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Home My WebLink About20051647.tiff RESOLUTION RE: APPROVE FOUR NOTIFICATION OF FINANCIAL ASSISTANCE AWARDS FOR SEX ABUSE TREATMENT PROGRAMS WITH VARIOUS PROVIDERS AND AUTHORIZE CHAIR TO SIGN WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, the Board has been presented with four Notification of Financial Assistance Awards for Sex Abuse Treatment Programs between the County of Weld,State of Colorado, by and through the Board of County Commissioners of Weld County,on behalf of the Department of Social Services,and various providers,listed below,commencing June 1,2005,and ending May 31,2006, with further terms and conditions being as stated in said awards: 1. Adolescent and Individual Therapy 2. Ackerman and Associates 3. Professional Counseling Services 4. 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 four Notification of Financial Assistance Awards for Sex Abuse Treatment Programs between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Social Services,and various providers listed above, be,and hereby are, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said awards. 2005-1647 (le , SS0032 o�ao � FOUR NOTIFICATION OF FINANCIAL ASSISTANCE AWARDS FOR SEX ABUSE TREATMENT PROGRAMS 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 WELD COUNTY, COLORADO :'°tom a 11861 ' A� gel William H. Jer , Chair -Id -on Clerk to the Board 44,41 ei e, ro-Tem Deputy Clerk to the Board id E. Long APP AS • Robert D. asde minty Att ey oink_ Glenn Vaad Date of signature: 4 c O& 2005-1647 SS0032 - a DEPARTMENT OF SOCIAL SERVICES P.O. BOX A 141 GREELEY, CO. 80632 Website:www.co.weld.co.us Administration and Public Assistance(970)352-1551 11 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 Services ,-et 0 ,x143 RE: Notification of Financial Assistance Awards for Sex Abuse Treatment Programs with Various Providers Enclosed for Board approval are Notification of Financial Assistance Awards (NOFAAs) for Intensive Family Therapy 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 Sex Abuse Treatment Programs. These services are for children, youth, and families receiving child welfare services. 3. Providers will be reimbursed according to various rates and services as provided below: No. Core Services Description of Program/Special Award Amount Contractor Conditions A. Adolescent& Adolescent program for a maximum of 5 $50 per hour individual Individual Therapy youth, 1 hour weekly group session, 1 counseling (Ft. Lupton) group session with mandated attendance of $100 per hour court parent/guardian. testimony $35 per episode/group $500 after care evaluation depending on services/episode $225 polygraph (average)/episode B. Ackerman&Associates Maximum is 3 families for non-offending $90 per hour parent,victims,and siblings of the $100 per hour court perpetrator. testimony C. Professional Average capacity is 15 for non-offending $98.11 per hour Counseling parents,victims,and siblings of the $130 per hour court perpetrator. Average stay is 18 weeks with testimony 2005-1647 client participation at 1 hour per week. D. Individual&Group Adolescent program using a non-medical, $40.60 per hour Therapy Services cognitive behavioral model, including $100 per hour court group, individual,couples, and family testimony therapy. Services include assessment, outpatient, group therapy,polygraph, chaperoned group, and aftercare. 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 FY05-CORE-0027 Revision (RFP-FYC-05007) Contract Award PerMd Name and Address of Contractor Beg • •/01/2005 • Adolescent&Individual Therapy Ending 05/31/2006 Sex Abuse Treatment P. O.Box 321 Fort Lupton, CO 80621 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Assistance This program serves sexually abusive adolescents from Award is based upon your Request for Proposal(RFP). The the ages of 12 though 20.The mission of A.I.D. is RFP specifies the scope of services and conditions of award. designed to protect the safety of the community. A.I.D. Except where it is in conflict with this NOFAA in which services those who have been adjudicated, have case the NOFAA governs,the RFP upon which this award is admitted to sexual abuse, or are sexually reactive. The based is an integral part of the action. program provides for a maximum of 5 clients, 1 hour weekly group sessions, 1 group session with mandated Special conditions attendance of parent-guardian. Currently Bilingual 1) Reimbursement for the Unit of Services will be based on an services are not available. South County services are hourly rate per child or per family. provided if an adequate number of clients are referred. 2) The hourly rate will be paid for only direct face-to-face Family reunification services upon request. contact with the child and/or family,as evidenced by client- Cost Per Unit of Service signed verification form,and as specified in the unit of cost Hourly Rate Per computation. Individual Counseling $ 50.00 3) Unit of service costs cannot exceed the hourly and yearly Court Testimony $100.00 cost per child and/or family. Rate per episode 4) Payment will only be remitted on cases open with, and Treatment Package $35.00 referrals made by the Weld County Department of Social After care(Evaluation) $500.00* Services. Polygraph(Average Rate) $225.00** 5) Requests for payment must be an original submitted to the *Cost of evaluation is dependent upon services Weld County Department of Social Services by the end of provided. the 25th calendar day following the end of the month of ** Variable Rate is dependent on cost of polygraph. service. The provider must submit requests for payment on Other Services forms approved by Weld County Department of Social Notebook(One time at first group session)$10.00 Services. Unit of Service Based on Approved Plan Enclosures: 6) The Contractor will notify the Department of any changes in X Signed RFP: Exhibit A staff at the time of the change. Supplemental Narrative to REP: Exhibit B Recommendation(s) _Conditions of Approval Approvals: Program Official: By deUt > By William H. Jerke, Chair Judy riego,D rector Board of Weld County Commissioners Weld n y De artment o Social Services Date: JUN Q6 pfloS Date: 41)111s c O05 /6Y ? SIGNED RFP: EXHIBIT A INVITATION TO BID BID 002-05 (05005-05011 and 006-00) DATE:February 16, 2005 BID NO: RFP-FYC-05007 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-05007) for:Colorado Family Preservation Act--Sexual Abuse Treatment Program--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 Sexual Abuse Treatment Program must provide for therapeutic intervention through one or more modalities to prevent further sexual abuse perpetration or victimization. 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 �Eheccr< .1 . l-RU )Gk imet, (-k'C, 'C TYPED OR PRINTED SIGNATURE VENDOR /9-delfSecii- 1- s-NDi0tOcue I � '(4 Lc;- ry 4)c- (Name) q , CP 1Dc'• a (>rn r (,)F Hand tten Signat e y ed Officer or Agent of Vendor ADDRESS P- O , 60 x ,�j i TITLE C_Act Cckx LCC-4QC-ErCc F o c t k c.c so CC) `SG& al DATE -ac- Os PHONE# 303 - scO - y6- c' - The above bid is subject to Terms and Conditions as attached hereto and incorporated. Page 1 of 32 Bid 002-05 (RFP-FYC-05007) Attached A SEXUAL ABUSE TREATMENT PROGRAM BID PROPOSAL AND REQUEST FOR CONTINUATION OF AWARD UNDER FPP CORE SERVICES FUNDING FAMILY PRESERVATION PROGRAM 2005-2006 BID PROPOSAL APPLICATION PROGRAM FUNDS YEAR 2005-2006 f/ BID 002-05,RFP-FYC-05007 IXCINAME OF AGENCY: /a 1 P S C 'e it S T Ti)K) rip (t) ' DLit cc I Do U (O YI i e rJ ADDRESS: P.O (3o x 3av 1 Foci' �tt > 4c r� C !, aoLo a PHONE: (3,aS cce-ce 5 S nn / CONTACT PERSON:Q.0),C 0 r c� Q LC i s TITLE: P_X F e i t (I tic' I�t eat'C o t DESCRIPTION OF FAMILY PRESERVATION PROGRAM CATEGORY: The Sexual Abuse Treatment Program must provide for therapeutic intervention through one or more modalities to prevent further sexual abuse perpetration or victimization. 12-Month approximate Project Dates: _ 12-month contract with actual time lines of: Start June 1,2005 Start End May 31,2006 End �1 TITLE OF PROJECT: V Ork-C pUS E' S i)G C Ste_e_ Try_a � (YIJe w U f Name and Signatur aring Document Date Cn cec mac_ as Name and Signature Chief dmimstrative Officer 2Cpplicatit Agency Date `RebLcCe` S . IGLU_ cJ< 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 Irk 7 A b Cho j Target/Eligibility Populations hi C j y .r Types of services Provided IL% c Measurable Outcomes Service Objectives ML; 0 C Workload Standards h1 c <_hp ti Staff Qualifications c; ei c Unit of Service Rate Computation e ,-,. Z Program Capacity per Month Nc, S Certificate of Insurance 0 Page 26 of 32 Bid 002-05 (RFP-FYC-05007) Attached A Date of Meeting(s)with Social Services Division Supervisor: Comments by SSD Supervisor: IS - Pl:tL_ _9i6 414j— ?-7).-r--(49c---- Name d Signature of SSD Supervisor Date Page 27 of 32 ADOLESCENT & INDIVIDUAL DEVELOPMENT Mailing: PO Box 321 Fort Lupton, CO 80621 Fax: 303-857-9720 Cell Phone: 303-596-4586 February 25, 2005 To Whom It May Concern: Adolescent and Individual Development has been in existence since January, 2000 . This agency' s main focus is on the Adolescent who has sexually offended. As the Executive Director, owner of the agency, and therapist my primary concern is for the troubled adolescent to gain the best possible services and become a productive member of society. I will work with the adolescent, his/her parent (s) , and any supportive individual or group involved with this individual in making sure that all will not only hold the adolescent accountable for his/her actions but, also support this young person in his/her life . I will only hire co-therapists who also hold this standard of thinking. It is very important that those who work with adolescents provide treatment which is age appropriate . This program stresses the importance of the therapist and co-therapist to challenge the adolescent without disrespecting them. I have witnessed adolescents become productive individuals who have taken full responsibility of their behaviors . I continue to appreciate the support Weld County Department of Social Services has had in my program and the referrals they have given to this agency. Sincere , Lc Re ecca J. Q ick M.A. CRC Licensed Professional Counselor Full Operating Level Offense Specific Evaluator and Treatment Provider ADOLESCENT & INDIVIDUAL DEVELOPMENT Mailing: PO Box 321 Fort Lupton, CO 80621 Fax: 303-857-9720 cell Phone: 303-596-4586 February 25, 2005 Cost Per Unit of Service : Hourly Rate Per Individual/Family $50 . 00 Staffings with Family/Client $50 . 00 Rate per episode Group Session $35 . 00 Evaluation $500 . 00* Polygraph (Average Rate) $225 . 00** *Cost of evaluation is dependent upon services provided. ** Variable Rate is dependent on cost of polygraph. Supplies Notebook (One time at first of group session) $10 . 00 Unit of Service Based on Approved Plan Court Testimony Per Hour $100 . 00 The purpose of the above break downs is so Weld County Department of Social Services is not billed more than the other clients . Therefore an itemized bill will follow the client Core Services Program Verification Form each month. I have been billing this way since the contract of June 2004 . It is necessary I continue with this method of billing to keep the cost of each service in line with clients who are not WCDSS clients . Sin ere , ere a Re ecca . . CRC Licensed Professional Counselor Full Operating Level Offense Specific Evaluator and Treatment Provider BRANCH B/A ' PRODUCER NUMBER I CLIENT NUMBER ! DATE OF ISSUE RENEWAL OR REPLACEMENT NO. 23 A 0001614 * 130 2936O7 O4/15/O4 8OM-1193737 PROFESSIONAL LIABILITY OCCURRENCE INSURANCE POLICY FOR PROFESSIONAL COUNSELORS AND HUMAN DEVELOPMENT PRACTITIONERS ALLIED HEALTH PURCHASING GROUP ASSOCIATION POLICY NUMBER: 44-2010129 Item? DECLARATIONS CERTIFICATE NUMBER 80M- 1193737 1. Named Insured ADOLESCENT & INDIVIDUAL DEV. 2. MAILING ADDRESS PO BOX 321 FT. LUPTON, CO 8O621-O321 3. Policy Period 12:01 A.M. Standard Time At From: 04/03/2004 To: 04/03/2005 Location Of Designated Premises 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] $330.00 B. General Liability [ ] C. Endorsements [ ] Total: $330.00 5. LIMITS OF LIABILITY $ 1,000,000 each Incident $ 3,000,000 in the Aggregate or Occurrence B. The Named Insured Is: Sole Proprietor (including Individual) Partnership Corporation Other: Organization Affiliation: MENTAL HEALTH INSURANCE PROGRAM 7. Business or Occupation of the Named Insured: COUNSELOR 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 formis) or endorsementls): PLE-2081, PLi-2016(10/94), PON-2003, PLE-2189(09/97) l CHICAGO INSURANCE COMPANY 55 E. MONROE STREET, CHICAGO, ILLINOIS 6O6O3 REPRESENTATIVE: MARSH Affinity Group Services a service of SEABURY & SMITH 1440 RENAISSANCE DRIVE PARK RIDGE, IL 60068 1-800-503-9230 PLP-2O16 (Rev. 1O/94) (Elec.) INSURED COPY PLP-2O31 (10/94) F W O a P7 .7 6 a z a LL I'' , .. J) 4 1 O ,F V 0 9,v r CI 13) n 1 i f• WI I I J,„ 441 °JCL) •,,"-a 4: , O H_ a R3 v .'; ��i,* ,, 0Iti ,4 G U 3 d e- w m A E o / X U U U } CD } w Q W 0 w CD w 0 U `-- J U U 0 W g + U z ,o) I -* ' x i p f 0 x ? U y `� U La; w 8 w O O Q v H w 0 U d H LL a 0 0 O U 2 0 0 U U y� �` 0 0 p 2 § I ~ a o Ce Y re ? 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's a l d'el r ;is' W 1,4 11'14'11 lin "' #am IT O a. t k as re Q Q N t} s ! .'. .t1 W W 7 4° !qqt �i O ' ,-y� CC R' U Sy7 711„..141 vi H J m G xtY tvi W W u W 5 - .,i , 'et' rc I rk4{ K O 3 F r# � a , s O- , s rc Y ox o W d DEPARTMENT OF SOCIAL SERVICES P.O. BOX A GREELEY, CO. 80632 TT Website:www.co.weld.co.us ' Administration and Public Assistance(970)352-1551 Child Support(970)352-6933 11 O • COLORADO April 18, 2005 Rebecca Quick, Executive Director Adolescent&Individual Therapy P O Box 321 Fort Lupton, CO 80621 Re: RFP 05007 Dear Ms. Quick: The purpose of this letter is to outline the results of the Bid process for PY 2005-2006 and to request written confirmation from you by Wednesday, April 27, 2005. A. Results of the Bid Process for PY 2005-2006 The Families,Youth and Children(FYC) Commission recommended approval of the bid, RFP 05007, Sex Abuse Treatment, for inclusion on our vendor list. • Unit of Service Rate Computation Your bid did not include back-up documentation on the cost sheets. You are requested to contact John Kruse, Business Office Manager, extension 6530 to clarify your information. If you have questions,please call Gloria Romansik, Administrator, at 352.1551, extension 6295. Sincerely, tttOy riego, ector cc: Juan Lopez,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 FY05-CORE-05007 Revision (RFP-FYC-05007) Contract Award Period Name and Address of Contractor Beginning 06/01/2005 and Ackerman and Associates P.C. Ending 05/31/2006 Sex Abuse Treatment 1750 25th Avenue, Suite 101 Greeley, CO 80634 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Time-limited, outcome-focused therapy services Assistance Award is based upon your Request for for the non-offending parent, victims, and Proposal (RFP). The RFP specifies the scope of siblings of the victim. Individual services are in services and conditions of award. Except where it is office. Group services provided in office, foster in conflict with this NOFAA in which case the home, or WCDSS.The program maximum is 3 NOFAA governs,the RFP upon which this award is new families per month with a maximum ability based is an integral part of the action. to carry eight open cases a month. Services are culturally sensitive.Bilingual services are Special conditions available. 1) Reimbursement for the Unit of Services will be based on an hourly rate per child or per family. Cost Per Unit of Service 2) The hourly rate will be paid for only direct face-to- Hourly Rate Per Treatment Package $ 90.00 face contact with the child and/or family as evidenced Hourly Rate Per Court Testimony $100.00 by client-signed verification form, and as specified in the unit of cost computation. 3) Unit of service costs cannot exceed the hourly and Enclosures: yearly cost per child and/or family. X Signed RFP:Exhibit A 4) Rates will only be remitted on cases open with, and Supplemental Narrative to RFP: Exhibit B referrals made by the Weld County Department of Recommendation(s) Social Services. Conditions of Approval 5) Requests for payment must be an original and submitted to the Weld County Department of Social Services by the end of the 25th calendar day following the end of the month of service. The provider must submit requests for payment on forms approved by Weld County Department of Social Services. 6) The Contractor will notify the Department of any change in staff at the time of the change. Approvals: Program Official: n By , ,,..�_ By Ilv a_ her William H. Jerke, Chair Jud . Grieg Directo Board of Weld County Commissioners We Co ty1 epartment of Social Services Date: JUN 0 6 2005 Date: �/ 2 (OS- 1 ! h((7 SIGNED RFP: EXHIBIT A INVITATION TO BID BID 002-05 (05005-05011 and 006-00) DATE:February 16, 2005 BID NO: RFP-FYC-05007 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-05007) for:Colorado Family Preservation Act--Sexual Abuse Treatment Program--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 Sexual Abuse Treatment Program must provide for therapeutic intervention through one or more modalities to prevent further sexual abuse perpetration or victimization. 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 I "-r^ (/ a S (After receipt of order) BID MUST BE SIG/NED IN INK ��11 cOyc IT//�� cite rrr`rrti th2 /► II � n( TYPE OR PRINTED SIGNATURE VENDOR /TCkerrA c ggftSSOLc — IC (Name) Handwritt Si ture By Authorized Officer or Agent of Vendor • ADDRESS 05-0 (ler. &Lk_ TITLE PsycL t o r qr ee �e y_ Cn 5-o(,3 tl DATE M a r,J no @-O5S- PHONE# /'7(7-3.S 3 -?3 73 The above bid is subject to Terms and Conditions as attached hereto and incorporated. Page 1 of 32 • Bid 002-05 (RFP-FYC-05007) Attached A SEXUAL ABUSE TREATMENT PROGRAM BID PROPOSAL AND REQUEST FOR CONTINUATION OF AWARD UNDER FPP CORE SERVICES FUNDING FAMILY PRESERVATION PROGRAM 2005-2006 BID PROPOSAL APPLICATION PROGRAM FUNDS YEAR 2005-2006 DD BID 002-05,,RFP-FYC-05007 NAME OF AGENCY: A GAR,- ,-Mr-- . � ASS o e I C ADDRESS: J SD 9-S t1-‘ A !ER- .siw1- l 0 ! G.-ee l p Co eoc37 PHONE: (770 3 c3 33')3 /� Q / CONTACT PERSON: T.C y cz Acitern-wn- CA- •0 TITLE: /?57 c /� /7__As t DESCRIPTION OF FAMILY PRESERVATION PROGRAM CATEGORY: The Sexual Abuse Treatment Program must provide for therapeutic intervention through one or more modalities to prevent further sexual abuse perpetration or victimization. 12-Month approximate Project Dates: _ 12-month contract with actual lime lines of: Start June 1,2005 Start End May 31,2006 / End TITLE OF PROJECT: f oke-- � n s--,ex``f e ±rert✓✓e,t" / Y'oy/_,— C ca- e. 1 4ior 4cktrn o,—PA Q QP/ce Yt citerntor ea-40 (� _,31;) t /h#-I /o was Name and Signature of Person Preparin o m Date lo 9-eol" Name and Si a 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 N Target/Eligibility Populations N / Types of services Provided yT ,/ Measurable Outcomes N ,/ Service Objectives / Workload Standards Al / Staff Qualifications Unit of Service Rate Computation / Program Capacity per Month �L ✓ Certificate of Insurance Page 26 of 32 - Bid.002-05 (RFP-FYC-05007) Attached A ------------------------------------------------------------------------------------- Date of Meeting(s)with Social Services Division Supervisor: Comments by SSD Supervisor: 'mi l A d ✓l . A vL rei • 7-7Wa Name an ignature f SSD Supervisor Date Page 27 of 32 Bid 002-05 (RFP-FYC-05007) Attached A Program Category Sexual Abuse Treatment rogram Bid Category AcA Project Title pp,�/VQr.(Fl F6 T) $o�,F'e 1-/e- rin-,-7, Ply"' Vendor PROJECT DESCRIPTION Provide a one-page brief description of the project. II. TARGET/ELIGIBILITY POPULATIONS Provide a one-page brief description of the proposed target/eligibility populations. At a minimum your description must address: A. Total number of clients to be served. B. Total individual clients to be served. Please describe if your clients are: 1. Victims under age 18. 2. Perpetrators under age 18. 3. Adult incest perpetrators. 4. Non-abusing spouse 5. Relatives (under 18) in the household of incest victims and/or incest perpetrators. 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. Subtotal of individuals who will provide 24-hour access to services. 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. III. TYPE OF SERVICES TO BE PROVIDED Please 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. Comprehensive, diagnostic and treatment planning with the family and other service providers. B. Therapeutic intervention with flexibility to bring in other services if needed. C. Therapeutic services through a variety of modalities including: individual, family, group, marital, data, etc. D. Therapy designed to address issues and behaviors related to sexual abuse victimization, sexual dysfunction, sexual abuse perpetration, and to prevent further sexual abuse. E. Specialized intake/investigation function for families with sexual abuse allegations. Also,provide your quantitative measures as they directly relate to each service. At a minimum, include a number to be served in each service component. Describe your internal process to assure that FYC resources will not supplant existing and available services in the community; e.g. mental health capitation services, ADAD and professional services otherwise funded. Page 28 of 32 • Bid 002-05 (RFP-FYC-05007) Attached A IV. MEASURABLE OUTCOMES Please provide a two-page description of your expected measurable outcomes of the project. Please address the following measurable outcomes: A. Reduced rate of recidivism of sexual abuse perpetration within a stated time frame. B. Decrease in re-victimization. C. Prevent victim perpetration. D. A percentage of child abuse incest victims receiving services do not go into placement. E. Improvement in parental competency as measured by pre and post placement functional test. F. More rapid reunification of children with families. Describe your quantitative measures: Also, describe the methods you will use to measure, evaluate, and monitor each quantitative measure. V. SERVICE OBJECTIVES Please provide a one-page description of your expected service objectives and quantitative measures. Please address, at a minimum, the following ways the project will: A. Improve Parental Competency- Capacity of parents to maintain sound relationships and appropriate physical and emotional boundaries with their children, and to empower non- abusing parents and victims. B. Improve Family Conflict Management-Mediation and counseling designed to resolve conflicts and disagreements within the family contributing to child maltreatment and sexual abuse. C. Improve Personal and Individual Competencies -Primarily in terms of self-esteem,victim awareness, awareness and management of one's own personal history of victimization, sex education,peer relationships enhancement, establishing appropriate physical and emotional boundaries, assertive in lieu of aggressive behaviors, and assuming responsibility for one's own behavior. D. Improve Ability to Access Resources- Services shall assist parent in learning to obtain help from other sources in the community and within local, state, and federal governments. Describe the methods you will use to measure, evaluate, and monitor each service objective. VI. WORKLOAD STANDARDS Please provide a one-page description of the project's work load standards and quantitative measures. Please 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 in the intake function and in the Sexual Abuse Treatment. D. Modality of treatment E. Total number of hours per day/week/month. Page 29 of 32 Bid 002-05 (RFP-FYC-05007) Attached A F. Total number of individuals providing these services. G. The maximum caseload per supervisor. H. The modality of treatment. I. Insurance. VII. STAFF QUALIFICATIONS Please 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 as defined in Staff Manual Volume VII, Section 7.303.17, and Section 7.000.6,Q, Colorado Department of Human Services. Describe. B. Total number of staff, including supervisors, available for the project. C. Is your agency approved by the Sexual Offender Management Board? Explain your compliance with any mandatory regulating agency. 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. Please 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 Page 30 of 32 Bid 002-05 (RFP-FYC-0500'7) Attached A 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, 2006. 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. (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 Page 31 of 32 Bid 002-05 (RFP-FYC-05007) Attached A 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. (1) 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. (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 Project Description 2005-2006 Sexual Abuse Family Education and Treatment Program The SAFE-T Program Project Description: Ackerman and Associates P.C. proposes to continue to provide, in 2005-2006, the time limited, outcome focused therapy model for treatment of the non-offending parent, the victim and siblings of the victim in sexual abuse cases. The program is proposed in four parts: (each of these parts may be used as part of an integrated program, may stand alone or be used in combination with other treatment regimens.) A. The development of the prescriptive safety education and treatment plan of the family unit. This will take place over no more than fifteen hours and should average ten hours. B. The implementation of the plan with the non-offending parent to increase safety and avoid repetition of sexual abuse in the family unit. This will take place over no more than 20 sessions. Up to ten of these sessions would be for individual treatment. Up to an additional ten of these individual session times could be converted to ten hours of group work. (Throughout the proposal, whenever we discuss group work, note that it will be billed as one hour of individual treatment for each two hours of group treatment). C. Short term treatment for the child who was abused and for the siblings over a maximum of fifteen sessions to develop skills for future safety and to reestablish trust, including family issues that need to be addressed with the children. Each child in treatment, whether the victim or the sibling, should have their own authorization for treatment. D. A protocol of therapy to taper down the frequency of support needed to provide maintenance of skills developed. This will take place over no more than ten sessions designed to be delivered on a twice a month basis over a maximum of five months. This provides an additional support program for those families in need of the service. Based on past experience Parts A, B, and C have been used by WCDSS and D has not been used much. Nevertheless, we submit it here as an appropriate program for potential future use. Note that part D is presented as a separate budget page. For any family who is not appropriate to continue in the treatment model due to severity that will be transferred. Determination of progress in the program will occur at the following review points: 1 Program Review point#1: A report of recommendations for treatment will be completed at the end of part A. It will specify 1. The goals to be achieved in part B and part C, which can then proceed over the next two or three months if authorized 2. What other types of treatment or intervention are appropriate and 3. If no other intervention is recommended. Program review point#2: A report of the summary of treatment as the completion of the treatment plan in part B and part C. The purpose of this report is to answer questions. 