HomeMy WebLinkAbout20041634.tiff RESOLUTION
RE: APPROVE FIVE NOTIFICATION OF FINANCIAL ASSISTANCE AWARDS WITH
VARIOUS PROVIDERS FOR HOME STUDY, UPDATES, AND RELINQUISHMENT
COUNSELING AND AUTHORIZE CHAIR TO SIGN
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with five Notification of Financial Assistance
Awards for Home Study, Updates, and Relinquishment Counseling between the County of Weld,
State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf
of the Department of Social Services,and the following providers,commencing June 1,2004,and
ending May 31, 2005, with further terms and conditions being as stated in said awards:
1) Transitions Psychology Group, LLC
2) Julie Box
3) Lori Kochevar, LLC
4) North Colorado Medical Center-Youth Passages
5) Ackerman and Associates, P.C., and
WHEREAS,after review, the Board deems it advisable to approve said awards, copies of
which are attached hereto and incorporated herein by reference.
NOW,THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld
County, Colorado, ex-officio Board of Social Services, that the five Notification of Financial
Assistance Awards for Home Study, Updates,and Relinquishment Counseling between the County
of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County,
on behalf of the Department of Social Services,and the above listed providers be,and hereby are,
approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to
sign said awards.
2004-1634
SS0031
ng; SS C) Oo �3 ��
FIVE NOTIFICATION OF FINANCIAL ASSISTANCE AWARDS FOR HOME STUDY, UPDATES,
AND RELINQUISHMENT COUNSELING
PAGE 2
The above and foregoing Resolution was,on motion duly made and seconded,adopted by
the following vote on the 16th day of June, A.D., 2004, NUNC PRO TUNC June 1, 2004.
dessar.„. BOARD OF COUNTY COMMISSIONERS
,/4114/ 4% WELD CO N , COLORADO
rur ( .*APK O Robert D. Malden, Chair
rk to the Board
prr
4% j \i I� c � William H. ke, Pro-Tem
Deputy Clerk to the Board Q.. _2
M. eile
O D AS TO
David . Long
ty or y
Glenn Vaad
Date of signature: G -4-n'-Oy
2004-1634
SS0031
‘......;:,6 t DEPARTMENT OF SOCIAL SERVICES
P.O. BOX A
GREELEY,CO. 80632
' Website:www.co.weld.co.us
iii Administration and Public Assistance(970)352-1551
Child Support(970)352-6933
O
•
COLORADO
MEMORANDUM
TO: Robert D. Masden, Chair Date: June 14, 2004
Board of County Commissioners FR: Judy A. Griego, Director, Social Services fU0t1l6t4_t9JO
LI
RE: Notification of Financial Assistance Awards for Home Study, H ome
Study Updates, and Relinquishment Counseling with Various Providers
Enclosed for Board approval are Notification of Financial Assistance Awards (NOFAAs) for
Home Study, Home Study Updates, and Relinquishment Counseling between the Weld County
Department of Social Services and various providers. The NOFAAs are based upon the
provider's Request for Proposal,which has been reviewed and approved by the Families, Youth
and Children(FYC) Commission. The NOFAAs were reviewed at the Board's Work Session of
June 14, 2004.
The major provisions of the NOFAA are as follows:
1. The term period is from June 1, 2004 through May 31, 2005.
2. The Department agrees to reimburse providers under Child Welfare Administration
funding according to the NOFAA and their respective bid proposal for Home Study,
Home Study Updates, and Relinquishment Counseling. These homes studies assess the
suitability of foster care and adoptive homes for children in the custody of Social
Services. The provider will conduct home studies in compliance with the uniform format
utilized by the State of Colorado Department of Human Services since October 1, 1999,
and be listed on the State's home study vendor list. Relinquishment counseling, at a
minimum, will be provided in conformance with Section 19-5-103(1)(b)(II), C.R.S,that
provides for a standardized form prescribed by the judicial department.
3. Providers will be reimbursed according to various rates as provided below:
Vendor Name Rate
A. Transitions Psychology Group,LLC $975.00 per full home study
$585.00 per updated home study
2004-1634
$97.50 per hour(relinquishment
counseling)
B. Julie Box,Private Practice $850.00 per full home study with
background
$750.00 per full home study
$425.00 per updated home study
• $225.00 per home study cancelled(3
hr. minimum direct face-to-face
contact)
$200.00 additional fee for additional
adult per home study
$103.89 per hour(relinquishment
counseling)
C. Lori Kochevar LLC $975.76 per full home study for foster
parents only
$525.00 per updated home study
$275.00 additional fee for additional
adult per home study
$252.24 per session-2 hour maximum
(relinquishment counseling)
D. North Colorado Medical Center—Youth Passages $800.00 per full home study(5
interviews)
$848.00 per full home study(6
interviews)
$896.00 per full home study(7
interviews)
$944.00 per full home study(8
interviews)
$1,040.00 per full home study(9
interviews)
$530.00 per updated home study
$71.00 per hour(relinquishment
counseling)
E. Ackerman and Associates P.C. $960.00 per full home study
$640.00 per updated home study
$250.00 per session(relinquishment
counseling)
If you have any questions,please contact me at extension 6510.
Weld County Department of Social Services
Notification of Financial Assistance Award
for Child Welfare Regular Administration
Type of Action Contract Award No.
X Initial Award 04-HS-0029
Revision (RFP-06-000)
Contract Award Period Name and Address of Contractor
Beginning 06/01/2004 and Transitions Psychology Group
Ending 05/31/2005 Home Study,Updates, and Relinquishment Counseling
804 11`h Avenue
Greeley, CO 80631
Computation of Awards Description
Unit of Service The issuance of the Notification of Financial
Capacity for three new referrals per month,two Assistance Award is based upon your Request for
new referrals per month for updates,and four Proposal (RFP). The RFP specifies the scope of
referrals per month for relinquishment services and conditions of award. Except where it is
counseling.Total monthly capacity is 16 in conflict with this NOFAA in which case the
families, with a monthly average of 10 families. NOFAA governs,the RFP upon which this award is
Approximately 80 individuals would receive based is an integral part of the action.
Bilingual-bicultural services, and an estimated Special conditions
130 individuals would receive services in South 1) Reimbursement for the Unit of Service will be based
Weld County. The average stay in the program on a rate per home study; home study update,and
is six weeks for home studies, four weeks for relinquishment counseling session.
updates and relinquishment counseling,with an 2) Reimbursement requests must be an original with an
average of two hours participation per week. original signature from the provider and/or designee.
Services are available in English, Spanish, and 3) Reimbursements requests must include the date the
Japanese. home study,update, or relinquishment counseling was
Cost Per Unit of Service completed.The request must reflect the referral
Rate per Study number assigned to each home study,the amount
Full Home Study $975.00 billed for each home study,and the month the service
Updated Home Study $585.00 was provided.
Hourly Rate per 4) Payment will only be remitted on referrals made by
Relinquishment Counseling $ 97.50 the Weld County Department of Social Services.
5) Requests for payment must be an original submitted
Unit of Service Based on Approved Plan 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
Enclosures: requests for payment on forms approved by Weld
X Signed RFP:Exhibit A County Department of Social Services.
X Supplemental Narrative to RFP: Exhibit B 6) The Contractor will notify the Department of any
Recommendation(s) changes in staff at the time of the change.
X Conditions of Approval
Approvals: �p Program Official:
By VA k S 5/Of
Robert D. Masden,Chair J y . o, Dire r
Board of Weld County Commissioners W Coun Department of Social Services
Date: JUN 16 2004 Date:
:@O /-✓6csize
, •
•
SIGNED RFP-EXHIBIT A
• ' INVITATION TO BID
DATE:February 11, 2004 Off System Bid No. B002-04 RFP FYC 006-00B
RETURN BID TO: Pat Persichino,Director of General Services
915 10th Street,P.O. Box 758, Greeley, CO 80632
SUMMARY
Request for Proposal(RFP-FYC 006-00B) for: Adoption,Foster Care, and Expedited Permanency
Planning Home Studies, and Relinquishment Counseling
Deadline: March 5,2004,Friday, 10:00 a.m.
The Families, Youth and Children Commission, an advisory commission to the Weld County Department of
Social Services,announces that competing applications will be accepted for approved vendors pursuant to the
Board of Weld County Commissioners' authority pursuant to Colorado Statute and the Weld County Home
Rule Charter. The Families,Youth and Children Commission wishes to approve services targeted to run
from June 1,2004, through May 31, 2005, at specific rates for home studies,home study updates, and
relinquishment counseling services. The County will authorize approved vendors and rates for services only.
This program announcement consists of five parts, as follows:
PART A...Administrative Information PART D...Bidder Response Format
PART B...Background,Overview and Goals PART E...Bid Evaluation Process
PART C...Statement of Work •Delivery Date Girt o V S • � ee IJ
(After receipt of order) BID MUST BE SIGNED IN INK
iI'ED PRINTED SIGNATURE
Trams bh
VENDOR P4,Seciy aro 199, LLL
(Name) Handwritten Signature By Authorized
Officer or Agent of Vender
ADDRESS Gre eAll L4 �OVbI TITLE c. -(2-if"! -
DATE its (rt)
PHONE# (gib) 3% l Ir))
The above bid is subject to Terms and Conditions as attached hereto and incorporated.
Page 1 of 34
Off-System Bid No. B002-04 RFP-FYC-006-00B Attached A
• ' HOME STUDY,UPDATE, & RELINQUISHMENT COUNSELING BID PROPOSAL AND
REQUEST FOR CONTINUATION OF AWARD UNDER
CHILD WELFARE ADMINISTRATION FUNDING
2004-2005 BID PROPOSAL APPLICATION
PROGRAM FUNDS YEAR 2004-2005
BID Off-System/ _I Bid B002-04 RFP-FYC-006-00B
NAME OF AGENCY: Tra051}f Gn5 P50Lhd03y frog[ L.LC-
ADDRESS: t Ave, Cele / LD e0(D3 IPHONE: ('t33(-1 I23
CONTACT PERSON: 34 171 i We"ita.dint n Nitl-PG TITLE: CO-DW V l e
DESCRIPTION OF HOME STUDY PROGRAM CATEGORY: Adoption,Foster Care,and Expedited Permanency Planning
Home Studies in compliance with the uniform format utilized by the State of Colorado Department of Human Services since
October 1, 1999(Attached A).
11-Month approximate Project Dates: 12-month contract with actual time lines of:
Start June 1,2004 Start
End May 31.2005 J End
TITLE OF PROJECT: V'i&shay
Torn we-l-IZtrbnan 6/1On0 o'/os/oy-
Name and Signature of Person Preparing Document Date /dry S. Cred,e( 511-110Clal 3 Name and Signature Chief Administrative Officer Applicant Agency Date
MANDATORY PROPOSAL REQUIREMENTS
For new and renewal bids,please initial to indicate that the following required sections are included in this Proposal for Bid.
For renewal bids,please indicate which of the required sections have not changed from Program Year 2003-2004 to Program
e 2004-2005. ( at( hadcoVnecktti4.C9)
oject Description _Project Description
ample Home Study _Sample Home Study
Tar et/Eligibility Populations _ Target/Eligibility Populations
General General
ultural/Eligibility Populations Cultural/Eligibility Populations
ypes of services provided _Types of services provided
Measurable Outcomes _ Measurable Outcomes
Service Objectives Service Objectives
Workload Standards _ Workload Standards
Staff Qualifications _ Staff Qualifications
Unit of Service Rate Computation _ Unit of Service Rate Computation
o Capacity per Month _ Program Capacity per Month
Certificate of Insurance
Page 23 of 34
Home Study Program Bid Proposal Transitions Psychology, LLC 1
2004-2005• ipar• • • ♦ Home Study, Update and Relinquishment
• •� • Counseling Bid Proposal
oak ♦
•w 2004-2005
•
• •
• •• ♦ . .
Transitions
PSYCHOLOGY GROUP, LLC
I. PROJECT DESCRIPTION
Transitions Psychology Group, LLC is a private counseling agency consisting
of a multidisciplinary team of human service professionals, including Licensed
Psychologist and School Psychologist, Licensed Professional Counselors,
Licensed Clinical Social Worker and other degreed paraprofessionals.
Transitions provides superior counseling, assessment and consultation
services to children and families in Northern Colorado. The purpose of the
Home Study, Update and Relinquishment Counseling program is to provide
quality home assessment and consultation services to expedite permanency
placements of children in Weld County.
A. Home Study
The Home Study segment of the program strives to effectively and efficiently
evaluate prospective foster and adoptive homes in order to provide for safe,
nurturing environments for children as quickly as possible. A Home Study
begins with a referral from a Weld County caseworker. A staff member from
Transitions Psychology Group, LLC (hereafter referred to as "Transitions")
begins the study by gathering background and reference information. The
family is asked to complete an application, self-study forms and a FACES II
(Family Adaptability and Cohesion Evaluation Scales) assessment form.
Next, a Transitions counselor contacts the referred parent in order to
schedule a Family Screening. The Family Screening interview is held in the
family's home and includes all members of the household. The home, yard
and neighborhood are viewed by the Transitions counselor at this time.
When the screening process is completed, a second Transitions counselor
meets with the prospective foster/adoptive parents for a Parental Unit
interview. The joint interview is followed by Individual Interviews of each
parent and child in the home, as age appropriate. The Clinical Rating Scale
(CRS) is then completed. Both Transitions counselors involved in the
interviews with the family then meet with the Transitions supervisor for the
Home Study Program Bid Proposal Transitions Psychology, LLC 2
2004-2005
Team Consultation. The team identifies further areas to explore and makes
recommendations. The second Transitions counselor meets again with the
parental unit, with part of this Final Interview usually including all of the
members of the household. The information collected is compiled into a
written report that follows the State of Colorado format. The written report is
submitted to the referring caseworker, along with all of the background check
and reference materials.
B. Update
The Update program begins with a review of the prior Home Study. A
counselor from Transitions then interviews the Parental Unit to discuss any
changes in the family since the previous Home Study. Following this
interview, the counselor meets with the entire household to view the home
and observe interactions among family members.
C. Relinquishment Counseling
The Relinquishment Counseling program consists of two individual sessions
with a parent referred by Weld County who is considering relinquishing a
child. A minimum of six days will transpire between the two sessions and the
sessions will address all of the components of the Weld County Department
of Social Services Relinquishment Counseling Outline.
II. SAMPLE HOME STUDY
See attached copy.
III. TARGET/ELIGIBILITY POPULATIONS
The Home Study, Update and Relinquishment Counseling Program
serves adults of Weld County, who are interested in foster parenting,
becoming foster/adoptive parents or relinquishing children. Program
participants must be referred by the Weld County Department of Social
Services. Transitions does not discriminate based on race, color,
religion, national origin or sex, in accordance with State and Federal
Laws, rules and regulations.
The Transitions program can serve a total of 108 family units, including
72 families for Home Studies, 24 families for Home Study Updates and
12 families for relinquishment counseling. The 108 family units would
consist of approximately 396 individuals. Of the 396 individuals, 192
Home Study Program Bid Proposal Transitions Psychology, LLC 3
2004-2005
would be children ages 0-18. Eighty individuals could receive bilingual
services and approximately 130 will receive services in South Weld
County. All individuals in the Transitions program can typically access
a counselor between 8 AM and 8 PM, Monday through Friday.
Twenty-four hour services are not provided as part of the Home Study,
Update and Relinquishment Counseling Program. The monthly
maximum program capacity would be 16 families, with an average of
10 active families each month. The average stay in the program would
be six weeks for Home Studies and four weeks for Updates and
Relinquishment Counseling. The average hours per week in the
program would be two per family.
IV. TYPES OF SERVICES PROVIDED
Transitions will provide Home Studies, Updates and Relinquishment
Counseling as referred by the Weld County Department of Social
Services. These services will not supplant existing services in the
community, as these services are not funded by mental health
capitation services, ADAD or other funding.
A. Home Study
1. Background Checks and References
A Transitions staff member contacts the family to collect
information for the background checks. The family will be
asked to complete an application, release of information,
self-study forms and FACES II family assessment forms.
All adults in the household will be supplied with fingerprint
cards to complete the CBI checks (FBI checks will be
performed on individuals who have resided in CO for less
than two years). Transitions will collect and submit the
fingerprint cards, incurring the costs for fingerprint
processing for individuals referred by Weld County child
protection caseworkers. Prospective foster/adoptive
parents will be responsible for their own fingerprint
processing cost. Additionally, Transitions will pay for and
complete background checks with the local police
department and the Department of Motor Vehicles.
Transitions will distribute reference forms to up to four
references provided by applicants. The reference persons
will be provided with a postage paid return envelope in
which to return the reference form.
• Home Study Program Bid Proposal Transitions Psychology, LLC 4
2004-2005
2. Family Screening
A counselor from Transitions meets with all the members
of the prospective foster family in the family home. The
counselor explains the Home Study process, reviews the
application and assesses family interactions and
functioning.
3. Parental Unit Interview
A second counselor from Transitions meets with the
prospective parent(s) to review the elements of the self-
studies and evaluate the parental unit's ability to function
as caretakers of children. This interview will occur at least
one week after the Family Screening and will be held in the
family home.
4. Family Assessments
Transitions uses a multidimensional assessment package,
which measures the dimensions of cohesion, adaptability,
and communication. The package, which includes the
FACES II and CRS (Clinical Rating Scales), utilizes the
self-reports of adult and adolescent family members and
the observations of the counselor to assess individual,
couple and family functioning. This provides Transitions
with an "insider's perspective" as well as a professional
perspective of the family.
5. Individual Interviews
Following the Parental Unit Interview, in households with
more than one parent, each parent will be interviewed
individually. These interviews focus on evaluating each
parent's general functioning, personal history, views on
childrearing and motivation to become a foster parent. An
age appropriate, developmentally sensitive interview will
also be held with each child residing in the home. The
purpose of these interviews will be to assess the probable
impact of fostering on the child and explore any child
issues that could adversely impact foster children. The
location of the individual interviews will be either in the
family home or in the Transitions office at the counselor's
discretion.
6. Team Consultation
After the majority of the information from the Home Study
has been compiled, both Transitions counselors involved in
the Home Study meet with the Transitions supervisor to
review the case. The team specifies areas for further
•• Home Study Program Bid Proposal Transitions Psychology, LLC 5
2004-2005
exploration, develops conclusions and delineates specific
recommendations for the family.
7. Final Interview
The parental unit is interviewed again to address the
issues identified in the Team Consultation. The counselor
will then share some of their perceptions with the family
and any recommendations made by the team.
8. Written Report
Within six weeks of the receipt of the Home Study request
from Weld County, the Transitions counselor will submit a
written report to the referring caseworker. The report will
follow the State of Colorado format. Included with the
report will be the original fingerprint cards, CBI or FBI
reports, original written reference forms and copies of the
self-studies. After submitting the report, the Transitions
counselor will contact the referring caseworker to ensure
that the report was received and compiled satisfactorily.
B. Update
1. Review of the Initial Home Study
A Transitions counselor will review the previous Home
Study and/or updates. The counselor will then contact
the referring Weld County caseworker in order to
determine the focus of the Update.
2. Parental Unit Interview
Parent(s) will meet with a Transitions counselor to
discuss any changes that have occurred since the last
Home Study or Update. Family strengths will be re-
evaluated and progress towards improving areas of need
identified in the previous study will be determined.
3. Family Interview and Home Inspection
At least seven days following the Parental Unit Interview,
The Transitions counselor will meet with all members of
the household in the family home. The counselor will
view the home and observe the interactions among
family members.
4. Supervisory Consultation
Home Study Program Bid Proposal Transitions Psychology, LLC 6
2004-2005
The Transitions counselor will meet with the Transitions
supervisor to discuss the case and make
recommendations.
5. Written Report
The Transitions counselor will submit a written report to
the referring caseworker within one month of the date on
which the Update request was received. The report will
include specific recommendations regarding the family's
ability to provide a safe, nurturing environment for
children.
C. Relinquishment Counseling
1. Individual Parent Consultation
After receiving a referral from a Weld County caseworker, a
Transitions counselor will meet with the referred parent to address
questions from the Weld County Relinquishment Counseling
Outline.
2. Follow-up Consultation and Review
At least seven days after the first parent consultation session, the
Transitions counselor will again meet with the referred parent to
review the previous session, check for understanding and address
any further questions the parent may have. The counselor will also
provide the parent with referrals and recommendations for other
services as deemed appropriate.
3. Written Report
The Transitions counselor will provide a written description of the
services provided that addresses all of the questions in the Weld
County Relinquishment Counseling Outline. It will be submitted to
the referring Weld County caseworker within one month of the date
on which the referral was received.
V. MEASURABLE OUTCOMES
A. More Expedient Placement of Children
Transitions will track the date on which the referrals from the Weld County
caseworker are received as well as the date the Transitions reports are
submitted to the referring Weld County Caseworker. There will be no
more than six weeks that transpire between the date of the receipt of the
• Home Study Program Bid Proposal Transitions Psychology, LLC 7
2004-2005
referral and the date the report is submitted to the county for Home
Studies. Reports for Home Study Updates and Relinquishment
Counseling will be submitted within one month of the receipt of the referral.
If Transitions experiences delays, (i.e. applicants not completing fingerprint
cards or applicant vacations), the referring caseworker will be notified and
an adjusted time line will be determined. Submitting the vast majority of
the reports within the one month and six week time parameters will enable
Weld County caseworkers to place children more quickly. To further
facilitate caseworkers' decisions regarding placement, Transitions will
perform an internal review of each Home Study and Update to ensure that
it includes definitive conclusions and specific recommendations regarding
the viability of referred families to become foster or adoptive homes.
B. Quality Adoptive Home Studies Done in a Timely Manner
Transitions' Home Studies, Updates and Relinquishment Counseling,
including bilingual services, will be performed only by degreed human
service professionals. Transitions counselors possess Master's Degrees
in a human service field; all current providers are licensed by the State of
Colorado as Licensed Professional Counselors, Licensed School
Psychologists or Licensed Clinical Social Workers. Transitions' co-owner,
a licensed professional counselor, is able to provide services in English,
Spanish or Japanese. Proof of each counselor's education will be
provided to Weld County. The Transitions counselors and the supervisor
have also applied for inclusion on the State Vendor List. Transitions uses
a multidisciplinary team approach to staff each Home Study before the
final report is completed and recommendations are made. This will be
measured by at least three members of the Team Consultation, including
the initial counselor, the primary counselor and the supervisor, signing off
on the final report. Transitions will further ensure quality by performing an
internal review of all Home Study, Update and Relinquishment Counseling
reports. The reviewer will document that the review has been completed
and the proofed copy will remain in the chart. Transitions will track
received dates for Home Study, Update and Relinquishment Counseling
requests as well as the submission dates of the corresponding reports.
Home Studies will be submitted within six weeks from the received date;
Updates and Relinquishment Counseling reports will be submitted within
one month from the referral date.
C. Number of Acceptable Home Studies Submitted
The Transitions counselor submitting the written report will contact the
referring Weld County caseworker within one week to ensure that the
Home Study, Update or Relinquishment Counseling report submitted was
acceptable. Transitions staff will then document the contact in order to
track the number of acceptable studies submitted.
•
Home Study Program Bid Proposal Transitions Psychology, LLC 8
2004-2005
VI. SERVICE OBJECTIVES
A. Provide Quality Home Studies, Updates and Relinquishment
Counseling for Adoptive Parents, Foster Parents and Department
of Social Services' Clients
1. Transitions Home Studies, Updates and Relinquishment
Counseling will be performed only by degreed human
service professionals. Proof of each counselor's education
will be submitted to Weld County. All of the services
provided, including bilingual services, will be performed by
Master's level counselors, with the exception of the tasks
listed in the Background Check and Reference portion of the
home study; these tasks will be performed by
paraprofessional staff.
2. A multidisciplinary team approach will be utilized to staff
each Home Study referral before the final report is
completed and recommendations are made. This will be
measured by at least three Team Consultation participants
signing the final report: the initial counselor, primary
counselor and the supervisor. Updates will be staffed
between the primary counselor and the supervisor; both will
sign the final report.
3. Transitions will perform an internal review of all reports to
check for overall quality, writing skills, definitive conclusions
and specific recommendations. The reviewer will document
in the chart that the review has been completed.
4. The Transitions counselor submitting the Home Study will
contact the referring Weld County caseworker to ensure that
the Home Study, Update or Relinquishment Counseling
report is acceptable. Transitions staff will then document the
follow-up contact and track the number of acceptable studies
submitted.
Home Study Program Bid Proposal Transitions Psychology, LLC 9
2004-2005
VII. WORKLOAD STANDARDS
A. Number of Hours Per Day, Week or Month
Families in the Home Study program will participate for a minimum
of one hour per week for a maximum of six weeks. Update families
will participate for a minimum of three hours during the month of
service. Weld County clients referred for Relinquishment
Counseling will participate for a minimum of two hours during the
month of service.
B. Number of Individuals Providing the Services
Each Home Study will be performed by two individuals: one
counselor who conducts the initial Family Screening and another
counselor who completes the remaining interviews of the family
members and produces the report. A licensed psychologist will
also be involved in the Home Study in a supervisory capacity, to
assist with evaluation and recommendations. However, the
supervisor will typically not have direct contact with the referred
family. Updates will be performed by one counselor, but will also
have the Team Consultation component for evaluation and
recommendations. Relinquishment counseling will be performed by
one Master's level, licensed counselor or social worker.
C. Maximum Caseload Per Worker
Each counselor will not carry more than four open Home Studies or
Updates at any time. Counselors will not carry more than two
Relinquishment Counseling cases at a time.
D. Modality of Service
Home Studies and Updates will consist of individual, couple and
family service modalities with the referred family. Most of the
services will be delivered in the family home, with the possible
exception of the Individual Interviews, which may be held in the
Transitions office. Case management services, case reviews and
consultation without the family members present are also included.
E. Total Number of Hours per Dav/Week/Month
Transitions will provide approximately 2 hours of direct services per
day, 10 hours per week and 43 hours per month.
Home Study Program Bid Proposal Transitions Psychology, LLC 10
2004-2005
F. Total Number of Individuals Providing These Services
Eight. Transitions has two co-owners, both Licensed Professional
Counselors, available to provide these services along with one
bachelor's level counselor to provide support activities, and one
Licensed Psychologist to provide supervision and case
consultation. Four additional master's level licensed professional
contractors are also available.
G. The Maximum Caseload per Supervisor
The Transitions supervisor will not exceed 24 open cases for Home
Studies and Updates.
H. Insurance
Transitions is insured through Healthcare Providers Service
Organization Purchasing Group (HPSO). The limits of liability are
$1,000,000 per occurrence and $6,000,000 aggregate. Contract
staff members maintain their own policies, each with a minimum of
$1 M/$3M liability. Current contracted staff members are insured
through HPSO and the Philadelphia Indemnity Insurance Company.
VIII. STAFF QUALIFICATIONS
A. All Transitions staff, including supervisors, who are providing direct
services have a minimum of a bachelor's degree in a human
service field. The supervisor has a Doctorate in Psychology and is
a licensed psychologist. All staff performing Home Studies,
Updates and Relinquishment Counseling have at least a Master's
degree in a human service field. All current providers are licensed
in State of Colorado as Professional Counselors, Clinical Social
Workers, or School Psychologists. Transitions staff have training
and expertise in family systems and experience working with social
services, foster/adoptive parents and foster/adopted children. The
supervisor has had four years of experience performing home
assessments. Transitions staff have applied for inclusion on the
State of Colorado Department of Human Services Vendor list.
B. Transitions has eight staff members, including a supervisor,
available for the project.
•
Home Study Program Bid Proposal Transitions Psychology, LLC 11
2004-2005
IX. UNIT OF SERVICE RATE COMPUTATION
Please see attached budget form. Flat rates are as follows: $975 for
full home study; $585 for update; relinquishment counseling is
calculated at the hourly rate of$97.50.
Transitions Psychology Group, LLC Sample Home Study Report 2004
Clark 1
••lig ♦ , HOME STUDY REPORT
•
' • 4.•�. • NAME: Clark
••• ♦ ADDRESS: 513 Walnut St.
•
•ems ' Eaton, CO 80543
• a a PHONE: (970)663-5541
transitionsDATE: 02/26/2004
PSYCHOLOGY GROUP.LLC
FULL NAME: Steven B. Clark Rebecca M. Clark
DOB: 03/06/1964 01/09/1967
BIRTHPLACE: Longmont, CO Denver, CO
OCCUPATION: Pharmaceutical Sales Interpreter/Homemaker
MARRIAGE DATE: August 24, 1986
CHILDREN IN THE HOME AGE DOB
Michael B. Clark 15 01/17/89
Joshua R. Clark 12 05/23/91
LOG OF CONTACTS
01/15/04 Referral received at Transitions
01/19/04 Initial telephone contact with family
02/03/04 Family Screening in home (Creed), 1.5 hours
02/10/04 Parental Unit Interview in home (Moe-Hartman), 1.25 hours
02/12/04 Individual Interview with Rebecca at Transitions (Moe-Hartman), 1.0 hour
02/17/04 Individual Interview with Steven at Transitions (Moe-Hartman), 1.0 hour
02/19/04 Individual Interviews with Michael & Joshua in home (Moe-Hartman), 1 hr.
02/20/04 Team Consultation, 1 hour (Moe-Hartman, Creed, Howard), 1.0 hour
02/24/04 Final Interview with family in home (Moe-Hartman), 1. hour
HISTORY
Steven Clark: Steven is the second of four boys born to Sandra and Randall Clark.
Sandra worked in the medical field as a medical assistant, receptionist and
transcriptionist; she also was a homemaker. Randall Clark worked as a farm manager.
Both of Steven's parents finished high school; his mother had some post secondary
education. Steven describes his early years as "happy" and "busy", with him and his
three brothers at home. The brothers are very close in age: all four were born within a 5
'/z year period. As a young child, Steven remembers his parents hugging each other
and the children. Steven reports that his parents' primary discipline strategies were
talking and removing privileges. He admits that he and his siblings were occasionally
disciplined with spankings, but Steven describes this as a rare occurrence
3 .
Transitions Psychology Group, LLC Sample Home Study Report 2004
Clark 2
(approximately once a year for him until age 9). In his teen years, he recalls more
fighting and resentment in the family. He attributes much of the family strife to his
father's extramarital affair. He denies any history of abuse, although acknowledges
that he and his younger brothers were often "bullied" by his oldest brother. Steven's
parents ended up divorcing when Steven was 16. His father remarried two years later,
creating a blended family with his stepmother, stepbrother and stepsister. Although
Steven was already 18 when the family blended, he continued to live with his father and
stepmother until he married at age 23. Steven describes his stepmother as very
encouraging to him. Despite his positive relationship with his mother as a child, he
describes his current relationship with her as "distant". He indicates that his mother
became very withdrawn and angry after the divorce and their relationship has never fully
recovered. His mother has since remarried twice. She has been married to her current
husband for about a year and Steven reports that she seems happy again for the first
time in many years. Steven remains connected with his father, but admits harboring
some resentment about his parents' divorce. Most of Steven's siblings remain in the
Longmont area. He states that they get along well with each other and look forward to
opportunities to spend time together. Steven attended private school throughout his
elementary and junior high school years then transferred to public school for high
school. He describes involvement in drama, sports, church youth groups, coaching
and speech team. Steven states that he graduate from high school and continued on to
college to earn his bachelor's degree. He is currently employed in pharmaceutical
sales.
Rebecca Clark: Rebecca is the second of two children born to Margaret and Robert
Price. She has one brother, David, who is three years older than she. Margaret and
Robert are highly educated; each holds master's degrees in health adminstration
according to Rebecca. Rebecca reports that her mother also holds a degree in speech
therapy. Margaret is a retired hospital administrator while Robert is a retired insurance
executive. Rebecca describes a rather idyllic, "Pollyannaish" childhood. Her family is
described as very stable (Rebecca was born and raised in the same house) and loving.
Although there were not a lot of physical displays of affection, the family spent time
together, showed respect to one another, listened and gave good advice and
compliments, according to Rebecca. Rebecca states that her parents relied primarily
on natural consequences and restricting her privileges. She adds that incurring their
disapproval was usually enough of a deterrent to getting in trouble. She denies any
abuse in her childhood. Rebecca's parents have been married for 45 years. When they
retired five years ago, they decided to become "snowbirds", splitting their time between
Colorado and California. For approximately six months of the year, Rebecca's parents
live with her in a lower level apartment in her home. Rebecca describes a close
relationship with her brother growing up but reports they do not see as much of each
other as adults because they live in different states. They maintain frequent phone
contact, according to Rebecca, and enjoy getting together a few times each year.
Rebecca is a high school graduate who also has attended two years of college in early
childhood education. She currently works as a freelance interpreter for the deaf. She
was on staff at a local school district as an interpreter until she was "let go" two months
ago. Rebecca cites additional experience, operating home daycares in Colorado and
Transitions Psychology Group, LLC Sample Home Study Report 2004
Clark 3
Georgia that accepted special needs children. Rebecca has some serious health
issues, including rheumatoid arthritis and Crohn's disease, but reports that they rarely
interfere with her daily functioning. She has been pregnant twice and birthed two
children. However, she had significant complications during both pregnancies.
ADULT GENERAL FUNCTIONING:
Steven Clark: Steven describes himself as a "helper" and mediator. He reports that he
is generally easy-going and happy, enjoying joking around and laughing. When he
loses his temper, he will either shout or sulk. He finds that when he is experiencing high
levels of stress he feels very sleepy. He copes by praying and sharing his feelings with
people in his support network. Steven indicates that he also tries to eat well and seek
out new learning opportunities or challenges. His leisure activities include golfing,
cooking and reading historical fiction. He limits television viewing to five hours per
week. Steven believes he is good at listening, leading and motivating. He describes
himself as friendly, loving, empathetic and funny. He hopes others see him as he sees
himself, as a good friend and family man.
Rebecca Clark: Rebecca sees herself as a "thinker", enjoying learning new things and
being informed. She seems very happy, warm and optimistic. She indicates that she
loves to make new friends and nurture close relationships. Rebecca describes losing
her temper only with inanimate objects, like the computer. In these situations, she may
yell and pound on the desk. When experiencing stress, Rebecca indicates that her
most effective coping skill is to go for a walk and pray to "let go and let God". Another
coping skill she has in her repertoire is calling a friend or family member to talk.
Rebecca uses nutrition and exercise to maintain her health. She also uses chiropractic
care and massage therapy when possible. Rebecca likes to relax with meditation,
prayer and reading. She also enjoys shopping, spending time with her children and
corresponding via e-mail to friends and family.
PARENTING-DISCIPLINE
Rebecca and Steven both cite that they try to establish clear expectations and
boundaries as a proactive parenting technique to avoid problems. They use other
controls that are available, such as the time-out service offered by their Internet provider
that automatically shuts down after one hour. They indicate, and the children confirm,
that they rarely have to implement consequences. Typical behavior issues with these
children include avoiding homework or watching too much television or not doing a
chore they were asked to do. When such problems occur, they try to use natural
consequences (i.e. if you miss your bus, you walk to school and get a tardy slip; if you
aren't getting your homework done because you are watching television instead, then
no television). Steven admits that he sometimes struggles with giving up this much
control, especially when it comes to academics. They have spent a lot of energy trying
to get their oldest son to complete homework, but recently have decided to allow their
15-year old son to accept full responsibility for his grades. Because he is failing a
Transitions Psychology Group, LLC Sample Home Study Report 2004
Clark 4
class, they have told him that he does not have time to play in his hockey league; he will
likely also have to repeat the class. Rebecca and Steven will also take away privileges
but report that they never use physical discipline. When they disagree about a
discipline strategy, they will use a talking exercise they learned through marriage
encounter to discuss it. Both feel confident in their parenting abilities and believe they
have developed some "tried and true" methods that they can utilize with other children.
PARENTING VALUES & PRACTICE
Rebecca and Steven both cite unconditional love as their greatest parenting strength.
As a weakness, Steven admits he is overscheduled at times and this detracts from
quality time with his children. After consulting her children, Rebecca acknowledges that
her greatest weakness as a parent is letting go of her adolescents: they tell her they
want more freedom and "their way" more often. Steven and Rebecca both indicate that
they verbalize to their children that they love them, listen to them and give them hugs.
Rebecca wants her boys to realize their potential and be good husbands and fathers.
Steven expects respect, love and a relationship from his sons. Christian values are the
center of life in the Clark home. They also acknowledge the importance of education.
The Clark children are involved in activities outside the home, including church youth
groups, hockey, tennis, basketball and swimming. Rebecca and Steven plan to
introduce their foster child as their daughter and have her involved in all aspects of their
family life.
CHILDREN
Michael Clark: Michael is described as "sweet and smart" by his mother and "loving and
giving" by his father. He has presented some parenting challenges, as Rebecca and
Steven indicate that he is diagnosed with attention deficit hyperactivity disorder. This
seems to manifest in academic problems, as Michael reportedly forgets to complete or
turn in homework. After several years of attempting different interventions to help
Michael cope with the disorder, the Clark's agreed to try medication. Michael has
reportedly been on ADHD medication for about one year. Michael enjoys hockey and
tennis; he is also involved in youth group. He also is passionate about sailing, an
activity that he does with his maternal grandfather. He is described as a popular
babysitter in the community; his mother attributes this to his special talent with young
children.
Joshua Clark: Joshua is described as a leader who is loved by friends and family.
Joshua has had some significant health problems, as he was born prematurely, has
asthma and sleep apnea. He had to use a ventilator to help him breathe at night for
many years and had heart surgery at age 6. In spite of all this, his father states that he
"has the best smile". His mother describes him as "touchy-Feely", responding to
physical displays of affection. Joshua is involved in youth group, hockey, basketball
and swimming.
Transitions Psychology Group, LLC Sample Home Study Report 2004
Clark 5
Michael and Joshua were both friendly and respectful during the interviews with both
counselors. They appear to get along very well and have minimal concerns about
sharing a room (i.e. Michael likes the room very dark to sleep while Joshua prefers
some light). The family already begins problem solving around this issue during the
interview, developing a viable solution quickly. The family has already begun to
renovate the boys' outdoor playhouse to provide them with more options for private
space when they no longer have their own bedrooms.
FAMILY SYSTEM
Family Functioning: The Clark's are a Caucasian, middle class family. They
seem to have developed some family interests and enjoy spending time together. The
family appears to have established some clear role responsibilities, but also indicate
they have some flexibility about who does what. The Clark children, ages 15 and 12,
have appropriate responsibilities to attend school, complete homework, care for family
pets and help parents with household and yard chores. At 15, Michael also has some
responsibilities to others outside the family, such as operating the church sound system,
babysitting and fundraisers. Rebecca and Steven describe utilizing a joint decision-
making process that includes prayer. Steven is reported to have some "veto" power, so
is essentially at the top of the family hierarchy. There seems to be an established
boundary between the parent and child subsystems that allows the children to have
some input into decisions affecting the family with the parents making the final decision.
The Clark family tries to maintain family dinners as a consistent arena for
communication. They report that disagreements are infrequent, but they try to talk them
out when they arise. The Clark family expresses affection towards on another with hugs
and saying "I love you".
Family Adaptability and Cohesion: Transitions uses the Family Adaptability and
Cohesion Scales(FACES)II to assess family functioning. FACES Il measures family cohesion(the
emotional bonding between family members) and family adaptability(the ability of a marital of family
system to change its power structure, role relationships and relationship rules in response to situational
and developmental stress. Family cohesion is used to assess emotional bonding, boundaries,
coalitions, time, space, friends, decision-making, interests and recreation. Family adaptability is used to
assess family power(assertiveness, control and discipline), negotiation style, role relationships and
relationship rules. There are four levels of family cohesion: disengaged, separated, connected and
enmeshed. There are also four levels of family adaptability: rigid, structured, flexible and chaotic.
The instrument assesses marital and family times in the sense of extreme types, mid-range types and
balanced types. Scores on each scale range from 1-8, with 8 being high. Overall reliability for the scale
is.90.
The Clark family describes itself as "flexible", with a family adaptability score of six;
there was a minimal discrepancy in the individual members' reports on these measures,
with each placing the family in the flexible range (a score of 5 or 6). The family
members differed on their perception of their family's cohesion. Rebecca scored a 7,
indicating that she sees the family as "very connected". Steven and Michael perceive
the family as "connected", with scores of 6 and 5 respectively. Joshua's score of 4
Transitions Psychology Group, LLC Sample Home Study Report 2004
Clark 6
indicates that he views his family as "separated". The family's combined cohesiveness
score was a six, defined as "connected", but due to the differences in the individual
reports it may not be an accurate reflection of the family. The discrepancies scores
between family members ranged from 1.4 to 3.2, with an overall family discrepancy
score of 2. This suggests that there are significant differences in the way family
members perceive their family.
Adult Relationships/Marriage:
Steven and Rebecca Clark married on August 24,1986, when Steven was 23-years old
and Rebecca 19. The couple has been married for more than 17 years and describes
their marriage as "strong". Both are committed to the relationship, identifying that their
marriage and friendship is one of the most important things in their life. They state that
they "make a conscious decision to love each other everyday, no matter what". Steven
and Rebecca have been involved in Worldwide Marriage Encounter for the last five
years. Currently, they serve as group leaders in the Rocky Mountain Region, facilitating
two to three encounter weekends each year. They believe these experiences have
improved their relationship, as they get regular opportunities to work on their
relationship and develop skills to help them in their everyday life. One skill they report
using frequently, "dialogue", involves each member writing on a topic of their choice
then sharing it with the other person. This skill is utilized both as a connecting activity
as well as a way to settle disagreements. As their children get older and more
independent, Steven and Rebecca have found that they have more "couple" time. Most
Friday evenings are designated as "date night": the children spend time at a friend's
house and Rebecca and Steven go out to dinner or spend a quiet evening at home.
Both see the primary weakness of their marriage as their tendency to get too busy to
focus on it, forgetting to be playful and romantic. They recognize that an infant foster
child will introduce new challenges to their relationship, especially finding time for the
couple to be alone together. However, they believe loving the child together will be
another way to enhance their relationship and expect the experience of foster parenting
to be very fulfilling.
FAMILY SUPPORT NETWORK
Rebecca and Steven appear to have a large support network. Rebecca's parents, and
Robert Harrison, live in the lower level apartment of the family home for approximately
six months of the year (they spend the colder months in California). During the time
they are living together, the families mutually support one another. For example,
Rebecca cooks meals for both families and her mother does the laundry. The Clark's
also have a year-round support network of friends, family and church members.
Steven's father and stepmother, along with two of his brothers and his stepbrother, all
live nearby in Longmont, Colorado. Steven and Rebecca report that they have several
"couple friends" that they like to spend time with and can call on for support. They are
already working to develop the more "specialized" support network they will need as
foster parents: they have friends and Windsor and Steven's stepbrother in Longmont
Transitions Psychology Group, LLC Sample Home Study Report 2004
Clark 7
who are all foster parents and can provide respite care; they also have two college
students who they say are willing to help out.
DEMOGRAPHICS
Steven is employed as a pharmaceutical salesperson, with reported earnings of
$47,000 each year. Rebecca supplements the family income with freelance
interpreting; her anticipated earnings are about $12,000 per year. The Clark's reside in
the upper level of a home in Eaton. They have three bedrooms and two bathrooms in
their living space. Their living, dining and kitchen areas are spacious with a great view
of the mountains. The basement of their home serves as a separate residence for
Rebecca's parents during the warmer months. Her parents have their own bedroom,
living area, kitchenette, walkout door and screened in patio area. Each family owns
their part of the home separately, but at this time there is no physical barrier between
the two residences. A stairway effectively divides the two spaces and family members
have arranged to "knock on the wall" as they are coming up or down the stairs to warn
that they are coming to the other person's home. They are willing to install a locked
door at the base of the stairs if needed. The Clark home sits on 2.5 acres that backs up
to farmland. On their property are a barn and a "playhouse"—a kid's retreat area
complete with heat, television and video games. The current renovations will add a loft
to the play space. The home also has an attached garage. The Clarks' neighborhood
primarily consists of middle income, single-family homes with some acreage. However,
new housing developments are bringing more diverse people and multi-family dwellings
into the area.
BIRTH FAMILY
Rebecca and Steven both acknowledge some negative feelings about parents who
maltreat their children. Steven indicates that he would deal with this through prayer for
the parents. Rebecca realizes that the parents have their own histories and maybe are
"not as far on the walk" as she is. She states that she cannot blame them for not being
as far along in their "journey with Christ" as she is and admits that she too would likely
make similar poor choices (i.e. substance abuse) if she shared the same negative life
experiences. The Clark's believe in open adoptions, as they believe that birth parents
need reassurance, through seeing their child healthy and happy, to know they made the
right choice. They also believe children have the right to know about their birth heritage.
Rebecca and Steven both would try to help foster children cope with birth family issues
through love, acceptance and age-appropriate discussions. Rebecca has had some
experiences with foster children through her work in schools and through her extended
family. She does not see any differences in the children themselves, although she has
noted some who have experienced such difficulties to be more resilient. The Clark's
have experienced diversity where they lived, worked and studied in Denver and
Georgia. They see themselves as accepting of all people; they would consider a foster
child of any race. As parents of two boys and coming from families in which they were
raised with only brothers, Rebecca and Steven express a strong preference to parent a
girl. They are especially interested in infants, but would accept a child under age two.
•
Transitions Psychology Group, LLC Sample Home Study Report 2004
Clark 8
The Clark's, especially Rebecca, have extensive experience working with special needs
children. Over the last 20 years, Rebecca has worked in the schools with children who
are autistic, deaf or had auditory processing issues. She is fluent in sign language. In
her home daycares, she has worked with children who had Attention Deficit
Hyperactivity Disorder, various developmental delays, Cerebral Palsy, Downs
Syndrome and hearing impairments. Steven has been involved with the daycare
children on a more limited basis, but also has the experience of parenting his own
"special needs" children. The Clark's oldest son is reportedly diagnosed with Attention
Deficit Hyperactivity Disorder and their younger son has had a series of medical issues.
They are willing to consider caring for an infant with special medical, physical or
emotional needs.
FOSTER/ADOPTIVE FAMILY PREPARATION
Steven and Rebecca both feel prepared to foster a child. They have been considering
foster/adopting a little girl for the last 13 years and have had numerous discussions on
the subject over the years. They have taken care of numerous children, including those
with special needs, as a daycare home. Steven and Rebecca express the willingness
to seek out cultural opportunities for a foster child of a different race or background than
they. However, due to the intensity of their involvement with their church, they would
not be able to exclude foster children from their religious activities. Rebecca and
Steven plan to introduce their foster child as their daughter and part of their family.
They are confident that they can meet the multiple needs of another child in their home.
The Clark children express excitement about having a "little sister". They are open to
having another child in the home, as long as it is an infant or toddler. Apparently, the
family had a negative experience several years ago with an older exchange student,
who stayed with the family for a couple weeks and was very mean and aggressive to
the Clark children.
