HomeMy WebLinkAbout20031059.tiff RESOLUTION
RE: APPROVE NOTIFICATION OF FINANCIAL ASSISTANCE AWARD FOR THE LITTLER
CENTER, DAY TREATMENT, AND AUTHORIZE CHAIR TO SIGN - NORTH RANGE
BEHAVIORAL HEALTH
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 a Notification of Financial Assistance
Award for The Littler Center, Day Treatment, 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 North Range Behavioral Health, commencing June 1, 2003,
and ending May 31, 2004, with further terms and conditions being as stated in said award, and
WHEREAS, after review, the Board deems it advisable to approve said award, a copy of
which is 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 Notification of Financial
Assistance Award for the above listed program between the County of Weld, State of Colorado,
by and through the Board of County Commissioners of Weld County, on behalf of the
Department of Social Services, and North Range Behavioral Health be, and hereby is,
approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized
to sign said award.
The above and foregoing Resolution was, on motion duly made and seconded, adopted
by the following vote on the 30th day of April, A.D., 2003.
BOARD OF COUNTY COMMISSIONERS
W COUNTY, COLORADO
ATTEST: Mill
D vid E. Lon Ch it
Weld County Clerk to the ar ax. e ,
•
L ? _ -Robert D. sden, Pro-Tem
BY: % /
Deputy Clerk to the Bo d it j z,.f-\// .J.(S iet2�
M. J. Geile
P OVED AS M: OVA
Williarrt H. Jerke
County A o ey iVX^I—C�)u �„ dieij
Glenn Vaad
Date of signature: 5"
2003-1059
SS0030
00 : sS(-)6-4-6-‘64)
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 FY03-PAC-2004
Revision (RFP-FYC-03006)
Contract Award Period Name and Address of Contractor
Beginning 06/01/2003 and North Range Behavioral Health
Ending 05/31/2004 The Littler Center-Day Treatment
1306 11th Avenue
Greeley,CO 80631
Computation of Awards Description
Unit of Service The issuance of the Notification of Financial
Assistance Award is based upon your Request for
A comprehensive,highly structured service Proposal (RFP). The RFP specifies the scope of
alternative to the out-of-home placement or the services and conditions of award. Except where it is
more intensive placement,that provides mental in conflict with this NOFAA in which case the
health care and education to its student clients. NOFAA governs, the RFP upon which this award is
Monthly average capacity of 8,29.5 hours based is an integral part of the action.
weekly, an average of 5.9 hours daily, for 36-52
weeks. Special conditions
Cost Per Unit of Service 1) Reimbursement for the Unit of Services will be based on
an hourly rate per child or per family.
Daily Rate Per $ 89.14 2) The hourly rate will be paid for only direct face to face
contact with the child and/or family, as specified in the
Based on Approved Plan unit of cost computation.
3) Unit of service costs cannot exceed the hourly and yearly
Enclosures: cost per child and/or family.
X Signed RFP:Exhibit A 4) Payment will only be remitted on cases open with, and
Supplemental Narrative to RFP: Exhibit B referrals made by the Weld County Department of Social
Recommendation(s) Services.
Conditions of Approval 5) Requests for payment must be an original submitted to
the Weld County Department of Social Services by the
end of the 25th calendar day following the end of the
month of service.The provider must submit requests for
payment on forms approved by Weld County
Department of Social Services.
Approva : Program Official:
By ByDa
vid E. Long,Chair Judy . 'eg irecto%uic
Board of Weld County Commissio ers Weld tuunty Department of Social Services
Date: -1-30 - 70j Date: `/2,1/03
((( �co3 lv5`1
EXHIBIT "A"
t
• INVITATION TO BID
OFF SYSTEM BID 02-03 RFP-FYC 03006
DATE: February 19, 2003 BID NO: RFP-FYC-03006
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-03006) for:Colorado Family Preservation Act--Day Treatment Program
Emergency Assistance Program
Deadline: March 14, 2003, Friday, 10:00 a.m.
The Families, Youth and Children Commission, an advisory commission to the Weld County Department of
Social Services, announces that 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, 2003, through May 31, 2004, at specific rates for different types of service,the county will authorize
approved vendors and rates for services only. The Day Treatment Program Category must provide a
comprehensive, highly structured program alternative to placement or more restrictive placement that
provides therapy and education for children. 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
Wayne A. Maxwell, Ph.D.
TYPED OR PRINTED SIGNATURE
VENDOR North Range Behavioral Health (jtievi)
(Name) Handwfitten Signature By Authorized
Officer or Agent of Vendor
ADDRESS 1306 11th Avenue TITLE Executive Director
Greeley, Colorado 80631
DATE March 11, 2003
PHONE# 970-353-3686
The above bid is subject to Terms and Conditions as attached hereto and incorporated.
Page 1 of 32
' RFP-FYC-03006 Attached A
DAY TREATMENT PROGRAM BID PROPOSAL
COLORADO FAMILY PRESERVATION ACT
2003/2004 BID PROPOSAL APPLICATION
PROGRAM FUNDS YEAR 2003-2004
OFF-SYSTEM BID 02-03 RFP-FYC-03006
NAME OF AGENCY: North Range Behavioral Health
ADDRESS: 1306 11th Avenue Greeley, Colorado 80631
PHONE: ( 970) 353-3686 or 352-2201
CONTACT PERSON: Sandra K. Atwood, MSW, LCSW TITLE: Director Littler Center
DESCRIPTION OF COLORADO FAMILY PRESERVATION ACT CATEGORY: The Day Treatment Program Category
must provide a comprehensive,highly structured program alternative to placement that provides therapy and education for
children.
I2-Month approximate Project Dates: 12-month contract with actual time lines of:
Start June 1, 2003 Start
End May 31,2004 End
TITL . : P OJECT: KATHLEEN PAINTER LITTLER CENTER
/ & Sandra K. Atwood 3-0 �3
7. . d Signature o' f Person Preparing MSW, LCSW Date
.O7G-1.%" Wayne A. Maxwell 3/11/03
Name azi Signature Chief Administrative Officer Applicant Agency ph,D, Date
MANDATORY PROPOSAL REQUIREMENTS
For both new bids and renewal bids,please initial to indicate that the following required sections are included in this Posposal
for Bid. For renewal bids,please indicate which of the required sections have not changed from Program Fund Year 2002-
2003 to Program Fund year 2003-2004.