1. How much progress has been made to date in relation to treatment plan? 2. Is it probable the family will complete the treatment in part B or part C within the session limits specified and if not what other services might be needed. This will also be the time point that a determination will be made as to if there is a need for an extension of sessions in phase B and C and if so why this is needed. An extension, if needed, will be limited to twelve sessions. Such an extension can occur only though a second authorization. The criteria for making judgments as to the family's progress will be based upon their completion of the prescriptive treatment plan and the adequacy of that treatment plan to protect the child and family from repeat offenses in relation to sexual abuse. Families not making progress will be discussed with the caseworker and as needed referred to other programs. Please note: the end point of treatment is not necessarily intended to be the full and complete resolution of all psychodynamic issues precipitated by the sexual abuse event. Such issues will likely continue to emerge as the child enters different stages of development into adulthood. If further funds are needed for full and complete restoration of mental health (beyond that required for family safety) these funds should be obtained from the perpetrator and or through victim's assistance and other funds. The purpose of this program is to recommend to WCDDS if the incident of the actual abuse has been resolved sufficiently to provide for the ongoing physical and mental health and safety of the non- offending parent, the child victim and siblings at the time of discharge from the program. The purpose of this highly structured system is to assist family members to achieve careful implementation of safety and child protection plans. Through role modeling, psychoeducational work with adults and /or child therapy, families will progress along a structured treatment course. Treatment will move from recognition of the factors that lead to the sexual abuse in their particular case to 2 developing and effective plan to eliminate the resurfacing of these factors and repetition of these types of events in the future. Of the four phases of the program, Part A would be limited to 15 sessions delivered over no longer than three months. Part B and C would be limited to twenty sessions each delivered either separately or concurrently over four months. The step down phase of the program Part D would be limited to no more than 10 sessions over four to six months. Reviews for the need to continue in the program would occur in month one, month three and month five. Families will need the sexual abuse family education and treatment program (the SAFE-Treatment Program) because the sexual abuse and its implications have either 1. Imminently placed the children at risk of outplacement from the non offending parent (or parents), 2. Created a need to be reunified or 3. The family is facing imminent reunification failure or 4.the family has failed to implement the behaviors required of them. Our model does not treat the adult offender .If that offender is the parent (usually the father or step father) and reunification is the agreed upon course of action desired, we would only assist the parties in developing a formal reunification plan after the offender has completed treatment in another program. In those cases, we accept based upon our clinical judgment. Our model is expected to work best with younger children and younger teens. It is expected to be especially useful where the non offending parent is herself a victim of sexual or physical abuse in her home of origin, or who has a highly disrupted home of origin from other causes. The program will provide continuity for the non offending parent and the children through each family having a coordinator within Ackerman and Associates. That coordinator will also coordinate the case and be the contact for the case worker and lead the clinical team on the family. The coordinator will also track the goals of treatment and organize the aspects of treatment within our clinical team approach. Clinical teams will discuss each case as necessary. Purpose: The purpose of the time limited, outcome (safety) focused (as opposed to psychodynamically focused) therapy is to implement the changes needed to insure future safety from further sexual abuse. The model assumes a clinical team oriented family systems approach of education and treatment and seeks clearly defined behaviors and outcomes that will insure safety. The role of the non offending parent in the sexual abuse will be explored, looking for points where protection can be strengthened in the future. The life experiences of abuse or neglect of the non-offending parent in the home of origin will be a part of the psychoeducational work that will be necessary by many of the families. In order to develop a treatment plan for addressing the sexual abuse that has brought the family into social services, the first part of the model will be the development of the psychological scope of work that will need to be completed. What are the goals needed to insure future safety? This will be developed 3 through a review of the case, psychological testing if indicated, and assessment of the victim and of the victim's siblings. From there, clearly defined, achievable, structured behavioral changes that are needed to insure future safety of the child will be developed into a written plan. Once agreed on by the therapist and non- offending parent, this plan will become the treatment goals for the family in relation to the safety of the child. Time lines and work to be achieved by phase are listed below: Part A. The development of the prescriptive treatment plan of the family unit over no more than fifteen sessions with a goal of the program for prescriptive assessment to average ten sessions. The prescriptive treatment plan typically involves interviews with the non-offending parent (up to five hours) three hours of case review, three hours of assessment and interpretation and up to four hours of assessment of other family members. Part B. The implementation of the plan focuses on the non-offending parent to assure the eventual safety of the child and to avoid the repetition of sexual abuse in the family unit. Treatment takes place over more than 20 sessions. Ten hours of these 20 sessions can be through group work (at a cost equivalent of 10 individual hour long sessions) For the non offending parent a mentoring of psychoeducational process of identifying factors that contributed to the abuse and dealing with these factors will be explored. This will be particularly important if negligence or home of origin issues are present. We postulate that a large percentage of the non-offending parents will either have been themselves sexual abuse victims or have come from significantly dysfunctional backgrounds. Such a psychological history would be amenable to this mentoring approach. Part C. For the child victim or sibling, the restoration of trust and safety assurance after the abuse incident itself would be a goal of child treatment. If appropriate and if the offending parent has successfully completed treatment and if the victim and the non-offending parent are appropriate for reunification, steps toward reunification may progress in selected cases. Part D. A step down protocol of therapy for no more than ten sessions designed to be delivered on no more than a twice a month basis for supportive transition from the support program, for those families in need of this service. Other Considerations: There is no risk of the program running costs up to levels beyond those budgeted for any one family because we set a treatment cap for social services funds at a maximum number of sessions, 15 for part A 20 for part B 15 per child for part C. Our experience has been that sections A, B and C have been used and D is not used often. Limitations on service delivery allow only 12 additional hours to be provided in part D. If significant resolution cannot be achieved to assure the 4 safety of the child within 45 hours of competent psychological treatment, other options should be considered to attain that safety. In our opinion it will be very rare for a case to go on for a lengthy period and then fail, as the family will need to make progress sufficient at each review point to continue in the process. Target/Eligibility Populations Total number of clients to be served in this twelve month program has been calculated as follows. Three families per month times twelve months equals thirty six families per year. If we assume a nuclear family size of five, two adults and three children, then the total client pool to be served is 180 individuals. If we subtract from the five family members the one offending parent the total becomes 144 individuals. As a minimum, there will be up to 36 non-offending parents and 36 victim children to be served. We expect the need to be lower than this number and anticipate 18-24 families in treatment over a one year period. We calculated the budget based on one child in treatment in part C, thus each child in treatment in part C will need an individual referral. Distribution of clients.Total number of clients we will serve is approximately 36 index children or more as calculated above. Our experience suggests that for the family we would expect approximately 36 additional of these would be adult members of the family (the non offending parent) and approximately 72 additional siblings who would be minors. Families Served. We would anticipate serving 36 family units or less. We expect 18-24 families is a more likely use rate. Sub total who will receive bicultural/bilingual services. We have a Hispanic member of the staff Emily (Jaramillo) Montoya M.A., L.P.C. who speaks Spanish. One of the facilitator's (Joyce Shohet Ackerman) doctoral work was on Hispanic patients' mental health treatment patterns compared to Anglo patients in Weld County. She also has four years of direct cross cultural experience with an American Indian population. All of the other staff have cross cultural experience. We expect 50% of referrals can receive services in Spanish and 100% will receive services in a culturally appropriate mariner. We have been able to and will continue to provide bilingual services for any family who needs them. We anticipate that the majority of the work in this program will be conducted at our Greeley offices. Accessibility. On weekdays a provider is on call from Ackerman and Associates for the each day and is accessible through our office and through the connected 24 hour answering service and pager system. On weekends, the 24 hour access reaches the provider on call for that weekend all of whom are Ackerman and Associates' licensed mental health providers described in the staff section of this proposal. 5 Maximum per month. The program maximum is three new families per month with a maximum ability to carry eight open cases a month. The monthly average capacity is two new families per month with the average load of five open cases a month. The average stay in the program is expected to be 40 sessions over a six month period. The maximum stay is 45 sessions over a twelve month period assuming one child in part Cc with parts A and B also being used. Use of part D would add 10 hours to this total. Group treatment would be provided at a rate of one half of the rate for individual sessions so that each two hours of group session treatment would be at the same rate as one hour of individual treatment Them are a number of options WCDSS can use to decrease the cost of this program. For example if assessment is complete prior to referral then part A might be omitted. Part D costs have been less than projected over the several of this project Nevertheless, we have tried to make best estimates for the average length of stay in our budget Types of Services Provided The types of services have been described in detail above under project description and purpose sections. They are summarized here. We propose to provide a maximum of 55 sessions of outcome focused treatment over four program subtypes (A, B, C or D) for the victim of sexual abuse, his or her siblings and the non offending parent Part A offers assessment of the non offending parent and the children in terms of treatment needed and if they would benefit from this program (15 sessions maximum). Part B is for treatment of the non offending parent (20 sessions maximum) to improve safety of the child in the future, Part C is to treat the child victim (15 sessions maximum) of the abuse and the siblings to improve safety and to establish short term treatment goals for safety as well as to develop a long term treatment plan. Part D is a transition of up to 10 sessions for maintenance of achieved skill in those families requiring this service. Measurable Outcomes Measurable outcomes are of two varieties. One type is termed formative outcomes and the other type is called summative outcomes. Formative outcomes measure how the program is proceeding while the treatment takes place. Summative outcomes are the results of the treatment In terms of formative measures we have the following... Family cooperation with appointments and process of treatment in parts A, BC or D form components of the formative review. Did the family cooperate in treatment is a primary formative measure. 6 This data will be extracted from the case file. Summative Outcomes A. To reduce the rate of recidivism of sexual perpetration. This program does not treat sexual perpetrators so at one level this question does not directly apply. However the goal of the program is to prevent 100% of revictimizations by treating the victim and the non- offending parent to after the family environment and opportunities for revictimization. B. Decrease in revictimization should be substantial and persistent. The program is set up to empower the non-offending parent to identify situations where victimization is likely and to reduce these occurrences. We set a goal of 90% of families who complete treatment will not be victimized in the next two years. This number assumes that after treatment is completed that the non-offending parent does not reenter a marital relationship with the offending parent. We set a goal at 50% at two years post treatment would avoid revictimization if marital reunification occurs with the offending parent occurs in the next year. C. Prevention of victim perpetration. For those victims who complete part C treatment, most will be children who are not sexually active. We expect that for a two year period following treatment victim perpetration will be rare and that 90% of children will not be perpetrators over a two year period following end of treatment. Comments on individual case risk will be made in final reports. D. We expect that 70% of non-offending parents will complete treatment Of these we expect that 90%will be able to keep their children over the next two years if they do not reenter a marital relationship with the perpetrator. E. Improvement in parental competency: Parameters measured in this area include acceptance of the sexual abuse and the need for restructuring the family environment as well as the clients ability to achieve that goal to prevent such abuse from occurring again. Clinical improvement in this area is the goal of the Part B treatment program and for each client will be reported at the end of treatment. F. While we do not expect more rapid reunification with biological family members (the offending parent), we do expect the acquisition of life skills in anger management and an increase in psychoeducational 7 knowledge. These should lead to risk reduction for a return to an abusive environment. Quantitative measures of these outcomes could be a cn-cd at WCDSS discretion at chart review at two years post treatment by WCDSS to determine if new charges had been reported or cases opened. Individuals who leave the county would be lost to follow up in this mechanism. A more vigorous evaluation method would be preferred but is not budgeted within this proposal Service objectives This proposal meets all the service objectives for the non-offending parent and the victim. The areas for improvement are documented in the quantitative measures that will be rated for the non-offending parent at the review points and at the completion of therapy as listed under the measurable objectives section. These areas include the required components of improving parental competency, improving family conflict management, improving family conflict management improving personal and individual competencies and improving ability and access resources for the non offending parent. Work Load Standards A. The program has a capacity of 5 families per month with an average of 3 per month. The families will receive an average of 45 hours of service as described if parts A, B and C are utilized. B. We have 5 providers for this program. They are Emily Jaramillo M.A., Licensed. Professional. Counselor., Susan Plock Bromley, Psy D Licensed Psychologist, Laurence Kerrigan Ph.D. Licensed Psychologist, Tom Pappas, MSW. Licensed Social Worker and Joyce Ackerman Ed.D. Licensed Psychologist • Emily Jaramillo, M.A. L.P.C. received her masters in Agency Counseling from UNC. Prior to joining Ackerman and Associates, P.C., she had a wide range of work in mental health including treatment for alcoholic patients and support of minority college students. She is fluent in Spanish. Her undergraduate major was in Criminal Justice and Sociology. 8 • • Joyce Ackerman Ed.D. Psychologist will function as the clinical supervisor of the program. She has 20 years of private practice experience and is listed in the National Register of Health Service Providers in Psychology C. Of the up to 36 families the caseload is projected seven families with each provider. D. The modality of treatment is individual or group therapy. E. Hours/weeks. The total number of therapist hours is 60 per family over six months, or a total for the budget calculation of 3600 per year based on our projected average. Maximum capacity is the same as this level. The hourly fee is requested at $ 90 as documented in the rate calculation section. F. Staff. There are 5 individual providers supported by two office professionals in the practice as well as a contracted accountant. G. Supervisor. This contact would be supervised and clinically managed by Joyce Shohet Ackerman, Ed.D. who will monitor the project for compliance. The maximum caseload for the supervisor is five families per month. H. Insurance. Ackerman and Associates, P.C. carries one million, three million liability coverage for professional liability on the corporation and its associates and each associate also carries the same level of coverage individually. In addition, Ackerman and Associates, P.C. carries a general liability policy related to accident or injury on our premises through Farmer's Insurance. Staff Qualifications A. All staff members exceed the minimum qualifications needed for this project in both education and experience as described above. B. Staff available for the project are listed above. Unit of service rate computation We have calculated the unit of service rate based in the instructions. We used 2004 data for our agency. Using overall figures for the agency we arrive at a figure of$90 per contact hour. Group rates are billed at one half this rate per hour. The profit for Ackerman and Associates for all programs was approximately 1% for the 2004-2005FY The proposed cost is $90 per face to face contact hour. This is ten to 30% lower than our fees for face to face therapy hour. 9 Budget Justification Ackerman and Associates purchases services for accounting through an independent contractor and through Anderson and Whitney to track funds. No special issues are present related to project audit to out knowledge. Ackerman and Associates mediation program were audited in a random audit (conducted by Anderson and Whitney) after its first year of operation with no deficiencies. Audits of the program are conducted on a yearly basis, as required by WCDSS, with no deficiencies noted. Ackerman and Associates, P.C. is a type S professional for profit corporation and not a 501.c.3. 10 03/10/2005 14:24 9703536134 FARMERS PAGE 02 • • TRUCK INSURANCE EXCHANGE MEMBERS OF THE FARMERS INSURANCE GROUP OF COMPANIES NOME OFFICE:4U0 WILSHIRE BLVD„LOS ANGELES,CALIFORNIA 80010 1. POLICY DECLARATIONS RETAIL Named • DR JOYCE SHOHETAC ERMAw PC RVIC£ - PREMIER Insured • Count ,-�--� Melling • 1750 25TH AVE STE 101 EasyPayAcclNo. Prod. Address _ GREELEY CO 80634-4844 07-0—4-362 04576-38-07 The named insured is an individual unless otherwise stated Agent No. Polley Number ❑Partnership 0 Corporation El Joint Venture 0 Organization (Any other) Type of Business DOCTOR'S OFFICE 2. Policy Period from 07/01/04 (not prior to time applied for) to 07/01/OS 12:01 a-m. Standard Time If this policy replaces other coverage that ends at noon standard time of the same ay this policy begins, this policy will not take effect until the other coverage ends. This policy will continue for sncceasiye policy periods as fellows: If we elect to continue this insurance, we win renew this policy if you pay the required renewal premium for each successive policy period subject to our premiums, rules and forms then in effect. 3. Insured location same as mailing address unless otherwise stated; 4• We provide insurance only for those coverages described below and for which a specific limit of insurance is shown. PROPERTY COVERAGES AND LIMITS OF INSURANCE COVERAGES PREN NO. 001 001 BUSINESS PERSONAL PROPERTY PROPERTY DEDUCTIBLE 963,100 GLASS DEDUCTIBLE $$500 loo TENANTS OUTDOOR TREESIOSggIgS, PLANTS S INCLUDED FINE ARTS COVERAGE $2,500 $2,000 COVERAGE ADDITIONAL COVERAGES All Premises seam 7410 /vcvenes �i,.run,trj X11: CERS1201 PAGE 1 OF 8 'Atja'ch to your:policy with:the same number shown on•this:endorsement + 4 E4�1 eft 2nd Edition named insured• Agent Policy Number DR JOYCE SHOHET ACKERMAti'PC Address• 1750 25TH AVE SUITE 101 07-04-362 04576-38-07 • GREELEY CO 80631 • of the Company designated in the Declarations • Insured . Location • (Same as above unless otherwise stated here) • . 1,000,000 each occurrence • Effective Date 07/31/96 Limit of Liability_$ .. $ 1,000,000 Annual Aggregate ADDITIONAL.INSURED.ENDORSEMENT (SPECIAL SENTINEL) In consideration of the premium we agree with you to the following: 1. The insurance provided by this policy for bodily injury liability and property damage liability under Coverage D—Business Liability insurance will also apply to the additional insured named below, but only with respect to an occurrence arising out of the ownership, maintenance or use of that part of the insured location occupied by you. 2. This insurance does not apply to: (a) Any occurrence which takes place after you cease to occupy the Insured location. (b) Any structural alterations, new construction or demolition operations performed by or for any additional insured named below. 3. The additional insures)will not be construed or deemed to be a subscriber to the Company issuing this policy.. 4. The additional insured will not be or become liable for any premium payments due upon this policy. 5. If this policy is terminated for any reason we will give 30 (THIRTY) days notice in writing to the additional insured named below. I This endorsement is part of your policy. It supersedes and controls anything to the contrary. It is otherwise subject to all other terms of the policy. STATE OF COLORADO Additional C/0 WELD COUNTY SOCIAL SERVICES—DEPT—-- nsured • ATTN: JUDY GRIECO PO BOX A • GREELPY CO 80632 Countersigned Authorized Representative a, . FARMERS 4IINiUROI1) eRYRPrt. - a o CO N N .2. R (,--5N f/! 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B 2 � ii " § iiiil' ■ E k k _I / 7 k ! § k k | / a • • JOYCE SHOHET ACKERMAN, Ed.D. 1750 25th Avenue,Suite 101 Greeley, Colorado 80634 RESUME PERSONAL DATA Date of Birth: August 3, 1950 Health: Excellent Married; two children CERTIFICATION - LICENSURE Licensed Clinical Psychologist,State of Colorado since 1984 Listed in National Register of Health Service Providers in Psychology since 1986 Staff Privileges, North Colorado Medical Center, Greeley, Colorado since 1985 PROFESSIONAL MEMBERSHIP American Psychological Association Colorado Psychological Association (elected board member 1986-1989) HONORS President's Award - Colorado Psychological Association, 1989 EDUCATION 1978 - 1981 Ed.D. in Counseling Psychology, University of Northern Colorado, December 1981 graduate 1972- 1974 M.S. in Education (E.D./L.D.) Lesley College, Cambridge, Massachusetts, August graduate 1968 - 1971 B.S. in Special Education and Elementary Education with a minor in psychology Boston University, Boston, MA, December 1971 graduate • PROFESSIONAL EXPERIENCE 1981 - present Clinical Director in group practice in Greeley,CO. Among responsibilities are: Diagnosis, therapeutic intervention and referral for adults, families, children and groups. Primary areas are: mediation, alternative conflict resolution,stress reduction. Also developing, organizing and presenting workshops and consultative programs to community,schools, organizations and agencies. 1986- present Consulting psychologist on interdisciplinary team for in-patient rehabilitation program. Progressive Care Rehabilitation Center, Greeley, CO. Medical Director Dr.Judith Vaughan,Neurologist. Adults with traumatic injuries- primary problems are: psychological aspects of physical rehabilitation, grief counseling,and brief group counseling using cognitive-behavioral goal oriented therapy. 1989- 1992 Consulting psychologist for Head Injury Treatment Team North Colorado Medical Center,Greeley CO Team coordinator - Dr.John McVicker,neurosurgeon. 1986 - 1989 Consulting psychologist for Family Recovery Center (in-patient substance abuse/chemical dependency program), North Colorado Medical Center,Greeley CO Coordinator Ruth Wick,R.N. 1986 - 1989 Provider and Coordinator for Mental Health Services in Northern Colorado for Peak Health Care (HMO). Peak mental health services utilized a three-session model for initial services followed by referral. Activities included coordination of Psychological and Psychiatric Services for approximately the last two years of the Contract. Peak supervisor- Elaine Taylor 1983 - 1986 Psychologist subcontractor for a Vietnam Veteran's Counseling Program funded by the Veteran's Administration. Principal Contract Dr. Robert Stewart. 1980- 1987 Part time faculty member with responsibilities for classes, workshops and community programs in parenting skills. Family/Life Education Program, Aims Community College, Greeley CO August 1980- August 1981 -Clinical internship on Children's Team of Community Mental Health Center. Responsibilities included: consultation to schools and community programs; therapy for children and families; and assessment of diverse mental health programs. Assistant program evaluator - developed evaluation tools to determine cross-cultural perceptions of expectations and satisfaction with services. Supervisors - Dr. Joan Gillespie and Dr. Laurence P. Kerrigan. APA National Convention in Toronto,Canada"Psychology and National Health Reform: "National Health Insurance: Policy Considerations, Benefit Designs. and Economic Realities", and"Marketing: Psychology's Key to National Health Reform. 1993 Disaster Relief Training. Alan Keck through Colorado Psychological Association,Denver CO 1992- Fall Short Term Therapy, Bernard Bloom; University of Northern Colorado, Greeley CO 1990- Fall National Cognitive Rehabilitation Conference, Richmond VA 1990 - summer Postgraduate training: 1. Adult Neuropsychological Method based on Lezak Neuropsychological assessment,1983. 2. Child Neuropsychology, Dr. Hynd. 3. Child Neuropsychological Methods 1988 Cognitive Rehabilitation Training Program, Dr.Sena, Ph.D., Colorado Springs CO 1988- present Psychologist- Head Injury Treatment Team at North Colorado Medical Center,Greeley CO 1987 Halstead Reitan Neuropsychological Assessment Training. Ralph Reitan, Ph.D., Washington DC Summer 1986 Albert Einstein School of Medicine, Workshop on Adolescent Therapy, Cape Cod MA 1985 to present North Colorado Interdisciplinary Team of Child Custody Member and participant Fall 1985 Interdisciplinary Workshop on Child Custody, Keystone CO Summer 1984 Workshop in Clinical Use of Hypnosis, Boston MA Winter 1983 Workshop on In-patient Programs for Service Related Disorders, Cheyenne Veterans Administration Hospital. Fall 1983 Veteran's Administration Workshop on Post Traumatic Stress Syndrome, Denver Veteran's Center. Fall 1981-Winter 1984 Post-Doctoral Supervised Candidate for Licensure (psychology) under Gale R. Giebler, Ph.D. Licensed Psychologist and Susan Spilman, Ph.D., Licensed Psychologist 1980 - 1981 Intern- Weld County Sexual Abuse Team,Greeley CO • Weld Mental Health Center,Greeley CO adults,adolescents, families. Primary areas anxiety disorders, mood disorders and adjustment disorders. Typical problems included: trauma, physical abuse substance abuse,job stress. Orientation used - primarily cognitive-behavioral therapy. 1980 Group Facilitator- Regional and National Conferences in cross-cultural community needs. Flagstaff, AZ- Colorado Springs CO August 1975 -July 1978 Chairperson of the Department of Education and Behavioral Science at an accredited, Indian controlled community college on the Navajo Reservation. Administration responsibilities included: Supervision and evaluation of faculty; budget preparation and management;curriculum development and integration of Navajo culture; personnel recruitment and selection;class scheduling and program development. Also faculty member with academic responsibilities for instruction in Psychology, Child Development and Counseling courses, advising and counseling students. Navajo Community College,Tsaile AZ September 1974 - August 1975 Education Specialist and counselor at an Indian controlled primary and secondary school on the Navajo Reservation. Coordinated community resource program, which included: counseling,student assessment, prescriptive programming,staff development and curriculum. Also, adjunct faculty for the University of New Mexico and for Navajo Community College at the Rough Rock Demonstration school, Rough Rock, AZ September 1972 -June 1974 Designed and coordinated Learning Center Program for Dedham Public Schools. A program and crisis intervention center for emotionally disturbed children. Responsibilities included: Diagnostic prescriptive programming,counseling, supervision and training of aides, tutors and volunteers,and consultation with regular classrooms teachers. Also organized group and individual meetings with parents. Adjunct faculty for Curry College assisting with in-service instruction for Dedham School System employees. Dedham Public Schools, Dedham MA WORKSHOPS AND SPECIAL TRAINING 1996 Biodyne training workshop adolescent treatment in short term therapy, Tom Kalous, Ph.D. 1995 Biodyne Training Workshops in short term therapy Julian Ang, Ph.D. 1994 Certification in family mediation, CDR Associates, Boulder CO 1993 Disaster Relief Training. Alan Keck, through Colorado Psychological Association, Denver CO 1993 August Hospital Practice for Psychologists Summer 1981 Independent Study of Child Sexual Abuse, University of Northern Colorado Spring 1981 Interdisciplinary Workshop on Assessment of Sexual Assault, Boulder Social Services Summer 1979 Biofeedback Training related to labor and delivery. Summer 1974 Participant in Institute on Obstacles to Learning. Joint Symposium between McLean psychiatric hospital, Harvard University and Lesley Graduate School, Cambridge MA Summer 1973 Kennedy Memorial Hospital,Boston MA. Participant,Summer Aphasia Institute. PUBLICATIONS Ackerman A., Ackerman,J.S., Kelley K. Hale K. Family Planning Attitudes of Traditional and Acculturated Navajo Indians. Key Issues in Population and Food Policy. University Press of America, pp. 178-171 (1979) Ackerman,J.S.,Client Expectations and Satisfaction with Community Mental Health Center Services: A Cross-Cultural Analysis Between Hispanics and Anglos. Published Doctor Dissertation,University of North Colorado. Copyright 1981. BRANCH . B/A PRODUCER NUMBER DATE OF ISSUE PRIOR CERTIFICATE NUMBER 23 A 0004087 05/04/2004 Renewal PSYCHOLOGISTS PROFESSIONAL LIABILITY CLAIMS-MADE INSURANCE POLICY NOTICE: THIS IS A CLAIMS-MADE POLICY, PLEASE READ THE POLICY CAREFULLY PURCHASING GROUP POLICY NUMBER: 45-0002000 Item DECLARATIONS CERTIFICATE NUMBER: 45P- 2032570 1. Named Insured Ackerman and Associates PC 1750 25th Ave ADDRESS Greeley, CO 80634-4943 Number&Street,Town, County,State&Zip No.) 2. Policy Period: 12:01 A.M. Standard Time At From: To: _ Location of Designated Premises 05/01/2004 05/01/2005 3. COVERAGE LIMITS OF LIABILITY PREMIUM Professional Liability $ 1,000,000 each incident I $3,000,000 aggregate $ 1,529.00 4. BUSINESS OF THE INSURED: PSYCHOLOGY 5. The Named Insured is: _ Sole Proprietor (including independent contractors) _ Partnership X Corporation _ Other: 6. This policy shall only apply to incidents which happen on or after: a) the policy effective date shown on the Declarations: or b) the effective date of the earliest claims-made policy issued by the Company to which this policy is a renewal; or c) the date specified in any endorsement hereto. 