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Home My WebLink About20041631.tiff RESOLUTION RE: APPROVE THREE NOTIFICATION OF FINANCIAL ASSISTANCE AWARDS WITH VARIOUS PROVIDERS FOR OPTION B-HOME BASED INTENSIVE 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 three Notification of Financial Assistance Awards for Option B- Home Based Intensive between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Social Services,and the following providers,commencing June 1,2004,and ending May 31,2005, with further terms and conditions being as stated in said awards: 1) Ackerman and Associates, P.C. 2) Lutheran Family Services 3) North Colorado Medical Center- Youth Passages, 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 three Notification of Financial Assistance Awards for Option B- Homes Based Intensive 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. 2004-1631 SS0031 ge, S_S C�� 15 ) Ow 3 vl THREE NOTIFICATION OF FINANCIAL ASSISTANCE AWARDS FOR OPTION B-HOME BASED INTENSIVE PAGE 2 The above and foregoing Resolution was,on motion duly made and seconded,adopted by 40 „owing vote on the 16th day of June, A.D., 2004, nunc pro tunc June 1, 2004. ', l/f ' 4 %` BOARD OF COUNTY COMMISSIONERS r 1861 ,� /� WE COUNTY, COLORADO (, ��,,,� � ti kr 7' %/V Robert D. Masden, Chair .* Clerk to the Board // // William H. rke, Pro-Tern BY: /S��/�j/ eputy Clerk to the Board M. J. ile AP V AS TO • David Long un y Attorpe Glenn Vaad Date of signature: 4 -g-Y-CV 2004-1631 SS0031 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 • COLORADO MEMORANDUM TO: Robert D. Masden, Chair Date: June 14, 2004 Board of County Commissioners FR: Judy A. Griego,Director, Social Services Lab 6 q.t., RE: Notification of Financial Assistance Awards for Home Based Intervention with Various Providers Enclosed for Board approval are Notification of Financial Assistance Awards(NOFAAs) for Home Based Intervention 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 Home Based Intervention. These services are for children,youth, and families receiving child welfare services. Generally, services provided primarily in the home of the client and include a variety of services, which can include therapeutic services, concrete services, collateral services and crisis intervention directed to meet the needs of the child and family. 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. Lutheran Family Services $84.02 per hour C. North Colorado Medical Center—Youth Passages $71.45 per hour If you have any questions,please contact me at extension 6510. 2004-1631 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 FY 04-PAC-2001 Revision (RFP-FYC- (04010) Contract Award Period Name and Address of Contractor Beginning 06/01/2004 and Ackerman and Associates,P.C. Ending 05/31/2005 Option B—Home Based Intensive 1750 25th Avenue, Suite 101 Greeley,CO 80634 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Solution-focused services provided primarily in Assistance Award is based upon your Request for the home. Maximum hours provided is 20 hours Proposal(RFP). The RFP specifies the scope of per referral. Services are focused on assessing services and conditions of award. Except where it is needs,providing short-term intervention and in conflict with this NOFAA in which case the assisting Department with recommendations. NOFAA governs,the RFP upon which this award is Program maximum is 8 families per month with based is an integral part of the action. a monthly average capacity of 5 families per Special conditions month.The average stay in the program is 3 1) Reimbursement for the Unit of Services will be based hours per week over an average of a 3-month on an hourly rate per child or per family. period. Bilingual/Bicultural and South County 2) The hourly rate will be paid for only direct face-to- services are available. face contact with the child and/or family, as evidenced by client-signed verification form, and as Cost Per Unit of Service specified in the unit of cost computation. Hourly Rate Per $ 80.00 3) Unit of service costs cannot exceed the hourly, and Unit of Service Based on Approved Plan yearly cost per child and/or family. 4) Rates will only be remitted on cases open with, and referrals made by the Weld County Department of Social Services. 5) Requests for payment must be an original and submitted to the Weld County Department of Social Services by the end of the 25`"calendar day following Enclosures: the end of the month of service. The provider must X Signed RFP:Exhibit A submit requests for payment on forms approved by X Supplemental Narrative to RFP: Exhibit B Weld County Department of Social Services. Recommendation(s) 6) The Contractor will notify the Department of any X Conditions of Approval change in staff at the time of the change. Appro als: Program Official: By By a Robert D. Masden, Chair Judy Grieygo, Di for Board of Weld County Commissioners Wel ount'y Depa ent of Social Services Date: JUN 1 6 2004 Date: 5/25104 d�n5�/l SIGNED RFP-EXHIBIT A INVITATION TO BID OFF-SYSTEM BID B001-04 (04005--04011 and 006-00) DATE: February 11, 2004 BID NO: RFP-FYC-04010 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-04010) for:Colorado Family Preservation Act--Home Based Intensive Emergency Assistance Program Deadline: March 5, 2004,Friday, 10:00 a.m. The Families,Youth and Children Commission, an advisory commission to the Weld County Department of Social Services, announces that competing applications will be accepted for approved vendors pursuant to the Board of Weld County Commissioners' authority 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 Home Based Intensive Family Intervention Program is a family strength focused home-based services to families in crisis which are time limited,phased in intensity, and produce positive change which protects children,prevents or ends placement, and preserves families. 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 v7 _y —011 c\v e p P rn o n (After receipt of order) BID MUST BE SIGNED IN INK ��e‘stee RC1 a n,rYn Pb p TYPED OR PRINTED SIGNATURE VENDOR V`OLLQk. Man e (l I p kssni ickc c. car v ` �� (Name) H d 'ttez\ Signature By Authorized /� Offic r or Agent of Vender ADDRESA 1��O 3'60 k) - Sul\ to I TITLE a deny � t_eley , DATE 3 -3 PHONE# Cc 33� 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-04010) Attached A HOME BASED INTENSIVE FAMILY INTERVENTION 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 (04010) NAME OF AGENCY: C P rn c fl CL Ind ��ce p '4\ C •ADDRESS: \ 7 �j 25"e. ICU t\ue l CcA\e v tom\ q �c\L3 PHONE en CONTACT PERSON: C�v�e� 1 p rC p in m n 1 ' TITLE: 9 vhSk DESCRIPTION OF FAMILY PRESERVATION PROGRAM CATEGORY: The Home Based Intensive Family Intervention Program is a family strength focused home-based services to families in crisis which are time limited,phased intensity,and produce positive change which protects children,prevents or ends placement, and preserves families. 12-Month approximate Project Dates: 12-month contract with actual time lines of: Start June 1,2004 Start End May 31, 2005 �i End TITLE OF PROJECT: +��G mn r> 1�(�lhlo a Cis Q� C�n rY��r� ��c�j n n -3-oina kP �� 33 oti Name d .ignatre of Person Preparing Document Date 6-man, Name and ignature Chief Administrative Officer Applicant Agency Date MANDATORY PROPOSAL REQUIREMENTS For both new bids and renewal bids,please initial to indicate that the following required sections are included in this Proposal for Bid.For renewal bids,please indicate which of the required sections have not changed from Program Fund Year 2003- 2004 to Program Fund year 2004-2005. Indicate No Chance from FY 2003-2004 to 2004-2005 Project Description Target/Eligibility Populations Types of services Provided pPA Measurable Outcomes _ � (p Service Objectives J2_ �) 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-04010) Attached A Date of Meeting(s)with Social Services Division Supervisor: , i-,?(`-ti 4 Co ents b SSD Supervisor \ G pt ii_. -L �C kAtt i i iL-) 'It r LC AL LI sL A 1_ -t c,`_ `C Ck:�p et �t t. UU � e P �� 1-t. k_- fir) ( i ; t i o 4 r e f •o fi-e t •L� F C� r L ode s e t t to '}/� c.(, f k c c to - (L. Lie k At,cz,,✓ lea . 1 ,�,v C C�tcA.i G,_✓ e 111_,A4 u f.--(_r t k - Lp /ry' -I 4 • {� d 1.t ��C,� l��J�� +I � A l 'EL R�—C,C1.� � _Q�4C .��( I� � / P :t i &i G ,) / He k t sr a,t h ,L/ r.( £ lt'kb✓.Bic" - e-•_ et 1-1-e A Lt , Jo V `6u (1 P L + r qt y eIt d.' UJLi.Le _- 9-k_ LIA r L-ei L-4 4,2. l l ., tiLL (Le � �� FJ ( tI h :{-� • n -c) LI- Name and Signature of Supervisor Date Page 27 of 32 Off-System Bid B001-04 (RFP-FYC-04010) Attached A Program Category Home Based Intensive Family Intervention Program Bid Category Project Title /}ckercra-- a--I- ,i ssm #few, c . Vendor Aclts imec-A Dome. (areal 2 ttflivc I-z'ti.�l y J-nte v'E ..T,O,.,/Q„-P,..? 4 PROJECT DESCRIPTION ✓ ✓ Provide a brief one-page description of the project. II. TARGET/ELIGIBILITY POPULATIONS Provide a one page brief description of the proposed target/eligibility populations. At a minimum your description must address: A. Total number of clients to be served. B. Total individual clients and the children's ages. C. Total family units. D. Sub-total of individuals who will receive bicultural/bilingual services. E. Sub-total of individuals who will receive services in South Weld County. F. Sub-total of Individuals who will have access to 24-hour service. G. The monthly maximum program capacity. H. The monthly average capacity. I. Average stay in the program(weeks). J. Average hours per week in the program. III. TYPE OF SERVICES TO BE PROVIDED Provide a two-page description of the types of services to be provided. Please address if your project will provide the service minimums as follows: A. Therapeutic Services - includes re-parenting, limited family therapy,problem solving, communication skills,parent-child conflict management, etc. Duration of service is limited to 20 hours face-to-face contact per referral. B. Concrete Services -means concentrated assistance in the development and enhancement of parenting skills,problem solving,hands-on parenting. C. Collateral Services -teaching families to work with other community agencies such as drug and alcohol,health care,job training, information and referral, advocacy, etc.,use of community support groups. D. Crisis Intervention Services- including in-home counseling and other interventions available on a 24-hour basis. Provide your quantitative measures as they directly relate to each service. At a minimum, include a nuiSer To be served in each service component. Describe your internal process to assure that FYC resources will not supplant existing and available services in the community; e.g. mental health capitation services,ADAD and professional services otherwise funded. Page 28 of 32 PROGRAM BUDGETS n PROGRAM I K r �o /Ir�o, 175soc� r G Moot b 44t LA 51,/k ittvr,ron(y> /he aze fita(Tr ,We f7tN'fonAT Tt ^5bre. MANUA is,aays.cdtran. a TOTAL HOURS OR DAYS OF DIRECT SERVICE PER CLIENT a 6 ,3e 42i_ as VS LS- - 3 TOTAL CLIENTS TO BE SERVED 6,0 620 100 //00 lig- 34. oe2O TOTAL HOURS OR DAYS OF DIRECT SERVICE FOR YEAR(A X B) /'POO / 1 a0 jZ goo /9490 1 G7o G 0O COST PER HOURS OR DAYS OF DIRECT SERVICES(E/C) $7 00 57. 00 y r 00 GO.oo V w x/(.00 TOTAL DIRECT SERVICE COSTS C i P-00 9/ roa 57(Xf1grV00 7 9-ax' 21,60 `z8'f00 ADMINISTRATION COSTS NON-DIRECT ALLOCABLE TO PROGRAM glob 10ga° Loco ygoo g y 00 472.9-0 ,3Gbb 3 OVERHEAD COSTS ALLOCABLE TO PROGRAM 33 Boo Co Vac a,GOco ng'OO .3% L 0V ya/A0 1,rG on I TOTAL DIRECT,ADMINISTRATION&OVERHEAD COSTS(E+F+G) /O9.000 15-3 Poo siCiiti)l % ow,' 10 coo 191,600 ,(9:000 ANTICIPATED PROFITS CONTRIBUTED BY THIS PROGRAM O O 0 0 0 o TOTAL COSTS AND PROFITS FROM THIS PROGRAM(H +I) 109-000 /5-3002 V gl!Au LYo°O /P-0000 /629,too yew TOTAL HOURS OR DAYS OF DIRECT SERVICE FOR YEAR(C) 19-0b _ 31_20±._ Q,qm j Zoo /6 7o G bo RATE PER HOURS OR DAYS OF DIRECT,FACE-TO-FACE SERVICE TO BE CHARGED TO WELD COUNTY SOCIAL SERVICES(J/K) 8'D.oa 81.00 'O,00 /00.O0 86. 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MOS OWN NM Or. NN en mat OWN MS CON Mt p, ar. OTN OM OWN OWNa arN 001$ as ONON CON aN a NN NN OM CON OWN as as as as OON N 0011$ OWN NN MN arN NN 00N 001$ DUOS arm W. OWN arN NN NN arN arN as ara OWN a ON MSas arN OWN araa a arM arN an Mt a arN as WO CONS CO. OWN 00. N a. NM N'N OWN OWN OWN 001$ MO CON ON WM OM as aam arN as Ot. ON CON OMOSM CO. wank araa OWN 001$ onn as ara .01 oaN 00. OWN OM OWN 00. On DS. COOS OWN 00. ar arapaN Na OM WOOS OOnn as 00'00 OWN as arN aN ON OWN on 0000 OWO 1$0 WO aro aro ar'a WO! 0x10 miaow 10SOOaW NO DM.SLO miaow 41000 ON NO Lade WY'meow saw fOO ~es two NO MOOS N SO NO O 0taco Sato LOa0 SOW POWWOW OOLVOWnY OW1$MINIS aun0 0!Y a .4140F LWWS 014130% AWTR IMP% AMMO N%taa% AVM Mt CNN NO 140% An NWOa� %1$4 PIta x d aay pi SO ICMA 1uay ygtaM arwvo�®Anwro ' 301*01•gbv3NnN I nee,Nawnw UVtKNtAD COSTS AND PROFITS COMPUTERIZED ACTUAL TOTAL ALLOCATED ALLOCATED ALLOCATED ALLOCATED I ALLOCATED ALLOCATED ' D 100% ALLOCATED OVERHEAD COSTS ALLOCATED OVERHEAD COSTS ALLOCATED OVERHEAD COSTS ALLOCATED >VERHEAD COSTS %ALLOCATED)VERHEAD COSTS %ALLOCATED)VERHEAD COSTS COSTS ALLOCATE TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM 0.00 0.00 0.00 0.00 0.00 0.00 $1140 NO $000 $0.00 $0.00 $0.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 NO $0.00 $000 $0.00 $0.00 $0.0 $000 NO $0.00 $0.00 $0.00 $0.00 $0.03 $0.00 NO $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 NO $0.00 $000 $0.03 8000 $0.00 $000 NO $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 NO $0.00 80.00 $0.00 $0.00 $0.00 $0.00 NO $000 $0.00 $0.00 $0.00 50.00 $0.00 NO $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 NO $0.00 $000 $000 $000 $0.00 $0.00 NO $0.00 $0.00 $0.00 $0.O0 $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 $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 $0.00 $0.00 NO $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 IRO $0.00 $000 $0.00 $0.00 $0.00 $11.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 / // ✓'t n.T e-,-,., once X10.- �O$sn..1� cof l'S `ii.OQ (2 6C7S* art.'rnwr� far COnf-f itPC'(cr.s 'Ea /n.twkn- Project Description, 2004-2005 Option B Home Based Services Overview: Ackerman and Associates, P.C. proposes to continue to deliver an Option B Intensive Home Based program. We have had a very successful past seven years of operation. The proposal presented incorporates our accumulated experiences. Target families are either facing imminent out of home placement or the family has a member who has returned from foster placement. These short term services are designed to help maintain placement at home or to help reunification succeed. In addition, in specific cases, home based services can help prevent placement in residential treatment. Modifications have been made in this proposal to time limit the delivery of services to one twenty hour cycle. Entry into the program would involve construction of very clearly defined and measurable goals for the family to achieve during the Option B program. Such goal construction would be completed and accepted by the client by the end of the second hour of contact. Purpose: We propose to continue to provide home-based services in Weld County that: 1. are strongly based in the principles of bilingual/bicultural treatment, 2. continue to be promptly responsive to the needs of Social Services for feedback on the enrollment of families and the progress of families in the home-based treatment process, 3. continue to be effective at preventing placement of referred children, reunifying children and are time efficient using principles of solution focused therapy 4. place the needs of the child first and is consistent within that mandate while simultaneously being valued and appreciated by caseworkers, social services supervisors and the families that are being served. 5. conform to good management practices that are both cost effective and cost contained as set forth in the practice standard stated in the overview above and further in the project design below. Our target for prevention of placement for the past year was 85% which means of the projected 60 families in our program, no more than nine families should have to ultimately receive placement during the program period. Design: Implementation of our program in Weld County has been quite successful in the last seven years. The proposal incorporates changes requiring more intensive and rapid responses by families to meet the requirements set forth in their case plan. We believe the program should be time limited and results oriented in the delivery of services as specified in the bid request. The goal for 2004-2005 for the program is to maintain service delivery standards as follows: 1. To have all clients referred need no more than twenty total hours of service. 