MOTIVATION/COMMITMENT
Rebecca had had a difficult pregnancy with her first son so the couple decided they
would try to adopt their next child. They gave up hope after losing four possible
adoptive placements (the birth parents decided to keep their babies). They decided to
try pregnancy again, but this time it was even more difficult for Rebecca. Rebecca and
Steven had another son, born prematurely with significant medical issues, and decided
that another pregnancy was not an option, even though both still wanted a daughter.
They decided to do foster care, but remain open to considering adoption if appropriate.
Rebecca and Steven seem to be trying to protect themselves from experiencing
additional losses and disappointments by setting themselves up for foster placements
instead of planning to adopt at the outset. They are primarily interested in fostering one
infant girl, but would consider a sibling group of two very young girls (both under age
three). Steven and Rebecca believe they have been "called by God "to be foster
parents at this time and plan to continue this venture "as long as they feel God leading
us". Steven indicates that this could mean a long-term, possibly lifetime, commitment.
Rebecca states that she will follow through with any child God sends her way as long as
Transitions Psychology Group, LLC Sample Home Study Report 2004
Clark 9
the child needs the placement. The Clark children seem to have invested in foster care
as the whole family's mission. Religion supplies strong motivation for this family, but
alternately could provide a convenient "out" if things are not working for them.
INTERVENTION
Rebecca and Steven both indicate a willingness to participate in foster parenting
consultation services. However, they seem very confident in their own knowledge,
abilities and beliefs so may struggle with accepting others' advice or opinions. The
family seems to have a general understanding of confidentiality issues, as they have
dealt with this on some level because of Rebecca's role as an interpreter.
RESOURCES NEEDED TO SUPPORT THE PLACEMENT
The Clark's indicate that they already have respite care (Steven's stepbrother and
sister-in-law are reportedly licensed foster parents through Boulder County) and
babysitters available. They will need weekend respite care at least three times per
year in order to continue with their Marriage Encounter activities. Rebecca is employed
outside the home as an interpreter, but is only doing this on an on-call basis at this time.
Thus, the Clark's do not plan to have their foster child in daycare but may utilize some
babysitting so Rebecca can continue working (she typically works only two hours at a
time, once or twice per week). Although Steven reports that his income supports the
family and Rebecca's income is for "extras", there may be some financial motivation to
provide foster care following Rebecca's job loss. They will be dependent on social
services for foster care monies, respite care costs and medical insurance for the foster
child.
TRAINING
Steven and Rebecca report that they have already completed their foster parent core
training and are planning to start their consultation groups this month. Additionally,
Rebecca states that she studied child development and educational psychology in
college that she has supplemented with many other parenting workshops since that
time. Steven and Rebecca both have the experience of parenting their own children,
one with emotional/behavioral needs and another with medical needs. They also have
cared for a variety of special needs children through Rebecca's role as a daycare
provider. The Clark's do not appear to need any additional parent training at this time.
Some training regarding working within the social services system may be helpful, if it
has not already occurred. Rebecca was "let go" from her job as an interpreter,
purportedly due to a conflict with her supervisor about how to deal with a child with
whom she was working. This suggests she could potentially have problems with
caseworkers if she disagrees with their decisions about children placed in her care.
The Clark's may also need some training specific to the special needs of the child
placed in their care, especially if it is not a special need that they have dealt with in the
past.
' Transitions Psychology Group, LLC Sample Home Study Report 2004
• Clark 10
CONCLUSIONS/RECOMMENDATIONS
The Clark's appear to be a very stable, loving family. They have strong moral
convictions and a large support network. They see foster parenting as their"family
mission", believing they have been called by God to contribute in this way. Rebecca
Clark reports specific experience in child development and extensive experience
working with children with a variety of special needs over the last 15 years. Both
Rebecca and Steven have experience parenting their own children, who also have
special needs, through infancy and childhood. At 15 and 12, the Clark children are at
an age where they are appropriately trying to separate more from their parents and
become more independent, so minimal jealousy of the child is anticipated. Rebecca
and Steven indicate that they have parenting skills and "room in our hearts" for another
child. The Clark's are specific in their desire to parent an infant girl but are willing to
care for children with special needs, whether those needs are medical, physical,
emotional or some combination thereof. They may also consider adoption if the child's
needs are not too severe (i.e. they would not want to assume responsibility for a child
that could never reach an age of independence and would always need assistive care).
They have had considerable exposure to people of different races and an interest in
seeking out different cultural and ethnic opportunities, so seem to be suitable placement
for a child of any race. Although they are open to a sibling group of infant/toddler girls,
this may be too taxing for the family initially, especially if one or both children have
medical or emotional issues. Rebecca has significant health problems (Crohn's disease
and rheumatoid arthritis) that could be exacerbated by the stress of caring for a child.
However, she seems to have the necessary lifestyle management, coping skills and
supports to prevent this from happening. Rebecca and Steven seem to have some
rigidity in their beliefs and could potentially disagree with caseworkers about a child's
care. Nonetheless, they seem to realize that agency requirements are "part of the deal"
for providing foster care and express a willingness to accept these conditions.
. Transitions Psychology Group, LLC Sample Home Study Report 2004
• Clark 11
Primary Counselor: MA, LPC Date
Intake Counselor: MA, LPC Date
Supervisor. Charles Howard, PhD Date
02/27/2004 FRI 12:43 FAX 0002/003
Off-System Bid No.B002-04 RFP-FYC-000-OOB Attached A
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Date of Meeting(s)with Social Services Division Supervisor:
C, • bySSD Supervisor:
•
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•
K ,
Name and Signature of SSD Date 7
PROGRAM BUDGETS
COMPUTERIZED ACTUAL
PROGRAM Home Studies Life Skills
A TOTAL HOURS OR DAYS OF DIRECT SERVICE PER CLIENT 10 34
B TOTAL CLIENTS SERVED 72 32
C TOTAL HOURS OR DAYS OF DIRECT SERVICE FOR YEAR(A X B) 720 1,088
D COST PER HOURS OR DAYS OF DIRECT SERVICES(E/C)
E TOTAL DIRECT SERVICE COSTS FACE-TO-FACE $46,800 $57,600
F ADMINISTRATION COSTS NON-FACE-TO-FACE ALLOCABLE TO PROGRAM $9,525 $16,700
G OVERHEAD COSTS ALLOCABLE TO PROGRAM $6,875 $9,625
H TOTAL DIRECT,ADMINISTRATION&OVERHEAD COSTS(E+F+G) $63,200 $83,925
I PROFITS CONTRIBUTED BY THIS PROGRAM $7,000 $9,300
J TOTAL COSTS AND PROFITS FROM THIS PROGRAM(H +I) $70,200 $93,225
K TOTAL HOURS OR DAYS OF DIRECT SERVICE FOR THE YEAR(C) 720 1,088
L RATE PER HOURS OR DAYS OF DIRECT,FACE-TO-FACE SERVICE
(J/K) $97.50 $85.68
CERTIFICATION STATEMENT
I Clreiyry C4-te01 declare to the best of my knowledge and belief that the statements made on this document are true and complete and that the wage rates
and other factual unit costs supporting the compensation paid or to be paid under this contract are accurate,complete and includes no duplicate costs and
and that I am the CEO or duly authorized agent of Trot*,n ons P6jclwIogy brottpt.uez.
DIRECTCOMPUTERIZED ACTUAL
SERVICE COSTS
Minimum Budget Average Total %OF TIME SALARY %OF TIME SALARY
D•grs• 7t OF Salary/Bene Salaries/ 100% SPENT ON AND SPENT ON AND
DESCRIPTION or Cent FTEs €1.0 Fit Benefits/Oth•r ALLOCATED PROGRAM OTHER COSTS PROGRAM OTHER COSTS
Ir
PROGRAM
� a
A TOTAL CLIENT HOURS OR DAYS PER PROGRAM ;riv - �'.6:?y"
B TOTAL CLIENTS TO BE SERVED PER PROGRAM " ' a '";;`
C TOTAL HOURS OR DAYS PER PROGRAM FOR YEAR 720.00 1088.00
DIRECT LABOR FACE- O-FACE POSITION.TITLE OR JOB FUNCTION
-zs#* = 'j"kt ,r-'`xa..:, % :. rs YES v.xl $46,800.00 $0.00
F ' ' x .yL-. d 'At wntt ': 't $0.00 r,t' $0.00
e *"3:'�[ 7 • s n - ,,fi - 6a s '' $0.00 YES t`!e"r ' c,. d rarr ,
r. _-..r " ,.x"'qt y tt t x ' "cgs a° '.,A c.,,:m3 : $0.00 $57,600.00
$
wi:' �. ,./t I' t '7t, , , -*,t* $0.00 NO s $0.00 .4., $0.00
.. "" "'N a ' x u $0.00 NO $0.00 $0.00
e .:2 •.rf�L .':- F „9°3 '�4- $0.00 NO ::� ,� $0.00 -, w�i $0.00
` sx �s ,�v �' • i s-3 * :� t $0.00 NOittErt 't'", $0.00n ; � $0.00 gralit:S.. lm" v�y a �' K rm , $0.00 NO .:s $0.00 a.- $0.00
e s ro i .,4 i5.'* ytR i� -t F. -'� $0.00 NO *r,,. $0.00 awe $0.00
at
,. uiF • ;° $ - $0.00 NO . $0.00 r, $0.00 EatIw °' t" x x '"-� - $0.00 NOse
x $0.00 $0.00
N*'� � '` a r "g "v us. ' m a 3 $0.00 NO41� $0.00 _ $0.00
a .. 1 4 r.. "�` '. . k ' „" , x-..z is at.r j„ $0.00 NO "3.' $0.00 $0.00
;. ,x,.._ ..._. .. r y"' ..._, ;_ $0.00 NO a:-'." _. .,.�:: $0.00 r $0.00
TOTAL DIRECT LABOR PER PROGRAM $46,800.00 $57,600.00
OTHER DIRECT COSTS PER PROGRAM FACE TO-FACE
"¢ -,;' "s 4.%#,":.` YES _ 'ke $2,952.00 $0.00
s; g s- ' "
r ." : NO ',�� $0.00 '� _ $0.00
'�' .₹ *. ',$ { ,. a E, NO "E� $0.00 $0.00
r ;x P { * '°° eM "'5: NO v„ a *,t $0.00 $0.00$0.00
$0.00 xi S�� ter.�,%a ,rk.a• n t'`tfarnirtnr s? 4ti. ��`rt NO `r '., c $0.00R�" � :ai+ $0.00
TOTAL OTHER DIRECT COSTS PER PROGRAM $2,952.00 $0.00
E GRAND TOTAL DIRECT SERVICE COSTS $49,320.00 $49,752.00 $57,600.00
..�•.
'•its•
:. 804 11th Avenue
Greeley, CO 80631
Transitions
ADMIN COST NON-FACE-TO-FACE COMPUTERIZED ACTUAL
Minimum Budget Average Total %OF TIME SALARY %OF TIME SALARY %OF TIME
Degree If Of Salary/Bene Salaries/ 100% SPENT ON AND SPENT ON AND SPENT ON
DESCRIPTION or Cent FTEs @ 1.0 FTE Benefits/Other ALLOCATED PROGRAM OTHER COSTS PROGRAM OTHER COSTS PROGRAM
PROGRAM Home Studies Life Skills
A TOTAL CLIENT HOURS OR DAYS PER PROGRAM 10 34
B TOTAL CLIENTS TO BE SERVED PER PROGRAM 72 32
C TOTAL HOURS OR DAYS PER PROGRAM FOR YEAR 720.00 1088.00
DIRECT LABOR NOT FACE-TO-FACE
a •„ x �.1 r "IT,-4+ --.3� s a '$�. :� ,�, YES �'`3ki ai $9,525.00 ,e- $16,700.00 ate'
.,-a.. d`, .'21,4Ta a 11 a y„ :a L, as;'s32„xaw0011 NO $0 00 $0 00 —t.
'":` c ;414-7, ` • • .5,. NO $0 00 $0 00 at
'a.
-E t,-;,. c}. wfaC r ", ' _ ::::'t ' s NO 1� m
tr $0 00 $0.00
.,-..,# '$*�"�j':' 3`' 5 x 1 x ₹ #,1. .:t d�`' `N NO 9 $0.00 4'� e ' $0.00 Y ,
' s'�= . n3, e ''` - .x •eu y $0.0 NO +-� $0.00 __ n $0.00
' 'Sk ' s+F4 i '.n;.,* -e `FP-11x ,_ '.yLt. .q '. +s'�`zl i $0.00 NO S $0.00 -a.z^j $0.00 y
s t. '' ,^ '' z e, $0.00 NO sir., $0.00 -p ` 1i $0.00
.' F * x t "` �w` �s .r ,6A:: bA t" $0.00 NO ' i $0.00
' $0 O t
.'` ' $ '*;� § e s ? + $0.00 NO $0.00 '^� $000 s "i
x+k, $ . ��: .�. h'z lic 2 t -^.F,. xw a` + i1S "�� $0.00 NO �.,1, F $0.00 -a $0.00
. ," s ' $0.00 NO $0.00 '- $0.0040%,
n -
+� �'' z� ,tea yu. Tg�,..tsr c z .E,,� - s, E � r�',r $0.00 NO t���,f¢ $0.00 �,> �5:: $0.00 �,k a
TOTAL DIRECT LABOR PER PROGRAM NOT FACE-TO-FACE $0.00 $9,525.00 $16,700.00
OTHER DIRECT COSTS PER PROGRAM NOT FACE-TO-FACE
g kw. ,,� �t x d�'xx 5 Me'u c ,r NO �� :,r-' $0.00 $0.00 n;.w-- ,, t
c.� a t Y'- iw ' i 7 �� NO r,* ' $0.00 $0.00
Eta
`a„„7 , : s ,1- .41• v , ' rrtf _ NO W $000 `g $0.00 aa:y
4a9c *4�,'a., y #spaVY z ,3 :ree.. NO nigaitca-, $000 ° $0.00 Lazar
„$Ii.. `' �'' xk - ifr: '. T's --a ' NO ,.. :: $0.00 $0.00 �.. '.
.`},s'"s:.'' - , .. .•x ..: .': . F•. . ,_1a..O, }M... iir,- , ,.� ° $0 00 .. .. ��_^_ $0.00 -x .;
TOTAL OTHER DIRECT COSTS NOT FACE-TO-FACE PER PROGRAM $0.00 $0.00 $0.00
F GRAND TOTAL DIRECT SERVICE COSTS NOT FACE-TO-FACE $0.00 $13.23 $9,525.00 $15.35 $16,700.00
: ;j; : 804 11th Avenue
;f; I Greeley, CO 80631
Transitions
1 OVERHEAD COSTS AND PROFITS
COMPUTERIZED ACTUAL
TOTAL ALLOCATED ALLOCATED ALLOCATED
D 100% ALLOCATED OVERHEAD COSTS ALLOCATED OVERHEAD COSTS ALLOCATED OVERHEAD COSTS
DESCRIPTION COSTS D TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM
PROGRAM Home Studies Life Skills
A TOTAL CLIENT HOURS OR DAYS PER PROGRAM 510.00 $34.00
B TOTAL CLIENTS TO BE SERVED PER PROGRAM $72.00 $32.00
C TOTAL HOURS OR DAYS PER PROGRAM FOR YEAR 720.00 1088.00
OVERHEAD
•'' ,r, it z " `^t-. ri .�;I NO • $6,875.00 $9,625.00 sa=BSy. $0.00
At 'f'' # 4� x. , {1 4 t 3" -4 NO trantr4 $0.00 • $0.00 •
$0.00
ro °' h i ' n 'sc-s ? % a 7:.:.1e.,±99,
. NOg $0.00 '- �'' j": $0.00 " ' $0.00
a: w-'g: n. _- } v * a '.n'^ s ' " NO u $0.00 $0.00 $0.00
pixy ' w x+ € '*.- z * a-r a. `ice
n ' # NOt $0.00r4�
r #� .+-v - .� .� 1 $� fi' 7 $0.00 $0.00
' " d€ .NO € _kPw` 'a. $0.00 :.. $0.00 .
^;t r - ,t T` n, Y NO a $0.00
_ ,c $0.00 $0.00 $0.00
x „g a r 'r` } 3 e +w am ''= i NO $0.00 r'. $0.00 $0.00
'xy � r r S -. a '- "'as : 'M �� -t n 8.5i AL.
,• •;: t R } s NO .x. x $0.00 k 50.00 :13:1rIll:11t1:711
$0.00
� 1s'� 7 • r.,y yNO .W-F- .,, $0.00 $0.00 ;-`"-'; $0.00
's . $0.00 5 ,_ $0.00 $0.00
rws s .uY r,- �.a ii s - i a ., NO i •e. $0.00
•}` s= '.. rh ka s , NO $0.00 �� $0.0:00000:00000:
$0.00
1: s � � + } wa T5 Rr _s* NO p. -... $0.00 $0.00 > =S e°M'`'. $0.00
v .z $�:,,.' 4 �7•A ':',/,'i--'7;',, < t�_ tr NO $0.00 fl $0.00 °" $0.00
a „ itiq �# h r >. 4: 'x x- r NO _ $0.00 $0.00 ` $0.00$0.00
x +` tt= w, 5: t .ua NO n,- $0.00 "7 7 $0.00 t
. L;,--915 ',I `:4'14' ' >sx i _ +,:;tom. ....t- -t,-.. .sw ,•.'7:7 .`;.::*NO `' ,-:-,,.--°@`"-. $0.00 $0.00 r.�-v.wu _.::,..e'a $0.00
'liG TOTAL OVERHEAD COSTS $27,500.00 $6,875.00 $9,625.00 $0.00
I TOTAL ANTICIPATED PROFITS t5 '
�, NO i., e`'A $7,000.00 re a�' $0.00 �aS in $0.00
TOTAL OVERHEAD AND ANTICIPATED PROFITS $27,500.00 $13,875.00 $9,625.00 $0.00•. •
..
:j: 804 11th Avenue
. ® Greeley, CO 80631
Transitions
CNA Healthcare Providers Service
Qrganization Purchasing Group ®HPSO
CNA Plaza, r}t *p y� 1 �+ H..r..o r..r.,.s...r.o..r.�.-
Chi�go,IL 60685 (1..e L L f catt of J neu-L a ce
•
Producer Branch Prefix Policy Number Policy Period
from: 12:01 AM Standard Time on: 07/04/03
018098 970 HPG 270170798-8 _ to;_: 12:01 AM Standard Time on 07/04/04 _
Named Insured and Address Program Administrator
~
Healthcare Providers Service Organization
JAMI MOE HARTMAN 159 East County Line Road
804 11TH AVENUE Hatboro, PA 19040-1218
GREELEY CO 80631-3246
Medical Specialty: Code: Insurance Provided by
Clinical/RehabilitationCounselor 72990 American Casualty Co. of Reading, PA
CNA Plaza 26S Chicago, IL 60685
COVERAGE PARTS LIMITS OF LIABILITY
A. PROFESSIONAL LIABILITY-. - ---- -- __
Professional Liability $1,000,000.00 each claim- _ S6-000.000.00 aggregate
Good Samaritan Liability Included above
Personal Injury Liability Included above
Malplacement Liability Included above 1
B. Coverage Extensions
License Protection $5,000.00 per proceecj,ng _ $12.500.00 aggregate
i Defendant Expense Benefit $5,000.00 aggregate
Deposition Representation $1,250.00 per deposition $2,500.00 aggregate
Assault $5,000.00 per incident _ $12,500.00 aggregate
Medical Payments $1,000.00 per person $50,000.00 aggregate
First Aid $1,250.00 aggregate
Damage to Property of Others $250.00 per incident $5,000.00 aggregate
C. WORKPLACE LIABILITY Coverage part C. does not apply if Coverage part D. is made part of this policy.
• Workplace Liability Included in A. Professional Liability Limit shown above
Fire and Water Legal Liability Included above subject to $150,000 sub-limit
Personal Liability 1 $500,000.00 aggregate
D. GENERAL LIABILITY Coverage part D. does not apply if Coverage part C. is made part of this policy.
—_' Work llce-Liabilit
p y None - _---_.
Hired Auto & Non Owned Auto None
Fire & Water Legal Liability None None
Personal Liability 1 None
Total Premium $250.00
Policy forms and endorsements attached at inception 9UESTIONS? CALL: 1-800-982-9491
0-144872-A G-144959-A G-121500C G-121501C G-123846C-05 G-121503C
G-121489-ACA
Healthcare Providers Service Orgy izition is a division of Affinity Insurance Services,Inc.:in NY and NIL,AIS Affinity Insurance Agency;in MN and OK,AIS Affinity Insurance
Agency,Inc.:and in CA.AIS Affinity Insurance Agency.Inc.dba Ann Direct Insurance Administrators License#0795465.
Master Policy: 188711433
Crv1 t'V 14,t/Li Keep this document in a safe place. This and
J � f f your cancelled check act as proof of coverage.
f>"),e4. ten. ill
Chairman of the Roarrl • Secretary
SUPPLEMENTAL NARRATIVE TO RFP: EXHIBIT B
RECOMMENDATIONS
X CONDITIONS
•
•'• ��� •♦ 80411 "Avenue i*Ct IE[) By
. . ••• • . Greeley, CO 80631
• • •••• •• Phone: (970)336-1123
; FAX: (970)351-0182 APR 1 3 2004
• . • • •
,
WELD '
•• • ♦ . OF on, ^.n°w ,
Transitions
PSYCHOLOGY GROUP,LLC
April 13, 2004
Gloria Romansik
Weld County Department of Social Services
P.O. Box A
Greeley, CO 80632
Re: RFP 04005: Lifeskills
RFP 006-00: Foster Parent Consultation
RFP 006-00: Home Study, Relinquishment Counseling
Dear Ms. Romansik,
Please accept this letter as our written confirmation for the results of the Core Service
bid evaluation process PY 2004-2005. Transitions Psychology Group, LLC accepts all
of the programs bid for:
1. RFP 04005: Lifeskills
2. RFP 006-00: Foster Parent Consultation
3. RFP 006-00: Home Study, Relinquishment Counseling
Transitions also accepts Condition B as stated in your notification letter dated April 6,
2004. The condition is as follows: "the provider will notify the Department of any change
in staff at the time of the change."
As an agency, we are very appreciative of the opportunity to work with you in these
programs that mean so much to our community. We look forward to continuing a
productive and mutually beneficial relationship with the Department of Social Services.
Please feel free to contact us, if you have any questions.
Sincerely,
-f51)()%1
Gregory S. Creed, MA, LPC Jami Moe-Hartman, MA, LPC
Co-Owner Co-Owner
a
.r
DEPARTMENT OF SOCIAL SERVICES
P.O.BOX A
GREELEY, CO.80632
website:www.comeld.co.us
Administration and Public Assistance(970)352-1551
Child Support(970)352-6933
O
COLORADO April 6, 2004
Greg Creed, Co-owner
Transitions Psychology Group, LLC
804 11 Avenue
Greeley,CO 80631
Re: RFP 04005: Lifesldlls
RFP 006-00: Foster Parent Consultation
RFP 006-00: Home Study,Relinquishment Counseling
Dear Mr. Creed:
The purpose of this letter is to outline the results of the Bid process for PY 2004-2005 and to request
written confirmation from you by Wednesday,April 14, 2004.
A. Results of the Bid Process for PY 2004-2005
Through the 2004-2005 Core Services bid evaluation process,the Families,Youth and Children
(FYC)Commission recommended approval of the bids listed below for inclusion on our vendor
list with no recommendations.
1. RFP 04005: Lifesldlls
2. RFP 006-00: Foster Parent Consultation
3. RFP 006-00: Home Studies,Relinquishment Counseling
B. The Families,Youth,and Children Commission recommended the following condition be
applied to all 2004-2005 contracts.
The condition is: the provider will notify the Department of any change in staff at the time of the
change.
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
Transitions Psychology Group,LLC/Results of Bid Process 2004/2005
The Weld County Department of Social Services is requesting your written response to the FYC
Commission's recommendations and conditions.Please respond in writing to Gloria Romansik,Weld
County Department of Social Services,P.O.Box A,Greeley, CO, 80632,by Wednesday,April 14,
2004,close of business.
If you have questions concerning the above,please call Gloria Romansik at 352.1551, extension 6230.
Sincerely,
J y A. 'ego, ecto
cc: Juan Lopez,Chair,FYC Commission
Gloria Romansik, Social Services Administrator
Weld County Department of Social Services
Notification of Financial Assistance Award
for Child Welfare Regular Administration&EPP Funds
Type of Action Contract Award No.
X Initial Award 04-CPS-31
Revision (RFP-006-00)
Contract Award Period Name and Address of Contractor
Beginning 06/01/2004 and Julie Box, Private Practice.
Ending 05/31/2005 Home Studies,Updates,Relinquishment Counseling
1702 68th Avenue
Greeley, CO 80634
Computation of Awards Description
Unit of Service The issuance of the Notification of Financial
Home study format is based on 20 hours of Assistance Award is based upon your Request for
work.Relinquishment counseling for a Proposal(RFP). The RFP specifies the scope of
maximum of 4 hours per parent. Program services and conditions of award. Except where it is
capacity is 3 home studies or updates per month in conflict with this NOFAA in which case the
and 16 hours of relinquishment counseling per NOFAA governs, the RFP upon which this award is
month.The average stay is expected to be 3 based is an integral part of the action.
weeks for a home study, and two weeks for each Special conditions
parent in relinquishment counseling. Bilingual- 1) Reimbursement for the Unit of Service will be based
bicultural services available the subcontract. on a rate per home study; home study update,and
relinquishment counseling session.
Cost Per Unit of Service 2) Reimbursement requests must be an original with an
Hourly Rate per Relinquishment Counseling $103.89 original signature from the provider and/or designee.
Full Home Study with Background Check* $850.00 3) Reimbursements requests must include the date the
Full Home Study(No Background Check)* $750.00 home study,update, or relinquishment counseling was
Updated Home Study $425.00 completed. The request must reflect the referral
Home Study(3 Hour Minimum Direct Face- number assigned to each home study, the amount
to-Face Contact) Cancellation by DSS $225.00 billed for each home study, and the month the service
Additional Fee per Additional Adults in was provided.
Household per Home Study * $200.00 4) Payment will only be remitted on referrals made by
the Weld County Department of Social Services.
5) Requests for payment must be an original submitted
to the Weld County Department of Social Services
Enclosures: by the end of the 25th calendar day following the end
X Signed RFP:Exhibit A of the month of service. The provider must submit
X Supplemental Narrative to RFP: Exhibit B requests for payment on forms approved by Weld
Recommendation(s) County 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 'b ,k & \XICa---- By 2 Robert D. Masden, Chair Ju A. e o,Di41.1,,C4Th
or
Board of Weld County Commissioners Wel o e artment of Social Services
Date: JUN 1 6 2004 Date: 5725/ov
SIGNED RFP-EXHIBIT A
INVITATION TO BID
DATE:February 11, 2004 Off System Bid No.B002-04 RFP FYC 006-OOB
RETURN BID TO: Pat Persichino,Director of General Services
915 10th Street,P.O. Box 758, Greeley, CO 80632
SUMMARY
Request for Proposal (RFP-FYC 006-00B) for: Adoption, Foster Care, and Expedited Permanency
Planning Home Studies, and Relinquishment Counseling
Deadline: March 5, 2004,Friday, 10:00 a.m.
The Families, Youth and Children Commission, an advisory commission to the Weld County Department of
Social Services, announces that competing applications will be accepted for approved vendors pursuant to the
Board of Weld County Commissioners' authority pursuant to Colorado Statute and the Weld County Home
Rule Charter. The Families,Youth and Children Commission wishes to approve services targeted to run
from June 1, 2004, through May 31, 2005, at specific rates for home studies,home study updates, and
relinquishment counseling services. The County will authorize approved vendors and rates for services only.
This program announcement consists of five parts, as follows:
PART A...Administrative Information PART D...Bidder Response Format
PART B...Background, Overview and Goals PART E...Bid Evaluation Process
PART C...Statement of Work
Delivery Date 4 .C`I-
(After receipt of order) BID MUST BE SIGNED IN INK
.-31.(1)c-
TYPED ,
1 � OR PRINTED SIGNATURE
VENDOR j tA.1 te.
(Name) Handwn en Signatur By Authorized
Officer Agent of Vender
ADDRESS ( 102 i.-,-t TITLE
(,rrpCIc1 C� ?sir) 4 DATE
PHONE# tie. . Z t4"I I
The above bid is subject to Terms and Conditions as attached hereto and incorporated.
Page 1 of 34
Off-System Bid No.B002-04 RFP-FYC-006-00B Attached A
HOME STUDY,UPDATE, & RELINQUISHMENT COUNSELING BID PROPOSAL AND
• REQUEST FOR CONTINUATION OF AWARD UNDER
CHILD WELFARE ADMINISTRATION FUNDING
2004-2005 BID PROPOSAL APPLICATION
PROGRAM FUNDS YEAR 2004-2005
BID Off-System Bid B002-04 RFP-FYC-006-00B
NAME OF AGENCY: ,j U.1 I f �, 1"�o X
ADDRESS: ( 1VZ (j2 _ _. &ree .J Co 8�°Yt31 PHONE: (Kio) 30z. 1471
1
CONTACT PERSON: lAA,-t lSoA TITLE: L-('W
DESCRIPTION OF HOME STUDY PROGRAM CATEGORY: Adoption,Foster Care,and Expedited Permanency Planning
Home Studies in compliance with the uniform format utilized by the State of Colorado Department of Human Services since
October 1, 1999(Attached A).
11-Month approximate Project Dates: 12-month contract with actual time lines of:
Start June 1, 2004 Start.!,,AZ t r icO4 ,
End May 31, 2005 End Mu,1 31)2405
TITLE OF PROJECT: .\ctwc `�\tk1.r es,1?-tL 7;i t4�,Alv,, --
•
çdPnPrepag Document Date
, Z . O f
Name and gnature Chief A ministrative Officer Applicant Agency Date
cj
MANDATORY PROPOSAL REQUIREMENTS
For new and renewal bids,please initial to indicate that the following required sections are included in this Proposal for Bid.
For renewal bids,please indicate which of the required sections have not changed from Program Year 2003-2004 to Program
Year 2004-2005.
Project Description _Project Description
Sample Home Study _Sample Home Study
4_ Target/Eligibility Populations _ Target/Eligibility Populations
tGeneral _General
Cultural/Eligibility Populations Cultural/Eligibility Populations
es of services provided _Types of services provided
Measurable Outcomes _ Measurable Outcomes
.. Service Objectives Service Objectives
Workload Standards _ Workload Standards
Staff Qualifications _ Staff Qualifications
- Unit of Service Rate Computation _ Unit of Service Rate Computation
4 Program Capacity per Month Program Capacity per Month
Certificate of Insurance
Page 23 of 34
02/26/2004 15'16 FAX
03535215 SOCIAL SERVICES O002/002
OftSystem Bid No.B002-04 RFP-F'YC-006-00B
Attached A
�� . z� goy Re, d�,eaPa
Date of Meeting(s)with Social Services Division Supervisor.
Comments by SSD Superviso
,? . "9844 ' i
O7 as a
� � - i
•
letits a7n. .,,:.t, -
VC
•
jai,
Name and Signature of SSD u sor r! �ro y
Date
Page 24 of 34
June, 2004
Off-System Bid B001-04 (RFP-FYC-04005)
Home Studies, Relinquishment Counseling
Julie Box, LCSW
I. PROJECT DESCRIPTION
Julie Box(Bidder) is a Licensed Clinical Social Worker offering a wide range of services to
children, families and adults. Bidder has been providing human services to the Northern Colorado
area since 1986. During the past 18 years, Bidder has provided services as a counselor, a
caseworker and a therapist in the field of child welfare. Bidder has provided services to all
individuals without consideration of religious beliefs, race, ethnicity, sex or economic status.
For the past three years, Bidder has been providing home study and relinquishment counseling
services to the Weld County Department of Social Services as well as through this Bidder's
employer, Lutheran Family Services, a non-profit agency. Bidder uses the Foster Family
Assessment System developed by ACTION for Child Protection. A written, narrative home study
will be provided to the Weld County Department of Social Services. Bidder is currently on the
state vendor list for adoptive home study providers.
Additionally, Bidder has the experience and expertise to provide relinquishment counseling in a
timely fashion.
II. SAMPLE HOME STUDY
A sample home study is attached to this proposal.
III. TARGET/ELIGIBILITY POPULATIONS:
The population to be served under this contract includes: families who wish to adopt children
from the Weld County Department of Social Services; relinquishment counseling for parents who
are considering relinquishing children and applicants for foster care certification.
Bidder has been providing home study services to Weld County for the past three years through
Lutheran Family Services and has never turned down a referral. At 20 hours per home study,
Bidder would be able to complete 3 home studies per month. Home studies are given ten hours
of direct service and ten hours indirect service. Bidder is cross-trained to provide a variety of
clinical services including therapy, clinical case management, relinquishment counseling or home
studies. The following numbers reflect a case load of 3 home studies per month:
A. Total Number of Clients to be served:
Each home study is'worth'20 hours and will be spread over a six-week period of time. Bidder
estimates she could complete 36 home studies per year.
Relinquishment counseling will be provided on an hourly basis. Bidder estimates the
relinquishment counseling takes an average of four hours of direct service per person. Bidder
estimates she could counsel 24 individuals per year.
B. Total Individual clients and the children's ages.
The number of individuals and ages of children is completely dependent on the demographics of
the families referred for services. Bidder does not limit services to families with children of
specific ages.
C. Total family units.
Bidder estimates she could complete 36 home studies per year.
D. Subtotal of individuals who will receive bicultural/bilingual services
Unfortunately, Bidder is not bilingual; however, Bidder would be able to contract with a qualified
Spanish speaking clinician to complete home studies as referred. Bidder would not refuse any
bicultural services.
E. Subtotal of individuals who will receive services in South Weld County.
Bidder does not limit her services to specific geographical areas so Bidder will provide services in
the Southern part of Weld County as they are referred.
F. The monthly maximum program capacity.
Bidder estimates she could complete 3 home studies every month.
G. The monthly average capacity.
Bidder estimates she can manage the volume of home studies as Bidder has done so this past
year. At the present rate of referral, Bidder would plan to complete 3 home studies per month.
H. Average stay in the program (weeks)
Bidder's goal is to complete home studies within six weeks of implementation of the home study.
Bidder is estimating that relinquishment counseling averages 2 weeks.
I. Average hours per week in the program.
Families who are having a home study completed will average 3-4 hours of direct service per
week, for 3 weeks.
Individuals receiving relinquishment-counseling services will average 1 hour per week of direct
service.
IV. TYPES OF SERVICES TO BE PROVIDED
Adoption and Foster Care Home Studies
Bidder uses the Foster Family Assessment(FFA) System developed by ACTION for Child
Protection. This is the format that was taught in state sponsored training. That format is the
format used in the fictitious home study submitted with this bid. A narrative home study is
produced using the FFA system. These home studies are 'adoptive quality'and meet the state
prescribed format. There is no difference between adoption, foster care or kinship care home
studies. Bidder is currently on the state vendor list for adoptive home study providers.
Home study updates will be completed using the FFA System and there will be a reduced fee
charged.
The following background checks will be completed by Bidder unless otherwise indicated on the
referral:
1 Fingerprints sent to CBI on Weld County Department of Social Services fingerprint cards,
results will be retumed directly by CBI to the Weld County DSS. Bidder will collect and
submit the fingerprint cards after the Weld County Department of Social Services has
distributed the cards. Bidder will cover the fee for the submission of these cards. If the
applicant has lived in the state for less than two years, an FBI search will be requested.
Bidder will cover this additional fee.
2 Department of Motor Vehicles (results returned to Bidder).
3 Local county DSS search for open or past cases (results returned to Bidder).
4 Four reference questionnaires will be sent out with a SASE (results returned to Bidder).
5 Local police department (results returned to Bidder).
6 Central Registry will be completed by the referring caseworker through the Trails system
at the Weld County Department of Social Services.
All original background check information will be forwarded to the Weld County DSS with the
written home study. A copy will be retained in Bidder's files.
Bidder has all of the forms and processes in place necessary to complete these background
checks. Additionally, Bidder can provide a safety inspection of the home, if requested, at no
additional fee to the county.
Relinquishment Counseling Services
Relinquishment counseling services will be provided to all adult individuals referred for this service
by the Weld County Department of Social Services as well as to their children age 12 and older.
Services will be provided individually and Bidder will submit a written report and the appropriate
affidavits.
V. MEASURABLE OUTCOMES
The goal for each home study referral is to complete a comprehensive, written home study within
six weeks of initiation of the home study. The outcome will be measured through timely
submission of the home study to the referring caseworker. Bidder will also track the number of
home studies referred that Bidder did not accept and the number of home studies referred and
subsequently cancelled by the department. The Foster Family Assessment(FFA) System
provides a rating system used to measure the risk of the placement in an applicant foster family or
adoption of a child in any given home.
Relinquishment counseling referrals will be tracked and measured in the same way as home
studies.
VI. SERVICE OBJECTIVES
The service objectives are the same as the measurable outcomes, that is: the completion of
quality home studies, updates and relinquishment counseling services in a timely manner. All
home studies will be completed using the state endorsed FFA System.
VII. WORKLOAD STANDARDS
Please see the previous section "Target/Eligibility Populations"for a detailed explanation of
Bidder's workload standards. In summary, Bidder intends to devote 20 hours per week to
completing the home studies referred. Half of Bidder's time will be in Direct Service hours and
half in Indirect Service hours. The requested minimum standards for insurance have been met
and documentation provided.
VIII. STAFF QUALIFICATIONS
Bidder has a bachelors degree in Psychology(BA), a Masters degree in Social Work (MSW)and
is a Licensed Clinical Social Worker(LCSW) since January 21, 2003 (license number: 992996).
Please see the attached copy of Bidder's license.
Bidder secures a minimum of 32 hours per year of continuing education training.
IX. COMPUTATION OF DIRECT SERVICE RATE
Please refer to the attached budget for computation of direct service rate.
This hourly rate is what Bidder will charge for each hour of direct service of relinquishment
counseling provided.
Home studies are charged at a flat rate: for a full home study with background check: $850
for a full home study without background check: $750
for an updated home study: $425
This fee includes the background check and all necessary interviews for a two-parent family. The
assessment of additional adults living in the home will necessitate an additional fee of$200 per
adult.
Bidder would like to propose a flat fee of$225 for any home study that was initiated and where
Bidder provided a minimum of 3 hours of direct, face-to-face contact, and the home study was
subsequently cancelled by the Weld County DSS or the family.
X. PROGRAM CAPACITY BY MONTH
As outlined in this proposal, Bidder's capacity is based on a direct/indirect service ratio. Bidder
estimates that her monthly capacity is 3 home studies and 2 individuals needing relinquishment
counseling per month.
4
FAMILY ASSESSMENT AND UPDATE
INITIAL ASSESSMENT: DATE: February 28, 2004
RE-CERTIFICATION: DATE: N/A
Family Name: Bob and Jane Doe
Clinician Name: Julie Box, LCSW
Parent Force
1. History Element: Social History/Background Check, Character and Suitability (Adults)
What is the parents' childhood and adult history? Consider the individual's cultural context in
your description. When updating or re-certifying, describe new or significant information that
indicates a change from previous assessment.
Specific areas include: personal history of abuse, marriages, divorces, births, deaths; issues
of grief and loss, employment; education; physical/mental health; childbearing or infertility;
arrests or legal encounters; relationships (including other races/cultures); number and type of
foster/adoptive placements (CPS, Juvenile Justice, other); placement success or disruption;
other information.
Mr. and Mrs. Doe are requesting they be considered as a foster/adoptive family through
the Weld County Department of Social Services for children, three to four-years-old.
They stated they would accept a child of either gender and they would accept a child of
any race, culture or religion.
Parent#1: Jane Doe
Jane Doe was born on November 12, 1966, in Chicago, Illinois,to Sally and Ralph Doodle. She
has one full-brother and one half-brother. Her older, full-brother, Doug Doodle, is 45 years old,
living in Chicago and divorced with two children. Her younger, half-brother, Brian Doodle, is 25
years old, living in California and married with two children. Both of her parents currently live in
the Chicago area.
Mrs. Doe reported that her parents divorced when she was two-years-old. She stated that they
divorced because her father had an affair. Mrs. Doe stated, "I didn't know about the affair until I
was an adult. I heard about it from a neighbor who my mom had confided in. It helped me
understand a lot because my parents never fought and I was really confused about the divorce."
Mrs. Doe and her brother, Doug, remained with their mother. Their father remained in the area
and she had semi-regular contact with her father. Mrs. Doe's father was in construction and her
mother was a secretary.
Mrs. Doe reported that when she was seven or eight years old,her mother's boyfriend, Paul,
moved in with them. Her mother and Paul married when Mrs. Doe was twelve-years-old. When
asked about her relationship with her stepfather, Mrs. Doe replied, "We didn't get along very well.
We didn't bicker but I didn't care for him. I kept my distance because he was physically
inappropriate. There was never any rape or anything like that, but some physical touching and
verbally sexual comments. I told mom after a long time, probably about ten, but he talked his
way out of that one. I told my mom again when I was about sixteen; it had been progressing,
becoming more emotionally traumatic for me, so I finally told her again. She left me out of the
loop when she divorced him but I found out that was the reason." Mrs. Doe went on to add that it
was a huge relief to have Paul gone and she was fine after he left. She stated that she had told her
older brother what happened after Paul left and her brother was very angry. Mrs. Doe stated that
she asked her brother not to tell their father because she was afraid of what her father would do.
She said she never told her younger brother what his father had done because she didn't want to
hurt him. Mrs. Doe's mother never remarried. Mrs. Doe reported that she is very close to her
mother.
Mrs. Doe stated that her father married two more times after her parents'divorce. He married
Connie, who had a son from a previous relationship,when Mrs. Doe was three-years-old. Her
father and Connie never had any children together. They divorced when Mrs. Doe was fourteen-
years-old and he married Pam when Mrs. Doe was fifteen. They did not have any children and
they divorced when Mrs. Doe was 19. Mrs. Doe stated that she is not close to her father.
When Mrs. Doe was fourteen-years-old, she and her family moved to North Hollywood,
California. When asked why they moved, Mrs. Doe replied, "Paul had been there and liked it
there and thought it would be a better place for Brian. Mom was okay with it. Doug stayed in
Chicago; he was eighteen and already had a work and a serious girlfriend. I was dead set against
moving. I had just graduated eighth grade and had gone through the process to go to another
school and be on the volleyball team and then we had to move. It was probably my most
traumatic experience. I didn't want to leave my grandparents (maternal)and Doug." When asked
how she handled her feelings of loss, Mrs. Doe responded, "I kind of withdrew. I was never an
angry or aggressive child and I just stayed in my room. I was really shy my first year of school
there. I pretty much kept to myself. Eventually I adjusted. My grandparents would pay for me to
go back to Chicago every summer for about six weeks and that helped a lot."
Mrs. Doe was asked to talk about her childhood memories. She said, "Mainly positive, mostly
because of my mom's family. I have awesome, awesome grandparents and an uncle who tried to
step in and fill dad's shoes. I remember spending almost every weekend at my grandparents.
They lived out in the suburbs and I really enjoyed it. Doug went too until he was thirteen or
fourteen. That's where I got my example of wonderful, healthy relationships. It's probably where
I learned that this is the way it's supposed to be." When asked if she ever told her grandparents
about her stepfather's behavior, Mrs. Doe became very teary-eyed and replied, "I feel very
protective of them and I knew it would have hurt them and maybe I was afraid they'd look badly
on my mom and I didn't want that. They take things in and they're hurt very easily when their
family is hurt. Then when he was gone the problem was gone so I never brought it up. I haven't
told anyone in my family except my mother and my older brother. I feel very, very blessed and
very lucky it wasn't worse. I have friends who have been through much worse and it's awful."
When asked if she has any anger toward her mother for not responding the first time she told her,
Mrs. Doe replied, "Yes, mainly while it was still going on after I told her and she believed him.
I've never talked to her about it as an adult. One of the traits of my family is not to talk about
things. I had to learn to communicate. I learned with Dan. I told him,but I don't want to hurt
someone in my family or anger someone."
Regarding grief and loss issues, Mrs. Doe said, "The move to California; I was at that selfish age
where you're focused inward. I guess loss issues are the family and school and my brother,
leaving him behind. We were actually closer at that age." As reported earlier, Mrs. Doe reported
that she handled her losses by isolating herself.
Mrs. Doe stated that she has never been physically abused. She added, "I don't think I was ever
even spanked." Regarding sexual abuse, Mrs. Doe stated that she has never suffered sexual abuse
other than the reported incidents with her stepfather, which occurred over approximately eight
years. She added, "It didn't affect any of my relationships with any of the men in my life." Mrs.
Doe stated that she has never suffered from neglect. When asked how she was disciplined, Mrs.
Doe responded, "Honestly, I was a pretty good kid. My brother had the role of being in trouble
all the time. I remember not getting home for dinner on time and I might get grounded for a day
or two."
Mrs. Doe reported that there were no substance abuse or domestic violence issues in her home.
She said there were no problems with gambling or pornography either. She added, "My dad went
to jail in 1990. I haven't spoken to him since then,he's removed all contact from my brother and
I. He was there for five or six years for running a Meth lab with his stepbrother. I don't
remember ever seeing him drink,he was always sober. My mom said he never used drugs. It
was pretty much a shock when this happened." Mrs. Doe reported no personal history of
substance abuse, domestic violence,gambling or pornography issues.
Mrs. Doe reported attending Kindergarten through the eighth grade in Chicago. She then
attended ninth through twelfth grade in North Hollywood, California. She graduated from high
school in 1984. Mrs. Doe stated that she then attended one year of junior college at Valley
Community College and then received her AA degree in Interior Design from the Fashion
Institute of Design and Merchandizing in 1988. Mrs. Doe stated that she liked school. She said,
"I was in volleyball in elementary school and in California I got into music. I got into the
Madrigal Group, a more formal choir. You travel more and do more performances outside of
school. My major in high school was art and music. I loved being part of the [Madrigal] group.
It was a huge self-esteem booster. I had a lot of good friends in high school. High school was
fun for me. I really enjoyed being there."
Mrs. Doe reported that she started dating when she was 19 years old. She stated, "No one sticks
out." Mrs. Doe related that she met her husband, Bob Doe, at her best friend's wedding. She
stated, "We started dating when I was 21 and dated for one year. We were engaged for a year and
married on July 14, 1990." Mr. and Mrs. Doe have two children, Taylor,twelve-years-old, and
Matthew, six-years-old. Mrs. Doe reported this is her only marriage and she has no other
children.
