W u re a app WF Q� ox 1 IL 0 F W Q al UI 0 Yd 12 P y0j '� tw 4 K 0 0 X '8, w K K O J 88 I- I- O ', DEt a � a iq a IL U OF N F OF 0 Q CO 0 W •2I- " 111 � CS I— me u12 ° _ & ( --.__. ._ _ aaaaa a _ 0 CD _ 2 § w /k k\2§ k � x - 0w0 § ®o , /e (E & § ___aaaa2aa■ OCC La LLI 72 ; CC CO 19 0 _ - § in_ '0 = � mo co ; - a \ 22m co . 0 & . _ E 0 I - k2 2 co - 2 O w § § 2 &2222 ; 2222222 § « § re 11, 04aa22aaaaaaa « � ! I �at Ul J a © . § ® u Cl: 13 . 2 k i•k § c ® s � o § & ` � ' ' , � 2 $ LU . 0 § �) IT R 2 s ( � § a Le w � ) F- ) a.x tu j co 2 g 0 a. a § I @8 $ § & 5 a. a • E 0 0 2 § ' ! ' < w B k m f ) � / k X _ O ® Z § a ■ I- z i $ 0 i- / 41 Ui ` D p0 § a a @ . i _ ■ § e a a « I XI I ) 2 § § k F - 0I § k a e 0 , , « - - - - - - - \ ) a. � k � §m §§ • 00 Cli§ - _0_ om ee /� o® ~oo 2 § 2 __ __ _ aaa ; saaaa2a2a 2 _ — co ) § § CS ° -r. 4 re = = mo ui2 0\ 0 | <� \ /§ 2 - _ CO_§ 11)49222 a2aa22aa f 3 / 2 § 5 § } © . • _ LI < ) 2 § a5 O0000 § § D )§ § mk $ mpa ■ ct o� , @ ■ „ „ m °� 8888888 a ■ ■ ! ■ ■ rk ■ ■ ■ 4 ■ . § g%K/ § ■ 0 0 § $ k ` 2-##■ 0 CC CD 0 8 u. � § . . \ § j . § ` tu 0. 0DJ ele x i IT § 0. w 0 DJ E § o & - ! a. ■ C 8 0 0 0 § a. ` ■ k k se - ° I of a - - o ■ re k § as ! I 0 0 2 E o cog $ § ! § § UJ ■ _ 02 ! ! ! = § ■ — & 0 ` 7k �! f 0 ■ § ) k § k same ) / at k a. e ° = 2 > < ! 0 § g § g « co 0 0 _ EVEREST NATIONAL INSURANCE CUMYAN x JUN 2 g 2004 Site pit USN- MENTAL HEALTH PRACTITIONER'S PROFESSIONAL LIABILITY DECLARATIONS OCCURRENCE POLICY Policy Number : 2200006488-041 Renewal of Number: 2200006488-031 Item 1.Named Insured and Mailing Address Broker Name and Address Barry R Lindstrom and/or ROCKPORT INSURANCE ASSOC Barry R Lindstom,PhD,LLC P.O.BOX 1809 3211 20th St., Suite D ROCKPORT,TEXAS 78381-1809 Greeley, CO 80364 1-800423-5344 Item 2.Additional Insureds None Item 3. Policy Period From: 08/01/2004 To: 08/01/2005 at 12:01 A.M., Standard Time at the insured's mailing address shown above. Item 4. Description of Business: Form of Business: [X]Individual [ ] Partnership [ ] Joint Venture [ ] Limited Liability Company [ ]Trust [ ] Organization,including a Corporation(but not including a Partnership,Joint Venture or Limited Liability Company) Business Description: Mental Health Practitioner(s) Item 5. Limits of Insurance and Regulatory Defense Amount $ 3,000,000 AGGREGATE LIMIT $ 1,000,000 EACH WRONGFUL ACT LIMIT $ 1,000,000 EACH OCCURRENCE LIMIT-PREMISES LIABILITY $ 25,000 SEXUAL MISCONDUCT AGGREGATE LIMIT $ 5,000 REGULATORY DEFENSE AMOUNT Item 6. In return for the payment of the premium,and subject to all the terms of this policy,we agree with you to provide the insurance as stated in this policy. Premium Schedule CLASSIFICATION NUMBER RATE ANNUAL PREMIUM D3 1 900.00 $ 900.00 Terrorism Insurance $ 0.00 Total Premium $ 900.00 Item 6. Forms and Endorsements Form(s)and Endorsement(s)made a part of this policy at time of issue: EDEC 134 09 01, EEO 00 507 09 01,EIL 00 515 07 00,IL 00 17 11 98,IL 02 28 07 02,EEO 21 572 02 03, THIS DECLARATIONS,TOGETHER WITH THE COMMON POLICY CONDITIONS AND COVERAGE FORM AND ANY ENDORSEMENT(S),COMPLETE THE ABOVE NUMBERED POLICY. [(^^ ^& 00110 BARRY LINDSTR0M, Ph.D., L.L.C. AUTHORIZED(/ REPRESENTATIVE LICENSED CLINICAL PSYCHOLOGIST (or countersignature where applicable) 3211 20TH ST., #D GREELEY, CO 80634 EDEC 134 09 01 Date issued: 6/23/04 COUNTRY AUTO INSURANCE Insurance a Financial Services STATEMENT OF RENEWAL COVERAGES AND PREMIUMS Account Number 0385404-001-00001 Policy Period Beginning NOV 12. 2004 COUNTRY MUTUAL INSURANCE COMPANY - PREFERRED PLAN -POLICY NUMBER A05A6374425 POLICY TERM 6 MONTHS PAYMENT PLAN SEMI-ANNUAL TOTAL POLICY PREMIUM $449.43 VEHICLE VEHICLE, USE AND DRIVER INFORMATION 1983 VOLVO 918796 AUTOMOBILE, WORK UNDER 10, MALE, 30-64 1994 CHEVR 220366 AUTOMOBILE, PLEASURE, FEMALE, 30-64 POLICY COVERAGE LIMITS EACH PERSON EACH OCCURRENCE LIABILITY-BODILY INJURY 250.000 500,000 PROPERTY DAMAGE - 100,000 UNINSURED MOTORISTS 250,000 500.000 - UNDERINSURED MOTORISTS -250,000 500,000 - -- - 1983 VOLVO 1994 CHEVR A05A6374425 A05A6374425 VEHICLE COVERAGE LIMITS COLLISION - ACTUAL CASH VALUE LESS DED r 500 COMPREHENSIVE - ACTUAL CASH VALUE LESS DED r 500 ENDORSEMENTS AMENDATORY END-CO YES YES PREMIUMS LIABILITY-BODILY INJURY 141.26 141.26 PROPERTY DAMAGE included included UNINSURED MOTORISTS 32.49 • 32.49 UNDERINSURED MOTORISTS included . included COLLISION + 64.73 COMPREHENSIVE + 37.20 AMENDATORY END-CO included included VEHICLE PREMIUM $173.75 $275.68 The VEHICLE PREMIUM has • already been changed by the following DISCOUNTS GOOD DRIVER included included MULTICAR - - - included included — AUTO-HOME ADVANTAGE included included TOTAL DISCOUNT -91.82 -158.06 + Not applicable to this vehicle. COUNTRY •Flnendai� Insurance- Not applicable to this policy. services COUNTRY Mutual Insurance Company 20990' P.O.Box 2100,Bloomington,Illinois 61702-2100 COLORADO INSURANCE CARD LINDSTROM BONNIE & BARRY 413 SKYSAIL IN FORT COLLINS CO 80525-5904 POLICY NUMBER A05A6374425 1983 VOLVO 240 EFFECTIVE DATE NOV 12, 2004 BARRY LINDSTROM, Ph.D., L.L.C. EXPIRATION DATE MAY 12, 2005 LICENSED CLINICAL PSYCHOLOGIST VIII YV 1AK8849Di918796 20TH ST., $D COVERAGE BODILY INJURY LIABILITY 3211 3211 2 T CO HI D4 PROPERTY DAMAGE LIABILITY GRECOUNTRY HELPLINEe 1-800-846-0100 THIS CAI ) MUST BE CARRIED IN THE INSURED MOTOR VEHICLE FOR PRODUCTION UPON DEMAND. TIE COVBIA. • PROVIDED BY THIS POLICY MEETS THE MINIMUM LIABL. INSURANCE LIMITS PRESCRIBED BY LAW. 50104 (01-11/03) PAGE 1 OF 1 • BILL oWErts �ov-co DEPARTMENT OF LABOR AND EMPLOYMENT Governor �_I Unemployment Insurance Tax Administration,Liability