Indicate No Chance from FY 2002-2003
OM/ Project Description X
Olga_ Target/Eligibility Populations X
Cie/ Types of services Provided X
tiAni Measurable Outcomes X
U/4n1 Service Objectives X
U//Am Workload Standards X
(API Staff Qualifications X
ulM Unit of Service Rate Computation (cost of living increase)
Ail Program Capacity per Month X
W Certiiicate of Insurance X
Assurance Statement X
YAM Provider Number for State Child Care Licensing X
Page 26 of 32
RFP—FYC-03006 Attached A
Date of Meeting(s)with Social Services Division Supervisor:
Comments by SSD Supervisor:
,
T � - 7
/7 z tr t e- �7e-. 71 3//', 3
Name and Signature a of SS Supervisor Date
Page 27 of 32
•
COLORADO FAMILY PRESERVATION PROGRAM — DAY TREATMENT— North Range Behavioral Health
2003-2004 BID#RFP-FYC-03006
I. PROJECT DESCRIPTION
In August 1995, Weld County School District Six (District 6), the University of Northern Colorado
(UNC), and North Range Behavioral Health (NRBH) jointly opened the Carson Children's
Center (CCC). In August 1999 the CCC became the Kathleen Painter Littler Center. Littler is a
year around residential and day treatment program for children ages five through 12 years. It
has capacity of 18 residential and 12 day treatment students.
Day treatment is a comprehensive, highly structured alternative to the out-of-home placement
or the more intensive placement of a child already in placement, that provides mental health
care and education to its student clients. Treatment services for each client's family are an
integral part of the program. The Littler Center provides highly integrated and coordinated
educational and treatment services to its students. The affective needs of each child are
responded to not only by the treatment staff, but by the educational and supportive services
staff as well. Similarly, the students' education and emotional and behavioral needs are not
solely the responsibility of the teaching staff but shared by all on-site personnel. Because all
Littler students are staffed as special needs children, additional services called for in each
child's individualized education plans (JEP) such as occupational therapy, speech/language
services, and physical therapy are provided on-site.
The Littler day begins with a welcoming group to greet the children and to help them make the
transition from life at home to a day in school and in treatment. Information from each student's
parents, guardians, or foster parents is obtained directly or via notebooks sent home with and
brought back each day by the students to keep the staff and parents/guardians up-to-date and
to encourage open communication. Each child's goals and progress toward them are updated
daily before the children move to other aspects of the day. Educational and affective curricula
are simultaneously in place as much as is feasible in the various daily activities. The students
progress through a series of treatment and educational offerings each day. While some
children are in the classroom for group or individual instruction, others are seen in individual
therapy while others are in a treatment group. Each day treatment student is assigned a master
level therapist who not only assists in developing individualized treatment plans, but also serves
as an on-going consultant and treatment coordinator to all school staff. There are ongoing,
scheduled psycho-educational groups that address new themes as well as themes from earlier
sessions. These groups address social skills, conflict resolution, self-esteem, and positive
relation building as well as how to handle feelings. The daily schedule is similar from day to day
promoting the consistent milieu essential to the children's success. Recess, lunch, and other
activities are similarly integrated. The day ends back in the room where the focus is to review
the day with the children and prepare them for the transition back to their homes. Goals and
successes of the day are the focus of this activity. Children may remain for a family therapy
session. Family therapy typically is planned for the end of the day to allow for parents' work
schedules. The schedule is sufficiently flexible to allow for such sessions during the school day
as well. Individual and family therapy continues to occur during school breaks, depending on
the availability of the clients. Participation in family therapy is a requirement in the day
treatment program at the Littler Center to achieve optimum success.
• COLORADO FAMILY PRESERVATION PROGRAM— DAY TREATMENT—North Range Behavioral Health
2003-2004 BID #RFP-FYC-03006
Psychiatric services are integrated in the program. Each child receives a psychiatric evaluation
including a determination of need for psychotropic medications. Follow-up psychiatric services
are provided throughout each student's stay and, when appropriate, in the care that follows
treatment at Littler.
Students with special treatment needs have available to them the full array of services of NRBH
in addition to those available at Littler. Students can be seen in groups designed to help them
deal with sexual abuse and other trauma they have endured.
II. TARGET/ELIGIBILITY POPULATIONS
It is intended that the Littler Center serve up to 20 children ages five through 12 years and their
families at any given time in the 6 to 18 month day treatment program. Of these, it is
anticipated that up to ten could have the financial aspect of their care covered under the
services proposed herein. Up to 18 children and their families will be served annually of whom
12 will possibly be eligible for FYC-funded services. It is anticipated that approximately 25% of
all the students and/or their families will receive some level of bilingual/bicultural services on-
site. Based on current utilization rates, it is estimated that up to 25% of the Littler students will
be from southern Weld County. For the purposes of this grant, the monthly maximum program
capacity is defined as 10 children with a monthly average program capacity of eight. The
average length of stay in the program is estimated to be in the range of 36 to 52 weeks.
Students spend a minimum of 29.5 hours weekly in the total program. In order for a child to be
considered as a potential student of the Littler Center, she or he must be staffed into special
education services in her or his home school district and must have demonstrated the capacity
to return to her or his home school upon successful completion of the Littler program. In
addition, the student must have a full scale IQ of 76 to benefit from the Littler Center program
levels and expectations.
Children referred to the project will have met, or be at high risk to meet, the out-of-home
placement criteria detailed in the request for proposal. As mentioned above, each will also
have met or be believed to qualify for special education services.
III. TYPE OF SERVICES TO BE PROVIDED
Site-based services to the students of the Littler Center and their families will be held each day
District 6 schools are regularly in session plus through the summer. An academic year will
consist of 46 total weeks with an average of not less than 29.5 hours of programming weekly,
5.9 average daily hours.
The planning and implementation of the Littler Center has been a collaborative and cooperative
effort from its inception. The Weld County Department of Social Services (WCDSS), involved
early on in the planning process, agreed to utilize the services of this day treatment program for
those of its clients demonstrating the need for it and for whom they believe they have financial
responsibility. The Littler Center's admission coordinator works to ensure that FYC resources
do not supplant other community resources and WCDSS caseworkers are involved prior to the
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COLORADO FAMILY PRESERVATION PROGRAM — DAY TREATMENT—North Range Behavioral Health
2003 -2004 BID #RFP-FYC-03006
screening process for all WCDSS children. The collaborative role of Weld County School
District 6 has been exemplary from the planning stage forward as it furnished the past site,
recruited and hired professional and paraprofessional staff, and provided administrative
guidance. Similarly, NRBH, with the strong support of its Board of Directors and management
team, offered administrative assistance in planning and implementing the treatment program.
Extensive effort has been invested into planning the milieu and overall program of the Littler
Center so that educational, therapeutic, behavioral, and recreational components are closely
integrated. By design, each of these four components contains aspects of the other three.
Concerted efforts helped to achieve and now serve to maintain this high level of integration.
The educational component is primarily the responsibility of the District 6 teaching staff plus
other instructional staff as may be required. The therapeutic component is primarily the
responsibility of the NRBH on-site staff. The behavioral component of the Littler Center is
present across all activities of the program and is the responsibility of all on-site personnel.