05/01/1992 7. This policy is made and accepted subject to the printed conditions in this policy together with the provisions, stipulations and agreements contained in the following form(s) or endorsement(s). PLP-2012 (06/93), PLJ-2008(Rev. 10/94), , PLE-8035 (09/97), PLE-2167 (07/00), POE-8004(05/88) (Ed. `10/93), PLE-2081 Current, PON-2003(08/02) CHICAGO INSURANCE COMPANY 55 E. MONROE STREET, CHICAGO, ILLINOIS 60603 REPRESENTATIVE: Agent or broker: Trust Risk Management Services, Inc. 875 N Michigan Ave Office address: Chicago, IL 60611-1803 City, State, Zip: Toll-Free Number: 1-877-637-9700 PLP-2012 (06/93) APA- • -- PERSONAL.. DATA SHEET Identif in Information: Name : Laurence "Larry" P. Kerrigan, Ph. D. Address : 1706 19th Avenue Greeley, CO 80631 DOB : 9/20/32 Phone : E 353-3373 - business BSC - Business MS - Economics , from Creighton University, 1954 . Economics , from St . Louis University, St . Louis , MA - Mo. , 1963 . Theology, from St. Mary' s University, Regis College Ph . L. - Campus , Toronto, Ontario , Canada, 1967 . Philosophy, St. Louis University, St . Louis , Mo . 1960 , (Ecclesial Degree ) . Ph . D . - California School of Berkele Professional Psycholugy , Y/Alameda Campus , 1974 , Clinical Psychology. Currently a licensed psychologist in the state of Colorado . Educational Back round: 1950-54 Creighton University, Business economics , 1954-56 Marquette University, Milwaukee , WI . , Classical studies 1956-57 and ascetical theology, Springhill College , Grand Coteau LA. Campus , Classical studies , 1957-60 St . Louis University, Philosophy and Economics , 1963-67 St. Mary ' s University, Toronto Campus , Theology , 1971 -74 California School of Professional Psychology , clinical psychology, Berkeley/Alameda Campus Positions Held : 1969-71 Member of Board of Directors , Campion College , Prairie du Chien, WI . 1968-71 Director, Department of Psychology, Campion College . 1971 -74 Director of Student Counseling Center , Long Mountain College . 1975-80 Director of Short-term Children and Family Team, Weld Mental Health Center, Greeley, CO . 1975-'87 Clinical Psychologist, Child and Family Team , Weld Mental Health Center, Greeley, CO . • 1976-88 Co-founder of Weld County Child Protection Team, 1987-88 Member of Executive Board, Weld Mental Health Center, Greeley, CO . Honors Received : 1968-69 and Teacher of the 1970-71 year, Campion College . 1972-73 Class Representative to Campus Executive Committee , and California School of Professional Psychology 1973-74 IJoric and Ex eriential Daek round : 1959-60 Counselor at Dismas Halfway House for ex-convicts , St. Louis , Missouri , 1960-63 Teacher-counselor-coach, Marquette Prep High School , Milwaukee , WI . 1964-67 Counselor-therapist at Street Haven and Sancta Maria Halfway Houses for women and at the Don ( metro ) Jail in Toronto , Canada. 1967-68 Teacher and Campus Counselor at Creighton University, Omaha, NB. 1968-71 Teacher at Campion College , Prairie du Chien , WI . , Director of Psychology Department , Department chairman . 1970-71 Director. and Staff member of a total environment for Inter-city boys , late grade school age from Milwaukee , WI . 1971-73 Director of Student Counseling , Lone Mountain College , San Francisco , CA . Teacher at the Lone Mountain College , San Francisco , California. 1973-74 Psychologist Trainee at San Francisco Mental Health Center, Richmond District, Outpatient Care . 1974-75 Private Practice , So . Bay Human Services Center, San Diego , CA. Part-time instructor at/California School of Professional Psychology, San Diego , CA. • 1,975-80 Director , Short-Term Therapy Team, Children and Family Unit , Weld Mental Health Center , Greeley, CO . 1980-87 Member of Children and Family Therapy Team, Weld Mental Health Center, Greeley , CO . 1987- present Full time private practice with Joyce Shohet Ackerman , Ed . D. , Licensed Psychologist , Greeley , CO . Part time practice at Weld Mental Health Center , Greeley , CO , Publication : • Kerrigan , Laurence P. The Relationship Between Therapist and Client ' s Perceptions of One Therapy Session. Published Doctoral Dissertation , University of California School of Professional Psychology • Copyright , 1974 . Worksho_lli an0 t_ ,ec inl :fl�zi_ihiill;: . Since 1974 , I have attended an average of about three workshops per year . Host of these workshops have presented specialized training in the following areas : Neuro-linguistic training , Autogenic and relaxation training , Visualization-Imagery- Hypnosis , Cognitive-Behavioral Therapy, Ericksonian approaches to hypnotherapy and psychotherapy, Family therapy, Strategic family therapy , Sexual abuse , dynamics and applied treatment , Paradoxical intention psychotherapy, and other related areas . In the last fifteen years , I have taught classes and conducted workshops in the following subjects : The Psychology of Dreams Emotional and Physical Health through Visualization and Imagery Western Psychotherapies and Eastern Ways of Liberation Cognitive and Behavioral Therapy Hypnosis in Pain and Habit Control The Psychology of Consciousness and Meditation 11/18/04 - A EXECUTIVE RISK SPECIALTY CO. PSYCHOLOGISTS PROFESSIONAL LIABILITY POLICY THIS IS A CLAIMS MADE POLICY-PLEASE READ CAREFULLY • NOTICE:gLp *** RENEWAL *** WER LIMIT OF LIABILITY APPLIES TO JUDGEMENTS OR SETTLEMENTS WHEN THERE ARE ALLEGATIONS OF SEXUAL MISCONDUCT(SEE THE SPECIAL PROVISION"SEXUAL MISCONDUCT"IN THE POLICY). POLICY NO: 008-1766682 DECL_ IONS ITEM I. (a)NAME AND ADDRESS OF INSURED: ACCOUNT N0: ITEM I. CO-KERL175-0 0099745B (b)ADDITIONAL NAMED INSUREDS: LAURENCE P. KERRIGAN, PH.D. 1750 25TH AVE. SUITE #101 GREELEY, CO 80634 EM 2. ADDITIONAL INSUREDS: TYPE OF ORG: INDIVIDUAL M 3. POLICY PERIOD: FROM: 12/01/04 TO: 12/01/05 12:01 A.M.STANDARD TIME AT THE ADDRESS OF THE INSURED AS STATED HEREIN: 44. LIMITS OF LIABILITY: (a)$ • 1, 000, 000 EACH WRONGFUL ACT OR SERIES OF CONTINUOUS,REPEATED OR INTERRELATED WRONGFUL ACTS OR OCCURRENCE N$ 5, 000 DEFENSE REIMBURSEMENT • (c)$ 3000, 000 AGGREGATE 5. PREMIUM SCHEDULE: CLASSIFICATION NUMBER RATE ANNUAL PREMIUM 1ST PSYCHOLOGIST 1 1191 . 00 1, 191 . 00 SURPLUS LINESFTAXE LIMIT . 00 INSPECTION FEE 1 35 . 73 1 1 . 19 RETROACTIVE DATE: 12/01/91 EXTENDED REPORTING PERIOD TOTAL PREMIUM: 1, 227. 92 ADDITIONAL PREMIUM(if exercised):$ 2, 148 . 60 NO DISCOUNT INCLUDED POLICY FORMS AND ENDORSEMENTS ATTACHED TO THIS POLICY 3 (7/95 ED. ) B22137 NOT 0/95) A BILL.PREMIUM HAS BEEN PAID. AUT RIZED COMPANY REPRE NTATIVE America Professional Aornry*Gs p.,,..A,,.., A -.:,,_ ...,.,_.., • EMILY L. JARAMILLO, M.A. 183 50th Avenue Place Greeley,Colorado 80634 Home Phone (970)3534388 EDUCATION 1996,Master of Arts,Agency Counseling University of Northern Colorado, Greeley, Colorado 1993, Graduate Fellowship Study, Criminology Rutgers State University, Newark, New Jersey 1988,Bachelor of Arts, Sociology/Criminal Justice with emphasis in Psychology University of Northern Colorado, Greeley,Colorado PROFESSIONAL EXPERIENCE 1998-Present Psychotherapist, Ackerman &Associates, Greeley, CO Provide intensive home based family therapy to families referred by the Department of Social Services. Provide mediation services to families. Co-facilitate family group decision making conferences for permanent placement of children. Provide short- term, solution-focused therapy. Provide therapy to individuals referred from Employee Assistance Programs. Facilitate foster parent training workshops. Provide foster parent consultation. Practice is supervised by Sherri Malloy, Ph.D., Licensed Clinical Psychologist. 1996-1999 Director,McNair Scholars Program, University of Northern Colorado, Greeley, CO Provided counseling, guidance, and academic advising to students who were low- income, first-generation college students,and of a minority group. Identified critical personal, familial, cultural, academic, and financial issues to aid in the development of individual success plans. Planned, developed, and implemented scholarly activities nationally. Developed and directed academic year research seminars. Coordinated research activities for scholars preparing for doctoral study. Directed all efforts to ensure efficient administration of a federal grant. Monitored project budget, supervised and trained staff members. 1995-1996 Assistant Director,McNair Scholars Program, University of Northern Colorado Provided counseling, guidance, and academic advising to students who were low- income, first-generation, and of a minority group. Identified critical personal, familial, cultural, academic, and financial issues to aid in the development of individual success plans. Coordinated the recruitment and selection of program scholars. • 1996 Psychotherapist(Intern), North Colorado PsychCare/Family Recovery Center, Greeley, CO Facilitated psychotherapy counseling groups and individual counseling for patients and families, with focus on chemically dependent and eating disorders. Performed case management from admission to discharge. Presented psychoeducational information to patients, family members,and staff. Worked collaboratively with a counseling team. 1994-1995 Assistant Coordinator, Student Support Services, University of Northern Colorado, Greeley, CO Provided counseling and academic advisement to at-risk first-generation, low-income, minority students. Identified critical personal, familial,cultural, academic, and financial issues to aid in the development of individual success plans. 1994-1995 Psychotherapist, Weld Mental Health Acute Treatment Unit, Greeley, CO Provided individual and group counseling to chronically mentally ill in-patient clients. Assisted clients in learning self-care and daily hygiene. Coordinated and implemented client life-skills and social-skills activities. CONTINUING EDUCATION/SEMINARS Jurisprudence Workshop for Psychotherapists Family Preservation Bask and Advanced Training Supervised Practicum in Family Preservation Reaching Children through Play Therapy Play Therapy and Therapeutic Care Fire Starter Training Diverse Learners Academy Counseling At-Risk Students Cultural Diversity Conference Parent/Child Hispanic Youth Leadership Conference PRESENTER/FACILITATOR The Terrific Twos Prenatal Insults and Long Term Effects Social, Emotional&Sexual Development: Infancy through Adulthood Cognitive&Physical Development: Infancy through Adulthood Parenting with Love&Logic Eating Disorders Cultural Sensitivity and Awareness Communicating Across Cultures Conflict Resolution/Communication Skills Setting Limits&Boundaries HONORS/AWARDS Hispanic Leader of the Year, Cesar Chavez Center, University of Northern Colorado, 1999 Keynote Speaker, Latina Youth Leadership Conference, University of Northern Colorado, 1998 Distinguished Alumni, Department of Sociology, University of Northern Colorado Fellowship, Graduate Study, Rutgers State University of New Jersey Scholarship, National Hispanic Scholarship Fund Scholarship, Candelaria Scholarship Br r ch la Producer �r • Is 32 A sue Dare Renew 0003107 eplacemQ 11/05/2004 RENEWAL PROFESSIONAL LIABILITY OCCURRENCE INSURANCE POLICY FOR PROFESSIONAL COUNSELORS HUMAN DEVELOPMENTAND PURCHASING GROUP POLICYNUMBER:PRACTITIONERS 2101229. Item DECLARATIONS CERTIFICATE NUMBER 80n. 4003488 1. Named Insured EMILY L MONTOYA MA LPC 2. MAILING ADDRESS 1851 13 AVENUE GREELEY CO 80631 3. Policy Period 12:01 AM Standard Time At From: 11/01/2004 To: 11/01/2005 Location of Designated Premises 4. The insurance afforded is only with respect to such of the following by specific premium charge or charges: types of insurance as indicated C VERA E A. Professional Liability X PREMIiIM B. General Liability $ 293.00 $ 293.00 5. each Incident LIMITS OF LIABILITY $ 1,000,000 or each Occurrence $ 3,000,000 in the Aggregate 6. The Named Insured is: Other: Sole Proprietor (including Individual) Partnership _ Corporation 7. Business or Occupation of the Named Insured: 3 policy COUNSELING This 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-2189 (9/97) PLE-2081 PON-2003 CHICAGO INSURANCE COMPANY 55 E. MONROE STREET,•C'HICAGO, 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 P-2016 (10/94) (Elec.) TOM PAPPAS, LCSW 2595 Iris Court Montrose, Colorado 970-240-8468 TomPappasLCSW@Montrose.net EDUCATION 6/86 Masters Degree in Clinical Social Work, Simmons College School of Social Work,Boston, Massachusetts. 5/80 Bachelor of Arts Degree in Psychology and Secondary Education University of Lowell,Lowell,Massachusetts. EMPLOYMENT 3/94- Clinical Social Worker. Montrose Memorial Hospital Care Center Inpatient/Outpatient Services, Montrose, Colorado. Individual, family,marital and group therapy; discharge planning services. Co-therapist for geriatric partial-hospitalization program; supervisor for Masters Level student. 3/90-3/94 Senior Clinician. Justice Resource Center/The Butler Center, Westboro,Massachusetts. Individual, family and group therapy specializing in sexual offender treatment to adjudicated adolescent males in secure treatment facility. 11/86-4/89 Clinical Social Worker. New Bedford Area For Human Services, Inc., Children Services Unit. Individual, family and group therapy in outpatient setting. Co-therapist for latency-age girls' sexual abuse groups. 9/85-6/86 Social Work Intern. Beaverbrook Guidance Center, Waltham, Massachusetts. Individual, family and group therapy with children in outpatient setting. 9/84-5/85 Social Work Intern. Children's Hospital, Boston,Massachusetts. Individual, family and group therapy in pediatric out-patient setting. 12/81-5/84 Mental Health Counselor. Marlboro Hospital Mental Health Unit, Marlboro, Massachusetts. Individual, family and group therapy with adolescents and adults in inpatient psychiatric setting. 5/80-5/81 Mental Health Counselor. Littleton Girls House,Littleton, Massachusetts. Counseling to adjudicated adolescent females in secure treatment facility. TRAINING 2/01 Certificate in Level II EMDR Training. 5/91 Postgraduate Certificate in Advanced Psychotherapy With Children and Adolescents, Boston University, Boston,Massachusetts. REFERENCES AVAILBLE UPON REQUEST . CNAHealthcare Providers Service Organization Purchasing Group ®HPSO CNA Plaza, Chicago,IL 60685 _ C�Ex#ttca#e of Producer Branch Prefix Policy Number Policy Period 018098 970 HPG 269949616-8 from: 12:01 AM Standard Time on: 10/01/04 to: 12:01 AM Standard Time on: 10/01/05 Named Insured and Address Program Administrator TOM PAPPAS Healthcare Providers Service Organization i 2595 IRIS CT 159 East County Line Road Hatboro, PA 19040-1218 MONTR0SE CO 81401-7485 Medical Sper alty. Code: Insurance Provided by Socia72990 American Casualty Co. of Reading, PA CNA Plaza 265 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 i B. Coverage Extensions License Protection $10,000.00 per proceeding $25,000.00 aggregate Defendant Expense Benefit $10,000.00 aggregate Deposition Representation $2,500.00 per deposition $5,000.00 aggregate Assault $10,000.00 per incident $25,000.00 aggregate Medical Payments $2,000.00 per person $100,000.00 aggregate First Aid $2,500.00 aggregate Damage to Property of Others $500.00 per incident $10,000.00 aggregate C. WORKPLACE LIABILITY Covera e 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 $1,000,000.00 aggregate D. GENERAL LIABILITY Coverage part D. does not apply if Coverage part C. is made part of this policy. i Workplace Liability None None Hired Auto & Non Owned Auto None Fire & Water Legal Liability None None Personal Liability I None Total Premium $250.00 Policy forms and endorsements attached at inception QUESTIONS? CALL 1 800. 982 .9491 G-144872-A G-145184-A G-1215000 G-1215010 G-123846C-05 G-1215030 G-147292-A Healthcare Providers Agency, d m CService glS cOr�usion is a division of Affinity Insurance Services,Inc.;in NY and NH,MS Affinity Insurance Agency,in MN and OK,MS Affinity Insolence Affinity Insurance Agency,Inc.dba Aon Direct Insurance Administrators License#0795465. Master Policy: 188711433 (\ I .p .1/ J Keep this document in a safe place. This and /�� til lrlb� V I/U' // Y�'L your cancelled check act as proof of coverage. Chairman of the Board Secretary 601 XX 0000041-N 040913 NENHcP 8/01 N133HN 04257 • VITA NAME: BROMLEY. Susan Plock May 2004 SOCIAL SECURITY NUMBER: 483-50-9243 POSITION: Licensed Psychologist Ackerman&Associates 1750 25th Ave. Ste 101 Greeley, CO 80634 HOME ADDRESS: 1621 13th Avenue Greeley. CO 80631 TELEPHONE: Office: (970) 353.3373 Home: (970) 352-8750 EMAIL: sbromlevOtarthlinknet EDUCATION: Year(s) Degree Institution Area of Study 1983 Psy.D University of Denver Clinical Psychology School of Professional Psychology Denver. Colorado 1968 MSSA Case Western Reserve University Casework (MSW) School of Applied Social Sciences Cleveland.Ohio 1965 BA Mt. Holyoke College g Economics/Sociology South Hadley.Massachusetts WORK EXPERIENCE --Professional Academic: Years) Institutioiyorganizatinn Position Responsibilities 1996-03 University of Northern Colorado Assoc. Professor Psychology aching/Research 1985-96 University of Northern Colorado Asst. Professore Psycho Psychology Teaching/Research 1983-84 University of Northern Colorado Asst. Professor Psychology Teaching WORK EXPERIENCE --Profes.sionml;Von-Academic: Year(s) Institution/Organization Position Responsibilities 1996-present Ackerman and Associates Psychologist 1984-85 Kaiser Permanence Clinical Psychotherapist Clinical Lakewood, Colorado 1979-80 Bethesda Mental Health Center Psychology Intern Clinical/ Denver, Colorado Administrative 1968-79 Denver General Hospital p Clinical Social Worker/ Clinical/ Denver. Colorado Supervisor P Administrative AREA OF SPECIALIZATION: Behavioral Medicine/Pain Management/Clinical Hypnosis/EMDR RESEARCH AREAS/INTERESTS: Hypnosis/Pain Assessment and Management/Women's Issues/Teaching Methods • PROFESSIONAL ACTIVITIES: Colorado Licensure: Psychology License#1086 PUBLICATIONS--Professional Juried: Musgrave-Marquart, D., Bromley. S.P. &Dailey. M.B. (1997). "Personality.academic attribution.and substance abuse as predictors of academic achievement in college students". Journal of Social Behavior and Personality 12(2), 501-511. Karlin. N.J. and Bromley, S.P. (1996). Differences in caregivers of demented and lucid chronically in family members. American Journal of Alzheimer's Disease, 11(5) 39-45. Retzlaff. P. and Bromley. S. (1994). Counseling personality disorders. In Roach.J.L.. VanOrnum. W. & Stillwell. N.C. (Eds)The counseling sourcebook: A practical reference on contemporary issues. New York: Crossroad Publishing group. pp. 466-474. Bromley, S. and Hewitt,P. (1992). Fatal attraction: The sinister side of women's conflict about career and family. Journal of Popular Culture. 26(3), pp. 17-24. Retzlaff,P. and Bromley, S. (1991). "A Multi-Test Alcoholic Taxonomy: Canonical Coefficient Clusters". Journal of Clinical Psychology, 47(2). pp. 299-309. Bromley. S.P. (1985). "Treatment of Pain: Theory and Research"in Zahourek, R. (Ed.). Clinical Hypnosis and Therapeutic Suggestion. New York: Grune and Stratton. Reprinted in Zahourek, R. (Ed.)(1990). New York: Bruner/Mazel, Inc., pp. 77-98. PROFESSIONAL PRESENTATIONS--Juried: Touchton. M.A. &Bromley, S.P. (2000). Complementary/altemative medical use among undergraduates at the University of Northern Colorado. Poster session presented at the Rocky Mountain Psychological Association, Tucson, AZ. (April). Nickisson. J.W. and Bromley. S.P. (1999)"Hypnosis: Attitudes, knowledge and experience among psychology and nursing students". Paper presentation at the American Psychological Association Convention. Boston. (August) Bromley, S. (1998)Hypnosis. psychology and managed care. In S. Bromley' (Chair) Complementary. nontraditional and indigenous healing practices. Symposium conducted at the combined meetings of the Western and Rocky Mountain Psychological Associations. Albuquerque. (April) Bromley. S. (1998). Complementary healing methods: A psychological and artistic exploration. In L. Wickerlgren (Chair). Interdisciplinary courses involving psychology: A sampler. Symposium conducted at the combined meetings of the Western and Rocky Mountain Psychological Associations, Albuquerque. (April) Campbell. J. S.. Titus, J. and Bromley S. P. (1998). "Neuroanatomy teaching technique for introductory psychology students. Poster presented at the joint WPA/RMPA convention,Albuquerque, NM. (April) Bromley, S. (1997) (Chair) "Linking through honors programs: The cross-discipline course). Paper presentation as part of a symposium titled"Creating links between psychology and other disciplines," American Psychological Association Convention, Chicago. (August) Bromley. S. . Gilliam D., &Johnson.T. (1995). "Assessment of student created tests as an evaluation method". Poster presented at the American Psychological Association Convention, New York City. (August) Bromley, S. (1994). "Student created tests as an evaluation method". Poster presented at 16th Annual National Institute on the Teaching of Psychology. St. Petersburg, Florida. Karlin, N. and Bromley. S. (1992). " Similarities and differences for caregivers of demented and lucid chronically ill". Poster presented at the Rocky Mountain Psychology Association Convention,Boise. Idaho. (April) Montoya, K.J. and Bromley. S. (Chair) (1992). " Changes in undergraduate counseling shies in an introductory counseling theories course". Paper presented at the Rocky Mountain Psychology Association Convention,Boise, Idaho(April) Bromley, S. (1992). "Connected learning methods to facilitate research understanding". Paper presentation as part of panel titled, 'Teaching techniques in the social sciences". Western Social Science Association Convention,Denver. Colorado. (April) Bromley, S., Ramirez, S., and McCoy, J. (1991). "Impact of a health psychology course on student health beliefs". Poster presented at the Rocky Mountain Psychology Association Convention. Denver. Colorado. (April) Karlin, N. and Bromley, S. (1991). " Support,burden and affect among caregiver of dementia and non-dementia patients". Poster presented at the American Psychology Association, San Francisco.California. (August) Bosley, G. and Bromley, S. (1990). Post death ritual in a Colorado community. Paper presentation at the American Psychology Association, San Francisco, California. (August) Bromley, S. (1990). "Husbands at Childbirth: Who Does It Help?"Paper presentation at Far West Popular Culture Association, Las Vegas, Nevada (January). Hewitt, P. and Bromley S. (1989). "Images of Work and Intimacy in'Turning Point'and'Fatal Attraction"'. Paper presentation National Convention of Popular Culture Association and American Culture Association, St. Louis, Missouri. (Session Chair) Retzlaff, P. and Bromley, S. (1989). "The Basic Personality Inventory: Alcoh Sub-Group Identification". Poster session at the Joint Convention of the Rock Mountain Psychological Association and Western Psychological Association, Reno. Nevada. Bromley, S. (1988). "Our Culture Affects Our Pain." Paper presentation, National Convention of Popular Culture Association and American Culture Association, New Orleans,LA. (March). Bromley, S. (1987). "Husband-Assisted Autohypnosis for Labor and Delivery: A Clinical Model". Paper presented at Rocky Mountain Psychological Association. Albuquerque, New Mexico(April). Bromley. S. and Loy, P. (1987). "Politics of PMS". Paper presentation Association of Women Psychologists, Denver. Colorado(March). PROFESSIONAL PRESENTATIONS --Invited: Bromley, S.P. & Canales, G. (2000). Issues in presenting information on historically underrepresented groups in the classroom. Symposium conducted at the Rocky Mountain Psychological Association. Tucson. (April). Strongin, D. &Bromley, S. (1999). Student and faculty reactions to the introduction of a graduate ethics course. In Miller, R. (Chair)Ethics in college teaching. Symposium conducted at the Rocky Mountain Psychological Association, Ft. Collins, CO(April) Bromley, S. (1999). Issues of religion and spirituality with therapists and clients. In S. Bromley(Chair)Religion and spirituality in research, practice and the classroom. Symposium conducted at the Rocky Mountain Psychological Association, Ft. Collins. Co(April) Handelsman, M.M., Bromley. S.P. &Davis, S.F. (1995). "Clinical Psychologist. Counseling Psychologist, Clinical Social Worker, or Psychology Professor: Which Degree is Right for Me?"Psi Chi invited panel presentation, Rocky Mountain Psychological Association, Boulder, CO(April). Bromley, S. (Co-Chair), Seibert.P. (Co-Chair). Knuckey,D.,Bohlin,M.,Zaweski, C., Watson, D..Hammett D., West. K. &Robins, J. (1994). "Training the Teaching Assistant"Invited Panel Presentation, Rocky Mountain Psychological Association,Las Vegas, Nevada(April) 3 Bromley. S. (1993). "Hypnosis in Dentistry."Presentation at Monthly Meeting of Weld County Dentistry Association. Greeley, Colorado (February). Bromley, S. (1993). "Learning about the author as a way to understand research." Presentation at "Teaching Take Out", CTUP Special Event. WPA/RMPA Convention.Phoenix, Arizona(April). Allen, M. and Bromley, S. (1993). Co-Chairs Two CTUP Special Event Sessions, "Teaching Take Out: Experiences in Collaborative Learning". Western Psychological Association/Rocky Mountain Psychological Association Convention, Phoenix, Arizona(April). Bromley, S. (1993). Chair, Invited Symposium, "Psychological and Social Perspectives on Male Violence Against Women". Western Psychological Association/Rocky Mountain Psychological Association Convention,Phoenix, Arizona (April). Bromley. S. (1992). "Enhancement of student research and writing skills in any course". CTUP Workshop presented at the Rocky Mountain Psychology Association Convention,Boise,Idaho. (April) Bromley, S. and Karlin,N. (1992). "General and health locus of control of adult caregivers". Poster session at the UNC Research Forum, Greeley. Colorado. Bromley. S. (1992). Panel member in Mental Health Symposia for Victim Compensation Convention as part of the Colorado Organization for Victim Assistance Conference. (Estes Park/October) Bolocofski.Bromley, Foster and Mean(1988). "Hypnosis: Research and Clinical Perspectives," symposium presentation. Colorado Psychological Association, Greeley(March). Bromley, S. (1986). "Pain: A Psychological Event". Presenter-20th Annual Emotional Crisis Workshop.University of Northern Colorado, Greeley, Colorado(July). LECTURES--Invited: Bromley, S. (1998) "Psychological methods of pain control" Invited lecture for the annual meeting of the Weld County Arthritis Society. Bromley, S. (1998). "Hypnosis for pain control of arthritis" Invited lecture for"Brown Bag" lunch series sponsored by the Greeley Medical Clinic. Bromley. S. (1998)"Headache Control -Psychological Methods". Invited lecture as part of a seminar titled"Coping with headache". Sponsored by the Greeley Medical Clinic. Bromley. S. & Ackerman J. (1998)."What to do to handle burnout"A workshop conducted for foster parents working with Weld County Social Services. Bromley, S. (1995). Keynote speaker for Golden Key Honor Society Induction Ceremony. University of Colorado, Boulder. Co. (November) Bromley, S. (1992). Keynote speaker for Sophomore Honor Society Induction Ceremony. Bromley, S. (1991)Featured speaker. UNC Academic Honors Convocation. (April) Bromley. S. (1991). Banquet speaker Emotional Crisis Workshop, Greeley, Colorado. (July) GRANTS: Bromley, S(1994)Honors Grant($500)to attend research training at the Society for Clinical Hypnosis meeting, San Francisco(October) Bromley. S. (1994). Research and Publications award of$1500.00. "Assessment protocols to measure the efficacy of 4 • hypnotic treatment for injured workers. Karlin. N. and Bromley. S. (1990). Research and Publications award of$2.4440.00. "Control, support,burden and affect differences among dementia and non-dementia caregivers". BOOK/GRANT REVIEWS: Grant review for Boise State Department of Education(1995) Review of Santrock• J. (1991). The science of mind and behavior. W.C. Brown and Benchmark. Review of McKee, P. &Thiem, J. (1993). Real life: Ten stories of aging. University of Colorado Press. PROFESSIONAL CONSULTATION/PRACTICE: Year(s) Institution/Organization Role 1996-presnt Ackerman and Associates Clinical Psychologist 1988 Bonnet Good Samaritan Center Pain Management Consultant and Trainer 1984-85 Denver Metropolitan Dental Care Consultant in Pain Management 1984 Iowa Association of Registered Physical Therapists Hypnosis for Pain Management Consultant and Teacher PROFESSIONAL ASSOCIATION PARTICIPATION: Membership 1986-2003 Rocky Mountain Psychological Association 1988-present American Psychological Association(Divisions 2. 