The URL can be used to link to this page

Browse Search

Home My WebLink About20041629.tiff RESOLUTION RE: APPROVE TWO NOTIFICATION OF FINANCIAL ASSISTANCE AWARDS WITH VARIOUS PROVIDERS FOR MEDIATION AND FACILITATION UNDER THE INTENSIVE FAMILY THERAPY PROGRAM 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 two Notification of Financial Assistance Awards for Mediation and Facilitation under the Intensive Family Therapy Program 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 award: 1) Ackerman and Associates, P.C. 2) Mediation Communication Training, Inc., 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 two Notification of Financial Assistance Awards for Mediation and Facilitation under the Intensive Family Therapy Program 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. 2004-1629 SS0031 TWO NOTIFICATION OF FINANCIAL ASSISTANCE AWARDS FOR MEDICATION AND FACILITATION UNDER THE INTENSIVE FAMILY THERAPY PROGRAM 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 tuns June 1, 2004. onsta,„,4, BOARD OF COUNTY COMMISSIONERS I \ I . /,\ WE \\DIl COUNTY, COLORADO iatfk "Ierk / /S ti �\ n b. U V �.1/-�- .,,+„�.� Robert D. Masden, Chair to the Board ,� � William H, erke Pro-Tern . � I eputy Clerk to the Board M. J. eile OV AST David E Long ounty Atto ey Glenn Vaad Date of signature: aR 49y 2004-1629 SS0031 (it a DEPARTMENT OF SOCIAL SERVICES P.O. BOX A GREELEY,CO. 80632 I Website:www.co.weld.co.us Administration and Public Assistance(970)352-1551 OChild Support(970)352-6933 COLORADO MEMORANDUM TO: Robert D. Masden, Chair Date: June 14, 2004 Board of County Commissioners J / £2 FR: Judy A. Griego,Director, Social Services,/ c(,Gh(,, 0691% i RE: Notification of Financial Assistance Awar for Intensive Family Therapy with Various Providers Enclosed for Board approval are Notification of Financial Assistance Awards (NOFAAs) for Intensive Family Therapy between the Weld County Department of Social Services and various providers. The NOFAAs are based upon the provider's Request for Proposal, which has been reviewed and approved by the Families, Youth and Children (FYC) Commission. The NOFAAs were reviewed at the Board's Work Session of 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 Core Services funding according to the NOFAA and their respective bid proposal for Intensive Family Therapy. These services are for children,youth, and families receiving child welfare services. Generally, Intensive Family Therapy provides for therapeutic intervention typically with all family members to improve family communication, functioning, and relationships. 3. Providers will be reimbursed according to various rates as provided below: Vendor Name Rate A. Ackerman and Associates P.C. $80.00 per hour B. Mediation Communication Training,Inc. $150.60 per hour If you have any questions,please contact me at extension 6510. • 2004-1629 Weld County Department of Social Services Notification of Financial Assistance Award for Families,Youth and Children Commission(Core)Funds Type of Action Contract Award No. X Initial Award FY04-PAC-4000 Revision (RFP-FYC-04008) Contract Award Period Name and Address of Contractor Beginning 06/01/2004 and Ackerman and Associates P.C. Ending 05/31/2005 Mediation&Facilitation under Intensive Family Therapy 1750 25th Avenue, Suite 101 Greeley, CO 80634 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Assistance Award is based upon your Request for This program offers(1)assistance to WCDSS in Proposal (RFP). The RFP specifies the scope of identification of extended family for family services and conditions of award. Except where it is planning meetings; (2)mediation services up to in conflict with this NOFAA in which case the a five-hour model; and(3)goal achievement NOFAA governs, the RFP upon which this award is program up to a five-hour model. Maximum based is an integral part of the action. capacity is 10 families per month, average stay in program is 5 hours. Bilingual/bicultural Special conditions services. 1) Reimbursement for the Unit of Services will be based Cost Per Unit of Service on an hourly rate per household,per therapist. 2) The designated rate will be paid for only direct face to Hourly Rate Per $ 80.00 face contact with the child and/or family as evidenced Unit of Service Based on Approved Plan by client-signed verification form and as specified in the unit of cost computation. Enclosures: 3) Unit of service costs cannot exceed the designate rate and yearly cost per child and/or family. X Signed RFP:Exhibit A 4) Payment will only be remitted on cases open with, X Supplemental Narrative to RFP: Exhibit B and referrals made by the Weld County Department Recommendation(s) of Social Services. X Conditions of Approval 5) Requests for payment must be an original submitted to the Weld County Department of Social Services by the end of the 25th calendar day following the end of the month of service. The provider must submit requests for payment on forms approved by Weld County Department of Social Services. 6) The Contractor will notify the Department of any change in staff at the time of the change. Approval : Program Official: BY1 BYE Robert D.Masden, Chair Jud ��' o, Dir for 1 t Board of Weld County Commissioners Wel County Department of Social Services Date: JUN 1 6 2004 Date: e)i z s�� ,. 1 SIGNED RFP-EXHIBIT A • S INVITATION TO BID OFF-SYSTEM BID B001-04 (04005- 04011 AND 006-00) DATE: February 11, 2004 BID NO: RFP-FYC-04008 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-04008) for:Colorado Family Preservation Act--Intensive Family Mediation and Facilitation under the Intensive Family Therapy Program Area—Emergency Assistance Program Deadline: March 7, 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 under the Colorado Family Preservation Act(C.R.S. 26-5.5- 101) and Emergency Assistance for Families with Children at Imminent Risk of Out-of-Home Placement Act (C.R.S. 26-5.3-101). The Families,Youth, and Children Commission wishes to approve services targeted to run from June 1, 2004, through May 31, 2005, at specific rates for different types of service, the County will authorize approved vendors and rates for services only. The Intensive Family Mediation and Facilitation program under the Intensive Family Therapy Program area must provide for therapeutic intervention through one or more qualified family therapists, typically with all family members, to improve family communication, function, and relationships. This program announcement consists of five parts, as follows: PART A...Administrative Information PART D...Bidder Response Format PART B...Background, Overview and Goals PART E...Bid Evaluation Process PART C...Statement of Work Delivery Date fna I ch 4 , 2 OO I cJ oyue Non IP (After receipt of order) BID MUST BE SIGNED IN INK --"& ee f\C6tfincan,kdp TYPED OR PRINTED SIGNATURE VENDOR (NCU 1Y\OA end NCA IC' (Name) Han wn en Signature By Authorized (� Officer or Agent of Vender ADDRESS 11t° rF h i `Ue . TITLE C '�� ‘\e_. 1O \ CaC (ZSHke4k F �� 1 DATE 3 PHONE# 4)0 The above bid is subject to Terms and Conditions as attached hereto and incorporated. Page 1 of 32 ' Off-System Bid B001-04 (RFP-FYC-04008) Attached A INTENSIVE FAMILY THERAPY MEDIATION/FACILITATION PROGRAM BID PROPOSAL AND REQUEST FOR CONTINUATION OF AWARD UNDER CORE SERVICES FUNDING EMERGENCY ASSISTANCE PROGRAM 2004-2005 BID PROPOSAL APPLICATION PROGRAM FUNDS YEAR 2004-2005 OFF-SYSTEM BID B001-04 (04008) NAME OF AGENCY: Awit-pncan catnot AS&pCICS7eS1 ADDRESS: IhJy 0 cr ,5'-h iNvQ- nUe GCe\e1/43 PHONE: Z 35' CONTACT PERSON: SC.cjce Pt-CA lltv't M n n 1 ---. 6‘.1) . TITLE: Pt 0 Si tit,-11t DESCRIPTION OF EMERGENCY ASSISTANCE PROGRAM CATEGORY: The Mediation/Facilitation Program must provide for solution-focused therapy through one or more qualified therapists,typically with all family members,to resolve conflicts and disagreements within the family contributing to child maltreatment,running away,and to the behavior constituting status offenses. 12-Month approximate Project Dates: _ 12-month contract with actual time lines of: Start June 1,2004 Start End May 31,2005 End TITLE OF PROJECT: ern n 1\ \ e e`nt ti th nk\ ri' c'n/ AMOUNT REQUESTED: 1, u s,QC(; �c\kOM• �a�`nn LLcv mn n ``e, Cb. eQ ;2 -3 -- O�t Name and ignattire of Person Preparing Document e 1� Date N�C&iQe U"- tctr) ��(:4- Name and Si ture Chief Administrative Officer Applicant Agency Date MANDATORY PROPOSAL REOUIREMENTS For both new bids and renewal bids,please initial to indicate that the following required sections are included in this Proposal for Bid. For renewal bids,please indicate which of the required sections have not changed from Program Fund Year 2003- 2004 to Program Fund Year 2004-2005. Indicate No Change from FY 2003-2004 to 2004-2005 Project Description 1/7 Target/Eligibility Populations I/ Types of services Provided Measurable Outcomes `/ Service Objectives / -Workload Standards Staff Qualifications Unit of Service Rate Computation ,/ Program Capacity per Month - Certificate of Insurance Page 26 of 32 • " Off-System Bid B001-04 (RFP-FYC-04008) Attached A (2 ---0/' -------------------------- --------- -------------------------------------------- Date of Meeting(s)with Social Services Division Supervisor: Co is by SSD Su In Px F '7-visor: A R-c C-� ? L-Lei h ��2 A i �. - y'rL-0 P Luz h,ke � i t L ,t- `a - k- '' iz_ '''t P-f A. C7' ) _ — 14 itk e Pi k-(71k e � � , Al ee :� �j felt PJ , I ,� �t A-e• A��L Pt / c,i . 1UT LL , i1 , �� (vi.( ,t( /Tn�/,i`�e J �.(,� iO 1 L Lk t 1L.� !`� . `11_1--if '�// /+ � �[ /t P �,��p.� ,�.�PAci0t, , , ,,,_ ,u , ,__?kiw; ) ([i_ ti.,4 ), Lii(c) O ,_21_)__oiti \_ Name and Signature of SSD Supervisor Date Page 27 of 32 Off-System Bid B001-04 (RFP-FYC-04008) Attached A Program Category Intensive Family Mediation and Facilitation under the Intensive Family Therapy Program Area Bid Category Project Title rnro-,-- ntens,✓C'. pew) PN � li,,� 'LA ca.t. r t°'^. Vendor Citcae..apt - c - & jQssoc..,ac (C. PROJECT DESCRIPTION Please provide a one page brief description of the project. II. TARGET/ELIGIBILITY POPULATIONS Please 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 services. G. The monthly maximum program capacity. H. The monthly average capacity. I. Average stay in the program (weeks). J. Average hours per week in the program. III. TYPE OF SERVICES TO BE PROVIDED Please provide a two-page description of the types of services to be provided. Please address if your project will provide the service minimums as follows: A. Solution-focused therapy that is designed to resolve conflicts and disagreements within the family contributing to child maltreatment, running away, and to the behavior constituting status offenses. Service is goal specific and limited to five(5)hours of therapy per referral. Services are limited to therapy services only, and do not include treatment services. Also,provide your quantitative measures as they directly relate to each service. At a minimum, include a number to be served in each service component. Describe your internal process to assure that FYC resources will not supplant existing and available services in the community; e.g. mental health capitation services,ADAD and professional services otherwise funded. IV. MEASURABLE OUTCOMES Please provide aiwo-page description of your expected measurable outcomes of the project. Please address the measurable outcomes for each area as described below: A. Children receiving services do not go into placement. Page 28 of 32 Off-System Bid B001-04 (RFP-FYC-04008) Attached A B. Families remain intact. C. Reunification of children with families. D. Improvements in parental competency,parent/child conflict management as determined or measured by pre and post placement functional tests. E. More cost efficient services through the Intensive Family Therapy Program than the placement of the child. F. Therapeutic outcomes include fundamental changes in the family functioning and dynamics. Describe your quantitative measures: Also, describe the methods you will use to measure, evaluate, and monitor each quantitative measure. V. SERVICE OBJECTIVES Please provide a one-page description of your expected service objectives and quantitative measures. Please address, at a minimum, the following ways the project will: A. Improve Family Conflict Management-Mediation and counseling