Each student has an individualized education plan and a mental health services/treatment plan
that spell out educational, behavioral, and emotional concerns and detail how those concerns
will be addressed in the daily activities of the student. Similarly, the recreational component of
the Littler Center includes educational, therapeutic, and behavioral programming to meet each
student's needs. All components of the program are typically carried out on-site. Exceptions to
this occur primarily during times when a student is in a transitional stage in returning to her or
his home school and when off-site services, such as involvement in a particular therapy group
not offered on-site, are indicated.
Beginning at intake and throughout the program, parents, guardians, and other caretakers are
actively encouraged to engage in their children's education and treatment. Family therapy
sessions are held at least weekly for each student. In all cases, parental or guardian
involvement is mandatory. This stems from a core belief that not just the child, but also his or
her family must actively involve themselves in the treatment/education process for it to be
effective and for the positive results to be longstanding. The mental health services plan
dictates the specific nature of the family work that is required for each child.
The teachers at the Littler Center are certified special education teacher for significantly
identifiable emotionally disturbed children. They are assisted by three full-time, specially trained
paraprofessionals in carrying out each student's individualized educational plan. Due to age of
the Littler students, there has been no need for vocational or independent living assessment or
training to date.
Each student receives an initial mental health assessment. The therapist, parents/guardians,
caseworker, if appropriate, and psychiatrist work to establish a behaviorally specific service plan
that details individual therapy, family therapy, psychiatric needs, and case management needs.
The service plan identifies the specific outcomes necessary for the child to be successful at a
lower level of care. It is the tool by which progress is measured. Typically each student weekly
receives at least one individual therapy session, five sessions of therapeutic or psycho-
educational group activities, and one session of family therapy. This can vary based on the
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COLORADO FAMILY PRESERVATION PROGRAM— DAY TREATMENT— North Range Behavioral Health
2003-2004 BID#RFP-FYC-03006
needs of the specific child and their family. More frequent services may be provided during the
initial stages of treatment or during a time of crisis. Fewer services maybe provided during the
lafter stages of treatment when a child is transitioning back to their home school. Those
students with psychotropic medication needs are the responsibility of the Littler staff
psychiatrist, Wallace LaBaw, MD. There is simultaneous development or updating of the
individualized education plan when a child is staffed into the Littler Center.
The physical health needs of Littler students including, but not limited to nutrition, medical, and
dental, are primarily the responsibility of District 6 nursing staff. These are shared as
appropriate by the staff of the Littler Center.
Proactive planning for reintegrating a student into her or his home school begins during the
initial screening of the child for consideration of admission to Littler. The capacity to return to
one's home school, i.e., the school referring the child, or the school the child will be returning to,
will depend upon promotion to her or his next higher grade, must be established before a child
will be accepted into the Littler program as must be the referring school's willingness to have the
student return there.
Similarly, the graduation requirements for students admitted to the Littler Center are formulated
in a preliminary manner during the screening and planning sessions held with each child and
her or his family, the staff of the referring school, and social services caseworkers when
appropriate. The requirements are largely expressed in terms of outcomes the child will
achieve. The program is constructed to emphasize the positive outcomes and gains each
student will make. Whenever possible, the strengths of the child will be used as the primary
tools for progress.
Follow-up mental health care for students graduating from the Littler will be arranged by the
Littler Center's mental health staff with NRBH, other mental health centers, or a private
practitioner of the graduate's family's or guardian's choosing. The transition plan that guides the
student's return to her or his own school also provides for a stepped, systematic introduction to
the new therapist or reintroduction to a previous therapist to ensure continuity from day
treatment to more traditional outpatient services.
IV. MEASURABLE OUTCOMES
At the time of admission to the Littler Center, each student will be evaluated using, in part, the
Colorado Clinical Assessment Report (CCAR) developed by the Colorado Office of Mental
Health Services. Every six months thereafter and at discharge from the Littler Center the CCAR
will again be administered. The three-page form covers a wide range of variables and
assessments. The Littler Center Admission and Termination Evaluation Forms are to be used
as evaluation tools as well. These look specifically at the effects of the littler program. Copies
of these forms are attached at the end of this proposal. The therapist conducts a complete
assessment 10 days after enrollment to develop an all inclusive behavior/treatment plan to meet
the student's needs. Discharge goals are developed for all identified areas of need and the
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COLORADO FAMILY PRESERVATION PROGRAM — DAY TREATMENT—North Range Behavioral Health
2003 -2004 BID #RFP-FYC-03006
measurable short-term goals developed monthly to measure and work toward the discharge
goal.
It is anticipated that 90% of the children successfully completing the Littler program will reside in
their own homes, or remain in placement at a similar level of care as they were at the time of
their referral, for the first six months after their discharge. The criteria for success will be that
each child returns to or remains in her or his home or foster home and is able to safely and
constructively do so for at least the first six months they are no longer attending the Littler
Center. This information will be gathered by three and six month follow-ups with the child's
family and their WCDSS caseworker, if appropriate.
Additionally, all successful graduates will enter, remain in, and make satisfactory progress in
public school after their discharge from the Littler Center. More specifically, each graduate of
Littler will maintain or enhance the progress she or he made academically, socially,
behaviorally, and emotionally during her or his time in the program. This will be monitored by
three and six month follow ups with the child's family, their WCDSS caseworker, if appropriate,
and by the school community facilitator (or the equivalent) from her or his home school. The
criteria for success will be maintenance of or improvement upon her or his levels of functioning
in the four areas mentioned above as stated in their individualized educational plan and their
mental health services plan.
The families of 90% of the children successfully completing the Littler program will report a
more relaxed, nurturing, and competent relationship with their children than existed prior to
enrollment. Families will be surveyed at discharge, three months and at six months after
discharge.
Ninety percent of the children completing the Littler program will report and demonstrate an
improved sense of self worth, self-confidence, and decreased high-risk behaviors. Appropriate
improvements will be revealed when pre-C.C.C. CCAR ratings are compared with similar ratings
done at the time of completed transition back to the home school.
V. SERVICE OBJECTIVES
The primary goal of the Littler Center is to successfully intervene in the lives of its students and
their families to minimize the future need for similar intensive services, to enhance each child's
ability to be educated and to benefit from that education in her or his home school, to enhance
each child's ability and capacity to respond appropriately and healthfully to her or his family, and
to improve each child's family's abilities to adequately and appropriately respond to and provide
for the child's needs in a competent, safe, nurturing, and growth enhancing manner.