Unit / JEFFREY M.WFf J s '\ I P.O.Box 8789,Denver,CO 80201-8789 Executive Director .1 r 303-318-9100(Denver-metro area)or 1-800-480-8299(outside Denver-metro area) NOTICE OF EMPLOYER LIABILITY AND UNEMPLOYMENT INSURANCE TAX ACCOUNT NUMBER 06/14/04 BARRY R LINDSTROM PHD LLC 3211 W 20TH ST STE D GREELEY CO 80634JUIi 1 8 2004 Your unemployment insurance (UI)account number is: 617694.00-7 Your UI liability date is: 4/1/04 You are an employer subject to pay UI taxes in the state of Colorado because: HAVING PAID WAGES OF $1500 OR MORE IN A CALENDAR QUARTER, OR HAVING ONE EMPLOYEE WHO PERFORMED SERVICES IN EACH OF 20 CALENDAR WEEKS WITHIN THE YEAR. Your UI combined tax rate is: • YEAR BASE RATE + TOTAL SURCHARGE(S) = COMBINED RATE 2004 .01700 .00820 .02520 This tax rate may change when your industrial classification is reviewed. The tax rate may also change if it is later determined that you are a successor to a previous employer. Please see reverse side for definitions of UI terms. BARRY LINDSTR0M, Ph.D., L.L.C. LICENSED CLINICAL PSYCHOLOGIST 3211 20TH ST., #D GREELEY, CO 80634 UITL-3(R 01/03) • - C0Pe 33296 PATNA ACORDT. CERTIFICATE OF LIABILITY INSURANCE roil MSc a" TMS CEIDIRCATE WOWED AS A MATTER OF INIORMTION Fb.A t Pdrson 9n..Inc- 0183'MC CORPUS NO NGNS UPON THE CDIIW I 1TE P.O.Ike 578 HOLDEN.TOSS CEINIRCATE DOB NOT MEM 8867 W.MI unmetALTER THE COVERAGE AFFORDED STTIEE OUOES BELOW. amity.CO 80132 INSURERS AFFORDING COVERAGE NAILS ISWA at.Paid Tnr.laY Insurance Cann. 3211 20th SIASt Suite Dson C 6nebp,CO NM eaErt¢ BR UEAE COVERAGE THE POLCESCr INUUIICE LISTED BELOW NAVE IOW tW TO 11€PUMPED IMICMOVE FOR THE POLICY PERIOD BLOATED.NOIWINSTNC5IG ANY RECUMBENT/fall CR CORONER OF MY CONTRACT OR OOER CCOA E TWMIN RESPECT T0 MOT 1NM CERTFlGTE WY SE MEW OR MAY PE IM,TIE saMANCEAFFODED BY TIE POLICES DESCRIED HOOT Y SUBJECT TO ALLIME lava E CLUSCIISAND COMMONS OF WOI POJCESAGOREW SCAN CAN WY NNE BEEN REDUCED ST PAD aas.l pg�E Ey�p 1179= ins OF n.nar PORSMOS Mn®flYl .amfb laT. A memwaAT NSO386NH/3TCTW 11101106 1101106 EACHow nsla 11.000,000 X -----a a nam OAMP.E � COWS JMLM.nIAME now., TEDE,.w._raw � REHEAR AROErOE aura rteLAMMERnEWTAWTBP� 7 Parrn.� nf.c IItl011CIP-OaIpAOfi AOTOIaIE LANNY GOWNED lEassOloO NITAIq .RaEI..I = ROAMED RUM WAY SOURS SOEOAMOS po®N ssal HOED RUMS SOULS NOICa®AUME �sAE PROPERTY MAW Pyr Axle* OIRArWIaIn MOO CORY-SA SCONES S AaAOW Orne#4110 .t ate' _ AURA Oat /DSc s EICENRIMIRRIA.naan TAW ONMBIa E jOWNI n PISORERVE E 1PDUOaEREECHO" 3 nap CSOMPAROURIO _ innLawnstar ' 1 I: ANT PNOIOETONPNUMEREEOONE FL FAOIAW0OIT S oTFlaaE O01.1.00)?JMTO01.1.00)? ELOMORE_EA EIIID. f W iP E Y �M PiT.x.�iDla Me. EL WEAK-'MECUM S CUED Oiolan W CrOWICROI1OOIROSS POURES,NWAM.Y_EAcgD DIEMOCROUBT I.Ea HTgA.rE CERTIFICATE HOLDER CANCELLATION RUC ANT Of 1St MOW Droa®Pam r OnOYIID ISMS T MDEMI Deny Lbddlan MIX LW wax•. .TarumaNstatlEwan.ea A_ DAnmom 3211 20th a SPN.D NOTICE TOM aRTIRCVE MUM PANED TOTE MST.SW FALYH1000SO WALL GT.dy,CO 30134 MOM NO MARTOI a UMW/OSMIUM UPON THE nn_Ett NNAESISa RE On61OTOla AENa®NFPR �f�la.Ee noOlal r /t cno.j r.•,r.. "arcA In 'c. ACORD 2f(2001/01)1 d 2 9308253 JEM B ACORD CORPORATION flee /17 PINN/I COL E Lowry 3d Denver,CO 802230-7006 ASSURANCE www.pinneeol.com POLICY INFORMATION PAGE POLICY#: 3217113' POLICY TYPE: ADVANCE Date: June 16, 2004 ITEM 1. POLICYHOLDER: PATHWAYS MANAGEMENT, LLC PATHWAYS 3211 20TH ST. STE D GREELEY CO 80634 • ST / 7.00 ITEM 2. POLICY PERIOD: FROM 05/01/2004 TO 05/01/2005 12:01 A.M.MOUNTAIN STANDARD TIME ITEM 3. A. Workers'Compensation Insurance: Part One of the policy applies to the workers' compensation law of the states listed here: COLORADO B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3 A. The limits of our liability under part two are: BODILY INJURY BY ACCIDENT $100,000 EACH ACCIDENT BODILY INJURY BY DISEASE $100,000 EACH EMPLOYEE BODILY INJURY BY DISEASE $500,000 POLICY LIMIT C. Other States Insurance: Part Three of the policy applies to the states,if any,listed here: NONE (Please contact Pinnacol Assurance for information on coverage outside the state of Colorado) D. This policy includes the attached endorsements and schedules: 0404 Premium Credit Addendum ITEM 4. We will determine the premium for this policy by our manuals of rules.classifications. rates and rating plans. All information required below is subject to verification and change by audit. The statements of estimated advanced premium arc also a part of this policy. BARRY LINDSTROM, Ph.D., L.L.C. LICENSED CLINICAL PSYCHOLOGIST 3211 20TH ST., #D GREELEY, CO 80634 I'N,IILI' A.uau 14': IW:nun x.,IixNx� II.I:`.y.0 Ix W 4I i�lll It rpaol riu.l. SUPPLEMENTAL NARRATIVE TO RFP: EXHIBIT B CONDITIONS May 09 05 08: 31a Pathways 9703564827 p. 1 V Pathways 3211 20b Street/ Ste D Gree[en CO 80634 FAX COVER SHEET or 1I Date: c Front � '( To: G L 044 Aavh �i e:970-35 °° . , �: �s") - (.i Fax gra-35� 2 7 CC: Re: ±�1 c k a. el G , rct ding caner ,, , 71-- ❑ For Review ❑ As Requested ❑ Please Reply If you do not receive the al bone pa o number of pages or if there are problems with the quality of legibility, please contact the person Notes/Comments: CONFIDENTIALITY NOTICE ion belonging to Pathways.,protected by the physician/therapist-patient privilege.ege. State Law onfidential tprohiti is further disclosure of this h person to whom it pertains or as otherwise information without specific written consent of the rmitted b law. Re-Disclosure Statement For Federal Substance Abuse Cases: This information has been disclosed to you from records by Federal Confidentiality Rules (42 CFR Part2) TI federal