Regarding her employment, Mrs. Doe stated, "I was 18 and I worked for a florist in California. I
was there almost a year and we got held up and I thought "no" and left. I went to Price Club, like
a Sam's, as a cashier. I was there approximately two and a half years. I finished college and went
to a designer center; Pacific Designer Center. They had showrooms for designers and I worked in
the furniture showroom but I got laid off after six months. Then I went to a design firm,
California Business Interiors, CBI, and was there for two years. Then I worked at Kraft General
Foods as an administrator for two years and then we moved to Ault(Colorado) in 1991. Then we
moved to Windsor(Colorado) in'93 or'94. I worked for Bataa Oil for four years in
administration. I was licensed for home day care for five years in Weld County." Currently, Mrs.
Doe is the office manager for the Doe's construction business.
When asked about her beliefs about people of differing races, cultures and religions, Mrs. Doe
replied, "In Windsor there's not a huge variety. I have Hispanic and Caucasian friends. Most of
our friends are from our church family. It's all Caucasian in our immediate neighborhood. I have
friends in California that are Caucasian and Hispanic. I'm very accepting of differences. I grew
up in Chicago where it's very racially and culturally mixed. It's new to me to be out here without
other races. I usually base people on their actions."
Mrs. Doe reported that her physical health is "excellent." She and her husband recently
completed physicals. Regarding her mental health, Mrs. Doe stated, "I think excellent." She
reported that she has never been diagnosed with any mental health disorders. When asked if she's
ever been arrested, Mrs. Doe replied, "No." She stated that she has had two traffic tickets but has
never had a DUI.
Mrs. Doe stated that she has never fostered children in her home in any state.
Rating: _3.5_
Parent#2: Bob Doe
Bob Doe was born on October 19, 1962, in Whitter, a suburb of Los Angeles, California,to Sue
and Robert Doe. He has three full siblings and one half-sister. His full siblings are: Judy Loop,
44 years old, living in Idaho, married with children; Mike Doe, 42 years old, living in California,
divorced with one child and Karen Roberts, 36 years old, living in California, married with
children. His half-sister, Susan Soel, is 35 years old, lives in California, and is married with two
children. Currently his parents are divorced and living in California.
When asked how old he was when his parents divorced, Mr. Doe replied, "I'm guessing five." He
remained with his mother, as did his siblings. Mr. Doe reported that he continued to have contact
with his father after the divorce. He stated, "It wasn't like today where you get visitation rights.
We saw him once a month when he'd drop off the check. He moved near us when I was twelve
and we could ride our bikes to see him." His mother worked at school as a teacher's aide and his
father worked for the phone company. Mr. Doe said his mother never remarried. He stated, "She
was going to many Sonny but he split town. I was about ten and they'd dated for a few years. I
really liked him. We never found out why he left." When asked if his father ever remarried. Mr.
Doe replied, "I think he married Marie. I think he married her when I was six or seven." He
stated that his parents divorced because his father "cheated" on his mother with Marie who was
their babysitter. When asked if he knew his half-sister, Susan,growing up, Mr. Doe responded,
"Not really. When we were younger I knew her but when we became teens she went to a
different school." When asked if he knew the reason his parents divorced, Mr. Doe said, "Not
then, she(Susan)was the same age as my sister so when I was older, I figured it out." Mr. Doe's
father left Marie and has been living with a woman, Mary, for the past eighteen years.
Mr. Doe stated that his relationship with his mother when he was a child was "good." He stated
that he was "closer to mom"than his father. He said his relationship with his father was "good,
but I didn't see him that much." Growing up, Mr. Doe reported that his relationship with his
sister, Judy, was "good." He added, "We had a good family, it didn't seem terrible." Regarding
his relationship with his brother, Mike, Mr. Doe stated, "It was good'til we were teenagers and
then we kinda went our separate ways." Mr. Doe reported that he was "Closest to Karen growing
up, we were the last two in the house." Currently, Mr. Doe said that he is close to his father. He
stated, "My relationship with my mother is good, but I'm closer to my dad now. She still drinks
beer." When asked about his current relationship with his siblings, Mr. Doe replied, "It's good
with everyone except my brother. It's not that it's bad, we just don't really talk. I see my family
about once a year. We try to have family reunions. Sometimes mom or dad will come to visit."
When asked how he was disciplined as a child, Mr. Doe responded, "I don't really remember. I
never got spanked. My mom yelled and threatened to call our dad over and if she ever did he'd
come over and give us a talk. Same as we got older, we got yelled at and lectured to." Regarding
substance abuse issues in his family, Mr. Doe stated, "I remember her(mother) drinking beer. I
remember she'd always get really sad. She was never abusive. I don't think she ever blacked
out." He reported that his mother never used any drugs and that there was never any domestic
violence, no gambling issues or any pornography issues with either parent. He stated that his
father would drink but he never saw him drunk or using any drugs. Mr. Doe stated that he was
never physically or sexually abused. When asked if he was neglected, Mr. Doe replied, "No, not
in the sense of being left alone or no food. Not having dad there at special events and stuff was
hard sometimes."
Mr. Doe was asked to discuss his childhood memories. He responded, "Mainly good. We had a
single mom with four kids but she took us camping and fishing. Dad helped out financially. We
were poor but we managed. Dad took us fishing. Like I said, it was hard sometimes, dad not
being at basketball games and stuff." When asked about grief and loss issues, Mr. Doe stated,
"None really." When asked about his father not being around for special events, Mr. Doe replied,
"I'm not sure." He added, "I've had relatives die; my grandfathers and grandmothers and my
great-grandmother. To be honest, I always felt weird because I wasn't bawling,but I wasn't close
to them. With my dad's side,they disconnected after the divorce."
Mr. Doe reported that he attended Kindergarten through twelfth grade in Whitler. He stated that
he graduated from high school in 1980. When asked how he felt about school, Mr. Doe replied,
"I always knew I wasn't going to go to college. Not because of financial reasons, it just wasn't
my thing. I think I enjoyed school." He reported that he was not involved in any sports or other
activities at school. He said he enjoyed shop; welding, and didn't like English or Algebra. Mr.
Doe said he liked to surf. After graduation, he stated that he went through an apprenticeship
program for carpenters through the local junior college. He stated that he worked at a hardware
store from age fifteen to seventeen. He reported that he then worked at a "drive through dairy
where you could drive up to the dairy and get your dairy products" for approximately two years.
He then worked at carpentry through a union for twelve years. Mr. Doe stated that he then moved
to Colorado and worked subcontracting carpentry work through a construction company.
Currently he owns his own construction company.
Mr. Doe reported that he started dating when he was approximately sixteen. When asked to
discuss his relationships, Mr. Doe replied, "I dated Lisa for eight years and then we went our
separate ways. I wanted to get married and she didn't, I guess." He then said he met his wife,
Donna Young, at a wedding. Mr. Doe reported that they dated for approximately two years and
married on July 14, 1990. Mr. and Mrs. Doe have two children, Taylor,twelve-years-old, and
Matthew, six-years-old. Mr. Doe reported that his son stuttered from the three to four-years-old.
He added, "He went to speech therapy at school, we didn't make a big deal of it and it just kind of
went away." Mr. Doe reported that this is his only marriage and he has no other children.
Mr. Doe stated that his physical health is "excellent." He said his mental health is "Fine, as far as
I know." He reported that he has never been in therapy, has never been diagnosed with any
mental health disorders and he has never been on any psychotropic medications. Mr. Doe stated
that he has no infertility issues. He said that, after their two children were born, he had a
vasectomy.
Mr. Doe stated that he has never been arrested and the only legal encounters he has ever had were
speeding tickets or minor accidents. When asked if he has ever received a DUI, Mr. Doe stated,
"No." When asked is he has any substance abuse history, Mr. Doe replied, "I did. I think I was
an alcoholic for about eighteen years. I've been clean for the past five years." When asked why
he stopped abusing alcohol, Mr. Doe stated, "I just knew it wasn't right." He reported that he has
no domestic violence issues and no issues with gambling or pornography.
Regarding his attitude toward other races, cultures or religions, Mr. Doe stated, "I'm comfortable
with others and have friends of other races. I don't like racism and I'm not tolerant of racial
remarks. I would say something." Mr. Doe reported that he has never fostered children in any
state.
Rating: _3
Parent Force
2. Adult General Functioning Element: Character and Suitability How does the
adult function with respect to daily management and general adaptation? When
updating or re-certifying, describe new or significant information that indicates a change
from the previous assessment.
Specific areas include: previous emotional problems, mental illnesses, substance abuse
issues, or marital/relationship problems that may have an impact on a child(ren);
problem solving capacity/history, response/reaction to stress, ability to communicate, styles
of communication, cognitive functioning; ability to make judgments/decisions and capacity
to/history of follow through; use of defense mechanisms; levels of self-esteem; awareness of
own capabilities and limitations; ability to control emotions; adaptation to infertility (if
appropriate); levels of impulse control; expression of emotions/feelings/general
temperament; attitudes towards people of similar/different races, cultures, religions;
attitudes toward and response to sexual contact between children; homophobia.
Parent#1: Jane Doe
As previously reported, Mrs. Doe reported no prior emotional problems, no mental health issues
or any substance abuse issues. Mrs. Doe stated that she has no marital issues that may have a
negative impact on children in her home. When asked about her problem solving ability, Mrs.
Doe replied, "I'm pretty good with emotional or personal problem solving. I'm getting better as
I'm getting older. I don't get too worked up. It depends on the situation, we pretty much use each
other as a sounding board and that helps. We usually talk things through pretty much in depth."
Mrs. Doe was asked to discuss how she handles stress. She responded, "I usually talk to Dan if
something's really bugging me, or I talk to someone. I vent and get it all out and that helps.
Recently, I'm reading a book,Don't Sweat The Small Stuff And It's All Small Stuff and it's really
good." Mrs. Doe said she's "pretty good" at communicating. Regarding her history of follow
through, Mrs. Doe stated, "I think we're pretty good. Sometimes we'll get overwhelmed with
things at church, but with the majority of decisions we always follow through."
When asked about her self-esteem, Mrs. Doe responded, "I think it's pretty good. I think with
body image you go back and forth about that, as a woman. On my abilities to do things it goes
back and forth. It could be better maybe." Mrs. Doe was asked to list her strengths. She replied,
"I think I'm a good listener. I think I have a kind heart. I think I'm always willing to grow and
learn in all areas of my life and definitely my faith is very strong." Regarding weaknesses or
areas she would like to work on, Mrs. Doe said, "Probably those brief moments of self-doubt and
letting things overwhelm me. Patience, I think you can always use more patience."
Regarding her ability to control her emotions, Mrs. Doe stated, "Oh, I cry on the drop of a hat, I
have no control. I can control things like anger and frustration but I cry when I'm happy and
•
when I'm sad." When asked about her ability to express her emotions, Mrs. Doe responded, "I
think I usually let people know when I'm angry, in a nice way. It's another thing I'm working on
as I get older." Mrs. Doe reported that she is "in the middle" in terms of her impulse control. She
added, "It depends on what I'm dealing with; like, lets go somewhere, okay, but with something
major that would affect our lives I'm not impulsive."
When making decisions, Mrs. Doe stated that she and her husband discuss the issue and then
make decisions. When asked about her attitude toward and her response to sexual contact
between children, Mrs. Doe replied, "I would definitely be shocked at first. I think I'm
knowledgeable enough to know the child is probably acting out something. I would seek out help
to deal with it. It's one of my major concerns. My children are quite sheltered and I do feel quite
protective but I will work with whatever does come up." Regarding her beliefs about
homosexuality, Mrs. Doe stated, "I don't judge them for it. I don't agree with it because of my
faith. We've had homosexual friends and I don't judge them, I just don't agree with it."
Rating: _3.5
Parent#2: Bob Doe
As previously reported, Mr. Doe reported no prior emotional problems and no mental health
issues. He previously discussed his substance abuse issues, stating he has not been drinking for
the past five years. Mr. Doe stated that he has no marital issues that may have a negative impact
on children in his home. He stated that he is good at problem solving. When asked how he
handles stress, Mr. Doe replied, I usually just try to get over it. I just sit down,try to calm down
and tell myself it's not worth it."
When asked about his decision-making abilities, Mr. Doe said (laughing), "I ask her if it's okay.
Really, if it's a major one we always talk about it. If it's a new tool, I just get it. It's something
she's always understood,with my work I need the tools." Regarding his history of following
through on decisions, Mr. Doe stated, "I don't always follow through with some ideas, but
typically once I get into something I get every magazine on the topic and I go over it and go for
it." Mr. Doe reported that his self-esteem is "good." He added, "It probably comes from my
work, I really like my work."
Regarding his strengths, Mr. Doe stated, "I'm honest, I don't mind talking to my wife, I'm a good
carpenter and I'm a good dad. I'm a goof(with the children)." Remaining calm and realizing
little stuff doesn't matter were the areas he stated he would like to improve. He added, "I'm trying
to read more and listen to more motivational type stuff." Mr. Doe reported that he is "pretty
good" at controlling his emotions. He stated, "The kids know when I'm angry,the way I talk to
them or raise my voice." Regarding his ability to express his emotions, Mr. Doe stated, "I
typically let people know verbally or with body language and actions."
Mr. Doe stated that he is not impulsive, "unless it's a tool." Mr. Doe was asked to discuss his
attitude toward and his response to sexual contact between children. He responded, "My
response would be shock. I'd obviously tell them to stop, call you and ask, 'Okay, now what?' I
don't think I would be angry. Obviously something's wrong here and I'd need to figure it out
probably." Regarding his attitude toward homosexual people, Mr. Doe stated, "I don't agree with
it but it's none of my business. It's their lifestyle I guess, whatever."
Rating: _3
Parent Force
3. Parenting -- Discipline Element: What are the disciplinary approaches used by the
potential foster or adoptive parent, including the typical context? When updating or re-certifying,
describe new or significant information that indicates a change from the previous assessment.
Specific areas include: view of the role of discipline (teaching, punishment, safety, etc.);
parenting practices in the family in terms of expectations, frustrations, supervision, and
disciplinary approaches. Specifically include discipline used with their own children,
grandchildren, daycare, etc.; other information.
Parent#1: Jane Doe
Mrs. Doe was asked to discuss her view of the role of discipline. She replied, "The basic reason
is that kids need to know right from wrong and they have to take responsibility for their actions.
We all have to follow guidelines and rules. Discipline helps them to realize that was not okay,
teaching them that what they did was not okay." When asked what she expects of herself as a
foster parent, Mrs. Doe responded, "To be accepting and loving and nurturing. To be open
minded and flexible. To provide a safe haven and a sense of security." When asked what she
expects of the foster children, Mrs. Doe stated, "I don't know that I have expectations. I guess I
hope that they will, over time, accept the kindness and accept the love. I hope they become
accepting of us and trust us."
Regarding what frustrates her as a parent, Mrs. Doe stated, "When you don't have the answers to
solve their problems. Like the button pushing problem with my son,trying to get across to him
something is wrong with this. He says, 'Okay'and then turns around and does the same thing. I
get frustrated thinking, 'What can I do that's going to get through to this child?"' Mrs. Doe
reported that both she and her husband would be responsible for supervising any foster children.
Regarding discipline, Mrs. Doe reported that she and her husband have spanked their son. She
stated, "We don't spank our son often. I don't think he's been spanked in quite awhile, but we
have in the past." Mrs. Doe was informed that corporal punishment is not allowed with foster
children. When asked how she intends to discipline foster children, Mrs. Doe replied, "Taking
away privileges, sending them to their rooms unless they think it's fun. We might cancel plans
for doing something fun depending on how serious it is."
Rating: 3_
Parent#2: Bob Doe
When asked how he views the role of discipline, Mr. Doe responded, "To show them right from
wrong. To make them realize there's consequences for actions." Regarding his expectations of
himself as a foster parent, Mr. Doe stated, "My main goal is to show them a loving family and
make them laugh. To prove that there's love out there." When asked what he expects of foster
children, Mr. Doe said, "I have no idea."
Mr. Doe was asked what he finds frustrating about parenting. He replied, "Getting through to
them. Sometimes I think I expect too much for their age." Regarding supervision, Mr. Doe said,
"At home,both of us, for church,both of us and everybody there." When asked how he
disciplines his children and how he will discipline a foster child, Mr. Doe responded, "Typically,
time-outs. Matt sometimes will get a swat on the butt with a hand. I threaten. With foster kids,
time-outs and loss of privileges." Mr. Doe was informed that he is not allowed to use corporal
punishment with foster children.
Rating: 3
Parent Force
4. Parenting -- General Element: What are the overall, typical, pervasive parenting practices
used by the applicant?Do not include discipline. When updating or recertifying, describe new or
significant information that indicates a change from the previous assessment.
Specific areas include: knowledge of child development and expectations of children,
parenting/child rearing practices in the family in terms of sensitivity, concern, provision of
basics; comfort with parent role; ability to parent transracial/transcultural child(ren) or
with special needs and/or disabilities; school attendance of all children; parent's school
involvement; bonding; dress, hygiene, general appearance of children; parent's ability to meet
children's emotional needs (time alone with parent, etc.); checking with county
departments for any reports of child maltreatment and investigations; other information.
Parent#1: Jane Doe
Mrs. Doe was asked about her knowledge of child development. She stated, "It's about average, I
did child care for about five years with different aged kids. I guess it's average to slightly above,
at least up to that twelve-year-old stage." Mrs. Doe reported that she has no concerns about her
ability to provide senility or the basics for any child. Regarding her comfort with the role of
foster parent, Mrs. Doe said, "It's unlike anything we've ever done but we're pretty open and
affectionate with little children." Mrs. Doe stated that she doesn't have any concerns about the
race, culture or religion of a child. Regarding children with special needs or disabilities, Mrs.
Doe stated, "We've discussed it somewhat. I don't think we feel equipped to handle anything
major, like Autism, but anything developmental, like speech issues, we're okay. Part of it is we're
doing all of this to expand our family and to give a child a family but not to sacrifice our family
while doing it."
When asked about her participation in the child's schooling, Mrs. Doe replied, "We both pretty
much do it. I do the majority of it, all the daytime stuff, he comes to the evenings." Mrs. Doe
reported that her children are bonded to her. She added, "There's a lot of physical contact,
holding hands, hugging and reassuring them that we love them. I understand that attachment
disordered kids aren't going to want the hugs and stuff. I think it's important to be honestly
interested in what they're doing. That shows them in a non-physical way you care."
Mrs. Doe reported that she thinks hygiene and physical appearance are important. She stated,
"Hygiene is a health issue. I'm kinda anal about clothes matching but I'm getting better. We do
censor as our daughter gets older, no belly shirts or short shorts that we feel are inappropriate."
Mrs. Doe was asked how she intends to meet her own children's emotional needs. She responded,
"What we do already, try to take time with them. He'll take Matt and go do something and Taylor
and I will have a girl's day out. We try to have a fun day with them, let them pick what they want
to do, spend one-on-one time with them. It would be the same with a foster child. We'd talk
about it with them too. They understand a foster child might need more understanding and take
more time, but if they feel they're being pushed aside come and tell us."
The Weld County Department of Social Services is completing the background checks on Mrs.
Doe. This clinician has not seen the results of this background check. Mrs. Doe reported that she
has never been accused, investigated or convicted of child maltreatment.
Rating: _3.5
Parent#2: Bob Doe
Mr. Doe was asked about his knowledge of child development. He stated, "On a scale of one to
ten? I'd say a five. I think I always expect them to act older than they are. I realize this by
reading books or seeing something on television." Mr. Doe stated that he has no concerns about
being sensitive to children or providing the basics for them. When asked about his comfort with
the role of foster parent, Mr. Doe said, "Yeah, I'll be comfortable." Mr. Doe stated that he isn't
concerned about the race, culture or religion of a foster child.
Mr. Doe reported that he doesn't attend PTA meetings at school but he attends the school
conferences, open houses and the "beginning of the year stuff." He added, "I attend their
activities and coached T-ball." Mr. Doe stated that his children are bonded to him and he thinks a
foster child will start bonding, "When they start feeling they can trust you. I don't know how it
works." Regarding meeting his children's emotional needs, Mr. Doe stated, "I've thought about it.
I don't know if we'll need to take them aside and do date nights." Mr. Doe reported that he
believes hygiene and physical appearance are important.
The Weld County Department of Social Services is completing the background checks on Mr.
Doe. This clinician has not seen the results of this background check. Mr. Doe reported that he
has never been accused, investigated or convicted of child maltreatment.
Rating: _3
Child Force
Child 1: Name Taylor Doe Age_12 (enter"0" if no child exists.)
5. Child Functioning Element: Social History/Background (Child) How does the
child function on a daily basis? When re-licensing, describe significant information that
indicates a change from the previous assessment.
Specific areas include: Parents' Own Children in Placement, Other Children in the Home
Age Appropriate, general temperament, expressions of emotions/feelings, typical behaviors,
presence and level of peer relationships, school performance, known mental health disorders
including substance abuse (organic/inorganic); issues of independence/dependence; issues
related to racial/cultural identity; other information.
Taylor Doe presented as a friendly, pleasant twelve-year-old girl. She was attentive and articulate
during the individual interview. Taylor was asked if her parents had talked to her about why this
clinician was there. She replied, "That we're going to adopt and we need to be interviewed so
they know if we're a great family or not." Regarding how she feels about adopting a child, Taylor
said, "I'm excited." She was asked how she thinks she will handle jealousy issues. Taylor
responded, "I don't know really, I'm not sure."
Taylor reported that her parents,her brother, Matt, and she live in their home. When asked how
she thinks a foster child might feel, Taylor said, "Scared, not knowing what would happen next."
She was then asked what she thinks she would have to offer a foster child. Taylor replied,
"Comfort it and tell it it's okay and you'll be fine. Be nice and care for them." Taylor reported
that she would expect the foster child to "be respectful and nice" in return. When asked for her
opinion on parents who mistreat their children, Taylor responded, "I think it's just wrong and no
child should be treated like that." When asked what she thinks a foster child might think about
her, Taylor said, "I don't know. Maybe they'd try to work harder. Maybe they might think, 'She's
the birth child so I have to work harder so they might respect me.'
Regarding what her family does together, Taylor stated, "Sometimes we go camping and fishing.
We'll have a movie night and stuff like that." When asked what movies they watch, Taylor
replied, "Most, like, cartoons. My mom likes classical stuff and I started liking it so I like that
stuff too." Taylor was asked how she gets along with her brother. She responded, "Sometimes
we'll be like best friends and stuff and sometimes we're like enemies and stuff,but I think we've
gotten a lot better." Regarding how she gets along with her mother, Taylor said, "Fine, I think we
have a good relationship. We have a girl's day and go to the mall the whole day. Just me and
her." When asked how she gets along with her father, Taylor stated, "Fine, sometimes we get in
little arguments, but most of the time he's fun. I like when he wrestles us."
Taylor was asked how she gets along with her peers. She replied, "Good, I get along with them
pretty much because they're my age and they like to do what I like. Not a lot of arguments." She
stated that she gets along with younger children. Taylor added, "Most I like to baby-sit
sometimes. I like little kids,they're cute and fun." Taylor reported that she doesn't know many
older kids. Regarding her extended family, Taylor stated, "I have family in California, Illinois
and Chicago. I don't get to see them much. We mostly go to California in the summer. Last
summer we went to Chicago for my grandpa's 90th birthday."
For fun, Taylor stated, "I like to do gymnastics. I like to draw and color and play on the
computer." Regarding clubs or organizations, Taylor said, "I'm in Youth Group at church(United
Methodist Church). I like it a lot. Some of my friends are there from school." Taylor reported
her hobbies as collecting "porcelain dolls and snow globes mostly."
Taylor reported that she is in the sixth grade at Windsor Middle School. She added, "I have lots
of friends. Two really best friends, Priscilla and Meagan. I like science because I've always
loved science. I like experiments and doing new things and I like my teacher. He picks on me
but it's fun. I don't like math, probably'cause I'm not good at it." Taylor reported that she plays
with her friends everyday at school. She added, "I get to see Meagan every Saturday'cause she's
in gymnastics too. Every once in awhile I have a sleep over. We switch off at each other's
house."
Taylor was asked to list two or three things she likes about herself She replied, "I like my hair
'cause not a lot of people have red hair. I like being athletic and I think I'm nice. Most people say
I'm really nice, it makes me feel really good." When asked to list two or three things she doesn't
like about herself, Taylor said, "I would like to believe in myself more. That's really all." When
she is mad, Taylor reported she will, "Sometimes just go to my room and be by myself for a
minute. That's all I really need, or read a book." Taylor reported that,when she is sad, she would
do the "same thing, I just go in my room to have some quiet time to myself" When she is happy,
Taylor said, "I'm all hyper, I never stop talking. I talk really loud and never stop talking. My
parents say I get annoying." Taylor reported that when her mother is mad, "She'll kinda just tell
us what we did wrong and sometimes send us to our room and sometimes her voice will get a
little louder, but not too much." When her father becomes angry, Taylor said, "He gives us this
long lecture and sometimes he yells when he's really mad." When asked what she does to make
her parents angry, Taylor stated, "I usually do something to my brother or not listen or not do the
dishes when I'm supposed to or argue with whichever one's getting mad at me."
Taylor was asked to list any chores she is responsible for. She responded, "I have to clean my
hamster cage, do the dishes, clean my room,pick up the dog poop and dump the trash in the
office's." Taylor reported that her family shows they care for one another by hugging. She
added, "Mom comes and hugs us and says 'I love you.' We get along really good and have a fun
time." When asked who gives orders in the home, Taylor replied, "Mostly my dad." When
orders aren't followed, Taylor said, "We get in trouble." Taylor was asked which parent she is
most like. She stated, "My dad because, like, we're both funny. Sometimes he'll say something
and I'll have this really good comeback and we'll both wrestle." Taylor reported that the rules in
her home are, "Usually we have to eat what's on the table, no playing ball or gymnastics in the
house, clean up when you're told to and don't leave trash on the floor."
Taylor reported that she feels safe in her home. When asked if she would like to add anything to
this report, Taylor replied, "I just think we're a really good, caring and loving family and we're all
really excited about it."
Rating: _4_
Child Force
Child 2: Name Matthew Doe Age_6 (enter"0" if no child exists.)
5. Child Functioning Element: Social History/Background (Child) How does the
child function on a daily basis? When re-licensing, describe significant information that
indicates a change from the previous assessment.
Specific areas include: Parents' Own Children in Placement, Other Children in the
Home
Age Appropriate, general temperament, expressions of emotions/feelings, typical behaviors,
presence and level of peer relationships, school performance, known mental health disorders
including substance abuse (organic/inorganic); issues of independence/dependence; issues
related to racial/cultural identity; other information.
Matthew Doe presented as a typically shy, quiet six-year-old boy. He was able to make good eye
contact and smiled shyly at this clinician during the individual interview. When asked if his
parents had talked to him about why this clinician was there, Matthew said, "A little,there are
lots of kids in foster care." When asked how he feels about a foster child living in his home,
Matthew replied, "Good. Uchida want a brother that's four." Matthew was asked to list the
people who live with him. He stated, "Taylor, Dan, Donna and that's all." When asked if he calls
his parents "Dan" and "Donna", Matthew said, "No, mom and dad." Matthew reported that he
thinks a foster child might feel "embarrassed" about being in foster care.
When asked what his family does together, Matthew responded, "Puzzles,games, video games
and watch TV." Matthew said he feels "bad and sad" about parents who hurt their children.
Regarding how he gets along with his sister, Matthew stated, "Pretty good. If I go in her room,
she tells on me and sometimes I get spanked and sent to my room." He reported that he gets
along "good" with his parents. When asked what his favorite thing is about his mother, Matthew
said, "The food that she makes." He said his favorite thing about his father is, "That he likes
building things with me." Matthew was asked about his grandparents, aunts and uncles. He
stated, "My grandparents live far, some of them live in California. Aunts and uncles live far
away too."
Regarding what he likes to do for fun, Matthew stated, "Sometimes just watch TV and do
puzzles. I like hockey and baseball. I'm in T-ball. I'm thinking about doing soccer." he said he
likes to watch movies like "Shrek, Finding Nemo and Jurassic Park." Matthew reported that his
hobby is collecting rocks. When asked how often he plays with his friends, Matthew replied,
"Probably like,the most I play at school with them. I play kick-ball at school. I got hit in the
face with the ball twice, it didn't hurt."
Matthew reported that he is in the first grade at Brandview Elementary School, "right up the
street." When asked what he likes to do at school, Matthew said, "Probably recess. I don't like to
do homework or spelling tests." Matthew was asked to list two or three things he likes about
himself. He stated, "I don't say bad words. I be nice to other people and I'm a good friend."
When asked if there's anything he doesn't like about himself, Matthew said, "No." Matthew said
when he gets mad he gets "angry, it's not good. I just get really mad." When he is sad, Matthew
stated, "I cry and if it's my family, when somebody says something bad to me, it hurts my
feelings." Matthew reported that, when he is happy,he does "nice things to people." When asked
if he laughs and dances around, Matthew laughed and shook his head.
When asked what happens when his mother is mad, Matthew responded, "She sends me to my
room. I know her face, how it looks when she's mad and she has a very angry voice and she
grounds me from the video games and stuff." When his father is mad,Matthew said, "He spanks
me and he sends me to my room and does the same thing as mom." When asked why his parents
get mad at him, Matthew replied, "Not being nice to Taylor."
Matthew was asked if he has any chores he's responsible for. He responded, "Take out the trash,
empty all the trash cans, clean up the backyard, that's really all." When asked if he earns an
allowance, Matthew stated, "Yes, two dollars and two quarters. One dollar's for my savings, one
dollar's for my wallet and I keep the two quarters." When asked who gives orders in his home,
Matthew said, "Mom and dad." If orders aren't followed, Matthew reported, "We get in trouble."
Matthew was then asked to list the rules in his home. He replied, "Be nice to Taylor and do the
things you're asked to do."
When Matthew was asked if he would like to add anything else,he stated, "They don't smoke,
they don't drink,they don't go to drug parties,they don't do any drugs at all." When asked where
he learned about drugs, Matthew stated, "From my dad. He used to drink before me and Taylor
were born and he stopped."
Rating: 3.5
Family Force
6. Family Functioning Element: Current Status of the Family, Family
System, Lifestyle How does the family function, communicate and interact? Consider the
family's cultural context as you describe family functioning. When updating or re-certifying,
describe new or significant information that indicates a change from the previous assessment.
Specific areas include: family structure and flexibility; clarity of roles and boundaries
(including roles children), who is in charge, how family decisions are reached, the level and
type of communication used, the presence and use of affection, marital issues, unresolved
infertility issues of couple (if appropriate), presence/absence of family violence, open/closed
to trans-racial/trans-cultural/religious experiences; general feelings/climate within the family;
other information.
Mr. and Mrs. Doe were asked to describe their family structure. Mrs. Doe replied, "I think
we're in the middle. Structure for school days but flexible for the weekends." Mrs. Doe
reported that the roles in the family are clear. She stated, "For the most part, I'd say so. I
think the kids know it's pretty much equal. My daughter is a little bit of a mother hen. He's
(Mr. Doe) the player, the playful one. We both put them to bed and say prayers." Mr. Doe
reported that he is responsible "for taking out the trash and if things are broken, I fix them."
Mrs. Doe stated that her responsibilities include, "Most of the transporting to school,
gymnastics and doctors appointments. I do the cooking and I primarily help with the
homework."
Mr. and Mrs. Doe reported that they are both in charge. They stated that they make decisions
together. Mrs. Doe stated, "We make decisions a lot of times as a family. We discuss it and
come up with the best solution. With something small we let the kids help decide."
Regarding communication skills, Mrs. Doe said, "It's very good. We talk a lot, our daughter
talks a lot. She opens up and talks about friends at school and who's doing what and then
she'll go to her dad and tell him what's going on." Mr. Doe added, "I tell her that's the
problem with cell phones; I call and tell her what's going on so I don't have anything to talk
about at night."
Mr. Doe reported that family members show affection with "hugs, kisses and play wrestling."
Mrs. Doe added, "We talk to them and tell them that we're proud of them and say 'I love
you."' Mr. and Mrs. Doe stated they have no marital issues. Mr. Doe stated, "We can both be
stubborn but it's not necessarily an issue." The Doe's reported no infertility issues. They
stated there is no violence in their home.
Mr. and Mrs. Doe reported that they are open to accepting children of other races, cultures or
religions. Mrs. Doe stated, "We're open. I guess it would be hard if a child came in saying
'I'm Buddhist'or Muslim. It would be difficult."
Rating: _3.5_
Family Force
7. Family Support Network Element: Child Safety and Well-Being, Availability
of Support System. What is the quality of supportive relationships (formal and informal)
outside the home? Consider the family's cultural context as you describe their support network
When updating or re-certifying, describe new or significant information that indicates a change
from the previous assessment.
Specific areas include: nature of extended family support; support of unrelated persons
(friends, confidantes); involvement/support of organizations, clubs, churches, agencies;
involvement/support of neighbors, business and social associates; other information.
Mr. and Mrs. Doe were asked to discuss their extended support system. Mrs. Doe replied,
"Definitely our church family, it's small so everybody knows everybody. Our Pastor's daughter
just adopted from a foster/adopt situation and she encouraged us to adopt. All of our family is out
of state." Mr. Doe added, "That's our main friends." Mr. and Mrs. Doe stated that they attend the
First United Methodist Church.
Mr. Doe reported that they belong to the Business Network International group as well as
belonging to the Chamber of Commerce. Mrs. Doe attends the PTAC and PAC meetings at her
children's schools. She stated that she also volunteers at school two mornings a week. They do
not belong to any other organizations, groups or clubs.
Rating: _3_
Family Force
8. Demographic Element: Finances, Home Safety Inspection, Employment,
Community Makeup What are the demographics of the family? Consider the family's
cultural context as you describe demographics. When updating or re-certifying, describe new or
significant information that indicates a change from the previous assessment.
Specific areas include: economic resources; employment; home (additions/remodeling with
square footage); neighborhood and community (include racial/cultural/religious integration);
health problems; financial self-sufficiency; stresses related to demographics and how
handled (e.g., medical, bankruptcy, family moves, household members leaving); other
information.
Mr. and Mrs. Doe own their own business; D. Doe Construction Company. Mr. Doe stated that
he has been self-employed for ten years. He generally works Monday through Friday, nine to ten
hours per day. Mrs. Doe works on their books, appointments and payroll from home. She stated,
"I don't budget my time. I pretty much work when the kids are in school." She volunteers at her
children's schools on Tuesday and Thursday mornings, generally until noon. They estimated their
yearly income at$95,000.00. They reported that they receive no other income.
The Doe's own their home and have lived there for four years. They reported that they have been
in Windsor, Colorado, for nine years, living for one year in Ault, Colorado. The home is a ranch
style home with a finished basement. The square footage on the main floor is 1565 square feet
and the basement is 1300 square feet. On the main floor there are three bedrooms, two
bathrooms, a kitchen with dining area, a living room and laundry room. The basement has one
bedroom, one bathroom, a family room, office and a general play area. Their house payment is
$1,235.00 per month. The only other large payment they reported is on their Suburban; $400.00
per month.
There is a park across the street and another park with playground equipment approximately two
miles away. The closest hospitals are in Greeley, Colorado, or Ft. Collins, Colorado. There are
two medical clinics in Windsor with Urgent Care available until 8:00pm. Brandview Elementary
is six blocks away and the junior high school and high school are approximately one mile away.
Mr. and Mrs. Doe described their immediate neighborhood as having middle aged neighbors with
teens. There are also older couples and younger people with no children. Mrs. Doe reported that
the community is "98% Caucasian." Mrs. Doe stated that she and her husband just completed
their physical exams and they are both in "excellent"physical health.
When asked if they have any stress over finances, Mrs. Doe replied, "Nothing on-going. Every
once in awhile we get stressed from running our own business." They stated that they have never
filed for bankruptcy, don't intend to remodel their home and there are no moves planned.
Rating: _3.5
Birth Family Force
9. Viewpoint of Birth Parents Element: How do the parents view child maltreatment,
parents who maltreat their child(ren), parents who place their children in foster care, and
parents whose children are placed by a court in foster care? When updating or re-certifying,
describe new or significant information that is a change from the previous assessment and
examine the attitude toward the birth family and understanding/support of positive relationships
and/or memories of birth family.
Specific areas include: training completed or needed concerning the parent's
viewpoint of birth parents when updating or re-certifying, contact with birth
parents and learning gained from the experience; general learning regarding birth
parents; other information.
Parent#I: Jane Doe
Mrs. Doe was asked how she views parents who maltreat their children. She responded, "I think
they definitely need guidance and help. It angers me that people have kids who shouldn't and
others who should can't have them. I wish they could reach out and get help before it gets out of
hand." Regarding parents who place their children voluntarily, Mrs. Doe stated, "I give them a
lot of credit. That takes an awful lot of courage. They're trying to do what's best for their child in
most cases. Hopefully they're not just giving up on the kids."
When asked for her viewpoint on the courts removing the children, Mrs. Doe replied, "I think
there was obviously a problem, something not right. I feel bad for the family, but worse for the
kids who had to be in a situation that's not healthy for them."
Mrs. Doe has not had any formal training on the viewpoint of the birth family. She reported that
they were supposed to start the CORE training program through the Weld County Department of
Social Services in January of 2004 but they got "bumped." Mrs. Doe stated that they are to begin
their CORE training in February of 2004.
Rating: _3.5_
Parent#2: Bob Doe
Mr. Doe stated that his viewpoint on birth parents is that"It's sad that you need to take a test to
get a drivers license but anyone can get together and have kids. It's upsetting, hearing all the
trauma about these kids. I wish they could be more educated about the amount of damage they
do to the kids." When asked for his viewpoint on parents who voluntarily place their children,
Mr. Doe replied, "I think it's gotta be hard on them and their whole family but they're looking out
for the best interest of their child. They're looking for help and will hopefully get it."
Regarding his viewpoint on the court placing children, Mr. Doe stated, "I think I would have to
assume that most of the time the court has to intervene is because there has been some kind of
substance abuse and then the parents sober up and find out they've lost their kids. I feel sorry for
them."
Mr. Doe has not had any formal training on the viewpoint of the birth family. He reported that
they were supposed to start the CORE training program through the Weld County Department of
Social Services in January of 2004 but they got "bumped." Mr. Doe stated that they are to begin
their CORE training in February of 2004.
Rating: _3.5_
Birth Family Force
10. Viewpoint of Foster Children Element: How does the parent view children
placed in foster care? Any differences in view based on type/age/race/culture/religion of the
child? When updating or re-certifying describe new or significant information that indicates a
change from the previous assessment
Specific areas include: feelings toward and treatment of foster children (general, and
specific to their foster children, if updating or re-certifying); training completed or needed
concerning parent's viewpoint of foster children; when updating or re-certifying,
consider presentation of children to community(sensitivity, advocacy); other information.
Parent 41: Jane Doe
Mrs. Doe was asked for her viewpoint on children in foster care. She replied, "I feel they're
pretty fragile. They need to be treated with a lot of compassion and understanding. They need to
be treated like your own kids but with more sensitivity. You may not know what they've gone
through. I want to show them a positive family life and that not all are like they've been exposed
to so far."
When asked if there is any difference in how a foster child of a differing race, culture or religion
should be treated, Mrs. Doe responded, "Not as far as how I would treat them, no. As far as
adoption, we don't feel we could meet the needs of an African American child culturally living
where we do."
Mrs. Doe has not had any formal training on the viewpoint of foster children. She reported that
they were supposed to start the CORE training program through the Weld County Department of
Social Services in January of 2004 but they got"bumped." Mrs. Doe stated that they are to begin
their CORE training in February of 2004.
Rating: _3.5_
Parent#2: Bob Doe
Regarding his viewpoint on foster children, Mr. Doe stated, "I feel they've been let down. I feel
they've probably got a real aching in their heart to have a real family." When asked if there is any
difference in how a foster child of a differing race, culture or religion should be treated, Mr. Doe
responded, "No, it wouldn't matter."
Mr. Doe has not had any formal training on the viewpoint of foster children. He reported that
they were supposed to start the CORE training program through the Weld County Department of
Social Services in January of 2004 but they got"bumped." Mr. Doe stated that they are to begin
their CORE training in February of 2004.
Rating: _3
Foster Family Force
11. Preparation Element: How prepared is the family for adoption/fostering?How able is
the family to provide children with relevant racial, cultural, and religious experiences?Include
issues related to visitation with birth relatives and reunification as appropriate. When updating
or re-certifying, describe new or significant information that indicates a change from the
previous assessment.
Specific areas include: family's own children's current view of fostering, including
jealousy issues; parents' specific capabilities as related to foster parenting; training
completed or needed concerning impact of fostering/adoption; when re-licensing
consider effects of foster parenting on extended family; attachment to foster children, and
feelings about foster children who may have left the home; other information.
When asked how prepared they think they are to provide foster care, Mrs. Doe stated, "He's kind
of anxious. He thinks he's too old." Mr. Doe stated, "When we do this, we're looking for a child
who's already been given up." Mrs. Doe added, "I think we're willing to go through whatever
training and classes we need. Are we prepared today? It depends on the child and if we can keep
the child. I'm worried about our youngest child's reaction. I've tried to address jealousy issues
with our youngest. His biggest concern is not being the youngest. We know we have a choice in
which kids to take. Our twelve-year-old is asking when do we get a child. She's very eager. She
dotes on little ones. We're worried she might ignore Matt, we'll watch for this."
Mr. and Mrs. Doe stated they only want a child who is available for adoption. When asked if
they would consider taking a child on the verge of availability, Mrs. Doe replied, "We're wary of
bringing a child in the home and becoming attached. We've discussed it a lot, if a child returns
home it's God's intention the child return." Mr. Doe added, "I think in our hearts we'd say yes."
The Doe's have not had any formal training on fostering children. They reported that they were
supposed to start the CORE training program through the Weld County Department of Social
Services in January of 2004 but they got "bumped." They are to begin their CORE training in
February of 2004.
Rating: _3
Foster/Adoptive Family Force
12. Motivational Commitment Element: Motivation for Child What is the nature
and level of motivation and commitment demonstrated by the family?Include infertility issues as
appropriate. When updating or re-certifying, describe new or significant information that
indicates a change from the previous assessment.
Specific areas include: basis/reasons for motivation/commitment(e.g., status, financial.
emotional, adoption, own needs, service to community. etc.); other information.
The Doe's were asked about their motivation in foster/adopting a child. Mrs. Doe replied,
"We've been talking about it for three years. I really would like another child, even before we
were married we talked about it." Mr. Doe added, "To help a child. We decided a long time ago
to have two and if we wanted more to adopt."
Mr. and Mrs. Doe stated they do not wish to adopt for financial reasons.
Rating: _3.5
Intervention Force
13. Family Response Element: Relationship with County Department of
Human Services, Agency How capable are the potential parents to use agency
involvement and to seek help on their own? Include willingness of family to seek cross-cultural
models and experiences. When re-certifying, describe new or significant information that
indicates a change from the previous assessment.
Specific areas include: communication with agency staff; relationship with agency staff
(includes willingness to receive consultation/advice); relationship with other professionals;
ability to share information; ability to keep information confidential; ability to keep
schedules and appointments; willingness to be involved with birth family (as
appropriate); resourcefulness in pursuit of services; willingness to provide
transportation; participation in foster/adoptive parent activities (e.g., newsletter, foster
parent association/support groups, parties/picnics, assist with trainings, provide/use respite
care); other information. When updating or re-certifying also consider preparation of foster
children for removal from home (includes gathering belongings, handling good byes).
Indicate summary of training attended since last certification. Also identify any
rule/contract violations and corrective/action plan if appropriate.
Mrs. Doe stated that her communication so far with the Weld County Department of Social
Services has been "very comfortable,they're easy to talk to and answered questions honestly."
The Doe's stated they have no concerns about their ability to communicate appropriately with
other professionals. Mr. Doe added, "We'll just eavesdrop and learn." Regarding sharing
information with appropriate people, Mrs. Doe stated, "I would assume the more information we
give them,the better they can help." Neither of the Doe's felt keeping confidentiality would be an
issue for them.
They stated that providing transportation would be no problem as Mrs. Doe works from home and
can set her own hours. When asked about their willingness to be involved with the birth family,
Mrs. Doe replied, "To the extent it needs to be, like at visitation. I can handle being polite."
Regarding their interest in participating in foster/adoptive activities, Mrs. Doe stated, "I'm
assuming I'd want to do a support group with foster/adoptive parents."
The Doe's have not had any formal training on fostering children. They reported that they were
supposed to start the CORE training program through the Weld County Department of Social
Services in January of 2004 but they got"bumped." They are to begin their CORE training in
February of 2004.
Rating:
Intervention Force
14. Resource Element: Availability of Support Systems What are the resources,
external to the family, which support the placement(s)?Includes ongoing training
services and support groups. When updating or re-certifying, describe new or significant
information that indicates a change from the previous assessment.
Specific areas include:the availability of support to the family 24 hours a day, including
agency/staff resources; other information.
The Doe's were informed that the Weld County Department of Social Services provides support
24 hours a day, seven days a week through caseworkers and an emergency duty worker evenings,
weekends and on holidays. They were given the phone number to Greeley Dispatch to contact
the emergency duty worker at need and given instructions on how to call.
Rating: _4_
PARENT FORCE CHILD FORCE FAMILY FORCE BIRTH FAMILY FOSTER FAMILY INTERVENTION
FORCE FORCE FORCE
History _3_ Child Funct.3.5 Family Funcl. 3.5 Viewpoint Parent 3.5 Preparation 3 Family 3
_ _ _ _
Adult general _3_ Family Support 3 Viewpoint Child _3_ Motivation 3.5 Resource 4
Parenting Dcp_3_ Demograpic 3.5
Parenting Gen 3
Conclusion
1. Add the ratings entered above in the 14 elements _45.5
(If no child in home, score "0" on "Child Functioning " in the Child Force)
2. Based on the rating in #1, identity the presence of positive parenting/effective family
functioning or the likelihood of disruption:
a. Very positive family field/No apparent risk (48 to 56)
The presence of positive parenting and effective family functioning are apparent.There appear to be no
conditions of risk which exist;the parents capability to care for children is adequate.Based on appropriate
matching,a child will likely be/is enhanced by this placement.Indications are that a placement will be/is
secure,productive and stable.
b. Generally positive family field/Minimal risk (37 to 47) X
Generally,there is evidence of positive parenting and effective family functioning.There are indications that
there is a balance between the capacity,conditions,and needs of the family and the needs of the child.There
are minimal risks present;the family is aware of and willing to address the areas of risk.Consideration
should be given to continued matching of the skills and abilities of the family with the needs of the child in
order to insure that the child will continue to be enhanced by the placement.
c. Somewhat positive family field/Low risk (22 to 36.5)
Although there is evidence of positive parenting and effective family functioning,there is an indication that
the child may not benefit/be benefiting from this placement and the placement may be problematic.There
may be an imbalance between the capacity,conditions,and needs of the family and the needs of the child.