designed to resolve conflicts and disagreement within the family contributing to child maltreatment,running away and other offenses. B. Improve Parental Competency- capacity of parents to maintain sound relationships with their children and provide care,nutrition,hygiene, discipline,protection,instructions, and supervision. • C. Improve Ability to Access Resources- services shall assist parents to work with other sources in the community and within the local, state, and federal governments. D. Address specific referral issue(s)—services shall be solution focused and address issues specified by the Department of Social Services. Describe the methods you will use to measure, evaluate, and monitor each service objective. VI. WORKLOAD STANDARDS Please provide a one-page description of the project's workload standards and quantitative measures. Please address, at a minimum,the following areas: A. Number of hours per day, week or month. B. Number of individuals providing the services. C. Maximum caseload per worker. (Generally 12 families per worker. Eight to 10 families per worker if the worker provides case management services to the families on the caseload.) D. Modality of treatment E. Total number of hours per day/week/month(Minimum average of two hours-of service per family per week. F. Total number of individuals providing these services. G. The maximum caseload per supervisor. (Minimum of 6 workers per supervisor.) Page 29 of 32 Off-System Bid B001-04 (RFP-FYC-04008) Attached A H. Insurance. VII. STAFF QUALIFICATIONS Please provide a one-page description of staff qualifications and address, at a minimum, the following: A. Will your staff, including supervisors,who are providing direct services have the minimum qualifications in education and experience as defined in Staff Manual Volume VII, Section 7.303.17, and Section 7.000.6,Q, Colorado Department of Human Services. Describe. B. Total number of staff, including supervisors, available for the project. C. Will staff have expertise in family therapy as demonstrated by specialized training,workshops and experience. D. Will staff have a minimum of eight hours per year of continuing education; i.e. courses, workshops, and/or review of literature to be documented by county. E. Will staff have a minimum of one hour per week of clinical supervision provided by someone with advanced skills in Intensive Family Therapy. F. Will the clinical supervisor(s)be involved in regular training to keep current in state-of-the-art counseling modalities and findings. VIII. Unit of Service Rate Computation The budget form is to be used to provide detailed explanation of the hourly or daily rate your organization will charge the Core Services Program for the services offered in this Request for Proposal. This rate may only be used to bill the Weld County Department of Social Services for direct, face-to-face services provided to clients referred by the Department. Requests for payment based on units of service such as telephone calls,no shows, travel time, mileage reimbursement, preparation,documentation, and other costs not involving direct face-to-face services will not be honored. Likewise,bills must be for hours or days of direct services to the client, regardless of the number of staff involved in providing those services. Therefore, it is imperative that this rate be sufficient to cover all costs associated with this client,regardless of the number of staff involved in providing these services. There are two different ways to fill out the budget form. The budget can either be done manually or by computer. Regarding the manual budget, all areas that are required to be filled in are highlighted. The computerized budget is less work due to predefined calculations,but does require Microsoft Excel for Weld County's predefined budget. There are highlighted areas on the computerized budget that are required to be filled in as well. There are disks available that have this predefined budget on it. Firms can also design its own budget form on a spreadsheet,but at minimum, it must have all of the columns that are on the manual or computerized budget. Explanations on how to fill out the budget form are provided below and on the following pages. (A) This is an estimate of the totals ours or days of direct, face-to-face services each client-will - receive from the time he or she enters the program until completing the program. On the manual budget, the only place to put this number is on the Program Budget worksheet. The computerized budget requires this number to be entered on the Direct Service Cost Page 30 of 32 Off-System Bid B001-04 (RFP-FYC-04008) Attached A worksheet only. Once filled in there,this number is populated throughout the entire budget. (B) This is an estimate of the number of clients who will be served during the period from June 1, 2004,through May 31, 2005. On the manual budget,the only place to put this number is on the Program Budget worksheet. The computerized budget requires this number to be entered on the Direct Service Cost worksheet only. Once filled in there, this number is populated throughout the entire budget. (C) This is the total number of hours or days per client multiplied by the total number of clients to be served for(B). On the manual budget, this will have to be calculated manually on the ' Program Budget worksheet. The computerized budget will automatically calculate this then populated throughout the entire budget. (D) This is calculated by taking the total direct service costs(E) and dividing it by the total number of hours in ( C ). On the manual budget, this will have to be calculated manually. The computerized budget will automatically do this calculation for you. (E)This number represents the salary and benefits that your organization pays its direct service providers plus any costs which are directly attributable to the face-to-face session with the client. On the manual budget, all areas that are highlighted on the Direct Service Costs worksheet must be filled out according the descriptions. The Grand Total Direct Service Costs must be then carried over to the Program Budget worksheet. The computerized budget, once all of the highlighted areas are filled in, it will automatically carry the total over to the Program Budget worksheet. • (F) This represents the salary and benefits of direct service, supervisory, and clerical personnel which are not incurred in providing direct, face-to-face service to the client,but can be allocated to this program for time spent on the program for activities such as travel,phone conversations,no-shows, discussions with involved parties,meeting preparation, and report completion. On the manual budget, all areas that are highlighted on the Admin Costs Non- Face-to-Face worksheet must be filled out according to the descriptions. The Grand Total Direct Service Costs Not-Face-To-Face must be carried over to the Program Budget worksheet. The computerized budget, once all of the highlighted areas are filled in on the Admin Costs Non-Face-to Face worksheet, it will automatically carry the total over to the Program Budget worksheet. (G)This represents the agency overhead costs, such as rent, utilities, supplies,postage, travel reimbursement, telephone charges, equipment, depreciation, data processing, interest, and taxes which are not incurred in providing direct, face-to-face service to the client,but can be allocated to this program for time spent on the program for activities such as travel,phone conversations, no-shows, discussions with involved parties,meeting preparation, and report completion. On the manual budget, all highlighted areas on the Overhead Costs and Profits worksheet must be completed according to the descriptions. The Total Overhead Costs must be carried over to the Program Budget worksheet. The computerized budget, once-all of the highlighted areas are filled,will automatically carry over to the Program Budget worksheet. (H) This represents the total of all direct face-to-face costs, admin direct non face-to-face costs, Page 31 of 32 Off-System Bid B001-04 (RFP-FYC-04008) Attached A and overhead costs. On the manual budget,this will have to be manually calculated by adding these three total costs together. The computerized budget does it automatically. (I) This represents the total amount of profit your firms expects to realize as a result of operating this program. Any difference between lines (H) and (J)must be substantiated by an amount indicated on this line. The manual budget, this amount will be entered on the Overhead Costs and Profit worksheet and then have to be carried over to the Program Budget worksheet. The computerized budget, once it is filled in on the Overhead Costs worksheet, it will then automatically be carried over to the Program Budget worksheet. , (J) This represents the total costs and profits added together. This is(H) and(I). On the manual budget, it will have to be calculated manually on the Program Budget worksheet. The computerized budget will automatically calculate it on the Program Budget worksheet. (K)This represents the total hours or days of direct service for the year. This is (C) above. On the manual budget, you will have to carry this number down from( C ). On the computerized budget, it is automatically carried down. (L)This is the actual direct, face-to-face hourly or daily rate at which you will be requesting payment for the services provided under the conditions of this Request for Proposal. This amount cannot be more then what is charged to the general public or collected from insurance providers. On the manual budget, this amount must be calculated by taking the total costs and profits(J) and dividing it by the total hours or days of direct service for the year(C or K). The computerized budget automatically calculates this total. All providers who receive a NOFAA must also submit a certified computation of the organization's actual expenditures for the approved Core Service program by January 31, 2005, for a seven-month period from June 1, 2004 to December 31, 2004. The actual expenditures must be submitted in the same format as the budget was prepared. The certification language must be the same as on the Computerized Actual Expenditures worksheet. The document must be signed by the Chief Executive Officer or the authorized officer of the bidder in order for it to be considered certified. The use of the actual program expenditures is to insure that the direct, face-to-face hours/daily rate is comparable to the budget computation. The actual numbers will be taken into consideration for the 2004-2005 Request for Proposal for that specific program. Page 32 of 32 i-erm,.,,,-�ss p4 PG PROGRAM BUDGETS y ' PROGRAM lama bar/Q L A 54,1k /tir,„N rlwanR 114,,tri, ,Sch r�+,r ne MANw+ ns-2,/f,' ,a cafl.. . TOTAL HOURS OR DAYS OF DIRECT SERVICE PER CLIENT ge, ,36 ni-- 0.5-- 115- ,.S 3 TOTAL CLIENTS TO BE SERVED &O (Do 100 /0 0 'qg ,3` AD TOTAL HOURS OR DAYS OF DIRECT SERVICE FOR YEAR(A X B) /9-00 / $oo I goo /a©o / 6$0 G 00 COST PER HOURS OR DAYS OF DIRECT SERVICES(E/C) 51.00 57. 00 it too bo.po fr C tie.v0 TOTAL DIRECT SERVICE COSTS 6;?O0 9/ ro° S�'7( '13n00 2.9-0x0 77)60 ` 8po ADMINISTRATION COSTS NON-DIRECT ALLOCABLE TO PROGRAM 9)-00 10800 6�g00 9 c/00 q 9Zv 3000 J OVERHEAD COSTS ALLOCABLE TO PROGRAM 33 8P0 Sv roe a.Goco P-orpo 3 T 6.00 'I /P-0 ti--6 on I TOTAL DIRECT,ADMINISTRATION&OVERHEAD COSTS(E+F+G) /09-o 00 153000 %I i p yopo 045 opp /911,00 /g000 ANTICIPATED PROFITS CONTRIBUTED BY THIS PROGRAM O 0 0 o 0 o TOTAL COSTS AND PROFITS FROM THIS PROGRAM(H +I) /0P-000 /S3oco gg tvy 6Y0.0 /P-o00o /619,60o Ye00o TOTAL HOURS OR DAYS OF DIRECT SERVICE FOR YEAR(C) 0-00 /gcts o l ao0 /6 go 6. o0 RATE PER HOURS OR DAYS OF DIRECT, FACE-TO-FACE SERVICE TO BE CHARGED TO WELD COUNTY SOCIAL SERVICES(J/K) 80.00 groo 4'0,00 /00.00 SO. 40 go,00 P 11 I Lcfz E FICATION STATEMENT ,,Ar. t r�G�h,,,..,�� . 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 id o he factual unit cosh supporting the compensation paid or to be paid under this contract are accurate,complete and includes no duplicate costs and id that I am the CEO or duly authorized agent of f\-t\k -mhr\ 0 /`wll .pe,: cons. = 19(70 , U)i,nt lit neieW pana .ax1y) t 2.. $ct�tu.: ' 4.-ztu is = 4Woo (Si,c 1-...,r,Lei Ant eta//./O 3 !d/, yu.Q rn L C .4t P-S-0•00 CTLvc L.,-d r.