rules prohibit you from making any further disclosure of this information or snlessrfu sh permitted s further dbyisclosure is 42 expressly permitted by the written consent of the person to whom it pertains CFR Part 2. The general authorization for release of medical and other information is not sufficient for this purpose. The federal rules restrict tire use of the information to criminally investigate or prosecute any alcot ' or drug abuse patient. Re-disclosure Statement For Ps chothera Notes: h are ected by ate Law hat fThis inormation is proided to ou from confidential records urtherfdi closure of this in ormation without the specificritten consentt of t the person tto whom it sit pertains, as otherwise permitted by law. May 09 05 08: 31a Pathways 9703564827 P. 2 • Barry R.Lindstrom,Ph.D.,LLC Licensed Clinical Psychologist 3211 20th Street, Suite D Greeley,CO 80634 970.356.3100 May 9, 2005 at Via Facsimile cy pe e5 Ccv gerg"'�t `Ne i c0,sun Gloria Romansik 2.°16WCDDS Mph p 9 PO Box A Greeley, CO 80632 RE: RFP 006-00 Mental Health Services Dear Ms. Romansik: I apologize for the delay in writing to you to confirm that I accept the FYC Commission's conditions for the mental health services contract. I will provide written documentation of my psychological evaluations within 90 days of the beginning of the evaluation. It is my understanding that if there are any extenuating circumstances, such as client cooperation in completing the evaluation, that I may request an extension in writing. Sincerely. .� LiicA9 Barry R. Lindstrom,PhD Licensed Clinical Psychologist Cc Lory Secher file • 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 111 O • COLORADO April 18,2005 Barry Lindstrom,Ph.D.,L.L.C. Licensed Clinical Psychologist 3211 20 Street#D Greeley, CO 80634 Re: RFP 006-00 Mental Health Services Dear Dr. Lindstrom: The purpose of this letter is to outline the results of the Bid process for PY 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 Bid 006-00, Mental Health,for inclusion on our vendor list,attaching the following condition for all Mental Health 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, a J y A. 'ego,D' ctor cc: Juan Lopez,Chair,FYC Commission Gloria Romansik, Social Services Administra Weld County Department of Social Services Notification of Financial Assistance Award for Families,Youth and Children Commission (Core) Funds Type of Action Contract Award No. X Initial Award 05-CORE-58 Revision (RFP-FYC-006-00) Contract Award Period Name and Address of Contractor Beginning 06/01/2005 and Individual &Group Therapy Services Ending 05/31/2006 Mental Health Services 824-B 9th Street Greeley, CO 80631 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Program provides mental health evaluations, Assistance Award is based upon your Request for couples and family therapy, domestic violence Proposal (RFP). The RFP specifies the scope of evaluation&treatment, evaluation &treatment services and conditions of award. Except where it is of youth in conflict, and therapy for those in conflict with this NOFAA in which case the involved in dependency&neglect cases. Ability NOFAA governs, the RFP upon which this award is to evaluate and treat individuals with high levels based is an integral part of the action. of anti-social traits, as well as anger Special conditions management problems. Services for Domestic 1) Reimbursement for the Unit of Services will be based Violence Offender Management Board approved on an hourly rate per child or per family. clientele, victims of sexual abuse, victims of 2) The hourly rate will be paid for only direct face to domestic violence, children and extended family face contact with the child and/or family, as members who are secondary victims of crimes, evidenced by client-signed verification form, and as including mental health sex offense specific specified in the unit of cost computation. evaluations, psychometric testing, and 3) Unit of service costs cannot exceed the hourly and plethysmograph if necessary. Monthly capacity yearly cost per child and/or family. is 12,total number of clients to be served is 30. 4) Payment will only be remitted on cases open with, and Services in Ft. Lupton, Greeley, Del Camino,the referrals made by the Weld County Department of Department of Corrections and County Social Services. Correctional facilities. 5) Requests for payment must be an original submitted to the Weld County Department of Social Services by the Cost Per Unit of Service end of the 25th calendar day following the end of the Hourly Rate month of service. The provider must submit requests Treatment Package $39.44 for payment on forms approved by Weld County Court Testimony $100.00 Department of Social Services. Enclosures: 6) The Contractor will notify the Department of any X Signed RFP: Exhibit A changes in staff at the time of the change. X Supplemental Narrative to RFP: Exhibit B Recommendation(s) X Conditions of Approval Approvals: Program Official: By 4-1. s � G By William H. Jerke, Chair Judy GriegbDirecto Boar f Weld Comity Commissioners Weld unty Department of Social Services Date: duN 0 6 2005 Date: (c/ZjCJlc SIGNED RFP: EXHIBIT A Bid 002-05 (RFP-FYC-006-00) Attached A MENTAL HEALTH SERVICES PROGRAM BID PROPOSAL AND REQUEST FOR CONTINUATION OF AWARD UNDER CORE SERVICES FUNDING EMERGENCY ASSISTANCE PROGRAM 2005-2006 BID PROPOSAL APPLICATION PROGRAM FUNDS YEAR 2005-2006 BID 002-05 (006-00) T • NAME OF AGENCY: _x-. -1C.I 1 V i O41.O_ I E• Gr c p ! Il et Z-�Ptj S Ct�6�r C ADDRESS: 624-13 `f1 Sr• , &r er to j , Co e<963, PHONE (M0) 3 J3- 11 CONTACT