Consideration should be given to the most pronounced risks and how manageable or adjustable they are.
Documentation in the case record as to these risks needs to be clear.When updating or re-certifying,a
support/action plan should be entered into with the foster family in order to manage the most pronounced risk
elements,if they are considered serious enough to address.
d. Negative family field/Moderate risk (11 to 21.5)
Enough negative influences have been identified within the field so that there is a threat that the child will
suffer/is suffering directly from this placement and the placement may disrupt.There is an imbalance
between the capacity,conditions,and needs of the home and the needs of the child.Analysis of the most
concerning risks needs to occur.Clear documentation of these risks is imperative. If a placement exists when
updating or re-certifying,it is recommended that consideration be given to removing the children from the
home and that the family not be approved for any future placements.
e. Very negative family field/Significant to High Risk...(0 to 10.5)
It is probable that the child will suffer/is suffering directly from this placement and the placement will
disrupt.Continued or future placements of a child could result in some form of maltreatment to the child.The
agency needs to inform the family of the areas of risk influences.All risk influences need to be documented
in the case record.It is recommended that if a placement exists,the child should be removed from the home.
The home should not be approved for any future placements.If ANY children reside in this family,
consideration should be given to making a referral for a CPS assessment.
3. Is there concern for maltreatment or likelihood of maltreatment in this home?
Yes No X
If yes, identify decisions and actions concerning responsibility to refer for a Child
Protection assessment:
4. Is there a concern for disruption likelihood for disruption in the potential foster/adoptive
home?
Yes No_X_
If this foster/adoptive applicant family is currently providing foster care, does the family
require agency support to strengthen skills/abilities to remain a foster family?
Yes No N/A_X_
If the foster/adoptive applicant family is not providing foster care, are there decisions
and actions that can be taken to prevent future disruptions and strengthen the family?
Yes No_X_
If the answer to any of the above questions is "Yes," complete the Action/Support Plan
designed to remedy the disruptive condition(s) or to strengthen the family's
skills/abilities.
Evaluation and Decision:
Based upon all materials, interviews, and use of this system,the conclusion of the assessment
X or re-assessment is as follows:
A. Provide a general summary of the strengths and weaknesses of the family, indicating any
categories within the field which raise concerns regarding the ability of the family to
parent children who may be or are now placed in the home. Address the significance of
any support plan that has been offered with regard to certification or re-certification of
the family.
Mr. and Mrs. Doe appear to be a very caring, supportive couple. They have two children of their
own who appear to be well adjusted and bonded in a healthy manner to their parents. The Doe's
own their own business, which they have been successful running for the past ten years. They
receive a great deal of support from their church, although it is slightly concerning that this is the
only area of support they were able to identify. They have never fostered before and are therefore
somewhat naive regarding children involved in the child welfare system. However,they are both
intelligent, caring people who are motivated to learn more and help a child. They have both
expressed an interest in understanding the needs of these children and an enjoyment in learning.
The Doe's stated that, although they would not be comfortable with a child with severe
developmental issues,they are willing to take a child with special needs and minor disabilities.
B..Indicate your judgement as to the type of children) that should be considered for this
family. When updating or re-certifying, consider: with which type of child does the family
excel? With which type of child does the family provide adequate care? Which type of
child likely does not benefit from placement in this family?Describe children in terms of
age, race, sex and general functioning.
Dependent upon the results of the background check, this clinician would recommend this family
as acceptable applicants for the foster/adoption of a child aged three to four years. Either gender
is acceptable to this couple. Although the Doe's stated that they would accept a child of any race,
culture or religion, Mrs. Doe expressed some concern about being able to meet the cultural needs
of an African American child in the Windsor area. She also expressed some doubt as to her level
of comfort should a child be of the Buddhist or Muslim religion's. This should be considered
when deciding on a child to be placed in the Doe home.
Julie Box, LCSW
Date
JG/ Gu/ cuu4 1J : uG : ua American Prof Agency --> P. 002/002
Account Number: CO BOXJ 1700 Date: 2/20/04 Initials : JUDITH
AMERICAN HOME ASSURANCE CO.
0/0: American Professional Agency, Inc .
95 Broadway, Amityville, NY 11701
This is to certify that the insurance policies specified below have been issued by the company indicated
above to the insured named herein and that, subject to their provisions and conditions, such policies afford
the coverages indicated insofar as such coverages apply to the occupation or business of the Named insured(s)
as stated.
THIS CERTIFICATE OF INSURANCE NEITHER AFFIRMATIVELY NOR NEGATIVELY AMENDS, EXTENDS OR
ALTERS THE COVERAGE(S) AFFORDED BY THE POLICY(IES) LISTED ON THIS CERTIFICATE.
Name and Address of Insured: - Additional Named Insureds :
JULIENNE E . BOX
1702 68TH AVENUE
GREELEY CO 80634
Type of Work Covered: PROFESSIONAL SOCIAL WORKER
Location of Operations : N/A
(If different than address listed above)
Claim History: •
Policy Effective Expiration - Limits of
Coverages Number Date Date • Liability
PROFESSIONAL/ 1,000,000
LIABILITY SWL-0000000 2/20/04 2/20/05 1 , 000,000
NOTICE OF CANCELLATION WILL ONLY BE GIVEN TO THE FIRST NAMED INSURED ON THIS
POLICY AND HE OR SHE SHALL ACT ON BEHALF OF ALL INSUREDS WITH RESPECT TO GIVING
OR RECEIVING NOTICE OF CANCELLATION.
Comments: ADDITIONAL INSURED LISTED: STATE OF COLORADO/THE WELD
COUNTY DEPARTMENT OF SOCIAL SERVICES
This Certificate Issued to:
Name: JULIENNE E. BOX
1702 68TH AVENUE
Address: —�
GREELEY CO 80634
Au orized Representative
•
STATE OF COLORADO
DEPARTMENT OF REGULATORY AGENCIES
DIVISION OF REGISTRATIONS
SOCIAL WORK EXAMINERS BOARD
ACTIVE /Z_
LCSW 0-2.1n .
992996 07/01/2003 06/30/2005 DIRECTOR v
DIVISION OF REGISTRATIONS
NUMBER ISSUED ' EXPIRES
JULIENNE ELISE BOX, M.S.W.
3800 AUTOMATION WAY
SUITE 200
FT COLLINS CO 80525
LICE E'S SIGNATURE
PROGRAM BUDGETS
a COA3UIIItIACTUALBD ACTUAL
PROGRAM Hone Studies
A TOTAL HOURS OR DAYS OF DIRECT SERVICE PER CLIENT 10
B TOTAL CLIENTS SERVED 38
8725
C TOTAL HOURS OR DAYS OF DIRECT SERVICE FOR YEAR(AX B) 380 78A1
0 COST PER HOURS OR DAYS OF DIRECT SERVICES(E/C) 23931
E TOTAL DIRECT SERVICE COSTS FACE-TO-FACE 314,150
F ADMINISTRATION COSTS NON-FACE-TO-FACE ALLOCABLE TO PROGRAM $12,500 _
G OVERHEAD COSTS ALLOCABLE TO PROGRAM S0250
H TOTAL DIRECT,ADMINISTRATION&OVERHEAD COSTS(E•F•0) $35.200
I PROFITS CONTRIBUTED BY THIS PROGRAM $1,500
J TOTAL COSTS AND PROFITS FROM THIS PROGRAM(H•I) S3T,400
K TOTAL HOURS OR DAYS OF DIRECT SERVICE FOR THE YEAR(C) 350 _
L RATE PER HOURS OR DAYS OF DIRECT,FACE-TO-FACE SERVICE
(J I K) $103.89
DIRECT SERVICE COSTS
COMPIRFgvYD ACTUAL
m Butlpt AMnp Teel %OF THE SALARY %OF TYE SALARY 7.OF TIME SALARY 7.OF TIME SALARY %OF TIME SALARY %OF TIME SALARY
67 25
OeRrti Bq $Wrylo.I. SAYtrI 1FO% SPENT OM AND SPENT OM AND SPENT ON AND SPENT OM ANO SPENT OM AND SPENT ON 1X0
DESCRIPTION -CM FTE. @10 PTE BenefSIUXe ALLOCATED PROGRAM OTHER COSTS PROGRAM OTHER COSTS PROGRAM OTHER COSTS PROGRAM OTHER COSTS PROGRAM OTHER COSTS PROGRAM OTHER COSTS
PROGRAM Hats Sb dM.
... )0 Al
A TOTAL CLIENT HOURS OR DAYS PER PROGRAM :10
B TOTALCLIEMTS TO BE SERVED PER PROGRAM
C TOTAL HOURS OR OAYS PER PROGRAM FOR YEAR 26O00 000 0.00 000 0.00 000
BCNJVi NSW. OYv 5`0000 113SW00 YES '10000% 11150000 5000 SOnG 0000 SOW 0000
LORD NO $000 5000 5000 SD00 1000 3000
0D.O0 NO 1000 1000 1000 0000 1000 10.01
50.00 NO 0000 .10.00 1000 1000 1000 50.00
10.00 NO 0000 50.00 0000 1000 1O00 00DO
$000 HO $000 $000 $000 0000 5000 00.00
50.00 HO 5000 f00D 5000 0000 0000 00.0
0000 HO $ODD 1000 5000 1000 0000 10,00
NO 3000 10.00 00 D0 5000 5000 10.00
1000 NO 1O00 50.00 1000 ' $000 1000 1000
50.00 NO 0000 1000' f0D0 $000 1O00 0000
SOW HO 0000 50.00 0000 0000 0000 00.00
0000 NO 0000 30.00 1000 $000 $000 0000
..,( ` $000 NO 1O00 30.00 1000 1000 $000 10.00
TOTAL DIRECT LABOR PER PROGRAM
$12 500,00 513.500.00 5000 10.00 00.00 1000 10,00
(OTHER MYFCT COSTS PER PROGRAM FACE-TMFACF
TnW L ' '• ..�-::c�_. $J00.¢ YES fOM% 0120000 y $000 .,^ $000 0000 0000 SO 00
C.RPMI., - 3W.OP YES 10'0%. 145000 v _ - 0000 sold 1000 sold 1000
10
HO 1000 :0 GO 5000 5000 0000 SO00
NO 1000 SO.00" 5000 0000 0000 10.00
5000` 1000 $000 0000 _ 1000 00.00
_ 0000 $000 1O00 5000 $000
TOTAL OTHER DIRECT COSTS PER PROGRAM1155000 SASH $155000 1000 0,0 GO
00,00 SOLO
E GRAND TOTAL DIRECT SERVICE COSTS 514150.00 51091 $1{130.00 1000 10.00 10,00 10,00 SO,00
ADMIN COST NON-FACE-TO-FACE
•
COMET=ACTUAL
Minimum BVOgI 1r�nP T0YI % TIME SALARY % TIME SALARY %OF TIME SALARY %OF TIME SALARY %OF TIME SALARY %OF TIME SALARY
Des,.. F M S\Mry/Sone Salann/ 100% SPENT ON AND SPENT ON AND SPENT ON AND SPENT ON AND SPENT ON AND SPENT ON AND
DESCRIPTION w C.N FTE. ®10 FIE Be fitYOlgr ALLOCATED PROGRAM OTHER COSTS PROGRAM OTHER COSTS PROGRAM OTHER COSTS PROGRAM OTHER COSTS PROGRAM OTHER COSTS PROGRAM OTHER COSTS
67 1
PROGRAM - 704
romA5M�a 60.25
A TOTAL CLIENT HOURS OR DAYS PER PROGRAM 10
$ TOTAL CLIENTS TO BE SERVED PER PROGRAM 36
C TOTAL HOURS OR DAYS PER PROGRAM FOR YEAR 360 W 000 0.00 0.00 0.00 0.00
PISrT I AnnR WIT FACE-TO-FACE
Ba..IIF- 07$ fW,OD3: 01250000 rEs tDO LYM 01]00000 $000 $000 5000 $000 $0.00
$000 NO $OW $Om : 5000 $000 $003 $0.00
$0.00 NO 0000 0000 5000 5000 $GW $0.00
$0.00 NO $000 00.00 5000 $000 $000 $o D0
$0.00 No $000 00.00 1000 0000 $000 bM
$0.00 No $000 $000 . $000 5000 1000 3000
$0.00 NO $000 $0.00 $000 $000 0000 50.00
$0.00 NO $000 30.00 $000 $000 1000 $0.00
$000 NO $000 $0.00 $ON 0000 5000 $0..36
$0,00 NO $000 0000 1000 5003 $000 $0.03
$0.00 NO $000 5000 $000 $000 5000 $0.00
00.00 NO $000 00.00 $000 $000 0000 SO.00
$0.03 NO SOM $0.00 $000 $000 5000 $0.00
_. .. ... SOLO NO SOW SO.W SOW 5000 fOM .. 50.00
TOTAL DIRECT LABOR PER PROGRAM NOT FACE-TO-FACE $120W.W 612,500.00 10.00 SO.CO SO W $000 SO DO
OTHPR DIRECT COSTS PFR PROGRAM NOT FACE-Tn4A/'F
NO Y= 6000 y. SO CO- $000 $000 $000 $0.00
i No $000 $OW $000 $000 $OW $0.00
-.".,.' SOW :. SOW SOW r SOW W_W
NO $OW 00.3 i 5000 1000 SOW SO.00
NO $000 3.3 $0 W SC W - MI3 $0.00
NO SD W ,..;, 00.00 $0 3 SOW so W -1, y $0.00
TOTAL OTHER DIRECT T COSTS NOT PACE-TO-FACE PER PROGRAM $0.00 51000 10.00 $0.00 $050 $000 5000
F GRAND TOTAL DIRECT SERVICE COSTS NOT FACE-TO-FACE S12 500 S34 72 $1250.3 10,00 103 SO 00 50,3 10.00
COMPUTERIZED ACTUAL
OVERHEAD COSTS AND PROFITS
TOTAL ALLOCATED ALLOCATED ALLOCATED ALLOCATED I ALLOCATED ALLOCATED
D 100% ALLOCATED OVERHEAD COSTS ALLOCATED OVERHEAD COST ALLOCATED OVERHEAD COSTS ALLOCATED IVERHEAD COSTS %ALLOCATED•VERHEAD COSTS %ALLOCATED DVERHEAD COSTS
DESCRIPTION COSTS 0 TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM
PROGRAM Home Studies
A TOTAL CLIENT HOURS OR DAYS PER PROGRAM $10.00
B TOTAL CLIENTS TO BE SERVED PER PROGRAM $36.00
C TOTAL HOURS OR DAYS PER PROGRAM FOR YEAR 360.D0 0.00 0.00 0.00 0.00 0.00
OVFRHFAD
Rent $4,800.00 YES 100.00% $6,800.00 $0 00 $0 00 $0.00
USMies - $600.00 YES 100:0% $60D.00 $0 00 $0.00
$0 00 $0.00 $0.00
Phone $300.0° YES 100.00% $300 00 $0 00 $0 00 $0 00 $0.00
Office Supplies .. - $400.00.YES 100,00% $40000 $0 o0 $0 W 0 00 $0.00 $0.00
t]eprede6on{Computer eRMpment) $500.00,YES 100.00%
$500.00 $0 00 $0.00 $0.00 $0.00
Insurgnce(Prof tieb6tX,AVIo.Worker's Come) '-E' $750 0 YES - 100.00% $]50.00 $0 00 $0 00 .71-'..<, $0.00 $0.00
[OuesR.bmbershps $200-00 YES TW.Wx $200.00 $000 $000 $000 _ $0.00 $0.00
Pmfessio^at Lceme $100 001 YES 100.00% $100.00 $0 00 $0 00 $p 00 $0.00
Confennces1Nohsrmys- . L` L; 1500.00 YES . ;m;`tO0.Wx $500.00 ;, O00 $00 $000 $0.00 $0.00
10400X.. $5OD0 t 50 00 $0 00 $0 00 50.00 50.00
E5Np111M11 SSW W'YEE tW.00% $500.00 $000 50 00 $0.00
$100.00 $0 00'-
yam - 50 00 $0.00 $0.00
$0.0 $0 00 $0 W $0 00 50.00
am _ $p 007--(,,$-.(::::' $0 00 $0.00 i $0.00
NO - 50.00 $0 00 $0 00 $0 00 50.00 $0.00
..,. No $0.0 $00 vT $000 $000 50.00 50.00
.- $00 000 $0.00 00 5000 $0.00
. .. "v _ $0 00 M1 $0.00
G TOTAL OVERHEAD COSTS $9,250.00 $9,250.00 $0.00 $0.00 $0.0 $0.00 $0 00
I TOTAL ANTICIPATED PROFITS S4,W0,W., VES 500$6' $00 $000 $00 , _.,,,,.,_ $0.00
TOTAL OVERHEAD AND ANTICIPATED PROFITS $10,]50.0 $10,750.00 $0.00 $0.0 $0.00 $0.00 50.00
J
SUPPLEMENTAL NARRATIVE TO RFP: EXHIBIT B
RECOMMENDATIONS
X CONDITIONS
-79
f723
�)
f7
t
Julie Box, LCSW
1702 68 Ave
Greeley, CO 80634
970.302.1471 (cell)
970.339.9036(fax)
April 12, 2004
Weld County Department of Social Services
P.O. Box A
Greeley, CO 80632
Gloria Romansik
Re: Response to FYC Commission's recommendation re: RFP 006-00: Home Studies and
Relinquishment Counseling
Dear Ms. Romansik,
The purpose of this letter is to respond to the FYC Commission's recommendation that"the
provider will notify the Department of any change in staff at the time of the change." This provider,
Julie Box, LCSW, agrees to the recommendation and will notify the Department immediately of
any change in staff at the time of the change.
Thank you for your approval for inclusion on the Departments vendor list. Please let me know if
there is anything else I can do for the Department.
•ncerely,
lie x, LC� SWl uc �
riva a Practice
aaJ-
4 .tz.oc
a
DEPARTMENT OF SOCIAL SERVICES
P.O.BOX A
GREELEY,CO.80632
Website:www.co.weld.co.us
Administration and Public Assistance(970)352-1551
Child Support(970)3524933
0
COLORADO April 7,2004
Julie Box,Private Practice
1702 68 Avenue
Greeley,CO 80634
Re: RFP 006-00:Home Studies and Relinquishment Counseling
Dear Ms.Box:
The purpose of this letter is to outline the results of the Bid process for PY 2004-2005 and to request written
information or confirmation from you by Wednesday,April 14,2004.
A. Results of the Bid Process for PY 2004-2005
The Families,Youth and Children(FYC)Commission recommended approval of the bid,RFP 006-00,
Adoption,Foster Care,and Expedited Permanency Planning Home Studies,and Relinquishment
Counseling,for inclusion on our vendor list with no recommendations.
B. The Families,Youth,and Children Commission recommended the following condition be applied to
all approved 2004-2005 contracts.
The condition is:the provider will notify the Department of any change in staff at the time of the change.
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.
The Weld County Department of Social Services is requesting your written response to the FYC Commission's
recommendation.Please respond in writing to Gloria Romansilc,Weld County Department of Social Services,P.O.
Box A,Greeley, CO,80632,by Wednesday,April 14,2004,close of business.
If you have questions concerning the above,please call Gloria Romansik,970.352.1551,extension 6230.
Sincerely, ^
y A. ''ego,D ector
cc: Juan Lopez,Chair,FYC Commission
Gloria Romansik,Social Services Administrator
Weld County Department of Social Services
Notification of Financial Assistance Award
for Child Welfare Regular Administration Funds
Type of Action Contract Award No.
X Initial Award 04-CPS-32
Revision (RFP-006-00)
Contract Award Period Name and Address of Contractor
Beginning 06/01/2004 and Lori Kochevar,LLC.
Ending 05/31/2005 Home Studies,Updates, Relinquishment Counseling
23830 WCR48
LaSalle, CO 80645
Computation of Awards Description
Unit of Service The issuance of the Notification of Financial
Home study format is based on testing, 3 joint Assistance Award is based upon your Request for
interviews with a couple, 1 individual interview Proposal (RFP). The RFP specifies the scope of
with each adult member in household and an services and conditions of award. Except where it is
age/developmentally appropriate interview with in conflict with this NOFAA in which case the
all children residing in the home. For single NOFAA governs,the RFP upon which this award is
applicants,a minimum of 3 interviews will be based is an integral part of the action.
required. Home study updates as requested by Special conditions
foster parent coordinators. Relinquishment 1) Reimbursement for the Unit of Service will be based
Counseling to follow State outline. Monthly on a rate per home study; home study update, and
average capacity is 6 home studies and 1 unit relinquishment counseling session.
relinquishment counseling. The average stay in 2) Reimbursement requests must be an original with an
the program is 6 weeks, average hours per week original signature from the provider and/or designee.
in the program is 4. Bilingual-bicultural services 3) Reimbursements requests must include the date the
available through current staff. home study, update, or relinquishment counseling was
Cost Per Unit of Service completed. The request must reflect the referral
Relinquishment Counseling $252.24 number assigned to each home study, the amount
(2-hour maximum) billed for each home study,and the month the service
Rate per Study was provided.
Full Home Study* $975.76 4) Payment will only be remitted on referrals made by
Updated Home Study $525.00 the Weld County Department of Social Services.
Additional Adult-Home Study $275.00 5) Requests for payment must be an original submitted
*Referrals will be for Foster Parent Home Studies to the Weld County Department of Social Services by
only. the end of the 25th calendar day following the end of
Enclosures: the month of service. The provider must submit
X Signed RFP:Exhibit A requests for payment on forms approved by Weld
X Supplemental Narrative to RFP: Exhibit B County Department of Social Services.
_ Recommendation(s) 6) The Contractor will notify the Department of any
X Conditions of Approval changes in staff at the time of the change
Approvals: Program Official:
By \at k YUU By data
Robert D. Masden, Chair Jud . G 'e s
o,Dire r
Board of Weld County Commissioners Wel ount�Department of Social Services
Date: JUN 1 6 2004 Date: (1 04
SIGNED RFP-EXHIBIT A
INVITATION TO BID
DATE:February 11,2004 Off System Bid No. B002-04 RFP FYC 006-00B
RETURN BID TO: Pat Persichino, Director of General Services
915 10th Street, P.O. Box 758, Greeley, CO 80632
SUMMARY
Request for Proposal (RFP-FYC 006-00B) for: Adoption, Foster Care, and Expedited Permanency
Planning Home Studies, and Relinquishment Counseling
Deadline:March 5, 2004, Friday, 10:00 a.m.
The Families,Youth and Children Commission, an advisory commission to the Weld County Department of
Social Services, announces that competing applications will be accepted for approved vendors pursuant to the
Board of Weld County Commissioners' authority pursuant to Colorado Statute and the Weld County Home
Rule Charter. The Families, Youth and Children Commission wishes to approve services targeted to run
from June 1, 2004,through May 31, 2005, at specific rates for home studies, home study updates, and
relinquishment counseling services. The County will authorize approved vendors and rates for services only.
This program announcement consists of five parts, as follows:
PART A...Administrative Information PART D...Bidder Response Format
PART B...Background, Overview and Goals PART E...Bid Evaluation Process
PART C...Statement of Work .
Delivery Date
(After receipt of order) BID MUST BE SIGNED IN INK
Lori KoCHeLtW'
TYPED OR PRINTI✓D SIGNATURE
sob gafrot2A
VENDOR �t Iccchewor ms U%Cr I LC a l iC� b1 ms l LLC
(Name) Han written Signature By Authorized
Officer or Agent of Vender
ADDRESS !ID I )-1-1^ TITLE
C.)iD 00 Qt/ CD 2tt03/ DATE 3131 oti-
PHONE# 970 25 - z3� 73
The above bid is subject to Terms and Conditions as attached hereto and incorporated.
Page 1 of 34
Off-System Bid No. B002-04 RFP-FYC-006-00B Attached A
HOME STUDY,UPDATE,& RELINQUISHMENT COUNSELING BID PROPOSAL AND
REQUEST FOR CONTINUATION OF AWARD UNDER
CHILD WELFARE ADMINISTRATION FUNDING
2004-2005 BID PROPOSAL APPLICATION
PROGRAM FUNDS YEAR 2004-2005
BID Off—System Bid B002-04 RFP-FYC-00'6-00B t �p �
NAME OF AGENCY: 4 hp� MS. Lit L.LC % "--U orrapuwm 45 C JC" /��
ADDRESS: 1/0 ) a fh 5cLtcQ { PHONELB22 3S a 237 3
CONTACT PERSON: air)/ ITIC Iga- ' TITLE: ^
DESCRIPTION OF HOME STUDY PROGRAM CATEGORY: Adoption,Foster Care, and Expedited Permanency Planning
Home Studies in compliance with the uniform format utilized by the State of Colorado Department of Human Services since
October 1, 1999(Attached A).
11-Month approximate Project Dates: 12-month contract with actual time lines of:
Start June 1,2004 Start
End May 31, 2005 cc End
111_LE OF PROJECT: Uf I2 61444-41-,- moec"'r-
l;zxhaaa- VAS LeG /IC 3/5 / 04
N and Signature of Person Preparing Document Date
— I
Name and Signature Chief Administrative Officer Applicant Agency Date
MANDATORY PROPOSAL REOUIREMENTS
For new and renewal bids,please initial to indicate that the following required sections are included in this Proposal for Bid.
For renewal bids,please indicate which of the required sections have not changed from Program Year 2003-2004 to Program
Year 2004-2005.
,3(k Project Description _Project Description
A. Sample Home Study _Sample Home Study
ak- Target/Eligibility Populations _ Target/Eligibility Populations
4LGeneral General
44-Cultural/Eligibility Populations Cultural/Eligibility Populations
., < Types of services provided _Types of services provided
h� Measurable Outcomes _ Measurable Outcomes
/J'- Service Objectives Service Objectives
A Workload Standards _ Workload Standards
xl= Staff Qualifications _ Staff Qualifications
XK Unit of Service Rate Computation _ Unit of Service Rate Computation
Program Capacity per Month _ Program Capacity per Month
A). Certificate of Insurance
Page 23 of 34
02'20.2904 FRI 12:10 FAX ,e„iu2. 002
Off-System Bid B001-04 (RFP-FXC-04005) Attached A
Pate of Meeting(s)with Social Services Division Supervisor
'omrrents by SSD Supervisor •
G�CifL ,yD S //<" c .4144
ytit-cPS 4•10
•
•
neflat,Verne and Signature o SD Supervisor Date
Page 28 of 33
• Home Study and Relinquishment Program
Purpose: The purpose of the Home Study Program is to ensure that potential
foster, foster adopt, and extended families are well screened to identify issues that
may hinder their ability to provide positive healing relationships for the children
they serve in a timely manner. We will also provide relinquishment counseling for
birth parents.
Design: This program is designed to identify issues that potential foster, foster-
adopt, and extended family parents may have that hinder their ability to provide
quality care for the children in the foster care system. The evaluator for each home
study would complete testing and in-depth interviews with the potential parents
and developmentally/age appropriate interviews with each child in the family.
This is done to: 1) identify the ability of the parents to provide appropriate care for
the child's needs, 2) identify self-growth areas that would enhance the parents
ability to provide care for children that most often have multiple levels of need,
i.e.. trauma recovery, attachment, reunification, etc... and 3) make clear
recommendations about any potential red-flags that occur during the interview.
The evaluator will make detailed recommendations regarding needed resources,
type of child that would best fit in this family, and additional training that may be
helpful in preparing the potential foster foster/adopt parents to best meet the needs
of themselves, their family, and the child or children that are entrusted in their care.
Why Services are Important- Foster Parents and Kinship parents have the
difficult role of providing a loving relationship and a structured home environment
to children whom have most often been severely abused and or neglected. These
children often have a distorted sense of self. Children in the Foster Care system
often act out their feelings of unworthiness by displaying behavior that is
destructive to self and others. These parents need to be aware of how their own
history and ability to respond to crisis situations could affect their ability to provide
quality care for the children that are entrusted to them. For the safety and well
being of the children, as well as, liability it is important that the department of
Social Services enlist the services of parents whom are competent, capable of
knowing their own limitations, and are willing to ask for help to deal with behavior
that is beyond their ability. As caretakers parents need awareness and skills to
address their own issues in order to not repeat maladaptive interactions with the
foster children.
Home Studies - Home studies will consist of testing, three joint interviews with a
couple, one individual interview with each adult member in the household and as
age/developmentally appropriate interview with all children residing in the home.
For single applicants a minimum of three interviews will be required. The studies
1
will be conducted in compliance with the uniformed format utilized by the Sate of
Colorado Department of Human Services. Home studies will be completed within
six weeks from receiving the signed referral.
Target / Eligibility Population
A. Total number of clients to be served in the twelve month program has been
calculated as follows. We would be able to provide up to seventy home studies a
year. We would be able to provide relinquishment counseling for up to ten birth
parents.
B. Distribution of clients. On average most foster parents provide services for
approximately four foster children a year. Each foster child is in placement an
average of 6 months. By completing home studies on 70 families these services
improve that quality of care for approximately 560 children in the placement
system. The age of the children served will range between newborn and age 18. In
our experience there are a greater number of children placed below the age of 12
because of the increased risk factor due to age.
C. Families Served. We anticipate serving 80 families all together.
D. Sub total who will receive bicultural/ bilingual services. All services
provided will be in a manner which is sensitive to the culture of origin of the
family. All of the therapist have extensive training in cultural competency issues.
In addition, Lori Kochevar was the chair of the multicultural task force that
successfully implemented multicultural training throughout the San Luis Valley.
Due to our experience in bicultural settings, all individuals in our program will
receive bicultural services. Anna Lane, a bilingual provider, would be available for
any Spanish speaking families.
E. Services will be available in South Weld County. In that most of the home
study is conducted where the family lives, services will be available in South
County.
F. Access to 24-hour services- In that we will be providing evaluation services to
determine if families are appropriate for placement it is not deemed necessary to
have 24 hour access to services. Appointments will be scheduled ahead of time
and clients will always be able to reach a phone message that is checked frequently
if they need to change an appointment. There are instructions on the phone
message in the case of a mental health emergency requesting that the client go
directly to the emergency room for an evaluation.
2
G. The monthly maximum program capacity - If needed, we could expand the
number of home studies we are available to do to 90 a year which would average
out to 8 a month.
H. The monthly average capacity - The monthly average capacity of this
program is 6 home studies and 1 units of relinquishment Counseling.
I. Average stay in the program- 6 weeks.
J. Average hours per week in the program - 4 hours.
Services Provided
Types of Services to be Provided:
A. Home Studies for potential foster- foster/adopt families- Home studies will
consist of testing, three joint interviews with a couple, one individual interview
with each adult member in the household and an age/developmentally appropriate
interview with all children residing in the home. For single applicants a minimum
of three interviews will be required. The studies will be conducted in compliance
with the uniformed format utilized be the State of Colorado Department of Human
Services. Home studies will be completed within six weeks from receiving the
signed referral. If for some reason beyond our control we are unable to set up
times to meet with the potential family the referring worker will be notified.
Throughout the interview the potential parents ability to problem solve, use
resources, empower others, and parenting skills will be accessed. Evaluators will
also note the ability of the parent's willingness to work as a member of a team to
meet the needs of the children placed with them. Services will be accessed through
a referral from one of the foster care providers.
B. Home Studies for psychologically/biologically related families- that are not
involved in the foster care program as a kinship home. In our experience this
population is not as motivated and there is an increased number of no shows, and
resistance to the home study being completed. These families do not typically turn
in a comprehensive written self study. In addition, because it is unclear what the
financial status of this family is there is an added expense on the evaluator of
providing funding for all of the background checks necessary. Often in these cases
there is more background information to evaluate. Referrals for this program are
initiated from the ongoing child protection worker. These home studies will be
conducted in the same manner as above. Henceforth, that section will be repeated
here. Home studies will consist of testing, three joint interviews with a couple,
3
one individual interview with each adult member in the household and as
age/developmentally appropriate interview with all children residing in the home.
For single applicants a minimum of three interviews will be required. The studies
will be conducted in compliance with the uniformed format utilized be the State of
Colorado Department of Human Services. Home studies will be completed within
six weeks from receiving the signed referral. Throughout the interview the
potential parents ability to problem solve, use resources, empower others, and
parenting skills will be accessed. In this case, the child's level of attachment and
the parents bond to the child will also be evaluated. Evaluators will also note the
ability of the parent's ability to work as a member of a team to meet the needs of
the children placed with them.
C. Home Study Updates -Updates on completed home studies will occur as
requested by the foster parent coordinators. These updates will track all changes in
circumstances and living arrangements from the time of the initial home study. In
addition, we will examine the diffc -uces in testing scores on FACES III and the
Individualized Consultation Plan (see Appendix B) to determine progress in
functioning level and learning.
D. Relinquishment Counseling- Relinquishment counseling will be provided to
the Department of Social Service clients to help them make a decision about the
decision of relinquishing their rights to their children. We will follow the outline
provided by the state. We will explain their rights to them and help them explore
all of their options. In addition, we will clearly find out that they have not been
coerced,promised something in return for relinquishing their rights, or pressured in
any way to make this decision.
E. Evaluation services for families will not be provided in a home where the
evaluator has a personal relationship with any family member or any other conflict
of interest.
F. Agree to comply with 19-1-120 CRS, which requires that reports of child
abuse and any identifying information in those reports are strictly
confidential. All federal laws will be followed including the confidential reporting
of suspected child abuse.
In this program evaluation funds will not be used to fund therapy or drug and
alcohol services for foster parents. If deemed appropriate a referral to a mental
health provider or ADAD professional will be made.
Resource and Referrals - This program will facilitate the development of external
resources to enhance the parent's ability to meet the demanding requirements of
4
their role. It is important to link parents to appropriate community resources. We
will facilitate knowledge of and encourage use of available community resources.
Measurable Outcomes
A. Provide quality home studies in a timely manner so that children in the
social service system of Weld County will be placed in a more expedient
manner. It is imperative that quality home-studies are completed in a timely
manner so that children that are in the child protection system are not waiting to be
placed in a long term or forever home. When clients are referred to this program
they will be contacted within one business day to set up an interview schedule for
the home study evaluation. In addition, the referring worker will be contacted to
get an update of any additional concerns that they may have which occurred after
this referral was sent. Documentation of all interactions with potential placement
homes will be kept to assist in the evaluation. The first home visit will be set up to
include a joint interview, an adult interview and if applicable, an interview with
one or more of the children. During this interview written home studies will be
collected, as well as, the finger print cards to do a criminal background check.
During this interview the family will be given Individualized Consultation Plan
and FACES III (Family Adaptability and Cohesion Evaluation Scales). FACES III
is a 30 item, self-report instrument that accesses family functioning by measuring
adaptability and cohesion. The adaptability scale consists of child control,
discipline, leadership, roles, and rules. The cohesion scale is made up of emotional
bonding, family boundaries, interests and recreation, and supportiveness.
The second home visit will include a joint interview, an adult interview and
if applicable, an interview with one or more of the children. These interviews will
occur at least seven days after the first interview to ensure that we get an accurate
picture, across time, of the family's level of fmctioning. During this interview, the
evaluator will review the Self Improvement Plan (See Appendix B) given to them
during the first interview. The bulk of the evaluation will be written between the
second and third interview.
During the third interview,the evaluator will be prepared to share their
findings and recommendation with the potential placement couple in the third and
final joint interview. As required this interview will occur at least seven days after
the second interview.
The completed home-study, background checks and original written home
study will be delivered to the referring caseworker within six weeks of the
receiving the original signed referral. Having the home studies done in this six
week time frame will ensure that timely placement of children can occur. To
measure, evaluate and monitor this goal all dates on each home study will be kept
and reviewed on the Home Studies Procedures form, (see appendix A) and
reviewed internally for compliance of six week goal.
5
B. Quality adoptive Home Studies will be completed in a timely manner.
It is important to provide quality home studies so that we can decrease the number
of children that are placed in inappropriate environments, as well as, decrease the
number of disrupted placements. This decreases liability for the department of
social services, as well as, decreases the likelihood of multiple placements for the
children in the foster care system. In our program, a quality home study will be
defined by the following parameters:
• Adherence to the six week timetable for completion.
• In home interview for most of the sessions
• Request for background checks made no more then two days after the first
interview.
• Request for recommendation letters sent out no more then two days after the
first interview.
• Completions of FACES III testing and interpreted results in the body of the
report.
• Specific recommendations regarding areas of concern that may be remedied
through additional training and or other resources.
• Parents ability to solve problems, work as a team member, ask for help, use
resources, empower others, and parenting skills accessed.
• Level of commitment, and when applicable, child's level of attachment and the
potential parents bond to the child.
• Specific recommendations that are in accordance with other information in the
home study regarding recommending or not recommending each family for
placement of a child/ren with them.
• Interviews with all available family members.
• Interviews in compliance with the uniformed format utilized by the State of
Colorado Department of Human Services.
• Home studies are grammatically correct.
• Home studies explore all related themes set forth in the uniformed format and
synthesize all information to provide relevant recommendations.
We will internally monitor and evaluate effectiveness of our ability to meet these
standards during program supervision through the use of the document entitled,
Home Study Quality Checklist. (See Appendix B)
C. Outcomes will be defined by the number of acceptable home studies
submitted- On a yearly basis, the program supervisor will review with program
supervisors and staff the number of acceptable home studies submitted. At this
time we will be asking for feedback regarding home study evaluations.
Service Objectives
We have the following service objectives:
6
A. Provide quality home studies and updates for psychologically related or
kinship relatives of the Department of Social Services clients that are not
foster parents.
In that kinship homes that are not part of the foster care system they are not
provided with specific training regarding volume 7 regulations. It will take
additional time to create awareness of the regulations and resources. It is
imperative that potential kinship home placements are aware of and uphold
regulations outlined in Volume 7 regarding the need to maintain a safe household
environment that is adequately cleaned and maintained. In addition, they need to be
able to budget their resources so that they are able to provide for the additional
children in their household. It is important that the parents have a solid
relationship with each other and with their own biological children in order to
serve additional children in their home. In addition, these parents need to provide
developmentally appropriate care, nutrition, hygiene, discipline, protection,
guidance and supervision. Specific aspects on this service objective may include
the following: home study, extensive background checks, consultation with
caseworker, specific individualized recommendations, and testing materials as
deemed appropriate. Evaluation of these objectives and all other components of
state format for home studies will be completed in six weeks. This component will
be measured through the completion of the number of acceptable home studies
submitted and internal use of the Quality Home Study Checklist (see appendix B)
and external program evaluations.
B. Provide quality home studies and updates for foster and foster-adopt
parents.
It is imperative that potential foster foster/adopt home placements are aware of and
uphold regulations outlined in Volume 7 regarding the need to maintain a safe
household environment, that is adequately cleaned and maintained. In addition,
they need to be able to budget their resources so that they are able to provide for
the additional children in their household. It is important that the parents have a
solid relationship with each other, with their own biological children in order to
serve additional children in their home. In addition, these parents need to provide
developmentally appropriate care, nutrition, hygiene, discipline, protection,
guidance and supervision. Specific aspects on this service objective may include
the following: home study, extensive background checks, consultation with
caseworker, specific individualized recommendations, and testing materials as
deemed appropriate.
Evaluation of these objectives and all other components of state format for home
studies will be completed in six weeks. This service objective will be met through
7
the Home Study Process Outline (see appendix B). This component will be
measured through the completion of the number of acceptable home studies
submitted and internal use of the Quality Home Study Checklist (see appendix B)
and external program evaluations.
C. Provide quality relinquishment counseling for department of social service
clients. Relinquishment counseling will be provided to the Department of Social
Service clients to help them make a decision about relinquishing their rights to
their children. We will explain their rights to them and help them explore all of
their options. In addition, we will clearly find out that they have not been coerced,
promised something in return for relinquishing their rights, or pressured in any way
to make this decision. This component will be measured through the completion
of the number of acceptable relinquishment reports submitted and internal and
external yearly program evaluations.
Workload Standards
A. The program has the capacity to complete 70 home studies and 10 units of
relinquishment counseling. Evaluators would spend up to 144 hours a month
completing these studies. Total number of clinical hours provides over one year
would be 1728 hours.
B. Staff- There are two evaluators and one supervisor for this program. Lori
Kochevar M.S., L.P.C.., LLC will serve as the program supervisor for Anna Lane
M.A., L.P.C. and Lisa Downs M.A., L.P.C. All providers have extensive
experience in Family Services as documented in the attached resumes.
C. The caseload will be between 2-4 home studies per therapist. The caseload of
each therapist will depend on availability and need for Spanish speaking evaluator.
D. The modality of treatment is home study evaluations, home study up-dates
and relinquishment counseling. Referral and linking services will be provided.
E. Hours - Total number of clinical time devoted to this program equals 36 hours
a week, and 144 hours a month.
F. Staff- The providers are supported by part time bookkeeping and clerical
services.
G. Supervisor- This contract would be supervised part time by Lori Kochevar
M.S. L.P.C. who would monitor the project for program compliance and clinical
excellence.
8
H. Insurance - - Lori Kochevar M.S., L.P.C., LLC carries one million three
million liability on the company and each one of the independent contractors
connected to this bid. In addition, Lori Kochevar M.S., L.P.C., LLC carries a
general liability policy related to accident or injury on the premises. The State of
Colorado is named as an additional insured on this policy. Each individual
provider also carries one million three million liability insurance. Both general and
group liability coverage's are attached. All therapist providing services are self
employed and choose to be exempt from workman's compensation and Employer's
liability insurance.
Staff Qualifications
A. All the providers exceed the minimum qualifications needed for both
education and experience. All providers have their Master's Degree in Counseling.
In addition, the therapists have between 6-12 years a piece providing services for
families. See Resumes in Appendix C.
B. Staff available for this project consists of two experienced evaluators and a
supervisor that have a similar core value of clinical excellence. We believe in
providing strength-based, family-focused services that empower the families we
serve. Strength of our staff is our diverse areas of specialties.
• Lori Kochevar a licensed professional counselor has extensive experience and
training in providing services and supervision using the family preservation
model. She received her Master's Degree from the University of Southern
Mississippi. She has specialized training in substance abuse, trauma, grief, and
domestic violence.
• Anna Lane is licensed professional counselor who is bilingual in Spanish. She
received her Master's degree from the University of Northern Colorado. Anna
has worked as a play therapist, CASA advocate, a victim advocate with the
Boulder County's Sheriffs Department, and a mental health specialist. She has
experience child and family therapy and in the treatment of children who have
experienced trauma.
• Lisa Downs is a licensed professional counselor and a registered play therapist.
She received her Master's degree from the University of Northern Colorado.
She has experience working with children and families in both the mental
health and school setting. Her expertises are working with families that have
been affected by drug or alcohol addiction, play therapy, and women's issues.
9
Appendix A
. 1
HOME STUDY REPORT
FULL NAME: Jack R. Billings Jane A. Billings
DOW 12/12/1966 7/21/65
BIRTHPLACE: Milton,North Dakota Pierre, South Dakota
OCCUPATION: Engineer Homemaker
MARRIAGE DATE: May 27, 1989
LOG OF CONTACTS
6/6/03 Referral Received
6/7/03 Contact with the caseworker by phone
6/7/03 Initial contact with the family by phone
6/14/03 Individual Interview with Jack in home, 2 hours
6/14/03 Parental Unit Interview in home, 1.5 hours
6/14/03 Interview with children in home,ages 10 and 8, .5 hours
6/25/03 Individual Interview with Jane in home,2 hours
6/25/03 Parental Unit Interview in home, 1.5 hours
6/25/03 Interview with Child in home,age 14, .5 hours
6/30/03 Team consultation and review, 1 hour
7/7/03 Final Interview with couple, 1.5 hours
HISTORY
Partner 1: Jack was born in Milton,North Dakota to Bud and Betty Billings. He reports
no difficulties meeting his developmental milestones throughout his childhood. He is the
youngest of five children and the only male child. His sisters are 53, 52, 50 and 48 years
of age. He was born 9 years after the sister just older than himself. His eldest sister is an
alcoholic. Her relationships with men have been unstable with several marriages and
divorces in her history. He does not have a close relationship with his eldest sister
partially due to the age difference and partially due to the difficulty in establishing a
meaningful relationship with her. He believes that he has learned many life lessons from
the difficulties his eldest sister has been through He has seen the hardships the drinking
causes and prefers not to drink or use any kind of mind altering substance currently
because of this. He indicated that he had his own struggles with alcohol during his High
School years. He reports close relationships with his other three sisters. The sister just
older then he is has struggled with developmental delays and"emotional disturbances".
He admires her strength through adversity. She has been able to remain employed at the
same job for many years, drives and pays for her own truck and cares for herself without
assistance. He reports that his childhood was difficult emotionally,at times,due to the
struggles of his eldest sister and the sister just older than him. He said his mother's
attention was mostly focused on helping the sister just older than him to be able to
function in the real world. Most of the time spent with his mother was spent attending
numerous doctors' appointments addressing specific physical and emotional needs of his
developmentally delayed sister. He reports that he spent a great deal of time with his
2
father fishing and hunting. He loved growing up in rural North Dakota. His parents were
faithful in attending church and he describes the community as"basically an extended
family". His father was well known in the community because he was a welder. His
mother was active in the church and was a homemaker. He describes his father as a soft
spoken, happy, supportive man who did not know a stranger. His father died last year of
a rare lung disesice and his mother lives in the house he and his sisters were raised in He
describes his mother as loving,but highly emotional. Discipline was handled by his
father mostly and was reported to consist of"talking things out with occasional
grounding". As an adult he reports love and affection toward both parents. Neither
parent drank or smoked that he could recall. Jack reports no physical or sexual abuse.
He does report feeling emotionally abused by his mother,at times,when he was younger.
He reports that he has had difficulties with addiction to alcohol throughout his years.
Around age 16,he reports being admitted to a drug and alcohol rehabilitation hospital for
an evaluation due to binge drinking. He reports that he was only in the hospital through
the evaluation and it was determined that he was abusing alcohol. Jack was very
involved in his therapeutic program which included a peer support group and he has not
had any difficulties with substance abuse since that time Jack stated that he did have
occasional difficulties with depression. However he is currently on medication which has
stabilized his mood. Jack was raised in a small rural North Dakota community and
reports that cultural issues were never much of an issue. Jack graduated from Milton
High School in 1985 then went straight into a trade school to become a draftsman. He
worked several years as a draftsman until he married in May of 1989. He and his wife
had their first child and they moved to Kansas City,Kansas for her job as a school
psychology Para-professional. He was then employed by Pawnee Electrical Cooperative
as an electrical plant engineer. They had their second child and then Pawnee moved the
family to Greeley,Colorado. After their third child was born they moved to rural
Northeast Colorado. Jack remained with Pawnee until a few months ago and is now
employed by Calpine Corporation as an engineer.