+I l'Pv coe/(Ns, 9. Atka.P a,. 10,-1 Pr .. e-te0Ac Dl-r4 ,^ /rrs.z | Vi 1-1 { ± � } / / \ / { } \ y . |,| g!a: ; a S§a ■ $ \ \ \ , / \ §| // / % . | q;222§; as gags& a a . c. �� 1) ` " s < « ! , } III . } $ f : \ 2 as,b, } |,| §; a§; ! GSQI ; } \ \ / } a e � Iti ` a ! ` le, \'•- ~ | ill n3)§2; a : a ; : / / / 2 3 | | / \ \ '4 |,| # a g;§; | ! a ; | \ } f y ca III egg g | e^b \ \ |,§ EGG§§Gr • G; ` a ° \ \ \ | . . ! ) & Cl | ! w / \ \ q 0222222222222i 2222# \ a �| l2a G§a ! ; ■ \ -;4 \ \ 9 � • s 9 PI & . !p , t _ \ k \ | •i1StCi 3. \ 1 S 40 ci { 5 / \ k 1 % / . \\ / c & . y \ •k } f • ) � \ 77 � ili §ag § | asun � \ . . � ( !|| ` ■ / .) / / \ & |,| Gaa ah ; :mu: ; �/ \ } } §| ` s & } ,k §| QQaaa a ! HMI a \ \ \ it 2 $ % 4 coi C 8 1 ' a LC 1 .c•cg° t � - , ,| GG§aagl §gG§ ; > �2 9 cr--s \ iIn S / / i Ai � \ / -§ . | I;I;;l;;;I■;;; ; ;;;;;■■ ! | |■| { \ } \ } } th \ } \ \* | | a2§a§aaa mu:: : \ . ) /z. L" % §. � ) } ||| ` 14. ® \ i , ct § wwaawwa wan } � \ Z . ct 1|| ;■■;;l;l;■■■;; ; aa a , fig !_e ' OvtKKtAD COSTS AND PROFITS COMPVIERIZED ACTUAL TOTAL ALLOCATED ALLOCATED ALLOCATED ALLOCATED I ALLOCATED 1 ALLOCATED ' 0 100% ALLOCATED OVERHEAD COSTS ALLOCATED OVERHEAD COSTS ALLOCATED OVERHEAD COSTS ALLOCATED WERHEAD COSTS %ALLOCATED)VERHEAD COSTS %ALLOCATED)VERHEAD COSTS COSTS ALLOCATE TO PROGRAM TO PROGRAM TO PROGRAM "TO PROGRAM TO PROGRAM TO PROGRAM TO PROORAM TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM 0.00 0.00 0.00 0.00 0.00 0.00 $11.00 NO $0.00 MOO $0.00 $0.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 $0.00 WOO $0.00 NO $0.00 WOO $0.00 $0.00 MOO WOO NO $0.00 $0.00 $0.00 $0.00 $000 $0.00 NO WOO W.00 WOO WOO $0.00 W00 NO $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 NO MOD MOO $0.00 WOO $0.00 $0.00 NO WOO $0.00 $0.00 $0.00 $000 WOO NO WOO WOO WOO $0.00 MOO WOO NO $0.00 MOO $0.00 $0.00 $0.00 $0.00 NO MOO WOO WOO MOO WOO $0.00 NO $0.00 $0.00 $0.00 $0.00 $0.00 WOO NO $0.00 $0.00 $0.00 WOO $0.00 $0.00 NO MOO $0.00 $0.00 $0.00 MOO $0.00 NO $0.00 $0.00 WOO WOO WOO $0.00 NO $0.00 $0.00 W.00 WOO $0.00 $000 NO WOO WOO WOO WOO MOO $0.00 $11.00 $0.00 $0.00 WOO $0.00 $0.00 WOO WOO 'NO W.00 WOO W.OO $0.00 WOO $11.00 W.00 $0.00 $0.00 WOO $0.00 n $0.00 / 1^G rtT o1.y. O��//Cr ' /49#ST/calCosr"S 111,00 L2 6PSY p-,„aro for Cyr,t`r,4MIC-, s tO 412ari i i M-fic- Project Description 2004-2005 Short Term Intensive Family Therapy History of short term therapy services provided to WCDSS : . In 1998, we began offering short term mediation and goal oriented short term therapy services. Ackerman and Associates, P.C. began its program of Family Group Decision Making on February 1, 1998 for families undergoing expedited permanency planning. For other families that met PAC eligibility criteria, we began offering these services on June 1, 1998 This application modifies these short term services to meet the bid requirements for five hours of limited therapy services for 2004-2005. Purpose and design: We will continue to use formats and procedures developed previously and apply these to the current fiscal year. These therapy components have been adapted to short term therapy for directed behavioral outcomes. Three specific service components are offered: Service component one: Assistance to WCDSS in identification of extended family for family planning meetings. The Family Group Decision Making model involves extensive planning with the nuclear family of the index child. Ackerman and Associates has extensive experience in this activity over the past five years. We offer the service of helping identify appropriate participants for family planning meetings. Based on our accumulated experience we are in a position to efficiently assist in identifying the extended family members who might serve as placement for a child when parents are in active treatment and when parental rights are likely to be terminated if treatment fails. Up to five hours of services are offered to assist the department in greatly expanding the list of relatives and friends who may be qualified and desire to offer permanent placement options from within the extended family. Service component two: Mediation services will be offered in an up to five hour model. Often a specific conflict exists between two parties, either between spouses or within an extended family. The conflict contributes to conditions which imminently put a child at risk of placement or prevent the reunification of a child with the family. Resolution of the conflict may be expected to assist reunification or prevent placement. We have had seven years of offering mediation services to the department. Service component three: The goal achievement program was created six years ago to assist the department in short term solution focused therapy. In the current fiscal year we propose to deliver services within the up to five hour limitations of the proposed bid. The goal of the gap program is to address, in appropriate families, a very specific short term treatment goal that must be resolved in order to either avoid placement or allow reunification. The specifics requirements and desired goals of family meeting assistance, mediation or short term goal achievement services will be provided in detail by the caseworker and approved by the appropriate supervisor as reflected in the referral made to initiate these services. Target/Eligibility Populations Total number of clients to be served in this twelve month program has been calculated as follows. Ten families per month times twelve months equals one hundred and twenty families per year. If we assume a nuclear family size of five, two adults and three children, then the total client pool to be served is 600 individuals. Numbers presented represent maximum total s across all three service components Distribution of clients. Total number of clients we will serve is approximately 120 index children or more as calculated above. Our experience suggests that for the nuclear family we would expect approximately 240 of these would be adult members of the family and approximately 360 would be minors. The age distribution of the children would tend toward the very young children in expedited permanency planning and to older children in PAC referrals. Families Served. We would anticipate serving 120 family units. Sub total who will receive bicultural/bilingual services. We have a Hispanic member of the staff Emily Jaramillo Montoya M.A. L.P.C. who is fluent in Spanish. One of the facilitator's (Joyce Shohet Ackerman) doctoral work was on Hispanic patient's mental health treatment patterns compared to Anglo patients in Weld County. She also has four years of direct cross cultural experience with an American Indian population. We anticipate we can serve up to 100 percent of the total referred in a bicultural manner. We have been able to and will continue to provide bilingual services for any family who needs them. We can provide services in South Country if Social Services can provide a site to do such work. Accessibility. On weekdays all providers of Ackerman and Associates are accessible through 24 hour answering service and pager system. On weekends, the 24 hour access reaches the provider on call all of whom are Ackerman and Associates' providers. Maximum per month. The program maximum is ten families per month. The monthly average capacity is six families per month. The average stay in the program is a maximum of five hours. Types of Services Provided We will continue to use formats and procedures developed previously and apply these to the current fiscal year. These therapy components have been adapted to short term therapy for directed behavioral outcomes. Three specific service components are offered: Service component one: Assistance to WCDSS in identification of extended family for family planning meetings. The Family Group Decision Making model involves extensive planning with the nuclear family of the index child. Ackerman and Associates has extensive experience in this activity over the past five years. We offer the service of helping identify appropriate participants for family planning meetings. Based on our accumulated experience we are in a position to efficiently assist in identifying the extended family members who might serve as placement for a child when parents are in active treatment and when parental rights are likely to be terminated if treatment fails. Five hours of services are offered to assist the department in greatly expanding the list of relatives and friends who may be qualified and desire to offer permanent placement options from within the extended family. Service component two: Mediation services will be offered in an up to five hour model. Often a specific conflict exists between two parties, either between spouses or within an extended family. The conflict contributes to conditions which imminently put a child at risk of placement or prevent the reunification of a child with the family. Resolution of the conflict may be expected to assist reunification or prevent placement. We have had seven years of offering mediation services to the department leading to many successful outcomes. Service component three: The goal achievement program was created six years ago to assist the department in short term solution focused therapy. In the current fiscal year we propose to deliver services within the five hour limitations of the proposed bid. The goal of the gap program is to address, in appropriate families, a very specific short term treatment goal that must be resolved in order to either avoid placement or allow reunification. The specifics requirements and desired goals of family meeting assistance, mediation or short term goal achievement services will be provided in detail by the caseworker and approved by the appropriate supervisor as reflected in the referral made to initiate these services. In terms of the criteria for the PAC process: Comprehensiveness: Within the time constraints mandated by this bid, specific referral requests will be addressed in the most comprehensive manner feasible. Access to other services: Areas unable to be addressed within a five hour period will be identified and referrals offered to the family for them to continue therapy as needed Team based Treatment: Clinical meetings on a weekly basis at Ackerman and Associates allow therapists to confidentially problem solve difficult issues that arise in therapy. Conflict Resolution: Mediation is by definition a conflict resolution technique. Short term therapy will address conflict resolution as needed based on each referral. Assistance in family meeting planning is a specific action designed to resolve a family crisis. Measurable Outcomes Measurable outcomes are of two varieties. One type is termed formative outcomes and the other type is called summative outcomes. Formative outcomes measure how the program is proceeding while the treatment takes place. Summative outcomes are the results of the treatment. In terms of formative measures we have the following... 1. Did the family accept the intensive family therapy model? 2. Was contact successfully made with all specified parties and did those who could not attend provide sufficient information to the family meeting? 3. Did the family reach a mediated agreement in mediation? 