2. All families who need more than 20 hours of treatment will either be: • Referred to a specific life skills program, • Referred to short term intervention programs to finalize treatment, • Referred back to Social Services for determination of future action if progress in our determination has been inadequate. Other considerations: The strength of our staff in this project, in experience, in bilingual/bicultural service delivery and in the delivery of home-based services to over one hundred client families are considerations we think are important for the reviewers of this proposal. Cost containment due to state budget constraints have reduced the size of the staff and the number of doctoral level providers and psychologists participating in this proposal. Emily Jaramillo, M.A., is a bilingual Licensed Professional Counselor from the Greeley community with a master's degree in counseling. She also self-identifies as Hispanic. She has worked in the Family Recovery Center and in educational support for minority students at UNC as well in private practice, including work for Home Based clients for several years. Valerie Larson, M.S.W. is a Licensed Clinical Social Worker with experience in family issues, sexual abuse of children and intervention. She has worked in residential treatment prior to joining Ackerman and Associates and has been a home based provider over the last year. Dr. Joyce Ackerman, Licensed Psychologist, is director of Ackerman and Associates and clinical supervisor of the program. Other staff members are listed later in this proposal. John Gray MA LPC has extensive experience in family systems oriented therapy in a variety of casework settings for departments of social services. Bill Kelly is a master's level psychotherapist who has extensive experience in school related issues with teens and families. We seek to continue to be on the list of approved vendors for the provision of these services. Target/Eligibility Populations A. Total number of clients to be served. Five families per month times twelve months equal sixty families per year. If we assume a family size of six, two adults and four children, the total client pool to be served is 360 individuals. That number includes at least 60 individuals who face either imminent out of home placement or who need reunification services. B. Distribution of clients. Total number of clients we will serve is approximately 360 as calculated above. Our experience suggests we would expect approximately 120 of these to be adult members of the family and approximately 240 to be minors. The age of distribution of the index case children would tend toward the younger children based on our experience with home-based intensive therapy. We estimate that about one third of the index children would be older than ten with an average age of about 14 and about two thirds would be under ten. The older group would most likely be teenagers in conflict with their family. The younger group will consist of children of no particularly predictable age whose parents are in conflict usually in relation to instability in the marriage. C. Families Served. We would anticipate serving up to 60 family units. D. Sub total who will receive bicultural/bilingual services. As stated above, Emily Jaramillo is a master's level counselor(who is also Hispanic of Mexican American heritage) who can provide services in Spanish or English. She will serve one fourth of the projected caseload. Evelin Gomez, Ph.D. who is also a licensed professional counselor who is bilingual in Spanish (and of Central American heritage) could be able to cover an additional one fourth of the population referred. This represents a maximum of 30 families. Thus, one half (or more if needed) of the projected total will be able to be conducted bilingually. All of the services provided (for a maximum of 60 families) would be done in a manner that is sensitive to the culture of origin of the family. E. We can provide service in South County and have done so as requested since our inception of these services in 1997. We anticipate that up to one third of the projected caseload (or 20 families) may reside in the South County Area. F. Accessibility. All providers of Ackerman and Associates are accessible through a 24 hour answering service, cell phone and pager system. On weekends, our 24 hour access reaches the provider on call who is always a licensed Mental Health Provider. These providers are Laurence Kerrigan, Ph.D., Susan Plock Bromley, Psy. D., Emily Jaramillo Montoya, M.A,. L.P.C.,.John Gray MA LPC, Joyce Ackerman, Ed..D., Valerie Larson, M.S.W., L.C.S.W., G. Maximum per month. The program maximum is eight families accepted into the program per month. H. The monthly average capacity is five families per month. I. The average stay in the program is three hours or more per week over an average of a three month period (to a 20 hours maximum). For some families the twenty hours of treatment may be delivered over a longer or shorter period with more services delivered early in the program and less per week toward the end of treatment. This is a design where services are more intense during a crisis and decrease gradually as clinically appropriate. Types of Services Provided We will provide the following solution focused services to all families in the program. Specific details that further define these services are in the section of this bid called Service Objectives. Our model is summarized below: We are using the following strategies to help families attain desired outcomes: 1. An immediate initial response to the crisis is made because people who are in crisis are often motivated to change. 2. The therapist focuses on the family's presenting problem as defined clearly in the referral. Clear statement of the goals for behavioral change often increases the client's motivation to work on that problem. Solution focused therapy acknowledges that clients have the best information about themselves and their lives and can apply skills to solve these problems when properly treated. 3. Services are provided in the client's home environment as much as possible to increase accurate assessment, therapist credibility with the client, and the probability the client will incorporate the material they learn into daily family activities. 4. The practice is available on a 24-hour basis to address client concerns. Such access increases the ability to monitor for potentially dangerous situations and provide immediate assistance in crisis situations. Note that while the modalities outlined are general and may not apply to all families in all cases, the choice of clinical mode of treatment will be determined by the desire to produce evidence of change over the period of treatment in relation to the specific problem for which the family has come to the attention of Social Services System. There is obviously a balance between general improvement for the family unit and specific improvement in current behaviors and likely patterns of behavior that are detrimental to child safety. This balance 5. Home Based Services uses skills-based intervention to empower the client to handle life situations without the help of others. This also lessens the need for ongoing long-term intervention. A. Therapeutic Services: We will provide the following services and document the delivery of these services using an individualized treatment plan for each family. Progress on this treatment plan will be reported to the caseworker on a monthly basis. The family treatment plan based on the referral will be confirmed during the first week of contact. The plan will address the concerns identified by the WCDSS caseworker who fills out the family referral form as well as those raised through a clinical assessment of the family by the therapist. The therapist working with the family will choose clinically appropriate intervention strategies. Inherent in these modalities is the need to show rapid progress on the goals stated in the case treatment plan. Success or failure to do so will be communicated to WCDSS in the monthly reports. In most families served by this program a selection of the following modalities will be utilized based on the individualized list of identified family needs: 1. Re-parenting including emotional support to address those issues related to the parents' family of origin, and parenting role models. 2. Family therapy to address structural and issue related difficulties the family is experiencing. 3. Support groups to address couples' communication, alcohol and drug issues and other issues as identified. 4. Problem solving and negotiation skills to enhance the client's interpersonal effectiveness in implementing change. 5. Communication skills to enhance general aspects of interpersonal effectiveness. 6. Parent-child conflict management skills to enhance the parent's ability to set effective limits for the child in a nurturing manner. Note that while the modalities outlined are general and may not apply to all families in all cases, the choice of clinical mode of treatment will be determined by the desire to produce evidence of change over the period of treatment in relation to the specific problem for which the family has come to the attention of Social Services System. There is obviously a balance between general improvement for the family unit and specific improvement in current behaviors and likely patterns of behavior that are detrimental to child safety. This balance needs to be reflected in the case plan and therapy must focus on achieving child safety and family improvement sufficient to protect the child within the treatment time limits in this program. B. Other Services: In addition to the therapeutic interventions described above, client families must be able to apply concepts and skills to their own specific needs. They must be able to put what they learn into practice in their own family in order to protect their children. Their ability to do so is what we term concrete skills acquisition. We use the term concrete skills acquisition to describe the incorporation of behavioral management practices into daily life of the family. This is distinct from the functional aspects of concrete services that are described later. Progress in this area and in other aspects of treatment will be documented in the family treatment chart. Behavioral Components of Concrete Services: Specific aspects of the family behavior where concrete skill acquisition can be documented and usually is necessary for family success to either prevent placement or retain a child who has been returned to home include: 1. Development/enhancement and maintenance of parenting skills including nurturing, limit setting and appropriate child management. 2. Stress reduction and anger management skills. 3. Communications, problem solving, and negotiation skills to enhance interpersonal effectiveness. 4. Practice in hands on parenting skills using a coaching model to provide feedback, reinforcement, and clarification as to appropriate child management skills. 5. Money management including budgeting and resource acquisition. Only brief services in this area are possible under the current time limitations. Extensive needs in this area will be referred to a life skills program. 6. Other activities of daily living including recreational activities related to enhancing family development, spiritual support, community involvement and maintenance of physical and emotional well being. Only brief services in this area are possible under the current time limitations. Extensive needs in this area will be referred to a life skills program. Additional services may be needed and, if so, referral made to an appropriate resource for collateral services. C. Collateral Services: Collateral services involve connecting the family with the services they need in the community. Such services may include: • Drug and Alcohol Services. Referrals to alcohol and drug treatment programs including Island Grove and Family Recovery Center are available. • Health Care Referrals are also routinely available in our practice. Referrals to Sunrise Health Center, Monfort's Children's Clinic and The Family Residency Program are also available. • Job training referrals are available through the Job Services and through Vocational Rehabilitation. D. Crisis Intervention: Twenty four hour access is assured for the families to reach the providers. We have secretarial and office staff support 9-5 Monday through Friday at Ackerman and Associates, P.C. We maintain a twenty four hour, 365 day a year access system through our answering service. All providers can be reached through pagers by the answering service. In-home services for crisis intervention are available through this on call system. We have a rotating call system within the providers of Ackerman and Associates. 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 referral from their caseworker? 2. Did we accept the family to our program? 3. Is the family making progress with the treatment plan for each component as outlined in the service objectives? 4. Has the family followed through with recommendations and referrals during the course of treatment? Summative Outcomes: Over the duration of the twenty hour treatment, we determine the following information: Is the child still in the home? How well are the changes from treatment persisting? This measures if family behavior is different compared to their behavior before treatment. Specific summative goals are listed below. A. The child receiving services does not go into placement and remains at home at the time the case is closed. This will be measured by recording the status of the child at the time the case is closed. B. Improvement in Parental competency and parent child conflict management will be measured by clinical assessment. A narrative in the monthly summary of treatment of the family will be provided. This is based on a review of the treatment on a month to month basis. This narrative will document the therapist's judgment of changes in parental competency. Success or failure to make progress will be discussed in monthly reports. C. Children will remain in the home twelve months after the case is closed. This criterion can be measured at the twelve month follow up contact by the caseworker. D. Children who were reunified will still be in the home twelve months after the case is closed. This criterion can be measured at the twelve month follow up contact by the caseworker. E. Treatment families will not have a substantiated abuse or neglect twelve months after the case is closed. This information can be obtained by checking with the referring caseworker at Social Services at the same time as points C and D above are assessed. F. Families will be rated "low" on the risk assessment device at closure of the case. The providers will rate the family at the time of case closure on: 1. adherence and success with the treatment plan, 2. pre/post changes as documented in the discharge summary, 3. Clinical impression of future success. Service Objectives We have the following service objectives: A. Improvement of family conflict management. The program is specifically designed to resolve conflicts. A solution focused treatment approach is used. Specifically, treatment will be focused on behaviors that either 1. Precipitated the likely imminent placement of the child or 2. Which prevent the reunification of the child with the family. The initial goal of services is to assist the family in finding behavioral solutions to the existing conflict. Each provider is skilled in family systems work and solution focused therapy. Other aspects of conflict management include parent child conflict resolution, problem solving skills development and application of negotiation and communication skills. B. Improved parental competency in this treatment model concentrates on the parents developing more age appropriate strategies. In dealing with conflict with their child, especially with teenagers, the areas of discipline, protection, instruction and supervision seem most responsive to improvement. With younger children the therapy gives the parents the opportunity in their own home to practice and to clarify the roles each parent expects of the other and what is expected of the child. This model of home-based care is able to improve parental performance based on the experience that this staff brings to this proposal. Some examples of these service objectives include delivery of services in the following skill areas (although not all families will need all skills improved or to work on all topics): improvement of parenting skills related to discipline and management of child behavior, emotional skills set development such as anger management, identification of depression or anxiety related behavior, and techniques for dealing with frustration, interpersonal skills development and assertiveness skills. C. Improve household safety. One aspect of the treatment plan is associated with maintaining a safe household environment. Some families may need help in behaviors related to having a home adequately cleaned, maintained and stocked with food and supplies. Given time constraints in this proposal extensive needs in this area will be referred back to WCDSS for management. D. The program will provide access to needed services as documented in the treatment plan for each family. Specific types of referrals may include the following drug and alcohol treatment, school issues, probation coordination, domestic violence resources, victim's assistance or other referrals. Workload Standards A. The program has a capacity of ten families per month with an average of five families per month. The families will receive an average of three hours per week for twenty weeks with a maximum length of service being five months and a maximum number of hours per family being sixty. All families will be treated within this framework regardless of the family composition. B. We have four licensed mental health providers for this program who will be home based specialists. They areJohn Gray, Emily Jaramillo Montoya, Valerie Larson, and Bill Kelly: • Valerie Larson, M.S.W., L.C.S.W., is a licensed social worker who has residential treatment experience especially with sexually abused children and who has worked with us on home based interventions over the past two years. • Emily Jaramillo Montoya, M.A., L.P.C., received her masters in Agency Counseling. Prior to joining Ackerman and Associates, P.C., she had a wide range of work in mental health including treatment for alcoholic patients and support of minority college students. She is fluent in Spanish. Her undergraduate major was in Criminal Justice and Sociology. She has worked for three years in home based treatment delivery • John Gray M.A. L.P.C. is a caseworker with extensive experience in social services agencies and a specialty in family systems oriented treatment. • Bill Kelly M.A.. is a psychotherapist with extensive experience in educational and school related issues with families and teens All of our staff members are highly regarded by the caseworkers based on feedback we have received from supervisors. Three other psychologists and an additional licensed professional counselor complete the staff of Ackerman and Associates and serve as back up and support for the Home Based Specialists. The back up group is available on call to assist them as well as to consult on intervention strategies on an anonymous case presentation