30. 35) 1989-96 Greeley Area Mental Health Network 1987-88 Association of Women in Psychology 1980-89 Colorado Psychological Association 1988 CPA Program Committee Member for Spring Meeting--Greeley Coordinator SERVICE: EXTERNAL: NATIONAL SERVICE: 1994-2002 Rocky Mountain Coordinator- American Psychological Association, Division 2 -Teaching of Psychology 1992-94 Co-Chair, Rocky Mountain Region Council of Teachers of Undergraduate Psychology(CTUP). 1991-94 Mountain States Regional Academic Coordinator, Golden Key National Honor Society REGIONAL/STA1E SERVICE: 2000 -Moderator for G. Stanley Hall Lecturer-Dweck, C. (2000). Motivation and the self Presented at the Rocky Mountain Psychological Association Convention,Tucson. (April) 1999 -Moderator for G. Stanley Hall Lecturer-Viney. W. (1999). A larger canopy for psychology: Unifying themes and pragmatic empiricism. Presented at the Rocky Mountain Psychological Association Convention,Ft. Collins.CO(April) 1989-present Rocky Mountain Psychology Association 1998-present Ex-Officio Board Member As Division 2 Coordinator 1992-1998 Board Member 1995- 1998 Elected Chair. Groups Under-Represented in Psychology Committee 1992-94 Co-Chair, Groups Under Represented in Psychology Committee 1991 Coordinator of Student Volunteers,RMPA Convention. Denver, Colorado. 1995 Psychology Chair-CCHE Faculty to Faculty Conference(October) COMMUNITY SERVICE: 2003-present Board Member Weld County Area Agency on Aging 1999-present Member Weld Senior Wellness Program Evaluation Committee 1999-2000 Member, Weld County Area Agency on Aging, Grandparenting Committee 1998-present Member. Weld County Medical Society Committee on Alternative and Complementary Healing 1997-1998 UNC Loaned Executive-United Way of Weld County 1997 Mental Health Pro Bono Workshop,"Communication in the Workforce" 1991- 1996 Board Member, 19th Judicial District Victim Compensation Board 1995-96 Chair 1990-93 Board Member, Weld County Area Agency on Aging 1992-93 Chair 1991-92 Vice-Chair 1986-2001 Exam Supervisor-American Institute for Property and Liability Underwriters/Insurance Institute of America 1987-present Clinical Psychologist-pro-bono work with individual clients and community training INTERNAL: DEPARTMENTAL: 1993-2003 Member, Department Executive Committee 2000-2003 Advisor Psi Chi National Honor Society 1995-1999 Co-Advisor Psi Chi National Honor Society 1996-present Guest lecturer for Psi Chi Grad Night on getting into clinical/counseling grad programs. 1989-91,93, 1995-1998 Department Representative, CCHE Faculty to Faculty Conference 1987-94 Department Representative to graduation ceremonies 1986-94 Library Representative 1983. 86 89, 90-93.97,98 Member.Faculty Search and Screen Committee 1990-92 Member, Psychology Department Undergraduate Committee(Chair 1992) 1987-88 Co-Coordinator Semester Conversion Committee COLLEGE: 199193,96.97 Member of faculty invited to teach in the Cluster Program 1990-93 Graduation Marshall, Ads& Sciences 1988-89 Member. Arts and Sciences Teacher Education Committee 1986-89 Chair, Interdisciplinary Committee to develop and revise Human Development Major in the College of Arts and Sciences and Psychology Department UNIVERSITY: 2002 -present Graduate Faculty 2002-present Field Experience Coordinator for students at Ackerman&Associates 1992-94 1996-99 Member-Research and Publications Board 1993-94 Chair-Elect 1988-99 Founding Co-Advisor. Golden Key Honor Society 1992-95 Member-UNC Women's Commission 1992-94 Co-Chair-Assessment Task Force 1989-90 Faculty Representative, Student Fee Allocation Committee 1986-89 Member. Faculty Senate 1988-89 Secretary 1987-88 Vice-Chair 1986-87 At-Large Member. Executive Committee 1986-89 Member, Academic Policies Committee 1986-87 Member.Elections Committee 1988 Representative.Western States Faculty Leadership Conference. Reno 1988 Senate Representative.Statewide Commission Advisory Committee 1988 Advisor, In-Touch Help Line 1985-86 Volunteer Therapist, UNC Counseling Center GRADUATE STUDENT COMMITTEES--Docro,n/: 2003-present Committee Member. Stefanie Stecker(School Psychology) 2002-present Committee Member.Karen Bender(Professional Psychology) 6 • 1998-99 Committee Member, Shu-Shin Lu,Professional Psychology. "Using Metaphor in Child Counseling in Taiwan' 1997-00 Committee Member, Christine Rogers,Professional Psychology. "A Qualitative study of the experiences of pastor's wives." 1995-1997 Committee Member. Lisa Ing, Special Education 1994-2003 Committee Member,Marla Gallagher. Educational Psychology 1993 Committee Member.Hsiu-Lan Ma, Science Ed. -Oral Comprehensives 1993 Committee Member. Jerry Buford. School Psychology,"Treatment of depressive symptoms of early adolescents". 1993-1998 Committee Member, Pat Flanagan. CSPA,Orals,"A comparison of attitudes and practices of Teaching faculty regarding student academic dishonesty at a two year and four year institution". 1991 Committee Member. Mike Propriano, School Psychology 1990-94 Committee Member, Paul Jantz, School Psychology, 1989 Committee Member, Mike Peters, Vocational Rehabilitation,"The Effectiveness of Vocational Evaluation for Various Disabling Conditions 1987 Committee Member, Ane Marie Kajenckii,English, "The Concept of Free Association in Virginia Woolf The Waves" 1986 Committee Member. Fuming Liao. Mechanical Kinesiology, "Development and Validation of a Method for Providing Immediate Feedback Information on Speed and Angle of Release in Shotputting" GRADUATE STUDENT COMMIT LEES --Alasters: 2001 Jeremy Ehmke. Chair 1999-00 Jennifer Lawrence, Committee Member 1998-99 Vanessa Ewing, Committee Member 1997 Stephanie Blasi, Committee Member 1997 John Nickisson, Chair 1994 David Watson. Committee Member 1994 Tiernan McIlwaine, Committee Member 1994 Jerrod McCoy. Committee Member 1993 Sheldine Runyan, Committee Member 1993 Sue Cole. Committee Chair. "Influences on Occupational Goals of Selected Male and Female College Students". 1990 Jerry Benner, Committee Member 1990 Kurtis Armstrong, Committee Member.-Attitudinal Consequences of Pre-Employment and Random Employee Drug Testing" 1989 Michelle Hozer, Committee Member 1989 Anne Schnittgnmd, Committee Chair, •• Age and Electrothermal Biofeedback Training". 1988 Cherri Hockett, Committee Member, "The Effects of Turnover on Those Who Remain in an Organization" 1988 Tony Ambrosio. Committee Member. "The Belief in a Just-World and the AIDS Epidemic: Predictors of Attitudes Towards Individuals with AIDS" 1988 Steve Foster, Committee Chair. "Hypnotic Susceptibility As a Function of Locus of Control and Director Indirect Induct ional Deepening and Suggestion Style" 1988 Lisa Dillon, Committee Chair. "Cognitive-Behavioral Approach to the Treatment of Elderly Rheumatoid Arthritis Patients" 1987 Deanna Holmes, Committee Member 1987 Darlene Nold, Committee Member, "Reading and Writing Assessment Tests as Predictors of Success in the Basic Peace officer Academy at Aims Community College" 1987 Dan May, Committee Member 1986 Jeff Schiels, Committee Member. "The Reformulated Hypothesis: Is Its dominator of Learned Helplessness Literature Justifiable?" 1986 Linda Coulthard-Morris, Committee Member, "Biofeedback of Cortical Slow Wave Potentials. Hand Temperature and Muscle Tension in Normal and Attention Deficit Disorder with Hyperactivity Children" TEACHING: Honors Activities: 7 • 2000-2002 Thesis Co-coordinator, Stephanie Price, Allison Osag,Anna Grenier. Jennifer Donnelly 2000-2002 Thesis Co-advisor, Shanti Pepper,"Hindsight bias and prejudice against homosexuals" 2000-2002 Thesis Advisor, Angela Hanson, "Effects of aromatherapy on attention. 2000 Thesis Coordinator, Cindy Mitchell, Christin Hillyer, Angela Hanson 1999 Thesis Advisor,Melissa Touchton"Complementary/alternative medical use among undergraduates at the University of Northern Colorado". 1999 Thesis Advisor, Sarah Painton. "Early parent loss in terms of maintaining a connection with the deceased. 1999 UNC Research Day,Faculty Panel Coordinator, " Complementary Healing Methods" 1999 Thesis Coordinator-Kristin Pietryzick.Jennifer Kimberling, Cristine Dickey 1997 Thesis Co-Advisor Kelly Kinser. "An evaluation of the city of Greeley community outreach program". 1997 Honors Connection Course development-Alternative Healing Methods 1996-2002 Honors Co-Coordinator, Psychology Department 1989-94 Honors Coordinator, Psychology Department 1994 Thesis Co-Advisor, Diane Musgrave."The Relationships Among Personality Traits, Alcohol, Caffeine, and Nicotine Consumption, and Academic Performance in College Students" 1994 UNC Research Day. Faculty Panel Coordinator,"Hypnosis: Theory and Research" 1993 UNC Research Day, Faculty Panel Coordinator, "Non-traditional Theories of Therapy Serving Women and Minorities". 1993 Thesis Co-Advisor, Linda Norman, "Clozapine and Event Related Brain Potentials in Schizophrenics" 1992 Thesis Advisor, Deborah Knuckey, "The Effect of Touch on Affect Among Strangers Under Mildly Stressful Conditions" 1992 UNC Research Day, Faculty Panel Coordinator 1992 UNC Research Day, Faculty Panel Coordinator(2 student panels)"Sex Roles and Psychology."The Power of Social Influence 1989 Thesis Advisor, Geri Bosley. "Post Death Ritual in a Small Colorado Community" 1988 Thesis Advisor,Pain Clasen, "The Use of Relaxation and Imagery Techniques in Pain Management" I 989&97 Honors Connection Course Development Courses Taught: (1-4 Scale with 1 as Highest)(*1-5 Scale with 5 as highest) AVG. DATE COURSE TITLE IIRS ENR AVG.RATING 1986-1988 PSY 101 Intro Seminar Psychology 1 30 1.16 1983-1997 PSY 120 Principles of Psychology 4 113 2.35 1984 PSY 121 Intro to Psychology I 4 40 ---- 1985-1988 PSY 230 Human Growth &Development 5 68 1.46 1984 PSY 265 Social Psychology 3 25 ---- 1988-2000 PSY 323 Health Psychology 3 43 3.02 1986 PSY 330 Child&Adolescent Psych 3 27 1.4 1986-1993 PSY 331 Maturity& Aging 3 36 1.51 1984-2000 PSY 455 Abnormal Psychology 3 32 3.01 1983-1998 PSY 350 Theories of Personality 3 40 2.05 1986-2000 PSY 407 Intro to Counseling Theories 3 23 2.52 1987 PSY 499 Psychology of Sex Roles 3 16 1.18 2000 PSY 508 Health Psychology and Healing 2 17 4.57 1989 PSY 508 Emotional Crisis Workshop 1-2 39 --- "Frontiers of Mental Health And Education" 1988 PSY 508 Emotional Crisis Workshop 2-3 63 "MindBody Interactions" 1987 PSY 508 Emotional Crisis Workshop 2-3 106 "Relationships" 1991 PSY 595 Health Psychology 3 15 1990-2000 PSY 620 Assessment&Interviewing 3 12 3.13 1988 PSY 620 Issues in Behavioral Medicine 3 5 2.08 1992-1997 PSY 621 Practicum College Teaching 2 12 3.11 1997 HON 200 Honors Connections Seminar: "Alternative Healing Methods" 2 20 3.67 of 4 1989 HON 200 Honors Connection Seminar II: 2 9 --- 8 "Love" 1986 Elderhostel "Dream On" NC (25) 1987 Elderhostel "Mind/Body Interactions" NC 19 Courses Developed: 2000 PSY/PPSY 508,Health Psychology and Healing 1997 HON 200. Alternative Healing Methods 1991 PSY 595,Issues in Health Psychology. Summer 1989 23rd Annual Emotional Crisis Workshop. Frontiers of Mental Health and Education. Summer 1988 PSY 620, Assessment in Behavioral Medicine. Fall(Revised Spring 1998) 1988 PSY 423, Health Psychology,Fall 1988 22nd Annual Emotional Crisis Workshop. Mind/Body Interactions. Summer 1987 21st Annual Emotional Crisis Workshop, Relationships, Summer 1987 Mind/Body Interactions-Elderhostel Program. Summer 1987 PSY 499, Psychology of Sex Roles-Summer 1986 Dream On-Elderhostel, Summer Directed Studies: Graduate: 1995 Cynthia Holley. Hypnosis 1994 Tara Johnson,Hypnosis Theory and Practice 1994 Marla Gallagher, Sociometric Processes 1994 Marla Gallagher. Cluster Development in Intro Psychology Classes 1992 Bruce Holoman,Hypnosis Research and Practice 1988 Paul Jantz, Hypnosis for Pain With Children 1988 Lori Kochevar, Women as Leaders 1988 Jerri Israel, Alan Shaw. Issues in Health Psychology 1988 Steve Foster,Michele Hozer,Teaching Apprenticeship 1987 Tony Ambrosio,Hypnosis Models 1986 Candy Disch, Psychological Testing Undergraduate: 2000_ Lynell Rice -Cross-cultural attitudes towards healing methods 2000 Andrea Hagedorn-Attitudes towards counseling(in lieu of honors thesis) 2000 Laura Bell -Psychology of childbirth 1999 Lynell Rice -Healing Methods 1999 Stefani Stecker- Student's perceptions of parent-child sex communication(in lieu of honors thesis 1998 Jennifer Altman-Exercise and Psychology 1996 Kindra Sanchez-Biracial Identity 1996 Jenna Weatherbee-Pain Coping Styles 1995 Allison Ellis-Psychological Theories in Business Management • 1995 Holli Elrick. Counseling and the Hearing-Impaired Child 1994 Lewis Garza, Etiology of Schizophrenia 1994 Suzanne Bodetko, Autogenic Training 1994 Rebecca Furstenberg, Impact of Alzheimer's Disease on Families 1994 Bonnie Sarton. Hypervigilence in Youth (Hon 351) 1993 Mary Jo Hamilton. Hypnosis Theory 1994 Greg Schooley, Forgiveness as a Therapy Tool 1993 Jason DeBueno, Youth Advocacy 1993 Kelley Ferguson - Women in Psychology 1993 David Rosenberg-Offender Programs 1992 Robin Trostel, Analysis of Learning Styles 1992 Robin Trostel, Health Locus of Control 1992 Roberta Inman, Family Violence and Lesbians (Hon 351) 1991 Mark Kahl, Back Pain 1991 Tracy Moulton. Treatment of Sexual Abuse • 1991 Alice McPherson. African American Women and Higher Education 1991 Jody Huffier,Hypnosis:Theory and Practice 1990 Jimmie Berg, Women's Learning Styles 1989 Elary Violett, Cognition and Pain Management 1989 Geri Bosley, Chris Snodgrass,Bev Foster. Elan Violett,Issues in Personality 1989 Penny Vaughn. Female Pioneers in Social Work 1989 Lori Peterson,Pain and the Elderly 1988 Peer Training for Hotline Service 1987 Tracy Boh, Issues in Child Abuse 1987 Julie Stoddard, Grief and Divorce 1987 Eric Bouch,Hypnosis Models 1987 Mike Lesser, Assessment in Sport Psychology 1986 Lynne Sheffield. Childhood and Loss 1986 Jennifer March, Adolescence Practia 2000 Rebecca Kuhn-Aromatherapy research 2000 Ackerman and Associates-Berkely Holston 1999 Melissa Touchton-Applied statistics 1998 Andrea Lamb-Hypnosis and golf performance 1998 Rebecca Varoula-Women's Place 1998 Greeley Medical Clinic-Gay Lemons, Renae Smith 1998 Ackerman and Associates-Amy Munnel, Kristin Pietrzyk, Jennifer Kimberling. Greg Pedersen 1997 Greeley Medical Clinic-Lori Darst, Barbara Glode, Ann Marie McCullen, Jeff Titus 1993 Greg Schooley,Bereavement Research 1993 Di Smice, Women's Commission 1992 Mary Jo Hamilton.Hypnosis Research 1992 Carol Sexton,Psychology Testing 1992 Lisa Schlott, Learning Styles PROFESSIONAL DEVELOPMENT ACTIVITIES: Workshops, Clinics, Symposia. Conferences: (Excluding Conferences as a Presenter) 1999 Cognitive Behavioral Therapy Training Program, Institute for Behavioral Healthcare 1999 EMDR training and Level 1 certification 1998 Qualitative research lecture series-HNC 1998 Lewis M. Terman Western Regional Teacher's Conference sponsored by APA Division2 in conjunction with the WPA/RMPA joint convention. 1998 "Spirituality and health in counseling". CAHEC Workshop, Greeley 1998 "Divorce Busting: Solution oriented brief therapy with couples", Colorado Assoc. Marriage and Family 1997 Health Maintenance-Legal and Ethical Issues 1997 Body and Soul: Healing in the 90's 1996 Celebrating our Essence: Women's Health and Spirituality 1995 International Society for Clinical and Experimental Hypnosis-Research Workshop. San Francisco, CA (30 more hours toward certification) 1989 "Minding the Body.Mending the Mind", CAHEC Workshop,Ft. Collins 1988 "Demystifying Publishing", CAHEC Workshop,NCMC, Greeley 1985 "Attentional Deficit Disorders in Children", Meichenbaum,Denver 1980 International Society for Clinical and Experimental Hypnosis-30 certification hours, Denver Numerous other workshops on Parent Loss. Child Abuse, Grantsmanship, Short-Term Treatment, Supervision, Pain Management. Medical Terminology,Depression, Personality Disorders Courses Taken Credit: 1994 EPRE 603 -Analysis of Variance Audit: 1993 EPRE 602 -Elements of Statistics 1990 EPRE 700 -Advanced Research Methods Continuing Education Credit: 10 • 1976 C.U. Medical School-Medical Ethics 1972 C.U. School of Nursing-Hypnosis(10 weeks) 1969 University of Chicago -Kubler-Ross,Death and Dying HONORS AND AWARDS: 2000 "Wonderful Outstanding Woman" Award 1998 Distinguished Service Award-Rocky Mountain Psychological Association 1998 Arts and Sciences Teacher of the Year Award 1998 "Wonderful Outstanding Woman" Award-Highlighted in October newsletter-Women's Resource Center 1993 Commencement Banner Carrier, Arts and Sciences 2002,1993, 91,89, 88-Mortar Board Favorite Professor 1992 Student Representative Council University Professor of the Year 1992 Student Representative Council University Advisor of the Year 1989 Arts and Sciences Achievement Award 1988 Honors Advisor of the Year 1984 Psi Chi, University of Northern Colorado Chapter 1982-83 Writing Associateship-Rocky Mountain Women's Institute 11 . BRANCH BM PRODUCER NUMBER 23 DATE OF ISSUE PRIOR CERTIFICATE NUMBER A 0004087 04/08/2004 Renewal PSYCHOLOGISTS PROFESSIONAL LIABILITY CLAIMS-MADE INSURANCE POLICY NOTICE: THIS IS A CLAIMS-MADE POLICY, PLEASE READ THE POLICY CAREFULLY PURCHASING GROUP POLICY NUMBER: 45-0002000 Item DECLARATIONS CERTIFICATE NUMBER:455P- 2050203 1. Named Insured ;u 1 13th Ave ADDRESS Greeley,CO 80631-5415 Number&Street,Town,County,State&Zip No.) 2. Policy Period: 12:01 ant.Standard Time At From: To: Location of Designated Premises 04/01/2004 04/01/2005 3. COVERAGE LIMITS OF LIABILITY Professional Liability PREMIUM $ 1•�•� each indolent I $3,000,000 aggregate $ 1,298.00 4. BUSINESS OF THE INSURED: PSYCHOLOGY 5. The Named Insured is: X Sole Proprietor(including independent contracture) Partnership _ Corporation Other. 6. This policy shall only apply to incidents which happen on or after a)the policy effective date shown on the Declarations: or b)the effective date of the earliest claims-made policy issued by the Company to which this policy is a renewal:or c)the date specified in any endorsement hereto. 04/05/1996 7. This policy is made and accepted subject to the printed conditions in this policy together with the provisions,stipulations and agreements contained in the following form(s)or endorsement(s). PLP-2012(06/93), PLJ-2008(Rev. 10/94),,PLE-8035(09/97),PLE-2167(07/00),POE-8004(05/88)(Ed.*10/93),PLE-2081 Current,PON-2003(08/02) CHICAGO INSURANCE COMPANY 55 E. MONROE STREET, CHICAGO, ILLINOIS 60603 REPRESENTATIVE: Agent or broker: Trust Risk Management Services, Inc. 875 N Michigan Ave Office address: Chicago,IL 60611-1803 City, State,Tip: Toll-Free Number. 1_877_637_9700 PIP-2012(06/93) APA- Ackerman and Associates P.C. Dept. of tb Weld County 1750 25 Avenue,.Suite 101 Social Services Greeley, Colorado. 80634 Clerical Unit APR 2 7 2005 970-353-3373 Gloria Romansik Weld County Department of Social Services P.O. Box A Greeley, Colorado 80631 April 27, 2005 Dear Ms. Romansik: Thank you for your queries concerning the PY 2005-2006 bids containing the comments of the FYC commission. We understand that RFP 05007 Sex Abuse Treatment and 05010 Option B Intensive Home Based Therapy are recommended for inclusion on the vendor list. As to our Life Skills Program, 05005 : The following defines our capacity to do after hours visitation. Ackerman and Associates maintains a twenty four hour a day 365 day a year on call system to handle emergencies. Our hours to see clients in the office begin at Nine AM and frequently end at Nine PM depending on the provider. As to home based visitation after hours,we would expect the following scenario. A call would come into the answering service and the provider on call would be contacted. That provider would evaluate if emergency contact was needed or if police response would be more appropriate. Then we would schedule the family to be seen at our offices on an emergency basis only if the conditions did not permit contact in regular hours and police intervention was not needed. We do not anticipate providing emergency visits in the client's home after hours. Scheduled after hours contact within the time window described(after five PM and before nine PM)would be at the discretion of the provider. Concerning Intensive Mediation,we agree to the condition related to consultative conflicts.. It is our understanding that any consultative conflicts specific to the case pending will lead to the withdrawal of the mediator with the perceived conflict as requested by any party. 1 Page 2 Ackerman and Associates FYC Queries 2005-2006 Contact was made with John Kruse as requested concerning the unit of service rate consultations and all issues were resolved. John will be communicating his comments directly to Elaine. Basically, Ackerman and Associates has a 60% direct payment to providers and a 40%overhead rate. All social services programs submitted are justifiable within this framework as shown by the submitted budget worksheets. Please contact me to resolve any questions. We look forward to continued work with WCDSS. Sincerely, Joyce Sh het Ack �> � Ackerman and Associates P.C. 2 • ate- 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 wie COLORADO April 18,2005 Joyce Ackerman Ed. D. Ackerman&Associates,P.C. 1750 25th Avenue, Suite 101 Greeley,CO 80631 Re: RFP 05007-Sex Abuse Treatment RFP 05008-Mediation and Facilitation under the Intensive Family Therapy Program Area RFP 05010-Option B,Home Based Therapy RFP 05005-Lifeskills Dear Ms.Ackerman: The purpose of this letter is to outline the results of the Bid process for PY 2005-2006 and to request written information or confirmation from you by Wednesday,April 27,2005. A. Results of the Bid Process for PY 2005-2006 • Through the 2005-2006 bid evaluation process,the Families,Youth and Children (FYC)Commission recommended approval of the bids listed below for inclusion on our vendor list. 1. RFP 05007-Sex Abuse Treatment 2. RFP 05010-Option B-Intensive Home Based Therapy • Through the 2005-2006 bid evaluation process,the Families,Youth and Children (FYC)Commission recommended approval of the bid listed below for inclusion on our vendor list,attaching the following condition for all Lifeskills program providers. 1. RFP 05005-Lifeskills Condition: All providers must define their capacity to do after-hours visitation. • Through the 2005-2006 bid evaluation process,the Families,Youth and Children (FYC)Commission recommended approval of the bid listed below for inclusion on our vendor list,attaching the following condition for all Intensive Mediation program providers. Page 2 Ackerman&Associates,P.C./Results of Bid Process for PY 2005-2006 1. RFP 05008-Intensive Mediation under the Intensive Family Therapy Program Area Condition: If a consultation has occurred between a party to this action,and any party objects to the proposed mediator because of that consultation,the mediator shall remove himself/herself from performing the mediation. • Review of Unit of Service Rate Computations for All Submitted Bids: The Unit of Rate Computations on the submitted bids did not include a non face- to-face cost sheet. Further,the overhead does not calculate correctly on the Cover Cost Sheet. B. Required Response by FYC Bidden Concerning FYC Commission Conditions: 1. FYC Commission Conditions: All conditions will be incorporated as part of your RFP Bid and Notification of Financial Assistance Award(NOFAA). If you do not accept the condition(s),you will not be authorized as a vendor unless the FYC Commission and the Weld County Department of Social Services accept your mitigating circumstances. If you do not accept the condition,you must provide in writing reasons why. A meeting will be arranged to discuss your response.Your response to the above conditions will be incorporated in the RFP Bid and Notification of Financial Assistance Award. 2. Unit of Service Rate Computations: You are requested to contact John Kruse,Business Office Manager, extension 6530, to clarify the submitted Unit of Service Rate Computations. 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,970.352.1551, extension 6230. Sincerely, a_ y 'ego,Di for cc: Juan Lopez, Chair,FYC Commission Gloria Romansik, Social Services Administrator • Weld County Department of Social Services Notification of Financial Assistance Award for Families,Youth and Children Commission (Core) Funds Type of Action Contract Award No. X Initial Award FY05-CORE-52 Revision (RFP-FYC-05007) Contract Award Period Name and Address of Contractor Beginning 06/01/2005 and Professional Counseling Services Ending 05/31/2006 Sex Abuse Treatment 1228 8th Street Greeley, CO 80621 Computation of Awards Description Unit of Service The issuance of the Notification of Financial This program provides therapy services for Assistance Award is based upon your Request for victims, significant others (i.e., siblings), and non- Proposal (RFP). The RFP specifies the scope of offending parents who are in denial about the services and conditions of award. Except where it is in sexual abuse of their child. Services are in-office conflict with this NOFAA in which case the NOFAA only. Parents are seen individually. Services governs, the RFP upon which this award is based is an include educational and cognitive behavioral integral part of the action. techniques, as well as EMDR and BFF. Total number of non-offending parents to be served is Special conditions 30 for the contract period. Client will have 24-hour 1) Reimbursement for the Unit of Services will be based access to services. Monthly maximum and average on an hourly rate per child or per family. client capacity is 15, average stay is 18 weeks, 2) The hourly rate will be paid for only direct face-to- with client participation at 1 hour per week. face contact with the child and/or family, as evidenced Currently, there are no Bilingual or South County by client-signed verification form, and as specified in Services, although clinicians are educated and/or the unit of cost computation. have educated others in multicultural issues. 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 Hourly Rate Per referrals made by the Weld County Department of Treatment Package $ 98.11 Social Services. Hourly Rate per Court Testimony $130.00 5) Requests for payment must be an original submitted to the Weld County Department of Social Services by the Enclosures: end of the 25th calendar day following the end of the X Signed RFP: Exhibit A month of service. The provider must submit requests X Supplemental Narrative to RFP: Exhibit B for payment on forms approved by Weld County Recommendation(s) Department of Social Services. X Conditions of Approval 6) The Contractor will notify the Department of any changes in staff at the time of the change. Approvals: Program Official: By #t. % / By William H. Jerke, Chair Judy A rieg irector Board o Weld County Commissioners Weld unty Department of Social Services Date: JUN 0 6 L""5 Date: (e/2/US— c oc — / &<17 SIGNED RFP: EXHIBIT A • INVITATION TO BID BID 002-05 (05005-05011 and 006-00) DATE:February 16,2005 BID NO: RFP-FYC-05007 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-05007) for:Colorado Family Preservation Act--Sexual Abuse Treatment Program--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 Sexual Abuse Treatment Program must provide for therapeutic intervention through one or more modalities to prevent further sexual abuse perpetration or victimization. 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 /"V (( o 5 (After receipt of order) BID MUST BE SIGNED IN INK Soy GE_ ft oL r /1 LI � p1 n( TYPE OR PRINTED SIGNATURE VENDOR A-ok&rrr r C�.at l SSoct4XL (C. (Name) Handwritt Si Lure By Authorized Officer or Agent of Vendor ADDRESS 1 )cb q (ter u.e. TITLE Psyo-to4oycsT` G r ee Co 5t)C3 iy DATE M 61-COS— PHONE# 970-3S3 -331)3 The above bid is subject to Terms and Conditions as attached hereto and incorporated. Page 1 of 32 I3id 002-05 (RFP-FYC-05007) Attached A SEXUAL ABUSE TREATMENT PROGRAM BID PROPOSAL AND REQUEST FOR CONTINUATION OF AWARD UNDER FPP CORE SERVICES FUNDING FAMILY PRESERVATION PROGRAM 2005-2006 BID PROPOSAL APPLICATION PROGRAM FUNDS YEAR 2005-2006 /� p BID 002-05,/�RFP-FYC-05007 NAME OF AGENCY: A Ck mer ASS o u 2c., I. C , ADDRESS: 1 ) SD -5 TIN Ave. a /o / Greg.icy Co eoc3/ PHONE: (720-? &3 331)3 /1 V CONTACT PERSON: T 0/ce. 4(Ater,,,,, L A •Q TITLE: /&y a�o rye S t DESCRIPTION OF FAMILY PRESERVATION PROGRAM CATEGORY: The Sexual Abuse Treatment Program must provide for therapeutic intervention through one or more modalities to prevent further sexual abuse perpetration or victimization. 12-Month approximate Project Dates: _ 12-month contract with actual time lines of: Start June 1,2005 Start End Mav 31,2006 / End TITLE/ OF PROJECT: Q4/4ry'-1G, - -CacCI, 1-re ,r-e� r J�j pry/ (Ca- T--3 i II, !T(A�c/'/nOr�/ AU Tor, A the en.), eit. G —C�1�c�e.>" •r. � �"" g � Ma-n-4 /a X05 Name and Signature of Person Preparin o Date Ovu-clo J-BoX Name and Si Chief Administrative O cer 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 N ,/ Target/Eligibility Populations N ,/ Types of services Provided rT J Measurable Outcomes / Service Objectives rJ / Workload Standards Al ✓ Staff Qualifications Unit of Service Rate Computation O ,{ ✓ Program Capacity per Month �L I Certificate of Insurance Page 26 of 32 Bid 002-05 (RFP-FYC-0500') Attached A Date of Meeting(s)with Social Services Division Supervisor: '—'— Comments by SSD Supervisor: �_ _ 'yC,edi✓� r � �-vVq�y�„� it'2'evl4 1/ 4 Name an ignature f SSD Supervisor Date Page 27 of 32 Bid•002-05 (RFP-FYC-05007) Attached A Program Category Sexual Abuse Treatment program Bid Category Project Title pp/1 Mori r)A Fe Sa k 7-p � rEpro-�— Vendor Ale-e-rte ov.. "--A- 4.SSO /c tom« - P C . I. PROJECT DESCRIPTION Provide a one-page brief description of the project. II. TARGET/ELIGIBILITY POPULATIONS Provide a one-page brief description of the proposed target/eligibility populations. At a minimum your description must address: A. Total number of clients to be served. B. Total individual clients to be served. Please describe if your clients are: 1. Victims under age 18. 