4. Was the specified goal achieved in a short term solution focused therapy format This data will be extracted from the case file. Summative Outcomes The following four areas should be assessed at about six months after the completion of the five hour intensive family therapy process by the caseworker. A. Did the child receiving services not go into placement? B. Did the families remain intact? C. Was there reunification of children with their families? Did this take place within the nuclear family or within the extended family? D. Has there been an improvement in parental competency and parent child conflict management? Additional questions related to A-D above might include. Was a termination hearing avoided or modified through the use of the FGDM process? Did the index child find a placement in the extended family? Is this the case for siblings of the index child as well? Was a family proposed plan adopted in while or in part by the court? Has the proposed plan been effective over time? E. Does the program produce fundamental change in family dynamics? Let's define fundamental changes as those changes that persist for two months after the completion of therapy. It would be possible to measure the caseworker's perception of the family in relation to this question. At six months after the therapy is completed basic change in family dynamics may be present but these will be hard to quantify. Please note that we have not budgeted for ongoing evaluation of this project and suggested evaluations would need to be funded and conducted separately from this proposed work. Service objectives We have the following service objectives: A. Improvement of family conflict management. Family therapy is specifically designed to resolve conflicts that either precipitated the likely imminent placement of the child or which prevent the reunification of the child with the family (particularly service components of mediation and short term therapy.) The model teaches the family how to use its own strengths to resolve problems. B. Improved parental competency In this treatment model short term solution focus therapy could assist the parents in acute issues related to imminent placement. Long tern changes in parental competency are unlikely given the time limitations of the bid. Some of these parents are having their rights terminated and a relative of the index child will assume the parenting responsibilities. In these cases it is not a question of an improvement in competency for the biological parent. Rather the family is selecting a more competent relative to assume the nurturing roles the biological parent has failed to provide. Service component one can assist in identifying appropriate individuals from the extended family for this role. C. The ability of the family to access resources is enhanced by the short term therapy process and the mediation process. The need for a specific service should become apparent as the family develops the strategy to resolve the immediate conflict in mediation or short term therapy. The methods used to ascertain if the service objectives have been met would be through a report by the caseworker at six months after the completion of these services. Workload Standards A. The program has a capacity of 10 families per month. This is approximately 50 hours of therapist time per month. There are several therapists available for this program. Note that there is a need to continue to allow an exemption for the program in terms of the Face-to-Face rule usually within the PAC programs for the work done in identifying family resources for family group meetings. The identification of family resources relies upon telephone contact and written or faxed follow up. The need for telephone data gathering is also crucial for individuals of the extended family who live large distances away from Weld County. Telephone contacts have included California, Utah, Washington, New Mexico, Arizona, Nebraska, Kansas, Wyoming, South Dakota, Florida, and other states under family group decision making. Extensive contact around Colorado including the western slope and southern Colorado has occurred by phone. Work has also occurred by phone with Mexico. These costs are built into our administrative portions of the bid. B and C. There are seven providers who staff Ackerman and Associates. Joyce Ackerman, Ed.D. who supervises the contract is certified as a mediator and licensed as a psychologist. D. The modality of treatment has been described above under the design section. E. Hours/month The total number of therapist treatment hours is 5 per family. This totals to 50 hours per month for ten families pre month. A total of 600 hours per year is projected to be a maximum value. F. Staff There are seven individual providers supported by two office professionals in the practice. G. Supervisor The contract would be supervised by Joyce Shohet Ackerman, Ed.D. who monitors the project for compliance. Staff Qualifications A. and B. Staff Qualifications Seven staff are available for the project. They exceed the minimum qualifications specified as documented below. The staff are: Joyce Shohet Ackerman, Ed.D., Licensed Psychologist and mediator; Emily Jaramillo Montoya, M.A., L.P.C., Susan Bromely, Psy.D. D., Licensed Psychologist, Valerie Larson M.S.W, L.C.S.W., L.P.C. and Larry Kerrigan Ph.D., Licensed Psychologist. John Gray MA LPC and Bill Kelly MA psychotherapist C. Training The staff has extensive training in family therapy and mediation as documented by their extensive work experience. D. 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. These continuing education requirements arise from other contractual arrangements. E. Supervision All providers are independently licensed and not required to have clinical supervision. Alt the staff have advanced skills in intensive family therapy. The supervisor, Joyce Shohet Ackerman, Ed.D. will monitor the specifications made in this proposal. F. Supervisor and continuing education. The supervisor of the project is involved in ongoing training to keep current with her profession through advanced workshops and seminars and as a member of the Colorado Counsel of Mediators and the American Psychological Association. Unit of service rate computation We have chosen to offer a rate of $80 per hour of total time per therapist. This is ten dollars below our current therapy rate of service for licensed counselors and twenty dollars an hour less than our rate for psychologist's services. Budget Justification Ackerman and Associates, P.C. is a type S professional for profit corporation and not a 501.c.3. We generated a profit of 1% on gross revenue for the year 2003. Farmers-Insurance Group Issue Date 03/01/2004 Farmers Insurance Group This certificate is issued as a matter of information only and confers no rights PO Box 1054 upon the certificate holder. This certificate does not amend,extend or alter the Colorado Springs, CO 80901-1054 coverage efrorded by the policies shown below. INSURED Company Truck Insurance Exchange Alan & Joyce Ackerman 1750 25th Ave Ste.101 ireeley, CO 80634 overages This is to certify that the policies of insurance listed Below have been issued to the insured named above for the policy period "cheated. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate my be issued or may pertain, the insurance afforded by the policies described herein is subject to all the terms, exclusions and onditions of such policies. Limits shown may have been reduced by paid claims. O Type of Insurance Policy Policy Policy Policy Number Effective Expiration Limits Date Date General Liability 045763807 03/02/2004 07/01/2004 General Aggregate $1,000,000 Products Comp-Ops $1,000,000 Aggregate Personal & $1,000,000 Advertising Injury $1,000,000 Each Occurrence $1,0000,000 Fire Damage $150,000 (Any one Fire) Building Coverage 045763807 03/02/2004 07/01/2004 $195,000 Personal Property' 045763807 03/02/2004 07/01/2004 $58,400 Medical Expense $5,000 Automobile Liability Umbrella Liability Worker's Compensation rtificate Holder Cancellation :Id County Bank Should any of the above described policies be cancelled before the expiration date thereof. 35 23rd Ave the issuing company will endeavor to mail 30 days written notice to the certificate holder tans, CO 80621 named to the left, but failure to mail such notice shall impose no obligation or liability of any kind upon the company,its agents or representatives. Authorized Representative • EXECUTIVE E 1/20/04 - A PSYCHOLOGISTS PROFESSIONAL LIABILITY POLICY THIS IS A CLAIMS MADE POLICY-PLEASE READ CAREFULLY *** RENEWAL *** NOTICE:A LOWER LIMIT.OF LIABILITY APPLIES TO JUDGEMENTS OR SETTLEMENTS WHEN THERE ARE ALLEGATIONS OF SEXUAL MISCONDUCT(SEE THE SPECIAL PROVISION"SEXUAL MISCONDUCT"IN THE POLICY). POLICY NO: 008-1766682 DECLARATIONS ITEM 1. (a)NAME AND ADDRESS OF INSURED: ACCOUNT NO: CO-KERL175-0 0099745B ITEM 1. (b)ADDITIONAL NAMED INSUREDS: LAURENCE P. KERRIGAN, PH.D. 1750 25TH AVE. SUITE #101 GREELEY, CO 80634 TEM2. ADDITIONAL INSUREDS: TYPE OFORG: INDIVIDUAL CEM 3. POLICY PERIOD: FROM: 12/01/03 TO: 12/01/04 12:OIA.M.STANDARD TIME AT THE ADDRESS OF THE INSURED AS STATED HEREIN: 'EM 4. LIMITS OF LIABILITY: (a)$ EACH WRONGFUL ACT OR SERIES OF CONTINUOUS,REPEATED 1, 000, 000 OR INTERRELATED WRONGFUL ACTS OR OCCURRENCE (b)$ 5, 000 DEFENSE REIMBURSEMENT (c)$ , 000, 000 AGGREGATE - - - 3M 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 4 6. RETROACTIVE DATE: 12/01/91 TOTAL PREMIUM: 1, 229 . 11 47. EXTENDED REPORTING PERIOD ADDITIONAL PREMIUM Of exercised):$ 2 , 150 . 68 NO DISCOUNT INCLUDED 18. POLICY FORMS AND ENDORSEMENTS ATTACHED TO THIS POLICY 138 (7/95 ED. ) B22137 5 i PERSONAL.• DATA SHEET Identifying Information: Name : Laurence "Larry" Address y P. Kerrigan, Ph. D. I 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, Re Campus , Toronto , Ontario , Canada, 1967. College Ph . L. - Philosophy, St. Louis University, St . Louis , Mo . 1960 , (EcclesiPh . D. - California a Degree ) . School of Professional Psychology , Berkeley/Alameda Campus , 1974 , Clinical Psychology. Currently a licensed psychologist in the state of Colorado . Educational Back round: 1950-54 Creighton University, Business economics , 1954-56 Marquette University, Milwaukee , WI . , Classical studies and ascetical theology, 1956-57 Springhill College , Grand Coteau LA. Campus , Classical A studies , 1957-60 St. Louis University, Philosophy and Economics , t 1963-67 St. Mary' s University, Toronto Campus , Theology, 1971-74 California School of Professional Psychology, clinical psychology, Berkeley/Alameda Campus Positions Held: 1969-71 Member of Board of Directors, Campion College , Prairie du Chien, WI . 1968-71 Director, Department of Psychology, Campion College . 1971-74 Director of Student Counseling Center, Long Mountain College. 1975-80 Director of Short-term Children and Family Team, Weld Mental Health Center , Greeley, CO . 1975-'87 Clinical Psychologist, Child and Family Team, Weld Mental Health Center, Greeley, CO . 1976.-88 Co-founder of Weld County Child Protection Team, 1987-88 Member of Executive Board, Weld Mental Health Center , Greeley, CO . Honors Received : 1968-69 and Teacher of the 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-city boys , late grade school age from Milwaukee , WI . 1971-73 Director of Student Counseling , Lone Mountain College , San Francisco , CA. Teacher at the Lone Mountain College , San Francisco , California. 1973-74 Psychologist Trainee at San Francisco Mental Health Center, Richmond District, Outpatient Care . 1974-75 Private Practice , So . Bay Human Services Center, San Diego , CA. Part-time instructor at/California School of Professional Psychology, San Diego , CA. 1,975-80 Director , Short-Term Therapy Team, Children and Family Unit , Weld Mental Health Center , Greeley , CO . . 1980-87 Member of Children and Family Therapy Team, Weld Mental Health Center, Greeley , CO . 