basis. The psychologists are Joyce Ackerman, Ed.D., Laurence Kerrigan, Ph.D., and Susan Bromley, Psy.D. C. Of the up to 72 families the caseload is projected at 16 families with each provider. D. The modality of treatment is home-based solution focused short term therapy. As well, referral and support will be offered as described above. E. Hours/weeks. The total number of therapist hours is 20 per family over three months, or a total for the budget calculation of 1200 hours per year based on our projected average of sixty families. Maximum capacity for 72 families is 1440 hours per year. The hourly fee is requested at $85 as documented in the rate calculation section. F. Staff. There are four individual providers supported by two office professionals in the practice. There are also three psychologists who provide on call support and back up services. G. Supervisor. This contact would be supervised and clinically managed by Joyce Shohet Ackerman, Ed..D., who monitors the project for compliance. The maximum caseload for the supervisor is ten families per month. H. Insurance. Ackerman and Associates, P.C. carries one million three million liability coverage for professional liability on the corporation and its associates and each associate also carries the same level of coverage individually. In addition, Ackerman and Associates, P.C. carries a general liability policy related to accident or injury on our premises through Farmer's Insurance. Each provider carries individual automobile insurance. Staff Qualifications A. All staff members who will be Home Based Specialists exceed the minimum qualifications needed for this project in both education and experience as described above. B. Staff available for the project consists of the four Home Based specialists and three licensed psychologists and a Licensed Professional Counselor. C. Current Mandated Training: All of the above are trained at the master's degree or higher as mental health professionals. All also trained under the supervision of a home based specialist with our program before proving services to this program. D. All of the Home Based specialists and all the psychologists have knowledge of risk assessment and are skilled in the application of that knowledge especially in relation to the assessment of risk of harm to self or others. E. Will staff have required state home based training? We have operated for the past six years without additional training beyond that described in paragraph C above. Unit of service rate computation We have calculated the unit of service rate based in the instructions. We used 2003 data for our agency modified per requirements for low bid as of this fiscal year review process. Using overall figures for the agency we arrive at a figure of$85 per contact hour. The profit for Ackerman and Associates for all core service programs was less than 1% of gross revenues in 2003. The proposed cost is $85 per face to face contact hour. This is consistent with our operating fees for face to face therapy hour as allowed in other protocols we do with WCDSS and provides essentially the same provider fees consistent with the goals we set for all contractual relationships for our providers. Reduction in costs reflects a decrease in doctoral level psychologist participation in this program. Budget Justification A trained accountant who works as an independent subcontractor with Ackerman and Associates tracks contract funds. No special issues are present related to project audit to our knowledge. Ackerman and Associates programs were audited in a random audit (conducted by Anderson and Whitney) after its first year of operation with no deficiencies. Audit of this program conducted on a yearly basis over several years, by Anderson and Whitney, has detected no deficiencies. Ackerman and Associates, P.C. is a type S professional for profit corporation and not a 501.c.3. • 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 afforded by the policies shown below, INSURED Company 1 Truck Insurance Exchange 41an & Joyce Ackerman 1750 25th Ave Ste.101 Jreeley, 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 idicated. 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 Building Coverage 045763807 03/02/2004 07/01/2004 $195,000Fire) Personal Property' 045763807 03/02/2004 07/01/2004 $58,400 Medical Expense $5,000 Automobile Liability Umbrella Liability Worker's Compensation rtificate Holder Cancellation ;Id County Bank Should any of the above described policies be cancelled before the expiration date thereat'. 35 23`d Ave the issuing company will endeavor to mail 30 days written notice to the certificate holder /an S' CO 80621 named to the left, but failure to mail such notice shall impose no obligation or liability of any kind upon the company,its agents or representatives. Authorized Representative • EXECUTIVE E 1/20/04 - A PSYCHOLOGISTS PROFESS IONAL LIABILITY POLICY THIS IS A CLAIMS MADE POLICY-PLEASE READ CAREFULLY *** RENEWAL *** NOTICE:A LOWER LIMIT.OF LIABILITY APPLIES TO JUDGEMENTS OR SETTLEMENTS WHEN THERE ARE ALLEGATIONS OF SEXUAL MISCONDUCT(SEE THE SPECIAL PROVISION"SEXUAL MISCONDUCT"IN THE POLICY). POLICY NO: 008-1766682 DECLARATIONS ITEM 1. (a)NAME AND ADDRESS OFINSURED: ACCOUNT NO: CO-KERL175-0 0099745B ITEM 1. (b)ADDITIONAL NAMED INSUREDS: LAURENCE P. KERRIGAN, PH.D. 1750 25TH AVE. SUITE #101 GREELEY, CO 80634 TEM2. ADDITIONAL INSUREDS: TYPE OFORG: INDIVIDUAL EM 3. POLICY PERIOD: FROM: 12/01/03 TO: 12/01/04 12:01A.M.STANDARD TIME AT THE ADDRESS OF THE INSURED AS STATED HEREIN: 'EM 4. LIMITS OF LIABILITY: (a)$ EACH WRONGFUL ACT OR SERIES OF CONTINUOUS,REPEATED 1, 000, 000 OR INTERRELATED WRONGFUL ACTS OR OCCURRENCE (b)$ 5, 000 DEFENSE REIMBURSEMENT IcI , ODD, 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(if exercised):$ 2 , 150 . 68 NO DISCOUNT INCLUDED 18. POLICY FORMS AND ENDORSEMENTS ATTACHED TO THIS POLICY 13 8 (7/95 ED. ) B22137 PERSONAL.• DATA SHEET Identifying Information: Name : Laurence "Larry" P. Kerrigan, Ph. D. Address : ( 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, Campus , Regis College Ph. L. - Philosophy, Toronto,LouisnUniversity, st .tario , Canada, lLouis , Mo. 1960 , ( Ecclesial Degree ) . Ph . D. - California School of Professional Psychology , Berkeley/Alameda Campus , 1974 , Clinical Psychology. Currently a licensed psychologist in the state of Colorado. Educational BacIc 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 studies , 1957-60 St . Louis University, Philosophy and Economics , 1963-67 St. Mary' s University, Toronto Campus , Theology, 1971-74 California School of Professional Psychology, clinical psychology, Berkeley/Alameda Campus Positions Held : 1969-71 Member of Board of Directors, Campion College , Prairie du Chien, WI . 1968-71 Director, Department of Psychology, Campion College . 1971-74 Director of Student Counseling Center, Long Mountain College . 1975-80 Director of Short-term Children and Family Team, Weld Mental Health Center, Greeley, CO . 1975-'87 Clinical Psychologist, Child and Family Team, Weld Mental Health Center, Greeley, CO . a. • 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. 1975-80 Director , Short-Term Therapy Team , Children and Family Unit , Weld Mental Health Center, Greeley , CO . 1980-87 Member of Children and Family Therapy Team, Weld Mental Health Center, Greeley, CO . 1987- present Full time private practice with Joyce Shohet Ackerman , Ed . D. , Licensed Psychologist , Greeley, CO . Part time practice at Weld Mental Health Center , Greeley , CO . Publication :• Kerrigan , Laurence P. - The Relationship Between Therapist and Client ' s Perceptions of One Therapy Session . Published Doctoral. Dissertation , University of California School of Professional Psychology. Copyright , 1974 . Wor_ksho_s and Speci..al._Tra.ining: Since 1974 , I have attended an average of about three workshops per year. Most of these workshops have presented specialized training in the following areas : Neuro-linguistic training , Autogenic and relaxation training , Visualization-Imagery- Hypnosis , Cognitive-Behavioral Therapy, Ericksonian approaches to hypnotherapy and psychotherapy, family therapy, Strategic family therapy, Sexual abuse , dynamics and applied treatment , Paradoxical intention psychotherapy, and other related areas . In the last fifteen years , I have taught classes and conducted workshops in the following subjects : The - Psychology of Dreams • • 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:sbromley@bentley.unco.edu EDUCATION: Year(s) Degree Institution Area of Study 1983 PsyD University of Denver Clinical Psychology School of Professional Psychology Denver,Colorado 1968 MSSA lase 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: Year(sl Institution/Organization Position Responsibilities 1985-Pres University of Northern Colorado Assoc.Professor Psychology Teaching/Advising 1983-84 University of Northern Colorado Asst.Professor Psychology Contract Teaching WORK EXPERIENCE—Professional Non Academic: Year(s) Institution/Organization Position Responsibilities 1996-present Ackerman and Associates Psychologist Clinical 1984-85 Kaiser Permanente Psychotherapist Clinical Lakewood, Colorado 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 41086 PUBLICATIONS--Pro fessional/Juried: Musgrave-Marquart,D.,Bromley, S.P. &Dailey,M.B. (1997)"Personality,academic attribution,and substance abuse as predictors of academic achievement in college students". Journal of Social Behavior and Personality 12(2), 501-511. Karlin,N.J.and 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. (FM)The counseling sonrcebook A practical reference on con norary issues. New York: Crossroad Publishing group. pp.466-474. Bromley, S. and Hewitt,P. (1992). Fatal attraction:The sinister side of women's conflict about career and family. Journal of Popular Culture. 26(3),pp. 17-24. Retzlaff,P. and Bromley, S. (1991). "A Multi-Test Alcoholic Taxonomy: Canonical Coefficient Clusters". Journal of Clinical Psychology 47(2),pp. 299-309. Bromley, S.P. (1985). "Treatment of Pain:Theory and Research"in Zahourek,R. (Ed.). Clinical Hypnosis and Therapeutic Suggestion. New York: Game and Stratton. Reprinted in Zahourek,It (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) Retzlaff,P.and Bromley,S.(1989). "The Basic Personality Inventory:Alcoh Sub-Group Identification". Poster session at the Joint Convention of the Rock Mountain Psychological Association and Western Psychological Association,Reno, Nevada. Bromley, S. (1988). "Our Culture Affects Our Pain."Paper presentation,National Convention of Popular Culture Association and American Culture Association,New Orleans,LA. (March). Bromley, S. (1987). "Husband-Assisted Autohypnosis for Labor and Delivery: A Clinical Model". Paper presented at Rocky Mountain Psychological Association,Albuquerque,New Mexico(April). Bromley, S. and Loy,P. (1987). "Politics of PMS". Paper presentation Association of Women Psychologists, Denver,Colorado(March). PROFESSIONAL PRESENTATIONS—Invited: Handelsman, M.M.,Bromley, S.P. &Davis, S.F. (1995)."Clinical Psychologist,Counseling Psychologist, Clinical Social Workder, or Psychology Professor: Which Degree is Right for Me?"Psi Chi invited panel presentation,Rocky Mountain Psychological Association,Boulder,CO(April). Bromley, S. (Co-Chair), Seibert,P. (Co-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(sl Institution/Organization ≥ le 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 J Tinned 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 CLAIMS-MADE 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.) 2. Policy Period: 12:01 A.M.Standard Time At From: To: Location of Designated Premises 04/01/2003 04/012004 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 fomr(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- JOYCE SHOHET ACKERMAN, Ed.D. 1750 25lh 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 e American Psychological Association Colorado Psychological Association (elected board member 1986-1989) HONORS President's Award - Colorado Psychological Association, 1989 EDUCATION 1978 - 1981 Ed.D. in Counseling Psychology, University of Northern Colorado, December 1981 graduate 1972- 1974 M.S. in Education (E.D./L.D.) Lesley College,Cambridge, Massachusetts,August graduate 1968 - 1971 B.S. in Special Education and Elementary Education with a minor in psychology Boston University, Boston, MA, December 1971 graduate PROFESSIONAL EXPERIENCE 1981 - present Clinical Director in group practice in Greeley,CO. Among responsibilities are: Diagnosis, therapeutic intervention and referral for adults, families,children and groups. Primary areas are: mediation, alternative conflict resolution,stress reduction. Also developing, organizing and presenting workshops and consultative programs to community,schools,organizations and agencies. 1986- present Consulting psychologist on interdisciplinary team for in-patient rehabilitation program. Progressive Care Rehabilitation Center,Greeley, CO. Medical Director Dr,Judith Vaughan, Neurologist. Adults with traumatic injuries- primary problems are: psychological aspects of physical rehabilitation,grief counseling,and brief group counseling using cognitive-behavioral goal oriented therapy. 1989 - 1992 Consulting psychologist for Head Injury Treatment Team North Colorado Medical Center,Greeley CO Team coordinator - Dr. John McVicker,neurosurgeon. 1986 - 1989 Consulting psychologist for Family Recovery Center(in-patient substance abuse/chemical dependency program), North Colorado Medical Center,Greeley CO Coordinator Ruth Wick,R.N. 1986- 1989 Provider and Coordinator for Mental Health Services in Northern Colorado for Peak Health Care(HMO). Peak mental health services utilized a three-session model for initial services followed by referral. Activities included coordination of Psychological and Psychiatric Services for approximately the last two years of the Contract. Peak supervisor- Elaine Taylor 1983 - 1986 Psychologist subcontractor for a Vietnam Veteran's Counseling Program funded by the Veteran's Administration. Principal Contract Dr. Robert Stewart. 1980- 1987 Part time faculty member with responsibilities for classes, workshops and community programs in parenting skills. Family/Life Education Program, Aims Community College,Greeley CO August 1980- August 1981 -Clinical internship on Children's Team of Community Mental Health Center. Responsibilities included: consultation to schools and community programs; therapy for children and families; and assessment of diverse mental health programs. Assistant program evaluator - developed evaluation tools to determine cross-cultural perceptions of expectations and satisfaction with services. Supervisors - Dr. Joan Gillespie and Dr. Laurence P.Kerrigan. • APA National Convention in Toronto,Canada"Psychology and National Health Reform: "National Health Insurance: Policy Considerations. Benefit Designs. and Economic Realities",and"Marketing: Psychology's Key to National Health Reform. 1993 Disaster Relief Training. Alan Keck through Colorado Psychological Association,Denver CO 1992- Fall Short Term Therapy, Bernard Bloom; University of Northern Colorado, Greeley CO 1990- Fall National Cognitive Rehabilitation Conference, Richmond VA 1990 - summer Postgraduate training: 1. Adult Neuropsychological Method based on Lezak Neuropsychological assessment, 1983. 2. Child Neuropsychology, Dr.Hynd. 3. Child Neuropsychological Methods 1988 Cognitive Rehabilitation Training Program, Dr.Sena, Ph.D., Colorado Springs CO 1988 - present Psychologist-Head Injury Treatment Team at North Colorado Medical Center,Greeley CO 1987 Halstead Reitan Neuropsychological Assessment Training. Ralph Reitan, Ph.D., Washington DC Summer 1986 Albert Einstein School of Medicine, Workshop on Adolescent Therapy, Cape Cod MA 1985 to present North Colorado Interdisciplinary Team of Child Custody Member and participant Fall 1985 Interdisciplinary Workshop on Child Custody, Keystone CO Summer 1984 Workshop in Clinical Use of Hypnosis, Boston MA Winter 1983 Workshop on In-patient Programs for Service Related Disorders, Cheyenne Veterans Administration Hospital. Fall 1983 Veteran's Administration Workshop on Post Traumatic Stress Syndrome, Denver Veteran's Center. Fall 1981-Winter 1984 Post-Doctoral Supervised Candidate for Licensure(psychology) under Gale R. Giebler, Ph.D. Licensed Psychologist and Susan Spilman, Ph.D., Licensed Psychologist 1980 - 1981 Intern- Weld County Sexual Abuse Team,Greeley CO Weld Mental Health Center,Greeley CO adults,adolescents, families. Primary areas anxiety disorders,mood disorders and adjustment disorders. Typical problems included: trauma, physical abuse substance abuse,job stress. Orientation used - primarily cognitive-behavioral therapy. 