In working with families to achieve the goal of improving their abilities to manage family conflict
in a safe, constructive manner, the Litter Center staff works toward the objective of resolving
conflicts between parents and children so that no maltreatment of the children occurs, no
domestic violence occurs, no children run away from home, and no children commit status or
legal offenses. Success is measured by family, caseworker, and therapist reports that the
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COLORADO FAMILY PRESERVATION PROGRAM — DAY TREATMENT— North Range Behavioral Health
2003-2004 BID#RFP-FYC-03006
objective was met. Each family will also be asked to report on its subjective improvements in
this area.
To meet the Littler Center goal of improving overall parental competency, an objective of
increasing the parents' abilities to develop and maintain sound, caring, effective relationships
with each other and with their children is established. An additional objective is to enhance the
abilities of the parents to provide, with as much proficiency as possible, for their family's care,
nutrition, hygiene, discipline, protection, education, and supervision. All parents are
encouraged to develop appropriate support systems designed to last beyond their child's
involvement with the Littler Center. Again, the parents and children will be polled concerning
their subjective opinions about the improvements they have made, as will the therapist and
caseworker.
The Littler Center works with each client family to achieve the goal of improving its household
management competency. The objective is to enhance the capacity of the parents to provide a
safe household environment for the children through competently managing the home to
include cleaning, repairing, and maintaining the home, as well as via effective budgeting and
purchasing. The family, therapist, and caseworker will document the improvements made in
this area.
The Littler Center works to improve each family's ability to find and use appropriate resources.
Treatment and case management services assist each family to learn more effective means to
obtain needed help from other sources in the community and from local, state, and federal
governments. This is modeled in each of the families' relationships with the Littler staff. The
families will report, and their caseworker and therapist will confirm, all gains made in this area.
VI. WORKLOAD STANDARDS
The Littler Center will provide day treatment services to 20 children aged five through 12 years
who will meet the FYC funding criteria. A year round academic/treatment schedule is in place.
It is anticipated that up to 18 children will be enrolled in the course of a year. The average
length of stay in the program will range from 36 to 52 school weeks. Littler students will attend
an average of at least 5.9 hours of programming daily on all days the school is in session. The
total staff of the Littler Center numbers more than 17 individuals, comprising slightly more than
the equivalent of 13 full-time employees. This staffing level exceeds all Colorado licensing
rules. Said rules specify a student to total staff ratio of not more than eight to one which is far
less than the four to one ratio employed at Littler. If there is a time when only one staff member
is present, a second staff member is on call and immediately available to be summoned to an
emergency. NRBH certificate of insurance coverage is attached.
VII. STAFF QUALIFICATIONS
Licensing requirements mandate that day treatment programs have a treatment leader who is
responsible for the overall mental health services to each child. This person must hold a
master's degree in the behavioral sciences and have not less than three years of clinical
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COLORADO FAMILY PRESERVATION PROGRAM — DAY TREATMENT—North Range Behavioral Health
2003 -2004 BID #RFP-FYC-03006
experience. Counselors in day treatment programs are mandated by the State of Colorado to
have completed a bachelor's degree in the behavioral sciences or to have at least four years of
experience with appropriate aged children, and must be at least 21 years of age. All of the staff
meet or exceed these requirements. John Ashby, LCSW, with twelve years experience. Matt
Newman, LPC, with fifteen years of experience, much of it in intensive treatment area. Trish
Halsey, MA (soon to be LPC) with at least five years experience in group homes with behavior
disordered clients and Lara Schifbauer, MSW (soon to be LCSW) with six years inpatient
experience.
Sandee Atwood, MSW, LCSW, is the Littler Center Program Director as well as Clinical
Director. Once a child is accepted into the Littler Center the intake coordinator, Cath Stilwell,
MSW, establishes a preliminary treatment plan and then the clinical director works with the
primary therapist in the development of the day treatment plan for each student. Ms. Atwood
has fifteen years experience as a Psychiatric Social Worker in the school system and twelve
additional years as a clinical director for an outpatient treatment center and day treatment
center. Three of those years were as Clinical Director of Devereux Cleo Wallace Treatment
Center in Westminster, Colorado.
Wallace LaBaw, MD, staff psychiatrist for the Littler Center, is a board certified psychiatrist. He
is able to follow-up with children after they graduate from the Littler Center and enter more
traditional outpatient care through NRBH.
Mike Hoover, Ed.D. is the administrative supervisor of the Littler Center's educational
component. Since 1992, he has been a Special Education Coordinator for District 6. Currently
certified as a School Psychologist and Special Education Administrator, he has worked in the
field for more than 20 years.
The Littler Center's teachers are Gayle Schneider, MA, Linda Hanchulak, MA, Kathy Brittain,
MA, and Mike Opferman, MA. Ms. Schneider is a certified special education teacher for
significantly identifiable emotionally disturbed children and is also certified in the area of
learning disabilities and mentally handicapped. Ms. Hanchulak is certified in all areas of special
education and has an MA in counseling. Ms. Brittain is also certified in special education K-9
and an endorsement in early childhood special education. Her MA is in learning diabilities and
resource. Mr. Opferman has an MA in educational psychology and a BA in special education
with an emphasis in emotional disturbance. Leigh Ann Luberstedt is the speech/language
clinician. She has completed her MA degree in speech language pathology. Beth Gay is the
School Psychologist and does assessments and conducts IEP team meetings. Ms. Gay has an
Ed.S. degree in School Psychology and is a nationally certified school psychologist. Karen
O'Connell is a registered occupational therapist and provides both direct and consultative OT
services to the Littler Center. Three full-time paraprofessionals, Tammy Milke, Tammy
Gonzales and Rebecca Erickson assist the teachers in carrying out each student's
individualized educational plan.
•
COLORADO FAMILY PRESERVATION PROGRAM — DAY TREATMENT— North Range Behavioral Health
2003-2004 BID#RFP-FYC-03006
Peg Hoover, an RN and Nurse Practitioner, is the school nurse and health consultant to the
program. She regularly checks in with the staff and students and is also available as needed.
She is providing on-going health education classes for all students.
VIII. PROGRAM CAPACITY BY MONTH
The Littler Center is designed to function with a minimum clinical staff contingent of 4.0 FTE,
serving an average of 15 - 18 children and their families at any given time.
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COLORADO FAMILY PRESERVATION PROGRAM - DAY TREATMENT
North Range Behavioral Health
2003-2004 BID#RFP-FYC-03006
PROGRAM BUDGET
KATHLEEN PAINTER LITTLER CENTER DAY TREATMENT PROGRAM
A Total Hours or Days of Direct Service Per Client 164
B Total Clients to be Served 12
C Total Hours or Days of Direct Service for Year(A x B) 1,968
D Cost Per Hours Or Days of Direct Services (E /C) 75
E Total Direct Service Costs Face-To-Face 147,600
F Administration Costs Non-Face-To-Face Allocable to Program 5,150
G Overhead Costs Allocable to Program 22,670
H Total Direct, Administration & Overhead Costs (E + F + G) 175,420
I Anticipated Profits Contributed by This Program 0
J Total Costs and Profits from This Program (H + I) 175,420
K Total Hours or Days of Direct Service For the Year(C) 1,968
L Rate Per Hours or Days of Direct, Face-To-Face Service (J /K) $89.14
to be Charged to Weld County Social Services
•
RFP-FYC-03006 Attached A
Program Category Day Treatment Program Bid Category
Project Title KATHLEEN PAINTER LITTLER CENTER
Vendor North Range Behavioral Health
Please list your provider number as given to you from the State Child Care Licensing 06220
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. The monthly maximum program capacity.