1987- present Full time private practice with Joyce Shohet Ackerman , Ld . D. , Licensed Psychologist , Greeley, CO . Part time practice at Weld Mental Health Center , Greeley , CO . Publication : Kerrigan , Laurence P. - The Relationship Between Therapist and Client ' s Perceptions of One Therapy Session . Published Doctoral Dissertation , University of California School of Professional Psychology. Copyright , 19'14 . Workkshop_pnd Speci._al._'I_r_iining: 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 : Nenro-linguistic training , Autogenic and relaxation training , Visualization-Imagery- Hypnosis , Cognitive-Behavioral Therapy, Ericksonian approaches to hypnotherapy and psychotherapy, Family therapy, Strategic family therapy , Sexual abuse , dynamics and applied treatment , Paradoxical intention psychotherapy, and other related areas . In the last fifteen years , I have taught classes and conducted workshops in the following subjects : The Psychology of Dreams Emotional and -Physical ]Health through Visualization and Imagery Western Psychotherapies and Eastern Ways of Liberation Cognitive and Behavioral Therapy Hypnosis in Pain and Habit Control The Psychology of Consciousness and Meditation 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: Office: (303)351-2236 Home: (303)352-8750 EMAIL:slwomley@bentley.unco.edu EDUCATION: Yearts) Degree Institution Area of Studv 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 South Hadley,Massachusetts WORK EXPERIENCE—Professional Academic: Yearts) 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 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—ProfessionaUJuried: Musgrave-Marquart,D.,Bromley, S.P. &Dailey,M.B. (1997)"Personality,academic attribution,and substance abuse as predictors of academic achievement in college students". Journal of Social Behavior and Personality 12(2), 501-511. Karlin, N.J. and Bromley, S.P. (1996).Differences in caregivers of demented and lucid chronically 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.,VanOrnum,W. &Stillwell, N.C. (F1lc)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 symposium titled"Creating links between psychology and other disciplines"., American Psychological Association Convention,Chicago. (August) Bromley, S. , Gilliam D.,&Johnson,T. (1995). "Assessment of student created tests as an evaluation method". Poster presented at the American Psychological Association Convention,New York City. (August) Bromley, S. (1994). "Student created tests as an evaluation method". Poster presented at 16th Annual National Institute on the Teaching of Psychology, St.Petersburg,Florida. Karlin,N. and Bromley. S. (1992). " Similarities and differences for 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). "Husbands at Childbirth: Who Does It Help?"Paper presentation at Far West Popular Culture Association,Las Vegas,Nevada(January). Hewitt,P. and Bromley S. (1989). "Images of Work and Intimacy in'Turning Point'and'Fatal Attraction"'. Paper presentation National Convention of Popular Culture Association and American Culture Association, St.Louis, Missouri. (Session Chair) Retzlag 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-Chair),Knuckey,D.,Bohlin,M.,Zaweski, C.,Watson,D.,Hammon,D., West,K. &Robins,J. (1994). "Training the Teaching Assistant"Invited Panel Presentation,Rocky Mountain Psychological Association,Las Vegas,Nevada(April) 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 writing skills in any course". CTUP Workshop presented at the Rocky Mountain Psychology Association Convention,Boise, Idaho. (April) Bromley, S. and Karlin,N. (1992). "General and health locus of control of adult caregivers". Poster session at the UNC Research Forum,Greeley,Colorado. Bromley, S. (1992). Panel member in Mental Health Symposia for Victim Compensation Convention as part of the Colorado Organization for Victim Assistance Conference. (Estes Park/October) Bolocofski,Bromley,Foster and Mean(1988). "Hypnosis: Research and Clinical Perspectives," symposium presentation, Colorado Psychological Association,Greeley(March). Bromley, S. (1986). "Pain: A Psychological Event". Presentor-20th Annual Emotional Crisis Workshop, University of Northern Colorado, Greeley, Colorado(July). LECTURES—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 Education(1995) Review of Santrock,J. (1991). The science of mind and behavior. W.C.Brown and Benchmark. Review of McKee,P. &Thiem, J. (1993). Real life: Ten stories of aging. University of Colorado Press. PROFESSIONAL CONSULTATION/PRACTICE: Year(s) Institution/Organization Role 1996-presnt Ackerman and Associates Clinical Psychologist 1988 Bonnel Good Samaritan Center Pain Management Consultant and Trainer 1984-85 Denver Metropolitan Dental Care Consultant in Pain Management 1984 Iowa Association of Registered Physical Therapists Hypnosis for Pain Management Consultant And Teacher 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 B/A 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 CLAIMSMADE POLICY, PLEASE READ THE POLICY CAREFULLY PURCHASING GROUP POLICY NUMBER: 45-0002000 item DECLARATIONS CERTIFICATE NUMBER:45P- 2050203 1. Named Insured SUSAN PLOCK BROMLEY ADDRESS Number&Street,Town,County,State&Zip No.) I 2. Policy Period: 12:01 A.M.Standard Time 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 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: 1-8n-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) t HONORS President's Award - Colorado Psychological Association, 1989 EDUCATION 1978 - 1981 Ed.D. in Counseling Psychology, University of Northern Colorado, December 1981 graduate 1972-1974 M.S. in Education (E.D./L.D.) Lesley College,Cambridge, Massachusetts,August graduate 1968 - 1971 B.S. in Special Education and Elementary Education with a minor in psychology Boston University, Boston, MA, December 1971 graduate PROFESSIONAL EXPERIENCE 1981 - present Clinical Director in group practice in Greeley,CO. Among responsibilities are: Diagnosis,therapeutic intervention and referral for adults, families,children and groups. Primary areas are: mediation, alternative conflict resolution,stress reduction. Also developing, organizing and presenting workshops and consultative programs to community,schools, organizations and agencies. 1986- present Consulting psychologist on interdisciplinary team for in-patient rehabilitation program. Progressive Care Rehabilitation Center,Greeley, CO. Medical Director Dr,Judith Vaughan, Neurologist. Adults with traumatic injuries- primary problems are: psychological aspects of physical rehabilitation,grief counseling,and brief group counseling using cognitive-behavioral goal oriented therapy. 1989- 1992 Consulting psychologist for Head Injury Treatment Team North Colorado Medical Center,Greeley CO Team coordinator - Dr. John McVicker,neurosurgeon. 1986- 1989 Consulting psychologist for Family Recovery Center(in-patient substance abuse/chemical dependency program), North Colorado Medical Center,Greeley CO Coordinator Ruth Wick,R.N. 1986 - 1989 Provider and Coordinator for Mental Health Services in Northern Colorado for Peak Health Care (HMO). Peak mental health services utilized a three-session model for initial services followed by referral. Activities included coordination of Psychological and Psychiatric Services for approximately the last two years of the Contract. Peak supervisor- Elaine Taylor 1983- 1986 Psychologist subcontractor for a Vietnam Veteran's Counseling Program funded by the Veteran's Administration. Principal Contract Dr. Robert Stewart. 1980- 1987 Part time faculty member with responsibilities for classes, workshops and community programs in parenting skills. Family/Life Education Program, Aims Community College,Greeley CO August 1980- August 1981 -Clinical internship on Children's Team of Community Mental Health Center. Responsibilities included: consultation to schools and community programs; therapy for children and families; and assessment of diverse mental health programs. Assistant program evaluator - developed evaluation tools to determine cross-cultural perceptions of expectations and satisfaction with services. Supervisors - Dr. Joan Gillespie and Dr. Laurence P. Kerrigan. APA National Convention in Toronto,Canada"Psychology and National Health Reform: "National Health Insurance: Policy Considerations. Benefit Designs. and Economic Realities",and"Marketing: Psychology's Key to National Health Reform. 1993 Disaster Relief Training. Alan Keck through Colorado Psychological Association,Denver CO 1992- Fall Short Term Therapy,Bernard Bloom; University of Northern Colorado, Greeley CO 1990- Fall National Cognitive Rehabilitation Conference, Richmond VA 1990 - summer Postgraduate training: 1. Adult Neuropsychological Method based on Lezak Neuropsychological assessment,1983. 2. Child Neuropsychology, Dr. Hynd. 3. Child Neuropsychological Methods 1988 Cognitive Rehabilitation Training Program, Dr.Sena, Ph.D., Colorado Springs CO 1988- present Psychologist-Head Injury Treatment Team at North Colorado Medical Center,Greeley CO 1987 Halstead Reitan Neuropsychological Assessment Training. Ralph Reitan, Ph.D.,Washington DC Summer 1986 Albert Einstein School of Medicine, Workshop on Adolescent Therapy, Cape Cod MA 1985 to present North Colorado Interdisciplinary Team of Child Custody Member and participant Fall 1985 Interdisciplinary Workshop on Child Custody, Keystone CO Summer 1984 Workshop in Clinical Use of Hypnosis, Boston MA Winter 1983 Workshop on In-patient Programs for Service Related Disorders, Cheyenne Veterans Administration Hospital. Fall 1983 Veteran's Administration Workshop on Post Traumatic Stress Syndrome, Denver Veteran's Center. Fall 1981-Winter 1984 Post-Doctoral Supervised Candidate for Licensure(psychology) under Gale R. Giebler, Ph.D. Licensed Psychologist and Susan Spilman, Ph.D., Licensed Psychologist 1980- 1981 Intern- Weld County Sexual Abuse Team,Greeley CO Weld Mental Health Center,Greeley CO adults,adolescents, families. Primary areas anxiety disorders,mood disorders and adjustment disorders. Typical problems included: trauma, physical abuse substance abuse,job stress. Orientation used - primarily cognitive-behavioral therapy. 1980 Group Facilitator- Regional and National Conferences in cross-cultural community needs. Flagstaff,AZ-Colorado Springs CO August 1975-July 1978 Chairperson of the Department of Education and Behavioral Science at an accredited, Indian controlled community college on the Navajo Reservation. Administration responsibilities included: Supervision and evaluation of faculty;budget preparation and management;curriculum development and integration of Navajo culture; personnel recruitment and selection;class scheduling and program development. Also faculty member with academic responsibilities for instruction in Psychology, Child Development and Counseling courses, advising and counseling students. Navajo Community College,Tsaile AZ September 1974-August 1975 Education Specialist and counselor at an Indian controlled primary and secondary school on the Navajo Reservation. Coordinated community resource program, which included: counseling, student assessment,prescriptive programming,staff development and curriculum. Also,adjunct faculty for the University of New Mexico and for Navajo Community College at the Rough Rock Demonstration school, Rough Rock, AZ September 1972-June 1974 Designed and coordinated Learning Center Program for Dedham Public Schools. A program and crisis intervention center for emotionally disturbed children. Responsibilities included: Diagnostic prescriptive programming,counseling,supervision and training of aides, tutors and volunteers,and consultation with regular classrooms teachers. Also organized group and individual meetings with parents. Adjunct faculty for Curry College assisting with in-service instruction for Dedham School System employees. Dedham Public Schools, Dedham MA WORKSHOPS AND SPECIAL TRAINING 1996 Biodyne training workshop adolescent treatment in short term therapy, Tom Kalous, Ph.D. 1995 Biodyne Training Workshops in short term therapy Julian Ang, Ph.D. 1994 Certification in family mediation, CDR Associates, Boulder CO 1993 Disaster Relief Training. Alan Keck, through Colorado Psychological Association, Denver CO 1993 August Hospital Practice for Psychologists Summer 1981 Independent Study of Child Sexual Abuse, University of Northern Colorado Spring 1981 Interdisciplinary Workshop on Assessment of Sexual Assault, Boulder Social Services Summer 1979 Biofeedback Training related to labor and delivery. Summer 1974 Participant in Institute on Obstacles to Learning. Joint Symposium between McLean psychiatric hospital, Harvard University and Lesley Graduate School,Cambridge MA Summer 1973 Kennedy Memorial Hospital,Boston MA. Participant,Summer Aphasia Institute. PUBLICATIONS Ackerman A., Ackerman,J.S., Kelley K. Hale K. Family Planning Attitudes of Traditional and Acculturated Navajo Indians. Key Issues in Population and Food Policy. University Press of America, pp.178-171 (1979) Ackerman,J.S.,Client Expectations and Satisfaction with Community Mental Health Center Services: A Cross-Cultural Analysis Between Hi!anics and Antos. Published Doctor Dissertation, University of North Colorado. Copyright 1981. BRANCH BIA PRODUCER NUMBER DATE OF 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), PLJ-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 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 case management duties. These included completing monthly progress reports, performing psychosocial assessments, and attending court hearings and staffings. • 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 (Iir 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.KF.i.I Y 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 Piuf bsor,Education Department,Regis University,Denver,CO SECONDARY 2001-2002-Teacher,Mathematics and Speech,Holy Family High School,Broomfield,CO 1974-77—Principal,Greeley West high school,Greeley,CO. 1973-1974-Associate Principal,Longmont high school,Longmont,CO. 1966-67,68-70 Teacher/Administrator/Coach hi Denver Catholic High Schools- 1960-1963 Teacher/Conch Marquette University High School,Milwaukee,WI. COUNSELING EXPERIENCE 1999-Chem 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, 1O11O 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 �� Organization Purchasing Group CNA Plaza, ,d,i,.,,.a,,..i..,s,,..o.