2. Perpetrators under age 18. 3. Adult incest perpetrators. 4. Non-abusing spouse 5. Relatives(under 18)in the household of incest victims and/or incest perpetrators. 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. Subtotal of individuals who will provide 24-hour access to services. 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. la. TYPE OF SERVICES TO BE PROVIDED Please 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. Comprehensive, diagnostic and treatment planning with the family and other service providers. B. Therapeutic intervention with flexibility to bring in other services if needed. C. Therapeutic services through a variety of modalities including: individual, family,group, marital, data, etc. D. Therapy designed to address issues and behaviors related to sexual abuse victimization, sexual dysfunction, sexual abuse perpetration, and to prevent further sexual abuse. E. Specialized intake/investigation function for families with sexual abuse allegations. Also, provide your quantitative measures as they directly relate to each service. At a minimum, include a number to be served in each service component. Describe your internal process to assure that FYC resources will not supplant existing and available services in the community; e.g. mental health capitation services, ADAD and professional services otherwise funded. Page 28 of 32 Bid 002-05 (RFP-FYC-05007) Attached A • IV. MEASURABLE OUTCOMES Please provide a two-page description of your expected measurable outcomes of the project. Please address the following measurable outcomes: A. Reduced rate of recidivism of sexual abuse perpetration within a stated time frame. B. Decrease in re-victimization. C. Prevent victim perpetration. D. A percentage of child abuse incest victims receiving services do not go into placement. E. Improvement in parental competency as measured by pre and post placement functional test. F. More rapid reunification of children with families. Describe your quantitative measures: Also, describe the methods you will use to measure, evaluate, and monitor each quantitative measure. V. SERVICE OBJECTIVES Please provide a one-page description of your expected service objectives and quantitative measures. Please address, at a minimum,the following ways the project will: A. Improve Parental Competency-Capacity of parents to maintain sound relationships and appropriate physical and emotional boundaries with their children, and to empower non- abusing parents and victims. B. Improve Family Conflict Management-Mediation and counseling designed to resolve conflicts and disagreements within the family contributing to child maltreatment and sexual abuse. C. Improve Personal and Individual Competencies -Primarily in terms of self-esteem, victim awareness, awareness and management of one's own personal history of victimization, sex education,peer relationships enhancement, establishing appropriate physical and emotional boundaries, assertive in lieu of aggressive behaviors, and assuming responsibility for one's own behavior. D. Improve Ability to Access Resources- Services shall assist parent in learning to obtain help from other sources in the community and within local, state, and federal governments. Describe the methods you will use to measure, evaluate, and monitor each service objective. VI. WORKLOAD STANDARDS Please provide a one-page description of the project's work load standards and quantitative measures. Please 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 in the intake function and in the Sexual Abuse Treatment. D. Modality of treatment E. Total number of hours per day/week/month. Page 29 of 32 Bid OQ2-05 (RFP-FYC-05007) Attached A F. Total number of individuals providing these services. G. The maximum caseload per supervisor. H. The modality of treatment. I. Insurance. VII. STAFF QUALIFICATIONS Please 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 as defined in Staff Manual Volume VII, Section 7.303.17, and Section 7.000.6,Q, Colorado Department of Human Services. Describe. B. Total number of staff, including supervisors, available for the project. C. Is your agency approved by the Sexual Offender Management Board? Explain your compliance with any mandatory regulating agency. 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. Please 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 Page 30 of 32 • . • Bid 002-05 (RFP-FYC-05007) Attached A 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, 2006. 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. (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 Page 31 of 32 . Bid 002-05 (RFP-FYC-05007) Attached A 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(1). 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. (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 Project Description 2005-2006 Sexual Abuse Family Education and Treatment Program The SAFE-T Program Protect Description:Ackerman and Associates P.C. proposes to continue to provide, in 2005-2006, the time limited, outcome focused therapy model for treatment of the non-offending parent, the victim and siblings of the victim in sexual abuse cases. The program is proposed in four parts: (each of these parts may be used as part of an integrated program, may stand alone or be used in combination with other treatment regimens.) A. The development of the prescriptive safety education and treatment plan of the family unit. This will take place over no more than fifteen hours and should average ten hours. B. The implementation of the plan with the non-offending parent to increase safety and avoid repetition of sexual abuse in the family unit. This will take place over no more than 20 sessions. Up to ten of these sessions would be for individual treatment. Up to an additional ten of these individual session times could be converted to ten hours of group work. (Throughout the proposal, whenever we di rt'ss group work, note that it will be billed as one hour of individual treatment for each two hours of group treatment). C. Short term treatment for the child who was abused and for the siblings over a maximum of fifteen sessions to develop skills for future safety and to reestablish trust, including family issues that need to be addressed with the children. Each child in treatment, whether the victim or the sibling, should have their own authorization for treatment. D. A protocol of therapy to taper down the frequency of support needed to provide maintenance of skills developed. This will take place over no more than ten sessions designed to be delivered on a twice a month basis over a maximum of five months. This provides an additional support program for those families in need of the service. Based on past experience Parts A, B, and C have been used by WCDSS and D has not been used much. Nevertheless, we submit it here as an appropriate program for potential future use. Note that part D is presented as a separate budget page. For any family who is not appropriate to continue in the treatment model due to severity that will be transferred. Determination of progress in the program will occur at the following review points: 1 Program Review point#1: A report of recommendations for treatment will be completed at the end of part A. It will specify 1. The goals to be achieved in part B and part C, which can then proceed over the next two or three months if authorized 2. What other types of treatment or intervention are appropriate and 3. If no other intervention is recommended. Program review point#2: A report of the summary of treatment as the completion of the treatment plan in part B and part C. The purpose of this report is to answer questions. 1. How much progress has been made to date in relation to treatment plan? 2. Is it probable the family will complete the treatment in part B or part C within the session limits specified and if not what other services might be needed. This will also be the time point that a determination will be made as to if there is a need for an extension of sessions in phase B and C and if so why this is needed. An extension, if needed, will be limited to twelve sessions. Such an extension can occur only though a second authorization. The criteria for making judgments as to the family's progress will be based upon their completion of the prescriptive treatment plan and the adequacy of that treatment plan to protect the child and family from repeat offenses in relation to sexual abuse. Families not making progress will be discussed with the caseworker and as needed referred to other programs. Please note: the end point of treatment is not necessarily intended to be the full and complete resolution of all psychodynamic issues precipitated by the sexual abuse event. Such issues will likely continue to emerge as the child enters different stages of development into adulthood. If further funds are needed for full and complete restoration of mental health (beyond that required for family safety) these funds should be obtained from the perpetrator and or through victim's assistance and other funds. The purpose of this program is to recommend to WCDDS if the incident of the actual abuse has been resolved sufficiently to provide for the ongoing physical and mental health and safety of the non- offending parent, the child victim and siblings at the time of discharge from the program. The purpose of this highly structured system is to assist family members to achieve careful implementation of safety and child protection plans. Through role modeling, psychoeducational work with adults and /or child therapy, families will progress along a structured treatment course. Treatment will move from recognition of the factors that lead to the sexual abuse in their particular case to 2 developing and effective plan to eliminate the resurfacing of these factors and repetition of these types of events in the future. Of the four phases of the program, Part A would be limited to 15 sessions delivered over no longer than three months. Part B and C would be limited to twenty sessions each delivered either separately or concurrently over four months. The step down phase of the program Part D would be limited to no more than 10 sessions over four to six months. Reviews for the need to continue in the program would occur in month one, month three and month five. Families will need the sexual abuse family education and treatment program (the SAFE-Treatment Program) because the sexual abuse and its implications have either 1. Imminently placed the children at risk of outplacement from the non offending parent(or parents), 2. Created a need to be reunified or 3. The family is facing imminent reunification failure or 4.the family has failed to implement the behaviors required of them. Our model does not treat the adult offender .If that offender is the parent(usually the father or step father) and reunification is the agreed upon course of action desired, we would only assist the parties in developing a formal reunification plan after the offender has completed treatment in another program. In those cases, we accept based upon our clinical judgment. Our model is expected to work best with younger children and younger teens. It is expected to be especially useful where the non offending parent is herself a victim of sexual or physical abuse in her home of origin, or who has a highly disrupted home of origin from other causes. The program will provide continuity for the non offending parent and the children through each family having a coordinator within Ackerman and Associates. That coordinator will also coordinate the case and be the contact for the case worker and lead the clinical team on the family. The coordinator will also track the goals of treatment and organize the aspects of treatment within our clinical team approach. Clinical teams will discuss each case as necessary. Purpose: The purpose of the time limited, outcome (safety) focused (as opposed to psychodynamically focused) therapy is to implement the changes needed to insure future safety from further sexual abuse. The model assumes a clinical team oriented family systems approach of education and treatment and seeks clearly defined behaviors and outcomes that will insure safety. The role of the non offending parent in the sexual abuse will be explored, looking for points where protection can be strengthened in the future. The life experiences of abuse or neglect of the non-offending parent in the home of origin will be a part of the psychoeducational work that will be necessary by many of the families. In order to develop a treatment plan for addressing the sexual abuse that has brought the family into social services, the first part of the model will be the development of the psychological scope of work that will need to be completed. What are the goals needed to insure future safety? This will be developed 3 through a review of the case, psychological testing if indicated, and aacsment of the victim and of the victim's siblings. From there, clearly defined, achievable, structured behavioral changes that are needed to insure future safety of the child will be developed into a written plan. Once agreed on by the therapist and non- offending parent, this plan will become the treatment goals for the family in relation to the safety of the child. Time lines and work to be achieved by phase are listed below: Part A. The development of the prescriptive treatment plan of the family unit over no more than fifteen sessions with a goal of the program for prescriptive assessment to average ten sessions. The prescriptive treatment plan typically involves interviews with the non-offending parent (up to five hours) three hours of case review, three hours of assessment and interpretation and up to four hours of assessment of other family members. Part B. The implementation of the plan focuses on the non-offending parent to assure the eventual safety of the child and to avoid the repetition of sexual abuse in the family unit. Treatment takes place over more than 20 sessions. Ten hours of these 20 sessions can be through group work (at a cost equivalent of 10 individual hour long sessions) For the non offending parent a mentoring of psychoeducational process of identifying factors that contributed to the abuse and dealing with these factors will be explored. This will be particularly important if negligence or home of origin issues are present. We postulate that a large percentage of the non-offending parents will either have been themselves sexual abuse victims or have come from significantly dysfunctional backgrounds. Such a psychological history would be amenable to this mentoring approach. Part C. For the child victim or sibling, the restoration of trust and safety assurance after the abuse incident itself would be a goal of child treatment. If appropriate and if the offending parent has successfully completed treatment and if the victim and the non-offending parent are appropriate for reunification, steps toward reunification may progress in selected cases. Part D. A step down protocol of therapy for no more than ten sessions designed to be delivered on no more than a twice a month basis for supportive transition from the support program, for those families in need of this service. Other Considerations: There is no risk of the program running costs up to levels beyond those budgeted for any one family because we set a treatment cap for social services funds at a maximum number of sessions, 15 for part A 20 for part B 15 per child for part C. Our experience has been that sections A, B and C have been used and D is not used often. Limitations on service delivery allow only 12 additional hours to be provided in part D. If significant resolution cannot be achieved to assure the 4 safety of the child within 45 hours of competent psychological treatment, other options should be considered to attain that safety. In our opinion it will be very rare for a case to go on for a lengthy period and then fail, as the family will need to make progress sufficient at each review point to continue in the process. TargetlEligibility Populations Total number of clients to be served in this twelve month program has been calculated as follows. Three families per month times twelve months equals thirty six families per year. If we assume a nuclear family size of five, two adults and three children, then the total client pool to be served is 180 individuals. If we subtract from the five family members the one offending parent the total becomes 144 individuals. As a minimum, there will be up to 36 non-offending parents and 36 victim children to be served. We expect the need to be lower than this number and anticipate 18-24 families in treatment over a one year period.We calculated the budget based on one child in treatment in part C, thus each child in treatment in part C will need an individual referral. Distribution of clients.Total number of clients we will serve is approximately 36 index children or more as calculated above. Our experience suggests that for the family we would expect approximately 36 additional of these would be adult members of the family (the non offending parent) and approximately 72 additional siblings who would be minors. Families Served. We would anticipate serving 36 family units or less. We expect 18-24 families is a more likely use rate. Sub total who will receive biculturaUbilinoual services. We have a Hispanic member of the staff Emily (Jaramillo) Montoya MA, L.P.C. who speaks Spanish. One of the facilitator's (Joyce Shohet Ackerman) doctoral work was on Hispanic patients' mental health treatment patterns compared to Anglo patients in Weld County. She also has four years of direct cross cultural experience with an American Indian population.All of the other staff have cross cultural experience. We expect 50% of referrals can receive services in Spanish and 100% will receive services in a culturally appropriate manner. We have been able to and will continue to provide bilingual services for any family who needs them. We anticipate that the majority of the work in this program will be conducted at our Greeley offices. Accessibility. On weekdays a provider is on call from Ackerman and Associates for the each day and is accessible through our office and through the connected 24 hour answering service and pager system. On weekends, the 24 hour access reaches the provider on call for that weekend all of whom are Ackerman and Associates' licensed mental health providers described in the staff section of this proposal. 5 • Maximum per month. The program maximum is three new families per month with a maximum ability to carry eight open cases a month. The monthly average capacity is two new families per month with the average load of five open cases a month. The average stay in the program is expected to be 40 sessions over a six month period. The maximum stay is 45 sessions over a twelve month period assuming one child in part Cc with parts A and B also being used. Use of part D would add 10 hours to this total. Group tirabr old would be provided at a rate of one half of the rate for individual sessions so that each two hours of group session treatment would be at the same rate as one hour of individual treatment There are a number of options WCDSS can use to decrease the cost of this program. For example if assessment is complete prior to referral then part A might be omitted. Part D costs have been less than projected over the several of this project Nevertheless, we have tried to make best estimates for the average length of stay in our budget. Types of Services Provided The types of services have been described in detail above under project description and purpose sections. They are summarized here. We propose to provide a maximum of 55 sessions of outcome focused treatment over four program subtypes (A, B, C or D)for the victim of sexual abuse, his or her siblings and the non offending parent Part A offers assessment of the non offending parent and the children in terms of treatment needed and if they would benefd from this program (15 sessions maximum). Part B is for treatment of the non offending parent(20 sessions maximum)to improve safety of the child in the future, Part C is to treat the child victim (15 sessions maximum) of the abuse and the siblings to improve safety and to establish short term treatment goals for safety as well as to develop a long term treatment plan. Part D is a transition of up to 10 sessions for maintenance of achieved skill in those families requiring this service. Measurable Outcomes Measurable outcomes are of two varieties. One type is termed formative outcomes and the other type is called summative outcomes. Formative outcomes measure how the program is proceeding while the treatment takes place. Summative outcomes are the results of the treatment. In terms of formative measures we have the following... Family cooperation with appointments and process of treatment in parts A, BC or D form components of the formative review. Did the family cooperate in treatment is a primary formative measure. 6 This data will be extracted from the case file. Summative Outcomes A. To reduce the rate of recidivism of sexual perpetration.This program does not treat sexual perpetrators so at one level this question does not directly apply. However the goal of the program is to prevent 100% of revictimizations by treating the victim and the non- offending parent to alter the family environment and opportunities for revictimization. B. Decrease in revictimization should be substantial and persistent The program is set up to empower the non-offending parent to identify situations where victimization is likely and to reduce these occurrences.We set a goal of 90% of families who complete treatment will not be victimized in the next two years. This number assumes that after treatment is completed that the non-offending panes does not reenter a marital relationship with the offending parent. We set a goal at 50% at two years post treatment would avoid revictimization if marital reunification occurs with the offending parent occurs in the next year. C. Prevention of victim perpetration. For those victims who complete part C treatment, most will be children who are not sexually active. We expect that for a two year period following treatment victim perpetration will be rare and that 90% of children will not be perpetrators over a two year period following end of treatment. Comments on individual case risk will be made in fmal reports. D. We expect that 70% of non-offending parents will complete treatment Of these we expect that 90% will be able to keep their children over the next two years if they do not reenter a marital relationship with the perpetrator. E. Improvement in parental competency: Parameters measured in this area include acceptance of the sexual abuse and the need for restructuring the family environment as well as the client's ability to achieve that goal to prevent such abuse from occurring again. Clinical improvement in this area is the goal of the Part B treatment program and for each client will be reported at the end of treatment. F. While we do not expect more rapid reunification with biological family members (the offending parent), we do expect the acquisition of life skills in anger management and an increase in psychoeducational 7 knowledge. These should lead to risk reduction for a return to an abusive environment. Quantitative measures of these outcomes could be assessed at WCDSS discretion at chart review at two years post treatment by WCDSS to determine if new charges had been reported or cases opened. Individuals who leave the county would be lost to follow up in this mechanism. A more vigorous evaluation method would be preferred but is not budgeted within this proposal Service objectives This proposal meets all the service objectives for the non-offending parent and the victim. The areas for improvement are documented in the quantitative measures that will be rated for the non-offending parent at the review points and at the completion of therapy as listed under the measurable objectives section. These areas include the required components of improving parental competency, improving family conflict management, improving family conflict management improving personal and individual competencies and improving ability and access resources for the non offending parent. Work Load Standards A. The program has a capacity of 5 families per month with an average of 3 per month. The families will receive an average of 45 hours of service as described if parts A, B and C are utilized. B. We have 5 providers for this program. They are Emily Jaramillo M.A., Licensed. Professional. Counselor., Susan Nock Bromley, Psy D Licensed Psychologist, Laurence Kerrigan Ph.D. Licensed Psychologist, Tom Pappas, MSW. Licensed Social Worker and Joyce Ackerman Ed.D. Licensed Psychologist • Emily Jaramillo, M.A. L.P.C. received her masters in Agency Counseling from UNC. Prior to joining Ackerman and Associates, P.C., she had a wide range of work in mental health including treatment for alcoholic patients and support of minority college students. She is fluent in Spanish. Her undergraduate major was in Criminal Justice and Sociology. 8 • Joyce Ackerman Ed.D. Psychologist will function as the clinical supervisor of the program. She has 20 years of private practice experience and is listed in the National Register of Health Service Providers in Psychology C. Of the up to 36 families the caseload is projected seven families with each provider. D. The modality of treatment is individual Of group therapy. • E. Hours/weeks. The total number of therapist hours is 60 per family over six months, or a total for the budget calculation of 3600 per year based on our projected average. Maximum capacity is the same as this level. The hourly fee is requested at$ 90 as documented in the rate calculation section. F. Staff. There are 5 individual providers supported by two office professionals in the practice as well as a contracted accountant. G. Supervisor. This contact would be supervised and clinically managed by Joyce Shohet Ackerman, Ed.D. who will monitor the project for compliance. The maximum caseload for the supervisor is five families per month. H. Insurance. Ackerman and Associates, P.C. carries one million, three million liability coverage for professional liability on the corporation and its associates and each associate also carries the same level of coverage individually. In addition,Ackerman and Associates, P.C. carries a general liability policy related to accident or injury on our premises through Farmer's Insurance. Staff Qualifications A. All staff members exceed the minimum qualifications needed for this project in both education and experience as described above. B. Staff available for the project are listed above. Unit of service rate computation We have calculated the unit of service rate based in the instructions. We used 2004 data for our agency. Using overall figures for the agency we arrive at a figure of$90 per contact hour. Group rates are billed at one half this rate per hour. The profit for Ackerman and Associates for all programs was approximately 1% for the 2004-2005FY The proposed cost is $90 per face to face contact hour. This is ten to 30% lower than our fees for face to face therapy hour. 9 Budget Justification Ackerman and Associates purchases services for accounting through an independent contractor and through Anderson and Whitney to track funds. No special issues are present related to project audit to out knowledge. Ackerman and Associates mediation program were audited in a random audit (conducted by Anderson and Whitney)after its first year of operation with no deficiencies. Audits of the program are conducted on a yearly basis, as required by WCDSS, with no deficiencies noted. Ackerman and Associates, P.C. is a type S professional for profit corporation and not a 501.c.3. 10 ua,so,GOYJO 14:24 Jft3536134 FARMERS PAGE 02 TRUCK INSURANCE EXCHANGE gg GROUP HOMEdOFFICE:44884 WIL THE SHIRE BLVD LOSOSCANSELES,CCA�I CALIFORNIA 1. POLICY DECLARATIONS RETAIL Named • DR JOYCE SHOHETACKERMAN SE PC RVICE PREMIER insured - mailing . 1750 25TH AVE STE 101 EasyPay Acct NaAdd Prod.Count yeas • GREELEY CO 80634-4944 07-0— — 2 04576-38-07 The named insured is art individual unless otherwise stated: Agent No' pllNumber f Partnership O Corporation O Joint Venture ❑Organization (Any other) ,. Type of Business DOCTOR'S OFFICE 2. Policy Period from 07/01/04 (not 2 this policy replaces other prior to time applied for)to 07/01/OS 12:01 a.m. Standard Time IfIntl the other cocerage ends rThisage tha ends at noon standardtime of the same ay this policy begins, this policy will not take effect insurance.the th will renewemge n polity will continuo for successive policy periods as follows: If we elect rules and forms then in effectr d you pay the required renewal premium for each successivepolicy to continue this 3. Insured location same as mailing address unless otherwise stated; period subject to our premiums, 4. We provide insurance only for those coverages described below and for which a specific limit of insurance is shown. PROPERTY COVERAGES AND LIMITS OF INSURANCE COVERAG£5 PREP, NO. 001 001 BUSINESS PERSONAL PROPERTY PROPERTY DEDUCTIBLE 963,100 GLASS DEDUCTIBLE 9500 $1OUTDOTENANTOR TR£ESIOSHRUBSS PLANTS 00 FINE ARTS COV RAGE INCLUDED $2,500 82,000 COVERAGEADDITIONAL COVERAGES Afl Premises mutt 7410 • rC£Mfl: C5191201 PAGE t OF 8 . • Att6h ifl 9our,:rpolicy with the WOO mberushoWf•ondhis endorsement is• 2nd Edition famed Insured. , DR JOYCE SHOHET ACKERMAN'PC • • Agent Policy Number Address 1750 25TH AVE SUITE 101 07-04-362 04576-38-07 • GREELEY CO 80631 of the Company designated in the Declarations. Insured Location (Same as above unless otherwise stated here) Effective Date 07/31/96 Limit of Liability.