1980 Group Facilitator- Regional and National Conferences in cross-cultural community needs. Flagstaff,AZ-Colorado Springs CO August 1975 -July 1978 Chairperson of the Department of Education and Behavioral Science at an accredited, Indian controlled community college on the Navajo Reservation, Administration responsibilities included: Supervision and evaluation of faculty;budget preparation and management;curriculum development and integration of Navajo culture; personnel recruitment and selection;class scheduling and program development. Also faculty member with academic responsibilities for instruction in Psychology, Child Development and Counseling courses, advising and counseling students. Navajo Community College,Tsaile AZ September 1974-August 1975 Education Specialist and counselor at an Indian controlled primary and secondary school on the Navajo Reservation. Coordinated community resource program,which included: counseling,student assessment, prescriptive programming,staff development and curriculum. Also, adjunct faculty for the University of New Mexico and for Navajo Community College at the Rough Rock Demonstration school, Rough Rock, AZ September 1972-June 1974 Designed and coordinated Learning Center Program for Dedham Public Schools. A program and crisis intervention center for emotionally disturbed children. Responsibilities included: Diagnostic prescriptive programming,counseling,supervision and training of aides, tutors and volunteers,and consultation with regular classrooms teachers. Also organized group and individual meetings with parents. Adjunct faculty for Curry College assisting with in-service instruction for Dedham School System employees. Dedham Public Schools, Dedham MA WORKSHOPS AND SPECIAL TRAINING 1996 Biodyne training workshop adolescent treatment in short term therapy, Tom Kalous, Ph.D. 1995 Biodyne Training Workshops in short term therapy Julian Ang, Ph.D. 1994 Certification in family mediation, CDR Associates, Boulder CO 1993 Disaster Relief Training. Alan Keck, through Colorado Psychological Association, Denver CO 1993 August Hospital Practice for Psychologists Summer 1981 Independent Study of Child Sexual Abuse, University of Northern Colorado Spring 1981 Interdisciplinary Workshop on Assessment of Sexual Assault, Boulder Social Services Summer 1979 Biofeedback Training related to labor and delivery. Summer 1974 Participant in Institute on Obstacles to Learning. Joint Symposium between McLean psychiatric hospital, Harvard University and Lesley Graduate School,Cambridge MA Summer 1973 Kennedy Memorial Hospital,Boston MA. Participant,Summer Aphasia Institute. PUBLICATIONS Ackerman A.,Ackerman,J.S.,Kelley K. Hale K. Family Planning Attitudes of Traditional and Acculturated Navajo Indians. Key Issues in Population and Food Policy. University Press of America, pp. 178-171 (1979) Ackerman,J.S.,Client Expectations and Satisfaction with Community Mental Health Center Services: A Cross-Cultural Analysis Between Hi panics and Anglos. Published Doctor Dissertation,University of North Colorado. Copyright 1981. BRANCH B/A PRODUCER NUMBER DATE OF ISSUE PRIOR CERTIFICATE NUMBER 23 A 0004087 04/01/2003 Renewal PSYCHOLOGISTS PROFESSIONAL LIABILITY CLAIMS-MADE INSURANCE POLICY NOTICE: THIS IS A CLAIMS-MADE POLICY, PLEASE READ THE POLICY CAREFULLY PURCHASING GROUP POLICY NUMBER: 45-0002000 Item DECLARATIONS CERTIFICATE NUMBER: 45P- 2032570 1. Named Insured Ackerman and Associates PC 1750 25th Ave ADDRESS Greeley,CO 80634-4943 Number&Street,Town,County,State&Zip No.) 2. Policy Period: 12:01 A.M.Standard Time At From: To: Location of Designated Premises 05/01/2003 05/01/2004 3. COVERAGE LIMITS OF LIABILITY PREMIUM Professional Liability $ 1,000,000 each incident I $3,000,000 aggregate $ 1,667.00 4. BUSINESS OF THE INSURED: PSYCHOLOGY 5. The Named Insured is: _ Sole Proprietor (including independent contractors) _ Partnership X Corporation _ Other: 6. This policy shall only apply to incidents which happen on or after a) the policy effective date shown on the Declarations: or b)the effective date of the earliest claims-made policy issued by the Company to which this policy is a renewal; or c) the date specified in any endorsement hereto. 05/01/1992 7. This policy is made and accepted subject to the printed conditions in this policy together with the provisions, stipulations and agreements contained in the following form(s) or endorsement(s). PLP-2012(06/93), PU-2008(Rev. 10/94), , PLE-8035(09/97), PLE-8036(09/97), PLE-2167(07/00), POE-8004(05/88)(Ed. *10/93), PLE-2081 Current, PON-2003(08/02) CHICAGO INSURANCE COMPANY 55 E. MONROE STREET, CHICAGO, ILLINOIS 60603 Near North Insurance Brokerage REPRESENTATIVE: Agent or broker: in Association with Trust Risk Management Services Office address: 875 N Michigan Ave Ste 1900 City, State, Zip: Chicago, IL 60611-1803 Toll-Free Number: 1-877-637-9700 PLP-2012(06/93) APA- Valerie Larson PROFESSIONAL LICENSE' License Clinical Social Work, Colorado,License#992608 EDUCATION Completed Post-Graduate Family Therapy Coursework, Family Therapy Training Center of Colorado,Denver, Colorado,June, 1999 Masters in Social Work,University of Denver,Denver, Colorado,June, 1998 Bachelors in Social Work,Northeastern State University, Tahlequah, Oklahoma, December, 1995 PROFESSIONAL EXPERIENCE Shiloh Home Littleton, Colorado Therapist June, 1999—March,2001 • Conducted individual, group, and family therapy for day treatment and residential 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/O: American Professional Agency, Inc . 95 Broadway, Amityville, NY 11701 This is to certify that the insurance policies specified below have been issued by the company indicated above to the insured named herein and that, subject to their provisions and conditions, such policies afford the coverages indicated insofar as such coverages apply to the occupation or business of the Named insured(s) as stated. THIS CERTIFICATE OF INSURANCE NEITHER AFFIRMATIVELY NOR NEGATIVELY AMENDS, EXTENDS OR ALTERS THE COVERAGE(S) AFFORDED BY THE POLICY(IES) LISTED ON THIS CERTIFICATE. Name and Address of Insured: Additional Named Insureds : VALERIE LARSON Type of Work Covered: PROFESSIONAL SOCIAL WORKER Location of Operations : N/A (IF' different than address listed above) Claim History: Policy Effective Expiration Limits of Coverages Number Date Date Liability PROFESSIONAL/ — 1,000,000 LIABILITY SWL-0000000 6/01/03 6/01/04 3,000,000 NOTICE OF CANCELLATION WILL ONLY BE GIVEN TO THE FIRST NAMED INSURED ON THIS POLICY AND HE OR SHE SHALL ACT ON BEHALF OF ALL INSUREDS WITH RESPECT TO GIVING OR RECEIVING NOTICE OF CANCELLATION. Comments: This Certificate _Issued to: Name: VALERIE LARSON 2500 HAVEN COURT Address: EVANS, CO 80620 Au orized Representative WILLIAM P.KELLY EDUCATION 1997-MA-PROFESSIONAL COUNSELLING,UNIVERSITY OF NORTHERN COLORADO 1977-Ph.D.-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 r 1999-Professor Emeritus,Regis University,Denver,CO 1983-1999-Chair,Professor of Education,Regis University,Denver,CO 1978-1983 -Assistant Professor,Elementary and Secondary Education,University of Minnesota-Morris 1970-1973-Assistant Professor,Education Department,Regis University,Denver,CO SECONDARY 2001-2002-Teacher,Mathematics and Speech,Holy Family High School,Broomfield,CO 1974-77—Principal,Greeley West high school,Greeley,CO. 1973-1974-Associate Principal,Longmont high school,Longmont,CO. 1966-67,68-70 Teacher/Administrator/Coach In Denver Catholic High Schools- 1960-1963 Teacher/Coach Marquette University High School,Milwaukee,WI. COUNSELING EXPERIENCE 1999-Green Villa Residential Treatment Center-A Combination Half-Way House and Drug Treatment Center for Convicted Felons with Drug Abuse Problems-Paid Intern, Greenville,Texas 1998-99- Hunt County Mental Health/Mental Retardation-General Counseling for Children,Adolescents, Adults, Families,and Various Groups-Internship-Greenville,Texas 1995-96 Jefferson Center for Mental Health(South Office)General Counseling for Children, Adolescents, Adults,Families,and Various Groups-Intern INDUSTRY EXPERIENCE 1967-1%8- Performance Standards Administrator,CIMA,International Trade Association, Milwaukee, WI 1963-1966-Sales Representative,Denver Area Territory,Hoffrnarm-LaRoche Pharmaceutical Co., Nutley,N.J. LICENSES HELD(Current) Elementary School(K-8)Teaching License, State of Colorado Secondary(7-12)Mathematics and Science Teaching License, State of Colorado HOBBIES Playing Piano,Racquetball,Bicycling,Hiking,Reading,Swimming REFERENCES Dr.Daniel Clayton, Associate Professor of History and former Associate Academic Dean,Regis University, 3333 Regis Blvd.,Denver CO,80221 303-458-4914 Mr. James Neuman,MSW-LSW,Private Psychotherapist,Supervisor of My Practice, 10110 W.26 Ave., Paramount Bldg.,Wheat Ridge CO 303-233-9371 Dr. Allan Service,Provost,Regis University, 3333 W. Regis Blvd,Denver,CO 80221,303-458-1843 CNA Healthcare Providers Service Organization Purchasing Group ®HPSO CNA Plaza, Hohhcve Pm aker Service ory.l Chicago,IL 60685 ,��-- 4111-.ffurattcl.).:et - v . e O• Producer _ Branch Prefix _ Policy Number Policy Period . 018098 970 HI'G 273003448-8 from: 12:01 AM Standard Time on: 07/04/03 to: . 12: i 'M Standar•_Tiat_.911._.0 .4./04_I Named Insured and Address Program Administrator _ �u Healthcare Providers Service Organization WILLIAM P KELLY 159 unyie1R ne Road 11429 W BURGUNDY AVE Hatboro, Co t4L LITTLETON CO 80127-5870 Medical Specialty: Code: Insurance Provided by Clinical Counsclor 72990 American Casualty Co. of Reading, PA CNA Plaza 26S Chicago, IL 60685 COVERAGE PARTS LIMITS OF LIABILITY A. PROFESSIONAL LIABILITY Professional Liability , $1,000,000.00 each claim $6,000,000.00 aggregate Good Samaritan Liability I Included above Personal Injury Liability Included above Malplacement Liability Included above B. Coverage Extensions License Protection $5,000.00 per proceeding $12,500.00a e e Defendant Expense Benefit $5,000.00 aggregate Deposition Representation $1,250.00 per deposition $2,500.00 aggregate Assault $5,000.00 per incident $12,500.00 aggregate Medical Payments $1,000.00 per person - $50,000.00 aggregate First Aid $1,250.00 a re ate Damage to Property of Others $250.00 per ' ci ent S5,000.00 agqreqate 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 Fire and Water Iegai Liability _ Included above subject to $150,000 sub-limit Personal Liabilit 500 000.00 a re ate D. GENERAL LIABILITY Coverage part D. does not apply if Coverage part C. is made part of this policy. Workplace Liability _ None None Hired Auto & Non Owned Auto None Fire & Water Legal Liability None None Personal 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-121500C 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.AIS Affinity Insurance Agency:in MN and OK,AIS Airway Insurance Agency,Inc.;and in CA.AIS Affinity Insurance Agency,Inc.dba Aon Direct Insurance Administrators License#0795465. Master Policy: 188711433 Keep this document in a safe place. This and `� (///��[�(/ 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 £a Associates, Greeley, CO Provide intensive home based family-therapy to families referred by the Department of Social Services. Provide mediation services to families. Co-facilitate family group decision making conferences for permanent placement of children. Provide short- term, solution-focused therapy. Provide therapy to individuals referred from Employee Assistance Programs. Facilitate foster parent training workshops. Provide foster parent consultation. Practice is supervised by Sherri Malloy, Ph.D., Licensed Clinical Psychologist. 1996-1999 Director,McNair Scholars Program, University of Northern Colorado, Greeley, CO Provided counseling, guidance, and academic advising to students who were low- income,first-generation college students, and of a minority group. Identified critical personal,familial, cultural, academic,and financial issues to aid in the development of individual success plans. Planned, developed,and implemented scholarly activities nationally. Developed and directed academic year research seminars. Coordinated research activities for scholars preparing for doctoral study. Directed all efforts to ensure efficient administration of a federal grant. Monitored project budget, supervised and trained staff members. 1995-1996 Assistant Director,McNair Scholars Program, University of Northern Colorado '. Provided counseling, guidance, and academic advising to students who were low- income, first-generation, and of a minority group. Identified critical personal, familial, cultural, academic, and financial issues to aid in the development of individual success plans. Coordinated the recruitment and selection of program scholars. 1996 Psychotherapist(Intern), North Colorado PsychCare/Family Recovery Center, Greeley, CO Facilitated psychotherapy counseling groups and individual counseling for patients and families, with focus on chemically dependent and eating disorders. Performed case management from admission to discharge. Presented psychoeducational information to patients, family members, and staff. Worked collaboratively with a counseling team. 1994-1995 Assistant Coordinator, Student Support Services, University of Northern Colorado, Greeley, CO Provided counseling and academic advisement to at-risk first-generation, low-income, minority students. Identified critical personal,familial,cultural,academic,and financial issues to aid in the development of individual success plans. 1994-1995 Psychotherapist, Weld Mental Health Acute Treatment Unit, Greeley, CO Provided individual and group counseling to chronically mentally ill in-patient clients. Assisted clients in learning self-care and daily hygiene. Coordinated and implemented client life-skills and social-skills activities. CONTINUING EDUCATION/SEMINARS Jurisprudence Workshop for Psychotherapists Family Preservation Bask and Advanced Training Supervised.Practicum in Family Preservation Reaching Children through Play Therapy Play Therapy and Therapeutic Care Fire Starter Training Diverse Learners Academy Counseling At-Risk Students Cultural Diversity Conference Parent/Child Hispanic Youth Leadership Conference PRESENTER/FACILITATOR The Terrific Twos Prenatal Insults and Long Term Effects Social, Emotional&Sexual Development: Infancy through Adulthood Cognitive&Physical Development: Infancy through Adulthood Parenting with Love& Logic Eating Disorders Cultural Sensitivity and Awareness Communicating Across Cultures Conflict Resolution/Communication Skills Setting Limits&Boundaries HONORS/AWARDS Hispanic Leader of the Year, Cesar Chavez Center, University of Northern Colorado, 1999 Keynote Speaker, Latina Youth Leadership Conference, University of Northern Colorado, 1998 Distinguished Alumni, Department of Sociology, University of Northern Colorado Fellowship, Graduate Study, Rutgers State University of New Jersey Scholarship, National Hispanic Scholarship Fund Scholarship, Candelaria Scholarship Date Issued 10/14/2003 Memorandum Holder This memorandum is issued as a matter of information only and confers no ACKERMAN & ASSOCIATES rights upon the holder. This SUITE 101 memorandum does not amend, extend 1750 25 AVENUE or alter the coverages afforded by the GREELEY CO 80634 Certificate listed below. Producer Company Affording Coverage Chicago Insurance Company Seabury & Smith owner 1-776 West Lakes Parkway Covered Person (Status) West Des Moines, Iowa 50398 EMILY L 7ARAMILLO—BANSBERG MA LPC x Employee This is to certify that the Certificate listed below has been issued to the insured named herein for the policy period indicated, notwithstanding any requirement, term or condition of any,contract or other document with respect to which this memorandum may be issued or may pertain, the insurance afforded by the Certificate described_herein_issubjectto_all the terms, exclusions and.conditions-of snrh_Certificate.—The-limits shown may have been reduced by paid claims. Certificate Type of Insurance Number Effective Date Expiration Date Limits each incident 1,000,000 Professional Liability or occurrence Occurrence 80M-4003488 11/01/2003 11/01/2004 3,000,000 in the aggregate each incident General Liability or occurrence Occurrence in the aggregate Should the above described Certificate be canceled Insured before the expiration date thereof, the issuing company will endeavor to mail written notice to the named Memorandum Holder, but failure to mail such EMILY L SARAMILLO-BANSBERG MA LPC notice shall impose no obligation or liabilty of any 183 50 AVENUE PLACE kind upon the company, its agents or representatives. GREELEY CO 80634 Authorized Representative: . ._.,.. a dGeor 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 Extent Psych-care, Greeley, Colorado 1995 . Co-facilitate group therapy sessions in a clinical setting . Coordinate direction of group in conjunction with psychiatrist, director, and all members of therapy team Clinical Care Assistant: Acute Treatment Unit, Weld Mental Health, Greeley, Colorado 1993-1994 . Assist MHT in leading groups . Operate emergency mental health hotline . Participate in in-house professional growth training Teaching Instructor: Mesa State College Experience Montrose, CO 1997- 2002 Taught Classes in: . Social Psychology Social Problems . Marriage and Family Introduction to Sociology Teacher/Director, G&B Academy, Seoul, Korea 1996 . develop curriculum for new ESL program . train and advise ESL teachers . coordinate programs for parents/teachers/children University of Northern Colorado, Greeley, Colorado Instructor 1990-1993 Courses taught: . Sociology of Minorities . Introduction to Sociology Aims Community College, Greeley/Loveland, Colorado Instructor 1990-1993 Courses Taught: . Sociology of Minorities . Introduction to Sociology . Sociology of Education Minot High School, Minot,North Dakota Coach—wrestling 1985-87 Presentations "The use of the Looking Glass Self in Therapy," presented At the Conference for Applied Sociology. October 1998 "Bill McCartney and the Promise Keepers: Exploring Connections Among Sport, Masculinity, and Christianity."Presented at American Alliance of Health, Physical Education,Recreation, and Dance. National convention. 1995 "Social Attachment and Deviant Behavior." Presented at Western Social Science Conference. Regional Conference. 1994 "Mountain Biking as Counter-Culture." Presented at North American Society for the Sociology of Sport. International Conference. 1992 01/18/04 FRI 10:25 FAX 515 243 5180 SEABURY & SMITH O002 . 5 ,ak Date Issued Iatie.. 'f ' 01/15/2004 Insured s This memorandum is issued as a matter JOAN H GRAY of information only and confers no 230 N WIIRAY rights upon the holder. This FORT C0LLINS CO 80524 memorandum does not amend, extend • 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) O'2ier West Des Moines, Iowa 50398 JOHN M 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. C Type of Insurance Certificate rtificate Number Effective Date Expiration Date Limits 'rofessional Liability each incident Occurrence Or occurrence $1,000,000 80N-4005346 12/01/2003 12/01/2004 in the aggregate $3,000,000 seneral Liability each incident or occurrence Occurrence in the aggregate Memorandum Holder ihorized Representative: e SUPPLEMENTAL NARRATIVE TO RFP: EXHIBIT B _ RECOMMENDATIONS X CONDITIONS 94/13/2084 12: 21 '3/1145:334/4 HI;KGKMHN5 rHLat Gt/G[ Ackerman and Associates, P.C. 1750 25th Avenue, Suite 1O1 Greeley, Colorado 8O634 • (970)353-3373 fax(97O)353-3374 April 12, 2004 Gloria Romansik Weld County Department of Social Services P.O. Box A Greeley, Colorado 80632 Dear Gloria; This is in response to your letter of April 7 concerning the results of the bid process for fiscal year 2004-2005. • We accept the inclusion of all of our bids on the vendor list with the following conditions as recommended by the Family and Youth Commission. 