*,n;,a;,,,. Chicago,1L 60685 y vto e 4w is af 11:51: alICz Producer Branch Prefix f Policy Number Policy Period _.,_____ 1 018098 970 111'G 273003448-8 from: 12:01 AM Standard Time on: 07/04/03 to: 12:01 AM Standard mein; 01/44/94_I Named Insured and Address Program Administrator Healthcare Providers Service Organization WILLIAM P KELLY 159 East County ne Road 11429 W BURGUNDY AVE Ea PA 4L LITTLETON CO 80127-5870 -- Medical Specialty: Code: Insurance Provided by _...�_._._� Clinical Counselor 72990 American Casualty Co. of Reading, PA CNA Plaza 26S Chicago, IL 60685 COVERAGE PARTS LIMITS OF LIABILITY A. PROFESSIONAL LIABILITY Professional Liability $1,000,000.00 each claim $6,000,000.SD 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 512-500.00 aggregate Defendant Expense Benefit $5,000.00 aggregate Deposition Representation T $1,250.00 per deposition $2,500.00 aggregate Assault $5 ,000.00 per incident $12,500.00 agaregate 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. Work lace Liabilit Included in A. Professional Liabilit Limit shown above Eire and WaterLegal__Liabiliy- _ Included above subject to $150,000 sub-limit Personal Liability $500,000.00 aggregate D. GENERAL LIABILITY Coverage part D. does not apply if Coverage parr C. is made part of this policy. Workplace Liability None None ' Hired Auto & Non Owned Auto None Fire & Water Legal Liability None None Personal Liabilit 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-1215000 G-121501C G-123846C-05 G-121503C G-121489-ACA Healthcare Providers Service Organization is a division of Affinity Insurance Services.Inc.;in NY and NH,MS Affinity Insurance Agency;in MN and OK,MS Affinity Insurance Agency,Inc.;and in CA.MS Affinity Insurance Agency,Inc.dba Aon Direct Insurance Administrators License#0795465. Master Policy: 188711433 I Keep this document m a safe place. This and 2104/A iikAN4-%. �.w tic your cancelled check act as proof of coverage. • EMILY L. JARAMILLO,M.A. • EDUCATION 1996,Master of Arts,Agency Counseling University of Northern Colorado, Greeley, Colorado 1993, Graduate Fellowship Study, Criminology Rutgers State University, Newark, New Jersey 1988, Bachelor of Arts, Sociology/Criminal Justice with emphasis in Psychology University of Northern Colorado,Greeley, Colorado PROFESSIONAL EXPERIENCE ' 1998-Present Psychotherapist,Ackerman &Associates, Greeley, CO Provide intensive home based family therapy to families referred by the Department of Social Services. Provide mediation services to families. Co-facilitate family group decision making conferences for permanent placement of children. Provide short- term, solution-focused therapy. Provide therapy to individuals referred from Employee Assistance Programs. Facilitate foster parent training workshops. Provide foster parent consultation. Practice is supervised by Sherri Malloy, Ph.D., Licensed Clinical Psychologist. 1996-1999 Director,McNair Scholars Program, University of Northern Colorado, Greeley, CO Provided counseling, guidance, and academic advising to students who were low- income, first-generation college students, and of a minority group. Identified critical personal, familial, cultural, academic,and financial issues to aid in the development of individual success plans. Planned, developed, and implemented scholarly activities nationally. Developed and directed academic year research seminars. Coordinated research activities for scholars preparing for doctoral study. Directed all efforts to ensure efficient administration of a federal grant. Monitored project budget, supervised and trained staff members. 1995-1996 Assistant Director,McNair Scholars Program, University of Northern Colorado Provided counseling, guidance,and academic advising to students who were low- income, first-generation, and of a minority group. Identified critical personal,familial, cultural, academic, and financial issues to aid in the development of individual success plans. Coordinated the recruitment and selection of program scholars. 1996 Psychotherapist(Intern), North Colorado PsychCare/Family Recovery Center, Greeley, CO Facilitated psychotherapy counseling groups and individual counseling for patients and families, with focus on chemically dependent and eating disorders. Performed case management from admission to discharge. Presented psychoeducational information to patients, family members, and staff. Worked collaboratively with a counseling team. 1994-1995 Assistant Coordinator, Student Support Services, University of Northern Colorado, Greeley, CO Provided counseling and academic advisement to at-risk first-generation, low-income, minority students. Identified critical personal, familial,cultural,academic,and financial issues to aid in the development of individual success plans. 1994-1995 Psychotherapist, Weld Mental Health Acute Treatment Unit, Greeley, CO Provided individual and group counseling to chronically mentally ill in-patient clients. Assisted clients in learning self-care and daily hygiene. Coordinated and implemented client life-skills and social-skills activities. CONTINUING EDUCATION/SEMINARS Jurisprudence Workshop for Psychotherapists Family Preservation Basic and Advanced Training Supervised.Practicum in Family Preservation Reaching Children through Play Therapy Play Therapy and Therapeutic Care Fire Starter Training Diverse Learners Academy Counseling At-Risk Students Cultural Diversity Conference Parent/Child Hispanic Youth Leadership Conference PRESENTER/FACILITATOR The Terrific Twos Prenatal Insults and Long Term Effects Social,Emotional&Sexual Development:Infancy through Adulthood Cognitive&Physical Development:Infancy through Adulthood Parenting with Love& Logic Eating Disorders Cultural Sensitivity and Awareness Communicating Across Cultures Conflict Resolution/Communication Skills Setting Limits& Boundaries HONORS/AWARDS Hispanic Leader of the Year, Cesar Chavez Center, University of Northern Colorado, 1999 Keynote Speaker, Latina Youth Leadership Conference, University of Northern Colorado, 1998 Distinguished Alumni, Department of Sociology, University of Northern Colorado Fellowship, Graduate Study, Rutgers State University of New Jersey Scholarship, National Hispanic Scholarship Fund Scholarship, Candelaria Scholarship Date Issued 10/14/2003 Memorandum Holder This memorandum is issued as a matter of information only and confers no ACRERMAN & ASSOCIATES rights upon the holder. This SUITE 101 memorandum does not amend, extend 1750 25 AVENUE or alter the coverages afforded by the GREELEY Co 80634 Certificate listed below. Producer Company Affording Coverage Chicago Insurance Company Seabury & Smith -1'775 West Lakes Parkway Covered Person (Status) Owner W 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,contract or other document with respect to which this memorandum may be issued or may pertain, the insurance afforded by the Certificate describedherein_is_subject_to_all the terms, exclusions_and eonditions_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 1,000,000 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 not ice 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: tit . e Aiterse. 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 . 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 01/16/04 FRI 10:25 FAX 515 243 5180 SEABURY & SMITH g]062 4 x 'k,,,511,3444 �m , ,..-A,.1 'S, Date Issued ' :•`• . . 01/15/2004 Insured This memorandum is issued as a matter JOHN M GRAY of information only and confers no 230 N CRAY Ks rights upon the holder. This memorandum does not amend, extend FORT COLLINS CO 80524 or alter the coverages afforded by the Certificate listed below. Producer Company Affording Coverage Seabury & Smith Chicago Insurance Company 1776 West Lakes Parkway Covered Person (Status) (z)v ner West Des Moines, Iowa 50398 �d� JOHN H 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 'rofessional Liability each incident Occurrence $1,000,000 Or occurrence 8014-4005346 12/01/2003 12/01/2004 in the aggregate $3,000,000 General Liability each incident or occurrence Occurrence in the aggregate Memorandum Holder horize d R entative. I__ r SUPPLEMENTAL NARRATIVE TO RFP: EXHIBIT B _ RECOMMENDATIONS X CONDITIONS 04/13/2004 12:21 `J/03J333/4 NUKtKMRN5 1-14',t GL/GL Ackerman and Associates, P.C. 1750 25th Avenue, Suite 101 Greeley, Colorado 80634 (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), REP 04010 (Option B/Home-Based), RFP 04005 (Lifeskills), and RFP 006-00 (Foster Parent Consultation). Thank you very much. Respectfull , Joyce Shohet c erman, Ed.D. Licensed Psychologist President, Ackerman and Associates, P.C. 6• DEPARTMENT OF SOCIAL SERVICES P.O.BOX A GREELEY,ca 80632 Website:www.co.weld.co.us Admldstration and Public Assistance(970)352-1551 Child Support(970)352-6933 • T • 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 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 Families,Youth and Children Commission(Core)Funds Type of Action Contract Award No. X Initial Award FY04-FYC-1000 Revision (RFP-FYC-04008) Contract Award Period Name and Address of Contractor Beginning 06/01/2004 and Mediation Communication Training Ending 05/31/2005 Mediation and Facilitation under the Intensive Family Therapy Program Area 841 Durum Street Windsor, CO 80550 Computation of Awards Description Unit of Service The issuance of the Notification of Financial This program offers mediation services to Assistance Award is based upon your Request for families involved with Social Services. Proposal (RFP). The RFP specifies the scope of Mediation services are used for pre D&N pleas, services and conditions of award. Except where it is determining treatment plans, addressing in conflict with this NOFAA in which case the communication issues,termination of parental NOFAA governs, the RFP upon which this award is rights issues. Services to 60 families per year, based is an integral part of the action. open monthly capacity, services to four families per month. Bilingual services through an Special conditions interpreter. South County services available. 1) Reimbursement for the Unit of Services will be based Cost Per Unit of Service on an hourly rate per child or per family. 2) The hourly rate will be paid for only direct face to Hourly Rate Per $ 150.60 face contact with the child and/or family, as Unit of Service Based on Approved Plan evidenced by client-signed verification form, and as specified in the unit of cost computation. Enclosures: 3) Unit of service costs cannot exceed the hourly and X Signed RFP:Exhibit A yearly cost per child and/or family. X Supplemental Narrative to RFP: Exhibit B 4) Payment will only be remitted on cases open with, Recommendation(s) and referrals made by the Weld County Department X Conditions of Approval of Social Services. 5) Requests for payment must be an original submitted to the Weld County Department of Social Services by the end of the 25th calendar day following the end of the month of service. The provider must submit requests for payment on forms approved by Weld County Department of Social Services. 6) The Contractor will notify the Department of any changes in staff at the time of the change. Approvals: p� Program Official: By S?).