$ 1,000,000 each occurrence $ 1,000,000 Annual Aggregate ADDITIONAL INSURED ENDORSEMENT (SPECIAL SENTINEL) In consideration of the premium we agree with you to the following: 1. The insurance provided by this policy for bodily Injdry liability and property damage liability under Coverage D—Business Liability insurance will afso apply to the additional insured named below, but only with respect to an occurrence arising out of the ownership, maintenance or use of that part of the Insured location occupied by you. 2. This insurance does not apply to: (a) Any occurrence which takes place after you cease to occupy the insured location. (b) Any structural alterations, new construction or demolition operations performed by or for any additional insured named below. 3. The additional insuredrwill not be construed or deemed to be a subscriber to the Company issuing this policy.. 4. The additional insured Will not be or become liable for any premium payments due upon this policy. 5. If this policy is terminated for any reason we will give 30 (THIRTY) days notice j in writing to the additional insured named below. This endorsement is part of your policy. It supersedes and controls anything to the contrary. It is otherwise subject to all other terms of the policy. STATE OF COLORADO Additional Insured C/0 WELD COUNTY SOCIAL SERVICES IEPT ATTN: JUDY GRIECO PO BOX A • GREELEY CO 80632 Countersigned Authorized Representative • . p R o 2 3 ct. (;)... ,.., a o et 2.- O O N NN § p$ p3 1 SOt a gi rs- t;1-1 1 5 to a m CQ gg N 4 S c., d s 8 a p47). a w 0 ix 1 0 w m a 0 x Q — O U 8 W U Q I L 2 w Q w 0 O >- .� QQ� c� 1}u v� s` a Ow U OO + O a w w 5 w p '5- 0 O Ir a w o cn O g. � 5 w F � � = S W Cr) t7 ii U C CC >- p o CL p � O < w _i xY_re 2 c —I p' p cc o LL IL C/3 < 6 w m fn u.. 3 V- Cl) O w a. O w cOn ° � CL E Q p a O Z O 0 0U a o N o 0 w u) o w O m 2 O Q > 1 a > a cc w ' z m F w cn aw 0co w tt w O O z ¢ Z Fr— E-,_ w � t� cr w U U I- Qw _ SO i O co O T w F O 03 U E IX OQ a a 10 o w z ice- Q Q z Q © 0 8 0) I- ui O U 0 a v� O Z.I. O i re i .1 g OQ lil H CO = IOv (7 r O t a p W `p a0 °U OI Wo O F¢- i¢- F¢- � I-- Z W H P H F¢- Iw- a I-O O O O 0 Q O 0 ¢ 0 0 g 0 o ¢ m 0 O L..i tL O = - .-) Y _, • ii ,'Z3jaQNyii Ri yi88�81Ri8 iF 8 F 1 -7 8 faliif - Ii 455 li w 6''� a '� : e €€€E€ggoE € € fit ' ' ll 444444444 y A 4444 2 €g g g M N atee$ ec esezxaaievaa a 8 a # 8 ggaMRigglW»Sgigin o 8 0 It il !ss6e a8 tegsss Asa s 4111 04$10tiiisi9+i» f s 2 4 t � 1 s a g 9 a IIII 1111 ! !!!! pp p$861ym 88RR saaosa s .;2 t ; =,ai iii `J' y • ll OV4 "V 2 %VIZI l F +° 1 B g o o e S s.ten,_ 9 ll €2£$242299299€4222 4 888818888 E8 8888 "" i» g I H I I ii I I I II III 1 II D li ' Iii I s g g lEtl1hu ul}if1h11j; 1 1 O _ 1 o t a k Ili , V 0 PI f tla ft g 0' w g 4g 0) g w ig 88 a 111 l$ PR il Pt g$ IP I_ 1 9 1.1 i il 1 1 J,Ii� It E h I a Pilli li 1 i VIII 4 8 w I a g 1 illigi 11 t $ hihIlP hh a1 w i § § § K e a a a 0 me § k §§ i h k : §& 7 § ■ ) ® s $ § § t k§ 0 2 2§ © § 2 , a n � j§. \ g 1 a | � ! f « I t l ! I Jill 1 | a 1 oIii _ BEp ea' & . guilt� ` k B tea ! | I ! ■ ijili .§ � ! # ° § k § 2 ! o . § � 7 �� § Ali-� ! | ) . . ' s ® § [ Till ! iq § § § _ It . ° Ul § '' 7 ilIII 11 / k | $ 1 JOYCE SHOHET ACKERMAN, Ed.D. 1750 25th Avenue,Suite 101 Greeley, Colorado 80634 RESUME PERSONAL DATA Date of Birth: August 3, 1950 Health: Excellent Married; two children CERTIFICATION - LICENSURE Licensed Clinical Psychologist,State of Colorado since 1984 Listed in National Register of Health Service Providers in Psychology since 1986 Staff Privileges, North Colorado Medical Center, Greeley, Colorado since 1985 PROFESSIONAL MEMBERSHIP American Psychological Association Colorado Psychological Association (elected board member 1986-1989) HONORS President's Award - Colorado Psychological Association, 1989 EDUCATION 1978 - 1981 Ed.D. in Counseling Psychology, University of Northern Colorado, December 1981 graduate 1972- 1974 M.S. in Education (E.D./L.D.) Lesley College, Cambridge, Massachusetts, August graduate 1968 - 1971 B.S. in Special Education and Elementary Education with a minor in psychology Boston University, Boston, MA, December 1971 graduate PROFESSIONAL EXPERIENCE 1981 - present Clinical Director in group practice in Greeley,CO. Among responsibilities are: Diagnosis, therapeutic intervention and referral for adults, families,children and groups. Primary areas are: mediation, alternative conflict resolution,stress reduction. Also developing, organizing and presenting workshops and consultative programs to community,schools,organizations and agencies. 1986- present Consulting psychologist on interdisciplinary team for in-patient rehabilitation program. Progressive Care Rehabilitation Center,Greeley, CO. Medical Director Dr.Judith Vaughan, Neurologist. Adults with traumatic injuries- primary problems are: psychological aspects of physical rehabilitation, grief counseling,and brief group counseling using cognitive-behavioral goal oriented therapy. 1989- 1992 Consulting psychologist for Head Injury Treatment Team North Colorado Medical Center,Greeley CO Team coordinator - Dr.John McVicker,neurosurgeon. 1986- 1989 Consulting psychologist for Family Recovery Center(in-patient substance abuse/chemical dependency program), North Colorado Medical Center,Greeley CO Coordinator Ruth Wick,R.N. 1986 - 1989 Provider and Coordinator for Mental Health Services in Northern Colorado for Peak Health Care(HMO). Peak mental health services utilized a three-session model for initial services followed by referral. Activities included coordination of Psychological and Psychiatric Services for approximately the last two years of the Contract. Peak supervisor- Elaine Taylor 1983- 1986 Psychologist subcontractor for a Vietnam Veteran's Counseling Program funded by the Veteran's Administration. Principal Contract Dr. Robert Stewart. 1980- 1987 Part time faculty member with responsibilities for classes, workshops and community programs in parenting skills. Family/Life Education Program, Aims Community College,Greeley CO August 1980 - August 1981 -Clinical internship on Children's Team of Community Mental Health Center, Responsibilities included:consultation to schools and community programs; therapy for children and families; and assessment of diverse mental health programs. Assistant program evaluator - developed evaluation tools to determine cross-cultural perceptions of expectations and satisfaction with services. Supervisors- Dr.Joan Gillespie and Dr. Laurence P.Kerrigan. • APA National Convention in Toronto,Canada"Psychology and National Health Reform:"National Health Insurance: Policy Considerations, Benefit Designs. and Economic Realities",and"Marketing: Psychology's Key to National Health Reform. 1993 Disaster Relief Training. Alan Keck through Colorado Psychological Association,Denver CO 1992- Fall Short Term Therapy, Bernard Bloom; University of Northern Colorado, Greeley CO 1990- Fall National Cognitive Rehabilitation Conference, Richmond VA 1990 - summer Postgraduate training: 1. Adult Neuropsychological Method based on Lezak Neuropsychological assessment, 1983. 2. Child Neuropsychology, Dr. Hynd. 3. Child Neuropsychological Methods 1988 Cognitive Rehabilitation Training Program, Dr.Sena, Ph.D., Colorado Springs CO 1988- present Psychologist- Head Injury Treatment Team at North Colorado Medical Center,Greeley CO 1987 Halstead Reitan Neuropsychological Assessment Training. Ralph Reitan, Ph.D., Washington DC Summer 1986 Albert Einstein School of Medicine, Workshop on Adolescent Therapy, Cape Cod MA 1985 to present North Colorado Interdisciplinary Team of Child Custody Member and participant Fall 1985 Interdisciplinary Workshop on Child Custody, Keystone CO Summer 1984 Workshop in Clinical Use of Hypnosis, Boston MA Winter 1983 Workshop on In-patient Programs for Service Related Disorders, Cheyenne Veterans Administration Hospital. Fall 1983 Veteran's Administration Workshop on Post Traumatic Stress Syndrome, Denver Veteran's Center. Fall 1981-Winter 1984 Post-Doctoral Supervised Candidate for Licensure (psychology) under Gale R. Giebler, Ph.D. Licensed Psychologist and Susan Spilman, Ph.D., Licensed Psychologist 1980- 1981 Intern- Weld County Sexual Abuse Team,Greeley CO • Weld Mental Health Center,Greeley CO adults,adolescents, families. Primary areas anxiety disorders,mood disorders and adjustment disorders. Typical problems included: trauma, physical abuse substance abuse,job stress. Orientation used - primarily cognitive-behavioral therapy. 1980 Group Facilitator-Regional and National Conferences in cross-cultural community needs. Flagstaff,AZ- Colorado Springs CO August 1975-July 1978 Chairperson of the Department of Education and Behavioral Science at an accredited,Indian controlled community college on the Navajo Reservation. Administration responsibilities included: Supervision and evaluation of faculty; budget preparation and management;curriculum development and integration of Navajo culture; personnel recruitment and selection;class scheduling and program development. Also faculty member with academic responsibilities for instruction in Psychology, Child Development and Counseling courses,advising and counseling students. Navajo Community College,Tsaile AZ September 1974-August 1975 Education Specialist and counselor at an Indian controlled primary and secondary school on the Navajo Reservation. Coordinated community resource program, which included: counseling,student assessment,prescriptive programming,staff development and curriculum. Also, adjunct faculty for the University of New Mexico and for Navajo Community College at the Rough Rock Demonstration school, Rough Rock,AZ September 1972 -June 1974 Designed and coordinated Learning Center Program for Dedham Public Schools. A program and crisis intervention center for emotionally disturbed children. Responsibilities included: Diagnostic prescriptive programming,counseling,supervision and training of aides, tutors and volunteers,and consultation with regular classrooms teachers. Also organized group and individual meetings with parents. Adjunct faculty for Curry College assisting with in-service instruction for Dedham School System employees. Dedham Public Schools, Dedham MA WORKSHOPS AND SPECIAL TRAINING 1996 Biodyne training workshop adolescent treatment in short term therapy, Tom Kalous, Ph.D. 1995 Biodyne Training Workshops in short term therapy Julian Ang, Ph.D. 1994 Certification in family mediation, CDR Associates, Boulder CO 1993 Disaster Relief Training. Alan Keck, through Colorado Psychological Association, Denver CO 1993 August Hospital Practice for Psychologists • Summer 1981 Independent Study of Child Sexual Abuse, University of Northern Colorado Spring 1981 Interdisciplinary Workshop on Assessment of Sexual Assault, Boulder Social Services Summer 1979 Biofeedback Training related to labor and delivery. Summer 1974 Participant in Institute on Obstacles to Learning. Joint Symposium between McLean psychiatric hospital, Harvard University and Lesley Graduate School,Cambridge MA Summer 1973 Kennedy Memorial Hospital,Boston MA. Participant,Summer Aphasia Institute. PUBLICATIONS Ackerman A.,Ackerman,J.S., Kelley K. Hale K. Family Planning Attitudes of Traditional and Acculturated Navajo Indians. Key Issues in Population and Food Policy. University Press of America,pp. 178-171 (1979) Ackerman,J.S.,Client Expectations and Satisfaction with Community Mental Health Center Services: A Cross-Cultural Analysis Between Hispanics and Anglos. Published Doctor Dissertation, University of North Colorado. Copyright 1981, BRANCH B/A PRODUCER NUMBER DATE OF ISSUE PRIOR CERTIFICATE NUMBER 23 A 0004087 05/04/2004 Renewal PSYCHOLOGISTS PROFESSIONAL LIABILITY CLAIMS-MADE INSURANCE POLICY NOTICE: THIS €S A CLAIMS-MADE POLICY, PLEASE READ THE POLICY CAREFULLY PURCHASING GROUP POLICY NUMBER: 45-0002000 Item DECLARATIONS CERTIFICATE NUMBER: 45P- 2032570 1. Ackerman and Associates PC Named Insured 175025th Ave ADDRESS Greeley, CO 80634-4943 Number&Street,Town,County,State&Zip No.) 2. Policy Period: 12:01 A.M. Standard Time At From: To: Location of Designated Premises 05/01/2004 05/01/2005 3. COVERAGE LIMITS OF LIABILITY PREMIUM Professional Liability $ 1,000,000 each incident I $3,000,000 aggregate $ 1,529.00 4. BUSINESS OF THE INSURED: PSYCHOLOGY 5. The Named Insured is: _ Sole Proprietor (including independent contractors) _ Partnership X Corporation _ Other: 6. This policy shall only apply to incidents which happen on or after: a) the policy effective date shown on the Declarations: or b) the effective date of the earliest claims-made policy issued by the Company to which this policy is a renewal; or c) the date specified in any endorsement hereto. 05/01/1992 7. This policy is made and accepted subject to the printed conditions in this policy together with the provisions, stipulations and agreements contained in the following form(s) or endorsement(s). PLP-2012 (06/93), PLJ-2008(Rev. 10/94), , PLE-8035(09/97), PLE-2167(07/00), POE-8004(05/88) (Ed. *10/93), PLE-2081 Current, PON-2003(08/02) CHICAGO INSURANCE COMPANY 55 E. MONROE STREET, CHICAGO, ILLINOIS 60603 REPRESENTATIVE: Agent or broker: Trust Risk Management Services, Inc. 875 N Michigan Ave Office address: Chicago, IL 60611-1803 City, State, Zip: Toll-Free Number: 1-877-637-9700 PLP-2012(06/93) APA- . a PERSONAL.. DATA SHEET Identif ' n Informat ' • Name : Adme LaurLaurence "Larry" P. Kerrigan, Ph.D. 19th Avenue DOB: Greeley, CO 80631 9/20/32 Phone : 671:11353-3373 - business Degrees : BSC - Business MS - es Economics , from Creighton University, 1954 . from St . Louis University, St. Louis , MA •Economics ,s . Theology, , y from St. Mary's University, Regis College Ph . L. - Philoso Toronto , Ontario, Canada, 1967 . (EcclesialSDe Louis University, St . Louis , Mo . 1960 , Ph . D. - California Schooleof Berlcele Professional Psychology ,Y/Alameda Campus , 1974 , Clinical Psychology. Currently a licensed psychologist in the state of Colorado . Educational Back round : 1950-54 Creighton University, Business economics , 1954-56 Marquette University, and ascetical theology, WI . , Classical studies 1956-57 springhili College , Grand Coteau LA. Campus , Classical 1957-g0 studies , 1957-67 St . Louis University, Philosophy and Economics , 1961-64 St. Mary' s University, Toronto Campus , Theology, California School of Professional Psychol.ogy ,, clinical psychology, Berkeley/Alameda Campus Positions Held : 1969-71 Member of Board of Directors , Campion College , Prairie du Chien, WI . 1968-71 Director, Department of Psychology, Campion College . 1971-74 Director of Student Counseling Center, Long Mountain College. 1975-80 Director of Short-term Children and Family Team, Weld Mental Health Center, Greeley, CO . 1975-'87 Clinical Psychologist, Child and Family Team, Weld Mental Health Center, Greeley, CO . 19788 Co-founder of Weld County Child Protection Team, 1987-88 Member of Executive Board , Weld Mental Health Center, Greeley, CO . Honors Received : 1968-69 and Teacher of the 1970-71 year, Campion College . 1972-73 Class Representative to Campus Executive Committee , and California School of 19n-74 Professional Psychology Work and Ex eriential Back round . 1959-60 1959-60 Counselor at Dismas Halfway House for ex-convicts , St. Louis , Missouri , 1960-63 Teacher-counselor-coach, Marquette Prep High School , Milwaukee , WI . 1964-67 Counselor-therapist at Street Haven and Sancta Maria Halfway Houses for women and at the Don ( metro ) Jail in Toronto , Canada. 1967-68 Teacher and Campus Counselor at Creighton University, Omaha, NB. 1968-71 Teacher at Campion College, Prairie du Chien , WI . , Director of Psychology Department , Department chairman. 1970-71 Director and Staff member of a total environment for Inter-city boys , late grade school age from Milwaukee , WI . 1971-73 Director of Student Counseling , Lone Mountain College , San Francisco , CA. Teacher at the Lone Mountain College , San Francisco , California. 1973-74 Psychologist Trainee at San Francisco Mental Health Center, Richmond District, Outpatient Care . 1974-75 Private Practice , So . Day Human Services Center, San Diego , CA. Part-time instructor at/California School of Professional Psychology, San Diego , CA . a• 1j975-IIO Director , Short-Term Therapy Team, Children and Family Unit , Weld Mental Health Center, Greeley, CO . • 1980-87 Member of Children and Family Therapy Team , Weld Mental Health Center, Greeley, CO . 1987- present Full time private practice with Joyce Shohet Ackerman , Ed . D. , Licensed Psychologist , Greeley, CO . Part time practice at Weld Mental Health Center, Greeley , CO . P-uilication :• Kerrigan , Laurence P. The Relationship Between Therapist and Client ' s Perceptions of One Therapy Session . Published Doctoral Dissertation , University of California School of Professional Psychology. Copyright , 1974 . Wor ksho_LS_and S ,ecial._'fraining: Since 1974 , I have attended an average per year . Most of these workshops 11aVeof• esent three workshops ente training in the following areas : Neuro-linguistics training ,Autogenrc and relaxation training , Visualization-Imagery- 11Ypnosi.s , Cognitive-Behavioral Therapy, Ericksonian approaches to hypnotherapy and psychotherapy, Family therapy, Strategic therapy , Sexual abuse , dynamics and applied PPliecl treatment family intention psychotherapy, and other related areas . In the last fifteen years , I have taught classes and conducted workshops in the following subjects : The Psychology of Dreams Emotional and Physical Health through Visualization and Imagery Western Psychotherapies and Eastern Ways of Liberation Cognitive and Behavioral Therapy 11Ypnosis in Pain and Habit Control The Psychology of Consciousness and Meditation zAECUTIVE RISK CIALTY CO. • 11/18/04 - A PSYCHOLOGISTS PROFESSIONAL ELIABILITY POLICY THIS IS A CLAIMS MADE POLICY-PLEASE READ CAREFULLY NOTICE:A LOWER LIMIT OF LIABILIT *** * RENEWAL *** OF SEXUAL MISCONDUCT Y APPLIES TO JUDGEMENTS OR SETTLEMENTS WHEN THERE (SEE THE SPECIAL PROVISION"SEXUAL MISCONDUCT"IN THE POLICY). ARE ALLEGATIONS POLICY N0: 008-1766682 DECLARATIONS ITEM I. (a)NAMEgNDpDDRESSOFINSURED: CO-KERL175-0 0099745B ACCOUNT N0: ITEM I. (b)ADDITIONAL NAMED INSUREDS: • LAURENCE P. KERRIGAN, PH.D. 1750 25TH AVE. SUITE #101 GREELEY, CO 80634 EM 2. ADDITIONAL INSU REDS: TYPE OF ORG: INDIVIDUAL M 3. POLICY PERIOD: FROM: TO: 12/01/04 12:0IA.M.STANDARD TIME AT THE ADDRESS OF THE INSU12 RED AS105 S STATED HEREIN: 4 4. LIMITS OF LIABILITY: (a)$ EACH WRONGFUL ACT OR SERIES OF CONTINUOUS,REPEATED 1, 000, 000 OR INTERRELATED WRONGFUL ACTS OR OCCURRENCE (b)$ 5, 000 DEFENSE REIMBURSEMENT 5 (c)$ 3000, 000 AGGREGATE PREMIUM SCHEDULE: CLASSIFICATION NUMBER RATE ANNi.JAL PREMIUM 1ST PSYCHOLOGIST 1 1191 . 00 1, 191 . 00 DEFENSE LIMIT SURPLUS LINES TAX . 00 INSPECTION FEE 1 31 . 13 1 1. 19 RETROACTIVE DATE: 12/01/91 EXTENDED REPORTING PERIOD TOTAL PREMIUM: ADDITIONAL PREMIUM 1, 227. 92 Ofexercised):$ 2 148 . 60 NO DISCOUNT INCLUDED POLICY FORMS AND ENDORSEMENTS ATTACHED TO THIS POLICY 3 (7/95 ED. ) B22137• NOT 0/5)A BILL. PREMIUM HAS BEEN PAID. AUT RIZED COMPANY REPRE NTATIVE Americ Professional Aornry*o<a..s A • -II- -n, EMILY L. JARAMILLO,M.A. 183 50th Avenue Place Greeley,Colorado 80634 Home Phone(970)353-1388 EDUCATION 1996,Master of Arts,Agency Counseling University of Northern Colorado,Greeley,Colorado 1993,Graduate Fellowship Study, Criminology Rutgers State University,Newark, New Jersey 1988, Bachelor of Arts, Sociology/Criminal Justice with emphasis in Psychology University of Northern Colorado,Greeley,Colorado PROFESSIONAL EXPERIENCE 1998-Present Psychotherapist,Ackerman&Associates, Greeley, CO Provide intensive home based family therapy to families referred by the Department of Social Services. Provide mediation services to families. Co-facilitate family group decision making conferences for permanent placement of children. Provide short- term, solution-focused therapy. Provide therapy to individuals referred from Employee Assistance Programs. Facilitate foster parent training workshops. Provide foster parent consultation. Practice is supervised by Sherri Malloy, Ph.D.,Licensed Clinical Psychologist. 1996-1999 Director,McNair Scholars Program, University of Northern Colorado, Greeley, CO Provided counseling,guidance, and academic advising to students who were low- income,first-generation college students,and of a minority group. Identified critical personal, familial, cultural, academic, and financial issues to aid in the development of individual success plans. Planned, developed, and implemented scholarly activities nationally. Developed and directed academic year research seminars. Coordinated research activities for scholars preparing for doctoral study. Directed all efforts to ensure efficient administration of a federal grant. Monitored project budget, supervised and trained staff members. 1995-1996 Assistant Director,McNair Scholars Program, University of Northern Colorado Provided counseling, guidance, and academic advising to students who were low- income, first-generation,and of a minority group. Identified critical personal, familial, cultural, academic,and financial issues to aid in the development of individual success plans. Coordinated the recruitment and selection of program scholars. 1996 Psychotherapist(Intern), North Colorado PsychCare/Family Recovery Center, Greeley, CO Facilitated psychotherapy counseling groups and individual counseling for patients and families, with focus on chemically dependent and eating disorders. Performed case management from admission to discharge. Presented psychoeducational information to patients, family members,and staff. Worked collaboratively with a counseling team. 1994-1995 Assistant Coordinator, Student Support Services, University of Northern Colorado, Greeley, CO Provided counseling and academic advisement to at-risk first-generation,low-income, minority students. Identified critical personal, familial,cultural,academic, and financial issues to aid in the development of individual success plans. 1994-1995 Psychotherapist, Weld Mental Health Acute Treatment Unit, Greeley, CO Provided individual and group counseling to chronically mentally ill in-patient clients. Assisted clients in learning self-care and daily hygiene. Coordinated and implemented client life-skills and social-skills activities. CONTINUING EDUCATION/SEMINARS Jurisprudence Workshop for Psychotherapists Family Preservation Basic and Advanced Training Supervised.Practicum in Family Preservation Reaching Children through Play Therapy Play Therapy and Therapeutic Care Fire Starter Training Diverse Learners Academy Counseling At-Risk Students • Cultural Diversity Conference Parent/Child Hispanic Youth Leadership Conference PRESENTER/FACILITATOR The Terrific Twos Prenatal Insults and Long Term Effects Social, Emotional&Sexual Development:Infancy through Adulthood Cognitive&Physical Development: Infancy through Adulthood Parenting with Love&Logic Eating Disorders Cultural Sensitivity and Awareness Communicating Across Cultures Conflict Resolution/Communication Skills Setting Limits&Boundaries HONORS/AWARDS Hispanic Leader of the Year, Cesar Chavez Center, University of Northern Colorado, 1999 Keynote Speaker, Latina Youth Leadership Conference, University of Northern Colorado, 1998 Distinguished Alumni, Department of Sociology, University of Northern Colorado Fellowship, Graduate Study, Rutgers State University of New Jersey Scholarship, National Hispanic Scholarship Fund Scholarship, Candelaria Scholarship HA Producer N,,nom 32 A Issue. Dare ma la 0003107 cem en�N� 11/05/2004 RENEWAL PROFESSIONAL LIABILITY OCCURRENCE INSURANCE POLICY FOR PROFESSIONAL COUNSELORS AND HUMAN DEVELOP PURCHASING GROUP POLICYNUMBER: 44-2010S129 4-010ER9 Item DECLARATIONS CERTIFICATE NUMBER SUM. 4003488 1. Named Insured EMILY L MONTOYA MA LPC 2. MAILING ADDRESS 1851 13 AVENUE GREELEY CO 80631 3. Policy Period 12:01 AM Standard Time At Location of Designated Premises 4. The insurance afforded is only From: 11/01/2004 To: 11/01/2005 by specific premium with respect to such of the following charge or charges: g types of insurance as indicated E.Q A A. Professional Liability X P IUM B. General Liability $ 293.00 5 $ 293.00 LIMITS OF LIABILITY $ 1,000,000 each Incident or each Occurrence $ 3,000,000 in the Aggregate 6. The Named Insured is: Other: -- Sole Proprietor (including Individual) --- Partnership Corporation 7. Business or Occupation of the Named Insured: COUNSELING 3• This policy is made and provisions, s accepted subject to the printed conditions of this policy together with the stipulations and agreements contained in the following forms(s) or endorsement(s): PLJ-2016 (10/94) 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 P-2016 (10/94) (Elec.) • TOM PAPPAS, LCSW 2595 Iris Court Montrose,Colorado 970-240-8468 • TomPappasLCSW@Montrose.net EDUCATION 6/86 Masters Degree in Clinical Social Work, Simmons College School of Social Work,Boston,Massachusetts. 5/80 Bachelor of Arts Degree in Psychology and Secondary Education University of Lowell,Lowell,Massachusetts. EMPLOYMENT 3/94- Clinical Social Worker. Montrose Memorial Hospital Care Center Inpatient/Outpatient Services, Montrose, Colorado: Individual, family, marital and group therapy; discharge planning services. Co-therapist for geriatric partial-hospitalization program; supervisor for Masters Level student. 3/90-3/94 Senior Clinician. Justice Resource Center/The Butler Center, Westboro,Massachusetts. Individual, family and group therapy specializing in sexual offender treatment to adjudicated adolescent males in secure treatment facility. 11/86-4/89 Clinical Social Worker. New Bedford Area For Human Services, Inc:, Children Services Unit. Individual,family and group therapy in outpatient setting. Co-therapist for latency-age girls' sexual abuse groups. 9/85-6/86 Social Work Intern. Beaverbrook Guidance Center, Waltham, Massachusetts. Individual, family and group therapy with children in outpatient setting. 9/84-5/85 Social Work Intern. Children's Hospital,Boston, Massachusetts. Individual, family and group therapy in pediatric out-patient setting. 12/81-5/84 Mental Health Counselor. Marlboro Hospital Mental Health Unit, Marlboro, Massachusetts. Individual, family and group therapy with adolescents and adults in inpatient psychiatric setting. 1 1 5/80-5/81 Mental Health Counselor. Littleton Girls House,Littleton, Massachusetts. Counseling to adjudicated adolescent females in secure treatment facility. TRAINING 2/01 Certificate in Level II EMDR Training. 5/91. Postgraduate Certificate in Advanced Psychotherapy With Children and Adolescents, Boston University,Boston,Massachusetts. REWRENCES AVAILBLE UPON REQUEST CNAHealthcare Providers Service Organization Purchasing Group ®HPSO CNA Plaza, Chicago; IL 60685 ,` „ Terti Irate of C1JUZUnn tt.ce Producer Branch Prefix Policy Number Policy Period " 018098 970 IIPC from: 12:01 AM Standard Time on: 10/01/04 269949616-8 to: 12:01 AM Standard Time on: 10(01/05 '� $nsttred and Address } n to mini TOM PAPPAS Healthcare Providers Service Organization 2595 IRIS CT 159 East County Line Road MONTROSE CO 81401-7485 Hatboro, PA 19040-1218 Medical Specialty: Code: Social Worker 72990 u,' ' 'R; k .. , .,ad.! :` American Casualty Co. of Reading, PA CNA Plaza 26S Chicago, IL 60685 a , `' . ' - . ;,PLIABILITY ' t A. PROFESSIONAL LIABILITY Professional Liability $1,000,000.00 each claim $S6 000 000.00 aggregate Good Samaritan Liability Included above Personal Injury ,r Liability Included above rs 7 'r z�g ""T , a p acement Lia i ity Inc u e above B. Coverage Extensions License Protection $10,000.00 per proceeding $25,000.00 aggregate Defendant Expense Benefit _ :,. " y> fx1.,;:i . . " $10,000.00 aggregate Deposition Representation $2,500.00 per deposition $5,000.00 aggregate Assault $10,000.00 per incident $25,000.00 aggregate Medical Payments $2,000.00 per person $100,000.00 aggregate First Aid , _. .. ,'s3,x,,,,' $2,500.00 aggregate Damage to Property of Others $500.00 per incident $10,000.00 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 1 $1,000,000.00 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 1 None Total Premium $250.00 '�8.and endorsements attached at inception QUESTIONS? CALL: 1-800.982-9491 G-144872-A G-145184-A G-121500C G-121501C G-123846C-05 G-121503C G-147292-A i HAgency,Inc ealthcare ProviderA,AIs rOrganization ganirffinity ion is a d vision of Affinity Insurance Servicee,Inc.;in NY and NH,MS Affinity Insurance Agency,in MN and OK,MS Affinity Insurance Agency.Inc.dba Aon Direct Insurance Administrators License#0795665. Master Policy: 188711433-7)1,..4. / Q-- Keep this document in a safe place. This and /�¢ iL. r/.