1. On RFP 006-00, the caseworker will select the contractor for the home study or relinquishment counseling service, 2. We will notify the department if we have any changes in staff at the time of the change. 3. We will plan to have the following bids included on the vendor list with no additional recommendations: RFP 04007 (Sex Abuse Treatment), RFP 04008 (Mediation and Facilitation under Intensive Family Therapy), RFP 04010 (Option B/Home-Based), RFP 04005 (Lifeskills), and RFP 006-00 (Foster Parent Consultation). Thank you very much. Respectfilll , Joyce Shohet c erman, Ed.D. Licensed Psychologist President, Ackerman and Associates, P.C. • „, DEPARTMENT OF SOCIAL SERVICES P.O.BOX A GREELEY,CO.80632 Websitm www.co.weld.co.vs Administration and Public Assistance(970)352-1551 Child Support(970)352-6933 O • 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,Apri114,2004,'close of business. If you have questions concerning the above,please call Gloria Romansik, 970.352.1551,extension 6230. Sincerely, J/ A. ego, recto cc: Juan Lopez,Chair,FYC Commission Gloria Romansik, Social Services Administrator 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 04-CORE-0001 Revision (RFP-FYC-04010) Contract Award Period Name and Address of Contractor Beginning 06/01/2004 and Lutheran Family Services Ending 05/31/2005 Option B, Home Based Intensive 3800 Automation Way, Suite 200 Fort Collins,CO 80525 Computation of Awards Description Unit of Service The issuance of the Notification of Financial Designed to promote the safety and well being Assistance Award is based upon your Request for of children and their family members. Services Proposal (RFP). The RFP specifies the scope of will build on primary family connections and services and conditions of award. Except where it is help parents improve parenting abilities, identify in conflict with this NOFAA in which case the parental strengths and support their efforts to NOFAA governs,the RFP upon which this award is care for their children.The program will based is an integral part of the action. expedite the return of children to their family Special conditions and assist in creating a stable and nurturing 1) Reimbursement for the Unit of Services will be based family environment. The program serves on an hourly rate per child or per family. families where children are ages 0-18. The 2) The hourly rate will be paid for only direct face to number to be served is 18 families per funding face contact with the child and/or family,as year, average hours weekly 3 per family, evidenced by client-signed verification form, and as maximum of 20 hours direct service per referral, specified in the unit of cost computation. capacity is 3 families per month, average stay in 3) Unit of service costs cannot exceed the hourly and the program is 6-8 weeks. Bilingual-bicultural yearly cost per child and/or family. and South County services available. 4) Payment will only be remitted on cases open with,and referrals made by the Weld County Department of Cost Per Unit of Service Social Services. Hourly Rate Per $ 84.02 5) Requests for payment must be an original submitted to Unit of Service Based on Approved Plan the Weld County Department of Social Services by the end of the 25`'calendar day following the end of the Enclosures: month of service.The provider must submit requests X Signed RFP:Exhibit A for payment on forms approved by Weld County X Supplemental Narrative to RFP: Exhibit B Department of Social Services. Recommendation(s) 6) The Contractor will notify the Department of any X Conditions of Approval changes in staff at the time of the change. Approvals: n Program Official: By '�. \`��\L By Robert D. Masden, Chair Judy 'eg , irecto Board of Weld County Commissioners Weld ty D partmen of Social Services Date: JUN 1`6 2004 Date: 6/ZS/(1LI 6e)47-/43/ SIGNED RFP-EXHIBIT A INVITATION TO BID OFF-SYSTEM BID B001-04 (04005--04011 and 006-00) DATE: February 11, 2004 BID NO: RFP-FYC-04010 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-04010) for:Colorado Family Preservation Act--Home Based Intensive- • Emergency Assistance Program Deadline: March 5, 2004, Friday, 10:00 a.m. The Families, Youth and Children Commission, an advisory commission to the Weld County Department of Social Services, announces that competing applications will be accepted for approved vendors pursuant to the Board of Weld County Commissioners' authority 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 Home Based Intensive Family Intervention Program is a family strength focused home-based services to families in crisis which are time limited,phased in intensity, and produce positive change which protects children,prevents or ends placement, and preserves families. 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 ✓lltne 9e«v TYPED OR PRINTED SIGNA VENDOR Lutheran Family Services (Name) . .written ign e B uthorized Officer + A of Ve er ADDRESS 3800 Automation Way #200 TITLE �mwr- /��e, Ft. Collins CO 80525 / DATE 474C7 PHONE # 970.266. 1788 970.356.6080 The above bid is subject to Teens and Conditions as attached hereto and incorporated. Page 1 of 32 Off-System Bid B001-04 (RFP-FYC-04010) Attached A HOMF BASED INTENSIVE FAMILY INTERVENTION 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 (04010) NAME OF AGENCY: Lutheran Family Services of Colorado ADDRESS: 3800 Automation Way # 200 Ft Collins 80575 PHONE (970) 266. 1788 970.356.6080 CONTACT PERSON: Amy Hatcher TITLE: Program Manager DESCRIPTION OF FAMILY PRESERVATION PROGRAM CATEGORY: The Home Based Intensive Family Intervention Program is a family strength focused home-based services to families in crisis which are time limited,phased intensity, and produce positive change which protects children,prevents or ends placement, and preserves families. 12-Month approximate Project Dates: _ 12-month contract with actual time lines of: Start June 1,2004 Start End May 31, 2005 End T11'LE OF PROJECT: Home Based Family Intervention Program Julie E. Swanson 3/4/2004 Name and Signature of Person Preparing Document Date Judy A. Griego, Director Name and Signature Chief Administrative Officer Applicant Agency Date MANDATORY PROPOSAL REQUIREMENTS For both new bids and renewal bids,please initial to indicate that the following required sections are included in this Proposal for Bid.For renewal bids,please indicate which of the required sections have not changed from Program Fund Year 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 Staff Qualifications nit of Service Rate Computation Program Capacity per Month Certificate of Insurance Pao 25 of 32 Core Services Proposal Home-Based Intensive Family Intervention FY 04-05 Lutheran Family Services of Colorado Home-Based Therapy Option B PROJECT DESCRIPTION Lutheran Family Services of Colorado(LFS) is a community-based agency with an experienced staff that offers a wide range of services to children,families and adults. It is a nonprofit agency that has provided human services in Colorado since 1948. Although the agency was established as an affiliate of the Lutheran Church, it is an equal opportunity agency that provides services to all individuals without consideration of religious beliefs, race, ethnicity, gender or economic status. The purpose of the Home-Based Intensive Family Intervention Program is to promote the safety and well being of children and their family members by reducing the risk of child maltreatment in the home, reducing the risk of imminent placement out of the home and/or assisting with reunifying children with their families. The services provided through this program will build upon primary family connections, help parents improve their parenting abilities, identify parental strengths, identify and link families to community resources and sources of support, and support parental efforts to provide care for their children. The program is directed toward families,focused on family strengths, is protective of children, prevents placement or reunifies children and their families, is time limited, and solution-focused. Families must be receptive to the services; however, exceptions are made for families who are ordered by the court to obtain these services. The program will expedite the return of children to their families and assist in creating a stable and nurturing family environment in which children can grow and develop. If children are returning to their permanent home from out-of-home care, we intend to help them reintegrate and stabilize in the family system as soon as possible. The program goal is to improve both individual and family functioning in a time- limited, solution-focused manner. We will provide crisis intervention services and will link families to additional community resources throughout the duration of the families' involvement with our agency. The Home-Based Intensive Family Intervention Program combines all of the elements listed below. Elements included: • Short Term (six to eight weeks of service duration) • Intensive(a max.of 20 hours of direct service, an average of three hours of direct service weekly) • Home-Based (service is provided in the family's natural environment) • Individualized (treatment focuses on the family's specific strengths and needs) • Solution-Focused (brief counseling provided on areas of greatest risk in the family) • Crisis-Oriented (initial response to family within 24 hours of referral) • Strength-Oriented (intervention builds on behavioral strengths of family members) • Family and clinician as partners(emphasizes relationship between family and clinician;treatment based on family's expertise) The program uses the Family Risk Scales to assess each family's out-of-home placement risk areas,to enable program staff to individualize services for each family's specific needs. Additionally,we will be using a Child Behavior Checklists, when appropriate, to assess problematic behaviors, if any, presented by the children in the family. Lastly, we will use the Adult-Adolescent Parenting Inventory to assess parental values. II. TARGET/ELIGIBILITY POPULATIONS: Because referrals come to LFS from Weld County Department of Social Services (DSS) caseworkers,the decision that a child is at imminent risk of out-of-home placement has been made prior to the referral of the family to LFS for Parenting Coach services. However, if during the process of working with a family unit a LFS staff member feels that a child is in imminent danger, we will immediately contact Weld County DSS to discuss the conditions that exist in the family to determine whether they meet the criteria as defined in 26-5.3-103(2), C.R.S. Families considered to be the appropriate target population for these services are those in which family members are facing problems that have affected their well-being, safety, psychosocial growth and development, and family stability. Families in the midst of a transition, such as reunification, are also appropriate for this program. Families mandated or referred by the courts will be considered for the Option B program contingent upon their willingness to participate in and ability to profit by participation in such services. Primary caregivers must demonstrate a desire to maintain family relationships and must possess the mental stability to utilize home-based services. Children must be at imminent risk of out-of-home placement or have been removed from the home with imminent return expected. Clients will not be eligible for this program if they can be successfully treated with less intensive service programs and those services have not yet been tried. Families appropriate for this program should be able to benefit from services that are primarily therapeutic in nature(vs. concrete and collateral services). The provision of services will have a reasonable possibility of diminishing or ameliorating the problematic behaviors/issues in the home. There must be a manageable level of risk of harm to the child and/or among family members. A. Total number of clients to be served: 18 families or 72 individuals B. Total individual clients and the children's ages: The maximum number of individuals to be served would be 72(with the average family consisting of four members) with the ages of children ranging from birth to 18 years old. C. Total family units: 18 families This estimate is based on 20 hours of direct service per family provided over a seven-week period of time (three hours per week of direct service). We have budgeted .30 FTE (12 hours per week)of professional staff time to this program. D. Sub-total of individuals who will receive bicultural/bilingual services: 18 (4-5 families) We have one bilingual master's level clinician on staff, and we have not experienced a significant increase or decrease in referrals of families who are monolingual and speak Spanish. However, in anticipation of this need within Weld County, we have budgeted approximately one quarter of our clients to receive bicultural/bilingual services. The development of treatment plans takes into consideration culturally appropriate issues,family values and family strengths, and the family is actively involved as part of the team in developing treatment goals and objectives. Spanish classes and materials are also available. E. Sub-total of individuals who will receive services in South Weld County: 18 (4.5 families) This estimate is based on one quarter of our cases being from South Weld County. F. Sub-total of individuals who will have access to 24-hour service: 72 All clinicians carry cell phones and are available for crisis intervention 24-hours per day through an emergency on- call system. G. The monthly maximum program capacity: 4 family units This estimate is based on providing less than three hours of direct service per week per family unit. We have budgeted .30 FTE(12 hours per week)of professional staff time to this program. We have a total of seven clinicians who are available to provide services if needed for an increased number of referrals. H. The monthly average capacity: 3 family units This estimate is based on 20 hours of direct service per family provided over a 7-week period of time (3 hours per week of direct service). We have budgeted .30 FTE (12 hours per week)of professional staff time to this program. I. Average stay in the program(weeks): 6-8 weeks (20 hours of direct service maximum) J. Average hours per week in the program: 3 hours This estimate is based on 20 hours of direct service per family provided over a seven-week period of time. 2 III. TYPES OF SERVICES TO BE PROVIDED LFS offers services with a family-based focus. LFS will provide family therapy, crisis intervention, information and referral services, and will focus on skill building within the family. The program combines each of these following elements in service delivery and promotes the belief that in order for families to begin behavioral change, it is important to strengthen positive techniques that the family already utilizes: short-term, intensive, home-based, solution-focused, crisis oriented, individualized,strengths-based, and family and clinician as partners in the therapeutic process. Therapy is designed to resolve conflicts and disagreements within the family with specific goals identified using a structured and directive brief therapy modality. Services will be provided in a family's environment whenever possible and appropriate. We believe that this treatment approach reduces the stress on the family by reducing the need for the family to adjust to our environment. We further believe that we can provide more appropriate treatment in the family's natural environment. Lastly, we believe that in order to provide brief, solution- focused therapy to families that likely have more chronic needs, a concrete transition plan upon case closure is imperative. Assessment of Family Risks&Strengths: All families receiving home-based therapeutic serves are assessed utilizing the Family Risk Scale upon intake and at case closure. The assessment is helpful in the development of treatment goals and also serves as a means of measuring the progress toward adaptive strategies and pro-social values. The Family Risk Scale (FRS)was designed as a standardized measure to assess a particular kind of risk—a child's need for out-of-home placement. The risk variables measured are those that contribute to, or precipitate, the need for out-of-home placement(i.e., habitability of residence, financial problems, family social support, verbal discipline, knowledge of childcare, etc). The FRS consists of 26 individual rating scales, each with four to six levels that range from adequacy(1)to increasing degrees of inadequacy(5-6) on the variable being measured. The first initial visit with a family is spent assessing these risk variables along with family strengths and talking with the family members about their agenda and concerns. The DSS Caseworker will also be asked to complete a shortened version of the FRS in order to gain further input that will assist with goal development. Assessment of Parenting Values: The Adult-Adolescent Parenting Inventory(AAPI)will be utilized to assess high risk parenting attitudes and behaviors both upon intake and case closure. Responses to the inventory provide an index of risk for practicing behaviors positively correlated with child abuse and neglect(i.e., inappropriate expectations of children, parental lack of empathy toward children's needs, belief in corporal punishment, reversal of parent-child role responsibilities, and oppression of children's power and independence). Low scores indicate agreement in the aforementioned parenting behaviors and a high risk for abuse and neglect. A. Brief, Solution-Focused Therapeutic Intervention: The duration of services for each referral is limited to 20 hours of face-to-face contact