---Sa. ° "� By Robert D. Masden, Chair J A. ego, Dir tor Board of Weld County Commissioners Wed Co Department of Social Services Date:JUN 16 2004 Date: 5pq SIGNED RFP-EXHIBIT A INVTTATION TO BID OFF-SYSTEM BID B001-04 (04005-04011 AND 006-00) DATE: February 11, 2004 BID NO: RFP-FYC-04008 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-04008) for:Colorado Family Preservation Act--Intensive Family Mediation and Facilitation under the Intensive Family Therapy Program Area—Emergency Assistance Program Deadline: March 7, 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 under the Colorado Family Preservation Act(C.R.S. 26-5.5- 101) and Emergency Assistance for Families with Children at Imminent Risk of Out-of-Home Placement Act (C.R.S. 26-5.3-101). The Families, Youth, and Children Commission wishes to approve services targeted to run from June 1, 2004, through May 31, 2005, at specific rates for different types of service,the County will authorize approved vendors and rates for services only. The Intensive Family Mediation and Facilitation program under the Intensive Family Therapy Program area must provide for therapeutic intervention through one or more qualified family therapists,typically with all family members, to improve family communication, function, and relationships. This program announcement consists of five parts, as follows: PART A...Administrative Information PART D...Bidder Response Format PART B...Background, Overview and Goals PART E...Bid Evaluation Process PART C...Statement of Work Delivery Date (After receipt of order) BID MUST BE SIGNED IN INK K4 /FEZ_ / , 4 TYPED OR P �(J ED SIGNATURE VENDOR /T h C r _ (Name) Handwritten Signature By Authorized Officer or Agent of Vender ADDRESS Eel/ sa(a.ram 5/. TITLE ('goo DATE 490 rc-!s y/ ,doh{ PHONE# ?'t0 6711 c''I4'lef The above bid is subject to Turns and Conditions as attached hereto and incorporated. Page 1 of 32 • Off-System Bid B001-04 (RFP-FYC-04008) Attached A INTENSIVE FAMILY THERAPY MEDIATION/FACILITATION PROGRAM BID PROPOSAL AND REQUEST FOR CONTINUATION OF AWARD UNDER CORE SERVICES FUNDING EMERGENCY ASSISTANCE PROGRAM 2004-2005 BID PROPOSAL APPLICATION PROGRAM FUNDS YEAR 2004-2005 // OFF-SYSTEM BID B001-04 (04008) NAME OF AGENCY: A Fri / AT/'on ' CO/KMGet Jlnn //ai'nlrtG 0)1 e-r ADDRESS: 8`f/ it ru fli ( Yrirr'r A- LI)/no!y ri ) 5 iSro PHONE: 1 G /4i bye` • CONTACT PERSON: Ka alt /fFM �r";:c-X/Lt .O,‹) TITLE: DESCRIPTION OF EMERGENCY ASSISTANCE PROGRAM CATEGORY: The Mediation/Facilitation Program must provide for solution-focused therapy through one or more qualified therapists,typically with all family members,to resolve conflicts and disagreements within the family contributing to child maltreatment,running away, and to the behavior constituting status offenses. 12-Month approximate Project Dates: _ 12-month contract with actual time lines of: Start June 1,2004 Start End May 31,2005 ec� J End TITLE OF PROJECT: 0 L fcf //t i 4 //OA OA AMOUNT REQUESTED: 3e /y' ' og-/AarL. K6. -1 arA y Name and Signature of Person Preparing Document Date Name d Signature Chief Administrative Officer Applicant Agency Date MANDATORY PROPOSAL REOUIREMENTS For both new bids and renewal bids,please initial to indicate that the following required sections are included in this Proposal for Bid. For renewal bids,please indicate which of the required sections have not changed from Program Fund Year 2003- 2004 to Program Fund Year 2004-2005. Indicate No Change from FY 2003-2004 to 2004-2005 Project Description Target/Eligibility Populations _ Types of services Provided Measurable Outcomes Service Objectives Workload Standards �� p_ 4biks Staff Qualifications X -1-; u� T (5 _ Unit of Service Rate Computation Program Capacity per Month tr. H/1 //AE Cray: Certificate of Insurance Page 26 of 32 Off-System Bid B001-04(RFP-FYC-04008) Attached A Date of Meeting(s)with Social Services Division Supervisor: _ - Comments by SSD)Supervisor: (y h,?..tkut_....75 _Inv 1 r g f,(-Cel-e_J ./ L-11 f P 4 1 r /w .Q( e^ C P f t__f. Liu- ICt LicA ,t_A ` �/?..f Ike -L Cle k,„f f-tit t 1LA) s't ,tit _.C -kly S-et a-4 Hc_ t L,te / J ,i Iii JCL' e 02. ci,/ 1 Ce ; le (1 ( C _/1 l 2C-�i%LCA� �` l tttliJ 1LP � C LP ( l L ,4-±(.._ it Cll� kn ltC4 _ �C f�k .h d Y J ki ,_ ( tiCk- L It--(Th\:WE ? 0 ei 2 l -) I (it ) Name and Signature of SSD Supervisor Date Page 27 of 32 • Project Description Project Mission. To assist families to stay together or to expedite the re- unification of families by using mediation for conflict resolution. throughout the Department of Social Services (DSS) Dependency and Neglect (D&N) process. Project Purpose- To offer mediation services to families involved with the Department of Social Services for child protection issues. Research shows that families who actively solve their own problems are more motivated and follow through. In mediation, a neutral third party facilitates the problem-solving sessions which empowers parents to become active in resolving their issues. The neutral third party is critical to make this process work. By offering mediation as an alternative form of conflict resolution, the parents, their attorneys, the DSS caseworker, the GAL, and Special Respondents are able to explore together avenues of resolution beyond the typical solutions available through the current system. The Department of Social Services, always looking for innovative programs for their clients, started a pilot project in 1998 to mediate various issues for families on a fast track through the court system for child abuse/neglect (EPP). Of the EPP and core services cases mediated in 1999, all found resolution which resulted in lower costs for DSS and the courts, mare motivated parents and, most importantly, accelerated permanency for the children involved. Effective times in the D&N system to use mediation are: • for pre D&N pleas, • determining treatment plans or changes in treatment plans, • addressing communication issues that exist (these can be between the parents or between the family and the DSS caseworker, or other professionals involved with the family), and; • termination of parental rights issues. Project Desigp• The courts, professionals, or families request mediation. The mediator may meet with all parties individually to educate them about the process of mediation and get a sense of the main issues to be resolved in the mediation session. Two-hour mediations are set and include all relevant parties needed to successfully resolve the issues. The mediator clarifies the real issues of the conflict, promotes mutually agreed upon settlements and records solutions. The success of t:he mediation is measured by the parties' compliance on agreements and saving time in court. 1 Target/Eligibili y Populations A. Total number of clients to be served will be 60 families or approximately 120 parents and/or special respondents. Additionally, professionals from DSS, the County attorney's office, GAL's, and the family's attorney are also served through mediation. We are leaving the number of families served due to the use of the program during 2O02/03. To date, we have mediated over 36 cases. B. Total individual clients and the children's ages. In most mediation sessions there are a minimum of two family members and a minimum of four professionals. Sixty families will be served over the year representing over 125 children from infancy through eighteen years of age. C. Total family units will be 60. Our unit of service is family units, not individuals. D. Individuals needing bicultural-bilingual services will be accommodated with an interpreter. E. Any South Weld County residents referred to mediation will be served. F. Since mediation is not a crisis service, there is no 24-hour service. We are flexible in our hours and try to accommodate family schedules. G. The monthly maximum capacity is open. Since there are several mediators involved we can handle any number of families a month. H. The monthly average capacity is not applicable to this program. I. The average mediation time will be four hours throughout the families' involvement with the D&N system over one year. A typical mediation session is set for two hours at a time. A mediation averages 1.25 hours. J. Average hours per week is not applicable for this program. 2 Tyne Of Services To Be Provid d We will be providing mediation services exclusively in order to assist 60 Weld County families involved in the D&N system to resolve conflicts and disagreements within the family and between the family and the D&N system. The resolutions made in mediation will impact the reduction of child maltreatment and the reduction of behavior constituting status offenses. Mediation is a form of conflict resolution where a trained neutral third party {the mediator) intervenes between conflicting parties. Mediation will: • Clarify the real issues in the conflict. • Record possible solutions. • Promote mutually agreed upon settlements. Mediation is a process where the parties in conflict make the decisions. This means that the solutions arrived at are: • In their control. • Unique to their situation. • Enduring. This project will have up to three qualified mediators on hand to provide services. Each mediator will contact the parties involved prior to the mediation to request necessary materials and discuss the mediation process. Each mediation session will be scheduled in two-hour blocks with the family receiving up to two blocks of mediation (or four hours) throughout the year. Most resolutions occur within the first two hours. The remaining hours will be used as the family goes through the process and encounters other conflicts that are unresolved in the normal channels. Cases will be referred to mediation through the courts, DSS, GAL's or families. A. Mediation is the actual planning process to resolve family issues, so by nature, that problem-solving process guarantees comprehensive inclusion of all necessary service providers. B. Though mediation is not therapeutic in nature, it is a very flexible process and demands participation from any one who is able to assist in resolving the issue. 3 C. Again, mediation is not a therapeutic process, it is an alternative form of conflict resolution. Sometimes mediators work together to co- mediate. We have the capability to do that, however, most mediators work on their own. D. Mediation is designed solely to assist people to resolve conflicts. Currently, there are several mediators in practice throughout Weld County. This project differs in two main areas from mediations common in a private practice. First, D&N mediation requires a direct knowledge of the complexity of the D&N system and the issues involved in child protection cases. Second, the mediations in this project involve large numbers of people, whereas most private mediation practices are limited to divorce and work related mediations serving a small group. Additionally, most mediators in private practice charge a minimum of $150.00 an hour plus writing time and preparation time. An average divorce mediation takes 3-5 hours, with phone chats and scheduling as part of the cost which equals over $600 per case. The background of the mediators of this project, the complexity of the issues being resolved, and the unique system that the issues must be resolved within guarantee that this project is not duplicating other services in Weld County. In fact, the mediators in this project were urged to submit this proposal by the Court D&N case coordinator due to the large number of D&N cases currently in the system that would benefit from mediation. 4 Measurable Outcomes Success is easily measured in this project. First, when agreements are made, that means the conflicts that brought the case to the mediators initially have been bridged. Second, since resolution comes from all parties there will be motivation to complete the agreements. Third, there will be a reduction of time required for the D&N system by all parties involved, including the court. And last, but most important, children will reach permanency more rapidly. A. Though children typically are not part of a mediation process, their parents will be making decisions that will keep their children from going into placement and/or coming home from placement more rapidly. We expect this to happen in 80% of our mediations. So far, in 2003/04 it has been @ 70%. B. D&N mediations often focus on treatment plans. The decisions the parents make about their involvement with treatment plans directly helps keep families together. We expect this to happen in 70% of those cases. Other cases that are being referred for mediation are for termination of parental rights will obviously not meet this criteria. We anticipate that in 75% of these cases, we will bring a quick resolution on how to make the termination process as successful as possible for all involved. To date in 2003/04, we show 80% in both these areas. C. Again, as families take control of their decisions, they are empowered and motivated to follow through. This will cause quicker re-unification with their children in 90% of the cases. 