PERSON: • Rt1UYS , MA, Ll •N(r(fl? TITLE: GXecct-}itie -areekY/- DESCRIPTION OF EMERGENCY ASSISTANCE PROGRAM CATEGORY: The Mental Health Services program provides for"diagnostic, and/or therapeutic services to assist in the development of the family services plan, to assess and/or improve family communication,functioning, and relationships. (Volume VII, 7.303.1, G)" 12-Month approximate Project Dates: 12-month contract with actual time lines of: Start June 1, 2005 Startatilc I,;2-O05 End May 31, 2006 End Mad 31,a-00 TITLE OF PROJECT: trai V Clu c:-I E, Gtrotcp --rho r CL(a5 S4lrv,Icc S cv-, i-kevv4cu k-eak+L Prrd num, rvv f\ *uijraca A4,, L�� c�+e 3i 3 - 10--Xo Name and Signature of Person Preparing Document Date �L r rvve. (Zuy t a 1 lC �� C S`"`V`' , FAA, L-PC, INCAC o 3-to-Jco ; Name and Signature Chief Administrative Officer Applicant Agency Date MANDATORY PROPOSAL REQUIREMENTS For both new bids and renewal bids,please initial to indicate that the following required sections are included in this Proposal for Bid. For renewal bids,please indicate which of the required sections have not changed from Program Fund Year 2004- 2005 to Program Fund year 2005-2006. Indicate No Change from FY 2004-2005 a- Project Description th' Target/Eligibility Populations ii/w- Types of services Provided it- Measurable Outcomes ill Service Objectives W" Workload Standards Yom/ Staff Qualifications gr. Unit of Service Rate Computation NW Program Capacity per Month \IV Certificate of Insurance Date of Meeting(s)with Social Services Division Supervisor: Page 25 of 32 . 1 id 002-05(RFP-FYC-006-00) Attached A eats by SSD Supervisor: d-tOn '.m b \l► ' ' 4 di -2ua1. bi • ' • • Cochi ' garnil -. • at it di Vid tent . . '. r. ��. . .. ti is .! 's Q Y'a . - • iA r_•�� , r -. min of w i s ,r -1,C. .• l'not .Q M, ' glthq h NA -._ • - , . 9n iii li 014R_ Qt • ( t% 9AHL_ licitYlia •farmliQc. 3 (an .9.0x24 ' 4• in •Liq',lou,,Gm¢11g, i Pact 6&wi aa 1.mq am, OM u-SlMLi5 fsn oitSia-Q.-• (a)Ztc1t .Qt1a.Q4 @,D• 0 ,c.,•1,ci , locohionS Sn • (ten .}nix-' rd- atvli5oci i 0// 4/05 Lei raltithtru ` " itat \liC4IM estAp 4-er bV he• r:_ 1 p - �/�I � �' :ftc f Ytaf \{Kslimg 0c Dv --co non 0 1 eamnot OAMA9" 14)* b\IWA44/4-4.-44i fraykyttAt lafif Ceith3/4 4,146'i 5341 citaisti At, Or fame 'gnature of SSD Supervisor Date NJno 5vun0 • 4 will iruluot?P lowk n -abl;_ sutuths• llo fo t y5 U•o c' avirtliett �}ra(7}a.5. 'VS' >d4 ar {1C q'' •. , - (i45 -.- t'-t t*s awl on G\Nitic j it • if S For rnai/L (liars onit j bcCfr 3c f r 'irlak- cliords la - So yrsola( 8141°c RFP-FYC-006-00 MENTAL HEALTH SERVICES BID PROPOSAL INDIVIDUAL & GROUP THERAPY SERVICES OUTPATIENT TREATMENT PROGRAM I. PROJECT DESCRIPTION Individual & Group Therapy Services (IOTS) will utilize a non-medical, cognitive behavioral model, focusing primarily on the treatment on individuals with mental health concerns. This program will include mental health evaluations,couples and family therapy,domestic violence evaluation and treatment, evaluation and treatment of youth in conflict, and therapy for those involved in dependency and neglect cases. This program will provide services in Ft. Lupton, Greeley, Del Camino, the Department of Corrections, and County Correctional Facilities when needed. Individual&Group Therapy Services has the ability to evaluate and treat individuals with high levels of anti social traits, as well as anger management problems. In addition, this program would provide services for Domestic Violence Offender Management Board approved clientele, victims of sexual abuse,victims with domestic violence,children and extended family members who are secondary victims of crime. This program includes performing mental health sex offense specific evaluations, which includes a battery of psychometric testing, and the penile plethysmograph (if deemed necessary). The mission of Individual & Group Therapy Services is to continue to offer services which reflect our care and interest in our clients, and to provide useful services to the community. By doing so we will: • Provide a structured program and environment for the safety of the client, family, and community. • Increase awareness and empathy for family members, victims, and the community on the impact of the offense. • Foster a family environment to effect positive change. • Develop the use of appropriate cognitive, social, communication, and sexual skills to reduce reactive and concerning behaviors. The Individual & Group Therapy Services outpatient treatment program will treat: • Male and female clients, ages ten (10) and older. • Individuals with power and control, domestic violence and mental health concerns. • Individuals with developmentally delayed features and those with above average functioning. Program Services for targeted population include: • Mental health sex offense specific testing and evaluation,domestic violence offender management board offense specific evaluation, mental health evaluation • Group and/or individual anger management, and cognitive restructuring • Individual and or family therapy for general mental health concerns • Family education/ support groups, general mental health concerns • Victims education of support groups (Pro Bono) • Victim empathy and awareness, general mental health concerns • Anger Management/Impulse control skills • Cognitive behavioral modification • Self esteem building • Values clarification and examination. • Relapse prevention plan for domestic violence clients • After care services for domestic violence and general mental health clients • Relationship and interpersonal