G. The monthly average capacity.
H. Average stay in the program (weeks).
I. 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. Site based services (The Bidder must state that a minimum of site based services of 5 hours
per day, ages eight through twenty-one(21) and two and one-fourth hours minimum per day
for children ages three to seven)will be provided.
B. Community collaboration efforts. The Bidder must describe its community collaborative
efforts with:
1. The Department of Social Services.
2. The Department of Mental Health.
3. The Department of Education.
4. Others(Please Describe).
C. Program components. The Bidder must describe the program components of:
1. Educational
2. Therapeutic
3. Behavioral
4. Recreational
D. Parental/Caretaker involvement in all program components as indicated in the case plan and
as required.
Page 28 of 32
•
RFP-FYC-03006 Attached A
E. Assessment and plan to meet the needs of child and family including:
1. Education through a certified teacher.
2. Vocational/Independent living for age appropriate children.
3. Individual and family therapy which includes all family members.
4. Physical health needs, i.e., nutrition,medical, dental, sex education, HIV,
contraception, etc.
5. Mental health needs such as psychotropic medications, etc.
F. Proactive planning for transition to public school setting or independent living:
1. Reintegration into public school.
2. Follow-up for individual and family therapy.
3. Completion of Day Treatment.
4. Identifies progress/outcomes.
5. Reinforces gains.
Provide your quantitative measures as they directly relate to each service. At a minimum, include a
number to be served in each service component. Describe your internal process to assure that FYC
resources will not supplant existing and available services in the community; e.g. mental health
capitation services, ADAD and professional services otherwise funded.
IV. MEASURABLE OUTCOMES
Provide a two-page description of your expected measurable outcomes of the project. Please address
the following measurable outcomes:
A. The children completing the Day Treatment Program will be residing in their own homes 6
months after discharge from the program.
B. The children will enter public school upon graduation from Day Treatment.
Describe your quantitative measures: Also, describe the methods you will use to measure, evaluate,
and monitor each quantitative measure.
V. SERVICE OBJECTIVES
Provide a one-page description of your expected service objectives and quantitative measures.
Address, at a minimum, the following ways the project will:
A. The number of children placed within six months of Day Treatment graduation/discharge.
B. The number of children that were enrolled in public school from graduation/discharge from
the Day Treatment Program.
C. Improve ability to access resources - services shall assist parents to work with other sources in
the community and within the local, state, and federal governments.
Describe the methods you will use to measure, evaluate, and monitor each service objective.
Page 29 of 32
• RFP-FYC-03006 Attached A
VI. WORKLOAD STANDARDS
Provide a one-page description of the project's workload standards and quantitative measures. Address,
at a minimum,the following areas:
A. Total number of children and families served.
B. Duration/length of time in program.
C. Total number of hours per day/week/month.
D. Total number of individuals providing these services.
E. Insurance.
VII. STAFF QUALIFICATIONS
Please provide a one-page description of staff qualifications and address, at a minimum, the following:
A. Will your staff, including supervisors, who are providing direct services have the minimum
qualifications in education and experience as defined in Staff Manual Volume VII, Section
7.303.17, and Section 7.000.6, Q, Colorado Department of Human Services? Describe.
B. Total number of staff, including supervisors, available for the project.
C. Total number of counselor and/or treatment leader(s)to the number of children ages 5 years to 13
years. (Minimum expectation is 1 staff member to 8 children.)
D. Total number of counselor and/or treatment leader(s)to the number of children ages 16 years and
over. (Minimum expectation is 1 staff member to 10 children.)
VIII. Unit of Service Rate Computation
The budget form is to be used to provide detailed explanation of the hourly or daily rate your
organization will charge the Core Services Program for the services offered in this Request for
Proposal. This rate may only be used to bill the Weld County Department of Social Services for
direct, face-to-face services provided to clients referred by the Department. Requests for payment
based on units of service such as telephone calls,no shows, travel time,mileage reimbursement,
preparation, documentation, and other costs not involving direct face-to-face services will not be
honored. Likewise, bills must be for hours or days of direct services to the client,regardless of the
number of staff involved in providing those services. Therefore, it is imperative that this rate be
sufficient to cover all costs associated with this client,regardless of the number of staff involved in
providing these services.
There are two different ways to fill out the budget form. The budget can either be done manually or
by computer. Regarding the manual budget, all areas that are required to be filled in are highlighted.
The computerized budget is less work due to predefined calculations,but does require Microsoft
Excel for Weld County's predefined budget. There are highlighted areas on the computerized budget
that are required to be filled in as well. There are disks available that have this predefined budget on
it. Firms can also design its own budget form on a spreadsheet,but at minimum,it must have all of
the columns that are on the manual or computerized budget. Explanations on how to fill out the
budget form are provided below and on the following pages.
(A) This is an estimate of the total hours or days of direct, face-to-face services each client will
Page 30 of 32
RFP-FYC-03006 Attached A
receive from the time he or she enters the program until completing the program. On the
manual budget, the only place to put this number is on the Program Budget worksheet. The
computerized budget requires this number to be entered on the Direct Service Cost worksheet
only. Once filled in there, this number is populated throughout the entire budget.
(B) This is an estimate of the number of clients who will be served during the period from June 1,
2003, through May 31, 2004. On the manual budget, the only place to put this number is on the
Program Budget worksheet. The computerized budget requires this number to be entered on the
Direct Service Cost worksheet only. Once filled in there,this number is populated throughout
the entire budget.
(C) This is the total number of hours or days per client multiplied by the total number of clients to
be served for(B). On the manual budget,this will have to be calculated manually on the
Program Budget worksheet. The computerized budget will automatically calculate this then
populated throughout the entire budget.
(D) This is calculated by taking the total direct service costs (E) and dividing it by the total number
of hours in( C ). On the manual budget, this will have to be calculated manually. The
computerized budget will automatically do this calculation for you.
(E)This number represents the salary and benefits that your organization pays its direct service
providers plus any costs which are directly attributable to the face-to-face session with the client.
On the manual budget, all areas that are highlighted on the Direct Service Costs worksheet must
be filled out according the descriptions. The Grand Total Direct Service Costs must be then
carried over to the Program Budget worksheet. The computerized budget,once all of the
highlighted areas are filled in, it will automatically carry the total over to the Program Budget
worksheet.