Partner 2: Jane A. Billings was born Jane A. Lundeby on 7/21/1965 in Pierre, South
Dakota to Larry and Linda Lundeby. She too is the youngest of five children. Her
siblings are 54, 50,47 and 38 years old. All of them are married to hometown
individuals. The family has lived in the same house all of her life and she knows the
local community people on a first name basis. Her father died 10 years ago of throat
cancer. Her mother moved from the family home two years ago into a duplex in the same
rural community. Her mother has always been active in the church and continues to work
on many committees within the church. Jane's father was a lineman for Rural Electric
Association. Her mother retired from nursing and has been a homemaker since that time.
She describes her atmosphere at home as loving,but"emotionally flat". She reported
that there were not many"warm fuzzies", but they all knew that they were loved. Jane
states that her parents were not strict,but they expected the children to be respectful of
house rules and both parents. Discipline was handled by her father who would ground
them, send them to time-out, and occasionally spank them. Spankings were with the
hand and sometimes a belt if the"crime"was bad enough to warrant that She describes
her father as a kind man who loved to get to know other people. She stated that her
mother expressed her love through gestures such as family meals,gifts,and by spending
•
time with them. Jane indicated that she loved both of her parents,but knows that she has
difficulty expressing emotions because few were really"shown"in the household. Jane
denies any issues relating to drug or alcohol abuse within the family. She feels that her
relationship with her siblings has always been quite normal with some sibling rivalry
"thrown in for growth". She currently has good relationships with all of her siblings, but
again wishes that she were able to relate to them on a greater emotional level. She grew
up in a small town in South Dakota and indicated that she was raised to be tolerant of
individual differences in others and to try to accept people for who they are. Jane admits
to drinking on occasion. She claims to have had no involvement with the law up to this
point in time. Jane graduated from High School in Pierre, South Dakota. She went on to
undergraduate school at North Dakota State University in Fargo,North Dakota where she
met Jack. They married in May 1989. After they had their first child they moved to
Kansas for her job as a school psychology Para-professional. They had their second child
and then Jack's job moved the family to Greeley, Colorado. After their third child was
born they moved to rural Northeast Colorado. Jane returned to Graduate school at the
University of Northern Colorado. Jane reported two miscarriages between her first and
second children. She and Jack have always wanted 5 children,but she developed
endometriosis and is unable to have any more children.
ADULT GENERAL FUNCTIONING
Partner 1: Jack describes himself as having a very mild mannered temperament. He
describes himself as outgoing,patient and humorous. When he becomes angry or
frustrated he tries to talk through the problem,but sometimes he says he"closes up"and
is "unable to talk". Usually after a walk and some passage of time he is able to return to
communicate face to face to settle the problem. He denies any difficulties with his
cognitive functioning and he has no difficulties making decisions on his own. He reports
that when he starts a project he is determined to see the finished product. He did state
that,at times, he does use avoidance as a defense mechanism because he does not like to
engage in conflict. Jack said he has few issues with his self-esteem as an adult,but had
some difficulties as a child. He also reported that he has no difficulties controlling his
emotions. One weakness he willingly admitted to is a lack of impulse control at times.
He said it is difficult for him to wait to buy something he really wants, even though he
knows he can't afford it or really does not need it. He also admitted that he has little or
no education about cultural differences. He also reports little exposure to different
religions. He reports having faith that there is a higher power and feels the important
thing is that people have something to believe in that motivates them to do the right
things. Jack stated that he has difficulty understanding same sex relationships,but feels
that people should be allowed to make their own decisions regarding sexual preferences.
Jack admitted that he would like to be further educated about substance abuse due to the
amount of alcoholism in his family. Jack indicated that he would not be opposed to
attending therapy due to mental health concerns and would encourage his family to do so
if the need arises. Jack has had many losses in his life. His father came from a family of
13 siblings and his mother came from a family of 11 siblings. There are only 5 siblings
left in his father's family. His father passed away two years ago which he reported to be
the most hurtful loss he has experienced.
4
Partner 2: Jane believes that she is fairly mild mannered She said that at times she gets
frustrated when she is unable to get things to work out the way she wants them to. She
has no difficulty saying what is on her mind with her husband, but admits that it is hard
for her to tell her friends and family what she thinks sometimes. She attributes this to the
lack of emotions expressed within the family during her childhood. She admits that
sometimes she is unable to make decisions without running them by Jack or her family
first. She indicated that when she begins something she sees it through to the end. She
reports that she can become defensive when she feels like people might be attacking her
integrity. Jane admitted that she has always had difficulty with self-esteem, but has
greater faith in herself as an adult She reported that berc'ice of low self-esteem growing
up she did not have a genuine faith in her abilities. As she worked through school and
was able to attain her Master's degree she now believes that she could do anything she
sets her mind to. Jane said that she has some emotional"ups and downs". When she
found out she would not be able to have any more children she reported days that she was
unable to get herself out of bed. Initially she became very depressed,but then realized
that she has three children to love and she and Jack began to talk about becoming foster
parents. She does not feel that she has difficulty with impulse control. She feels she is
tolerant of other cultures and religions,but like Jack,would lilce further education about
other cultures and religions because she has been exposed to so few throughout her life.
She admitted that she was raised in a highly religious household and that she does not
believe in same sex relationships. In discussing substance abuse she reported"feeling
sorry" for people who become addicted and hoped she would be able to recognize any
difficulties and seek help for anyone in the family that might need it. Jane has been in
individual therapy on and off throughout her lifetime for depression. She stated that she
would encourage anyone in the family to seek help if it were to ever become an issue.
Jane has had few losses in her life. Her mother only had one sister,her father had 4
siblings. Two of his siblings are deceased and he passed away several years ago. Jane
reports that her strength is her genuine love for people, especially children. She believes
her biggest weakness is that she does not immediately trust other people's intentions.
Her goal is to eventually adopt two children and to raise them with no doubts that they
are unconditionally loved.
PARENTING-DISCIPLINE
Jack and Jane currently have three children. The oldest is a 14 year old male who is
currently in the 8th grade. Two females follow,ages 10 and 8. These children are
disciplined using time-outs, grounding and Jack indicated that he will spank the children
if necessary. Jane believes in the importance of communicating with the children and
letting them talk about what they think is fair punishment. Jack believes that he is the
authority figure therefore; he and Jane should make the rules. Jack has an inconsistent
work schedule due to being on shift work. This leaves Jane to do most of the disciplining
and housework. She reports being committed to doing whatever it takes to raise her
children with a great deal of love. She did admit that sometimes she and Jack disagree
about discipline at times. She indicated that there are times that she will decide on a
consequence and Jack will over rule her in front of the children. Both Jane and Jack
5
expressed interest in learning how to be more co-operative in disciplining the children.
Jack admitted that he has difficulty controlling how to react when his children
deliberately disobey him;Jane reported that she has difficulty when the children
deliberately lie. Jack admits that these are times when he believes spankings might be in
order.
PARENTING VALUES& PRACTICE
Jack and Jane currently have three biological children. Jack's job allows him to provide
for basic family living without any major money concerns. Jack believes that he has
developed much compassion and sensitivity for children after the experiences he has had
with his sister. She was in a state hospital once and he remembers the difficulties the
entire family encountered trying to help her and understand the difficulties she was
having. Jack and Jane are proud of their children. Each of them has received awards for
attendance and academics. Jack and Jane take turns attending the children's parent
teacher conferences depending on Jack's work schedule. Jane understands that children
who are placed in foster care may not attach to her immediately. Jack is unsure of why
this might happen. The children are all expected to help with chores around the
household. Each takes turn with taking out the trash,cleaning their bathroom and feeding
the animals. They are all expected to make their beds each morning and keep their rooms
relatively clean. Jack and Jane both believe that education is important and expect their
children to attend school unless they are very ill. Jane takes the children to church every
Sunday and Jack attends"on major holidays". The children are all involved in
community activities such as basketball,cheerleading and soccer. She realizes the
importance of having individual time with each child and tries to make this happen once
a day. Jack feels like he understands many things about children with developmental
difficulties due to the experiences with his sister. Although she was 9 years older than he
was,he always felt as though she was his little sister. He knows that she did not always
understand things in the adult world and appreciated her innocence about the world in
general.
CHILDREN
Jack and Jane have three biological children. Their eldest son is 14 years old. The eldest
boy, Tanner, is involved in the music program at school,plays basketball and baseball.
Upon meeting Tanner,one realizes that he is shy and perceptive about the adult world.
Jack and Jane report no behavior difficulties with Tanner. Their biggest concern is that
he does not bring school work home and this is sometimes reflected in his report cards.
As a young child,Tanner was exposed to developmentally delayed children and children
of different cultures,therefore,he is accepting of differences in others. Tanner does not
abuse drugs or alcohol,according to his parents. Tanner likes to lift weights, drive the
car on the family farm and talk on the intemet Ashley is 10 years old. She does well in
school and has earned many academic awards. Ashley appears to be soft hearted,
sensitive and very feminine as evidenced by her painted nails and dress. She is not
currently involved in extra curricular activities,but plans to begin dance soon. Sara,age
8, is the youngest of the Billings family. She appears to be full of energy and is reported
6
to also do well in school. She participates in the community basketball program for
children her age. Jack and Jane report that Sara is the best at expressing her emotions and
is very strong willed. According to Jane, Sara will challenge most adults if she thinks she
is right. Ashley, on the other hand, is quiet and tends to try and please others. Tanner is
a typical teenager according to Jack and Jane. Sometimes he is highly cooperative and at
other times it is impossible to talk to him about daily activities. The girls have not been
exposed to as many differences and tend to ask more questions regarding people with
developmental delays or cultural differences.After having three children the Billings
appear to have a good grasp of children's developmental needs. They both reported that
if they had foster children in their home they would treat them as if they were their own.
• They would go on family vacations, family outings and be treated with the same
standards as their biological children. Tanner is accepting of others and appears very
willing to share his room with a foster child. Both Ashley and Sara reported that they
would"love to have a little foster brother or sister".
Family System
Family Functioning: Jack and Jane indicated that they try to keep their lines of
communication open. They admitted that at times it is difficult to make time to talk to
each other with three children in the household. They try to share the household chores
and expect the children to help with chores around the house. Jack spends many hours
working, but tries to help out when he is at home. Jane reports that she loves being an"at
home mom"and is thankful that Jack is willing to help out when he can. The couple
report that their children are expected to act respectfully toward all adults and they would
expect their foster children to do the same. Twice per week the family meets in the
evenings to discuss family concerns and to make decisions regarding family
responsibilities. Jane reported that there are hugs and kisses at the beginning and end of
each day for all family members. The couple indicated that both sets of their parents are
in good physical and mental health. Both sets of grand-parents are willing to assist their
grand-children and any other children that become a part of the family. Both Jack and
Jane were raised in a mostly Caucasian environment with little exposure to different
cultures. It was not until they moved to Kansas City that they were exposed to various
ethnic and cultural individuals. Jack had less difficulty accepting cultural differences
because of having a sister with developmental delays. Jane,on the other hand,learned
tolerance due to exposure to different cultures in the classroom. They stated that there is
normal sibling rivalry in the household,but the children also care very deeply about each
other and are not afraid to stand up for each other.
Family Adaptability and Cohesion: FACES III(Family Adaptability and
Cohesion Evaluation Scales). FACES III is a 30 item, self-report instrument that assesses
family functioning by measuring adaptability and cohesion. FACES III measures family
cohesion(the emotional bonding between family members)and family adaptability(the
ability of a marital or family system to change its power structure,role relationships and
7
relationship rules in response to situational and developmental sheAs. Family cohesion is
used to assess emotional bonding, family boundaries, coalitions, time, space, friends,
decision making, interests and recreation. Family adaptability is used to assess family
power(assertiveness, control,and discipline), negotiation style,role relationships and
relationship rules. There are four levels of family cohesion: disengaged, separated,
connected and enmeshed. There are also four levels of family adaptability: rigid,
structured, flexible, and chaotic. This instrument assesses marital and family as extreme
types,mid range types, and balanced types. Scores on each scale range from 1-8, with 8
being high. Overall reliability for the scale is .90.
The FACES III revealed a balanced family type with the cohesive score of 6(high
connection)and an adaptability score of 7 (very flexible).
Adult Relationships/Marriage: Jack and Jane have known each other since Jane was a
freshman in college. A mutual friend introduced them and they began dating shortly after
that time. They both enjoy water skiing,camping,motorcycles and being in the outdoors
in general. They describe their relationship as one of mutual love and respect. They both
stated that there has been no violence between the two of them. Neither believes in
violence toward children. Jane reported that she believes the reason for the strength in
their marriage is that they still take time to be alone together away from the children.
Jack felt the reason for the strength between them was due to the fact that they have
common interests. Both agreed that one weakness is that they have some differing ideas
about discipline. Both stated they would be interested in increasing their communication
and parenting skills before fostering/adopting other children. Jack indicated that he
would like to be able to more effectively handle how he deals with defiance in his
children.
Family Support Network: The couple report having good support from both
sides of their extended families. Jane's mother frequently comes to take each of the
children for an afternoon and sometimes for the day. Jack's parents often take all of the
children for one weekend of each month. Both sets of parents have encouraged Jack and
Jane to explore the idea of becoming foster parents with the possibility of adopting. The
couple has friends that will support them through the process and are willing to help with
babysitting when necessary.
Demographics: The Billings live in rural Northeast Colorado on 10 acres of
land. They have neighbors that are about a quarter mile away. Most of the neighbors are
farmers that farm land that has been in their families for years. They attend a small
church in the country and know many of their neighbors very well. They have lived in
their current home for almost three years. The house and the acreage are well taken care
of. They own the home that has five bedrooms, a living room, dining room, a
recreational area and two and a half bathrooms. The nearest schools are 15 miles away in
Kersey. The closest hospital and recreation centers are approximately 20 miles west of
their home in Brighton.
8
Jack provides most of the financial stability for the family. He indicated that he makes
approximately$60,000 per year working for Calpine Corporation. The couple does have
full coverage health insurance with Behavioral Health Care Systems through Jack's work.
Jack has$150,000 in life insurance while Jane is covered for$75,000. Jane has a small
private mental health practice and does contribute financially to the family. Her income
is usually used for clothing and other items the children need. Their mortgage is
$1,500.00 per month,with other expenses which include a boat payment of$145.00 and a
motorcycle payment of$125.00. They carry insurance on all of their property.
Birth Family: The Billings' both indicated that they understand that everyone
goes through hard times and that parents should look at the placement as a time to learn
and hopefully make changes for the better. Jack did express difficulties regarding any
parent that would abuse or harm their own flesh and blood in anyway. Jane reported that
she feels that sometimes parents just have not been given the proper skills themselves.
The couple agreed that they feel it would be important for any foster child to know about
their birth family,but they would be cautious in regard to sharing information with the
foster child. They also agreed that they would seek guidance regarding the proper
information to share with the child. Both stated that they simply want to show all
children in their lives that they love them,want them to feel safe and want to help them
become all they can be. They do not foresee any difficulties with children who are
different culturally or religiously. They both recognize that they will need education
around these issues and should they have a child with these differences they may need to
address them as they present themselves. They have discussed possible ages they would
like to foster/adopt and prefer not to start with an adolescent. They reported concern that
their own teen may not have the capacity to deal with suicidal issues,teens who may be
sexually active, or a teen who is disrespectful. The children also agreed that it may be
easier to have younger children come into their home. The couple has a good
understanding of developmental milestones due to having three children of their own.
Should a child be placed with them,the entire family agreed that they would do their best
to treat the foster/adopt child as if they had always been a part of the family. They realize
there will be difficulties and obstacles to overcome,but they are willing to do what they
need to do to make the child feel loved. The foster/adopt child would be involved in the
same community activities that the rest of the family attends. The couple agreed that any
behaviors that are not acceptable to the family would need to be discussed and dealt with
in a family forum. Jack tends to handle any academic difficulties the children have. He
is willing to sit down with the children and help them to understand concepts they might
be having difficulties with. The family rule is that if the children get into trouble at
school,there will also be consequences at home.
Foster/Adoptive Family Preparation: Jack and Jane have talked at length about
foster/adoption. They have three children of their own and feel well prepared to have
additional children enter their home. They are aware of the need to be further educated in
the areas of cultural sensitivity,racial differences and religious concerns. The couple
9
knows it may be difficult to initially deal with visitations with biological parents, but they
are willing to help with transportation to and from visits should the need arise.
Their children are very excited about the prospect of having more siblings. Some of the
possible difficulties have been shared with the children;however, it is difficult to
anticipate all possible problems that may arise. The children are used to other children
coming and going from the home as there are frequent visits from cousins and the
children often have friends for over night visits. They are hopeful that they will be able
to attend any meetings necessary for success of the child and placement. They are
concerned about being able to share time equally with their own children and the time
that may be required with a child that has been newly placed. The Billings' report that
they are surrounded by friends and family that supports their decision and are willing to
help with the process along the way. The couple is currently attending the core training
for foster parents,doing research on the intend to become updated on recent parenting
techniques and they are generating a list of community resources to assist them in the
placement. Jane attends workshops related to attachment, is certified in CPR and is
willing to attend support groups for foster parents.
Motivation/Commitment: The couple and their children are highly committed
and motivated to add additional children into the family. Jack and Jane always wanted to
have at least 5 children and when Jane developed highly involved endometriosis they
were told that they would be unable to have more children of their own. Jane has friends
who are foster parents and Jane began to talk with Jack about the possibility of adding
additional children to their family through foster/adoption. They decided that it would
not only benefit them,but the children who needed to be unconditionally loved and
nurtured. They are hopeful that they can work through any difficult issues,but know that
there is a possibility that the placement may not work for the child or the family. Since
Jane is an at home mother,there will be no need for child care for the most part. Jane
does exchange babysitting with her friends when they are each in need of additional help
with child care.
Intervention: The couple currently attends the core classes for foster parenting.
They are willing to attend workshops,support groups and advocacy groups to increase
any skills that they may have weaknesses in. They realize that it is going to be important
for them to be open and willing to learn about cultural and racial differences and needs
when a child with those differences is placed into their home. Jack admits that he needs
to be educated about different communication styles and to learn to control his impulses
better. They are requesting to foster children between the ages of 0 and 12. Their oldest
child has just become a teenager and they feel that they have much to learn about
parenting a teenager and fear they are less equipped to handle at teenager at this time.
Resources needed to Support the Placement: This family has a great deal of
support from both friends and family. They are also involved in workshops related to
foster parenting and are willing to attend seminars to increase their foster parenting skills.
It is recommended that the couple attend a workshop on communication skills as it is
evident that Jack has difficulty communicating at times and especially if it involves
10
conflict. It is also recommended that they attend at least two workshops related to
attachment issues and caring for abused/neglected children. It is further recommended
that they attend a workshop related to bringing foster children into a family that is already
established.
Training: Jack and Jane are currently enrolled in the training for foster/adopt
families. Both have reported that they are gaining helpful information that they wish they
had when they were raising their own children. The couple is open to attending further
training and is willing to include their children on any training necessary for a successful
placement. They have raised three children of their own and feel that they are aware of
important developmental milestones. Jack reported that he feels he is well equipped to
deal with a child that may have developmental issues because of having a
developmentally delayed older sister. Jane indicated that she would be willing to obtain
further education in this area.
Conclusions/Recommendations: Jack and Jane have three children of their own.
After interviewing these children, it is evident that the Billings' have provided them with
a safe and loving environment. It is apparent that they are able to set clear boundaries
with their children. The couple agreed that they do have some differences regarding
discipline and difficulties with communication at times. It was made very clear that
corporal punishment is never allowed in the foster care system. Both Jack and Jane
agreed that this was important and have joined the Love and Logic support group to learn
more about how to implement non-power based parenting skills. This therapist would
recommend that the couple attend couples therapy to address the major concerns between
them regarding discipline, communication, and grief over not being able to have
additional biological children to ease the process of adding more children to their family.
In addition,Jack has indicated that he is interested in reviewing how growing up in a
home with Alcoholism has affected him. Even though Jack has been sober for 22 years,
he suspects that the more conscious he becomes of his own childhood wounds the more
effectively he will be able to address additional needs of a child from the foster care
system. Jane is currently reading Becoming Attached as recommend in Core training and
is very interested in further exploring how her upbringing affected her attachment style.
She is clear that this is an important aspect of addressing the emotional flatness she grew
up with and still at times experiences with others.
They have requested that children between the ages of zero and 12. They feel very
comfortable in their knowledge and skills with children this age due to the experiences
with their own children. They have concerns about fostering a child in the teenage years
because they have yet to really experience that age,as their son has just turned 14. It is
recommended that only children between the ages of zero and 12 be considered for
placement in this home. The couple is currently attending the core classes required for
foster parents, and continued training would be recommended. It is recommended that
they attend workshops on attachment disorders and behavior management for difficult or
strong-willed children to learn how to establish limits without resorting to spanking.
Should Jack and Jane follow the above recommendations I believe that they should be
considered for placing children into their home.
Individualized Consultation Plan
for
1. Foster parents will be able to identify an improvement in their parental
competency as measured by a pre and post assessment of skills needed to
implement non-power based parenting effectively.
• Increase adherence to and understanding of state and federal requirements
regarding discipline policies.
• Increase understanding of characteristics of children raised with inconsistent
parenting.
• Increase ability to use and identify alternative discipline strategies.
• Increase ability to acknowledge and listen to the child's concerns with empathy.
• Increase recognition of communication barriers.
• Increase ability to set effective limits using choices and enforceable statements
• Increase ability to use empathy and consequences effectively.
• Increase ability to facilitate problem solving skills in foster children.
• Increase understanding of the importance of positive relationship message when
delivering negative content message.
• Increase ability to redirect misbehavior.
• Increased understanding of foster children's need to learn about cause and
effect thinking in an emotionally neutral non blaming environment.
2. Foster parents will increase their ability to access resources independently so
that they are able to improve their ability to meet the specialized needs of each
individual foster child they serve.
• Increase understanding of the importance of knowing when to access support.
• Increase awareness of resources available.
• Increase ability to access resources available in the community and within the
local, state and federal government.
3. Foster parents will obtain higher skills and competency levels in fulfilling their
role in providing a healing relationship for children in out of home placement.
• Increase ability to accept the child as s/he is.
• Increase ability to deal with child's behavior in the context of a healing
relationship.
• Increase ability to support what the foster child is going through.
• Increase understanding of dynamics of child abuse and neglect.
• Increase understanding of developmentally appropriate expectations and the
effects of trauma on development.
• Increase understanding of the factors influencing the child's reaction to parent
separation and loss.
• Increase understanding of cultural competency issues that effect parenting.
11
• Increase understanding of roles and dynamics of children that grow up in homes
were parents have substance abuse issues.
• Increase ability to anticipate special emotional needs
• Increase attunement to attachment and bonding issues
• Increase understanding of the need for foster children to have empowering
corrective experiences.
• Increase understanding of regressive behavior and the need for reparative
bonding within the relationship.
• Increase understanding of the need for consistency and structure to establish
trust.
• Increase understanding of the effects severe boundary violations have on
children and how to facilitate the development of health boundaries in children.
4. Foster parents will positively meet their own and the needs of their biological
children's in adjusting to and dealing with the presence of foster children in the
home.
• Increase ability to set and maintain outside interests and relationships.
• Increase ability to communicate effectively with the multiple systems involved
in foster children lives.
• Increase ability to set and teach children how to set effective physical and
emotional boundaries.
• Increase awareness of symptoms of burnout.
• Increase understanding of the importance of knowing when to access support
• Increase awareness of inappropriate coping strategies (i.e , substance use,
denial, eating, fault-finding, passivity, revenge, withdrawal or excessive worry.)
• Increase ability to use appropriate coping strategies (i.e , diversions, balance,
conflict resolution, flexibility, networking, affirmations, assertiveness, contact,
enforceable limits, linking, organization, problem solving, re-labeling,
providing choices, time management, relaxation, self-care, exercise,
commitment,prayer, worship, surrender, etc...)
5.
The areas checked above would assist me in serving the needs of foster children
and the areas circled are were improvement has occurred.
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Household Management Issues
1. Parents will identify an improvement in their ability to deal competently with
household management issues.
• Increase knowledge of and understanding of Volume 7 requirements for
kinship care.
• Increase understanding of importance of documentation and timelines
concerning medical, dental and, medication monitoring.
• Increase awareness of state and federal requirements in Volume 7 regarding
higher standards of care required by kinship care
• Increase awareness of and adherence to household cleaning, safety, and
maintenance requirements outlined in Volume 7.
• Increase awareness of resources available to assist with budgeting and
purchasing resources for children.
13
Home Study Quality Checklist.
For the Family
In our program, a quality home study will be defined by the following parameters.
Please check off all of the following that you believe has been adequately met in
this home study.
• Adherence to the six week timetable for completion.
• In home interview for most of the sessions
• Request for background checks made no more then two days after the first
interview.
• Request for recommendation letters sent out no more then two days after the
first interview.
• Completions of FACES III testing and interpreted results in the body of the
report.
• Specific recommendations regarding areas of concern that may be remedied
through additional training and or other resources.
• Parents ability to problem solve, use resources, empower others, work as a team
ask for help, and parenting skills accessed.
• Level of commitment, when applicable, child's level of attachment and the
potential parents bond to the child.
• Specific recommendations that are in accordance with other information in the
home study regarding recommending or not recommending each family for
placement of a child with them.
• Interviews with all available family members.
• Noted if have a safe household environment that is adequately cleaned and
maintained.
• Ability to budget their resources so that they are able to provide for the
additional children in their household noted.
• Parents relationship with each other and with their own biological children
assessed
• Ability to serve additional children in their home noted.
• Parents ability to provide developmentally appropriate care, nutrition, hygiene,
discipline, protection, guidance and ability to nurture noted.
• Home studies are grammatically correct.
• Home studies explore all related themes set forth in the uniformed State format
and synthesize all information to provide relevant recommendations.
Evaluator Program Evaluator
13
Home Study Process
for
Dates
Signed referral received.
Call to set up interview schedule, request send written home
study, directions to house, remind that we will need finger print card, cashiers
check or money order for or (If lived here less then two years)
Received home study
Interview 1 (within 5 days of referral)
Couple (Relationship building)
Individual (Differences in presentation)
Child/ren
name age
Send out referral/recommendations
Order all background information
Interview II ( at least 7 days latter)
Couple
Individual
Child/ren _
E-mail the home study to Lori, and set up review time.
Call to referral source to discuss recommendations, any
additional concerns that have occurred/update.
Interview HI (Can be in office, at least 7 days after Interview H)
Couple (Wrap up, share recommendations and concerns)
Deliver to Weld County DSS (Date only 6 weeks after org ref)
Completed home study evaluation
Original written self-evaluation from parents
Any background checks information.
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Appendix 13
•
LORI KOCHEVAR, M.S., L.P.C.
2118 19th Avenue
Greeley, CO 80631
(970) 353-6568
EDUCATION:
University of Southern Mississippi, M.S.
Counseling Psychology,
Cumulative GPA 3.8 _
University of Northern Colorado, B.A.
Pre-Professional Psychology,
Cumulative GPA 3.5
PROFESSIONAL
EXPERIENCE:
5/95 - PRIVATE PRACTICE THERAPIST, STRETCHING
OUR STRENGTHS
Serve others through a creative process that stretches participants
strengths and provides an environment for authentic healing. Facilitate
opportunity for individuals, families, and groups to participate in body
centered spiritually based psychotherapy. Interpersonal dynamic
facilitation for community development, team budding, stress
reduction, anger management, parenting, and personal effectiveness
are available.
5/95 - 9/96 DIRECTOR,-VALLEY COMMUNITY FUND
Serve and manage Board of Directors to strengthen the internal
structure of the agency to increase fundraising capabilities.
Responsibilities include: arx cs state, government, and businesses
to participate in payroll deduction, grant writing, marketing, coordination
of special events and community trainings, and disbursement of funds.
5/92 - 5/95 FAMILY PRESERVATION SPECIALIST, SAN LUIS VALLEY
MENTAL HEALTH CENTER
Provide intensive home-based treatment for families that are at risk of
having youth removed from the home. Intervention emphasizing
strength-based approaches, including psychotherapy, skill building
(parenting, communication, anger control, problem-solving, etc.),
educational support, and assistance in obtaining support for concrete
needs. Management duties: public relations, supervise students,
hire staff, and provide training for staff and community.
•
3/92 - 5/95 WILDERNESS THERAPIST, SAN LUIS VALLEY MENTAL
HEALTH CENTER
Provide intensive tent-based treatment for youth ages 8-17. Facilitate
opportunities for young people to learn skills in leadership, team work,
decision making, dealing with stress, facing fears, and building
responsibility. Use outdoor challenge course experience such as
rafting, backpacking, mountaineering, and rock climbing to provide skills
based learning opportunities.
5/89 - 5/91 CONSULTANT, GRADUATE ASSISTANT, UNIVERSITY
AFFLILIATED PROGRAM, UNIVERISTY OF SOUTHERN-
MISSISSIPPI
Participating in an interdisciplinary team that provides assistance for
community-based child care centers who serve children with
disabilities and their families. Responsibilities include: Grant writing,
development and presentation of awareness training, assessment of
learning environment and handicapping conditions. Provide
consultation for teachers and parents using a coaching model, skills-
based training, and evaluation of improvement
1/89 - 5/89 TEACHING ASSISTANT, UNIVERSITY OF NORTHERN
COLORADO
Teach skills for report writing and use of computer programs, PC Write
and Labstat Teach weekly labs and grade lab reports.
4/86 - 9/89 RECREATION SUPERVISION, BOYS AND GIRLS
CLUB OF GREELEY
Providing guidance and support for at-risk youth, fundraising, program
planning, facilitate teenage drug and pregnancy prevention program,
family and community involvement, organization and supervision of
field trips, and participation in local and national staff development
INVOLVEMENT:
FOUNDER, BOARD MEMBER, BOYS AND GIRLS CLUB OF
ALAMOSA
Spearhead community organization to obtain Boys and Girls Club.
Organize fundraising, board development, marketing, and regional and
national networking.
MEMBER, SAN LUIS VALLEY COALITION FOR YOUTH
SERVICES .
Member of steering committee and chairperson of the multicultural task
force.
CONFERENCES:
SPIRITUAL
2000 Hakomi Training
11/05/99 Mariane Williamson - Enchanted Love
10/22-24/99 Shapeshitting: Shamanic Trardormation
1999 Women Who Run With the Wolves - Jungian
10/5-17/99 Phoenix Rising: Yoga Therapy Levels 1 and 2
09/24-26/99 Energy Medicine - Donna Eden
08/19/99 James Redfield -The Celestine Prophecy
08/14/99 Ruth and Naomi - Women's Partnerships _
04/24/99 Substanability and Spirituality
04/23/99 Time, Money and the Meaning of Life
03/19/99 Gandhi's Search for Meaning
10/23/98 Spirituality and Religion
06/06/98 Tying it all Together - Biblical Overview
03/28/99 Transformation-Job of the Old Testament
03/06/98 Matthew Fox - Spirituality of Compassion
11/6-9/97 Common Boundaries: Joy of Creation
07/10-13/97 Body and Soul Conference
04/26/97 Day of Prayer
04/19/97 Contemplative Living
1997 Catholic Biblical School
11/6-10/96 Common Boundaries: intentional Living
1993-1995 Creative Process
COMMUNITY DEVELOPMENT
1/7-8/00 Foster Parent Core Training
10/30/99 Matrix Leadership
10/21-22/96 Working as Partners with Managed Care
04/02-05/95 Leadership for Executive Directors
03/29/95 - Fundsaving Workshop
Fall 1995 Leading Edge/Business
02/09-13/95 Challenge by Choice: Ropes Course
05/20-22/94 Organizational Conflict Management: CSAP
05/06/94 CPR and First Aid Certification
02/01-/4/94 Multicultural Conference
11/30/93 Exploring Multiculturalism Within
10/13/93 Conflict Mediation Training
08/11-14/92 Multicutt Ural Training: CSAP
05/12-26/89 Women as Leaders
FAMILIES
06/4-6/99 Passionate Marriage
10/15-19/98 Marriage and Family Conference
05/16-17/98 Relationship Enhancement
12/08-9/97 Family Group Decision Making
10/06/97 Family Group Decision Making
05/2-3/97 Marriage and Family
9/15-16/94 Family Preservation - Supervision
07/20/94 Jim Fay Parenting
07/13/94 Family Sculpting
4/26-27/93 Family Sculpting
Spring 1993 Redirecting Chidren's Behavior
02/06/93 Meaningful Family Comunication
07/070-8/92 Active Parenting
03/16-19/92 Family Preservation Training
09/20-21/90 Parents and Professionals United
CHILDREN AND ADOLESCENTS
09/10/99 Testifying in Child Abuse Caes
07/12/99 Firestarting - Prevention and Intervention
01/29/99 Play Therapy
12/11/98 Attachment Disorders
10/18/97 Art Therapy for Children
04/04/97 Attachment Disorder
10/11-13/96 International Play Therapy Conference
07/8-9/94 Play Therapy
09/26/93 Traumatic Stress Reactins in Children
03/11-14/93 Child Adolescent Conference
Spring 1993 - • Play Therapy Class
02/16-17/91 Strategic Therapy for Adolescence
10/11-13/90 C.H.A.D.D. Conference on ADHD
05/30-6/1/90 Early Intervention
12/05/89 Play Assessment
TRAUMA AND GRIEF REACTIONS
•
12/03/99 Jurisprudence Workshop
06/25/99 Molecule of Emotions
04/09/99 Depression and Anxiety
05/19/97 Cultural Grief
09/14-16/95 Annual Hospice Conference
04/14/94 Empowering Resistive Client II
06/09/93 Empowering Resistive Clients
09/17-19/92 Annual Mental Health Conference
SUBSTANCE ABUSE AND DOMESTIC VIOLENCE
10/14/98 Working with Aggression in group Therapy
09/23/97 Domestuc Violence
09/17/97 Substsance Abuse
05/16-17194 FPS - Motivational Interviewing - Jill Kenney
05/3-14/94 Teen Baseline TOF - Drug Prevention
10/5-9/93 Baseline TOF - Drug Preverbon
04/23-24/92 Domestic Violence Conference
San Luis Valley
0 Comprehensive Community
Mental Health Center
CUNIC OFFICE
ADMIN AND CLINIC OFFICE 1015 FOURTH STREET CLINIC OFFICE
522 ALAMOSA AVENUE ALAMOSA.CO 81101 402 FOURTH STREET
ALAMOSA.CO 81101 TDD 719-589-3671 MONTE VISTA.CO 81 144
719-589-3673 719-589-3671 719-852-5186
FAX 719-589-1521 FAX 719-589-9136 FAX 719-852-3043
•
August 6, 1996
26041 Woodland Ave.
Esparto, CA 95627
Dear Colleagues:
I have worked very closely with Lori in the Family Preservation program. Lori has
been a wonderful asset to this program and to all her colleagues at Mental Health.
More importantly, her dedicated and skillful service to our clients has greatly benefitted
many SLV families.
Lori's skills are numerous. She is well organized and very conscientious. She has
excellent speaking and writing skills. Her forte is her ability to work with all kinds of
people, and work through difficult interpersonal situations. Lori has consistently
impressed me with her resilience and problem solving skills in dealing with some of the
most chaotic and resistive families. In working with these families, Lori has also come to
know the needs of SLV families and has become an expert in resources that are
available throughout the Valley. She has worked in every county in the Valley.
Despite carrying a full caseload of challenging cases, Lori took "time off for herself
by making solid contributions to other programs. I was amazed to see Lori doing good
work for such things as the Mental Health Center's Wilderness Program, the Boys and
Girls Club of Alamosa, the Multicultural Awareness Committee and the Drug and
Alcohol Baseline program. She attended trainings in all of these programs and then
consistently returned to share her expertise and take responsible roles in each, and
handling the mix of responsibilities effectively.
Lori has a strong philosophical commitment to the empowerment of the oppressed.
Lori will direct people toward healthy, fun relationships. Lori will earn the confidence of
the people with whom she works: staff, clients, and community leaders. I highly
recommend her.
Sincerely,VIILI Myl� A
/ Offering Comprehensive Mental Health Core For The Entire Son Lips Volley
ANNA LANE
4386 County Road P.8, Unit D
- Wiggins, CO 80654
(970)483-6164
SUMMARY OF QUALIFICATIONS
Insightful, team oriented agency counselor who quickly establishes rapport with clients and
facilitates outcomes by consistently communicating respect and belief in clients'ability to do
well. Special skills include:
• Bilingual -Spanish ' Crisis Management ' Adult Trauma
* Child Abuse * Brief Therapy * Play Therapy
EDUCATION
M.A. Agency Counseling
University of Northern Colorado,Greeley, CO
June/ 1993 -August/ 1998
B.A. Computer Information Sciences
Regis University, Denver, CO
October/ 1983 -August/ 1993
B.A. Languages: Spanish and Chinese
Indiana University, Bloomington, IN
September/ 1971 -May/ 1976
Numerous professional courses in: childhood development., substance abuse,play therapy and
PTSD-crisis counseling.
CERTIFICATION / LISCENSLIRE
LPC - #2658
NCC -National Certified Counselor-_t�54047
UT_-Roistered Play Therapist - Pendiqg
CISM - Critical Incident Sent
PROFESSIONAL EXPERIECE
Loveland Counseling Connections,Loveland, CO July 2003-Present
Psychotherapist
• Provide referrals for low-income clients to therapists who accept some Pro Bono
work in the Larimer County area.
• Consultation with the doctors concerning mental health issues and diagnosis
Counsel Spanish speaking adults, children, and couples with a wide range of emotional
problems for the Larimer Center of Mental Health in Loveland.
Salud Health Clinic, Brighton, CO November 2002 -Present
Psychotherapist
• Providing counseling to patients referred by the doctors:This includes performing
the initial assessment and providing one to one counseling.
• Provide a mental health screen to patients and brief therapy interventions,
including psycho educational materials.
• Consultation with the doctors concerning mental health issues and diagnosis.
Counsel adults, children, and couples with a wide range of emotional problems, including
clients who are Spanish speaking
Centennial Mental Health Center, Fort Morgan, CO October 1998 - June 2003
Mental Health Professional III
• Providing counseling to court ordered and self-referred clients including
performing the initial assessment, administering the mental status exam, creating
treatment plans and providing one to one counseling, treatment termination plans,
testifying in court on dependency and neglect cases, and participating on the
Child Protection Team.
• Provide on call crisis management including evaluations for 72 hour holds.
• Provide supervision to individuals and group supervision in play therapy.
• Counsel adults, children, and couples with a wide range of emotional problems,
including clients who are Spanish speaking.
BOULDER COUNTY HEALTH DEPARTMENT, Boulder, CO September 1997-August 1998
Substance Abuse Counseling Intern
• Provided counseling to court ordered and self referred clients including performing initial
assessment,administering mental status exam, creating treatment plans and providing one to one
counseling and executing treatment terminations.
• Counseled with clients who suffered from various forms of mental illness, differing forms of
substance abuse, couples issues,and anger management.
BOULDER COUNTY SHERIFF'S DEPARTMENT, Boulder, CO May 1995-June 2000
Outreach Advocate
• Provide crisis counseling and support to crime Victims including initial contact,providing
referrals and status updates in both Spanish and English, reducing the stress in being a victim of
crime.
VOICES FOR CHILDREN,Boulder, CO October 1989— May 1999
Court ApponCed Special Advocate
• Monitored children weekly for Guardians Ad Litem appointed to protect the children's rights in
child abuse and neglect cases.
• Evaluated children and families to ensure that their needs are met by a wide range of human
services organizations while in the judicial system.
IBM/MSC, Boulder, CO June 1982 - March 1998
System Support _ _ __ 1988 - 1998
• Improved customer satisfaction using diplomacy by leading a 3 -4 person team in providing
the customer with requested services. •
• Achieved quick turn around in resolving problems,which contributed to improved customer
relations.
glectronic Technician -----.------ --1982 - 1988
WESTERN ELECTRIC, Broomfield, CO September 1979—April 1982
Electronic Technician
Diagnosed digital and analog circuit packs that went into a mini-recorder unit.
PROFESSIONAL MEMBERSHIPS
National Board of Certified Counselors
Lisa R. Downs
4925 WCR 83
Roggen, CO 80653
Home (303) 514-6129
Work (970) 867-3770
SUMMARY OF OUALIFICATIONS
Insightful, creative, dedicated counselor who quickly establishes rapport with children and
adults of all ages. Able to facilitate change and outcomes by consistently communicating
respect and holding a belief that children, adults and families have the ability to heal.
Special skills include but are not limited to:
*Trained child/play therapist *Child and Adult Trauma *Children's Groups
*Supervision skilled *Crisis Management *Severe Mental Illness
EDUCATION
May 1996-December 2000
M.A. Community Counseling
University of Northern Colorado, Greeley, CO
August 1986-December 1990
B.A. Psychology, Minor in Music
University of North Dakota, Grand Forks,ND
August 1985-May 1986
General Education, Music & Sports Scholarships
Tabor College, Hillsboro, KS
Numerous professional courses and workshops attended to specialize in: child
development, divorce, play therapy, social skills training and crisis counseling.
CERTIFICATION/LICENSURE
L.P.C. -#3374
N.C.C. National Certified Counselor- #67252
A.C.A. American Counseling Association Member-#06115160
R.P.T. Registered Play Therapist Certification -T-862
•
PROFESSIONAL EXPERIENCE
CROSSROADS COUNSELING CENTER,Ft Morgan, CO March 2003 to present
Self Employed Mental Health Therapist
Providing individual,group and child therapy.
CENTENNIAL MENTAL HEALTH CENTER, Ft Morgan, CO Dec. 2000-March 2003
Mental Health Professional II
• Provided counseling to court ordered and self-referred clients including: performing the initial
assessment,administering the mental status exam,creating treatment plans, providing individual and
group therapy,testifying in court on dependency and neglect cases and case management.
• Provided on-call crisis management which included evaluations for 72 hour holds.
• Counseled adults,children and couples with a wide range of emotional issues. This included
providing therapy to individuals with persistent mental illness and developmental delays.
CENTENNIAL MENTAL HEALTH CENTER, Ft. Morgan CO Jan. 1999-Dec. 2000
Therapist Intern: Outpatient Team
• Co-facilitated therapeutic groups,conducted individual and group intakes,consulted with co-workers
to assess client progress,diagnosed clients and planned treatment strategies and group supervision
with co-workers.
• Counseled clients who were diagnosed with various mental health issues,differing forms of abuse,
family issues,gender issues,and dependence and neglect cases.
UNIVERSITY OF NORTHERN COLORADO, Greeley, CO Aug. 1998-Dec. 1998
Practicum: Master's Program
• Scheduled and treated individual clients.
• Observed peers through a one-way mirror.
• Conceptualized and treated individuals from different theoretical orientations.
HIGH PLAINS EDUCATIONAL COOPERATIVE, Ulysses, KS Aug. 1990-May 1993
School Psychologist Para-Professional: Undergraduate Experience
• Consulted with teachers regarding behavioral strategies for those with special needs,observed
children with developmental delays,provided counseling to parents, and conducted achievement
testing and behavioral assessments for brief therapeutic interventions.
Print Date: 02/16/04
HEALTHCARE PROVIDERS
SERVICE ORGANIZATION
PURCHASING GROUP
CERTIFICATE OF INSURANCE
Producer<-Branch = Prefix Policlr Number- - Policy Period
018098 970 HPG 0273177648 from:12:01 AM Standard Time on:02/26/04
to: 12:01 AM Standard Time on:02/26/05
Tamed Insured and Address v: � % Program.Administrator:
Lori Kochevar MS LPC LLC Healthcare Providers Service Organization
810 12th Street 159 East County Line Road
Greeley, CO 80631-4022 Hatboro, PA 19040-1218
Medical Specialty: Code: 'Insurance Providedtby -
Clinical Counselor Firm. 72990 •.
CAmerican Casualty Co. of Reading, PA
CNA Plaza 26S Chicago, IL 60685
'COVERAGE OF.LIABILRY <�
A. PROFESSIONAL LIABILITY
Professional Liability (PL) $ 1,000,000 each claim $ 6,000,000 aggregate
Good Samaritan Debility included above
Personal Injury Liability included above
—Mil-Placement ClaGliiy included above
B. COVERAGE EXTENSIONS:
License Protection $ 10,000 per proceeding 25,0-00 _aggregate
Defendant Expense Benefit---`r $ 10,000 aggregate
Deposition Representation .rk �rr ��. . ` k r ;; _$ 10,000 aggregate
Assault $ 10,000 per incident $ 25,000 aggregate
Medical Payments $ 2,000 per person $ 100,000 aggregate
First Aid - = ' ' .�r, .. $ 2 500 aggregate
Damage to Property of Others $ 2,500 per incident $ 10,000 aggregate
C. WORKPLACE LIABILITY Coverage part C.Workplace Liability does not apply if Coverage part D.General Liability is made part of this policy.
Workplace Liability none
_Fire&Water Legal Liability none
Personal Liability none D. GENERAL LIABILITY Coverage part D.General Liability does not apply if Coverage part C.Workplace Liability is made part of this policy.
General Liability (GL) $1,000,000 each occurrence $1,000,000 aggregate
�iirea Auto&won awned�_to—_ l'nefuc�ec�lTri�L-limit above :,<
Fire&Water Legal Liability included in GL limit above subject to $250,000 sub-limit
Personal Liability a none
Total Premium: $ 4 3 3 . 0 0 QUESTIONS?CALL: 1-888-288-3534
o atIached:at-nception: n
:l?alit;,y�f rms=end�endofsemerats:- �" � ..> =p°_ - s, �{�h.
G-121500-C G-121501-C G-144872-A G-144959-A
G-123846-005 G-121504--C G-123827—B G-141239—A
Master Policy# 188711433
Keep this document in a safe place. It and proof of payment are evidence of your insurance coverage.
cfyy--Ct caWA-4/ 1k\i4
Chairman of the Board Secretary
G-141241-A (07/2001) Coverage Change Date: Endorsement Change Date:
•
® HEALTHCARE PROVIDERS
GENERAL LIABILITY COVERAGE PART ENDORSEMENT
Additional Insured General Liability
In consideration of the premium paid, and subject to the General Liability limit of liability shown on the
certificate of insurance, it is agreed that the GENERAL LIABILITY COVERAGE PART is amended as
follows:
The person or entity named below(the "additional insured") is an insured under this Coverage Part but
only as respects its liability arising out of named insured's operations, or premises owned by or rented
by the named insured and solely to the extent that:
1. a general liability claim is made against the named insured and the additional insured; and
2. in any ensuing litigation arising out of such claim, the named insured and the additional insured
remain as co-defendants.
In no event is there any coverage provided under this policy for an occurrence that is the direct liability
of the additional insured.