social skills for general mental health clients II. TARGET /ELIGIBILITY POPULATIONS Guidelines for conducting general mental health and offense specific groups, as mandated by the Colorado Domestic Violence Offender Management Board indicates the ideal number of clients should be approximately eight (8) individuals with one facilitator, and up to twelve (12) individuals with co-facilitation. Clients for Individual & Group Therapy Services outpatient treatment program include male and female clients ten(10) years of age and up. Non-offending partner group therapy is offered weekly for victims of domestic violence free of charge. The children's program,offered in conjunction with the victims' services,education and support programs, range from infancy to the age of twelve (12). This program is co-facilitated by staff members of the Child Advocacy Resource and Education center (CARE), and is offered pro bono. Bilingual services are provided for Spanish speaking clients and their families. All of the services provided by Individual&Group Therapy Services will include individual, group, and family therapy. The services provided will take place at 824-B 9`h Street, Greeley, Colorado. All eligible Weld County families will need to arrange transportation to the facility. The total number of clients to be served are estimated to be thirty (30). Total family units are estimated to be a maximum of thirty(30) during the fiscal year. If the facility is made available, the number of individuals who will receive services in South Weld County will include a minimum of five(5)individuals. Bilingual/bicultural services will be limited to twelve(12)clients. Specific services for bilingual clients includes domestic violence, family therapy, sex offense specific evaluation, and general mental health services. Emergency services will be available to all clients nights and weekends for clients in crisis. The monthly and average maximum program capacity is 12. Average stay in the program varies, depending on the specific entity involved in the individual treatment plan. For example, if an individual is referred for domestic violence treatment, the minimum number of weeks in the program would be thirty six (36). Regarding general mental health services, an individual may attend anywhere from one therapy session to an unlimited amount of therapy services, with the average stay in the program of 12 weeks. Clients will need to attend an average of 2 hours per week. The program for youth in conflict would be similar, and would include a treatment plan to involve anywhere from one to an unlimited number of treatment sessions, with the average stay in the program of 12 weeks. III. TYPE OF SERVICES TO BE PROVIDED PSYCHOLOGICAL EVALUATION AND REPORT This service is not applicable to this request for funding,as the psychological evaluation and report is to be conducted by a licensed psychologist. Because there is no one meeting these credentials associated with Individual & Group Therapy Services, this section is not being applied for at this time. A. FAMILY/CHILD/ADOLESCENT ASSESSMENT SERVICES To begin a mental health evaluation, an initial appointment is scheduled between the client and the evaluator. In most cases at least one (1) comprehensive clinical/diagnostic interview will occur; however, occasionally two (2) or three (3) sessions will be necessary to accomplish all requirements for a mental health evaluation. The next step of the evaluation process includes a question and answer format designed to gather basic identifying information, mental status examination, the client's mental health issues, mental health history, family and medical history, substance abuse history, inpatient and outpatient history and current social situation. At times, a DSM-IV-T Revised diagnosis would be applicable and utilized. In addition,treatment recommendations may occur and if so,this recommendation will be in written format at the conclusion of the mental health evaluation. The next stage includes gathering collateral information from agencies noted by the client and/or supervising agency. At times, requests of the supervising agency will be made to assist in gathering collateral data. The last phase of the mental health evaluation includes psychometric testing, which may include any number of the following psychometric instruments, including: • HARE PCL-R (utilized in cases where psychopathy is to be assessed) • Minnesota Multiphasic Personality Inventory-II (measures personality traits) • Jesness Inventory (measures criminal thinking) • Multiphasic Sex Inventory (measures sexual knowledge, behaviors, attitudes, and beliefs) • Wilson Sex Fantasy Questionnaire (measures frequency of fantasies to various stimuli) • SASSI-III drug and alcohol inventory • Millon Clinical Multiaxial Inventory-III (measures personality traits) • Shipley Institute of Living Scales (measures intelligence) • State Trait Angry Inventory-II (measures level/control over anger) • Violence risk assessment guide (measures level of risk) After all phases of the mental health evaluation have been completed, the evaluator then combines all of the information from the clinical interview, collateral data, and testing summaries in order to ascertain the client's amenability for treatment. Individual counseling includes one client and one therapist. Group counseling would include one therapist and two (2) or more clients. It is a policy of Individual & Group Therapy Services to limit the ratio to one therapist per eight(8) clients in most group scenarios, with the exception of