per referral for a period of six to eight weeks. Weekly family therapy sessions will be designed to provide comprehensive, diagnostic and treatment planning with the family and other service providers. Therapeutic interventions will be flexible enough to bring in other service providers, if needed. The clinician will provide home-based, short-term, solution-focused therapy which will include the development of problem solving and coping skills, strengthening of the family's communication skills, addressing the current parenting practices and developing healthier parenting habits, working with the family on parent-child conflict management skills, aiding in the transition of reunification, etc. Therapy is designed to resolve conflicts and disagreements within the family with specific goals identified using a structured and directive brief therapy modality. B. Concrete Transition Planning and C. Collateral -Community Resource Linkage The clinician will assist the family in accessing and utilizing community resources to deal with particular risk areas identified (ex: access to health care, housing, employment, extracurricular activities, support groups, continuing therapy, etc). The family's effective use of community resources is an imperative goal within this program, as 3 accessing resources is generally a core issue for families who have achieved a level of stress that would indicate a need for family preservation services. Furthermore, access to community resources reduces isolation and increases support for the family. D. Crisis Intervention Services The clinician will be available to open CORE Services cases on a 24-hour basis. All clinical staff carry cell phones and can respond to a crisis(via telephone)within one hour. The clinician and their supervisor will review cases at least on a monthly basis. A regular monthly meeting will be held with the county caseworker,family, and other involved parties to assess whether or not the family's needs can be met with alternative community services. Every effort will be made to stay within the above parameters. Should a family present with extremely high needs at any given phase of treatment that require services above the stated maximum amounts of time per week to maintain the safety of the family members, the caseworker will be contacted and additional time negotiated. IV. MEASURABLE OUTCOMES The Family Risk Assessment Scales(FRS) and the Adult-Adolescent Parenting Inventory(AAPI)will be used as pre- and post-assessment instruments to measure the following: A. Child remains in the home at the time the case is closed: measured by the status of the child's residence at closing B. Improvements in parental competency, parent/child conflict management and household management competency: measured by components of the FRS and AAPI. Amy, can you specify the variables as you did in the other one? We estimate that 80%of families will improve in this area, i.e., will evidence changed or improved scores from pre-to post-test. C. Children who are currently in their own home will remain in their own home 12 months after the completion of Home Based Intensive Family Intervention family preservation services: measured by observation by the Weld County Department of Social Services. D. Children currently in long-term placement who are provided reunification Home-Based Intensive Family Intervention services will return to their own home and not reenter out-of-home placement 12 months after completion of services: measured by observation by the Weld County Department of Social Services. E. Families who receive either family preservation or reunification services will not have a substantiated abuse or neglect 12 months after completion of Home-Based Intensive Family Intervention services: measured by observation by the Weld County Department of Social Services. F. Cases which receive either family preservation or reunification services by Home-Based Intensive Family Intervention will measure"LOW'on the risk assessment instrument at service closure: measured by the Family Risk Assessment Scales. We estimate that 80% of families will improve in this area, i.e., will evidence changed or lowered scores from pre-to post-test. The FRS and AAPI will be used with the family at the onset of treatment to pinpoint the family's specific intervention needs. The tools may be used throughout the course of treatment to measure the family's movement toward amelioration of the highest risk concerns. The FRS and AAPI will be completed immediately prior to program completion in order to measure the expected improvement in the family and child's functioning. 4 The child's living arrangements will be documented at the time the case is closed. (Is the child still in the home?). An aftercare plan for each family will be developed which includes referral to a less intensive family counseling program and/or the use of informal and community resources, such as family self-help groups or support network. The program staff will follow up regarding the status of the family/child at six months and 12 months with the Weld County DSS. V. SERVICE OBJECTIVES Objective 1. When determined as a need, no less than 80%of individual/foster family households will show improved family conflict management as demonstrated by increased ability to resolve conflicts in a healthy manner, lessened child maltreatment issues, lessened incidents of domestic violence and decreased incidents of delinquent behavior in the children. Objective 2. When determined as a need, no less than 85%of individual/foster family households will show improved household management competencies as demonstrated by an improved financial situation, increased habitability of residence,equitable division of household responsibilities, etc. Objective 3. When determined as a need, no less than 80%of individual/foster family households will show improved ability to access resources as demonstrated by the number of encounters with community agencies, healthcare providers, schools, etc. The three minimum service objectives that the Department would like to have assessed are inherent in both the AAPI and the FRS. The FRS provides a more detailed assessment of the family's risk areas and will satisfy these criteria while the AAPI specifically addresses parenting values and behaviors. Also, a Child Behavior Checklist will be used to assess the children's level of functioning as it applies to these objectives when appropriate. The assessments will be done before and after, as well as during the course of treatment as deemed necessary by the clinician. Monthly Progress Reports and ongoing updating of the Treatment Plan will monitor the objectives. VI. WORKLOAD STANDARDS A. Number of hours per day,week or month: 3 hours per week per family. B. Number of individuals providing the services: 1 (.30 FTE) We have budgeted .30 FTE (12 hours per week)of professional staff time to this program. C. Maximum caseload per worker: 3 D. Modality of treatment: LFS will provide family therapy, crisis intervention, information and referral services, and will focus on skill building within the family. The program combines each of these following elements in service delivery and promotes the belief that in order for families to begin behavioral change, it is important to strengthen techniques that the family already utilizes: short-term, intensive, home-based, solution-focused, crisis oriented, individualized, strengths-based, and family and clinician as partners in the therapeutic process. Therapy is designed to resolve conflicts and disagreements within the family with specific goals identified using a structured and directive brief therapy modality. Services will be provided in a family's home environment whenever possible and appropriate. We believe that this treatment approach reduces the stress on the family by reducing the need for the family to adjust to our environment. We further believe that we can provide more appropriate treatment in the family's natural environment. Lastly, we believe that in order to provide brief, solution-focused therapy to families that likely have more chronic needs, a concrete transition plan upon case closure is imperative. 5 E. Total number of hours per day/week/month: 3 hours per week per family F. Total number of individuals providing these services: 1 (.30 FTE) We have budgeted .30 FTE (12 hours per week) of professional staff time to this program. We have a total of seven clinicians who could provide services if the number of referrals increases. G. The maximum caseload per supervisor: 1:7 H. Insurance: Proof of insurance is attached. VII. STAFF QUALIFICATIONS A. Minimum qualifications in education and experience Clinicians assigned to this program are qualified by one of the following: • A master's degree in social work or another human service field; and/or • A bachelor's degree in social work or another human service field and at least 5 years of post-degree experience in family and children's services. B. Total number of staff We currently employ two Licensed Clinical Social Workers, one clinician with a Master's in Social Work, three clinicians with Masters in Human Development and Family studies, and two employee with a Bachelor's Degree plus over 10 years experience that could potentially provide services in this program. C. Mandated new caseworker training All staff has expertise in family therapy and/or foster care services as demonstrated by specialized training and/or experience. All staff in this program is required to secure 16 hours per year of continuing education training. All staff will receive weekly supervision from a supervisor experienced in foster family support work. The clinical supervisors are also required to secure 16 hours per year of continuing education training. D. Knowledge in risk assessment All LFS staff in the Home-Based Intensive Family Intervention Option B program are trained to use the Family Risk Scales(FRS) in risk assessment. E. Required State Home-Based Intensive Family Services Training LFS staff in the Home-Based Intensive Family Intervention Option B program are trained in the Boys Town family preservation model. If specific training is required by the state, LFS will make every effort for its staff to complete that training at the earliest possible time. VIII. COMPUTATION OF DIRECT SERVICE RATE The required budget spreadsheet is attached. 6 , Off-System Bid B001-04 (RFP-FYC-04010) Attached A Date of Meeting(s)with Social Services Division Supervisor: o?-43 _e, Comments by SSD Supervisor: • A'F'd rif�Laf .-E` ti`" ti -P xA-C-L-- ;L-t-t ,J `Ld� -t.? e-ei-c," ,, . . • 1 e .(e LPGLP P.P ItP f L A Art} . LFS A.,tt-J/ E • ' , v a At At+, 411-‘1,2—, 0t�, iz �� .P e � hi � ri Lpf.c.e ,e`� ,a-w ( ') „-G�EL,,J aej Q._�-�t b cc_u_ P r± p 0 ) �L±,d. R a k P ),1.1.4 f�.P,P i p. i /p l( Cxl�l 3 Name and Signature of SSD Supervisor Date Page 27 of 32 • MRr'-54-2354 14:51 MPRSH RDVRN-RGB RMERjCR 115 383 5573 3.32 A GRe:s „ CER€IFECATF OF L€ASILETY €NSURA.NCc 03/04/200? `"`-` THIS CERTIFICATE :5 ISSUED AS A MATTER OF INFORMATION Ea-sta Advantage America ONLY AND CONFER$ NO RIGHTS UPON THE CERTIFICATE 160 Spear St. 151 Floor HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED ED( THE POLICIES DELAW. San Francisco, CA. 94105 415-983-5145 INSURERS AFFORDING COVERAGE NAILS NW,,.P Lutheran Famzly services o± Coloraao GuideOne Specialty :,PRRA „.M.eeB GuideOne Mutual 363 South Harlan, Suite 200 ,„ey„eQC Denver, CO 80226 ANRERP ,303-922-3433 x 109 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE PDIJCT PERIOD INDICATED.NOTWITHSTANDING ANY REOUIRLAENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THiS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IB EUE.IECT TO ALL THE TERMS,EXCLUSIONS AND CONDITION'S OP SUCH POUCICS.ADGRECATE LIMREBHOWN MAT HAVEBEENREOUCEDET PAID CLAIMS. �n ..n •. :..,n .aln.uulnven PEAKY!FI!CTNS O 41 T.FATnu ,. ,••.. .M .u. LIMIT* wWPAL u..nln E u OCCUMeACE I , 1 1 1, I I Ill X COUMERCLLLGENERAL LMBLPT EAw.DETORErrtm onnNrsesIt.ra,..—, '1, 000, 000 XI oL.0.41.4.0E X OCCUR MEDEIVIA.Yeti 5. 000 A X Counselors 1213-263 7/1/03 7/1/04 ,E.eD„ALAA.IIUMAY .1, 000, 000 OENERN. AVOR6vATE ,3, 000, 000 OENi AGGREGATE LIME IMPIFB PER PRODUCTS.COMPrtWADO I1, 000, 000 • x PDUCY I Up": I I LDC AMIRMwA...AIn , ARUM COMRNED ANGLE LIME a 1,000, 000 IF.�.I w„EOAuTOA 'SCHEDULED AUTOS • BOOIL•MIURY $ I.P.MIEN B e°alit BA1714-122 4/1/03 4/1/04 e XV�EOAUTDS eDDILTI„,I�. I (PmMB M P.DP<.nD.MAne (PM PA".aaL�RY AUTO DALY-EAAGOIDENT a AN,.WTD &ACE DOORMAN e MOODILY AGO cice.nIM..AI,A UAevrtr EACH acEUMRS„CS 34, 000, 009 ODOUR EI.UYSMAOE AGGREGATE , 4, 000, 000 9618-912 7/1/03 ' 7/1/04 B DFGU'CRE.E I x .EYE„„E,I , 10, 000 I •au.Po+slw>uuw I T'I ITIMITE I POFR ew.mt.r u.mnTY "' r. ^. E.EAOH ACCIDENT I —enicaran mar ,IP.Im4,,..y - CL DISEASE-EA EMPLOYEE S TD6CIALPMNOFNeYb • E L.D IS EASE•POLICY LIMIT I AMEN I.cSm1woeoc.ATmnncamm IVCIID.SitkeLUeCN.AeaeeY?I IflIeNrnKGI&PROVMIDM Certificate holder is additional insured as respects general liability only re : contract services of insured as per form CG2026/1185. :ATTFICATE HOLDER CANCELLATION IYN.C ANT CE TIC AVE MOM=PDLLIE&YY CP/CELLO wFRG TIN LTRATW Weld County Social Services MT!MGM, c.wlOwOneA DLLexeeA BTPum 30 PO Box A ,fl a Nonce 2C..,,.F.Te„,L�.Nosey TO, eunMTSAIL„P_row.omoor Greeley, CO 80632 Axe ATTN Judy Greigo DIR R�RIE A,M.EMULATE!, 1Ye�T..I INSURER, AuDoHI:IP RZPRISINTAT :ORD2C(2901/0#' A I OR UciRTURA T ION19B{ PROGRAM BUDGETS COMPUTERIZED AVIDAI. PROGRAM HBT Parent Coach A TOTAL HOURS OR DAYS OF DIRECT SERVICE PER CLIENT 20 28 B TOTAL CLIENTS SERVED (Number indicated is for family units) 18 20 C TOTAL HOURS OR DAYS OF DIRECT SERVICE FOR YEAR(A X B) 360 560 D COST PER HOURS OR DAYS OF DIRECT SERVICES(E/C ) $26.17 $22.39 E TOTAL DIRECT SERVICE COSTS FACE-TO-FACE $9,420 $12,540 F ADMINISTRATION COSTS NON-FACE-TO-FACE ALLOCABLE TO PROGRAM $15,528 $18,648 G OVERHEAD COSTS ALLOCABLE TO PROGRAM $5,298 $5,298 H TOTAL DIRECT,ADMINISTRATION&OVERHEAD COSTS(E+F+G) $30,246 $36,486 I PROFITS CONTRIBUTED BY THIS PROGRAM $0 $0 J TOTAL COSTS AND PROFITS FROM THIS PROGRAM(H +I) $30,246 $36,486 K TOTAL HOURS OR DAYS OF DIRECT SERVICE FOR THE YEAR(C) 360 560 L RATE PER HOURS OR DAYS OF DIRECT, FACE-TO-FACE SERVICE (J/K) $84.02 $65.15 PROGRAM BUDGETS COMPUTERIZED ACTUAL Minimum Budget Average Total Y.OF TIME SALARY %OF TIME SALARY Degree F Of Salary/gene Salaries/ 100% SPENT ON AND SPENT ON AND DESCRIPTION or Cert FTEs @ 1.0 FTE Benefits/Other ALLOCATED PROGRAM OTHER COSTS PROGRAM OTHER COSTS PROGRAM HBT Parent Coach A TOTAL CLIENT HOURS OR DAYS PER PROGRAM 20 28 B TOTAL CLIENTS TO BE SERVED PER PROGRAM 18 20 C TOTAL HOURS OR DAYS PER PROGRAM FOR YEAR 360.00 560.00 DIRECT LABOR FACE-TO-FACE POSITION,TITLE OR JOB FUNCTION Clinician l BA 0.50 $38,400 $19,200.00 NO $0.00 50.00% $9,600.00 Clinician 2 MA 0.30 $43,200 $12,960.00 NO 50.00% $6,480.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 NO $0 $0.00 $0.00 NO $0.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 NO $0.00 WO $0.00 NO $0.00 $0.00 TOTAL DIRECT LABOR PER PROGRAM $32,160.00 $6,480.00 $9,600.00 OTHER DIRECT COSTS PER PROGRAM FACE-TO-FACE Cell Phones $1,080.00 YES 50% $540.00 50% $540.00 Mileage $4,800.00 YES 50% $2,400.00 50% $240000 NO $0.00 $0.00 NO $000 $0.00 NO $0.00 $0.00 NO $0.00 $000 TOTAL OTHER DIRECT COSTS PER PROGRAM $5,880.00 $8.17 $2,940.00 $5.25 $2,940.00 E GRAND TOTAL DIRECT SERVICE COSTS $38,040.00 $26.17 $9,420.00 $22.39 $12,540,00 PROGRAM BUDGETS COMPUTERIZED AC I tIA 1. Minimum Budget Average Total %OF TIME SALARY %OF TIME SALARY Degree #Of Salary/gene Salaries/ 100% SPENT ON AND SPENT ON AND DESCRIPTION or Cert FTEs @ 1.0 FTE Benefits/Other ALLOCATED PROGRAM OTHER COSTS PROGRAM OTHER COSTS PROGRAM HBT Parent Coach A TOTAL CLIENT HOURS OR DAYS PER PROGRAM 20 28 B TOTAL CLIENTS TO BE SERVED PER PROGRAM 18 20 C TOTAL HOURS OR DAYS PER PROGRAM FOR YEAR 360.00 560.00 DIRECT LABOR NOT FACE-TO-FACE Clinician 1 BA 0.50 $38,400 $19,200.00 NO $0.00 50.00% $9,600.00 Clinician 2 MA 0.30 $43,200 $12,960.00 NO 50.00% $6,480.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 NO $0.00 $0.00 Supervisor MA 0.15 $43,200 $6,480.00 YES 50.00% $3,240.00 50.00% $3,240.00 Bookkeeping 0.10 $34,944 $3,494.40 YES 50.00% $1,747.20 50.00% $1,747.20 Other Administrative 0.03 $27,456 $686.40 YES 50.00% $343.20 50.00% $343.20 $0.00 NO $0.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 NO $0.00 $0.00 TOTAL DIRECT LABOR PER PROGRAM NOT FACE-TO-FACE $42,820.80 $11,810.40 $14,930.40 OTHER DIRECT COSTS PER PROGRAM NOT FACE-TO-FACE Professional Fees $58.00 YES 50% $29.00 50% $29.00 Contracted Services $2,600.00 YES 50% $1,300.00 50% $1,300.00 Conference 8 Training $450.00 YES .50% $225.00 50% $225.00 Travel B Transportation $350.00 YES 50% $175.00 50% $175.00 Telephone 8 Data Communications $300.00 YES 50% $150.00 50% $150.00 Occupancy $2,800.00 YES 50% $1,400.00 50% $1,400.00 Office Services $520.00 YES 50% $260.00 50% $260.00 Insurance $357.40 YES 50% $178.70 50% $178.70 NO $0.00 $0.00 TOTAL OTHER DIRECT COSTS NOT FACE-TO-FACE PER PROGRAM $7,435.40 $10.33 $3,717.70 $6.64 $3,717.70 F GRAND TOTAL DIRECT SERVICE COSTS NOT FACE-TO-FACE $50,256.20 $43.13 $15,528.10 $33.30 $18,648.10 PROGRAM BUDGETS COMPLY]FM/ED ACTl1AI TOTAL ALLOCATED ALLOCATED OVERHEAD 100% %ALLOCATED OVERHEAD COSTS %ALLOCATED OVERHEAD COSTS DESCRIPTION COSTS ALLOCATED TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM PROGRAM HBT Parent Coach A TOTAL CLIENT HOURS OR DAYS PER PROGRAM $20.00 $28.00 B TOTAL CLIENTS TO BE SERVED PER PROGRAM $18.00 $20.00 C TOTAL HOURS OR DAYS PER PROGRAM FOR YEAR 360.00 560.00 OVERHEAD 12% $10,595.54 YES 50.00% $5,297.77 50.00% $5,297.77 NO $0.00 $0.00 NO $0.00 $0.00 NO $0.00 $0.00 NO $0.00 $0.00 NO $0.00 $0.00 NO • $0.00 $0.00 NO $0.00 $0.00 NO $0.00 $0.00 NO $0.00 $0.00 NO $0.00 $0.00 NO $0.00 $0.00 NO $0.00 $0.00 NO $0.00 $0.00 NO $0.00 $0.00 NO $0.00 $0.00 NO $0.00 $0.00 NO $0.00 $0.00 G TOTAL OVERHEAD COSTS $10,595.54 $5,297.77 $5,297.77 I TOTAL ANTICIPATED PROFITS $0.00 IVEs 50% $0.00 50% $0.00 TOTAL OVERHEAD AND ANTICIPATED PROFITS $10,595.55 $5,297.77 $5,297.77 • SUPPLEMENTAL NARRATIVE TO RFP: EXHIBIT B RECOMMENDATIONS X CONDITIONS V.V/4\\°°%""\—M • Lutheran Family Services of Colorado c.