� � ' your cancelled check act as proof of coverage. Chairman of the Board Secretary 601 XX 0000041-N 040913 NENNCP 8/01 N133NM 04257 • • VITA NAME: BROMLEY, Susan Flock May 2004 SOCIAL SECURITY NUMBER: 483-50-9243 POSITION: Licensed Psychologist Ackerman& Associates 1750 25'h Ave. Ste 101 Greeley, CO 80634 HOME ADDRESS: 1621 13th Avenue Greeley, CO 80631 TELEPHONE: Office: (970)353-3373 Home: (970)352-8750 EMAIL: sbromleyaearthlink.net EDUCATION: Year(s) Degree Institution Area of Study 1983 Psy.D University of Denver Clinical Psychology School of Professional Psychology Denver, Colorado 1968 MSSA Case Western Reserve University Casework (MSW) School of Applied Social Sciences Cleveland.Ohio 1965 BA Mt.Holyoke College y g Economics/Sociology South Hadley,Massachusetts WORK EXPERIENCE—Professional Academic: Years) Institution/organizatin n Position Responsibilities 1996-03 University of Northern Colorado Assoc. Professor Psych1985-96 University of Northern Colorado Asst. r Teaching/Research Professor Psychology Teachin 1983-84 University of Northern Colorado Asst.Professor Psychology Teaching/Research Psychology g WORK EXPERIENCE --Professional,Von Academic: Year(s) Institution/Organization Position Responsibilities 1996-present Ackerman and Associates Psychologist 1984-85 Kaiser Permanence Clinical Psychotherapist Clinical Lakewood, Colorado 1979-80 Bethesda Mental Health Center Psychology Intern Clinical/ Denver, Colorado 1968-79 Denver General Hospital Administrative P Clinical Social Worker/ Clinical/ Denver, Colorado Supervisor Pe Administrative AREA OF SPECIALIZATION: Behavioral Medicine/Pain Management/Clinical Hypnosis/EMDR RESEARCH AREAS/INTERESTS: Hypnosis/Pain Assessment and Management/Women's Issues/Teaching Methods 1 PROFESSIONAL ACTIVITIES: Colorado Licensure: Psychology License#1086 PUBLICATIONS --Pro fessional"Juried• Musgrave-Marquart, D.,Bromley, S.P. &Dailey. M.B. (1997). "Personality,academic attribution,and substance abuse as predictors of academic achievement in college students". Journal of Social Behavior and Personality 12(2), 501-511. Karlin. N.J. and Broniley, S.P. (1996). Differences in caregivers of demented and lucid chronically ill family members. American Journal of Alzheimer's Disease, 11(5)39-45. Retzlaff,P. and Bromley, S. (1994). Counseling personality disorders. In Ronch,J.L., VanOrnum, W. & Stillwell, N.C. (Eds)The counseling sourcebook: A practical reference on contemporary issues. New York: Crossroad Publishing group. pp. 466-474. Bromley, S. and Hewitt,P. (1992). Fatal attraction: The sinister side of women's conflict about career and family. Journal of Popular Culture. 26(3),pp. 17-24. Retzlaff,P. and Bromley, S. (1991). "A Multi-Test Alcoholic Taxonomy: Canonical Coefficient Clusters". Journal of Clinical P cholo 47 2 ,pp. 299-309. Bromley. S.P. (1985). "Treatment of Pain: Theory and Research"in Zahourek.R. (Ed.). Clinical Hypnosis and Theraueuh r_ New York: Gmne and Stratton. Reprinted in Zahourek,R. (Ed.)(1990). New York: Bruner/Mazel, Inc., pp. 77-98. PROFESSIONAL PRESENTATIONS --Juried: Touchton, M.A. &Bromley, S.P. (2000). Complementary/alternative medical use among undergraduates at the University of Northern Colorado. Poster session presented at the Rocky Mountain Psychological Association, Tucson. AZ. (April). Nickisson, J.W. and Bromley. S.P. (1999)"Hypnosis: Attitudes, knowledge and experience among psychology and nursing students". Paper presentation at the American Psychological Association Convention. Boston. (August) Bromley, S. (1998)Hypnosis, psychology and managed care. In S. Bromley (Chair) Complementary, nontraditional and indigenous healing practices. Symposium conducted at the combined meetings of the Western and Rocky Mountain Psychological Associations, Albuquerque. (April) Bromley, S. (1998). Complementary healing methods: A psychological and artistic exploration. In L. Wickerlgren (Chair). Interdisciplinary courses involving psychology: A sampler. Symposium conducted at the combined meetings of the Western and Rocky Mountain Psychological Associations, Albuquerque. (April) Campbell.J. S., Titus, J. and Bromley S. P. (1998). "Neuroanatomy teaching technique for introductory psychology students. Poster presented at the joint WPA/RMPA convention,Albuquerque, NM. (April) Broniley, S. (1997) (Chair) "Linking through honors programs: The cross-discipline course). Paper presentation as part of a symposium titled"Creating links between psychology and other disciplines," American Psychological Association Convention, Chicago. (August) Bromley, S. , Gilliam D. &Johnson, T. (1995). "Assessment of student created tests as an evaluation method". Poster presented at the American Psychological Association Convention,New York City. (August) Broniley, S. (1994). "Student created tests as an evaluation method". Poster presented at 16th Annual National Institute on the Teaching of Psychology. St. Petersburg,Florida. Karlin, N. and Bromley. S. (1992). " Similarities and differences for caregivers of demented and lucid chronically ill". Poster presented at the Rocky Mountain Psychology Association Convention,Boise. Idaho. (April) • Montoya,K.J. and Bromley, S. (Chair)(1992). "Changes in undergraduate counseling styles in an introductory counseling theories course". Paper presented at the Rocky Mountain Psychology Association Convention,Boise, Idaho(April) Bromley, S. (1992). "Connected learning methods to facilitate research understanding". Paper presentation as part of panel titled, `Teaching techniques in the social sciences", Western Social Science Association Convention,Denver, Colorado. (April) Bromley, S., Ramirez, S., and McCoy,J. (1991)."Impact of a health psychology course on student health beliefs". Poster presented at the Rocky Mountain Psychology Association Convention,Denver. Colorado. (April) Karlin, N. and Bromley, S. (1991). " Support,burden and affect among caregiver of dementia and non-dementia patients". Poster presented at the American Psychology Association, San Francisco, California. (August) Bosley, G. and Bromley, S. (1990). Post death ritual in a Colorado community. Paper presentation at the American Psychology Association, San Francisco, California. (August) Bromley, S. (1990). "Husbands at Childbirth: Who Does It Help?"Paper presentation at Far West Popular Culture Association, Las Vegas, Nevada (January). Hewitt, P. and Bromley S. (1989). "Images of Work and Intimacy in'Turning Point'and'Fatal Attraction'. Paper presentation National Convention of Popular Culture Association and American Culture Association, St. Louis, Missouri. (Session Chair) Retzlaff. P. and Bromley, S. (1989). "The Basic Personality Inventory: Alcoh Sub-Group Identification". Poster session at the Joint Convention of the Rock Mountain Psychological Association and Western Psychological Association, Reno, Nevada. Bromley, S. (1988). "Our Culture Affects Our Pain."Paper presentation, National Convention of Popular Culture Association and American Culture Association, New-Orleans,LA. (March). Bromley, S. (1987). "Husband-Assisted Autohypnosis for Labor and Delivery: A Clinical Model". Paper presented at Rocky Mountain Psychological Association, Albuquerque, New Mexico(April). Bromley, S. and Loy. P. (1987). "Politics of PMS". Paper presentation Association of Women Psychologists, Denver, Colorado (March). PROFESSIONAL PRESENTATIONS--Invited: Bromley, S.P. &Canales, G. (2000). Issues in presenting information on historically underrepresented groups in the classroom. Symposium conducted at the Rocky Mountain Psychological Association, Tucson. (April). Strongin,D. &Bromley, S. (1999). Student and faculty reactions to the introduction of a graduate ethics course. In Miller, R. (Chair)Ethics in college teaching. Symposium conducted at the Rocky Mountain Psychological Association, Ft. Collins, CO(April) Bromley. S. (1999). Issues of religion and spirituality with therapists and clients. In S. Bromley(Chair)Religion and spirituality in research, practice and the classroom. Symposium conducted at the Rocky Mountain Psychological Association, Ft. Collins, Co(April) Handelsman, M.M.,Bromley. S.P. &Davis. S.F. (1995). "Clinical Psychologist, Counseling Psychologist, Clinical Social Worker, or Psychology Professor: Which Degree is Right for Me?"Psi Chi invited panel presentation,Rocky Mountain Psychological Association,Boulder, CO(April). Bromley, S. (Co-Chair), Seibert, P. (Co-Chair), Knuckey,D.,Bohlin, M.,Zaweski, C.. Watson, D.,Hammon,D., West, K. & Robins, J. (1994). "Training the Teaching Assistant"Invited Panel Presentation.Rocky Mountain Psychological Association. Las Vegas. Nevada (April) 2 Bromley, S. (1993). "Hypnosis in Dentistry."Presentation at Monthly Meeting of Weld County Dentistry Association. Greeley, Colorado(February). Bromley, S. (1993). "Learning about the author as a way to understand research." Presentation at"Teaching Take Out", CTUP Special Event. WPAJRMPA Convention,Phoenix, Arizona(April). Allen, M. and Bromley, S. (1993). Co-Chairs Two CTUP Special Event Sessions, "Teaching Take Out: Experiences in Collaborative Learning", Western Psychological Association/Rocky Mountain Psychological Association Convention,Phoenix, Arizona(April). Bromley, S. (1993). Chair, Invited Symposium, "Psychological and Social Perspectives on Male Violence Against Women", Western Psychological Association/Rocky Mountain Psychological Association Convention.Phoenix, Arizona (April). Bromley, S. (1992). "Enhancement of student research and writing skills in any course". CTUP Workshop presented at the Rocky Mountain Psychology Association Convention,Boise, Idaho. (April) Bromley, S. and Karlin,N. (1992). "General and health locus of control of adult caregivers". Poster session at the UNC Research Forum, Greeley, Colorado. Bromley, S. (1992). Panel member in Mental Health Symposia for Victim Compensation Convention as part of the Colorado Organization for Victim Assistance Conference. (Estes Park/October) Bolocofski,Bromley,Foster and Mean(1988). "Hypnosis: Research and Clinical Perspectives." symposium presentation,Colorado Psychological Association, Greeley(March). Bromley, S. (1986). "Pain: A Psychological Event". Presenter-20th Annual Emotional Crisis Workshop,University of Northern Colorado, Greeley, Colorado(July). LECTURES--Invited: Bromley, S. (1998)"Psychological methods of pain control"Invited lecture for the annual meeting of the Weld County Arthritis Society. Bromley, S. (1998). "Hypnosis for pain control of arthritis" Invited lecture for`Brown Bag" lunch series sponsored by the Greeley Medical Clinic. Bromley, S. (1998) "Headache Control -Psychological Methods". Invited lecture as part of a seminar titled"Coping with headache". Sponsored by the Greeley Medical Clinic. Bromley, S. & Ackerman J. (1998):"What to do to handle burnout" A workshop conducted for foster parents working with Weld County Social Services. Bromley, S. (1995). Keynote speaker for Golden Key Honor Society Induction Ceremony. University of Colorado, Boulder. Co. (November) Bromley, S. (1992). Keynote speaker for Sophomore Honor Society Induction Ceremony. Bromley. S. (1991)Featured speaker. UNC Academic Honors Convocation. (April) Bromley, S. (1991). Banquet speaker Emotional Crisis Workshop, Greeley. Colorado. (July) GRANTS: Bromley, S(1994)Honors Grant($500)to attend research training at the Society for Clinical Hypnosis meeting, San Francisco(October) Bromley. S. (1994). Research and Publications award of$1500.00. "Assessment protocols to measure the efficacy of 4 hypnotic treatment for injured workers. Karlin,N. and Bromley, S. (1990). Research and Publications award of$2.4440.00. "Control,support,burden and affect differences among dementia and non-dementia caregivers". BOOK/GRANT REVIEWS: Grant review for Boise State Department of Education(1995) Review of Santrock,J. (1991). The science of mind and behavior. W.C. Brown and Benchmark. Review of McKee,P. &Thiem, J. (1993). Real life: Ten stories of aging. University of Colorado Press. PROFESSIONAL CONSULTATION/PRACTICE: Ycr s Institution/Organization Role 1996-presnt Ackerman and Associates 1988 Clinical Psychologist Bonnel Good Samaritan Center Pain Management Consultant and Trainer 1984-85 Denver Metropolitan Dental Care Consultant in Pain Management 1984 Iowa Association of Registered Physical Therapists Hypnosis for Pain Management Consultant and Teacher PROFESSIONAL ASSOCIATION PARTICIPATION: Membership 1986-2003 Rocky Mountain Psychological Association 1988-present American Psychological Association(Divisions 2,30,35) 1989-96 Greeley Area Mental Health Network 1987-88 Association of Women in Psychology 1980-89 Colorado Psychological Association 1988 CPA Program Committee Member for Spring Meeting--Greeley Coordinator SERVICE: EXTERNAL: NATIONAL SERVICE: 1994-2002 Rocky Mountain Coordinator-American Psychological Association, Division 2 -Teaching of Psychology 1992-94 Co-Chair, Rocky Mountain Region Council of Teachers of Undergraduate Psychology(CTUP). 1991-94 Mountain States Regional Academic Coordinator, Golden Key National Honor Society REGIONAL/STATE SERVICE: 2000-Moderator for G. Stanley Hall Lecturer-Dweck, C. (2000). Motivation and the self. Presented at the Rocky Mountain Psychological Association Convention,Tucson. (April) 1999 -Moderator for G. Stanley Hall Lecturer-Viney. W. (1999). A larger canopy for psychology: Unifying themes and pragmatic empiricism. Presented at the Rocky Mountain Psychological Association Convention,Ft. Collins, CO(April) 1989-present Rocky Mountain Psychology Association I 998-present Ex-Officio Board Member As Division 2 Coordinator 1992-1998 Board Member 1995- 1998 Elected Chair.Groups Under-Represented in Psychology Committee 1992-94 Co-Chair, Groups Under Represented in Psychology Committee 1991 Coordinator of Student Volunteers,RMPA Convention, Denver, Colorado. 1995 Psychology Chair-CCHE Faculty to Faculty Conference(October) COMMUNITY SERVICE: 2003-present Board Member Weld County Area Agency on Aging 1999-present Member Weld Senior Wellness Program Evaluation Committee 1999-2000 Member, Weld County Area Agency on Aging, Grandparenting Committee 1998-present Member, Weld County Medical Society Committee on Alternative and Complementary Healing 1997-1998 UNC Loaned Executive-United Way of Weld County G 1997 Mental Health Pro Bono Workshop,"Communication in the Workforce" 1991- 1996 Board Member, 19th Judicial District Victim Compensation Board 1995-96 Chair 1990-93 Board Member, Weld County Area Agency on Aging 1992-93 Chair 1991-92 Vice-Chair 1986-2001 Exam Supervisor-American Institute for Property and Liability Underwriters/Insurance Institute of America 1987-present Clinical Psychologist-pro-bono work with individual clients and community training INTERNAL: DEPARTMENTAL: 1993-2003 Member,Department Executive Committee 2000-2003 Advisor Psi Chi National Honor Society 1995-1999 Co-Advisor Psi Chi National Honor Society 1996-present Guest lecturer for Psi Chi Grad Night on getting into clinical/counseling grad programs. 1989-91,93, 1995-1998 Department Representative, CCHE Faculty to Faculty Conference 1987 -94 Department Representative to graduation ceremonies 1986-94 Library Representative 1983, 86 89, 90-93,97,98 Member,Faculty Search and Screen Committee 1990-92 Member,Psychology Department Undergraduate Committee(Chair 1992) 1987-88 Co-Coordinator Semester Conversion Committee COLLEGE: 1992,93.96.97 Member of faculty invited to teach in the Cluster Program 1990-93 Graduation Marshall, Arts&Sciences 1988-89 Member, Arts and Sciences Teacher Education Committee 1986-89 Chair, Interdisciplinary Committee to develop and revise Human Development Major in the College of Arts and Sciences and Psychology Department UNIVERSITY: 2002-present Graduate Faculty 2002-present Field Experience Coordinator for students at Ackerman&Associates 1992-94 1996-99 Member-Research and Publications Board 1993-94 Chair-Elect 1988-99 Founding Co-Advisor. Golden Key Honor Society 1992-95 Member-UNC Women's Commission 1992-94 Co-Chair-Assessment Task Force 1989-90 Faculty Representative. Student Fee Allocation Committee 1986-89 Member, Faculty Senate 1988-89 Secretary 1987-88 Vice-Chair 1986-87 At-Large Member, Executive Committee 1986-89 Member, Academic Policies Committee 1986-87 Member,Elections Committee 1988 Representative. Western States Faculty Leadership Conference,Reno 1988 Senate Representative, Statewide Commission Advisory Committee 1988 Advisor, In-Touch Help Line 1985-86 Volunteer Therapist, UNC Counseling Center GRADUATE STUDENT COlvIMITTEES--Doctora/.. 2003-present Committee Member. Stefanie Stecker(School Psychology) 2002-present Committee Member,Karen Bender(Professional Psychology) 6 1998-99 Committee Member, Shu-Shin Lu,Professional Psychology, "Using Metaphor in Child Counseling in Taiwan" 1997-00 Committee Member, Christine Rogers,Professional Psychology, "A Qualitative study of the experiences 1995-1997 Committee Member,Lisa In g, p Special pastor's wives." Education 1994-2003 Committee Member,Marla Gallagher,Educational Psychology 1993 Committee Member, Hsiu-Lan Ma, Science Ed. -Oral Comprehensives 1993 Committee Member,Jerry Buford, School Psychology,"Treatment of depressive symptoms of early adolescents". 1993-1998 Committee Member, Pat Flanagan. CSPA,Orals,"A comparison of attitudes and practices of Teaching faculty regarding student academic dishonesty at a two year and four year institution". 1991 Committee Member,Mike Propriano, School Psychology 1990-94 Committee Member, Paul Jantz, School Psychology, 1989 Committee Member, Mike Peters, Vocational Rehabilitation,"The Effectiveness of Vocational Evaluation for Various Disabling Conditions 1987 Committee Member, Ane Marie Kajenckii.English,"The Concept of Free Association in Virginia Woolf s The Waves" 1986 Committee Member, Fuming Liao,Mechanical Kinesiology,"Development and Validation of a Method for Providing Immediate Feedback Information on Speed and Angle of Release in Shotputting" GRADUATE STUDENT COMMIT IEES --Masters: 2001 Jeremy Ehmke, Chair 1999-00 Jennifer Lawrence, Committee Member 1998-99 Vanessa Ewing, Committee Member 1997 Stephanie Blasi, Committee Member 1997 John Nickisson, Chair 1994 David Watson, Committee Member 1994 Tiernan McIlwaine, Committee Member 1994 Jerrod McCoy, Committee Member 1993 Sheldine Runyan,Committee Member 1993 Sue Cole. Committee Chair. "Influences on Occupational Goals of Selected Male and Female College Students". 1990 Jerry Benner, Committee Member 1990 Kurtis Armstrong, Committee Member, "Attitudinal Consequences of Pre-Employment and Random Employee Drug Testing" 1989 Michelle Hozer, Committee Member 1989 Anne Schnittgnmd, Committee Chair,"Age and Electrothermal Biofeedback Training-. 1988 Cherri Hockett, Committee Member, "The Effects of Turnover on Those Who Remain in an Organization" 1988 Tony Ambrosio, Committee Member. "The Belief in a Just-World and the AIDS Epidemic: Predictors of Attitudes Towards Individuals with AIDS" 1988 Steve Foster, Committee Chair, "Hypnotic Susceptibility As a Function of Locus of Control and Director Indirect Induct ional Deepening and Suggestion Style" 1988 Lisa Dillon, Committee Chair, "Cognitive-Behavioral Approach to the Treatment of Elderly Rheumatoid Arthritis Patients" 1987 Deanna Holmes, Committee Member 1987 Darlene Nold, Committee Member, "Reading and Writing Assessment Tests as Predictors of Success in the Basic Peace officer Academy at Aims Community College" 1987 Dan May, Committee Member 1986 Jeff Schiels, Committee Member, "The Reformulated Hypothesis: Is Its dominator of Learned Helplessness Literature Justifiable?" 1986 Linda Coulthard-Morris, Committee Member, "Biofeedback of Conical Slow Wave Potentials, Hand Temperature and Muscle Tension in Normal and Attention Deficit Disorder with Hyperactivity Children" TEACHING: Honors Activities: 7 2000-2002 Thesis Co-coordinator, Stephanie Price,Allison Osag,Anna Grenier, Jennifer Donnelly 2000-2002 Thesis Co-advisor, Shanti Pepper."Hindsight bias and prejudice against homosexuals" 2000-2002 Thesis Advisor, Angela Hanson."Effects of aromatherapy on attention" 2000 Thesis Coordinator, Cindy Mitchell, Christin Hillyer,Angela Hanson 1999 Thesis Advisor,Melissa Touchton"Complementary/alternative medical use among undergraduates at the University of Northern Colorado". 1999 Thesis Advisor, Sarah Painton. "Early parent loss in terms of maintaining a connection with the deceased. 1999 UNC Research Day,Faculty Panel Coordinator,"Complementary Healing Methods" 1999 Thesis Coordinator-Kristin Pietryzick,Jennifer Kimberling, Cristine Dickey 1997 Thesis Co-Advisor Kelly Kinser. "An evaluation of the city of Greeley community outreach program". 1997 Honors Connection Course development-Alternative Healing Methods 1996-2002 Honors Co-Coordinator,Psychology Department 1989-94 Honors Coordinator, Psychology Department 1994 Thesis Co-Advisor,Diane Musgrave,"The Relationships Among Personality Traits. Alcohol. Caffeine,and Nicotine Consumption, and Academic Performance in College Students" 1994 UNC Research Day,Faculty Panel Coordinator,"Hypnosis: Theory and Research" 1993 UNC Research Day,Faculty Panel Coordinator,"Non-traditional Theories of Therapy Serving Women and Minorities". 1993 Thesis Co-Advisor,Linda Norman, "Clozapine and Event Related Brain Potentials in Schizophrenics" 1992 Thesis Advisor,Deborah Knuckey, "The Effect of Touch on Affect Among Strangers Under Mildly Stressful Conditions" 1992 UNC Research Day,Faculty Panel Coordinator 1992 UNC Research Day,Faculty Panel Coordinator(2 student panels)"Sex Roles and Psychology,"The Power of Social Influence 1989 Thesis Advisor. Geri Bosley. "Post Death Ritual in a Small Colorado Community" 1988 Thesis Advisor,Pain Clasen, "The Use of Relaxation and Imagery Techniques in Pain Management" 1989&97 Honors Connection Course Development Courses Taught: (1-4 Scale with 1 as Highest) (*1-5 Scale with 5 as highest) AVG. DATE COURSE TITLE HRS ENR AVG.RATING 1986-1988 PSY 101 Intro Seminar Psychology 1 30 1.16 1983-1997 PSY 120 Principles of Psychology 4 113 2.35 1984 PSY 121 Intro to Psychology I 4 40 ---- 1985-1988 PSY 230 Human Growth &Development 5 68 1.46 1984 PSY 265 Social Psychology 3 25 ---- 1988-2000 PSY 323 Health Psychology 3 43 3.02 1986 PSY 330 Child&Adolescent Psych3 27 1.4 1986-1993 PSY 331 Maturity&Aging 3 36 1.51 1984-2000 PSY 455 Abnormal Psychology 3 32 3.01 1983-1998 PSY 350 Theories of Personality 3 40 2.05 1986-2000 PSY 407 Intro to Counseling Theories 3 23 2.52 1987 PSY 499 Psychology of Sex Roles 3 16 1.18 2000 PSY 508 Health Psychology and Healing 2 17 4.57 1989 PSY 508 Emotional Crisis Workshop 1-2 39 --- "Frontiers of Mental Health And Education" 1988 PSY 508 Emotional Crisis Workshop 2-3 63 "Mind/Body Interactions" 1987 PSY 508 Emotional Crisis Workshop 2-3 106 "Relationships" 1991 PSY 595 Health Psychology 3 15 1990-2000 PSY 620 Assessment&Interviewing 3 12 3.13 1988 PSY 620 Issues in Behavioral Medicine 3 5 2.08 1992-1997 PSY 621 Practicum College Teaching 2 12 3.11 1997 HON 200 Honors Connections Seminar: "Alternative Healing Methods" 2 20 3.67 of 4 1989 HON 200 Honors Connection Seminar II: 2 9 --- 8 "Love" 1986 Elderhostel "Dream On" NC (25) 1987 Elderhostel "Mind/Body Interactions" NC 19 Courses Developed: 2000 PSY/PPSY 508,Health Psychology and Healing 1997 HON 200, Alternative Healing Methods 1991 PSY 595,Issues in Health Psychology, Summer 1989 23rd Annual Emotional Crisis Workshop,Frontiers of Mental Health and Education, Summer 1988 PSY 620, Assessment in Behavioral Medicine,Fall(Revised Spring 1998) 1988 PSY 423,Health Psychology,Fall 1988 22nd Annual Emotional Crisis Workshop,Mind/Body Interactions, Summer 1987 21st Annual Emotional Crisis Workshop,Relationships, Summer 1987 Mind/Body Interactions-Elderhostel Program, Summer 1987 PSY 499, Psychology of Sex Roles-Summer 1986 Dream On-Elderhostel, Summer Directed Studies: Graduate: 1995 Cynthia Holley, Hypnosis 1994 Tara Johnson, Hypnosis Theory and Practice 1994 Marla Gallagher,Sociometric Processes 1994 Marla Gallagher, Cluster Development in Intro Psychology Classes 1992 Bruce Holoman,Hypnosis Research and Practice 1988 Paul Jantz, Hypnosis for Pain With Children 1988 Lori Kochevar, Women as Leaders 1988 Jerri Israel, Alan Shaw,Issues in Health Psychology 1988 Steve Foster,Michele Hozer,Teaching Apprenticeship 1987 Tony Ambrosio, Hypnosis Models 1986 Candy Disch, Psychological Testing Undergraduate: 2000_ Lynell Rice -Cross-cultural attitudes towards healing methods 2000_ Andrea I-Iagedorn -Attitudes towards counseling(in lieu of honors thesis) 2000 Laura Bell -Psychology of childbirth 1999 Lynell Rice -Healing Methods 1999 Stefani Stecker-Student's perceptions of parent-child sex communication(in lieu of honors thesis 1998 Jennifer Altman-Exercise and Psychology 1996 Kindra Sanchez-Biracial Identity 1996 Jenna Weatherbee -Pain Coping Styles • 1995 Allison Ellis-Psychological Theories in Business Management 1995 Holli Elrick, Counseling and the Hearing-Impaired Child 1994 Lewis Garza,Etiology of Schizophrenia 1994 Suzanne Bodetko, Autogenic Training 1994 Rebecca Furstenberg, Impact of Alzheimer's Disease on Families 1994 Bonnie Sarton, Hypervigilence in Youth (Hon 351) 1993 Mary Jo Hamilton, Hypnosis Theory 1994 Greg Schooley, Forgiveness as a Therapy Tool 1993 Jason DeBueno, Youth Advocacy 1993 Kelley Ferguson-Women in Psychology 1993 David Rosenberg-Offender Programs 1992 Robin Trostel,Analysis of Learning Styles 1992 Robin Trostel, Health Locus of Control 1992 Roberta Inman, Family Violence and Lesbians(Hon 351) 1991 Mark Kahl, Back Pain 1991 Tracy Moulton, Treatment of Sexual Abuse S 1991 Alice McPherson, African American Women and Higher Education 1991 Jody limner,Hypnosis: Theory and Practice 1990 Jimmie Berg, Women's Learning Styles 1989 Elary Violet[, Cognition and Pain Management 1989 Geri Bosley, Chris Snodgrass,Bev Foster.Elary Violett, Issues in Personality 1989 Penny Vaughn,Female Pioneers in Social Work 1989 Lori Peterson,Pain and the Elderly 1988 Peer Training for Hotline Service 1987 Tracy Boh, Issues in Child Abuse 1987 Julie Stoddard, Grief and Divorce 1987 Eric Bouch, Hypnosis Models 1987 Mike Lesser,Assessment in Sport Psychology 1986 Lynne Sheffield, Childhood and Loss 1986 Jennifer March, Adolescence Practia 2000 Rebecca Kuhn-Aromatherapy research 2000 Ackerman and Associates-Berkely Holston 1999 Melissa Touchton-Applied statistics 1998 Andrea Lamb-Hypnosis and golf performance 1998 Rebecca Varoula-Women's Place 1998 Greeley Medical Clinic-Gay Lemons,Renae Smith 1998 Ackerman and Associates-Amy Munnel,Kristin Pietrzyk,Jennifer Kimberling. Greg Pedersen 1997 Greeley Medical Clinic -Lori Darst,Barbara Glode,Ann Marie McCullen,Jeff Titus 1993 Greg Schooley, Bereavement Research 1993 Di Smice, Women's Commission 1992 Mary Jo Hamilton,Hypnosis Research 1992 Carol Sexton,Psychology Testing 1992 Lisa Schlott, Learning Styles PROFESSIONAL DEVELOPMENT ACTIVITIES: Workshops, Clinics, Symposia, Conferences: (Excluding Conferences as a Presenter) 1999 Cognitive Behavioral Therapy Training Program, Institute for Behavioral Healthcare 1999 EMDR training and Level 1 certification 1998 Qualitative research lecture series-UNC 1998 Lewis M. Terman Western Regional Teacher's Conference sponsored by APA Division2 in conjunction with the WPA/RMPA joint convention. 1998 "Spirituality and health in counseling". CAHEC Workshop, Greeley 1998 "Divorce Busting: Solution oriented brief therapy with couples", Colorado Assoc. Marriage and Family 1997 Health Maintenance-Legal and Ethical Issues 1997 Body and Soul: Healing in the 90's 1996 Celebrating our Essence: Women's Health and Spirituality 1995 International Society for Clinical and Experimental Hypnosis-Research Workshop. San Francisco, CA (30 more hours toward certification) 1989 "Minding the Body, Mending the Mind", CAHEC Workshop,Ft. Collins 1988 "Demystifying Publishing", CAHEC Workshop.NCMC, Greeley 1985 "Attentional Deficit Disorders in Children", Meichenbaum,Denver 1980 International Society for Clinical and Experimental Hypnosis-30 certification hours, Denver Numerous other workshops on Parent Loss. Child Abuse, Grantsmanship, Short-Term Treatment, Supervision, Pain Management.Medical Terminology,Depression, Personality Disorders Courses Taken Credit: 1994 EPRE 603 -Analysis of Variance Audit: 1993 EPRE 602 -Elements of Statistics 1990 EPRE 700 -Advanced Research Methods Continuing Education Credit: 10 1976 C.U.Medical School-Medical Ethics 1972 C.U. School of Nursing-Hypnosis(10 weeks) 1969 University of Chicago -Kubler-Ross,Death and Dying HONORS AND AWARDS. 2000 "Wonderful Outstanding Woman"Award 1998 Distinguished Service Award-Rocky Mountain Psychological Association 1998 Arts and Sciences Teacher of the Year Award 1998 "Wonderful Outstanding Woman" Award-Highlighted in October newsletter-Women's Resource Center 1993 Commencement Banner Carrier, Arts and Sciences 2002,1993, 91,89, 88-Mortar Board Favorite Professor 1992 Student Representative Council University Professor of the Year 1992 Student Representative Council University Advisor of the Year 1989 Arts and Sciences Achievement Award 1988 Honors Advisor of the Year 1984 Psi Chi, University of Northern Colorado Chapter 1982-83 Writing Associateslup-Rocky Mountain Women's Institute 11 BRANCH B/A PRODUCER NUMBER DATE OF ISSUE 23 A 0004087 PRIOR CERTIFICATE NUMBER 04/08/2004 Renewal PSYCHOLOGISTS PROFESSIONAL LIABILITY CLAIMS-MADE INSURANCE POLICY NOTICE: THIS IS A CLAIMSMADE POLICY, PLEASE READ THE POLICY CAREFULLY PURCHASING GROUP POLICY NUMBER: 45-0002000 Item DECLARATIONS CERTIFICATE NUMBER:45P- 2050203 1. Named Insured S.T62usaini3tBrtimiAteey ADDRESS Greeley,CO 80631-5415 Number&Street,Town,County,State&Zip No.) Z Policy Period: 1201 A.M.Standard Time At From: To: Location of Designated Premises 04/01/2004 04/01/2005 3. COVERAGE LIMITS OF LUIBILITY PREMIUM Professional Liabif $ 1,000,000 each incident $3.000.000 :.. -.. 4. BUSINESS OF THE INSURED: $ 1,298.00 PSYCHOLOGY 5. The Named Insured is: X Sole Proprietor(Including independent contract ere) _ Partnership _ Cp atiun Other. In+r 6. This policy shall only apply to incidents which happen on or after a)the policy effective date shown on the Declarations: or b)the effective date of the earliest claims-made policy issued by the Company to which this policy is a renewal;or c)the date specified in any endorsement hereto. 04/05/1996 7. This policy is made and accepted subject to the printed conditions in this policy together with the provisions,stipulations and agreements contained in the following form(s)or endorsement(s). PLP-2012 2 06/993),PLJ-20'8(Rev. 10/94),,PLE-8035(09/97),PLE-2167(07/00),POE-8004(05/88)(Ed.