Additional Insured: State of Colorado
Go Weld County Social Svs.
PO Box A
Creeley, CO 80634
This endorsement is a part of your policy and takes effect on the effective date of your policy, unless
another effective date is shown below. All other provisions of the policy remain unchanged.
Must Be Completed Complete Only When This Endorsement Is Not Prepared with the
Policy
Or Is Not to be Effective with the Policy
ENDT. NO. POLICY NO. ISSUED TO ENDORSEMENT EFFECTIVE DATE
01 0273177648 Lori Kochevar MS LPC LLC 2/26/2004
G-123827-B(07/2001) Page 1 of 1
Appendix C
PROGRAM BUDGETS 1trzJ D Acrunc► � Sif
*PROGRAM Outstide DSO Home Study FP Home SShidy Client Relinquishment Bonding
s 7
A TOTAL HOURS OR DAYS OF DIRECT SERVICE PER CLIENT 1. I 1 24 I
B TOTAL CLIENTS SERVED 50 20 10 60 1 1
C TOTAL HOURS OR DAYS OF DIRECT SERVICE FOR YEAR(A X B) 50 20 10 1,440 1
D COST PER HOURS OR DAYS OF DIRECT SERVICES(£/C) $650.00 $7E0.00 $168.00 $45.00 35D I
35-
/3S
E TOTAL DIRECT SERVICE COSTS FACE-TO-FACE $32,500 $15,000 $1,680 $64,800. 36-2)
( Da
F ADMINISTRATION COSTS NON-FACE-TO-FACE ALLOCABLE TO PROGRAM $869 $7,342 $1,968 $694, $42,629 13 S-
G OVERHEAD COSTS ALLOCABLE TO PROGRAM $8,133 $5,545 $2,465 $123 $8,133 3 0 30
H TOTAL DIRECT,ADMINISTRATION&OVERHEAD COSTS(E+F+0) $45,388 $21,433 $2,497 $115,562 C/-S a iOS
I PROFITS CONTRIBUTED BY THIS PROGRAM $3,400 $2,450 $25 $6,841 10 I D
J TOTAL COSTS AND PROFITS FROM THIS PROGRAM(H +I) $48,788 $23,883 $2,522 $122,403 .5'a5 a 75'
K TOTAL HOURS OR DAYS OF DIRECT SERVICE FOR THE YEAR(C). 50 20 10 1,440 1 /
L RATE PER HOURS OR DAYS OF DIRECT,FACE-TO-FACE SERVICE 3 Say 'OD ,3 975-'0D
(J/K) $975.76 $1,194.15 $252.24 $85.00
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SUPPLEMENTAL NARRATIVE TO RFP: EXHIBIT B
RECOMMENDATIONS
X CONDITIONS
a
DEPARTMENT OF SOCIAL SERVICES
P.O.BOX A
GREELEY,CO.80632
Website:WW1'?co weld CO US
Administration and Public Assistance(970)352-1551
Child Support(970)3524933
O
• April 6,2004
COLORADO
Lori Kochevar,LLC
810 12th Street
Greeley,CO 80631
Re: RFP 04005: Lifeskills
RFP 006-00: Foster Parent Consultation
RFP 006-00: Home Study,Relinquishment Counseling
Dear Ms.Kochevar:
The purpose of this letter is to outline the results of the Bid process for PY 2004-2005 and to request
written confirmation from you by Wednesday,April 14,2004.
A. Results of the Bid Process for PY 2004-2005
The Families,Youth and Children(FYC)Commission recommended approval of the bid,RFP
006-00 Foster Parent Consultation, for inclusion on our vendor list with no recommendations.
The Families,Youth and Children(FYC)Commission recommended approval of the bid,RFP
04005,Lifeskills, for inclusion on our vendor list with the following conditions.
Condition 1:The provider shall provide a written explanation of the$20 increase in rate from
last year's program(2003-2004)to this year's program(2004-2005.)
Condition 2: The provider shall provide in writing a more detailed assessment of how progress
will be measured.
Condition 3:The program will not exceed the 24-hour limit,with the second 12 hours of services
contingent upon the outcome of the first 12 hours.
• If the parent(s)were not able to bond within the first 12 hours,the family would be referred
to an interactional level of intervention.Further,a letter would be submitted to the court with
recommendations to end the bonding nurse program and progress to an interactional and/or
psychological evaluation.The bonding provider, caseworker, and program area supervisor
will communicate progress.A staffing will be scheduled if appropriate.
B. The Families,Youth,and Children Commission recommended the following condition be
applied to all 2004-2005 contracts.
The condition is: the provider will notify the Department of any change in staff at the time of the
change.
Page 2
Lori Kochevar,LLC,Results of Bid Process 2004/2005
All conditions will be incorporated as part of your Bid and Notification of Financial Assistance
Award(NOFAA). If you do not accept the condition(s),you will not be authorized as a vendor
unless the FYC Commission and the Weld County Department of Social Services accept your
mitigating circumstances. If you do not accept the condition,you must provide in writing
reasons why.A meeting will be arranged to discuss your response.Your response to the above
conditions will be incorporated in the Bid and Notification of Financial Assistance Award.
The Weld County Department of Social Services is requesting your written response to the FYC
Commission's recommendations and conditions.Please respond in writing to Gloria Romansik,Weld
County Department of Social Services,P.O.Box A,Greeley,CO, 80632,by Wednesday,Apri114,
2004,close of business.
If you have questions concerning the above,please call Gloria Romansik at 352.1551, extension 6230.
Sincerely,
•
*Ctgo'
ctor
cc: Juan Lopez,Chair,FYC Commission
Gloria Romansik, Social Services Administrator
Page 1 of 2
Elaine Furister
From: lorik[lorikanddave@earthlink.net]
Sent: Thursday,April 15, 2004 7:39 AM
To: Elaine Furister
Subject: RE: Home Study Bid
Elaine,
Thank you for emailing me this information. Please attach this to the letter I delivered to you yesterday.
• Action:A motion was approved to recommend the acceptance of the following
Bid for Program Year 2004-2005 with the following condition.
A. Lori Kochevar, LLC
Condition: The provider is approved for Foster Care Home Studies only. This is
because of the higher bid rate for Adoption Home Studies.
Response: I would like to clarify that I understand this condition to mean that we are approved to take
referral for Foster Care Home Studies and Adoption Studies from the Foster Care Coordinators. The
Bid for the higher rate was for Home Studies that are reoffered from the Child Protection Unit because
of the increased cost of paying for background checks, the extensive amount of information typically
uncovered in background checks, and the increased number of no-shows, travel time, and resistance
encounter by clients that are often unmotivated to complete the home study. In order not to confuse this
with Foster Care home studies that often serve as adoptive home studies we may consider calling the
home studies referred by the Child Protection Unit, Child Welfare Home Studies.
I understand this condition to mean that we are approved for all home studies referred through the Foster
Care Coordinators and are not approved for home studies referred by the Child Protection Unit.
Feel free to contact me for further clarification. Thank you for the opportunity to serve the families in
Weld County,
Sincerely,
Lori Kochevar, M.S. LPC
Lori Kochevar, M.S. LPC
810 12th Street, Greeley Co 80631
www.aspacetogrow.com
Original Message
From: Elaine Furister [mailto:furistef@co.weld.co.us]
Sent: Wednesday, April 14, 2004 7:50 AM
To: lorik@aspacetogrow.com
Subject: Home Study Bid
Lori,
4/15/2004
Page 2 of 2
The following is an excerpt from the Minutes of the FYC Commission Evaluation
Committee. Please respond to your acceptance of the condition in the letter to the
Department. The condition will be included in your Notification of Financial
Assistance. If you have further questions,please let me know.
• Action:A motion was approved to recommend the acceptance of the following
Bid for Program Year 2004-2005 with the following condition.
A. Lori Kochevar, LLC
Condition: The provider is approved for Foster Care Home Studies only. This is
because of the higher bid rate for Adoption Home Studies.
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4/15/2004
Lori Kochevar, MS LPC
810 12th Street
Greeley Co 80631
Weld County DSS
PO Box A wesoc°linty
Greeley Co 80631 Ge ; senP Peat.
"De/ trees f
Re: RFP 04005; Lifeskills APR
Re: RFP 006-00: Foster Parent Consultation 4?004
Dear Ms. Griego,
This letter serves as written confirmation that I received the results of the Bid
Process for PY 2004-2005 except for RFP 006-00: Home Study, Relinquishment
Counseling. Elaine is currently sending me this part of the letter.
The following is the response requested by the conditions for the RFP 05005,
Lifeskills.
Condition 1: Written explanation of$20 increase in rate from last year.
Last years bid of$65 per hour of service did not cover program expenses, as
demonstrated .by the actual program budget from 6/1/03-12/31/03 that was submitted to
John Cruise 1/04. The actual budget indicated that the program cost$80.43 per hour of
service. I believe the $65 hourly bid was inadequate to cover cost because of a low
estimate on my part for the costs for this first time bid, as well as,the decreased number
of referrals to cover this programs percentage of fixed costs.
In hopes of increasing the number of referrals to this program we have made two
significant changes. First,we have added two additional Masters level therapists, which
are Licensed Professional Counselors, and therefore have raised the rate for providers by
$5 an hour. The actual costs of running the program and the increase in rate for the
provider are the costs that have increased the bid by $20.
In addition,we are currently in the process of locating a home to rent were family
visits can occur. This will expand our ability to provide supervised visitation and
exchanges in a home setting. One benefit, of this shift to a neutral home setting is that the
clinician can get a clearer assessment of the parent's ability to bond with and set
appropriate limits with their children in a typical environment . This setting also gives
more opportunity for interactional coaching of needed skills with the parents. Having
additional space for visitation will also alleviate some of the congestion at the Social
Service visitation rooms.
We are hoping that by providing a home setting for assessment and coaching
during visitation and more bonding specialist with a variety of expertise that the number
of referrals to this program will increase. With an increased number of referrals,the
fixed cost per session hour will decrease, henceforth covering the additional cost of
renting more space for this program.
Condition 2: Detailed assessment of how progress will be measured.
The provider shall complete the Pre and Post Bonding Assessment for child and
parent and/or the AIMS Developmental Indicators of Emotional Health as clinically
appropriate at the initial interview, after 12 hours or intervention, and as a final
measurement at 24 hours of intervention. See sample of measurements in Appendix to
this letter. These measurements of progress will be forwarded to the caseworker with the
monthly progress reports.
Condition 3: The program will not exceed the 24 hour limit,with the second 12
hours of service contingent upon the outcome of the first 12 hours.
The only change that we would like to suggest in this part is that the first sentence
changes to a process goal. It the parent(s)were not able to begin the bonding process
within the first twelve hours, and then the family would be referred to an interactional
and/or psychological evaluation.
B. All staff changes will be reported to DSS
Thank you for this opportunity to again serve the families of Weld County. Please let me
know if you are in need of any further clarification.
Sincerely,
" v ram
Lori Kochevar .5. LPC
AIMS: Developmental Indicators of Emotional Health
Guidelines for Psychosocial°Practice
POINTS OF O13SERN FIO\
Strengths Concerns
�t6fo; ak, :ATTACEMENT ATTACHMENT
�ypuwa�to taltc.abour
an3ylig.fcgrq thee,$ ❑ parent is at ease when holding baby ❑ parent appears stiff or awkward when holding baby
questionnaire? ❑ parent describes baby in positive terms 0 parent is unable to describe baby or uses primarily
negative terms
Adjustatent,and 0 parent shows concern over baby's crying or distress ❑ parent does not appear to"hear"or react/respond to_Asjoseisbaby's cries
fkbeint
How,*tbiaga going with-: ❑ parent appears pleased with being father/mother ❑ parent shows little or no pleasure in being a father/
you,your baby andlhe mother
baby's other parent? O parent looks at baby often,is attentive and smiles at ❑ parent does not look at baby,seems uninvolved,
.2. Tellmeaboutthe-delivery., baby detached or mechanical
S,.Are youg8ting-lfeip with 0 parent touches baby tenderly ❑ parent does not touch baby except to accomplish a
yourinew"baby?Are you basic child care task/parent touches baby abruptly,
getting enough aggressively,or impassively
4.Is your baby otatake ier or more INTERACTION INTERACTION
difficult to te care of than
you had imagined? 0 baby molds to parent's body ❑ baby recoils,arches,or stiffens when held by parent
5. Are you planning to return 0 baby appears alert ❑ baby appears lethargic,parent does not describe
to work?:llave,youdecided periods when baby is alert
who will care for your O parent seeks to protect baby from possible harm ❑ parent appears unaware of possible harm;no effort
by7.
(e.g.,covers when cold,comforts after shot,guards made to offer protection to baby
6. In there anything worrying baby from falling off table)
you since the birth of your 0 parent feeds baby according to baby's signals of ❑ parent appears intrusive,rushed or slow at feeding
baby?, hunger and satiation baby,does not seem attuned to baby's signals of
hunger and satiation
lrrsie 'f.ar` a andRel#ionship ❑ parent bolds baby in face-to-face position for O parent does not hold baby in face-to-face position;
tlgtd taby: feeding,eye contact is established positions baby away from body to feed;eye contact
1. Are you enjoying your not established
baby? 0 parent talks to baby 0 no verbalization to baby
2. Are you breast orbottle
'feec1ng?,How are theSTERY MASTERY
feedings going? 0 parent shows confidence in role as parent ❑ parent appears more anxious,depressed or
Axe.you`feeling.comfort overwhelmed than expected
able or uncertain using your ❑ parent has appropriate awareness of baby's abilities 0 parent expects baby to do more than baby can,or
own ng,clothing,
PProPri appears unaware of baby's innate abilities
feeding,clothing,diapering,
bathing and playing with 0 parent effectively uses a variety of techniques to ❑ parent does not try different things to comfort baby
your baby?` comfort or help baby settle but stays with one technique even if it appears not
to help baby
4, Row is your baby sleeping?:
5. How does.your family fed�" 0 parent is able to perform basic child care tasks ❑ parent is not able to perform basic child care skills
(e.g.,putting on clothing,diapering,feeding)
'about the baby?
SUPPORT SUPPORT
❑ parent asks for help or information 0 parent appears hesitant or unable to ask for help or
information
❑ parent appears sufficiently rested and healthy ❑ parent appears overwhelmed,tired,stressed or
unhealthy
O family appears and/or reports having adequate ❑ family appears and/or reports having inadequate
housing,transportation,finances and child care housing,transportation,finances and child care
8/5/96 O copyright,Project AIMS
.AIMS: Developmental Indicators of Emotional Health 2 MONTHS
Guidelines,for PsychosocialPractice „3a„
I\I'ER\'IEN1' I'OI\TS OF OI. SER�':CI'ION
QUESTIONS
rk -mss.,- Strengths Concerns
'rnr`wauctO to abiiut- ATTACHMENT ATTACHMENT
,
aa3Ahmgsfrom'xfi6All(4S ❑ parent is at ease when holding baby ❑ parent appears stiff or awkward when holding baby
iptesponnaire? - ❑ parent describes baby in positive terms O parent is unable to describe baby or uses primarily
negative terms
',+'ph ai4'da ent3 D baby is able to be comforted by parent ❑ baby remains distressed despite parental efforts
Ye(1 being, ';. ❑ parent shows concern over baby s crying or distress ❑ parent does not appear to"hear"or react/respond
'.1 ₹low'areyou *elftlg? to baby's cries
2.: 4 y .gCttng.gnouglt
yourself? '01TERACTlON INTERACTION
,. tp,evt(hriofubal}�2':: ❑ baby molds to parent's body ❑ baby recoils,arches,or stiffens when held by
=time'witfi fattylyand parent
friends?:' ❑ parent able to calm baby down when distressed ❑ parent is unable to calm baby
3, 3stheaanythlflto 'our' ❑ baby appears alert,socially involved ❑ baby appears lethargic,apathetic,socially
mind that;Yop would'likketo' uninvolved
ttiiiltAlloutyl ❑ parent's stimulation of baby is appropriate ❑ parent appears intrusive,over-stimulating,or
under-reactive toward baby
Thine Card and'Relaffonship, ❑ parent and baby make eye contact ❑ no eye contact between parent and baby
fiel!Syr ❑ parent seeks to protect baby from possible harm ❑ parent appears unaware of possible harm
1. ,Flow are thingsgoing.with (e.g.,covers when cold,comforts after shot,guards
';Xen;baby_?" baby from falling off table)
2 flow.are:yott,audthebaby
clOwSw1 the MASTI RY MASTERY
•Doirou aq"pecial
❑ parent appears confident in parent role ❑ parent appears more anxious,depressed or
worrl a**layout-baby? overwhelmed than expected
YOur.famflyl
❑ parent is able to perform basic child cam tasks D parent is not able to perform basic child care skills
4; flow does your family feel (e.g.,putting on clothing,diapering,holding)
.:..aboutthebaby?
❑ parent is prepared for baby's needs(e.g.,brings ❑ parent is ill-prepared for meeting baby's needs
' '.. .. bottle,toy,diaper)
SUPPORT; SUPPORT
a parent asks for help or information ❑ parent appears hesitant or unable to ask for help or
information
❑ parent is responsive to information,advice or other ❑ parent rejects offers of help
forms of help
❑ parent appears rested and healthy D parent appears overwhelmed,tired,stressed or
unhealthy
❑ family appears and/or reports having adequate ❑ family appears and/or reports having inadequate
housing,transportation,finances and child care housing,transportation,finances and child care
4/96 0 copyright,Project AIMS
AIMS:Developmental Indicators of Emotional Health
4 MONTHS
'Gumdeliues forL‘Rsycihasoi uah$ractwce-
INTERN I1'." POINTS OF OI4SF12' T(O\
QI. I S'FIO\S
- WW
, �� Strengths Concerns
��,,�oo'tc�f S t ATTACHMENT ATTACHMENT
'an, ,g. S ' 1Oparent is at ease when holding baby ❑ parent appears stiff or awkward when holding baby
q`¢ oti¢hit'8? ❑ parent describes baby in positive terms ❑ parent is unable to describe baby or uses primarily
negative terms
ParentalAdjusanentand ❑ baby shows preference for parent O baby shows no preference for parent
Rrt'i Mktg. ❑ parent maintains close proximity to baby ❑ parent makes no effort to maintain close proximity
I. ₹ikowareyou feeling?
O parent is pleased by positive comments made ❑ parent appears unaffected by positive comments
u-g
2. Are yoetting;enough: about baby about baby
-- foyourselfl . .
'�.- ai�Y' =neITLR:ACPION
--help with your baby? ❑ baby molds to parent's body ❑ baby recoils,arches,or stiffens when held by
time with family and parent
friends? ❑ parent's stimulation of baby is appropriate ❑ parent seems intrusive,overstimulating,or
3. Have you found_a,babysitter under-reactive toward baby
Who You like?Have Yop ❑ parent and baby make eye contact ❑ no eye contact between parent and baby
been out withoutyoui baby.
yet? - ❑ parent seeks to protect baby from possible harm ❑ parent appears unaware of possible harm
4. Is there i{ttyfltingon your (e.g.,covers when cold,comforts after shot,
mind pt.Yoil-Would Mato Sins baby from falling off table)
ti1Y"abtltiYttt>7fap? ❑ baby is able to signal needs to parent ❑ baby is difficult to read and unable to signal needs
effectively
fasic-Care and Relationship- ❑ baby appears to enjoy people and things ❑ baby appears uninvolved with people and things
cifftalled,r
I..Tell-meabouta,.tYPicaiday MASTERY MASTERY
with y°urbthy. ❑ parent appears confident in parent role ❑ parent seems more anxious,depressed,or
2: Whatnew:fhngsis your overwhelmed than expected
baby doing? ❑ parent effectively uses a variety of techniques to ❑ parent makes little or no effort to calm or comfort
3. Do you feel thatlifewith comfort baby baby
your baby has begunto U parent is able to perform basic child care tasks ❑ parent is not able to perform basic child care tasks
settle down.
(e.g.,putting on clothing,diapering)
l:toyou baveaAp apeetal ❑ parentis prepared for baby's needs(e.g.,brings ❑ parent is ill-prepared for meeting baby's needs
Woexles&bisu'kj~ottrpalay2 bottle,toy,diaper)
your family?
S. How does your family feel ❑ baby shows a beginning range of emotions ❑ baby demonstrates little affect
about the baby?
;'SUPPORT : . S$fliRT
❑ parent asks for help or information ❑ parent appears hesitant or unable to ask for help or
information
❑ parent is responsive to information,advice or other ❑ parent rejects offers of help
forms of help
❑ parent appears rested and healthy ❑ parent appears overwhelmed,tired,stressed or
unhealthy
❑ family appears and/or reports having adequate ❑ family appears and/or reports having inadequate
housing,transportation,finances and child care housing,transportation,finances and child care
4/96 *copyright Project AIMS
PRE AND POST ASSESSMENT
Bonding Program
Name: Date: Date:
1. Parents will be able to show improved competency in parenting
practices.
• Increased awareness of the emotional needs of the children.
• Increased understanding of bonding and how poor bonding
affects the child
• Increased positive responses to the child
• Increased ability to interact with the child in a manner which
enhances bonding
• Increased awareness of the developmental age of the child and
practice age appropriate expectations.
• Child will show increased response to the parent.
• Child will show increased respect for the parent
• Increased understanding of punishment vs. discipline
• Increased ability to utilize discipline measures which are not
emotionally detrimental to the children
2. Parents will develop a greater understanding of the components that
are necessary to insure a lasting family relationship.
• Increased ability to place the children a position of high priority
in the home.
• Increased ability to continue to utilize the parental and
relationship skills learned in the program.
• Increased ability to recognize and meet own needs.
• Increased ability to maintain sources of support in the
community for self and children.
• Increased awareness of the ongoing emotional needs of the
children.
3. Parents will be able to improve household management
competency as measured by a pre and post assessment of skills
needed to maintain a safe and secure home.
• Increased resources to provide for the family needs
• Improved ability to maintain a clean, healthy environment
• Increased ability to provide structure and consistency in the
home structure the home
• Increased awareness of the nutritional needs of the children
• Increased awareness of health and safety risks in the home
• Increased ability to keep the child safe
4. Increased ability to utilize resources available in the community.
• Increased knowledge of community resources.
• Increased understanding of how to access services.
• Increased confidence in seeking services.
•
5. The child will:
• Indicate through his behavior, that he has increased sense of
security with the parent.
• Demonstrate increased emotional bond with the parent.
• Behave appropriately in social interactions.
• Begin to progress developmentally with expected achievement.
The items checked above indicate areas of concern. A circled item indicates
improvement.
Parent: Bonding Specialist: Date:
2
PRE AND POST BONDING ASSESSMENT
Child Parent
Date: Date: Check:
_ / Avoids eye contact
_/_ Resists being- held-stiffens body,
T !_ Pulls away from touch
Does not respond to mothers voice-avoids, ignores
Resists feeding when mother holds bottle- prefers
propped bottle
Somber, sad expression,withdrawn
Lack of responsive smile
Prefers to play away from mom, does not check in
with mom periodically
Decreased stranger awareness, prefers others to
morn
/_ Eating problems, gorging, refusal,FT
Destructive of own or others property,frequently
breaks own toys
High pain tolerance,self-abusing behaviors
!_ Clingy,whiney, fussy baby, hard to console
! Defiant, resistive behavior
Manipulative
/_ Senseless lying
/ Hyperactive behavior,unable to be still or to focus,
Sullen, quiet and withdrawn
Frequent tantrums,often lasting for unusually long
time
/_ Developmental delays, learning, speech, motor
% Speech delays or speech is difficult to understand
_% Hurtful to others or animals
Weld County Department of Social Services
Notification of Financial Assistance Award
for Child Welfare Regular Administration Funds
Type of Action Contract Award No.
X Initial Award 04-HS-0030
Revision (RFP-06-000)
Contract Award Period Name and Address of Contractor
Beginning 06/01/2004 and North Colorado Medical Center-Youth Passages
Ending 05/31/2005 Home Studies,Home Study Updates, and Relinquishment
Counseling
928 12 Street
Greeley, CO 80631
Computation of Awards Description
Unit of Service The issuance of the Notification of Financial
The total number of client family units to be Assistance Award is based upon your Request for
served in this program is 72. This is estimated at Proposal(RFP). The RFP specifies the scope of
six evaluations per month for 12 months. services and conditions of award. Except where it is
Subtotal of individuals who receive in conflict with this NOFAA in which case the
Bilingual/bicultural services is 36; subtotal of NOFAA governs,the RFP upon which this award is
individuals who receive South county services is based is an integral part of the action.
36. The monthly maximum capacity is 10 client Special conditions
family units. 1) Reimbursement for the Unit of Service will be based
on a rate per home study; home study update,and
Cost Per Unit of Service relinquishment counseling session.
2) Reimbursement requests must be an original with an
Hourly Rate Per original signature from the provider and/or designee.
Relinquishment Counseling $ 71.00 3) Reimbursements requests must include the date the
home study, update,or relinquishment counseling was
Rate per Study completed.The request must reflect the referral
Full Home Study(5 interviews) $800.00 number assigned to each home study,the amount
Full Home Study(6 interviews) $848.00 billed for each home study, and the month the service
Full Home Study(7 interviews) $896.00 was provided.
Full Home Study(8 interviews) $944.00 4) Payment will only be remitted on referrals made by
Full Home Study(9 interviews)$1,040.00 the Weld County Department of Social Services.
Home Study Update $530.00 5) Requests for payment must be an original submitted
to the Weld County Department of Social Services
Unit of Service Based on Approved Plan by the end of the 25th calendar day following the end
of the month of service. The provider must submit
Enclosures: requests for payment on forms approved by Weld
X Signed RFP:Exhibit A County Department of Social Services.
X Supplemental Narrative to RFP: Exhibit B 6) The Contractor will notify the Department of any
Recommendation(s) changes in staff at the time of the change.
X Conditions of Approval
Approvals: � h� n Program Official:
By _ �Jll By < I if 1AX
Robert D. Masden, Chair Judy A. Griegc,Director
Board of Weld County Commissioners Weldtounty Department of Social Services
Date: JUN 1 F 7004 Date: q26/0 t.( a9a)s/-,/63g
1 i
SIGNED RFP-EXHIBIT A
INVITATION TO BID
DATE:February 11,2004 Off System Bid No. B002-04 RFP FYC 006-00B
RETURN BID TO: Pat Persichino, Director of General Services
915 10th Street,P.O. Box 758, Greeley, CO 80632
SUMMARY
Request for Proposal(RFP-FYC 006-00B) for: Adoption, Foster Care, and Expedited Permanency
Planning Home Studies, and Relinquishment Counseling
Deadline: March 5, 2004,Friday, 10:00 a.m.
The Families, Youth and Children Commission, an advisory commission to the Weld County Department of
Social Services, announces that competing applications will be accepted for approved vendors pursuant to the
Board of Weld County Commissioners' authority pursuant to Colorado Statute and the Weld County Home
Rule Charter. The Families, Youth and Children Commission wishes to approve services targeted to run
from June 1, 2004, through May 31, 2005, at specific rates for home studies,home study updates, and
relinquishment counseling services. The County will authorize approved vendors and rates for services only.
This program announcement consists of five parts, as follows:
PART A...Administrative Information PART D...Bidder Response Format
PART B...Background, Overview and Goals PART E...Bid Evaluation Process
PART C...Statement of Work •
Delivery Date
(After receipt of order) BID MUST BE SIGNED IN INK
Jon Sewell
TYPED OR PRINTED SIGNATURE
VENDOR North Colorado Medical Center )_
(Name) Handwritten Signature By Authorized
Officer or Agent of Vender
ADDRESS 1801 16th Street TITLE
Chief Executive Officer
Greeley , CO 80631 DATE
PHONE# 352-4121
2- -i-?- '-!
The above bid is subject to Terms and Conditions as attached hereto and incorporated.
Page 1 of 34
, "Off-System Bid No.B002-04 RFP-FYC-006-00B Attached A
HOME STUDY,UPDATE, & RELINQUISHMENT COUNSELING BID PROPOSAL AND
REQUEST FOR CONTINUATION OF AWARD UNDER
CHILD WELFARE ADMINISTRATION FUNDING
2004-2005 BID PROPOSAL APPLICATION
PROGRAM FUNDS YEAR 2004-2005
BID Off—System Bid B002-04 RFP-FYC-006-00B
NAME OF AGENCY: North Colorado Medical renter - Youth Passages
ADDRESS: 928 12th Street , Greeley, CO 80631 PHONE: ( ) 970-352-1056
CONTACTPERSON: Karen Nicholson TITLE: Behavioral Health Therapist II
DESCRIPTION OF HOME STUDY PROGRAM CATEGORY: Adoption,Foster Care, and Expedited Permanency Planning
Home Studies in compliance with the uniform format utilized by the State of Colorado Department of Human Services since
October 1, 1999(Attached A).
11-Month approximate Project Dates: 12-month contract with actual time lines of:
Start June 1,2004 Start June 1 , 2004
End May 31,2005 End May 31 , 2005
TITLE OF PROJECT: NCMC Youth Passages
David Rastatter (�. 7E 2/26/04
Name and Signature of Person iparing Document Date
Jon Sewell Z_1 7
Name and Signature Chief Administrative Officer Applicant Agency Date
MANDATORY PROPOSAL REQUIREMENTS
For new and renewal bids,please initial to indicate that the following required sections are included in this Proposal for Bid.
For renewal bids,please indicate which of the required sections have not changed from Program Year 2003-2004 to Program
Year 2004-2005.
x Project Description x Project Description
X Sample Home Study x Sample Home Study
Target/Eligibility Populations x Target/Eligibility Populations
x General x General
x Cultural/Eligibility Populations x Cultural/Eligibility Populations
x Types of services provided x Types of services provided
x Measurable Outcomes x Measurable Outcomes
x Service Objectives x Service Objectives
x Workload Standards x Workload Standards
X Staff Qualifications x Staff Qualifications
x Unit of Service Rate Computation _ Unit of Service Rate Computation
x Program Capacity per Month x Program Capacity per Month
X Certificate of Insurance
Page 23 of 34
Off-System Bid No. B002-04 RFP-FYC-006-00B Attached A
Date of Meeting(s)with Social Services Division Supervisor:
Comments by SSD Supervisor:
Name and Signature of SSD Supervisor Date
Page 24 of 34
' Off-System Bid No. B002-04 RFP-FYC-006-00B Attached A
Program Category Home Study,Update, and Relinquishment Counseling
Project Title Youth Passages
Vendor North Colorado Medical Center
PROJECT DESCRIPTION
Provide a brief, one-page description of the project.
II. SAMPLE HOME STUDY
Provide a fictitious home study written using the State format.
III. TARGET/ELIGIBILITY POPULATIONS
Provide a one page brief description of the proposed target/eligibility populations. At a minimum
your description must address:
A. Total number of clients to be served.
B. Total individual clients and the children's ages.
C. Total family units.
D. Sub-total of individuals who will receive bicultural/bilingual services.
E. Sub-total of individuals who wilI receive services in South Weld County.
F. Sub-total of Individuals who will have access to 24-hour service.
G. The monthly maximum program capacity.
H. The monthly average capacity.
I. Average stay in the program(weeks).
J. Average hours per week in the program.
IV. TYPE OF SERVICES TO BE PROVIDED
Provide a two-page description of the types of services to be provided. Please address if your project
will provide the service minimums as follows:
A. Home Studies,Updates, and Relinquishment Counseling as referred by the Weld County
Department of Social Services.
Provide your quantitative measures as they directly relate to each service. At a minimum, include a
number to be served in each service component. Describe your internal process to assure that FYC
resources will not supplant existing and available services in the community; e.g. mental health
capitation services, ADAD, and professional services otherwise funded.
Page 25 of 34
I. PROJECT DESCRIPTION
Youth Passages has been an FYC provider for ten years. Throughout that
time we have provided high quality intensive treatment to youths
experiencing significant emotional, behavioral, psychiatric, educational,
interpersonal, familial and chemical dependency problems. Treatment
modalities that we specialize in include: milieu, individual, group,
experiential, behavioral and family therapy. Our family therapy program,
which addresses issues specific to traditional, blended, adoptive and foster
families, is one of the strengths of our service delivery system. Youth
Passages staff possesses specific expertise in effectively evaluating family
systems and living situations. This information is utilized to formulate
treatment interventions and court recommendations. We feel this skill base
will be an asset in working with the type of families referred for Home
Studies, Home Study Updates and Relinquishment Counseling.
The Youth Passages Home Study, Home Study Update and Relinquishment
Counseling program (HSRC) will meet or exceed all fifteen specific
reporting requirements specified for Home Studies and Relinquishment
Counseling as outlined in Off-System Bid No. B002-04 RFP-FYC-06-00B.
The primary therapist who will complete these evaluations is a Licensed
Marital and Family Therapist who has previous employment experience as a
social services caseworker. If the need arises we can assign a Licensed
Master's Level bilingual therapist who has successfully provided FYC
services to the department for three years. To ensure high quality service
delivery Youth Passages staff will attend all related mandatory training
offered by Weld County Department of Social Services.
1
II. SAMPLE HOME STUDY
Client Name: CarinM Matthew M
Date of Birth: 2/24/1994 4/1/1999
Legal Guardian: Weld County Department of Social Services
Case Worker: Dave C.
PO Box A
Greeley, Co 80632
(970) 352-1551 ext. #4
People interviewed:
Name: Bob Lucy
Date of birth: 1/23/1964 12/8/1966
Relationship to children Family friend Family friend
Address: 1640 Pond Drive
Boulder, Colorado 80637
Phone #: home (303) 377-6767 work (303) 377-2999 (Bob)
Cell (303) 217-4455 (Lucy)
Interview dates: May 14, 2003 and May 21, 2003
PURPOSE OF THE HOME STUDY
This home study was requested by Weld County DSS to determine if Bob
and Lucy, long-time friends to the M. family, can provide a stable, nurturing
long-term placement for Carin and Matthew. There are currently no known
family members who are available to provide long-term care for these
children.
FAMILY HISTORY
Bob descends from a Norwegian farming family from Sioux Falls, S. D. His
family consisted of one older sister and one younger brother. Bob's birth
2
•
and childhood development were unremarkable. He reached his childhood
milestones as appropriate, as did his siblings. Bob's health was good; he had
chicken pox at age 4, broke his arm falling from a tractor at age 8, and had
his tonsils out when he was 11.
Bob completed high school and then attended college in Vermillion, S.D.
where he earned a bachelor's degree in Business. As a high-school student
Bob wrestled and played football. He was a fairly popular student but chose
to spend time with a small group of friends.
Bob reports that he and his family got along well. His parents were devoted
Lutherans and held to fairly traditional, conservative values. The family
attended church together each Sunday and participated regularly in church
activities. Due to this influence Bob was a fairly "normal" kid who only
drank beer occasionally after a football game and never tried drugs.
Bob related well to both his brother and sister and reported only the typical
sibling rivalry between them. Bob's dad was the disciplinarian, and his
mom was the homemaker. According to Bob it took only a few spankings at
the hand of his dad for him to understand his behavior had consequences. In
the times when discipline was needed Bob would lose privileges and have to
do extra chores around the farm.
At age 10 Bob's grandmother was in an accident and died. This was a very
difficult loss for the entire family and Bob and his family spent 3-4 evenings
at the home of the senior pastor, "processing" the death of his grandmother.
This is the closest thing to counseling Bob experienced in his youth.
In College Bob met Lucy. They began to date his junior year and were
engaged two years later. They married after Bob graduated, and Lucy was a
junior.
Lucy descends from an American father and a Spanish mother. She and her
younger sister grew up in Boulder, Colorado. The family moved three times
when Lucy was young, but they always remained in the city of Boulder. Her
family regularly attended a charismatic church since the time she was 7
years old.
3
Lucy's birth and childhood development were unremarkable, and she
reached childhood milestones at appropriate ages. Her sister, Pam, however,
was born with a disease similar to Cerebral Palsy. She suffered minimal
brain damage due to complications during her birth. As a result, Pam
required extensive home health medical care which was provided by her
family and a hired home-health care agency. Lucy spent many hours caring
for Pam, and though she does not resent this Lucy definitely believes she
missed out on a lot of social activities by staying home with Pam.
Lucy's health was generally good and she experienced common childhood
illnesses, including croup, chicken pox, and pinkeye. Lucy did experience
earaches as a toddler and as a result had tubes put in her ears. At age 14 she
had her appendix removed.
Lucy graduated from high school with honors, and moved to Vermillion to
attend college. Her desire to move out of state was motivated in part by the
desire to be free from caring for her sister. Lucy studied business and
completed her degree in four years. Her junior year in college she married
Bob, and he worked while she completed her senior year.
Lucy reports that her family was very close, partially due to the need they
had to care for Pam. They were strong participants in the Assemblies of
God church and often attended church together, taking Pam in her wheel
chair. Though Lucy's faith provided strength to her, it also created
frustration because she hoped God would heal Pam. Lucy's disillusionment
and confusion about this led her to step away from her faith when she moved
away to college.
While Lucy has no history of alcohol use she does admit to smoking pot off
and on in high school. She reports it was only recreational use and stopped
smoking when she married Bob.
Lucy was compliant with her parent's rules and reports that discipline
consisted of being grounded from the phone or the car, and "being talked to"
by both of her parents together.
After Lucy completed her college degree she and Bob moved to Boulder and
opened a restaurant. They managed the business together and were very
4
successful with their first restaurant. Bob decided to open a second
restaurant in Longmont. Even though the prospects appeared good early on
they had to close the restaurant within two years of opening. Their
perspective on the closing was optimistic since their first restaurant
continued to do very good business.
In 1996 Bob was forced to close the restaurant due to re-zoning by the city
of Boulder. He pursued legal action against the city to prohibit the closure
but was unsuccessful. The legal and the emotional cost to Bob and Lucy
was high and it created tremendous stress on their marriage. As a result they
chose to see a marriage therapist for 4 months as they attempted to deal with
the stress of losing a business they loved. They felt the counseling was very
helpful and effective.
Bob and Lucy have no biological children. After trying to conceive for 2
years without success they decided to seek the help of an infertility
specialist. The trials were not successful and because the cost was very
prohibitive Bob and Lucy were not able to repeat the procedures. The grief
that accompanied their infertility was the most difficult for Lucy and she
admits that she has some residual anger at God for this.
As a result they decided they wanted to adopt children, or become foster
parents. Both see the opportunity to care for Carin and Matthew as the
perfect opportunity.
GENERAL FUNCTIONING
During a business workshop in 1998 Bob was given the Myers-Briggs Type
Indicator (MBTI). His report indicated he was an ISTJ, introvert, sensing,
thinking,judging. After reviewing the results Bob agreed that the indicator
was accurate. To summarize here, Bob is an introvert who gains energy from
being alone more than with groups. He has strong friendships with 2-3 other
men, and his wife and believes he is self-disclosing with all of them, Lucy
the most. He prefers to look at situations by paying attention to the
information present in front of him, and tends to be logical when making
decisions. He is a very driven man who likes new challenges and believes it
is important to finish what he starts. Because Bob is logical and detail
oriented he tends to overlook emotions. He admits that he prefers not to
5
spend a lot of time worrying about something, or getting upset about things.
Instead, he thinks them through and tries to fix them. Bob's communication
is "short and sweet", communicating only the minimal amount of
information necessary in a conversation.
Lucy has not taken the MBTI assessment, but in comparing herself to Bob
she believes she is also an introvert, preferring quiet time and her own space,
but also enjoys going out with friends or other couples more than Bob. Lucy
prefers to look at situations by paying attention to the information present in
front of her. She diverts from Bob by making decisions primarily based on
her values and how she feels about the situation.
Lucy reports she is less driven than Bob, and though she likes to do good
work, she is much more relaxed about schedules and details.
Both Bob and Lucy believe they are good communicators, including when
they are angry. Lucy will cry more often when angry and Bob rarely cries
about anything. He admits that at times he is not aware of his own emotions
and it takes a number of conversations with Lucy for him to get at "the
whys" of what may be bothering him.
PARENTING - DISCIPLINE
Both Bob and Lucy agree that discipline is an important component of
parenting. They want to be "a united front" as they teach and discipline
Carin and Matthew and agree that they will share the responsibility equally.
Both agree that their hopes and expectations in this area are purely
conjecture since they have never had children.
They have read books (Parenting with Love and Logic and Boundaries with
Kids) and feel this has given them a strong starting point. Yet they also
realize most of the immediate active parenting will have to come from Lucy
since Bob will be at work full-time. They also believe that the exact
consequences for misbehavior may depend on the differences between Carin
and Matthew, including their age difference.
They agree that they favor taking away privileges, adding chores and
possibly utilizing time-out for Matthew. Both state they will not employ
corporal punishment.
6
Bob and Lucy believe the point of discipline is to teach and help a child
grow, not just to punish. They both admit to being a little nervous to see
how this plays out "in real life" once the children move in.
Currently there is no plan to use day care.
PARENTING - VALUES AND PRACTICE
Bob and Lucy have compiled a list of what they consider the "family non-
negotiables".
They want Carin and Matthew to be well provided for (i.e. clothes, toys,
etc...) but state they will be cautious about being too excessive in this area.
School attendance is required, and they would like to see both kids maintain
at least a "B" average. Extra-curricular activities will be encouraged.
A daily chore list will be established, at age-appropriate levels, and both kids
will earn allowance. A portion of their allowance will be put into a savings
account.
The family will have family meetings once a week to talk about how
everybody is doing, and to plan activities together. The family will attend
church together most Sundays.
Both kids will be provided the opportunity to participate in 2-3 activities per
year, such as swimming lessons or soccer, so they are exposed to various
activities and skills.
Depending on the disposition regarding Carin and Matthew's parents, Bob
and Lucy are hoping to eventually adopt the children. With this in mind,
and due to the history of abuse perpetrated on the children by their biological
parents, it is Bob and Lucy's preference that the parents have no contact
with Carin and Matthew. They will, however, abide by the court rulings on
this matter.
CHILDREN
Bob and Lucy have no children.
7
FAMILY SYSTEM
Family Functioning
Based partially on his Norwegian/Lutheran upbringing Bob brings the
following dynamics to his relationships with others. He tends to have strong
opinions and often will share them in a diplomatic, confident manner. Bob
knows clearly what he expects with, and from, others and rarely deviates
from his own rules. He professes that overall his thinking is black and
white, right or wrong. When he makes a decision it is most often with strong
conviction and he stands by his decisions. Because of this it can be difficult
to change his opinion and doing so requires a thorough explanation and
discussion of the issue. Early on in their marriage Bob rarely changed his
opinions, but over the years he has "softened" and will listen to others (Lucy
and co-workers) as they express differing opinions. Bob acknowledges that
he is more willing to change his mind now than when he was younger.
Generally Bob holds to what he describes as a "traditional line" when it
comes to rules and values, and anticipates that will remain the same when he
cares for Carin and Matthew.
The influence of Lucy's Hispanic heritage is exemplified through her core
family values. Lucy's parents taught her to respect and love her family and
honor her parents. The one striking divergence from traditional Hispanic
values is that her parents raised her in a home where parents shared equal
roles in the family. Her church background encompassed strong evangelical
values, with tolerance for differences in others, and some flexibility with
rules. Lucy is quite verbal and will process her thoughts out loud with
whomever she is talking. She often solicits the thoughts and opinions of
others when it comes to making a decision, yet is very clear within herself
about what she wants.
Bob and Lucy are openly affectionate with each other (this can be
uncomfortable for Bob), and Lucy openly hugs other friends and co-
workers. In terms of affection, both of them agreed that they want to openly
demonstrate care and respect for each other in front of the children. It is
their hope that Carin and Matthew will learn how to care for and respect
others and appropriately express these feelings.
8
Lucy travels to Longmont every other week to visit with her sister Pam, who
is being cared for in an assisted living facility. Though she acknowledges
feeling an obligation to do this, she willingly visits Pam and notes that it is
so much easier now than when she was caring for Pam on a daily basis.
Lucy would like to bring Carin and Matthew with her occasionally so that
they can learn to socialize with, and even help care for, people with
handicaps.
Bob and Lucy feel that their marriage is stronger at present than it ever has
been. Both believe they have adequately grieved their inability to have
biological children and Lucy is able to express this tearfully, but with
resolve. Lucy believes there will always be some degree of sorrow over the
fact that she herself could not carry and birth a baby.
FAMILY SUPPORT NETWORK
Bob and Lucy appear to have a strong support network. Both are active in
church social activities as their schedules permit. Lucy is in a women's
bible study and Bob participates in a men's accountability group that meets
every other Tuesday morning.
Bob feels close friendship with his assistant manager at the restaurant, as
well as a few other friends. Bob's family continues to live in South Dakota
and they have expressed an excitement for Bob and Lucy regarding caring
for Carin and Matthew. The hope of Bob's family is that they can all spend
time together in the summer and every Thanksgiving when his family travels
to Colorado for the holiday. Lucy's family supports her wishes to care for
the kids, and Lucy's parents are very excited about the prospect of becoming
grandparents.
DEMOGRAPHICS
Home
Bob and Lucy live in a 4-bedroom ranch-style home east of Boulder. Their
home rests on 2 acres of land, with a front and back yard, and a small field
behind the back yard. Their neighborhood is older, and there is ample space
9
between homes. Because they have lived in the home for 12 years they
know all of their neighbors, and have met the children in three homes on
their street. Two of the neighbors have children close in age to Carin and/or
Matthew.
Financial status
For the tax year 2002 Bob and Lucy's gross income was $68,000. They
anticipate a similar income in 2003 from their restaurant. They have limited
investments in mutual funds and stocks.
In February 2003 they refinanced their home on a 15-year loan. Bob and
Lucy took out a small home-equity loan when they refinanced so that they
can buy furniture for both of the kids' rooms and pay for clothes and other
essentials.
They own both of their cars, and have an outstanding credit card debt of
$650.00.
Once the children live in their home they will be added to Bob's current
health insurance plan. In their estimation they believe they will be able to
provide for a family of four financially without too much problem.
BIRTH FAMILY
Bob and Lucy have been friends with Carin and Matthew's parents for 6
years. They have been aware of the problems in the home and have been
there on a number of occasions to support and encourage Jim and Barb. As
the situation became more unstable in the home Lucy did try and offer
counsel, especially to Barb, but felt she was rebuffed. Bob became angry
and began to detach from Jim, primarily, in his words, because it did not do
any good to try and help.
In 2001 Bob and Lucy offered to care for the children for the summer so that
Jim and Barb could get the help they needed without having to worry about
caring for Carin and Matthew. Barb seemed appreciative of the offer, but
declined. To date there is tension between the couples, and because it is the
hope of Bob and Lucy to adopt they would like to have contact with the
10
children discontinued, "at least until the kids are settled in with us".