(F) This represents the salary and benefits of direct service, supervisory, and clerical personnel which
are not incurred in providing direct, face-to-face service to the client,but can be allocated to this
program for time spent on the program for activities such as travel,phone conversations,no-
shows, discussions with involved parties,meeting preparation, and report completion. On the
manual budget, all areas that are highlighted on the Admin Costs Non-Face-to-Face worksheet
must be filled out according to the descriptions. The Grand Total Direct Service Costs Not-Face-
To-Face must be carried over to the Program Budget worksheet. The computerized budget, once
all of the highlighted areas are filled in on the Admin Costs Non-Face-to Face worksheet, it will
automatically carry the total over to the Program Budget worksheet.
(G)This represents the agency overhead costs, such as rent,utilities, supplies,postage, travel
reimbursement, telephone charges, equipment,depreciation, data processing, interest, and taxes
which are not incurred in providing direct, face-to-face service to the client, but can be allocated
to this program for time spent on the program for activities such as travel,phone conversations,
no-shows, discussions with involved parties,meeting preparation, and report completion. On the
manual budget, all highlighted areas on the Overhead Costs and Profits worksheet must be
completed according to the descriptions. The Total Overhead Costs must be carried over to the
Program Budget worksheet. The computerized budget, once all of the highlighted areas are
filled,will automatically carry over to the Program Budget worksheet.
(H) This represents the total of all direct face-to-face costs, admin direct non face-to-face costs, and
Page 31 of 32
RFP-FYC-03006 Attached A
overhead costs. On the manual budget,this will have to be manually calculated by adding these
three total costs together. The computerized budget does it automatically.
(I) This represents the total amount of profit your fines expects to realize as a result of operating this
program. Any difference between lines(H) and (J)must be substantiated by an amount indicated
on this line. The manual budget, this amount will be entered on the Overhead Costs and Profit
worksheet and then have to be carried over to the Program Budget worksheet. The computerized
budget, once it is filled in on the Overhead Costs worksheet, it will then automatically be carried
over to the Program Budget worksheet.
(J) This represents the total costs and profits added together. This is(H) and(1). On the manual
budget, it will have to be calculated manually on the Program Budget worksheet. The
computerized budget will automatically calculate it on the Program Budget worksheet.
(K)This represents the total hours or days of direct service for the year. This is( C ) above. On the
manual budget,you will have to carry this number down from ( C ). On the computerized
budget, it is automatically carried down.
(L) This is the actual direct, face-to-face hourly or daily rate at which you will be requesting payment
for the services provided under the conditions of this Request for Proposal. This amount cannot
be more then what is charged to the general public or collected from insurance providers. On the
manual budget, this amount must be calculated by taking the total costs and profits (J) and
dividing it by the total hours or days of direct service for the year(C or K). The computerized
budget automatically calculates this total.
All providers who receive a NOFAA must also submit a certified computation of the organization's
actual expenditures for the approved Core Service program by January 31, 2004, for a seven-month
period from June 1, 2003 to December 31, 2003. The actual expenditures must be submitted in the same
format as the budget was prepared. The certification language must be the same as on the Computerized
Actual Expenditures worksheet. The document must be signed by the Chief Executive Officer or the
authorized officer of the bidder in order for it to be considered certified.
The use of the actual program expenditures is to insure that the direct, face-to-face hours/daily rate is
comparable to the budget computation. The actual numbers will be taken into consideration for the
2004-2005 Request for Proposal for that specific program.
Page 32 of 32
Supplemental Narrative to RFP:
Exhibit B
Recommendation(s)
RFP-FYC-03006-Day Treatment
North Range Behavioral Health
�, _ e ₹ uvry44,......—,.......,,a-.. x --r jam, �'s'z''s: a r -,y
... DEPARTMENT OF SOQUAL SERNI
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• .,a.J.vI.+*.ls+atAMbMYh4wvaaeF6iex ,
April 8,2002 1
( i
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North Range °ehavioral Health
1306 11 Avenue
+nut....a.Mw ..... - -gcp0y'y, jy�MzsWNe k..+ i............ .. Pa«WKx ...... M�'r5f. ........s •4 ,vusa.«al“W",fACNE:uN'.
Re Ifr92-03s Parent Consultation 5 r
...a4 R}'i ':O i f :in bith'.'>. +.rc-- •; .., idtm..;;T:.;.3.u...e3e.i« ..4. . , :-,,,414, t.:- . s,,,,,.tin'«.:.
s ,&"' _s1, u"nr ,'wit P.V MT 7 7 P. ah "its -Pt,
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p er is o o a resu o f e i process or PY 2. o"
2003
#°d ° eilu a aIR Y ' esc#ay. pu1i j1a 21102 .e
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Through the 2002-2003 Core Services bid evaluation process, the Families, Youth
and Children(FYC) Commission approved the RFP(s) listed above for inclusion
on our vendor list. The FYC Commission attached the following
recommendations)regarding your RFP bid(s).
The FYC Commission approved the following recommendation for all programs
on the vendor list for 2002-2003. The recommendation reads as follows:
Recommendation: Providers will report outcomes specific to their programs.
1. RFP PY 02-03 06-000, Foster Parent Consultation:
Approved with the above recommendation:
2. RFP 02006, Day Treatment:
Approved with the above recommendation:
B. Required Response by RFP Bidders Concerning FYC Commission
Recommendations
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 17, 2002, close
of business as follows:
Mme .,
4 fat rw , t+iu
m „:*;nr• e'd't tk`.' ., ivt #.:.-: 4`rri stila'It+M as„ •�..: ... :. ,. . .,..:. ,.... ,...
Page 2
North-Range Behavioral Health
., ..:.Itiaglic• Pr 1W 2OP ., y.
3 -- tLsgtlik r k..xL alt,wx.rtaLttrt,ew dyC.' Pkw Lt kL$v kt - ry.
You are requested to review the=t+ecomittendation(s)'and to:
a. - accept the
recommen a��s a wnttalix a FYC Csio"sn
Sadwenr rW.`�aJ a r ...
or
b. • request alternatives‘to the C Commission's recommendation(s);
'7.4rr y ��+ +.wZr4RNAu+Y+'�iin �:r.,�
1 • a✓, 1 i ��a>{ 11I11-1„oll'd 1111:1 4f e t tip 1, [ 1;,
Fe,.. saw.--- . ,-.re,-ear".-20,.•Sate*w .P.lease Provide ins:wri 4O1taiviAllilAampomtesrecommendation(S):.in a
`°1/4 ~gour;bid.„Ifyou'dd not'accept it(s);-please rovide ..; 4
-reasons why. MI approved recommendations under the NOFAA will be
red and eval
,11"on wish to arrange a meeting to discus§the'aboveionditions and/or
gxtonsion 6293; and
=r i •l .r+9x'..v.o. '}'k" V44,,N':.4'="1-3 trett-'•=kiitt-tWt . t n A':•--. V'4 2f 14G
fr* ayy=i '^,_ Nth a d$ E.
ego, w' or
Id County Department of Social Services
of
cc: Dick Palmisano, Chair, FYC Commission
Gloria Romansik, Social Services Administrator
North Range
Behavioral Health Sully Wank
President
!guilds Coiling
"cc-P,csidc,d.