educational settings. Family counseling will include at least one therapist and at times may include a second therapist. In addition, at least one client and one or more family members will attend a family counseling session. All therapists establish a treatment plan, either at the conclusion of the evaluation process, or at the conclusion at the intake session. A standard treatment plan with Individual & Group Therapy Services will include: • Short or long term goals. • Measurable objectives relating to the achievement of the established goals. • Type and frequency of services the client will be receiving. • Specific criteria for treatment completion. • Anticipated time frame. The therapist will document treatment plan reviews which will occur approximately every thirty(30)days that will include the continued date for treatment. Monthly progress reports will be provided to the referring agency to inform caseworkers on clients' progress. At the conclusion of services received by a client of Individual & Group Therapy Services, a discharge summary will be submitted within fifteen (15) days of treatment termination. A standard discharge summary will include the reason the client is being discharged,treatment history with Individual & Group Therapy Services, progress or lack of progress following the care of Individual&Group Therapy Services, and any recommendations made for future care. In the case of clients of domestic violence, risk to the community will also be included. The discharge summary will clearly delineate the client's status at discharge, which may include a successful, administrative, or negative discharge. B. CLINICAL CONSULTATION Clinical consultation will include an individual or group session with the Department of Social Services to discuss mental health supervision issues for the purpose of aiding and identification of offender problems and treatment issues. This may include a review of pre-sentence reports,prior psychological reports,and other existing information to identify the need for continued mental health services. When applicable,a written report will be submitted,which will include the mental status of the client, diagnostic impression, current psycho-social stressors, and obvious indicators of decompensation, recommended treatment activities, and report or records analysis. C. COURT TESTIMONY The staff of Individual & Group Therapy Services are qualified and experienced in court testimony. When given proper notification, Individual & Group Therapy Services is available for court testimony regarding clients with open and/or closed cases. IV. MEASURABLE OUTCOMES Upon completion of a mental health program, clients should be able to demonstrate the following behaviors: • Consistently defined all the abuse all the time to themself, to others, and property. • Acknowledges risk in the future, and demonstrates the ability for safety planning. • Consistently recognizes and interrupts their domestic violence cycle, anger management cycle, and general recidivism cycle. • The interruptions will take place no later than the first thought of an abusive solution. • Demonstrates new coping skills. • Demonstrates empathy and views the cues of others and responds. • Displays accurate attribution of responsibility and does not try to control the behaviors of others. • Able to manage frustration and unfavorable events in reference to anger management and self protection. • Rejects abusive thoughts as dissident and incongruent with self image. • Demonstrates pro-social relationship skills, such as closeness, trust, and trustworthiness. • Projects positive self image. • Demonstrates the ability to resolve conflict and make decisions through assertive communication, tolerance, forgiveness, cooperation, and is able to negotiate and compromise. • Celebrates good, experiences pleasure, and is able to relax and socialize. • Works toward achieving delayed gratification and is persistent in the pursuit of goals and submissive to reasonable authority. • Able to think and communicate effectively through rational cognitive processing, demonstrate adequate verbal skills, and is able to concentrate. • Has developed a family and or community support system. • Adapts a sense of purpose and future. Tracking progress through the program will take place in the following manner: • Clients attending group therapy will receive feedback weekly from their therapist in the form of a"group note." The purpose of the group note is to monitor progress on treatment goals. Group notes will be compiled by the therapist after each group. The therapist will evaluate whether the client is learning during group sessions. Feedback will be provided to help the individual obtain maximum benefit from their treatment modality. • Staff will also discuss the progress of the individual and indicate whether or not he or she is on track. • A compilation of these reports will be available to the Department of Social Services on a monthly basis, or as requested. • Progress in a computerized system will be made upon each contact with this agency by any one on the multi-disciplinary team, Department of Social Services caseworker, the client, or those who have been granted permission to associate with Individual & Group Therapy Services from the client. • For family therapy sessions, those of authority will be asked to report on the child's progress in the home. • Parents and therapists will evaluate the youth's progress on a monthly basis by verbally testing to see if they understand the concepts being taught, and can demonstrate the use of