FOSTER/ADOPTIVE FAMILY PREPARATION
Bob and Lucy have attended the county foster parent trainings and have
completed the home licensing process. They attended a "Growing Kids
God's Way" series at their neighbor's church, and though they agreed to
many of the principles they disagreed with what they felt were "rigid
behavioral expectations". Bob and Lucy plan to attend a different parenting
series in the future.
Bob and Lucy are unsure of how to deal with visitation from Carin and
Matthew's grandparents. They do not wish to isolate the children from
family members who love them, yet they want to protect the kids from
potential indirect harm of mom and dad. On this issue Bob and Lucy would
like outside counsel that incorporates the children's wishes.
MOTIVATION/COMMITMENT
Bob and Lucy express a high level of motivation to care for Carin and
Matthew. Their motivation is evidenced by reading books to strengthen
their parenting skills, discovering who the neighborhood children are for
possible friendships with Carin and Matthew, financial preparation to 'make
rooms' for the kids, and completing all necessary licensing requirements to
date.
Bob and Lucy have longed to be parents for many years. They have an
established relationship with the kids, and have shown a high level of care
and concern about their welfare for 6 years. Lucy admits her longing for
children feels a little more urgent due to their inability to have children.
They agree they do not know all there is to know about parenting, but, as all
parents do, they will learn as they go. Bob and Lucy are financially stable
and possess a strong support network through their faith community and
other friendships that will be a benefit to them as foster/adoptive parents.
They feel a slight apprehension about the adjustment from having a lot of
personal freedom to, at all times, considering the needs of a 9 year old and a
4 year old.
11
INTERVENTION
Bob and Lucy have agreed that they are open to seeking help from outside
resources when necessary. When pressed by this evaluator Bob admitted he
would be slower to seek help than Lucy, but that he would never oppose
help if Lucy or he really believed it was needed.
TRAINING/RESOURCES
Bob and Lucy have attended and completed all required DSS and licensing
classes. They completed one parenting class and are waiting to hear from
the Rocky Mountain Marriage and Family Institute about an up-coming
parenting class for families with special needs, i.e. abuse, adoption, behavior
concerns.
OBSERVATIONS
Based on the home study the undersigned submits the following
observations:
1. The home and neighborhood are safe and appropriate for Carin and
Matthew.
2. The financial status of Bob and Lucy is adequate to provide for Carin
and Matthew.
3. The expressed level of acceptance and excitement of the extended
family to include Carin and Matthew in their family is high.
4. The support system for Bob and Lucy is strong.
5. Bob and Lucy are very motivated and committed to caring for Carin
and Matthew.
6. The tension between Bob and Lucy and Jim and Barb does create
concerns.
7. Bob and Lucy do not yet understand the process of terminating
parental rights.
8. Bob's stoic nature and preference not to express emotion may create
difficulty for him to express empathy towards the children.
12
9. The emotional roller coaster of infertility and the longing within Lucy
to care for these children may contribute to her being an enabling or
permissive parent.
RECOMMENDATIONS
Based on the home study, the undersigned recommends the following:
1. Bob and Lucy should be considered as a viable foster/adoption home
for Carin and Matthew.
2. Bob and Lucy need information from DSS about the relinquishment
process and a written plan regarding visitation between Jim and Barb
and Carin and Matthew.
3. Parental visitation should be limited and supervised.
4. Bob and Lucy need counsel from DSS regarding grandparent
visitation, both now and in the future, if parental rights are terminated.
5. Carin and Matthew should participate in therapy with a skilled play
therapist that specializes in the treatment of domestic violence.
Evaluator Date
13
HOME STUDY RATING SCALE
SCORE
7-7 • Presence of positive parenting.
• Presence of healthy family functioning.
• No conditions of risk-indications are that child will be safe and his/her
well being enhanced by placement.
• Adult's capability to care for a child is excellent.
6-5 • Presence of positive parenting.
• Presence of healthy family functioning.
• Minimal conditions of risk are present and family is aware of risks and is
willing to address these risks.
• Adult's capability to care for a child is adequate.
• There is a balance between the capabilities and conditions of the family,
and the needs and conditions of the child.
4-3 • Presence of positive parenting is present, yet inconsistent.
• Presence of healthy family functioning is present, yet inconsistent.
• Presence of some pronounced risks to the safety or well being of the
child adult's capability to care for a child may require outside help and
resources until pronounced risks are gone.
• The balance between the capabilities and conditions of the family, and
the needs and conditions of the child is questionable. Therefore the child
may not benefit from placement in the home.
2-1 • Presence of positive parenting is not present.
• Presence of healthy family functioning is not present.
• Presence of pronounced risks to the safety or will being of the child are
present and should be addressed completely before placement should be
considered.
• The imbalance between the capabilities and conditions of the family and
the needs and condition of the child will harm the safety and/or well being
of the child.
14
HI. TARGET/ELIGIBILITY POPULATIONS
(Be Specific)
Yes/No Explain How This Item Will Be Met
A.72 Total number of clients to be served in the 6 evaluations/month for 12 months
program.
B. 72 Total individual clients who are children With younger children (under age 4) the parents may be the primary client
under age 18
C. 72 Total family units
D. 36 Sub-total of individuals who will receive Youth Passages will employ one full time bilingual therapist to provide
bicultural/bilingual services services for this program.
E. 36 Sub-total of individuals who will We will accept a limited percentage (50%) of cases for which we will
receive services in South Weld County provide services in the client's home in South Weld County.
F. 72 Subtotal of individuals who will have PsychCare/FRC is staffed with licensed professionals 24 hours per day,
access to 24 hour services. 365 days per year. These staff members will collect relevant case
information and communicate it to the direct service provider.
G. 10 The monthly maximum program
capacity
H. 6 The monthly average capacity
I. 6 Average stay in the program (weeks)
J. 2-4 Average hours per week in the program
15
IV. TYPE OF SERVICES TO BE PROVIDED
The Youth Passages Home Study, Home Study Update and Relinquishment
Counseling program (HSRC) will meet or exceed all fifteen specific
reporting requirements specified for Home Studies and Relinquishment
Counseling as outlined in Off-System Bid No. 010-03 FRP-FYC-06-000.
The primary therapist who will complete these evaluations is a Licensed
Marital and Family Therapist who has previous employment experience as a
social services caseworker. If the need arises we can assign a Licensed
Master's Level bilingual therapist who has successfully provided FYC
services to the department for three years. To ensure high quality service
delivery Youth Passages staff will attend all related mandatory training
offered by Weld County Department of Social Services.
Quantitative Measures
A. 100% of clients referred by Weld County Department of Social
Services for a Home Study or Home Study Update will be fully
evaluated on the fifteen specific reporting requirements specified
for Home Studies as outlined in Off-System Bid No. B002-04
RFP-FYC-06-00B. The background checks will be completed and
the written report submitted to Weld County Department of Social
Services within six weeks of our receipt of the referral.
B. 100% of clients referred by Weld County Department of Social
Services for Relinquishment Counseling will be fully evaluated on
their understanding of the fifteen specific categories specified for
Relinquishment Counseling as outlined in Off-System Bid No.
B002-04 RFP-FYC-06-00B. The written report will be submitted
to Weld County Department of Social Services within the
individualized timeframe specified for each case.
Weld County Department of Social Services will be the only referral source
for these types of services. As a result, we will only bill Weld DSS for
services rendered pursuant to this agreement.
16
V. MEASURABLE OUTCOMES
A. 100% of our home studies and relinquishment counseling cases
will be completed within the timeframe specified by the
department. Our timeliness will positively impact the mandate to
place children in an expedient manner.
B. 100% of our home studies will consist of high quality clinical
evaluations. 100% of our reports will be well written and
submitted to the department within the timelines outlined in Off-
System Bid No. B002-04 RFP-FYC-06-00B.
C. 100% of our submitted home studies will be defined by the
department as acceptable.
We will ensure quality reports by presenting them for internal clinical
review by supervisors prior to submitting them to Weld County Department
of Social Services.
VI. SERVICE OBJECTIVES
Youth Passages will ensure the provision of quality home studies, updates
and relinquishment counseling for Adoptive, Foster Parents and Department
of Social Services clients by hiring only highly qualified and well trained
licensed Master's Level therapists. These therapists will receive ongoing
clinical supervision and their reports will be reviewed by a supervisor prior
to submission to the department. 100% of our home studies, updates and
relinquishment counseling reports for Adoptive, Foster Parents and
Department of Social Services clients will consist of high quality clinical
evaluations. 100% of our reports will be well written, address the mandated
evaluation topics and submitted to the department within the timelines
outlined in Off-System Bid No. B002-04 RFP-FYC-06-00B.
17
VII. WORKLOAD STANDARDS
A. The person providing this service for North Colorado PsychCare
will be a per diem therapist who will not work more than 12 hours
per day, 40 hours per week, or 173 (on average) per month. One
bilingual Master's Level therapist will be available to assist on
special needs or high census periods.
B. 2
C. Maximum caseload per therapist - 6
D. The treatment modality will vary depending upon the requested
service. All submitted reports will meet standards outlined in Off-
System Bid No. B002-04 RFP-FYC-006-00B.
E. Total Number of Hours of Service -
2-4 hours per day on days clients are seen
4-8 hours per week
16-32 hours per month
F. Total number of individuals providing these services-
1 per diem therapist
1 bilingual therapist available for special needs cases or high
census periods
G. Maximum caseload per supervisor - 15
H. Insurance - See attached certificate of insurance
18
VIII. STAFF QUALIFICATIONS
A. The Behavioral Health Therapist(s) providing services will have a
minimum of a Master's Degree in psychology, counseling, social
work or a related field, possess a current Colorado licensure and
will be listed on the State of Colorado Department of Human
Services vendor list, having applied for inclusion..
B. Two staff members will be available for the direct service phase of
this project with one additional staff member providing
supervision.
19
Home Study
Home Study Update
ML Relinquishment 1:1
2004-2005
Number of
Statistic: Hours/Case Cases
Home Study 15 50
Home Study Update 8 15
ML Relinquishment 1:1 3 7
Total Cases 72
Revenue Per Case
Home Study 5 Interviews $ 800 $ 40,000
Home Study 6th interview $ 848
Home Study 7th interview $ 896
Home Study 8th interview $ 944
Home Study 9th interview $ 992
Home Study 10th interview $ 1,040
Home Study Update $ 530 $ 7,950
ML Relinquishment 1:1 $ 71 $ 497
Gross Revenue $ 48,447
Deductions:
No Shows $ 800
Net Revenue $ 47,647
Expenses:
Salary ML Therapist
(696 case 72 triptime) 768 $ 18,432
Salary Clinical Coordinator 195 $ 5,460
Other(BA,Reimb,MR,etc) 72 $ 864
Sub Total Salaries $ 24,756
Benefits 20% $ 4,951
Sub Total Salaries/Benefits $ 29,707
Non-Salary expense:
Mileage 50 MilesRndTrip 36 $ 675
Background Checks $60ea 130 $ 7,800
Postage 72 $ 72
Sub Total Non-Salary $ 8,547
Total Expense $ 38,254
Contribution Margin $ 9,393
VERIFICATION OF COVERAGE ISSUE DATE: Jan. 19, 2004
Issuer:Banner Health
This verification of coverage is issued as a matter of information only,and does not extend or alter the coverage carried by Banner Health.
COVERED PARTY COMPANIES PROVIDING COVERAGE
COMPANY
BANNER HEALTH LETTER A SAMARITAN INSURANCE FUNDING,LTD.
1441 N.12TH STREET COMPANY
PHOENIX, AZ 85006 LETTER B
COMPANY
LETTER C
COMPANY
LETTER D
COVERAGES
THIS IS TO CERTIFY THAT THE INSURANCE COVERAGE LISTED BELOW IS CARRIED BY THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
VERIFICATION OF COVERAGE MAY BE ISSUED OR MAY PERTAIN,THE COVERAGE DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS
AND CONDITIONS OF THE POLICIES OF INSURANCE CARRIED BY BANNER HEALTH.
CO
LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE POLICY EXP.DATE LIMITS
A HOSPITAL PROFESSIONAL& SIFL 2004 01/01/04 01/01/05 PL EACH LOSS _$10,000,000
GENERAL LIABILITY GL EACH LOSS $10,000,000
GL AGGREGATE $10,000,000
HOSPITAL PROFESSIONAL HPL EACH LOSS $
LIABILITY HPL AGGREGATE $
HOSPITAL PROFESSIONAL HPL EACH LOSS $
LIABILITY HPL AGGREGATE $
MEDICAL PROFESSIONAL PER MEDICAL INCIDENT $
LIABILITY ANNUAL AGGREGATE _$
EXCESS LIABILITY EACH OCCURRENCE _$
UMBRELLA FORM AGGREGATE ___$
m OTHER THAN UMBRELLA FORM
WORKER'S COMPENSATION STATUTORY LIMITS _$ _
A AND SIFL 2004 01/01/04 01/01/05 EMPLOYER'S LIABILITY $1,000,000
EMPLOYER'S LIABILITY
COMMENTS.
BANNER HEALTH HAS ARRANGED TO HAVE COVERAGE EXTENDED TO NORTH COLORADO MEDICAL CENTER.
THE INSURED ABOVE IS APPROVED BY THE INDUSTRIAL COMMISSION OF COLORADO TO SELF-INSURE WITHIN THE STATE OF COLORADO.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED OR MATERIALLY
TO WHOM IT MAY CONCERN CHANGED BEFORE THE EXPIRATION DATE,BANNER HEALTH WILL ENDEAVOR
TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER,BUT FAILURE TO
MAIL SUCH OTICE SHALL IMPOSE NO LIABILITY OF ANY KIND UPON BANNER
HEALTH,I INSPIRERS OR THEIR AGENTS R REPRESENTATIVES.
AUTHORI D REP RESENTATIV
ASSIGNED No..2004-119
G.\Tammy\CERTIFICATES\CERTS.2004\FacileiiesINCMCals Page 1
SUPPLEMENTAL NARRATIVE TO RFP: EXHIBIT B
_ RECOMMENDATIONS
X CONDITIONS
Y
Psychcare/Family Recovery Center
North Colorado Medical Center
Banner Health System
Gloria Romansik
Weld County Department of Social Services
P.O. Box A
Greeley, CO 80632
April 13,2004
Re: Response to Recommendation for FRP 04006
Gloria:
North Colorado Medical Center(NCMC) requires every employee to complete annual
mandatory training modules addressing diversity and discrimination. In addition,NCMC
has the most comprehensive interpretation service of any county agency with the ability
to translate information in over 20 languages. PsychCare/FRC currently employs six
bilingual staff members and financially supports the bilingual training of 3 other
employees. We will continue to actively pursue the acquisition of this skill set for all of
our staff members.
If I can be of further service in clarifying this issue please do not hesitate to contact me.
ectfully submitted,
David Rastatter
Clinical Resource Coordinator
RECEIVED BY
APR 1 3 2004
WELD :;UUN N' DEPT.
a
DEPARTMENT OF SOCIAL SERVICES
P.O.BOX A
GREELEY,CO.80632
Websfte:www.co.weld.co.us
' Administration and Puc Astance(970)352-1551
C'hildSupport(970)352-6933
•
COLORADO April 7, 2004
Jon Sewell Chief Executive Officer
North Colorado Medical Center
1801 16th Street
Greeley,CO 80631
Re: RFP 04010: Option B,Home Based Services
RFP 04006: Day Treatment
RFP 006-00: Home Studies,Relinquishment Counseling
Dear Mr. Sewell:
The purpose of this letter is to outline the results of the Bid process for PY 2004-2005 and to request
written information or confirmation from you by Wednesday,April 14, 2004.
A. Results of the Bid Process for PY 2004-2005
1. The Families,Youth and Children(FYC)Commission recommended approval of the bids
listed below for inclusion on our vendor list with no recommendations.
1. RFP 04010: Option B,Home Based Services
2. RFP 006-00: Foster Parent Consultation
2. The Families,Youth and Children(FYC)Commission recommended approval of the bid,
RFP 04006,Day Treatment, for inclusion on our vendor list.The FYC Commission
attached the following recommendation regarding your bid.
Recommendation: The provider will explain in writing how their program addresses
Bilingual/cultural sensitivity.
You are requested to review the FYC Commission recommendations and to:
a. accept the recommendation(s)as written by the FYC Commission; or
b. request alternatives to the FYC Commission's recommendation(s); or
c. not accept the recommendation(s)of the FYC Commission.
Please provide in writing how you will incorporate the recommendation(s)into your bid. If
you do not aecept the recommendation,please provide written reasons why.All approved
recommendations under the NOFAA will be monitored and evaluated by the FYC
Commission.
Page 2
North Colorado Medical Center/Results of Bid Process for PY 2004-2005
B. The Families,Youth, and Children Commission recommended the following condition be
applied to all 2004-2005 contracts.
The condition is: the provider will notify the Department of any change in staff at the time of the
change.
All conditions will be incorporated as part of your Bid and Notification of Financial Assistance
Award(NOFAA).If you do not accept the condition(s),you will not be authorized as a vendor
unless the FYC Commission and the Weld County Department of Social Services accept your
mitigating circumstances. If you do not accept the condition,you must provide in writing reasons
why. A meeting will be arranged to discuss your response.Your response to the above conditions
will be incorporated in the Bid and Notification of Financial Assistance Award.
The Weld County Department of Social Services is requesting your written response to the FYC
Commission's recommendations and conditions.Please respond in writing to Gloria Romansik,Weld
County Department of Social Services,P.O.Box A,Greeley,CO, 80632,by Wednesday,April 14,
2004,close of business.
If you have questions concerning the above,please call Gloria Romansik at 352.1551,extension 6230.
Sincerely,
tJ ego, cto
cc: Juan Lopez, Chair,FYC Commission
Gloria Romansik, Social Services Administrator
Weld County Department of Social Services
Notification of Financial Assistance Award
for Child Welfare Regular Administration&EPP Funds
Type of Action Contract Award No.
X Initial Award 04-HS-0028
Revision (RFP-06-000)
Contract Award Period Name and Address of Contractor
Beginning 06/01/2004 and Ackerman and Associates, P.C.
Ending 05/31/2005 Home Studies,Updates,Relinquishment Counseling
1750 25th Avenue, Suite 101
Greeley, CO 80634
Computation of Awards Description
Unit of Service The issuance of the Notification of Financial
Home study format is based on 16 hours of Assistance Award is based upon your Request for
work, 12 hours of direct professional services as Proposal (RFP). The RFP specifies the scope of
well as required background checks. Updates are services and conditions of award. Except where it is
based on a format of 12 hours, including 8 hours in conflict with this NOFAA in which case the
of direct professional services. Relinquishment NOFAA governs, the RFP upon which this award is
counseling for a maximum of 2 hours per parent. based is an integral part of the action.
Program capacity is 4 home studies or updates Special conditions
per month and 16 hours of relinquishment 1) Reimbursement for the Unit of Service will be based
counseling per month. The average stay is on a rate per home study; home study update,and
expected to be one month for a home study, and relinquishment counseling session.
two weeks for each parent in relinquishment 2) Reimbursement requests must be an original with an
counseling with up to two one-hour sessions of original signature from the provider and/or designee.
individual treatment. Bilingual-bicultural 3) Reimbursements requests must include the date the
services available through current staff. home study, update, or relinquishment counseling was
Cost Per Unit of Service completed. The request must reflect the referral
Relinquishment Counseling $250.00 number assigned to each home study,the amount
(2-hour maximum) billed for each home study, and the month the service
Rate per Study was provided.
Full Home Study $960.00 4) Payment will only be remitted on referrals made by
Updated Home Study $640.00 the Weld County Department of Social Services.
5) Requests for payment must be an original submitted to
Unit of Service Based on Approved Plan the Weld County Department of Social Services by
the end of the 25th calendar day following the end of
Enclosures: the month of service. The provider must submit
X Signed RFP:Exhibit A requests for payment on forms approved by Weld
X Supplemental Narrative to RFP: Exhibit B County Department of Social Services.
Recommendation(s) 6) The Contractor will notify the Department of any
X Conditions of Approval changes in staff at the time of the change
Approvals. Program Official:
By UQ, \K„,0 By
Robert D. Masden, Chair Judy A Grie .o Director
Board of Weld County Commissioners Weld '.unty Department f Social Services
Date: JUN 16 2004 Date: (B/ 3JO-1
SIGNED RFP-EXHIBIT A
INVITATION TO BID
DATE:February 11,2004 Off System Bid No. B002-04 RFP FYC 006-00B
RETURN BID TO: Pat Persichino,Director of General Services
915 10th Street,P.O.Box 758, Greeley, CO 80632
SUMMARY
Request for Proposal(RFP-FYC 006-00B) for: Adoption,Foster Care, and Expedited Permanency
Planning Home Studies, and Relinquishment Counseling
Deadline: March 5, 2004,Friday, 10:00 a.m.
The Families,Youth and Children Commission, an advisory commission to the Weld County Department of
Social Services, announces that competing applications will be accepted for approved vendors pursuant to the
Board of Weld County Commissioners' authority pursuant to Colorado Statute and the Weld County Home
Rule Charter. The Families,Youth and Children Commission wishes to approve services targeted to run
from June 1, 2004,through May 31,2005, at specific rates for home studies,home study updates, and
relinquishment counseling services. The County will authorize approved vendors and rates for services only.
This program announcement consists of five parts, as follows:
PART A...Administrative Information PART D...Bidder Response Format
PART B...Background, Overview and Goals PART E...Bid Evaluation Process
PART C...Statement of Work •
Delivery Date 3—t-1 —cfl 11 41o,1`11 Ct f1 ��
(After receipt of order) BID MUST BE SIGNED IN INK
JO4�e M3 H'na n
TYPED►OR PRINTED SIGNATURE.
VENDOR �'1c1 Pman and �SsoP'�as,PC NApi.4_ +1.6sb.
(Name) Han tt Signature By Authorized
Officer or Agent of Vender
ADDRESS , ` ��h TITLE �- &(dc 1
T,t� 1 Qt C jQ DATE 3 -a-O y
PHONE# 7� — GS - 3 3 7
The above bid is subject to Terms and Conditions as attached hereto and incorporated.
Page 1 of 34
t Off-System Bid No. B002-04 RFP-FYC-006-00B Attached A
HOME STUDY,UPDATE, & RELINQUISHMENT COUNSELING BID PROPOSAL AND
REQUEST FOR CONTINUATION OF AWARD UNDER
CHILD WELFARE ADMINISTRATION FUNDING
2004-2005 BID PROPOSAL APPLICATION
PROGRAM FUNDS YEAR 2004-2005
BID Off—System Bid B002-04 RFP-FYC-006-00B
aPc .
NAME OF AGENCY: R e�'G�P(�(�(1 whi j II,
ADDRESS: \�� �� �U�(1� PHONE: ( ) 3 33 •
CONTACT PERSON: ` Q t 1 t\CL+-1 TITLE: r@,.%-%1(113n
DESCRIPTION OF HOME STUDY PROGRAM CATEGORY: Adoption,Foster Care,and Expedited Permanency Planning
Home Studies in compliance with the uniform format utilized by the State of Colorado Department of Human Services since
October 1, 1999(Attached A).
11-Month approximate Project Dates: 12-month contract with actual time lines of:
Start June 1,2004 Start •
End Mav 31,2005 �`IE,nd 1 `
TITLE OF PROJECT: V \C\l,�t'mc r pews t z 4 c y 1 u1-O \ Gln Qi -O\`n j u t^
�p�ee I lC`t�Q�mct n AI N).
CC�1Sel�no��cOC�a r►1
Name and ign�ture of Person Preparing Docu ent Date
e (\Cll e� tcen l�c_
Name and S t fre Chief Administrative Officer Applicant Agency Date
MANDATORY PROPOSAL REQUIREMENTS
For new and renewal bids,please initial to indicate that the following required sections are included in this Proposal for Bid.
For renewal bids,please indicate which of the required sections have not changed from Program Year 2003-2004 to Program
Y 2004-2005.
• Project Description ✓Project Description
' Sample Home Study ✓Sample Home Study
arget/Eligibility Populations VTarget/Eligibility Populations
General ✓ General
Cultural/Eligibility Populations 7Cultural/Eligibility Populations
ypes of services provided ✓Types of services provided
Measurable Outcomes ;/Measurable Outcomes
Service Objectives Service Objectives
Workload Standards _ Workload Standards
Staff Qualifications v Staff Qualifications
Unit of Service Rate Computation ✓ Unit of Service Rate Computation
Program Capacity per Month V Program Capacity per Month
Certificate of Insurance
Page 23 of 34
02/26/2004 14:37 9703533374 ACKERMANS PAGE 03/03
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Page 24 of 34 •
Off-System Bid No.B002-04 RFP-FYC-006-00B Attached A
Program Category Home Study,Update, and Relinquishment Counseling
Project Title pp0-44, et ".49-" None Li-s r t' r" -
Vendor Cate firer-A4- Assoc-t- •
I. PROJECT DESCRIPTION
Provide a brief,one-page description of the project.
II. SAMPLE HOME STUDY
Provide a fictitious home study written using the State format.
III. TARGET/ELIGIBILITY POPULATIONS
Provide a one page brief description of the proposed target/eligibility populations. At a minimum
your description must address:
A. Total number of clients to be served.
B. Total individual clients and the children's ages.
C. Total family units.
D. Sub-total of individuals who will receive bicultural/bilingual services.
E. Sub-total of individuals who will receive services in South Weld County.
F. Sub-total of Individuals who will have access to 24-hour service.
G. The monthly maximum program capacity.
H. The monthly average capacity.
I. Average stay in the program(weeks).
J. Average hours per week in the program.
IV. TYPE OF SERVICES TO BE PROVIDED
Provide a two-page description of the types of services to be provided. Please address if your project
will provide the service minimums as follows:
A. Home Studies,Updates, and Relinquishment Counseling as referred by the Weld County
Department of Social Services.
Provide your quantitative measures as they directly relate to each service. At a minimum, include a
number to be served in each service component. Describe your internal process to assure that FYC
resources will not supplant existing and available services in the community; e.g. mental health
capitation services,ADAD, and professional services otherwise funded.
Page 25 of 34
Off-System Bid No. 0002-04 RFP-FYC-006-00B Attached A
V. MEASURABLE OUTCOMES
Provide a two-page description of your expected measurable outcomes of the project. Address the
following measurable outcomes:
A. More expedient placement of children.
B. Quality adoptive home studies that are done in a timely manner.
C. Outcomes will be defined by the number of acceptable home studies submitted. •Describe your quantitative measures: Also, describe the methods you will use to measure, evaluate,
and monitor each quantitative measure.
VI. SERVICE OBJECTIVES
Provide a one-page description of your expected service objectives and quantitative measures.
Address, at a minimum,the following ways the project will:
A. Provide quality home studies, updates, and relinquishment counseling for Adoptive,Foster ,
Parents, and Department of Social Services clients.
Describe the methods you will use to measure, evaluate, and monitor each service objective.
VII. WORKLOAD STANDARDS
Provide a one-page description of the project's workload standards and quantitative measures.
Address, at a minimum,the following areas:
A. Number of hours per day,week or month. (Minimum hours per week per family.)
B. Number of individuals providing the services.
C. Maximum caseload per worker.
D. Modality of service.
E. Total number of hours per day/week/month.
F. Total number of individuals providing these services.
G. The maximum caseload per supervisor.
H. Insurance.
VIII. STAFF QUALIFICATIONS
Provide a one-page description of staff qualifications and address, at a minimum,the following:
A. Will your staff, including supervisors,who are providing direct services meet the minimum
qualifications in education and experience required and be listed on the State of Colorado
DepartmenT of Human Services vendor-list,having applied for inclusion. Describe.
B. Total number of staff, including supervisors, available for the project.
Page 26 of 34
//�� PROGRAM BUDGETS
r11b-,J)l≤S ,r ,,,�77� n n Tn.�..sa,.e- MANtlAL
PROGRAM Pc /4o.,=ba a l,4 st,Ns gotit70,11° /sum 1 .tr{,
A TOTAL HOURS OR DAYS OF DIRECT SERVICE PER CLIENT a b 3e, - IV?S as uS 'S
B TOTAL CLIENTS TO BE SERVED Gv 60 /00 /00 L/g 34 °
C TOTAL HOURS OR DAYS OF DIRECT SERVICE FOR YEAR(A X B) /p-Do / 100 Orel I 0 /9-00 1 620 G G D
D COST PER HOURS OR DAYS OF DIRECT SERVICES(E/C) 51.Cx/. SI. 00 9 t Do GB.00 1(c.an efts 00
E TOTAL DIRECT SERVICE COSTS 66 i p-o0 9/ ro° ,5'7 toreYoo nay 97'do n-too
F ADMINISTRATION COSTS NON-DIRECT ALLOCABLE TO PROGRAM 9 200 108°0 6 eve, ya°° 9 9 00 9'2 ' 3&00
G OVERHEAD COSTS ALLOCABLE TO PROGRAM 33 8'°O .SO YOa Abaco goo 3`1 C.Cr) yR/a0 t,TG o0
H TOTAL DIRECT,ADMINISTRATION&OVERHEAD COSTS(E+F+G) /09.o 0o ' /S3ao°� 26 6Ymo %k,0°o 194,Lao tfg000
I ANTICIPATED PROFITS CONTRIBUTED BY THIS PROGRAM 0 0 0 0 0
J TOTAL COSTS AND PROFITS FROM THIS PROGRAM(H +I) /09-boo IS-3000 g4 t revo /poo°o /&9,Lao ve°l.°
K TOTAL HOURS OR DAYS OF DIRECT SERVICE FOR YEAR(C) /2-00 1 g-:f 80o 1 oo /62-0 4 oo
L RATE PER HOURS OR DAYS OF DIRECT,FACE-TO-FACE SERVICE TO BE CHARGED
TO WELD COUNTY SOCIAL SERVICES(J/K) 80.OP gj-oo 10,0 /00.a O 86. co 90•co
CE IFICATION STATEMENT
I c.�C.ie6_,,,..� Ce0,.j) declare to the best of my knowledge and belief that the statements made on this document are true and complete and that the wage rates
and o he factual unit costs supporting the compensation paid or to be paid under this contract are accurate,complete and includes no duplicate costs and
and that I am the CEO or duly authorized agent of ei3),I ptmnr N nd E,SLtt+a_k%.
0 Fwu cmiftenz ant = Set 630,) Lt)\fF. C1uncil`W, tnci,%2l0y)
a.. A-Lpt,.,: �i.co51s = 4410.00 (5t,c L.-Ma Alt 't°//.e)
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Project Description 2004 - 2005
ACKERMAN AND ASSOCIATES' HOME STUDY AND
ADOPTION RELINQUISHMENT SERVICES
Overview: Ackerman and Associates, P.C. has provided Foster Parent
Consultation Services to Weld County over the past seven years as well as
adoption services in the last year. We propose to continue:
1. A.home study program for new or existing cases where a family
study is needed to certify an adoption placement is in the best interest
of the specified potential adoptee and the adoptive family. A new home
study is referred to in the proposal simply as a home study. A home
study that is for an existing case, where an appropriate home study
has been completed previously and where new information is required
is termed a home study update.
2. The home study program would be required of new foster parent
homes.
3. Relinquishment counseling is designed to assure that each parent
relinquishing the child is fully aware of, in agreement with and capable
of making a decision related to relinquishment. We propose to provide
up to two hours of relinquishment counseling as specified by Colorado
and Weld County. Such services will be referred individually for each
parent relinquishing their rights and giving their child permanently to
another family in an adoption process.
We will provide these programs primarily through services in the home of the
family intending to adopt, the new foster parent home or in our offices. Services
will consist of:
1. A home study format of',.t to hours of work based on t`k of
direct professional services as well as required background checks.
Work performed will meet the state criteria for an appropriate home
study as illustrated by the fictional case study appended to this bid.
2. A home study format of twelve hours based on eight hours of direct
professional services to update an appropriate home study.The
update will meet the state criteria for an appropriate home study.
3. Two hours of relinquishment counseling services for each parent
billed in one hour increments. The billing format is designed to
recognize that the parents may be estranged or one unavailable for
the process. A maximum of two hours per referral is set in this
process,. The relinquishment counseling report will document the
criteria set forth in the WCDSS outline and the Colorado
relinquishment guidelines for relinquishment for each parent.
A primary strength of this proposal is the extensive experience of the
licensed staff of our mental health professionals, psychologists and
certified counselors. The goal of this agency is to: 1. assure that a
placement is in the best interest of the adoptee and the family
intending to adopt. 2. recommend fairly for or against the placement
with clear explanation for those recommendations 3. recommend
activities and work needed to improve or enhance the adoptive
process and outcomes for the adoptive child. 4 assure that
relinquishment is fully understood within the context of the Weld county
and Colorado process.
Target/Eligibility Populations
A. Total number of clients to be served in a twelve-month program has
been calculated as follows. Up to four home studies, either as complete
home studies or updates, per month for a maximum of 48 per year is the
anticipated capacity of our program
B. Distribution of clients. We anticipate that about 1/3 of studies will be for
new foster parents. About one third will be for kinship placements and the
remaining third for adoption outside the kinship system. This assumes a
maximum of approximately one hundred and twenty hours of counseling
services for relinquishment across 30 cases of relinquishment.(sixty
referrals)
C. Families Served. We anticipate serving 48 family units for home study
and thirty mothers and thirty fathers for relinquishment counseling.
D. Sub total who will receive bicultural/bilinqual services. We anticipate
we can serve up to 25% of families who need these services in a bilingual
manner. All of the staff have extensive cross cultural experience.
We have a Hispanic member of the staff, Emily Jaramillo, M.A., L.P.C. who is
fluent in Spanish. Joyce Ackerman, Ed.D. has spent several years working in
American Indian reservation populations and with Hispanic mental health in
Greeley. She has practiced in Greeley since 1981.
E. Accessibility. On weekdays, all providers of Ackerman and Associates
are accessible through our office secretary and through cell phones and
pagers. After hours we maintain a 24 hour answering service and page
system. On weekends, the 24 hour access reaches the provider on call
who is always a licensed Mental Health provider.
F. Maximum per month. The program maximum is estimated at four home
studies and sixteen hours of relinquishment counseling per month
G. The monthly average capacity is two home studies and eight hours
of relinquishment counseling per month.
H. The average stay in the program is expected to be one month for a home
study, and two weeks for each parent in relinquishment counseling with up
to two one hour sessions of individual treatment.
Types of Services Provided
Home study: The home study will consist of the following procedures ( l b hours
of which 1'ahours are billed to WCDSS.)
1. An initial meeting in the home with both parents desiring to adopt or
to be certified as foster parents. (two hours)
2. Each parent will complete a detailed questionnaire designed to
assist the interview process and return it prior to the next
appointment. (four hours*(unbilled hours)
3 .Each parent will complete the required activities for a background
check .( one billed hour to cover costs associated with Background
checks )
4 Interview and observation of all family members in the home setting.
( 3, hours)
5. Final meetings with each parent, age appropriate interviews with
children or others as needed. (two hours)
6. Data review and other interviews as needed ( 1 hour )
7. Home study report and recommendations. (/ 3 hours)
A sample home study report is attached.
Home study update: (12 hours of which 8 hours is billed to WCDSS)
1. A meeting with each parent desiring to be recertified as adoptive or
foster parent. (two hours) .
2. Each parent will complete a detailed questionnaire designed to assist
the interview process and return it prior to the next appointment. ( four
hours)
•
3. Each parent will complete the required activities for a background check
(one hour billable to cover costs of background checks)
4. A follow up meeting in the home with each parent. (one hour)
5. Interview and observation of all family members in the home setting
(one hour)
6. Additional data review or collection as needed.(one hour)
7. Home study report and recommendations. (two hours)
Relinquishment counseling:
1. Relinquishment counseling will consist of focused discussion based on
the required WCDSS outline for provision of relinquishment services and
the State of Colorado guidelines for relinquishment counseling
2. We also assure WCDSS as we have in the past that no individual
working with Ackerman and Associates and providing therapy or having
any other relationship with clients being served will provide home study or
relinquishment, thus avoiding any conflict of interest.
3. Up to two hours per referral (per parent) will be provided under
relinquishment counseling services.
Measurable Outcomes are specified as 1. acceptability of Home Study reports
to WCDSS. Our goal is for 100% of our home study reports are acceptable to
WCDSS Foster parent and adoptive services. 2. Timeliness of reports: Our goal
is that 90% of reports will be completed within one month of referral for those
whose background checks are processed within this period and that 100% of
reports (i.e. the remaining ten percent) will be completed within eight weeks of
referral. By adhering to these standards, we would expect that the department
could expedite permanent placement of children assuming that failure to provide
high quality home studies in a timely manner has been the factor which has
limited the rate of placement.
Service Obiectives
One aspect of all home studies will be to assess parental competency
We expect that all reports will comment on strengths and weakness of the
potential adoptive home. Very serious weaknesses that rise to a clinical potential
for injury to the adoptive child may disqualify a family as prospective adopters in
the judgment of WCDSS. However it is expected that the majority of reports will
suggests strategies for improvement where areas of deficiency are noted where
these deficiencies in themselves do not negate the potential of the home to serve
an adoptive role for the specified child. Some of the areas may include:
Improvement of parental competency
The ability if the family to access resources
Application of parental competencies in daily activities.
After a full assessment of the family and home recommendations are made in
each of these areas
The attached study report indicates how we have applied the state mandated
format to a fictional example of a case study.
Workload Standards
The program has a capacity of 48 home studies and relinquishment counseling
for thirty mothers and thirty fathers.
There are seven providers—three licensed psychologists, three professional
counselors and a licensed clinical social worker. All have specific training in
individual and family assessment and in counseling skills.
The maximum caseload a maximum of four home studies and 16 hours of
relinquishment counseling is projected per month.
The modality of treatment is face to face assessment and background checks
by written format. A questionnaire and other formats will be developed to
standardize the content of the home study.
Hours/month a maximum of four home studies and 16 hours of
relinquishment counseling is projected per month.
Staff There are 7 individual providers supported by two administrative
professionals in practice as well as contracted staff for billing and accounting.
Supervisor This contact would be supervised by Joyce Shohet Ackerman,
Ed. D., who would monitor the project for compliance. Providers are
individually licensed and do not require clinical supervision. The maximum
caseload per supervisor is 48 families per year.
Insurance All providers carry one million/three million liability policy
Ackerman and Associates carries an additional one million/three million
liability policy on the group and a general liability policy, which meets the
required criteria for this application. Co-listing of the state of Colorado on
Ackerman and Associates insurance for professional liability is required by
the procedures of the State vendor list.
Staff Qualifications
. Staff Qualifications Three staff are available for the project. They exceed the
minimum qualifications specified as documented below. The staff members are:
Joyce Shohet Ackerman, Ed. D., Licensed Psychologist; Licensed Psychologist
(and Licensed Social Worker); Emily Jaramillo M.A., L.P.C., and Valerie Larson,
M.S.W., L.C.S.W. All are listed as vendors for home studies by the state of
Colorado. (John Gray M.A. L.P.C. and Susan Bromley Psy. D. , M.S.W. both of
whom have extensive home based assessment experience will also be reviewed
by the State to see if they qualify as home study evaluators. If placed on the
vendor list, they will then be available to provide services under this proposal.)
Training The staff has extensive training in family therapy and short term
therapy as documented by their extensive work experience. All listed providers
are vendors on the state list for home study providers.
Continuing education As a part of their work in the private sector, all providers
in this group maintain continuing education programs more than the minimum
eight hours required. They participate in workshops and other activities. This
proposal's continuing education requirements coincide with the requirements of
other contractual arrangements and are being met on an ongoing basis by
members of the group.
Supervision All of the providers are independently licensed and not required to
have clinical supervision. All the staff have advanced skills in family therapy and
in individual and family assessment. The contract supervisor will monitor the
specifications made in this proposal.
Supervisor continuing education The supervisor of the project is involved in
ongoing training to keep current with her profession through advanced
workshops and seminars. Ackerman and Associates, P.C., of which the
supervisor is the president, has more than ten years contracting experience. Dr.
Ackerman has done extensive evaluation work in child custody and in special
advocate cases and Associates P.C. Dr. Ackerman manages all contracts for
Ackerman and Associates, P.C.
Unit of service rate computation
We will bill at a rate of $80 per hour which is below our standard rates.(Master
level professionals charge $90 per hour and doctoral level $100 For home study
professional time outlined above we are requesting a rate of$920 for a full home
study and $680 for a home study update. For relinquishment counseling we
will bill up to two hours of therapy services plus time for writing a report ($250 per
referral). Direct and indirect costs and how these relate to overall expenses
of the corporation are shown on the required bid sheet.
Standards of responsibility for 2004-2005 bids
Ackerman and Associates, P.C. is a type S professional corporation and not a
501.c.3.
. (Fictional)
ADOPTIVE PARENT EVALUATION
(Produced for Bid Number RFP-FYC 06-000)
February 12, 2017
RE: Mr. and Mrs. Rodriguez— Smith
Regarding adoptive home study for then placement of: Tamera Jones, age six
Evaluators: Joyce Shohet Ackerman, Ed.D., Licensed Psychologist
Valerie Larson, M.S.W., LCSW
Referral:
This home study was referred by the Weld County Department of Social Services to
evaluate the Rodriguez-Smith Family for permanent adoptive placement. The following
individuals were evaluated:
Mr. Fredrick John Rodriguez— Smith, Born July 29, 1966
Mrs. Mary Rodriguez— Smith, Born August 28, 1967
Felize Angelina Rodriquez- Smith, Born February 23, 1995
Samuel Jacob Smith, Born October 19, 1986
Mr. Rodriguez- Smith is a 38-year-old male who has been married for 10 years. He and
his wife Mrs. Mary Rodriguez- Smith have a little girl, Felize, age 7. He has a son
Samuel Jacob Smith age 16 from a previous marriage. Currently Mr. Rodriguez- Smith
is a principal of an elementary school in Greeley, Colorado. He and his wife are very
interested in becoming permanent adoptive parents and have participated enthusiastically
in this evaluation.
Brief description of the child being considered for adoption: Tamara Jones is a six year
old Caucasian female who has been in foster placement since age one. She was separated
from her biological parents as a result of child abuse which resulted in termination of
parental rights. The child abuse involved being shaken resulting an mild brain injury. She
has been living in three different foster homes the first from age 1 to age three and the
second from age three to age four. She is currently in first grade performing at an average
level.
Fred Rodriguez-Smith
According to Mr. Rodriguez- Smith, he grew up in Denver, Colorado. He indicated that
he had a good relationship with both of his parents, John and Marjorie Smith. His mother
was a"stay at home mom" who graduated high school. His father has attended two years
of post high school training in Auto Mechanics and was an auto mechanic who ran his
own garage, until his retirement three years ago. Mr. Rodriguez - Smith recalled that his
father was the primary disciplinarian in the home and used spanking for discipline.
•
According to Mr. Rodriguez- Smith, he is not sure whether spanking was inappropriate.
He does not feel that he was abused as a child.
Mr..Rodriguez- Smith was raised Lutheran. He has not been very involved in the
"Lutheran chur�`recently. However, he stated that his family was fairly involved in the
ehurch when he was growing up, and that his family of origin still attends church
regularly. Mr. Rodriguez- Smith will occasionally go with his wife and daughter to
services at their Catholic church. Mr. Rodriguez - Smith reports that his parents are
somewhat upset that Felize was baptized Catholic, and do not like that she has never
attended Lutheran services. However, Mr. Rodriguez- Smith also reports that the issue
has never been discussed in front of Felize, and that this has not affected his parent's
relationship with Felize.
Mr. Rodriguez- Smith reported that most of his childhood was"relatively normal". He
has good interactions with his two siblings, one younger brother and an older sister. Both
siblings are grown and live in the Colorado area at this time. He sees his older sister
several times a year and has minimal contact with his younger brother, who he states is
"into a bachelor's lifestyle" at this time.
Mr. Rodriguez - Smith reported that his father used to drink beer occasionally on
weekends, however he does not believe that his father was an alcoholic. He indicated
that he perceived that his mother was often moody, although he did not know if she had
ever been diagnosed with depression.
Mr. Rodriguez - Smith graduated high school and attended college in Denver, Colorado,
at the University of Colorado in Denver, where he studied education. While he was in
college, he met his first wife, Patricia, and they were married shortly after she became
pregnant. The pregnancy was unplanned. They were divorced one year later. Mr.
Rodriguez - Smith stated that the relationship was"rocky." Mr. Rodriguez- Smith
believes the marriage failed because they were too young to be married. He believes that
he was not able to make the compromises and decisions necessary to keep a marriage
healthy. Mr. Rodriguez- Smith continues to have contact with his 16-year-old son, Sam,
who he sees approximately two weekends a month. He married his current wife, Mrs.
Rodriguez - Smith about one year after they met approximately ten years ago. They met
at a singles bar and started dating soon after that.
Drug and Alcohol History/Mental Health History:
Mr. Rodriguez- Smith reports that he drinks socially two to three times a month, but he
denies having any problem with drug or alcohol abuse. He did report some history of
depression around the break up of his marriage about 15 years ago and about that time he
did have some mild suic&d4deation. However, since that time he has had no history of
mental health treatment.Wr. Rodriguez - Smith denies any current depression, suicide or
homicide ideation. He smoked cigarettes in college but quit about 14 years ago.
Currently, the home is a smoke free environment.
Mr. Rodriguez- Smith did display some sadness when relating his and his wife's struggle
to get pregnant. He was upset when discussing the two miscarriages he and his wife have
experienced.
Legal History:
As a minor, he volunteered that he had one arrest for shoplifting. He reported that he did
ten hours of community service and was never put in jail. However, other than this he
reports that he has no significant involvement with the law.
Employment History:
Mr. Rodriguez- Smith worked as a third grade teacher for seven years. He then worked
as assistant principal at the same school for approximately three years. He was recently
promoted to principal. It is apparent that Mr. Rodriguez- Smith can keep steady
employment, as he has worked at the same school for approximately 10 years.
Previous Experience with Foster Care/Beliefs about Adoption:
He has had no prior experience in working with foster care or adoptive children. He
stated that this review process was a little overwhelming for him at first. He said that he
was not sure what to expect. However, he reported that he is excited about being
considered as an adoptive father and willingly participated in this evaluation. He stated
that he was willing to follow any recommendations that are made. He seemed eager to
do what was necessary to become a good adoptive parent.
Adult General Functioning:
Our assessment of the father indicated that he has fairly well organized day-to-day
functioning. He was dressed appropriately and he was fully oriented to person, place and
time. He has a good work history,and is able to stay on task. He also presents
measurable success in his work situation, as demonstrated by his recent promotion.
Based on interview and assessment of adult general functioning, he seems to be well
within the normal range for adults his age. He exhibited a normal range of emotional
feelings and responses. He did exhibit some sadness when talking about several areas,
especially as to the frustration that he and his wife have had in their fertility problems and
the miscarriages that they have experienced. He exhibited a positive attitude towards
others. He has good skills in working with other individuals, particularly other adults, as
he works with parents on a routine basis. Hobbies include target shooting and hunting.