April 15, 2002
Fill Fisher
Treasurer
``
Gloria Romansik Poet esul�
Prcridcm
Weld County Department of Social Services
P.O. Box A
Greeley, CO 80632
SUBJECT: RFP 02-03 06-000 Foster Parent Consultation
RFP 02006 Day Treatment
Dear Ms. Romansik:
We are in receipt of your notification letter dated April 8, 2002 in reference to the results
of the RFP Bid process for 2002-2003.
North Range Behavioral Health agrees to report outcomes specific to each of the two
programs noted above as per your recommendation. Should you need anything further,
please contact me.
Sincerely,
Wayne Wayne A. Maxwell
Executive Director
I.ts. IIiI, Auui. /(n.rI.1. (,IAf K,:1 /P1,lll llna<M IIY.i -„♦ IV],11:{n;iLPNM, _
5310213(2/79)
COLORADO STATE DEPARTMENT OF SOCIAL SERVICES
AUTHORIZATION FOR CONTRACTURAL SERVICES
1. WELD COUNTY DATE:
2.
Name of Provider
3.
Address
4.
City, State, Zip
THE DESCRIBED SERVICE IS AUTHORIZED FOR THE CLIENT INDICATED:
5.
Name of Client Household# Cat Cat Grp.
6.
Description Sv.Code
7.APPROVAL:
Caseworker Date Co.Director or Supervisor
8.TO BE COMPLETED BY PROVIDER
DATE OF SERVICE
CHARGES$
I CERTIFY THE SERVICE AUTHORIZED WAS PROVIDED ON THE DATE INDICATED AND THE
CHARGES ARE MADE PURSUANT TO A BONA FIDE CONTRACT BETWEEN ME AND THE
COUNTY DEPARTMENT OF SOCIAL SERVICES INDICATED.
Provider Signature Date
Prepare in Triplicate,Original and One copy to Provider,One Copy for Pending File.
Completed Provider's Forms-Original to County Finance Office-Copy to Case Record
WELD COUNTY CORE SERVICES PROGRAM PROJECT REPORT
Remit to:Elaine Furister, CPS/CAP,Core Service Specialist
Weld County Department of Social Services
Program Month of Service P.O.Box A,315 B N 11 Avenue,Greeley,CO 80632
Telephone:970.352.1551,Ext. 6295 FAX:970.346.7698
#Households Referred #of Households Enrolled #of Households Served #of Households Monthly Expenditure Expenditures to Date
During Month During Month During Month Discharged During Month
Termination Reason Codes: SEP-Successfully Ended Program;M-Moved;UL-Unable to Locate;RCCF-Entered a Residential Facility;FCR-Foster Care Review;OT-Explain,
TM-Transferred to Another Program More Restrictive;FC-Entered Foster Care;NT-Terminated;Unable to Work with Client;RH-Returning to Relative
Child's Name Direct Date Service Termination Client Caseworker Provider Initial Case Monthly Funding Total Cost Social
Service Ended Reasons Survey Survey Survey Management Progress Source of Program Services
Date Plan(Date) R9ort to Date Use
Funding Source:EPP-Expedited Permanency Planning;M-Medicaid;CI-Client Insurance;O-Other
WELD COUNTY CORE SERVICES PROGRAM MONTHLY REQUEST FOR REIMBURSEMENT
Remit to:Elaine Furister,CPS/CAP,Core Service Specialist
Name of Program Month of Service Weld County Department of Social Services
Notice to Providers:List all clients currently enrolled in your program. P.O.Box A,315 B N 11 Avenue,Greeley,CO 80632
Enter 0 if no services were provided during billing month Telephone:970.352.1551,extension 6295 FAX:970.346.7698
Client Name HH#& Referral Approved Approved Actual Maximum Rate per Monthly Social Services Payments Services
Client Suffix # Entry Date Exit Date Hrs/Service Hours Unit Total Only-Comments Denied/Delayed Payable
(Example: Period Sessions/
11111-02) Service
Period
Social Service Codes:CE-Computation Error;NR-No Referral;EED-Exceeds End Date;EMH-Exceeds Maximum Hours;EMS-Exceeds Maximum Sessions;NP-Not Payable;
PD-Payment Delayed;SPD;Submitted Past Deadline;NDC-No Face to Face Contact;NV-No Client Verification;ICMP-Initial Case Management Plan Needed;PR-Progress
Report Needed
CORE SERVICES PROGRAM YEAR 2002-2003-CLIENT VERIFICATION FORM •
Notice to Provider:All clients served during the service month must complete this verification form at the time of service.No request for payment of services will be honored for
billed services unless accompanied by the appropriate signed client verification form.Payment for services will not exceed maximum hours or sessions as stated in provider's RFP.
Section I: (To be completed by the provider)
Primary Client billed: Total Hours Billed
Household Number: Referral Number: Contact Person:
SECTION II(To be completed by client)
Client signatures must be signed at the time of service.Your signature verifies that services were provided by the service provider for direct face-to-face contact only,for the hours
indicated.
Date Hours Number of Hours Client/Participant Signature(Please have all those attending sign.In the case of a child who is not able to sign,
Please state hours of Service please have someone sign for the child;i.e.,Sally Smith by Gregg Jones,Foster Parent
of services;i.e., Provided
1:00-2:30
7
Notice to Provider:Attach all client verification forms to the monthly billing when submitting your request for Payment for Contractual Services.All Requests for payment must
be received by the 25th day of the month following service in complete form.