therapy in the home. • When appropriate, schools, employment sites, and additional family members can be contacted on a regular basis to monitor behavior in those environments. • With regard to general mental health issues, the caseworker will be contacted any time a team meeting involving the client is needed. These meetings should take place in the therapeutic environment most comfortable for the client. V. SERVICE OBJECTIVES The primary objective of Individual & Group Therapy Services is to offer services which reflect our care and interest in our clients, and to provide useful services to the community. By doing so we will: A. Improve family conflict management: Family members will learn to talk about their underlying feelings resulting in anger, conflict, and their personal environments, impulse control, and general feelings of dysphoria. Family culture will be explored, and family members and the individual will learn to develop a relapse plan, implement constructive discipline, improve communication, and develop problem solving skills. Progress will be measured by successful completion of homework assignments, as well as the ability to demonstrate the concepts learned in therapy and at home. B. Improve Household Management Competency: With regard to youth specifically, parents will initially be assessed to determine their level of parenting skills. Parents will be offered parent education to increase their skill level. In addition,parents will be monitored weekly in family therapy to check on behaviors occurring at home,and help parents to understand"red flags,"which will indicate potential problem areas regarding safety in the home. Where appropriate, a referral will be made for parenting classes if the parenting issues cannot be resolved in this format. Progress will be measured by verbal demonstration of understanding of the concepts,successfully completion of homework assignments, and participation in family discussion. C. Improve ability to access resources: Part of treatment will include what resources an individual will need to have successful transition from the therapeutic environment into a self managed environment.Therapists,family members, the Department of Social Services caseworker, and other involved parties will assess what resources are needed and will assist family members and individuals in locating the resources as they are identified. Progress will be measured by successful follow through by the individual. VI. WORKLOAD STANDARDS A. Number of hours per day/week/month: Day maximum of two (2) hours Week maximum four (4) hours Month maximum three hundred twenty (16) hours B. Number of individuals providing treatment: Seven(7)group/individual/family therapists,all qualified to facilitate in these areas. C. Maximum case load per worker: twenty (20). D. Modality of treatment will be cognitive behavioral and will include group, individual, and family therapy. E. See A above F. Total number of individuals providing services: seven (7) G. Maximum case load per supervisor: twenty five (25) H. See D above I. See enclosed insurance agreement VII. STAFF QUALIFICATIONS A. The Individual & Group Therapy Services mental health outpatient treatment program will meet or exceed the minimal qualifications in education and experience. Services will be provided by seven (7) Masters level counselors who have met the standards of practice to perform mental health intake assessments and reports, as established by the State of Colorado Department of Regulatory Agencies. Four therapists are Licensed Professional Counselors for the State of Colorado. The remaining therapists have completed all course work requirements and are under the direct supervision of a licensed Masters level psychotherapist,Kim R.Ruybal,MA,LPC,NCAC II. All practitioners who are not licensed with the state of Colorado are listed with the Department of Regulatory Agencies in the non-licensed data base. B. Total staff available for the project= 7. C. Individual and Group Therapy Service employees are not required to attend mandated new caseworker training. D. All therapists at Individual and Group Therapy Services have received extensive risk assessment training through various workshops provided by the Colorado Domestic Violence and Sex Offender Boards. Branch B/A Producer Number Issue Date Renewal/Replacement No. 32 A 0003107 04/29/2004 RENEWAL PROFESSIONAL LIABILITY OCCURRENCE INSURANCE POLICY FOR PROFESSIONAL COUNSELORS AND HUMAN DEVELOPMENT PRACTITIONERS PURCHASING GROUP POLICY NUMBER: 44-2010129 Item DECLARATIONS CERTIFICATE NUMBER 80M- 2001461 1. Named Insured PERKLEN ENTERPRISES INC 2. MAILING ADDRESS 824-B 9TH STREET GREELEY CO 80631 3. Policy Period 12:01 AM Standard Time At Location of Designated Premises From: 04/01/2004 To: 04/01/2005 4. The insurance afforded is only with respect to such of the following types of insurance as indicated by specific premium charge or charges: COVERAGE PREMIUM A. Professional Liability X $ 2,582.00 B. General Liability $ 2,582.00 5. LIMITS OF LIABILITY each Incident $ 1,000,000 or each Occurrence $ 3,000,000 in the Aggregate 6. The Named Insured is: Sole Proprietor (including Individual) Partnership A Corporation Other: 7. Business or Occupation of the Named Insured: COUNSELING 8. This policy is made and accepted subject to the printed conditions of this policy together with the provisions, stipulations and agreements contained in the following forms(s) or endorsement(s): PLJ-2016 (10/94) PLE-2040 PLE-8003 PLE-2189 (9/97) PLE-2081 PON-2003 CHICAGO INSURANCE COMPANY 55 E. MONROE