• Services that heal,strengthen&provide hope (j April 12, 2004 Gloria Romansik Weld County Department of Social Services P.O. Box A Greeley, CO 80632 Dear Ms. Romansik: We are in receipt of the April 6, 2004 letter concerning the following bids that were submitted by Lutheran Family Services for FY 2004-05. 1. RFP 04010: Option B 2. RFP 04005: Home Based Parent Coach 3. RFP 04005: Visitation 4. RFT 006-00: Foster Parent Consultation Lutheran Family Services hereby accepts the condition applied to all 2004-05 contacts. In specific, LFS will notify the Department of any changes in staff at the time of the change. We look forwart • working with you during the upcoming fiscal year. If you have any questions . call me at 303-217-5830. : ricer- J• �- :arclay President/C' • 363 S. Harlan St., Su' e 200 • Denver, CO 80226-3552 • (303) 922-3433 • Fax (303) 922-7335 • www.lfsco.org LSAV W Wry hWM Nm a DEPARTMENT OF SOCIAL SERVICES P.O.BOX A GREELEY,CO.80632 ' Website:www.co.weld.co.us Administration and Public Assistance(979)352-1551 Child Support(970)352-6933 O • COLORADO April 6, 2004 James Barclay President/CEO Lutheran Family Services 3800 Automation Way, Suite 200 Fort Collins,CO 80525 • Re: RFP 04010: Option B,Home Based •` RFP 04005: Lifeskills,Home Based Parent Coach RFP 04005: Lifeskills,Visitation RFP 006-00:Foster Parent Consultation Dear Mr.Barclay: 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 bids listed below for inclusion on our vendor list with no recommendations. 1. RFP 04010: Option B 2. RFP 04005: Home Based Parent Coach 3. RFP 04005: Visitation 4. RFP 006-00: Foster Parent Consultation B. The Families,Youth,and Children Commission recommended the following condition be applied to all 2004-2005 contracts. The condition is: the provider will notify the Department of any change in staff at the time of the change. All conditions will be incorporated as part of your Bid and Notification of Financial Assistance Award(NOFAA). If you do not accept the condition(s),you will not be authorized as a vendor unless the FYC Commission and the Weld County Department of Social Services accept your mitigating circumstances. If you do not accept the condition,you must provide in writing reasons why. A meeting will be arranged to discuss your response.Your response to the above conditions will be incorporated in the Bid and Notification of Financial Assistance Award. Page 2 Lutheran Family Services/Results of RFP Process for PY 2004-2005 The Weld County Department of Social Services is requesting your written response to the FYC Commission's recommendations and/or 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, as follows: If you have questions concerning the above,please call Gloria Romansik, 970.352.1551 extension 6230. Sincerely, J y A. ego, irect 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-CORE-0010 Revision (FP-FYC-04010) Contract Award Period Name and Address of Contractor Beginning 06/01/2004 and North Colorado Medical Center-Youth Passages Ending 05/31/2005 Option B-Home Based Services 1801 16 Street Greeley,CO 80031 Computation of Awards Description Unit of Service The issuance of the Notification of Financial This program includes family treatment Assistance Award is based upon your Request for interventions that provide re-parenting,problem Proposal (RFP). The RFP specifies the scope of solving, communication skill building, and services and conditions of award. Except where it is parent-child conflict management. Services in conflict with this NOFAA in which case the available in the home and in the clinic-based NOFAA governs,the RFP upon which this award is Multi Family Systems Group held each based is an integral part of the action. Saturday. A full-time Bilingual therapist will Special conditions provide services up to 12 hours per day,40 1) Reimbursement for the Unit of Services will be based hours per week. A per diem Master's Level on an hourly rate per child or per family. therapist will be available to assist in high 2) The hourly rate will be paid for only direct face-to- census periods. Maximum concurrent caseload is face contact with the child and/or family or as 15. South County services are limited to 25%of specified in the unit of cost computation. total cases referred. 3) Unit of service costs cannot exceed the hourly and yearly cost per child and/or family. 4) Payments will only be remitted on cases open with, Cost Per Unit of Service and referrals made by the Weld County Department Hourly Rate Per $ 71.45 of Social Services. 5) Requests for payment must be an original submitted to the Weld County Department of Social Services Unit of Service Based on Approved Plan by the end of the 25th calendar day following the end Enclosures: of the month of service. The provider must submit X Signed RFP: Exhibit A requests for payment on forms approved by Weld X Supplemental Narrative to RFP: Exhibit B County Department of Social Services. Recommendation(s) 6) The Contractor will notify the Department of any X Conditions of Approval changes in staff at the rime of the change. Approvals: Program Official: By By Robert D. Masden, Chair Judy Gri g ,Direct Board of Weld County Commissioners Wel oun / epartment of Social Services Date: JUN 1 6 2004 Date: �/Zshki / o7fCUJ-/63/ SIGNED RFP-EXHIBIT A INVITATION TO BID OFF-SYSTEM BID B001-04 (04005--04011 and 006-00) DATE: February 11, 2004 BID NO: RFP-FYC-04010 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-04010) for:Colorado Family Preservation Act--Home Based Intensive.:, Emergency Assistance Program Deadline: March 5, 2004,Friday, 10:00 a.m. The Families, Youth and Children Commission, an advisory commission to the Weld County Department of Social Services, announces that competing applications will be accepted for approved vendors pursuant to the Board of Weld County Commissioners' authority 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 Home Based Intensive Family Intervention Program is a family strength focused home-based services to families in crisis which are time limited,phased in intensity, and produce positive change whichprotects children,prevents or ends placement, and preserves families. 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 Tnn Seranl l TYPE) OR PRINTED SIGNATURE VENDOR North Colorado Medical Center (Name) Handwritten Signature By Authorized Officer or Agent of Vender ADDRESS 1801 16th Street TITLE Chief Executive Officer Greeley, CO 80631 DATE Z-2-7- 1 PHONE# 352-4121 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-04010) Attached A HOME BASED INTENSIVE FAMILY INTERVENTION 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 (04010) NAME OF AGENCY: North Colorado Medical Center , ADDRESS: 1801 16th Street , Greeley, CO 80631 PHONE @7() 352-1056 CONTACT PERSON: Karen Nicholson TITLE:Behavioral Health Therapist II DESCRIPTION OF FAMILY PRESERVATION PROGRAM CATEGORY: The Home Based Intensive Family Intervention Program is a family strength focused home-based services to families in crisis which are time limited,phased intensity, and produce positive change which protects children,prevents or ends placement, and preserves families. 12-Month approximate Project Dates: _ 12-month contract with actual time lines of: Start June 1, 2004 Start T„n p 1 , 2004 End May 31, 2005 End may_ 31 , 2005 TITLE OF PROJECT: uthPP' assages David Rastatt�r ,j,V -144A . 2/27/04 Name and Signature of Persian Preparing Document Date Jon Sewell ,...)S---- Z_Z7_ i Name and Signature Chief Administrative Officer Applicant Agency Date MANDATORY PROPOSAL REOUIREMENTS For both new bids and renewal bids,please initial to indicate that the following required sections are included in this Proposal for Bid. For renewal bids,please indicate which of the required sections have not changed from Program Fund Year 2003- 2004 to Program Fund year 2004-2005. Indicate No Change from FY 2003-2004 to 2004-2005 _ Project Description x Target/Eligibility Populations x Types of services Provided x _ Measurable Outcomes x — Service Objectives — _ Workload Standards x _ Staff Qualifications x x Unit of Service Rate Computation _ Program Capacity per Month x x Certificate of Insurance Page 26 of 32 Off-System Bid B001-04 (RFP-FYC-04010) Attached A • Date ofMeeting(s)with Social Services Division Supervisor: -,-, 6"--49117 by 4 Co0� -lL D Supervisor: `-i-at—ii n (.tiff... � , It 0 kg,/ R..i a V �C.,rA� �( f.f_ ) fr .e. t -�i) /_n.Q yie LLLtnd_ ` _Lit.? ) �-e.c�tei � h - . r-tb 9r,r Lit). Q�LJ . 1 -kit Q,L- cee_� 1 L frur Atitele eLQ „/'Lv ch t e ,6P P P S f ti:CI @ P 'h.J 4 Li Wit' r A P.e n °/ LLU 44 p LEt_ ai 4 ' 'f .7) A ( I r J,) "..t d 91 �Pi4 �t f L Cr .�.r,C K, P lc.o>LJ In ) (i� 4Zg, ( f ir)-2T-t5 4 Name and Signature of S D Supervisor ' Date / Page 27 of 32 Off-System Bid B001-04 (RFP-FYC-04010) Attached A Program Category Home Based Intensive Family Intervention Program Bid Category Project Title vo>>t-b Pascages Vendor NCMC PROJECT DESCRIPTION Provide a brief one-page description of the project. II. TARGET/ELIGIBILITY POPULATIONS Provide a one page brief description of the proposed target/eligibility populations. At a minimum your description must address: A. Total number of clients to be served. B. Total individual clients and the children's ages. C. Total family units. D. Sub-total of individuals who will receive bicultural/bilingual services. E. Sub-total of individuals who will receive services in South Weld County. F. Sub-total of Individuals who will have access to 24-hour service. G. The monthly maximum program capacity. H. The monthly average capacity. I. Average stay in the program(weeks). J. Average hours per week in the program. III. TYPE OF SERVICES TO BE PROVIDED Provide a two-page description of the types of services to be provided. Please address if your project will provide the service minimums as follows: A. Therapeutic Services - includes re-parenting, limited family therapy,problem solving, communication skills,parent-child conflict management, etc. Duration of service is limited to 20 hours face-to-face contact per referral. B. Concrete Services-means concentrated assistance in the development and enhancement of parenting skills, problem solving,hands-on parenting. C. Collateral Services -teaching families to work with other community agencies such as drug and alcohol, health care,job training, information and referral, advocacy, etc.,use of community support groups. D. Crisis Intervention Services -including in-home counseling and other interventions available on a 24-hour basis. Provide your quantitative measures as they directly relate to each service. At a minimum, include a number be served in each service component. Describe your internal-process to assure that FYC resources will not supplant existing and available services in the community; e.g. mental health capitation services, ADAD and professional services otherwise funded. Page 28 of 32 I. PROJECT DESCRIPTION Youth Passages has been an FYC provider for ten years. Throughout that time we have provided high quality intensive treatment to youths experiencing significant emotional, behavioral, psychiatric, educational, interpersonal, familial and chemical dependency problems. Treatment modalities that we specialize in include: milieu, individual, group, experiential, behavioral and family therapy. Our family therapy program is one of the strengths of our service delivery system. Youth Passages staff has consistently demonstrated the ability to develop positive relationships and facilitate growth with an unmotivated clientele. We feel this skill base will be an asset in working with the type of families referred for Home Based Intensive Family Intervention Program (IFIP). The Youth Passages Home Based IFIP program will consist of 2 to 3 hours of direct service per week per family. The therapist assigned to these cases is bilingual and experienced in the treatment, management and life skills education for families with chemical dependency and domestic violence issues. The intervention model will be based on a brief therapy solution oriented model with an average length of treatment of 7 to 10 weeks. Youth Passages Home Based IFIP will serve children and adolescents under age 18 and their families. This program will serve new clients in our system as well as being utilized as a step down service for our partial hospitalization and intensive outpatient program clients. It should be noted that clients and their families can enter the Home Based Intensive Family Intervention Program directly without having been a Youth Passages partial hospitalization client. An individualized intervention plan will be developed for each family to specify appropriate and attainable goals. Input from referring agencies will be utilized in the formulation of these plans. Youth Passages staff will communicate progress toward treatment goals via biweekly phone reports to WCDSS caseworkers and a written discharge summary at the end of treatment. A clinic based adjunctive therapy program, titled Common Sense Parenting held on Tuesdays or Thursdays at PsychCare from 6:00 to 8:00 P.M. is available to our home based clients. This program offers two hours of parenting education and support focusing on effective praise, preventative teaching and proper use of consequences. The parenting program is research-based and produced by Boys Town Press. The open enrollment parenting group brings the experience of several families together to assist in finding effective methods to handle family difficulties. 1 X 12 Mo Program Name of Project: Youth Passages IFIP Vendor: NCMC Yes/No (Be Specific) Explain How This Item Will Be Met 2.TARGET ELIGIBILITY POPULATIONS QUANTITATIVE MEASURES A.96 Total number of clients to be served in the 12-month 8 kids/month for 12 months program. B.96 Total individual clients who are children under age 18 With younger children(under age 4) the parents maybe the primary client C.96 Total family units as described as follows: Immediate family,extended family and/or foster family D. 72 Sub-total of individuals who will receive bicultural/ Youth Passages will employ one full time bilingual therapist to provide services for this bilingual services program. E. 24 Sub-total of individuals who will receive services in We will accept a limited percentage(25%)of cases for which we will provide services in South Weld County the client's home in South Weld County. F. 96 Subtotal of individuals who will have access to 24 hour PsychCare/FRC is staffed with licensed professionals 24 hours per day,365 days per Services. year.These staff members will collect relevant case information and communicate it to the direct service provider. G. 15 The monthly maximum program capacity H. 8 The monthly average capacity I. 7-10 Average stay in the program(weeks) for IFIP J.2=3 Average hours per week in the program 2 • III. TYPE OF SERVICES TO BE PROVIDED A. Youth Passages Home Based IFIP will include family treatment interventions which provide re-parenting, problem solving, communication skill building and parent-child conflict management. These interventions are available as home or clinic-based services to individual families. Additionally, our clinic- based Common Sense Parenting groups are held on Tuesdays or Thursdays at PsychCare from 6:00-8:OOPM. B. Youth Passages Home Based IFIP will provide concentrated assistance in the development and enhancement of parenting skills, problem solving and "hands-on"parenting. C. Youth Passages Home Based IFIP will provide education and training which will enable families to improve their ability to access services from other community agencies such as drug and alcohol, health care,job training, information and referral, community support groups and client advocacy. D. Youth Passages Home Based IFIP will include in-home counseling for referred clients. PsychCare/FRC is staffed with licensed professionals 24 hours per, 365 days per year. These staff members will collect relevant case information and communicate it to the direct service provider as soon as possible. Quantitative Measures A. 100% of clients will receive family intervention services that include re- parenting, problem solving, communication skill building and parent-child conflict management. B. 100% of clients will receive treatment services that assist in the development and enhancement of parenting skills, problem solving and "hands-on" parenting. C. 100% of clients will receive collateral services which include teaching families to work with other community agencies. D. 100% of clients will receive in-home family intervention services and all clients will be able to call in to speak with a licensed professional 24 hours a day, 365 days a year. This professional will pass on the relevant information to the assigned therapist as soon as the therapist is available. North Colorado PsychCare/Family Recovery Center deals daily with patient funding issues which include mental health capitation, ADAD and private insurance. We will not utilize FYC funds when other payer sources are available. 3 IV. MEASURABLE OUTCOMES A. 80% of children remain in the home at time the case is closed. This will be tracked by gathering relevant information at discharge. B. 80% of clients will demonstrate improvements in parental competency, parent/child conflict management and household management competency as measured by pre and post placement functional tests. This will be measured via an approved parenting skills inventory administered at admission and discharge. C. 75% of children who are currently in their own homes will remain at least 12 months after the completion of Home Based Intensive Family Intervention services. This will be measured via FYC follow-up questionnaire administered 12 months after discharge. D. 70% of children currently in long-term placement who are provided reunification Home Based Intensive Family Intervention services will return to their own home and not reenter out-of-home placement 12 months after completion of Home Based Intensive Family Intervention services. This will be measured via: 1) gathering relevant info at discharge; and 2) FYC follow-up family questionnaires administered 12 months after discharge. E. 75% of families who receive either family preservation or reunification services will not have a substantiated abuse or neglect case 12 months after completion of Home Based Intensive Family Intervention services. This will be measured via a follow-up phone call to the assigned WCDSS caseworker. F. 75% of cases which receive either family preservation or reunification services by Home Based Intensive Family Intervention will measure "LOW" on the risk assessment devise at service closure. This will be measured by an approved questionnaire at the time of discharge. 