Parenting and Discipline Styles:
When observed with Felize, Mr. Rodriguez - Smith acted appropriately. Felize seemed
comfortable with her father. Mr. Rodriguez- Smith displayed affection through hugs.
Both Felize and her father initiated interactions. Felize followed directions, most of the
time, when her father asked her to complete a task.
Mr. Rodriguez - Smith used primarily verbal discipline while being observed with Felize.
He most often tried reasoning with her. Mr. Rodriguez- Smith was fairly patient with
Felize. There were a few instances when he seemed to get frustrated, but he did not raise
his voice at Felize or make negative comments to her.
Mr. Rodriguez- Smith stated during interview that he first tries to reason with both his
son and his daughter. He then tries grounding or removing privileges. He states that
Felize is kept on the same schedule year round. When Felize is not in school during the
summer, she is in day care at a licensed facility. Occasionally, Mrs. Rodriguez- Smith's
mother will take Felize for a day trip to the zoo or swimming pool.
Parenting Values and Practice:
Mr. Rodriguez- Smith believes that children need consistency and structure. He stated
that he sees what lack of structure can do to young children when he is at work. Mr.
Rodriguez- Smith stated that, as a child, he was spanked occasionally. He stated that he
has mixed feelings about using corporal punishment. He does not believe that he was
abused as a child. However, he reported that his educational training made him
reconsider the spanking his own children. Mr.Rodriguez - Smith stated that he spanked
Sam on only one occasion that he can recall, and that Felize has never been spanked by
either him or Mrs. Rodriguez - Smith. Mr. Rodriguez - Smith stated that he preferred to
reason with his children and found consequences, such as removal of privileges, to be
very effective with both his children.
Mr. Rodriguez- Smith stated that he believes parents should be involved in their
children's lives. Whenever possible, Mrs. Rodriguez- Smith, or her mother, go with
Felize on field trips and the family regularly goes to parks or movies on the weekends.
Mr. Rodriguez- Smith reported that his parents liked Mrs. Rodriguez - Smith, and that
they always got along well. Mr. Rodriguez - Smith stated that he knew about the abuse
issues Mrs. Rodriguez- Smith remembered concerning her own father, Mr. Rodriguez.
He stated that he understood that his wife wanted Felize to know her grandfather, but did
not want Felize to be alone with Mrs. Rodriguez- Smith's father.
Mrs. Mary Rodriguez—Smith:
Family and background:
Mary Rodriguez grew up in the San Luis Valley of Colorado and moved to Denver with
her family when she was ten. Her parents were divorced when she was eleven.
Mrs. Rodriguez- Smith's family is Hispanic and predominately Catholic. Mrs.
Rodriguez- Smith's mother and her siblings are practicing Catholics and are very
involved in the church. Mrs. Rodriguez- Smith stated that she, her mother, and Felize go
to church regularly. Mrs. Rodriguez - Smith reported that Mr.Rodriguez - Smith and her
family get along well. Mrs. Rodriguez- Smith reports that she still has very strong
religious beliefs.
Mrs. Rodriguez- Smith related that her family has always been close, and spent a lot of
time together. However,she reported that she only sees her father approximately three
times a year. Mrs. Rodriguez- Smith stated that she is not particularly close to her father
since her mother and her father divorced when she was eleven. She reported
remembering her father hitting her mother and yelling. She stated that she remembers
hiding in the closet with some of her siblings on one occasion. She stated that she
doesn't remember much about her father and his relationship with her mother and
siblings. She said that she and Felize visit her father a few times during the year, usually
in the summer. She reported Felize and her father getting along well. Mrs. Rodriguez -
Smith stated that she wants her daughter to know her grandfather, but isn't comfortable
leaving the two alone, due to her memories of past physical abuse of her mother by her
father.
She is currently aday care provider at a preschool. This is her first marriage. She was
raised primarily by her mother after her parents were divorced when she about eleven
years old. She has four older siblings. According to Mrs.Rodriguez— Smith, her father
was physically abusive to her mother and she has had little contact with her father until
she was a teenager. According to Mrs. Rodriguez- Smith, she has a relatively good
relationship with her four siblings who live in the area. Although she recalls her father
being abusive to her mother, she is not aware that her father was ever physically abusive
to her or to her siblings.
She reports one previous serious relationship when she was in high school. She was
engaged for a while but broke off the engagement after her senior year in high school.
This is her first marriage.
Drug and Alcohol History/Mental Health:
She reports no history of involvement with drugs or alcohol, beyond a glass of wine or a
beer occasionally. She does believe that her father did have a serious drinking problem,
but is not aware that anyone else in the family has had a problem. She stated that she had
never smoked cigarettes.
Employment History:
She indicated that she worked part time as a Nurse's Aide after high school, and then
after completing some training, received a certificate to be a day care provider. She
worked full time as a day care providers for the Pencil Fence School in Greeley until she
was married and she has been working on a part-time basis in day care since that time.
Previous Experience with Foster Care/Beliefs About Adoption:
She is very much looking forward to the possibility of being an adoptive mother. She
very much loves her child, seven year old Felize and she and her husband have tried to
have more children. She has had two miscarriages in the last five years. They, due to
religious reasons, are not interested in using in vitro fertilization techniques for fertility
problems. Mrs. Rodriguez - Smith was very cooperative during the evaluation and is
very much looking forward to the possibility of being an adoptive parent. She has not
previously been a foster parent.
Adult General Functioning:
Mrs. Rodriguez - Smith appeared to be well organized and within normal expectations for
an adult her age. She, on assessment and observation, was fully oriented to person place
and time and exhibits a stable work history. She appears to be functioning within normal
ranges cognitively. Mrs. Rodriguez - Smith also exhibited some sadness and, at times,
seemed to have some mild depressive symptoms. Since she is from a large family, she
very much wants some additional children, and she is very sad that they have not been
able to have children on their own. She very much wants to adopt a child and hopes to
adopt other children in the future. Hobbies include reading and sewing, particularly
quilting.
She does have good work skills and interactions with people. Most of her interactions are
with young children as she works in a setting with extremely young children.
Parenting and Discipline Styles:
Interviewed independently, Mrs. Rodriguez Smith appears to share many of the values
expressed by her husband in regard to parenting and discipline style. In general, Mary has
stronger feelings against the use of corporal punishment than Fred and it appears that this
has been a topic of discussion concerning how to raise Felize. In a number of areas
related to discipline and child rearing Mary would often begin a sentence ... "Fred and I
have talked about that and we think....", indicating a joint style for planning and
implementing child care decisions
Observation of her with Felize reveals a very comfortable and warm relationship between
mother and child, with appropriate role behaviors for each.
Parenting Values and Practice:
Except in the area of religious life and the role religious life should play in child
development, Mary's value and belief systems appear to mirror her husbands. She has a
stronger conviction than Fred as to the role the church plays in the development of
character and moral behavior in a child. Fred feels these values arise from family and
from the parental examples the children see. However, he is not opposed to formal
religious training. As such, religious practice and training of Felize has become in this
family system consistent with Mary's views and this is not an area of debate between
Fred and Mary.
Children/Child Functioning:
Felize
Felize is a 7 year old girl who is currently in second grade. Felize was interviewed
individually at home and observed at school. During the observation, she seemed well
adjusted to her class. She participated in class activities, was outgoing, and interacted
appropriately with other children her age. Felize and her teacher reported that she gets
good grades and maintains a"B" average. Felize appears to have friends in her class and
she and her parents reported that she meets with and plays with some of her classmates
outside of school. Felize goes to her friend's birthday parties and is allowed to go over to
their houses to play on the weekends. Felize is also allowed to have friends over at their
house. Felize is not yet allowed to spend the night at her friend's houses. Felize also has
friends in her neighborhood that she plays with after school and on the weekends.
Felize reported a good relationship with her half-brother, Sam. She stated that Sam
would play with her and the other neighborhood children when he was with the family
for the weekend. Felize said that Sam had "stuck up" for her when an older
neighborhood kid told her she couldn't play with them. She reported that she liked
having an older brother and that she wanted to be a"big sister".
Felize reported during her interview that she loves her mom and dad. She reported that
she really liked playing with her cousins, and was excited about having a baby brother or
sister. Felize also reported enjoying the time she spent with Grandma—her maternal
grandmother. She said that she liked school and had a"best-friend" from school that she
spent time with on many weekends. Felize stated that she didn't get to see Mrs.
Rodriguez- Smith's father very much, but that he had always been"nice" to her.
Issues of sibling rivalry and adjustment based on similarity in age can be anticipated
between Felize and Tamara if Tamara is adopted into the family. However, these issues
are not expected to be difficult to resolve but should be understood by the parents, Felize
and Tamara through family discussion and additional help if needed.
Sam
A brief interview was conducted with Sam. He presented as a soft spoken and polite
young man who considers his mother his primary parent and who seems to enjoy being
with his father and his step mom and step sister. He is supportive of his father's desire to
adopt a child. He denies any history of involvement with legal authorities. He says he
gets primarily B's in school, and sometimes an A and sometimes a C. He likes science
but doesn't like math. He denies drug use but admits to a beer sometimes at a party with
his friends. He says that he has not been physically abused as a child. He is interested in
dating and is enjoying his driver's license, which he earned a few moths ago. When asked
about interactions with Felize he states that he likes to see her on weekends. He has
grown up as an only child and enjoys the role of being a big brother when he is at his
dad's home. He anticipates he would feel the same way toward the adopted child
He states that his father is strict but uses grounding when he is at his dad's home as a
means of punishment. This hasn't happened much since he became a teen as he only
spends a few days a month with dad and he realizes it is easier to"get along" for this
time, because the parent who he's responsible to for most of the month is his mom.
Family System/Family Support Network
During the observation the family appeared to relate well to each other. Mother and
father were able to coordinate their time and energy, and were able to adequately
supervise and interact with both Sam and Felize. Both Mr. and Mrs. Rodriguez- Smith
interacted with each of the children. Mrs. Rodriguez- Smith and Sam appeared to relate
well to each other. Sam was willing, usually, to follow directions from either Mr. or Mrs.
Rodriguez— Smith, though he appeared somewhat bored occasionally. The parents were
able to communicate with the children in a positive way. Given Sam's age as a teen, his
behaviors appear to be within normal parameters for this type of observation.
The family appears well organized and appropriately structured. Extended family support
is present especially with a high level of involvement from the maternal aunts and
grandmother.
Adult Relationships Marriage:
Mr. and Mrs. Rodriguez - Smith reported ongoing issues with fertility after Felize was
born. Mrs. Rodriguez- Smith had a difficult pregnancy and had an emergency c-section.
After Felize was born, Mrs. Rodriguez- Smith became pregnant twice, and both times
miscarried. Mr. and Mrs. Rodriguez- Smith stated that they decided to try to adopt
children because the miscarriages seem to prevent them from having the large family
they desire. Both Mr. and Mrs. Rodriguez- Smith report that they realize adopting a
child is going to be a big adjustment for their family, but believe that they have the
resources to successfully make that transition.
Mr. and Mrs. Rodriguez- Smith appear to have a strong relationship. They may need
further training in communication and conflict resolution. They appear able to
successfully resolve conflict, however they do occasionally fight in front of the children.
Mr. and Mrs. Rodriguez- Smith both report strong extended family ties. Mr. and Mrs.
Rodriguez - Smith appear to be able to successfully and appropriately discipline their
children and both have training and expertise in childcare and development.
Demographics:
Parental age and education levels are appropriate to the adoption of a child of any age
without apparent issues. Mary and Fred both endorse a Christian upbringing, with a
practice of Catholicism primarily in the household at this time. Strong extended family
support is apparent particularly on the mother's side. Both parents are registered to vote.
Both possess valid driver's licenses. They own two vehicles, both of which are insured.
Income is reported in the medium to high medium range and appears stable. Background
checks revel no criminal history or sexual abuse history on either parent. Motor vehicle
records indicate an occasional parking ticket. One motor vehicle accident in a school
parking lot is noted for Fred, who apparently was hit by another car that was being
backed out into traffic.
Birth Family:
Both Mary and Fred exhibit a range of emotions regarding their opinions of families who
mistreat children or who need to have their children placed in Foster care or adoption.
They are generally empathetic that financial or economic problems can beset almost
anyone. They can understand how disability, or circumstance can create a need for foster
placement or that an unplanned pregnancy can create a need for adoption. They have a
harder time accepting that a child may be neglected or abused as a result of drug abuse
without this leading most of the time to an adoptive situation. They feel that when
physical or sexual abuse of a child is present, it is difficult to see these as a result of a
temporary or transient problem for the birth parents. The concept that these might be the
product of a treatable condition in the parental home or that one parent may be more fit
than another and obtain the children back from a foster to adopt home appeared to be
ones they had not considered. They seem much more willing to be involved in a
permanent placement than in a foster parent to adoption placement.
They recognize the need to convey to an adopted child positive images of the birth
parents. They believe the adopted child should be told they were adopted in an age
appropriate manner. How and what a child is told is dependent on the age and personality
of the child. If they were to adopt a child both Fred and Mary express discomfort at the
prospect of open and ongoing contact with the birth parents. They would like to know
information about the birth parents, especially medical history to appropriately help the
adoptive child. They express discomfort concerning an open adoption if the birth parents
will have future access to the child. If such contact were mandatory, they would want it at
their sole discretion.
Capacity of this family to deal with educational issues in childrearing is considered
superior to many other potential applicants based on education and work history.
Behaviors that are not acceptable were stated as drug use, bullying, and stealing or
purposeful destruction of property.
Foster/Adoptive Family Preparation:
This family is well prepared for permanent adoptive placement, but need further training
if they will be in a foster care to adopt scenario. They are not interested in foster care for
the purposes of birth family reunification as their reason for adoption is family growth
and expansion.
They state they are open to training and intervention with the Department of Social
Services.
Obvious preparations for possible adoption have occurred. Felize is aware of the family
changes that will occur, i.e. where a new child will sleep, her role as a big sister and
seems appropriately excited for a child her age. Mary and Fred both recognize increased
time commitments needed for provision of care and services. Mary's time is more
flexible than Fred's in this regard.
Motivation/Commitment:
Motivation and commitment of this family for a permanent adoption placement is high.
Family leave is available to Fred. However, as he has a lighter load of work in the
summer, he hopes for a late spring placement to assist in the early months of the adoption
as the best time for his schedule. Mary has less constraint on the time of the adoption as
she has more flexibility in the intensity of her part time work. One issue of note is that
Fred and Mary will continue to try to have children and will continue to adopt other
children, as they both desire a large family.
Intervention: Both parents are open to intervention and suggestions for alternatives to
solve problems as evidenced by their interaction throughout this evaluation and by their
stated willingness to work as foster parents. However, they seem most highly motivated
to be permanent adoptive parents.
Resources to Support the Placement: The maternal grandparent's role in the family
provides potential emergency twenty four hour coverage. Both parents are willing to
work with community resources and WCDSS on an ongoing basis. Both parents agree to
take recommended training regarding the foster parent role and an adoption preparation
course.
Training: Described below in Conclusions/Recommendations
Conclusions/Recommendations:
1. The Smith-Rodriguez family is appropriate for permanent adoptive placement of
this child with special needs. As the child has special developmental needs a
course for both parents in parenting a child with special needs is recommended.
2. Brief consultation by the family with their minister is recommended to help
integrate the child into the home. Additional mental health resources if needed
should =be obtained by the family if the need becomes apparent
3. A plan for the likely needs of the adoptive child and needed parental actions that
can be foreseen related to developmental delays or issues of attachment should be
the basis of consultation with the caseworker over the first month or two of the
placement.
4. A few sessions of brief counseling with Felize to help her accept the addition to
her family are recommended.
5. Development of a plan for telling the child about birth parents at age appropriate
stages is appropriate.
6. Based on the extensive attachment needs that Tamara presents, Mary should be
prepared to spend at least one year full time in the home and work with the child's
therapist to met the transition needs of the adopted child.
7. Safety issues seem to be minimal. However, given Fred's hobby involves
firearms, any guns kept in the home will be maintained in a locked cabinet and
have safety locks installed. Fred will complete a certified gun safety course, if he
has not previously done so.
8. As to the characteristics of an adoptive child,Fred and Mary state no preference
for sex. While they prefer a child under age three and prefer a child of mixed
Anglo—Hispanic origin or of Hispanic origin, placement of Tamara in the
Smith's home appears to be appropriate and is recommended by the evaluators.
Respectfully submitted
Joyce Shohet Ackerman, Ed.D., Licensed Psychologist
Valerie Larson, M.S.W., Licensed Clinical Social Worker
{��wa
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4
12:01A.M.STANDARD TIME AT THE ADDRESS OF THE INSURED AS STATED HEREIN:
PEM 4. LIMITS OF LIABILITY: (a)$ EACH WRONGFUL ACT OR SERIES OF CONTINUOUS,REPEATED
1, 0 0 0, 0 0 0 OR INTERRELATED WRONGFUL ACTS OR OCCURRENCE
(b)$ 5, 000 DEFENSE REIMBURSEMENT
(0$ 3, OHO, 0 0 0 AGGREGATE
'EM 5. -PREMIUM SCHEDULE:
CLASSIFICATION NUMBER RATE ANNUAL PREMIUM
1ST PSYCHOLOGIST 1 1191 . 00 1, 191 . 00
DEFENSE LIMIT . 00
SURPLUS LINES TAX 1 35 . 73
INSPECTION FEE 1 2 .38
:M 6. RETROACTIVE DATE: 12/01/91
TOTAL PREMIUM: 1, 229 . 11
M 7- EXTENDED REPORTING PERIOD
ADDITIONAL PREMIUM(if exercised):$ 2 , 150 . 68 NO DISCOUNT INCLUDED
M 8. POLICY FORMS AND ENDORSEMENTS ATTACHED TO THIS POLICY
2138 (7/95 ED. ) B22137
PERSONAL- DATA SHEET
;_
Identifying Information:
Name: Laurence "Larry" P. Kerrigan, Ph. D.
Address :
1
DOB:
Phone : ness
•
Degrees :
BSC - Business Economics , from Creighton University, 1954 .
MS - Economics , from St. Louis University, St. Louis ,
Mo . , 1963 .
MA - Theology, from St. Mary' s University, Regis College
Campus , Toronto, Ontario , Canada, 1967 .
Ph. L. - Philosophy, St . Louis University, St . Louis , Mo. 1960 ,
( Ecciesial Degree ) .
Ph. D. - California School of Professional Psychology ,
Berkeley/Alameda Campus , 1974 , Clinical Psychology.
Currently a licensed psychologist in the state of Colorado.
Educational Background:
1950-54 Creighton University, Business economics ,
1954-56 Marquette University, Milwaukee , WI . , Classical studies
and ascetical theology,
1956-57 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 .
1975,88 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 year, Campion College .
1970-71
1972-73 Class Representative to Campus Executive Committee ,
and California School of Professional Psychology
1973-74 .
Work and Experiential Background :
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=c_it-y 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 .
Pukcati on :
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 , 19'l4 .
Worksho_lii LIDO Spec_i_al_Traiming: •
Since 1974 , I have attended an average of- about three workshops
per year. Most 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
Emotrana:l—and-Physfcat Ileal.th 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
FACULTY VITA
February 1998
NAME: BROMLEY, Susan Plock
SOCIAL SECURITY NUMBER: 483-50-9243
POSITION: Associate Professor of Psychology
Department of Psychology
College of Arts and Sciences
University of Northern Colorado
Greeley,CO 80639
HOME ADDRESS:
TELEPHONE: Mee: (303)351-2236
Home: (303)352-8750
ElvIAIL:sbromley@bentleymico.edu
EDUCATION:
Years). Degree Institution Area of Study
1983 PsyD 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 Economics/Sociology
Smith Hadley,Massachusetts
WORK EXPERIENCE—Professional Academic:
Year(sl Institution/Organization Position Responsibilities
1985-Pres University of Northern Colorado Assoc.Professor Psychology Teaching/Advising
1983-84 University of Northern Colorado Asst. Professor Psychology Contract Teaching
WORK EXPERIENCE—Professional Non Academic:
Year(s) Institution/Organization Position Responsibilities
1996-present Ackerman and Associates Psychologist Clinical
1984-85 Kaiser Permanente Psychotherapist Clinical
Lakewood, Colorado
0
1979-80 Bethesda Mental Health Center Psychology Intern Clinical/
Denver,Colorado Administrative
1968-79 Denver General Hospital Clinical Social Worker/ Clinical/
Denver,Colorado Supervisor Administrative
1
AREA OF SPECIALIZATION:
Behavioral Medicine/Pain Management/Clinical Hypnosis
RESEARCH AREAS/INTERESTS:
Hypnosis/Pain Assessment and Management/Women's Issues/Teaching Methods
PROFESSIONAL ACTIVITIES:
Colorado Licensure: Psychology License#1086
PUBLICATIONS--Prgfessional/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. (19%).Differences in caregivers of demented and lucid chronically ill family
members. Journal of Alzheimer's Disease and Related Disorders and Research
Retzlaff,P. and Bromley, S. (1994). Counseling personality disorders.In Ronch,J.L.,VanOmum,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(21,pp. 299-309.
Bromley, S.P. (1985). "Treatment of Pain:Theory and Research" in Zahourek,R. (Ed.).clinical Hypnosis and
Therapeutic Suggestion. New York: Grime and Stratton. Reprinted in Zahourek,R. (Ed.)(1990). New
York:Bruner/Mazel,Inc.,pp. 77-98..
PROFESSIONAL PRESENTATIONS--Juried:
Bromley, S. (1997)(Chair)"Linking through honors programs: The cross-discipline course).Paper presentation as
part of a symposiumtitled"-Creatinglinks 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 caregiver 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 faciliate research understanding". Paper presentation as part
of panel titled, `Teaching techniques in the social sciences", Western Social Science Association Convention,
Denver, Colorado. (April)
2
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 nondementia
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). "Huchands 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:
Handelsman, M.M.,Bromley, S.P. &Davis, S.F. (1995)."Clinical Psychologist, Counseling Psychologist,Clinical
Social Workder,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-Char),-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)
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. Western Psychological Association/Rocky Mountain Psychological Association
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).
3
Bromley, S. (1992)."Enhancement of student research and wilting 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". Presentor-20th Annual Emotional Crisis Workshop,
University of Northern Colorado, Greeley,Colorado(July).
J.RCTI MPS—Invited'
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 Acadmic 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 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 Ffi,ration(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 aeine. 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
4
PROFESSIONAL ASSOCIATION PARTICIPATION:
Membership
1986-present Rocky Mountain Psychological Association
1988-present American Psychological Association(Divisions 2, 30,35)
1989-present 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-present 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:
1989-present Rocky Mountain Psychology Association
1992-present Board Member
1995-present 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:
1997-1998 UNC Loaned Executive-United Way of Weld County
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-Present 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:
1985-88,
1995-presnt Co-Advisor Psi Chi National Honor Society
1989-91,93,
95-present 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
5
BRANCH WA PRODUCER NUMBER ' DATE OF ISSUE - -PRIOR CERTIFICATE NUMBER
23 A 0004087 . 04/07/2003 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
kern DECLARATIONS CERTIFICATE NUMBER:45P- 2050203
1. Named Insured SUSANPLOCKBROMLEY
ADDRESS
Number&Street,Town,County,State&Zip No.)
2. Policy Period: 12:01 A.M.Standard lime At From: To:
Location of Designated Premises 04/01/2003 04/01/2004
3. COVERAGE LIMITS OF LIABILITY PREMIUM
Professional Liability $ 1,000,000 each incident I $3,000.000 aggregate $ 859.00
4. BUSINESS OF THE INSURED: PSYCHOLOGY
5. The Named Insured is: X Sole Proprietor(Including independent contractors) _ 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
I
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-8036(09/97),PLE-2167(07/00),POE-8004(05/88)(Ed.
90/93),PLE-2081 Current,PON-2003(08/02)
CHICAGO INSURANCE COMPANY
55 E. MONROE STREET, CHICAGO, ILLINOIS 60603
Near North Insurance Brokerage
REPRESENTATIVE: Agent or broker. In Association with Trust Risk Management Services
Mi
Office address: 875Ste 1N900 chiganAve
City, State, Zip: Chicago,IL 60611-1803
Toll-Free Number. 1.877.637-9700
PLP-2012(06/93) APA-
JOYCE SHOHET ACKERMAN, Ed.D.
1750 25th Avenue,Suite 101
Greeley, Colorado 80634
RESUME
PERSONAL DATA
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 Ansis Between Hispanics and Anglos. Published Doctor
Dissertation, University of North Colorado. Copyright 1981.
BRANCH B/A PRODUCER NUMBER DA7EOF ISSUE..:;. � - - PRIOR CERTIFICATE NUMBER
23 A 0004087 04/01/2003 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 05/01/2003 05/01/2004
3. COVERAGE LIMITS OF LIABILITY PREMIUM
Professional Liability $ 1,000,000 each incident I $3,000,000 aggregate $ 1,667.00
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), PU-2008(Rev. 10/94),, PLE-8035(09/97),PLE-8036(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
Near North Insurance Brokerage
REPRESENTATIVE: Agent or broker: in Association with Trust Risk Management Services
Office address: 875 N Michigan Ave
Ste 1900
City, State, Zip: Chicago, IL 60611-1803
Toll-Free Number: 1-877-637-9700
PLP-2012(06/93) APA-
Valerie Larson
PROFESSIONAL LICENSE
License Clinical Social Work, Colorado,License#992608
EDUCATION
Completed Post-Graduate Family Therapy Coursework,Family Therapy Training Center
of Colorado,Denver, Colorado,June, 1999
Masters in Social Work,University of Denver,Denver, Colorado,June, 1998
Bachelors in Social Work,Northeastern State University, Tahlequah, Oklahoma,
December, 1995
PROFESSIONAL EXPERIENCE
Shiloh Home Littleton,Colorado
Therapist June, 1999—March, 2001
) • Conducted individual, group,and family therapy for day treatment and residential
x youth ranging from age eight to eighteen. Addressed various treatment issues
including sexual perpetration, delinquency, sexual victimization,abuse/neglect,
substance abuse, anger management, grief/loss, attachment, and depression.
• Completed appropriate documentation and ease management duties. These
included completing monthly progress reports, performing psychosocial
assessments,and attending court hearings and staffmgs.
• Conducted trainings for on-line milieu staff and provided clinical advisement for
multi-disciplinary teams.
Progressive Therapy Systems Denver,Colorado
M.S.W. Student Internship June, 1997-June, 1998
Therapist June, 1998 -June, 1999
• Provided offense-specific treatment for adults and adolescents who had
committed sexual offenses. This treatment included group,individual, and family
therapy. Conducted educational groups for parents and spouses of the offenders.
• Provided individual and family therapy for children in foster care. Addressed
issues including enuresis, abandonment, anger management, and abuse/neglect.
• Facilitated anger management groups for men and women on parole for criminal
behaviors.
• Conducted intake assessments and developed appropriate treatment plans.
Account Number: CO LARV 2500 Date: 5/20/03 Initials: KEN
CERTIFICATE OF INSURANCE
AMERICAN HOME ASSURANCE CO.
C/0: American Professional Agency, Inc .
95 Broadway, Amityville, NY 11701
This is to certify that the insurance policies specified below have been issued by the company indicated
above to the insured named herein and that, subject to their provisions and conditions, such policies afford
the coverages indicated insofar as such coverages apply to the occupation or business of the Named insured(s)
as stated.
THIS CERTIFICATE OF INSURANCE NEITHER AFFIRMATIVELY NOR NEGATIVELY AMENDS, EXTENDS OR
ALTERS THE COVERAGE(S) AFFORDED BY THE POLICY(IES) LISTED ON THIS CERTIFICATE.
Name and Address of Insured: Additional Named Insureds:
VALERIE LARSON
Type of Work Covered: PROFESSIONAL SOCIAL WORKER
Location of Operations: N/A
(IS different than address listed above)
Claim History:
Policy Effective Expiration Limits of
Coverages Number Date Date Liability
PROFESSIONAL/ 1,000,000
LIABILITY SWL-0000000 6/01/03 6/01/04 3,000,000
NOTICE OF CANCELLATION WILL ONLY BE GIVEN TO THE FIRST NAMED INSURED ON THIS
POLICY AND HE OR SHE SHALL ACT ON BEHALF OF ALL INSUREDS WITH RESPECT TO GIVING
OR RECEIVING NOTICE OF CANCELLATION.
Comments:
This Certificate Issued to:
Name: VALERIE LARSON
2500 HAVEN COURT
Address:
EVANS, CO 80620
Au orized Representative
WILLIAM P.KELLY
EDUCATION
1997-MA-PROFESSIONAL COUNSELLING,UNIVERSITY OF NORTHERN COLORADO
1977-PhD:EDUCATIONAL ADMINISTRATION,UNIVERSITY OF COLORADO
1964-MA-SECONDARY EDUCATION,ST.LOUIS UNIVERSITY
1954-BS-MATHEMATICS,CREIGHTON UNIVERSITY
SCHOOL EXPERIENCE
UNIVERSITY-
2002-2003- Adjunct Professor,Regis University,Denver,CO
1999-Professor Emeritus,Regis University,Denver,CO
1983-1999-Chair,Professor of Education,Regis University,Denver,CO
1978-1983-Assistant Professor,Elementary and Secondary Education,University of Minnesota-Morris
1970-1973-Assistant Professor,Education Department,Regis University,Denver,CO
SECONDARY
2001-2002-Teacher,Mathematics and Speech,Holy Family High School,Broomfield,CO
1974-77—F.in ipal Greeley West high school,Greeley,CO.
1973-1974-Associate Principal,Longmont high school,Longmont,CO.
1966-67,68-70 Teacher/Administrator/Coach In Denver Catholic High Schools-
1960-1963 Teacher/Coach Marquette University High School,lvfilwaukee,WL
COUNSELING EXPERIENCE
1999-Green Villa Residential Treatment Center-A Combination Half-Way House and Drug Treatment
Center for Convicted Felons with Drug Abuse Problems-Paid Intern,Greenville,Texas
1998-99- Hunt County Mental Health/Mental Retardation-General Counseling for Children,Adolescents,
Adults, Families,and Various Groups-Internship-Greenville,Texas
1995-96 Jefferson Center for Mental Health(South Office)General Counseling for Children,
Adolescents, Adults,Families,and Various Groups-Intern
INDUSTRY EXPERIENCE
1967-1968- Performance Standards Administrator,CIMA,International Trade Association, Milwaukee,
WI
1963-1966-Sales Representative,Denver Area Territory,Hoffmann-LaRoche Pharmaceutical Co.,
Nutley,N.J.
LICENSES HELD(Current)
Elementary School(K-8)Teaching License,State of Colorado
Secondary(7-12)Mathematics and Science Teaching License, State of Colorado
HOBBIES
Playing Piano,Racquetball,Bicycling,Hiking,Reading,Swimming
REFERENCES
Dr.Daniel Clayton,Associate Professor of History and former Associate Academic Dean,Regis
University,3333 Regis Blvd.,Denver CO,80221 303-458-4914
Mr.James Neuman,MSW-LSW,Private Psychotherapist,Supervisor of My Practice, 10110 W.26 Ave.,
Paramount Bldg.,Wheat Ridge CO 303-233-9371
Dr. Allan Service,Provost,Regis University, 3333 W. Regis Blvd,Denver,CO 80221,303-458-1843
CNA Healthcare Providers Service u7�
Organization Purchasing Group ®HPSQ
CNA Plaza, .h �, umsca,.hoiden s, ,.;,.u.:..e.•
Chicago,IL 60685
ertt tca a x e : x to
Producer Branch Prefix Policy Number Policy Period
from: 12:01 AM Standard Time on: 07/04/03
018098 970 HPG 273003448-8 to 12.01 AM Standard Time on: 07/04J94_
Named Insured and Address Program Administrator _
Healthcare Providers Service Organization
WILLIAM P KELLY 159 East County Line Road
11429 W BURGUNDY AVE Hatboro, PA 19040-1218
LITTLETON CO 80127-5870 ---
Medical Specialty: Code: Insurance Provided by
Clinical Counselor 72990 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
B. Coverage Extensions
License Protection $5,000.00 per proceeding $12,500.00 aggregate
Defendant Expense Benefit $5,000.00 aggregate
Deposition Representation $1,250.00 per deposition $2,500.00 aggregate
Assault $5,000.00 per incident $12,500.00 aggregate
Medical Payments $1,000.00 per person $50,000.00 aggregate
First Aid $1,250.00 aggregate
Damage to Property of Others $250.00 per incident $5,000.00 aggregate
C. WORKPLACE LIABILITY Coverage part C. does not apply if Coverage part D. is made part of this policy.
Workplace Liability Included in A. Professional Liability Limit shown above
Fire_and Water_Le_gal_ Liability_ -__ Included above subject to $150,000 sub-limit
Personal Liability $500,000.00 aaareaate
D. GENERAL LIABILITY Coverage part D. does not apply if Coverage part C. is made part of this policy.
Workplace Liability None None
Hired Auto & Non Owned Auto None
Fire & Water Legal Liability None None
Personal Liability � None
Total Premium $250.00
Policy forms and endorsements attached at inception QUESTIONS? CALL: 1-800-982-9491
G-144872-A G-144959-A G-121500C G-121501C G-123846C-05 G-121503C
G-121489—ACA
Healthcare Providem%erinee Organization s idii'ision of Affinity Insurance Services,Inc.;in NY and NN,AIS Affinity Insurance Agency;m MN and OK,AIS Affinity Insurance
Agency,Inc.;and ill CA.AIS Affinity Insurance Agency.Inc.dba Aon Direct Insurance Administrators License#0795765.
Master Policy: 188711433
Keep this document in a safe place. This and
� ' t ---- your cancelled check act as proof of coverage.
Chairman of the Board Secretary
EMILY L.JARAMILLO, M.A. -
•
EDUCATION '
1996,Master of Arts,Agency Counseling
iversityof Northern Colorado,Greeley,,UnColorado ,
1993, Graduate Fellowship Study,Criminology
Rutgers State University, Newark,New Jersey- .
1988,.B•achelor of Arts, Sociology/Crinunal Justice,with emphasis to Psychology
University of Northern Colorado, Greeley, Colorado
PROFESSIONAL EXPERIENCE .
1998-Present..Psychotherapist,Ackerman F 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 work§hops.'"Provide
foster parent consultation. Practice is supervised by Sherri Malloy, PhD., Licensed
Clinical Psychologist.
199¢'1999 Director,McNair Scholars Program, University'of Northern Colorado, Greeley,,CO. - .
Provideed•counseling,guidance,and academic'advising to students wlro 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 arid'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 advisng to students who'were low-
incorne,-first generation, and of a minority group. Identified critical personal, familial,
cultural; academic,and financial issues to aid inthe 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 EDUC.ATION/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 HispPanic Scholarship Fund
Scholarship, Candelaria 5Cliwarship
.,ti
MEMO OF' S, CIE Date Issued
10/14/2003
Memorandum Holder This memorandum is issued as a matter
of information only and confers no
ACKERMAN & ASSOCIATES rights upon the holder. This
SUITE 101 memorandum does not amend, extend
1750 25 AVENUE yr alter the coverages afforded by the
GREELEY CO 80634 Certificate listed below.
Producer Company Affording Coverage
Chicago Insurance Company
Seabury & Smith Owner
—"1276-West Fakes Parkway -Covered Person"(Status)
West Des Moines, Iowa 50398 EMILY L 7ARAMILLO-BANSBERG MA LPC x
Employee
This is to certify that the Certificate listed below has been issued to the insured named herein for the policy
period indicated, notwithstanding any requirement, term or condition of any,cpntract or other document with
respect to which this memorandum may be issued or may pertain, the insurance afforded by the Certificate
describedhecein_issnbjectso_altthe terms, exclusions and cnnditionsof-such_Certificate. The limits-shown.----
may have been reduced by paid claims.
Certificate
Type of Insurance Number Effective Date Expiration Date Limits
each incident 1,000,000
Professional Liability or occurrence
Occurrence 80M-4003488 11/01/2003 11/01/2004 3,000,000
in the aggregate
each incident
General Liability or occurrence
Occurrence
in the aggregate
Should the above described Certificate be canceled Insured
before the expiration date thereof, •the issuing
company will endeavor to mail written notice to the
named Memorandum Holder, but failure to mail such EMILY L 7ARAMILLO-BANSBERG MA LPC
notice shall impose no obligation or liabilty of any 183 50 AVENUE PLACE
kind upon the company, its agents or representatives. GREELEY CO 80634
Authorized Representative:
.4! .a-v• a
John M. Gray
Education Master of Arts: Professional Psychology,
emphasis: Agency Counseling,
University of Northern Colorado, Greeley, Colorado
Graduation: August 1995
Nationally Certified Counselor,NBCC February 1996
Licensed Professional Counselor
Master of Arts: Sociology,Emphasis: Social Psychology
University of Northern Colorado, Greeley, Colorado
Graduation: December 1992
Bachelor of Arts: Sociology/Philosophy
Minot State University,Minot,North Dakota
Graduation: May 1989
Counseling Case Manager II: Larimer Department of
Human Services,Fort Collins,CO
. Adolescent Response Team member
00
. Conduct emergency intakes/investigations involving
parent/child conflicts,child abuse, sexual assault, and children
out of control of their parents.
• . Track,triage, and monitor clients
treatment.
. Facilitate and recommend treatment.
options.
. Establish and maintain good working
relationships between and among various
agencies, such as: schools, courts,police, •
and mental health agencies.
Psychotherapist: Private Practice
Fort Collins,CO
. Family Therapy
. Couples
. Individual
• EMDR Level II
Supervisor: CORE services
Center for Mental Health
Fort Collins,CO December 2002-August
2002
. Supervise CORE therapy team
Facilitate supervision and thereaputic sessions
Attend and contribute to the goals of Management Team
. Conduct Individual and Family therapy
Supervisor: Multi-Systemic
Therapy Team February 2002-August 2002
. Supervise MST team
. Monitor compliance to MST model
. Receive supervision from MST
consultant
Psychotherapist: Private Practice
Montrose,CO November 2000-December
2002
. Family Therapy
. Couples
. Individual/Group Therapy
. EMDR Level II for Trauma,Depression,
Addictions,Anxiety
Program Coordinator: Multi-Systemic Therapy Program Center
for Mental Health,Montrose, CO June 1999-June 2000
Supervise Therapy Team
. Ensure compliance with MST principles
and methods
. Conduct supervision sessions individually
and in groups
. Report to home office in South Carolina
. Report to in-house administration results
and status of program
. Responsible for hiring and terminations of
personnel in program
Mental Health Therapist: Outpatient
Therapist Center for Mental Health,
Montrose, CO 1997-1999
Mental Health Therapist: Family
Preservation Team
Weld Mental Health,Greeley,Colorado
1995-1996
. Conduct family therapy in various settings
. Conduct individual/group therapy
. Coordinate Mental Health groups
. Report progress oral and written
Facilitate cooperative working
environment between
systems involving families
Mental Health Therapist: Acute Treatment
Unit Weld Mental Health,Greeley,Colorado
1994-1995
. Conduct individual/group therapy
. Supervise clinical staff
. Facilitate professional growth among staff
. Maintain clinical integrity of ATU
. Conduct emergency room evaluations
. Report progress of clients and performance
of staff oral and written
Mental Health Therapist: Heath Junior High
Greeley, Colorado 1995-1996
. Facilitate anger management groups for
the retention of at-risk youth
. Coordinate needs of school with needs of
at-risk youth
in facilitation of groups
Extem: Psych-care, Greeley,Colorado 1995
. Co-facilitate group therapy sessions in a
clinical setting
. Coordinate direction of group in
conjunction with psychiatrist, director,
and all members of therapy team
Clinical Care Assistant: Acute Treatment
Unit, Weld Mental Health, Greeley,
Colorado 1993-1994
. Assist MHT in leading groups
. Operate emergency mental health hotline
. Participate in in-house professional growth
training
Teaching Instructor: Mesa State College
Experience Montrose, CO 1997-2002
Taught Classes in:
. Social Psychology
. Social Problems
. Marriage and Family
Introduction to Sociology
Teacher/Director,G&B Academy, Seoul,
Korea 1996
. develop curriculum for new ESL program
. train and advise ESL teachers
. coordinate programs for
parents/teachers/children
University of Northern Colorado, Greeley,
Colorado
Instructor 1990-1993
Courses taught:
. Sociology of Minorities
. Introduction to Sociology
Aims Community College,
Greeley/Loveland,Colorado
Instructor 1990-1993
____ Courses Taught:
. Sociology of Minorities
. Introduction to Sociology
. Sociology of Education
Minot High School,
Minot,North Dakota
Coach—wrestling
1985-87
Presentations "The use of the Looking Glass Self in
Therapy," presented
At the Conference for Applied Sociology.
October 1998
"Bill McCartney and the Promise Keepers:
Exploring Connections Among Sport,
Masculinity,and Christianity."Presented at
American Alliance of Health,
Physical Education,Recreation, and Dance.
National convention. 1995
"Social Attachment and Deviant Behavior."
Presented at Western Social Science Conference. Regional
Conference. 1994
"Mountain Biking as Counter-Culture."
Presented at North American Society for the
Sociology of Sport. International
Conference. 1992
01/18%04 FRI 10:25 FAX 515 243 5180 SEABIJRY & SMITH 0002
^mac $ G " 4 tr:” x4 a r
- ',c�' u.� Y .„.44 m h, ,' , i .r r : Date Issued
aca' Car; " r 01/15/2004
Insured This memorandum is issued as a matter
JO H GRAY of information only and confers no
230 N wCRAY i3
rights upon the holder. This
FORTHCOLLINSCO CO 80524 memorandum does not amend, extend
or alter the coverages afforded by the
Certificate listed below.
Producer Company Affording Coverage
Chicago Insurance Company
Seabury & Smith
1776 West Lakes Parkway Covered Person (Status) X"C1
West Des Moines, Iowa 50398
JOHN II GRAY Employee
This is to certify that the Certificate listed below has been issued to the insured named herein for the policy
period indicated, notwithstanding any requirement, term or condition of any contract or other document with
respect to which this memorandum may be issued or may pertain, the insurance afforded by the Certificate
described herein is subject to all the terms, exclusions and conditions of such Certificate. The limits shown
may have been reduced by paid claims.
Certificate
Type of Insurance Number Effective Date Expiration Date Limits
Professional Liability
each incident
or occurrence $1,000,000
Occurrence 808-4005346 12/01/2003 12/01/2004
in the aggregate $3,000,000
3eneral Liability each incident
or occurrence
Occurrence
in the aggregate
Memorandum Holder
dhorized Representative:
SUPPLEMENTAL NARRATIVE TO RFP: EXHIBIT B
RECOMMENDATIONS
x CONDITIONS
04/13/2004 12:21 ''3/0:15:44:3/4 NUKtKMMN5 rtut uziut
•
Ackerman and Associates, P.C.
1750 25th Avenue, Suite 1O1
Greeley, Colorado 8O634
(970)353-3373
fax(97O)353-3374
April 12, 2004
Gloria Romansik
Weld County Department of Social Services
P.O. Box A
Greeley, Colorado 80632
Dear Gloria;
This is in response to your letter of April 7 concerning the results of the bid process for fiscal
year 2004-2005.
We accept the inclusion of all of our bids on the vendor list with the following conditions as
recommended by the Family and Youth Commission.
1. On RFP 006-00, the caseworker will select the contractor for the home study or
relinquishment counseling service.
2. We will notify the department if we have any changes in staff at the time of the change.
3. We will plan to have the following bids included on the vendor list with no additional
recommendations: RFP 04007 (Sex Abuse Treatment), RFP 04008 (Mediation and
Facilitation under Intensive Family Therapy), RFP 04010 (Option B/Home-Based), RFP
04005 (Lifeskills), and RFP 006-00(Foster Parent Consultation).
Thank you very much.
Respectftill ,
Joyce Shohet c erman, Ed.D.
Licensed Psychologist
President, Ackerman and Associates, P.C.
DEPARTMENT OF SOCIAL SERVICES
P.O.BOX A
GREELEY,CO. 80632
' Webslte:www.co.weld co vs
Administration and Public Assistance(970)352-1551
Child Support(970)352.6933
C
COLORADO ' April 7,2004 •
Joyce Ackerman Ed.D.
Ackerman&Associates,P.C.
1750 25th Avenue, Suite 101
Greeley,CO 80631
•
Re: RFP 04007-Sex Abuse Treatment
RFP 04008-Mediation and Facilitation under the Intensive Family Therapy Program Area
RFP 04010-Option B,Home Based Therapy
RFP 04005-Lifeskills
RFP 006-00-Foster Parent Consultation
RFP 006-00 Home Study,Relinquishment Counseling
RFP 006-00 Mental Health Services
Dear Ms.Ackerman:
The purpose of this letter is to outline the results of the Bid process for PY 2004-2005 and to request
written information or confirmation from you by Wednesday,April 14,2004.
A. Results of the Bid Process for PY 2004-2005
1. The Families,Youth and Children(FYC)Commission recommended approval of the bids
listed below for inclusion on our vendor list with no recommendations.
1. RFP 04007-Sex Abuse Treatment
2. RFP 04008-Mediation and Facilitation under Intensive Family Therapy
3. RFP 04010-Option B,Home Based
4. RFP 04005-Lifeskills
5. RFP 006-00-Foster Parent Consultation
2. The Families,Youth and Children(FYC)Commission recommended approval of the bid,
RFP 006-00,Home Studies and Relinquishment Counseling,for inclusion on our vendor list,
attaching the condition listed below.
Condition: The caseworker will select the contractor for the home study, or relinquishment
counseling service.
3. The Families,Youth and Children(FYC) Commission did not recommend approval of Bid
Number 006-00,Mental Health Services.
Page 2
Ackerman&Associates,P.C./Results of Bid Process for PY 2004-2005
B. The Families,Youth,and Children Commission recommended the following condition be
applied to all 2004-2005 approved providers.
The condition is: the provider will notify the Department of any change in staff at the time of the
change.
C. Required Response by FYC Bidders Concerning FYC Commission Conditions:
All conditions will be incorporated as part of your RFP Bid and Notification of Financial
Assistance Award(NOFAA).If you do not accept the condition(s),you will not be authorized as
a vendor unless the FYC Commission and the Weld County Department of Social Services accept
your mitigating circumstances.If you do not accept the condition,you must provide in writing
reasons why.A meeting will be arranged to discuss your response.Your response to the above
conditions will be incorporated in the RFP Bid and Notification of Financial Assistance Award.
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 14,2004,'close of business.
If you have questions concerning the above,please call Gloria Romansik, 970.352.1551,extension 6230.
Sincerely,
J A. ego, recto
cc: Juan Lopez,Chair,FYC Commission
Gloria Romansik, Social Services Administrator
Hello