STREET, CHICAGO, ILLINOIS 60603 REPRESENTATIVE: Agent or Broker: Kirke Van Orsdel Office Address: 1776 West Lakes Parkway Town and State: West Des Moines, IA 50398 Toll-free Number: 1-800-557-5092 PLP-2016 (10/94) (Elec.) o Z § 0 F- O cu \ \ / g \ @ < CO 0 it O § ( r m7, Lri_ N. - 0 } o \ 4 R. CO Ce \� < 0 I 0 q z / 0 \ 5 o w < - E / co ( W 0 _ 0 U- < \ M j cc LU C —+ 0 ( > ;cc cem 0 ( 0 7 5 0 0 0 § w 0 / < = ± O I- 0 \ 2 2 CO 0 0 \ § k 0 9 0 ± & } \ 0 - ± b 0 o ) 0 w / \ \ } ) CO @ \ ± o ® % 2 0 0 ) § _ \ 5 co — I— p ) ] 2 05 g 5 } ± 0 0 2 2 § 2 ( 5 6 + / 0 + 0 / 5 ( ( 0 0 0 0 o < CL - ± w 0 / 0 < ( / ± / \/ k [ 0 \ \ 0 ( 2 ) < 0 \( ( \ S / 0 0 e 0 0 0 R } 30 ® 2 0 § 0 2 $ & o + ( 0 = E & 7 = o = ± a \ ) 5 7 S % / 5 o / / } ( < § ± / / / / E $ C ± R / / 0 p < 0 ( < / 2 ± p / < = 0 =OW LL 0 = _ - Y rn \ 0 = §§ Gu. k) cn H ✓ to re 0 0 = 0 % \} re O 0 u. \ a. Qi- 0 ) | § } } } } 0 cn §7 0 cd Rco co ` . ; 69 \ la o E Co ) O � a4 I I, 8 IX g§ ;. \ |!\ 0 -3 a a /4tu I- ) C3 0 ; co E g it E U a ! co | § § ( ! k ' k co 1- 7 k - ) V3 Isi — ! | $ re_ | | = [ ) H H H ) k k k 4 44 U) r< \ a � 2g . ce /) in In ) �= 0 u. \j re 0 0I I- 0 \a j ) <u ' 6 o isi §} § , ® , - - 0 G Cl, Cl' \ Cl) _ \ ii a ; _ z B | / c mi ,O « ® ] al |f� O ! co& Cl,q L6 }a � 2 E 0 ] O ; ? 0 17 . | IT 0z 2 k E 6 G O cn \ k .tc z o. § 0 ! ) k k 0 I- 7 ! $ § - ! 2 $ Ill LIJ | ) | Ce a a k ) ) ) F CO F- Z. I- 0 co r 0 O fQ W U a H U0 0 Q O 0 0 r IX a m a > I_ J 0 X a 2 a e O re a O ✓ N r 0 O a QQ W0 C p W C J x 0. Q w > r 0 f 0 O e O cc a 0 ✓ h I-- co f O Q W U K a 0 0 OJ• 1 a -J o 0 2 K I." eix a LL. O O H Ce a 0 o o 0 0 1 Ca to 2 Q O O O O • 0 K � 4, M Z W H 4 a 0 U w a H ° Xa X Co aw ° U ° a O o 4 g o O I • O a " (15C- Z a. W o O ° W 00 e ea 0 op o J J Q a0 J a W H Q xIn O WO O r > U o O x2 w m E >, A I- 2 °E I- L a a ° a 2 9 E 0 N c w W C en o o. a ao o w 0 a G N U 6 N LL z ° a°i N 0 4 v v N K 0 m 0 n U Q v in 0 0 0 W 0 a i, W a. 'a W g ry x x o O U L N 2 d E > z > 11 O a O a U U L J J J C a f f a 0 0 0 O 0 0 0 a SUPPLEMENTAL NARRATIVE TO RFP: EXHIBIT B CONDITIONS 05/1.0/2005 19:48 9703530371 IGTS PAGE 01 jnclividual & Group Therapy Services 824-5 9th Street, Grccley, Colorado,80631 • Ph: 970355.8171 • rax:970353.0571 April 26, 2005 Department of Social Services Attn: Gloria Romanisk P. O. Box A Greeley, CO 80632 RE: RFP 05007: Sex Abuse Treatment RFP 006-00: Mental Health Services Dear Ms. Romanisk: This letter is in response to the confirmation letter received on April 25, 2004, regarding Individual &Group Therapy Services' (JOTS)Bid Proposal for the above services. IGTS gladly accepts the conditions for placement on the vender list for the Department of Social Services. Specifically,relative to Condition#1,it is understood reports will be received no later than 90 days from the beginning date of services or it will not be eligible for payment. Relative to Condition#2, there are 6 staff and 2 supervisors. In addition,the staff to client ratio is 8 clients to 1 therapist and. 12 clients with 2 therapists. If there are further questions or concerns,please do not hesitate to contact IGTS. Respectfully submitted, S O-Q›(- _-(2 Kim R. Ruybal, MA, LPC,NCACII Executive Director • ramify • Couplts • Adolescents • Victim Services • Mental Health Assessments Domestic Violence t valuation and Treatment • 5OM15 evaluation,Treatment and Plethysmogn.ph9 05/1`0/2005 19:48 9703530371 IGTS PAGE 02 INDIVIDUAL & GROUP THERAPY SERVICES 824-8 9th Street Greeley, Colorado 80631 970-353-8171 970-353-0371 - Fax FAX TO: (/ Oty- SC! U Jtit hSS FAX 4f - 35-3- Sir n FROM: v► r� �Eak DATE: QQ � 1O O /� RE: !4-/L ! iLSIOS`e-e PERSONAL AND CONFIDENTIAL This fax transmission, and any documents accompanying it, may contain confidential information belonging to the sender, and which may in part or whole be protected by federal regulations . This information is intended solely for the use of the individual or agency named above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or the taking of action upon the contents of this information is prohibited. If you have received this fax in error, please notify our office immediately by telephone at 970-353-8171 for instructions on how to return the document (s) or arrangements for destroying the document (s) . Thank you for your cooperation. MESSAGE: # of Pages (including cover page) : TIME BEING FAXED: / d DEPARTMENT OF SOCIAL SERVICES (#0 P.O. BOX A GREELEY,CO. 80632 Website:www.co.weld.co.us 1 Administration and Public Assistance(970)352-1551 Child Support(970)352-6933 O • April 18, 2005 COLORADO Kim R. Ruybal M.A., LPC,NCAC II Individual &Group Therapy Services 824 B 9 Street Greeley, CO 80631 Re: RFP 05007: Sex Abuse Treatment RFP 006-00: Mental Health Services Dear Ms.Ruybal: 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 your bid, RFP 05007, Sex Abuse Treatment, for inclusion on our vendor list. • The Families, Youth and Children(FYC) Commission recommended approval of Bid 006-00,Mental Health, for inclusion on our vendor list, attaching the following conditions. Condition#1 is applicable for all Mental Health providers,while Condition #2 is specific to your Mental Health program. Condition#1: 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. Condition#2: Please clarify the ratio of staff to supervisor and the maximum total of clients to staff. 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. T age 2 Individual &Group Therapy Services/Results of Bid Process 2005-2006 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, td)J . go, Dir for cc: Juan Lopez, Chair, FYC Commission Gloria Romansik, Social Hello