4 V. SERVICE OBJECTIVES A. 80% of our clients will demonstrate improved family conflict management which will lead to decreased child maltreatment, running away and other offenses. This will be measured via an approved parenting skills and family functioning inventory administered at admission and discharge. B. 80% of our clients will demonstrate improved parental competency as based on their capacity to provide a safe household environment for their children. This will be accomplished during the intervention by addressing safety issues and improving parental protection of their children. This will be measured via an approved parenting skills inventory administered at admission and discharge. C. 100% of our clients will have increased their knowledge of and ability to access other resources in the community and those offered by the local, state and federal governments. This will be measured via an approved parenting skills inventory administered at admission and discharge. VI. WORKLOAD STANDARDS A. The person providing this service for North Colorado PsychCare will be a fulltime bilingual therapist who will not work more than 12 hours per day, 40 hours per week, or 173 (on average) per month. One per diem Master's Level therapist will be available to assist in high census periods. B. Youth Passages plans on treating no more than 15 families concurrently at its maximum capacity. Master's Level therapist(s), as specified in Section A, will handle this caseload. C. Maximum caseload per therapist - 15 D. The treatment modality is a systems based approach to family interventions. The treatment philosophy is brief in nature with solution oriented interventions. Anticipated duration of treatment is 8 to 10 weeks. 5 E. Total Number of Hours of Service- 1-3 hours per day of home based family treatment (on days clients are seen) 2-3 hours per week of family treatment 6 - 12 hours per month of family treatment F. Total number of individuals providing these services- 1 fulltime bilingual therapist 1 per diem therapist for high census G. Maximum caseload per supervisor- 15 H. Insurance- See attached certificate of insurance VII. STAFF QUALIFICATIONS A. The Behavioral Health Therapist(s) providing services will have a minimum of a Master's Degree in psychology, counseling, social work or a related field and work experience treating children, adolescents and families. B. Two staff members will be available for the direct service phase of this project with one additional staff member providing supervision. Additional direct service staff is available on a per diem basis if census dictates. C. Youth Passages staff members will participate in mandated orientation and training as required by NCMC. Our providers are not employees of DSS and should not require the 12 days of training mandated for new caseworkers. We are open to discussing orientation and short term training for our therapists in order for them to become more familiar with DSS rules and regulations. D. The therapists providing services to this program will be fully trained to cover all aspects of the Behavioral Health Therapist II position at North Colorado Medical Center. This includes providing assessment coverage at the Emergency Department as well as providing care to involuntary patients on our locked psychiatric unit. A significant portion of the training for this position includes risk assessment, involuntary treatment and legal reporting requirements. E. Our staff members are not employees of the State of Colorado and should not be subject to state training requirements. As previously mentioned, our 6 therapists possess a minimum of a Master's Degree in psychology, counseling, social work or related field. They also possess direct service experience providing family therapy to at risk children and adolescents. We are open to discussing an orientation period for our therapists to become more familiar with the requirements and requests of DSS. 7 PROGRAM BUDGETS COMPUTERIZED ACTUAL PROGRAM Home Based Intensive EAP A TOTAL HOURS OR DAYS OF DIRECT SERVICE PER CLIENT 20 B TOTAL CLIENTS SERVED 96 C TOTAL HOURS OR DAYS OF DIRECT SERVICE FOR YEAR(A X B) 1,920 D COST PER HOURS OR DAYS OF DIRECT SERVICES(E/C) $29.97 E TOTAL DIRECT SERVICE COSTS FACE-TO-FACE $57,537 F ADMINISTRATION COSTS NON-FACE-TO-FACE ALLOCABLE TO PROGRAM $53,163 G OVERHEAD COSTS ALLOCABLE TO PROGRAM $16,600 H TOTAL DIRECT,ADMINISTRATION&OVERHEAD COSTS(E+F+G) $127,300 I PROFITS CONTRIBUTED BY THIS PROGRAM $10,000 J TOTAL COSTS AND PROFITS FROM THIS PROGRAM(H + I) $137,300 K TOTAL HOURS OR DAYS OF DIRECT SERVICE FOR THE YEAR(C) 1,920 L RATE PER HOURS OR DAYS OF DIRECT, FACE-TO-FACE SERVICE (J/K) $71.45 CERTIFICAtfI ATEMENT I --'7 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 factua 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 //c nz d;,=, .w-a b., � (rti DIRECT SERVICE COSTS COMPUTERIZED ACTEAL Minimum Budget Amapa Total %OF TIME SALARY %OF TIME SALARY %OF TIME SALARY %OF TIME SALARY % TIME SALARY %OF TIME SALARY Degree $Of Salary/Bens Saunas/ 100% SPENT ON AND SPENT ON AND SPENT ON AND SPENT ON AND SPENT ON AND SPENT ON AND DESCRIPTION or Cart FTEs G 1.0 FIE BenefltelOther ALLOCATED PROGRAM OTHER COSTS PROGRAM OTHER COSTS PROGRAM OTHER COSTS PROGRAM OTHER COSTS PROGRAM OTHER COSTS PROGRAM OTHER COSTS PROGRAM Home Based Intensive EAP A TOTAL CLIENT HOURS PER PROGRAM 20 B TOTAL CLIENTS TO BE SERVED PER PROGRAM 98 C TOTAL HOURS PER PROGRAM FOR YEAR 1920.00 0.00 0.00 0.00 0.00 0.00 DIRECT LABOR FACE-TO-FACE POSITION.TITLE OR JOB FUNCTION Therapist AWMS 0.95 $58,906 $55.960.32 YES 100.00% $55,980.32 $0.00 $0.00 $0.00 $0.00 $0.00 Teacher MA/MS - $0.00 YES 100.00% $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Business Associate HS 001 $29,453 $147.28 YES 100.00% $147.28 $0.00 $0.00 $0.00 $0.00 $0.00 Ten Assistant 115 $0.00 YES 100.00% $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PsycMlilet MD 5000 YES 100.00% 10.00 $0.00 $0.00 $0.00 $0.00 $0.00 Per.Professional HS $0.00 YES 100.00% $0.00 5000 $0.00 $0.00 $0.00 $0.00 Food/Nu001wW Assistant N/A $0.00 YES 100.00% $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Clinical Psychologist PHD $0.00 YES 100.00% 10.00 $0.00 $0.00 50.00 $0.00 $0.00 Clinical Coordinator MAWS 0.01 $85,904 $429.52 YES 100.00% $429.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 NO $0.00 $0.00 50.00 $0.00 $0.00 $0.00 TOTAL DIRECT LABOR PER PROGRAM $56,537.10 $29.45 $56,537.10 $0.00 $0.00 $0.00 $0.00 $0.00 OTHER DIRECT COSTS PER PROGRAM FACE-TO-FACE TNraPJSuppees $1,000.00 YES 100.00% $1,000.00 $0.00 $0.00 $0.00 $0.00 $0.00 Educational supplies 10.00 NO $000 $0.00 $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 $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 $0.00 $0.00 TOTAL OTHER DIRECT COSTS PER PROGRAM $1,000.00 $0.52 $1,000.00 $0.00 $0.00 $0.00 $0.00 $0.00 E GRAND TOTAL DIRECT SERVICE COSTS $57,537.10 $29.97 $57,537.10 $0.00 $0.00 50.00 $0.00 $0.00 ADMIN COST NON-FACE-TO-FACE COMPUTERIZED ACTUAL Minimum Budget Avenge Total % TIME SALARY % TIME SALARY % TIME SALARY % TIME SALARY % TIME SALARY % TIME SALARY Degree 0Of Salary/Bens Salads,/ 100% SPENT ON AND SPENT ON AND SPENT ON AND SPENT ON AND SPENT ON AND SPENT ON AND DESCRIPTION or Cart FTEs 441.0 FTE Benefts/Other ALLOCATED PROGRAM OTHER COSTS PROGRAM OTHER COSTS PROGRAM OTHER COSTS PROGRAM OTHER COSTS PROGRAM OTHER COSTS PROGRAM OTHER COSTS PROGRAM Home Based Intensive EAP A TOTAL CLIENT HOURS PER PROGRAM 20 B TOTAL CLIENTS TO BE SERVED PER PROGRAM 96 C TOTAL HOURS PER PROGRAM FOR YEAR 1920.00 0.00 0.00 0,00 0.00 pIRECT LABOR NOT FACE-TO-FACE Regional Dira4a BS 0.010 $122,720 $1,227.20 YES 100.00% $1,227.20 $0.00 $0.00 $0.00 $0.00 $0.00 Clinical Services Coordinator MA 0.010 $65,904 $859.04 YES 100.00% $859.04 $0.00 $0.00 $0.00 $0.00 $0.00 Administrative ASWfad HS 0.010 $44,179 $441.79 YES 100.00% $441.79 $0.00 $0.00 $0.00 $0.00 $0.00 Reimbursement Coordinator HS 0.010 $44,179 $441.79 YES 100.00% $441.79 $0.00 $0.00 $0.00 $0.00 $0.00 Malntsnana Technician HS 0.010 $41,725 $417.25 YES 100.00% $417.25 $000 $0.00 $0.00 $0.00 $0.00 ITTedmiclna BS 0.010 $61,380 $613.60 YES 100.00% 5813.60 $0.00 $0.00 $0.00 $0.00 $0.00- Medical Recants HS 0.010 $31,907 $319.07 YES 100.00% $319.07 $0.00 $0.00 $0.00 $0.00 $0.00 Director Risk Management BS 0.001 $122,720 $61.36 YES 100.00% $81.36 $000 $0.00 $0.00 $0.00 $0.00 Associate Administrator BS 0.001 $245,440 $122.72 YES 10000% $122.72 $0.00 $0.00 $0.00 $0.00 $0.00 Operations Caodinator BS 0.001 585,904 $42.95 YES 100.00% $42.95 $0.00 $0.00 50.00 E000 $0.00 Houselceepiig N/A 0.001 $28,000 $13.00 YES 100.00% $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 Cline,/Psychologist PHD 0.010 $78,088 $760.88 YES 100.00% $760.88 $0.00 $0.00 $0.00 $0.00 $0.00 Therapist Supervisor MA 0.010 $88,289 $882.69 YES 100.00% $862.69 $0.00 $0.00 $0.00 $0.00 $0.00 Therapist MAIMS 0.75 $58,906 $44,17920 YES 100.00% $44,179.20 $0.00 $0.00 $0.00 $0.00 $0.00 TOTAL DIRECT LABOR PER PROGRAM NOT FACE-TO-FACE $50,162.53 $28.13 $50,182.53 $0.00 $0.00 $0.00 $0.00 $0.00 OTHER DIRECT COSTS PER PROGRAM NOT FACE-TO-FACE, Mileage $3,00000 YES 100.00% $3,000.00 0.00% $0.00 $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 $0.00 $0.00 NO $0.00 $0.00 $0.00 $0.00 50.00 $0.00 NO $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 NO $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TOTAL OTHER DIRECT COSTS NOT FACE-TO-FACE PER PROGRAM 53,000.00 $1.58 $3,000.00 $0.00 $0.00 $0.00 $0.00 $0.00 F GRAND TOTAL DIRECT SERVICE COSTS NOT FACE-TO-FACE $53,162.53 $27.69 $53,162.53 $0.00 $0.00 $0.00 $0.00 $0.00 OVERHEAD COSTS AND PROFITS COMPUI'ERIZ®ACTUAL TOTAL ALLOCATED ALLOCATED ALLOCATED ALLOCATED I ALLOCATED I ALLOCATED OVERHEAD 100% %ALLOCATED OVERHEAD COST %ALLOCATED OVERHEAD COSTS %ALLOCATED OVERHEAD COSTS %ALLOCATECOVERHEAD COSTS %ALLOCATED DVERHEAD COSTS %ALLOCATED DVERHEAD COSTS DESCRIPTION COSTS ALLOCATED TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM TO PROGRAM PROGRAM Hare Based Intensive EAP A TOTAL CLIENT HOURS PER PROGRAM 20.00 B TOTAL CLIENTS TO SE SERVED PER PROGRAM 96.00 C TOTAL HOURS PER PROGRAM FOR YEAR 1920.00 0.00 0.00 0.00 0.00 0.00 OVERHEAD UMW, $17,000.00 NO 2.00% $1,740.00 $0.00 $0.00 $0.00 $0.00 $0.00 Bldg Meinterunm $10,000.00 NO 2.00% $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 Food $0.00 NO 0.00% $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Haa*eegiq $52,000.00 NO 2.00% $1,040.00 $0.00 $0.00 $0.00 $0.00 $0.00 DepredMbn $107,000.00 NO 2.00% $2,140.00 $0.00 $0.00 $0.00 $0.00 $0.00 Other Operating Expense $124,000.00 NO 2.00% $2,480.00 $0.00 $0.00 $0.00 $0.00 $0.00 Upgraded $450,000.00 NO 2.00% $9,000.00 $0.00 $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 $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 $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 $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 $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 $0.00 $0.00 NO $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G TOTAL OVERHEAD COSTS $830,000.00 $16,600.00 $0.00 $0.00 $0.00 $0.00 $0.00 I TOTAL ANTICIPATED PROFITS $10,000.00 IVES 100% $10,000.00 $0.00 $0.00 $0.00 $0.00 $0.00 TOTAL OVERHEAD AND ANTICIPATED PROFITS $840,000.00 $28,600.00 $0.00 $0.00 $0.00 $0.00 $0.00 . VERIFICATION OF COVERAGE ISSUE DATE:Jan. 19,2004 Issuer:Banner Health This verification of coverage is issued as a matter of information only,and does not extend or alter the coverage carded by Banner Health. COVERED PARTY COMPANIES PROVIDING COVERAGE COMPANY BANNER HEALTH LETTER A SAMARITAN INSURANCE FUNDING,LTD. 1441 N.12TH STREET COMPANY PHOENIX, AZ 85006 LETTER B COMPANY LETTER C COMPANY LETTER D COVERAGES THIS IS TO CERTIFY THAT THE INSURANCE COVERAGE LISTED BELOW IS CARRIED BY THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS VERIFICATION OF COVERAGE MAY BE ISSUED OR MAY PERTAIN,THE COVERAGE DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF THE POLICIES OF INSURANCE CARRIED BY BANNER HEALTH. CO LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE POLICY EXP.DATE LIMITS A HOSPITAL PROFESSIONAL 8 SIFL 2004 01/01/04 01/01/05 PL EACH LOSS $10,000,000 GENERAL LIABILITY GL EACH LOSS $10,000,000 GL AGGREGATE $10,000,000 HOSPITAL PROFESSIONAL HPL EACH LOSS $ LIABILITY HPL AGGREGATE $ HOSPITAL PROFESSIONAL HPL EACH LOSS $ LIABILITY HPL AGGREGATE $ MEDICAL PROFESSIONAL PER MEDICAL INCIDENT $ LIABILITY ANNUAL AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM WORKER'S COMPENSATION STATUTORY LIMITS $ A AND SIFL 2004 01/01/04 01/01/05 EMPLOYER'S LIABILITY $1,000,000 EMPLOYER'S LIABILITY COMMENTS. BANNER HEALTH HAS ARRANGED TO HAVE COVERAGE EXTENDED TO NORTH COLORADO MEDICAL CENTER. THE INSURED ABOVE IS APPROVED BY THE INDUSTRIAL COMMISSION OF COLORADO TO SELF-INSURE WITHIN THE STATE OF COLORADO. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED OR MATERIALLY TO WHOM IT MAY CONCERN CHANGED BEFORE THE EXPIRATION DATE,BANNER HEALTH WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER,BUT FAILURE TO MAIL SUCH OTICE SHALL IMPOSE NO LIABILITY OF ANY KIND UPON BANNER HEALTH,I INSURERS OR THEIR AGENTS R REPRESENTATIVES. AUTHORI D REPRESENTATIV ASSIGNED NO.'.2004-119 G:TammNCERTI FICATESCERTS.2004\Facilitles\NCMO.xIs Page 1 SUPPLEMENTAL NARRATIVE TO RFP: EXHIBIT B RECOMMENDATIONS X CONDITIONS Psychcare/Family Recovery Center North Colorado Medical Center Banner Health System Gloria Romansik Weld County Department of Social Services P.O. Box A Greeley, CO 80632 April 13, 2004 Re: Response to Recommendation for FRP 04006 Gloria: North Colorado Medical Center(NCMC) requires every employee to complete annual mandatory training modules addressing diversity and discrimination. In addition,NCMC has the most comprehensive interpretation service of any county agency with the ability to translate information in over 20 languages. PsychCare/FRC currently employs six bilingual staff members and financially supports the bilingual training of 3 other employees. We will continue to actively pursue the acquisition of this skill set for all of our staff members. If I can be of further service in clarifying this issue please do not hesitate to contact me. ectfully submitted, David Rastatter Clinical Resource Coordinator RECEIVED BY APR 1 3 2004 WELD vCuiN F It DEPT. OF Qrsf".: -,r-C+"rlrir:CZ , a DEPARTMENT OF SOCIAL SERVICES P.O.BOX A GREELEY,CO. 80632 Webskt:www.co.wtld.co.us lID Administration and Public Assistance(970)352-1551 Child Support(970)352-6933 • • COLORADO April 7,2004 Jon Sewell Chief Executive Officer North Colorado Medical Center 1801 16th Street Greeley,CO 80631 Re: RFP 04010: Option B,Home Based Services RFP 04006: Day Treatment RFP 006-00: Home Studies,Relinquishment Counseling Dear Mr. Sewell: The purpose of this letter is to outline the results of the Bid process for PY 2004-2005 and to request written information or confirmation from you by Wednesday,April 14, 2004. A. Results of the Bid Process for PY 2004-2005 1. The Families,Youth and Children(FYC)Commission recommended approval of the bids listed below for inclusion on our vendor list with no recommendations. 1. RFP 04010: Option B,Home Based Services 2. RFP 006-00:Foster Parent Consultation 2. The Families,Youth and Children(FYC)Commission recommended approval of the bid, RFP 04006,Day Treatment, for inclusion on our vendor list.The FYC Commission attached the following recommendation regarding your bid. Recommendation: The provider will explain in writing how their program addresses Bilingual/cultural sensitivity. You are requested to review the FYC Commission recommendations and to: a. accept the recommendation(s)as written by the FYC Commission; or b. request alternatives to the FYC Commission's recommendation(s); or c. not accept the recommendation(s)of the FYC Commission. Please provide in writing how you will incorporate the recommendation(s)into your bid. If you do not aecept the recommendation,please provide written reasons why. All approved recommendations under the NOFAA will be monitored and evaluated by the FYC Commission. Page 2 North Colorado Medical Center/Results of Bid Process for PY 2004-2005 B. The Families,Youth, and Children Commission recommended the following condition be applied to all 2004-2005 contracts. The condition is: the provider will notify the Department of any change in staff at the rime of the change. All conditions will be incorporated as part of your Bid and Notification of Financial Assistance Award(NOFAA).If you do not accept the condition(s),you will not be authorized as a vendor unless the FYC Commission and the Weld County Department of Social Services accept your mitigating circumstances. If you do not accept the condition,you must provide in writing reasons why. A meeting will be arranged to discuss your response.Your response to the above conditions will be incorporated in the Bid and Notification of Financial Assistance Award. The Weld County Department of Social Services is requesting your written response to the FYC Commission's recommendations and conditions.Please respond in writing to Gloria Romansik,Weld County Department of Social Services,P.O.Box A,Greeley, CO, 80632,by Wednesday,April 14, 2004,close of business. If you have questions concerning the above,please call Gloria Romansik at 352.1551, extension 6230. Sincerely, J A. sego, ecto cc: Juan Lopez,Chair,FYC Commission Gloria Romansik, Social Services Administrator Hello