2003/04 cases are still pending. D. Learning effective conflict resolution through the mediation process definitely improves parental competency. Mediation is a short-term process and is focused on resolving specific issues in an expedited manner. By participating in the mediation process, families begin to learn new behaviors for conflict resolution. Since we are with the families a limited time, it is difficult to measure this outcome. E. Mediation is limited in this project to four hours per family. Thus, the cost per family annually compared to the cost of placement is significant. To date, the longest time spent with a family is 3 hours. We have been asked to mediate different conflicts with the same family. To date, we have stayed within our 4 hour time per family, 5 F. The behavioral changes will be specifically around conflict resolution. Many people who go through mediation pick up on new ways to communicate and express themselves. The biggest benefit in these cases is to give the parents the power to take responsibility to solve their own problems. We anticipate that will happen in many of the cases. We will measure our outcomes through the written mediated agreement that documents the resolutions made by the family and the professionals involved. Follow-up on the family's compliance with the agreements will be made monthly for up to three months. We will track any court time saved due to the agreements made in mediation. If possible, we will track the time saved in the permanency plan for the children due to the impact of mediation. To date, we have saved the court over 55 days of court time. 6 Service Objectives A. This project will show parents how to effectively resolve their conflicts through cooperation and decision-making techniques. All conflicts being solved will directly relate to child protection issues and how to effectively deal with child maltreatment issues. We will measure our success through the agreements made. When agreements are made that solve the child protection issue and save court time, we consider that successful. B. Parental competency will be measured in this program as to how well the parents do in resolving their issues and cooperating with the mediation process. Again, our measure of this is with the written agreements made by the parents and their dedication to follow-through with these agreements. C. Many of the professionals that the parents are involved with, such as attorneys and caseworkers, will participate in the mediation. In those cases, immediate ability to access resources is available. The professionals attending the mediation have vast knowledge of the services available in the County and can assist families in connecting with them. Additionally, the mediation process will assist the parents in dealing with professionals as they solve their conflicts. 7 Workload Standards A. Number of hours per day, week or month. Mediation sessions will take place in two-hour blocks. These blocks are typically a few weeks apart. B. There will be up to three qualified mediators available to provide this service. C. The caseload will depend on the mediator's availability to mediate a case in a timely fashion. Most mediators will handle four to five families throughout the year. D. Mediation is the form of conflict resolution being used in this project. E. We will average four hours of mediation per family annually. F. At least three mediators are available to provide these services. G. All of our mediators are experienced and no longer require supervision. We do have the option of meeting or conferring with each other on a case by case basis if necessary. All information in mediation is kept confidential, so any conferring is done taking this into account. H. Insurance policy is attached. I. Assurance Statement Attached S Staff Oualifications A. All mediators in this project have completed a minimum of forty hours of mediation training and have mediated for several years. Additionally, our mediators have direct experience with child protection issues. 1) Kathleen Luker, M.A. has been active in child protection issues since 1986. A former director of c.a.r.e., she is currently an EPP mediator for DSS. 2) Dana Wellman, M.A. has been a therapist at Northern Behavioral Center for over fifteen years. His expertise is working with parents involved in child protection issues. He, too, is an EPP mediator for DSS. 3) Hannah Staub, M.A. is a therapist/mediator/special advocate in private practice for over fifteen years. Her expertise is with children and child protection issues. 4) Gladys Sexton may join our team. Ms. Staub is retired and Ms. Sexton may be used to fill in. Ms. Sexton is an attorney with years of D&N experience. She has been mediating the past few years. B. Four mediators are available for this project. Having this selection of qualified experts in this area will enable the project to rapidly schedule mediations and make sure there are no potential conflicts of interest between the mediators and the cases. C. All mediators bring a wealth of expertise in the area of mediation, as well as child protection issues. These mediators were hand picked for their unique backgrounds. D. Not applicable for mediators, however, all mediators listed constantly seek further education to assist them in sharpening their skills. If a minimum of eight hours of continuing education is required, we can accommodate that request. E. Supervision is not required for mediators with this caliber of experience. Again, we are available to consult with each other. F. Not applicable. 9 • STATE FARM CERTIFICATE OF INSURANCE TI[sa t t ® STATE FARM FIRE AND CASUALTY COMPANY, Bloomington, Illinois 0 STATE FARM GENERAL INSURANCE COMPANY, Bloomington, Illinois in ur'the'foll wing policyholder for the coverages indicated below: Name of policyholder MEDIATION COMMUNICATION TRAINING, LLC . Address of policyholder 841 DURHAM ST WINDSOR, CO 80650 Location of operations Description of operations The policies listed below have been issued to the policyholder for the policy periods shown. The insurance described in these policies is subject to all the terms exclusions, and conditions of those policies.The limits of liability shown may have been reduced by any paid claims. POLICY NUMBER TYPE OF INSURANCE POLICY PERIOD LIMITS OF LIABILITY Effective Date Expiration Date (at beginning of policy period) Comprehensive BODILY INJURY AND 96-EB-4091-4 Business Liability 03/01/04 03/16/05 PROPERTY DAMAGE This insurance includes: ® Products-Completed Operations ▪ Contractual Liability 0 Underground Hazard Coverage Each Occurrence $ 500, 000 ❑ Personal Injury ® Advertising Injury General Aggregate $ 1, 00 0, 000 ❑ Explosion Hazard Coverage Products-Completed ❑ Collapse Hazard Coverage Operations Aggregate $ 1, 000, 000 ❑ General Aggregate Limit applies to each project 0 0 EXCESS LIABILITY POLICY PERIOD BODILY INJURY AND PROPERTY DAMAGE Effective Date Expiration Date (Combined Single Limit) ❑ Umbrella Each Occurrence $ 0 Other Aggregate $ Part 1 STATUTORY Part 2 BODILY INJURY Workers'Compensation and Employers Liability Each Accident $ Disease Each Employee $ Disease- Policy Limit $ POLICY NUMBER TYPE OF INSURANCE POLICY PERIOD LIMITS OF LIABILITY Effective Date Expiration Date (at beginning of policy period) If any of the described policies are canceled before its expiration date, State Farm will try to mail a written notice to the certificate holderj 0 days before cancellation. If, however, we fail to mail such notice, no obligation or liability will be imposed on State Farm or its agents or representatives. ////�� Name and Address of Certificate Holder o&" ` //,1 /Ler Pat Persi Chino Si lure of Au horiz eprese tative� 915 10th St Title PO Box 758 Greeley, CO 80632 Date PROGRAM BUDGETS PROGRAM ayivrata tYl MANUAL BUDGET A TOTAL HOURS OR DAYS OF DIRECT SERVICE PER CLIENT V B TOTAL CLIENTS TO BE SERVED 60 C TOTAL HOURS OR DAYS OF DIRECT SERVICE FOR YEAR(A X B) ;290 D COST PER HOURS OR DAYS OF DIRECT SERVICES ( E/C ) E TOTAL DIRECT SERVICE COSTS cS F ADMINISTRATION COSTS NON-DIRECT ALLOCABLE TO PROGRAM aT G OVERHEAD COSTS ALLOCABLE TO PROGRAM /$/s H TOTAL DIRECT,ADMINISTRATION & OVERHEAD COSTS (E + F +G) c teCC76 I ANTICIPATED PROFITS CONTRIBUTED BY THIS PROGRAM /S759 J TOTAL COSTS AND PROFITS FROM THIS PROGRAM (H + I) (3,27/4(4/ K TOTAL HOURS OR DAYS OF DIRECT SERVICE FOR YEAR(C ) O290 L RATE PER HOURS OR DAYS OF DIRECT, FACE-TO-FACE SERVICE TO BE CHARGED TO WELD COUNTY SOCIAL SERVICES (J 1K) /575,�D CERTIFICATION STATEMENT I I-A/PEA ,a!,i€Wt 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 in cr MANUAL BUDGET DIRECT SERVICE COSTS MANUAL BUDGET Minimum Budget Average Total % SALARY %OF SALARY % SALARY % SALARY Degree If Of Salary Salaries/ 100% ALLOCATION AND ALLOCATION AND ALLOCATION AND ALLOCATION AND y M DESCRIPTION L or Cert FTEs a 1.0 FTE Benefits ALLOCATED TO PROGRAM OTHER COSTS TO PROGRAM OTHER COSTS TO PROGRAM OTHER COSTS TO PROGRAM OTHER COSTS PROGRAM CAUN l // &..4//OYI :, DIRECT LABOR FACE-TO{ACE POSITION,TITLE OR JOB FUNCTION '� '[s °t TOTAL DIRECT LABOR PER PROGRAM ." :` - '` OTHER DIRECT COSTS PER PROGRAM FACE-TO-FACE u • O TOTAL DIRECT COSTS PER PROGRAM � [' S_ " E GRAND TOTAL DIRECT SERVICE COSTS MANUAL BUDGET ADMIN COSTS NON-DIRECT • MANUAL BUDGET Minimum Budget Average Total % SALARY % SALARY % SALARY % SALARY Degree tt Of Salary Salaries/ 100% ALLOCATION AND ALLOCATION AND ALLOCATION AND ALLOCATION AND DESCRIPTION or CellFTEs @ 1.0 FTE Benefits ALLOCATED TO PROGRAM OTHER COSTS TO PROGRAM OTHER COSTS TO PROGRAM OTHER COSTS TO PROGRAM OTHER COSTS PROGRAM Gad-! Arc)i' _lion . . DIRECT LABOR NOT FACE-TO-FACE ._ .- ` 777.: 7.._ _ 7777. _ ,. 77 : 7_. . . TOTAL DIRECT LABOR PER PROGRAM NOT FACE-TO-FACE C7 o°716°6 ' " ' OTHER DIRECT COSTS PER PROGRAM NOT FACE-TO-FACE TOTAL DIRECT COSTS PER PROGRAM F GRAND TOTAL DIRECT SERVICE COSTS NOT FACE-TO-FACE o O7/�J/O7sP ` ' MANUAL BUDGET OVERHEAD COSTS AND PROFITS - MANUAL BUDGET • TOTAL ALLOCATED ALLOCATED ALLOCATED ALLOCATED OVERHEAD 100% % OVERHEAD COSTS % OVERHEAD COSTS % OVERHEAD COSTS % OVERHEAD COSTS DESCRIPTION COSTS ALLOCATED TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM T— O PROGRAM TO PROGRAM PROGRAM Crs�>/1' Ail- Qri0/i .. . .. OVERHEAD � .�� Mr. . G TOTAL OVERHEAD COSTS /I/0 " " ' ' I TOTAL ANTICIPATED PROFITS /557 _ ., TOTAL OVERHEAD AND ANTICIPATED PROFITS ?��n '; " " r MANUAL BUDGET SUPPLEMENTAL NARRATIVE TO RFP: EXHIBIT B RECOMMENDATIONS x CONDITIONS RECEIVED BY APR 1 3 2004 VW WELD uuu DEPT. �-mmuntro i&n raining 841 Durum Street Windsor, Colorado 80550 (970) 674-8874 (970) 674-8875 Fax April 13, 2004 Ms. Gloria Romansik Weld County Department of Social Services P. O.Box A Greeley, Colorado 80632 Dear Gloria: I received your letter stating the conditions for renewal of the grant proposal. The condition: to notify the Department of any staff change at the time of the change. This condition is acceptable and I will definitely let the Department know of any additions when they occur. For darification, I added a potential new mediator to handle any overflow if necessary. I actually added her as I wrote the 2004/2005 grant. If the department has concerns with any mediator that I have listed,I trust you will let me know. If there is anything else I can assist you with about this proposal, please contact me. Sincerely, —)67"--/a4-•-'-' ,. 647 Kathleen L. Luker, M.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)352-6933 O e COJiORADO April 6,2004 a en Luker Mediation,Communication,&Training,Inc. 841 Durum Street Windsor,CO 80550 Re: RFP 04008:Mediation and Facilitation under the Intensive Family Therapy Program Area Dear Ms.Luker: 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 04008, Mediation and Facilitation under the Intensive Family Therapy program area, 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 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, 1,1 Ju A. go,D ector cc: Juan Lopez,Chair,FYC Commission Gloria Romansik, Social Services Administrator Hello