•10/93),PLE-2081 Current,P 1-2003(08/02) CHICAGO INSURANCE COMPANY 55 E. MONROE STREET, CHICAGO, ILLINOIS 60603 REPRESENTATIVE: Trust Risk Mana gement or broker: Services, Inc. Office address: 875 N Michigan Ave Chicago,IL 60611-1803 City, State,Zip: Toll-Free Number. .6877_637.9700 PLP-2012(06/93) APA- SUPPLEMENTAL NARRATIVE TO RFP: EXHIBIT B CONDITIONS Ackerman and Associates P.C. Dept. of 1750 251h Avenue, Suite 101 Weld County eGreeley, Colorado. 80634 SClericti Units 970-353-3373 APR 2 T 2005 Gloria Romansik Weld County Department of Social Services P.O. Box A Greeley, Colorado 80631 April 27, 2005 Dear Ms. Romansik: Thank you for your queries concerning the PY 2005-2006 bids containing the comments of the FYC commission. We understand that RFP 05007 Sex Abuse Treatment and 05010 Option B Intensive Home Based Therapy are recommended for inclusion on the vendor list. As to our Life Skills Program, 05005 : The following defines our capacity to do after hours visitation. Ackerman and Associates maintains a twenty four hour a day 365 day a year on call system to handle emergencies. Our hours to see clients in the office begin at Nine AM and frequently end at Nine PM depending on the provider. As to home based visitation after hours,we would expect the following scenario. A call would come into the answering service and the provider on call would be contacted. That provider would evaluate if emergency contact was needed or if police response would be more appropriate. Then we would schedule the family to be seen at our offices on an emergency basis only if the conditions did not permit contact in regular hours and police intervention was not needed. We do not anticipate providing emergency visits in the client's home after hours. Scheduled after hours contact within the time window described(after five PM and before nine PM)would be at the discretion of the provider. Concerning Intensive Mediation we agree to the condition related to consultative conflicts.. It is our understanding that any consultative conflicts specific to the case pending will lead to the withdrawal of the mediator with the perceived conflict as requested by any party. 1 Page 2 Ackerman and Associates FYC Queries 2005-2006 Contact was made with John Kruse as requested concerning the unit of service rate consultations and all issues were resolved. John will be communicating his comments directly to Elaine. Basically, Ackerman and Associates has a 60%direct payment to providers and a 40%overhead rate. All social services programs submitted are justifiable within this framework as shown by the submitted budget worksheets. Please contact me to resolve any questions. We look forward to continued work with WCDSS. Sincerely,00yy� ppV.�� Joyce Sh het Ack �Ed.C� �- Ackerman and Associates P.C. 2 a DEPARTMENT OF SOCIAL SERVICES P.O. BOX A GREELEY,CO. 80632 Website:www.co.weld.co.us ipe Administration and Public Assistance(970)352-1551 Child Support(970)352-6933 COLORADO April 18,2005 Joyce Ackerman Ed. D. Ackerman&Associates,P.C. 1750 25th Avenue, Suite 101 Greeley,CO 80631 Re: RFP 05007-Sex Abuse Treatment RFP 05008-Mediation and Facilitation under the Intensive Family Therapy Program Area RFP 05010-Option B,Home Based Therapy RFP 05005-Lifeskills Dear Ms. Ackerman: The purpose of this letter is to outline the results of the Bid process for PY 2005-2006 and to request written information or confirmation from you by Wednesday,April 27,2005. A. Results of the Bid Process for PY 2005-2006 • Through the 2005-2006 bid evaluation process,the Families,Youth and Children (FYC)Commission recommended approval of the bids listed below for inclusion on our vendor list. 1. RFP 05007-Sex Abuse Treatment 2. RFP 05010-Option B-Intensive Home Based Therapy • Through the 2005-2006 bid evaluation process,the Families,Youth and Children (FYC)Commission recommended approval of the bid listed below for inclusion on our vendor list,attaching the following condition for all Lifeskills program providers. 1. RFP 05005-Lifeskills Condition: All providers must define their capacity to do after-hours visitation. • Through the 2005-2006 bid evaluation process,the Families,Youth and Children (FYC)Commission recommended approval of the bid listed below for inclusion on our vendor list,attaching the following condition for all Intensive Mediation program providers. • Page 2 Ackerman&Associates,P.C./Results of Bid Process for PY 2005-2006 1. RFP 05008-Intensive Mediation under the Intensive Family Therapy Program Area Condition: If a consultation has occurred between a party to this action,and any party objects to the proposed mediator because of that consultation,the mediator shall remove himself/herself from performing the mediation. • Review of Unit of Service Rate Computations for All Submitted Bids: The Unit of Rate Computations on the submitted bids did not include a non face- to-face cost sheet. Further,the overhead does not calculate correctly on the Cover Cost Sheet. B. Required Response by FYC Bidden Concerning FYC Commission Conditions: 1. FYC Commission Conditions: All conditions will be incorporated as part of your RFP Bid and Notification of Financial Assistance Award(NOFAA). If you do not accept the condition(s),you will not be authorized as a vendor unless the FYC Commission and the Weld County Department of Social Services accept your mitigating circumstances. If you do not accept the condition,you must provide in writing reasons why. A meeting will be arranged to discuss your response.Your response to the above conditions will be incorporated in the RFP Bid and Notification of Financial Assistance Award. 2. Unit of Service Rate Computations: You are requested to contact John Kruse,Business Office Manager, extension 6530, to clarify the submitted Unit of Service Rate Computations. 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, 970.352.1551, extension 6230. Sincerely, a_ y 'ego, for cc: Juan Lopez, Chair,FYC Commission Gloria Romansik, Social Services Administrator Weld County Department of Social Services Notification of Financial Assistance Award for Families,Youth and Children Commission (Core) Funds Type of Action Contract Award No. X Initial Award FY05-CORE-51 Revision (RFP-FYC-05007) Contract Award Period Name and Address of Contractor Beginning 06/01/2005 and Individual & Group Therapy Services Ending 05/31/2006 Sex Abuse Treatment 824 B 9th Street Greeley, CO 80621 Computation of Awards Description Unit of Service The issuance of the Notification of Financial This program uses primarily a non-medical, Assistance Award is based upon your Request for cognitive behavioral model, including group, Proposal (RFP). The RFP specifies the scope of individual, couples, and family therapy, focusing services and conditions of award. Except where it is in primarily on the treatment of juveniles, ages 12- conflict with this NOFAA in which case the NOFAA 18, and adults, ages 18 and up, with sexually governs, the RFP upon which this award is based is an reactive behavior. Services include assessment, integral part of the action. outpatient, group therapy, and polygraph, Chaperones group, and aftercare. Special conditions 1) Reimbursement for the Unit of Services will be based Cost Per Unit of Service on an hourly rate per child or per family. Hourly Rate Per 2) The hourly rate will be paid for only direct face-to- Treatment Package $40.60 face contact with the child and/or family, as evidenced by client-signed verification form, and as specified in Hourly Rate per Court Testimony $100.00 the unit of cost computation. 3) Unit of service costs cannot exceed the hourly and Enclosures: yearly cost per child and/or family. X Signed RFP: Exhibit A 4) Payment will only be remitted on cases open with, and Supplemental Narrative to RFP: Exhibit B referrals made by the Weld County Department of Recommendation(s) Social Services. Conditions of Approval 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 month of service. The provider must submit requests for payment on forms approved by Weld County Department of Social Services. 6) The Contractor will notify the Department of any changes in staff at the time of the change. Approvals: / l/ Program Official: By ) l� / By William H. Jerke, Chair Judy Grie Directo Board of Weld County Commissioners Weld ounty Department of Social Services Date: JUN 06 MI5 Date: ((1/2 l U Y O2005 /6'C/ 7 • SIGNED RFP: EXHIBIT A Bid 002-05 (RFP-FYC-05007) Attached A SEXUAL ABUSE TREATMENT PROGRAM BID PROPOSAL AND REQUEST FOR CONTINUATION OF AWARD UNDER FPP CORE SERVICES FUNDING FAMILY PRESERVATION PROGRAM 2005-2006 BID PROPOSAL APPLICATION PROGRAM FUNDS YEAR 2005-2006 BID 002-05,RFP-FYC-05007 NAME OF AGENCY: 2-iJ D‘✓+ b iJ AL. £ GPr2v P i tE-eo P y SEIZv ice 5 ADDRESS: ?g, (j 9-ni Jtte�-TJ (cc-e-E1tYi Cc c 3 PHONE: (911O) 3ti.3 CONTACT PERSON: i i '1 {R c'J L A L \fl. 1 cat Welt TITLE: CA car] r T.biecc�� DESCRIPTION OF FAMILY PRESERVATION PROGRAM CATEGORY: The Sexual Abuse Treatment Program must provide for therapeutic intervention through one or more modalities to prevent further sexual abuse perpetration or victimization. 12-Month approximate Project Dates: 12-month contract with actual time lines of: Start June 1,2005 Start jo- ( -05- End Mav 31,2006 l End 5-3 I-0k) TITLE OF PROJECT: Sau, —Tie Erpn EP-17 1-2i2Oic :1- r ry \ V L I E )0'0 Sc .>) inn j LPG. S I I O)O4 Name and Signature of Person Preparing Document Date \o n- P. k_xci, i-�r�, l�Pc, mc*c a 3-w - Os- Name and Signature Chief Administrative Officer Applicant Agency Date MANDATORY PROPOSAL REOUIREMENTS For both new bids and renewal bids,please initial to indicate that the following required sections are included in this Proposal for Bid. 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 Page 26 of 32 • Bid 002-05 (RFP-FYC-05007) Attached A Date of Meeting(s)with Social Services Division Supervisor: Comments b SSD Supervisor: 76 .1--o 12 % Name d Signatureervsor Date gn Page 27 of 32 Request for Proposal RFP FYC 05007 Colorado Family Preservation Act Sexual Abuse Treatment Program Individual and Group Therapy Services I. PROJECT DESCRIPTION Individual and Group Therapy Services (IGTS) will utilize a non-medical, cognitive behavioral model,focusing primarily on the treatment ofjuveniles and adults with sexually reactive behavior. This program will be geared toward providing specialized outpatient services that meet the needs of male and female clients. Adolescent groups will focus on youth between the ages of 12 to 18 years old. Adult groups will accept clients age 18 and up. Both programs will provide education, treatment, and support to ensure a safe and successful integration with the family and community. This mission of the IGTS outpatient program for sexually reactive youth and sexually violent adults is to reduce recidivism rates by: • Providing a structured environment for the safety of the client, family and community. • Increasing awareness and empathy for the victim and the impact of the offense on the victims and family members. • Fostering a family environment to effect positive change. • Developing the use of appropriate social/sexual skills and expressions through recognition of situations and stimuli that trigger sexually aggressive behavior. • Assisting family members to develop the skills necessary to recognize and understand the sexual behavior oft heir family member for the purpose of providing support while the client progresses through treatment. The IGTS outpatient program for sexually reactive youth will treat: • Male and female youth twelve (12) to eighteen (18) years of age. • Youth with current sexual offense adjudications or youth who have admitted guilt and will provide a written letter from a parent or attorney stating they plan to plead guilty. • Youth with both regular intelligence and developmental delays. The IGTS outpatient program for sexually aggressive adults will treat: • Male and female adults age eighteen (18) and up. • Clients who have been found guilty of a sexual offense or have a written letter from an attorney stating they plan to plead guilty. 1 Program services for clients include: • Psychosexual testing and evaluation • Polygraph administration • Offense-specific group therapy • Individual, couples and/or family therapy • Informed Supervision groups - youth (1.5 hours/month) • Chaperones Group - adults (1.5 hours/month) • Relationship and interpersonal social skills • Sex education • Interdisciplinary team meetings (monthly or as needed) • Victim empathy and awareness • Anger management/impulse control skills • Cognitive behavioral modification • Self-esteem building • Values clarification and examination • Relapse prevention plan • Aftercare services II. TARGET/ELIGIBILITY POPULATIONS Guidelines for conducted offense-specific groups indicate that the ideal number of clients should be approximately nine youth, with a maximum group of twelve (12). As mentioned previously, clients for the offense-specific groups will include youth between the ages of 12 to 18 in the adolescent groups and clients 18 and up in the adult groups. Total family units will coincide with the number of youth in the offense-specific program. Bilingual services will be provided for Spanish-speaking clients. Offense-specific services, including individual, group, couples, and family therapy,will be provided at IGTS in Greeley. Additional services can be offered in the South Weld County area, if a minimum of five(5) clients need services. Bilingual services will be limited to 12 clients. All eligible Weld County families will have to arrange transportation to the group location. Emergency services are available nights and weekends for all clients or families in crisis. Monthly maximum capacity will be limited to 12 youth and their families, with monthly average capacity expected at 10. Due to the intensity of the program, youth are expected to complete the program in an average of 32 weeks. Adults can be expected to complete the program in a minimum of 104 weeks. Average hours per week in the program are expected at approximately 2.5 hours per week for adolescents and 5 hours per week for adults. Adult group maximum capacity will also be limited to 12. III. TYPE OF SERVICES TO BE PROVIDED Before clients can be accepted into the outpatient program, a psychosexual assessment is necessary to determine whether an outpatient program will be appropriate for the youth. Assessment 2 will examine six (6) areas: • The client's potential to reoffend • Amenability for treatment • Recommended treatment setting • Type of treatment needed • Risk factors/monitoring/potential new victims • Psychiatric/substance abuse/individual/family needs • Mental health concerns Assessment will include: • A structured clinical interview. • Collateral information from schools, caseworkers, probation/parole officers, therapists, doctors, courts, police reports or other relevant sources Other assessments tools may include (depending on the age of the offender and circumstances of the case): • HARE PCL-R(utilized in cases where psychopathy is to be assessed) • Minnesota Multiphasic Personality Inventory-II (measures personality traits) • Jessness 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) • Penile Plethysmograph (measures deviant and non-deviant arousal) Assessments may reveal the need for additional treatment,such as medication evaluation and monitoring of substance abuse, and/or substance abuse treatment. Referrals will be made to the appropriate agencies to address these treatment needs. Results of the initial assessment will indicate what treatment goals will need to be addressed. Measurable treatment goals will be developed and monitored on a monthly basis. Therapy for adolescents and adult sexual abusers consists of a cognitive behavioral, "carefrontational"model. Studies have shown that caring confrontation (pointing out client errors in thinking and behavior while treating the client with respect) is the most effective way of motivating the client to make changes. This model also focuses on the various types of abuse that clients have committed in addition to their deviant sexual behavior, including physical, emotional, verbal and psychological. Understanding of when sexual behavior is abusive will be taught by 3 helping clients understand the concept of consent and the SAFE formula(Secret,Abusive,Feelings, and Empty). An integral part of assessment will include a polygraph during portions of the program, as well as shortly before discharge from the program. The purpose of the polygraph includes: • Encouragement of more disclosure of additional victims or other deviant sexual behavior. • Monitoring for honesty of client to assess progress in treatment. Clients will also be introduced to the sexual abuse cycle. The cycle will be used throughout group therapy to help youth understand their personal abuse cycle,and develop ways they can make their behavioral patterns more functional. Part of the abuse cycle will include how defense mechanisms and cognitive distortions contribute to the continuation of the cycle. Clients will learn Rational Emotive Therapy, which will help them understand how their thoughts and feelings contribute to their behavior, to assist in changing faulty behavior patterns. An important part of group therapy will be addressing victim empathy. Clients will learn to read cues from others, interpret them accurately, and validate what they have heard from others. The goal is for clients to identify an empathic experience or interaction, and eventually develop empathic foresight on how their behavior affects others. An essential part of developing empathy includes addressing the client's own victimization, if applicable, and how it affected their own choices. Since the ultimate goal of offense-specific treatment is to prevent recidivism, clients will focus on developing a comprehensive relapse prevention plan, which will provide them with their own individual guidelines to prevent further deviant sexual behavior. Clients will review their relapse prevention plan during group with therapists and group members who are familiar with the client's offense to assist in developing a plan that will minimize the possibility for reoffense. Informed supervision is essential to help the adolescent remain safe at home and in the community. Informed supervision groups provide two essential elements: • Improve parental understanding of the pattern of sexual abuse. • Develop a support group with other parents to gain acknowledgment from others about their experiences as parents of sexually reactive youth. Family therapy will focus on the situations at home that may have contributed to past abuse, and what interventions would be necessary in order to provide a safe home environment for all family members. This may include sorting out feelings for each family member about the abuse, reunifying family members, and assessing how families can contribute to improving safety in the home. Family members will also learn how to support the client while he/she completes the therapy process. Parenting education and conflict resolution for family members will also be addressed. Victims who are part of the family will be included in family therapy when the client has progressed to the point where they are considered to be safe and the victim is ready to have contact. Adult 4 offenders are initially not allowed to have contact with anyone under the age of 18, but have the option of attending couples therapy. Chaperones group is offered for adult family members or spouses to develop the skills necessary to have contact with children under the supervision of trained adults. Like the informed supervision group, the purposes of the chaperones group are: • Improve understanding of the pattern of sexual abuse for adult offenders. • Develop a support group to gain acknowledgment from others about their experiences as significant others with family members who have been sexually aggressive. Aftercare will be provided for clients who have successfully completed an offense specific treatment program. Adolescent clients will begin attending groups weekly,then drop to bi-weekly, with the plan of releasing the client from aftercare treatment within six months. Aftercare will focus on providing the client with healthy and non-deviant ways of experiencing their sexuality. IV. MEASURABLE OUTCOMES Upon completion of the program, clients should be able to demonstrate the following behaviors: • Consistently defines all sexually abusive behavior • Acknowledges risk by demonstrating foresight and using safety planning • Consistently recognizes/interrupts sexual abuse cycle • Demonstrates new coping skills and develops stress management techniques • Demonstrates victim empathy and understands how his/her behavior effects the victim, family, community, etc. • Displays accurate attributions of responsibility for offending behavior • Able to manage frustration and unfavorable events • Rejects sexually abusive thoughts as dissonant with self image • Demonstrates pro-social relationship skills • Projects positive self image • Demonstrates ability to resolve conflicts and make decisions • Celebrates appropriate behavior and experiences pro-social pleasure • Works/struggles to achieve delayed gratification • Able to communicate assertively • Develops family and/or community support systems • Has an adaptive sense of purpose and future Tracking progress through the program will take place in the following manner: • Upon acceptance into group,clients will receive an individualized treatment plan that will outline what the client needs to accomplish in order to complete treatment. Therapists will be checking on the progress each client is making on their treatment 5 plan. Changes and updates will be made on treatment plans as needed. • Group notes will be compiled by clients after each group. The therapist will evaluate whether the client is understanding the concepts presented during groups. Feedback will be provided at the start of the next group to help the client obtain maximum benefit from groups. • Polygraphs will be conducted periodically to determine whether clients are being truthful regarding their referring offense, their current and continued safety in the community, and their sexual history. • For adult offenders,penile plethysmographs will be administered as needed to assist with arousal management. • The multi-disciplinary team will meet monthly to discuss client's progress in the program. Any major concerns that arise prior to the monthly meeting will be discussed with the case worker, probation or parole officer within 48 hours. V. SERVICE OBJECTIVES The primary objective of IGTS will be to provide safety for the victim and the community, decrease recidivism, and help clients develop healthy sexuality. Successful completion of this objective requires addressing issues in the following areas: • Improve parental competency- Parents will initially be assessed to determine their level of parenting skills. Parents will be referred to parenting education to increase their skill level. Parents of adolescent offenders will be monitored weekly in family therapy to check on behaviors occurring at home, and help parents understand "red flags"that indicate potential problem areas regarding safety in the home. Informed supervision groups will offer educational information on the "nuts and bolts" of sexual abuse(e.g.,polygraphs,the legal process of adjudication,thinking errors,etc.) Parents will also be encouraged to talk about their experiences and share support and information with each other. Progress will be measured by verbal demonstration of understanding of the concepts,successful completion of homework assignments,and participation in group discussion. For adult offenders who have children,parental competency will focus on assisting the non- offending parent in developing skills to support the children remaining in the home, especially children who are incest victims. Chaperones group educates the non-offending partner in supervision, safety, and support necessary to provide in-line-of-sight supervision while clients are visiting their children or other minors. Progress will be measured by the same criteria listed above for parents of juvenile offenders. • Improve family conflict management-Families will learn to talk about the underlying feelings resulting in anger and conflict at home. Family culture will be explored,and family members will learn to develop family meetings, 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. 6 • Improve personal and individual competencies-Upon acceptance into the program, clients will be assessed to determine deficiency areas. Problems that are not specifically limited to sexually inappropriate behavior, but may affect the client's ability to be successful in class, will be addressed in individual therapy. Sanctions group is also available to adult offenders to help them understand and change their destructive behaviors that hinder their progress in therapy. Sexual abuse issues will be discussed in group therapy. Clients will learn to describe the sexual abuse cycle in detail, and identify each step of the cycle as it pertains to their own abuse. Clients will also be able to explain cognitive distortions and thinking errors in relation to the sexual abuse cycle. Empathy training will include teaching clients to accurately read cues from others, interpret cues from others, and check for understanding by validating cues. Clients will learn to experience empathic interactions from others and will develop the ability to understand in advance how their actions affect others. To assist in controlling deviant fantasies, clients will be taught arousal management,which will assist them in extinguishing deviant thoughts and replacing them with positive, caring sexual thoughts. Finally, clients will address their own abuse, and learn how their abuse led to t heir choice to abuse others. Progress will be measured by successful completion of assignments, increasingly appropriate contributions in groups, completion of non-deceptive polygraphs as scheduled, and reports from family members, school, therapists, and the inter- disciplinary team. • Improve ability to access resources-An essential part of the psychosexual evaluation includes assessing what resources clients and their families need to have a successful transition back to the community. Recommendations will be made as a part of the assessment process and will assist clients and their families in locating these resources as they are identified. Progress will be measured by successful follow through by clients or non-offending partners. VI. WORKLOAD STANDARDS A. Number of hours per day/week/month Day- maximum of two hours per day Week-maximum of four hours per week Month-16 hours per month B. Number of individuals providing treatment 2 - Group therapists 1 - Individual/family therapists C. Maximum caseload per worker= 12 D. Modality of treatment will be cognitive/behavioral format, including group, individual, couples and family therapy 7 E. See A above F. Total number of individuals providing services = 3 G. Maximum caseload per supervisor= 12 H. See D above I. See enclosed insurance agreement VII. STAFF QUALIFICATIONS A. The IGTS adolescent and adult program for sexual offenders will meet or exceed the minimum qualifications in education and experience. Services will be provided by three 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. These therapists are Licensed Professional Counselors for the State of Colorado. B. Total staff available for the project= 4 C. Three therapists are SOMB approved to provide adolescent treatment. Two therapists are SOMB approved to provide adolescent, developmentally delayed offenders, and adult treatment, evaluations, and plethysmography. Therapists who are not fully approved in these areas are directly supervised by fully approved SOMB providers. IGTS follows all SOMB rules and regulations for adults and adolescents. 8 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.) 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(7...It ‘' DEPARTMENT OF SOCIAL SERVICES P.O.BOX A ff TIN GREELEY,CO. 80632 Website:www.co.weld.co.us Administration and Public Assistance(970)352-1551 .C Support(970)352-6933 April 18,2005 RADO 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 i 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 Bidden Concerning PVC Commission Conditions: All conditions will be incorporated as part of your Bid and Notification of Financial Assistance Award(NOFAA). If you do not accept the condition(s),you will not be authorized as a vendor unless the FYC Commission and the Weld County Department of Social Services accept your mitigating circumstances.If you do not accept the condition, you must provide in writing reasons why. A meeting will be arranged to discuss your response.Your response to the above conditions will be incorporated in the Bid and Notification of Financial Assistance Award. Page 2 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, a J A. go,air for cc: Juan Lopez,Chair,FYC Commission Gloria Romansik, Social 05/10/2005 19:48 9703530371 IGTS PAGE 01 individual & Group Tkerap9 Services 824-1S 9th Street, Grcele9,Colorado,80631 • ph,970353.8171 • rax:970353.0371 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' (IGTS)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 front 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, t~ fJ� CST 1• ' (J� Kim R.Ruybal, MA, LPC,NCACII Executive Director • ramify • Couples • Adolescents - Victim Services • Mental Health Assessments Domestic Violence t vale Lion and Treatment • SOME Evaluation,Treatment and PIcthysmography 05/10/2005 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: S�O'�. P t FAX #: 353- S-)r FROM: 4<y"'� Pak DATE: /QQ `,11/O/O� � /J RE: &a/ PA-61)OS`C-t 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: Hello