Scnd original signed billing and verifications to: Elaine Furister,CPS/CAP,Core Service Specialist,Weld County Department of Social Services
P. O.Box A, 315 B N 11 Avenue,Greeley,CO, 80632
Telephone: 970.352.1551,extension 6295;FAX: 970.346.7698
WELD COUNTY CORE SERVICES PROGRAM RE-BILL AND ADDITIONAL REQUEST FOR REIMBURSEMENT
Remit to:Elaine Furister,CPS/CAP,Core Service Specialist
Name of Program Month of Service Weld County Department of Social Services
Notice to Providers:List all clients currently enrolled in your program. P.O.Box A,315 B N 11 Avenue,Greeley,CO 80632
Enter 0 if no services were provided during billing month Telephone:970.352.1551,extension 6295 FAX:970.346.7698
Client Name HH#& Referral Month of Re-bill Approved Approved Actual Rate per Re-bill Certified Letter and (DSS Only)
Client Suffix # Service amount Entry Date Exit Date Hrs/ Unit Total Documentation Payable or
(Example: Re-billed Attached Not payable
11111-02) (Include reason if not
payable)
Social Service Codes: CE-Computation Error;NR-No Referral;EED-Exceeds End Date;EMH-Exceeds Maximum Hours;EMS-Exceeds Maximum Sessions;NP-Not Payable;
PD-Payment Delayed; SPD; Submitted Past Deadline;NDC-No Face to Face Contact;NV-No Client Verification;ICMP-Initial Case Management Plan Needed;PR-Progress
Report Needed
Client/1: 15394 NORRA
,ACORDTM CERTIFICATE OF LIABILITY INSURANCE 0DATE 1/03/03SAM/DO/Tref)
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Flood& Peterson Ins. Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
P. 0. Box 578 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
4687 W. 18th Street
Greeley, CO 80632 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: CNA Insurance Company
North Range Behavioral Health INSURER B: Pinnacol Assurance
1306 11th Avenue INSURER C: Fireman's Fund Insurance, Co.
Greeley, CO 80631 INSURER D:
INSURER E: ril'
COVERAGES /
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY i RI. 46. y ✓ a;j0, STANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THI T R T 7 a ED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSI e A I—COND •NS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADM POLICY EFFECTIVE POLICY EXPIRATION
LTR NSRC TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD/YYI DATE IMM/DD/YY) _ LIMITS
A GENERALLIABIUTY Pending 01/01/03 01/01/04 EACH OCCURRENCE $1,000,000
DAMAGE TO RENTED
X COMMERCIAL GENERAL LIABILITY PREMISES(Ea ocruence) $200,000
CLAIMS MADE n OCCUR MED EXP(Any one person) $15,000
PERSONAL&ADV INJURY 51,000,000
GENERAL AGGREGATE $3,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS.COMP/OP AGG $1,000,000
A A I POLICY nRP JE T n LOC
A AUTOMOBILE LIABIUTY Pending 01/01/03 01/01/04 COMBINED SINGLE LIMIT x1,000,000
X ANY AUTO (Ea accident)
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) S
X HIRED AUTOS BODILY INJURY
X NON-OWNED AUTOS (Per accident) $
X Drive Other Car PROPERTY DAMAGE
(Per accident) $
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG 5
A EXCESS/UMBRELLA LIABILITY Pending 01/01/03 01/01/04 EACH OCCURRENCE $2,000,000
IOCCUR n CLAIMS MADE AGGREGATE s2,000,000
_ $
DEDUCTIBLE $
X RETENTION $10,000 $
B WORKERS COMPENSATION AND 4044331 07/01/02 07/01/03 X I WC LIMIT I IOER
TORY LIMITS ER
EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $100,000
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $100,000
l/yyes,describe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $500,000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
Weld County Social Services DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL _30_ DAYS WRITTEN
315 N. 11th Avenue NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
Greeley, CO 80631 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
Roodlc-Pelt-J san lnswance , 1nc-
ACORD 25(2001/08) 1 of 2 #S235944/M235916 PSK O ACORD CORPORATION 1988
Littler Center
Forms
KATHLEEN P. LITTLER CENTER ADMISSION EVALUATION FORM(8/99)
Client Name Client Id #
Diagnosis: Primary Secondary
Date of Birth School Grade City
Admit Date Center Admit Littler
Medicaid Yes No(Check One) Sex Ethnicity
Who has custody of child at time of admit to Littler?
Where was child living immediately prior to admission to Littler?
Outpatient Therapist(if any)
Address/Phone
Special Behaviors or Circumstances/Reasons for referral
PAST PRESENT
Yes No Yes No
Suicidal
Violence toward others
Runaway Behavior
Self Mutilating Behavior
Social Isolation
Past Legal Charges
Current Legal Charges
On Probation
Victim Physical Abuse
Victim Sexual Abuse
Alcohol Use
Use of Inhalants
Other Drug Use
Learning Disabilities
Special Education
Others(specify)
GAF SCORE AT ADMISSION
OVERALL PROBLEM SEVERITY SCORE
LEVEL OF FUNTIONING SCORES AT ADMISSION(Rate all six areas.)
High Moder. Aver. Moder. Very
Func. High Low Low
1 2 3 4 5 6 7 8 9
Societal Functioning
Interpersonal Functioning
Daily Living Personal Care
Physical Functioning
Cognitive Intellectual
Overall Level of Functioning
KATHLEEN P. LITTLER CENTER TERMINATION EVALUATION FORM(8/99)
Client Name Client Id#
Littler Discharge Date:
Discharge Diagnosis: Primary Secondary
If psychotropic meds were used, please list below:
1.
2.
3.
Who has custody of child at time of discharge from Littler?
Where will the child be living immediately after discharge from Littler?
Who will follow youth after discharge?
Special Behaviors or Circumstances
PRESENT
Yes No
Suicidal
Violence toward others
Runaway Behavior — —
Self Mutilating Behavior Social Isolation Legal Charges Pending — —
On Probation —
Victim Physical Abuse
Victim Sexual Abuse
Alcohol Use
Use of Inhalants
Other Drug Use
Learning Disabilities
Special Education
Others(specify)
GAF SCORE AT DISCHARGE
OVERALL PROBLEM SEVERITY SCORE
LEVEL OF FUNTIONING SCORES AT ADMISSION(Rate all six areas.)
High Moder. Aver. Moder. Very
Func. High Low Low
I 2 3 4 5 6 7 8 9
Societal Functioning
Interpersonal Functioning
Daily Living Personal Care
Physical Functioning
Cognitive Intellectual
Overall Level of Functioning
•
•
1 COLORADO CLIENT ASSESSMENT RECORD - - 1II
Nom: TT1 GAF SCORE
I 1 I (AGENCY 14 I I (PROGRAM 44 (1))Arnie*Indian/Alaskan Native
I I I I I I I I I ICLIEPNT ID s14 (2)Asian/Pacific islander-
(3)
Black
Bleck
REFERRING AGYr
(5 WNW(Non-H
CLSJT II21tw (6)Matl,R.a.l ispanic)
11 I I I I I I 'MEDICAID ID>442 HISPANIC ORIGIN n
I I I I I I IADM1ssloN DATE 3340 (1)Nct a►Hispanic Origin
MONTH DAY YEAR (2)
(3)Puerto Rican
ACTION TYPE (Manual Input Only) 41-42 (4)Cuban
(5)Other Hispanic
01=Admission 11=Correction to Admission MARITAL STATUS 76 I
02=Activate 12=Caroclbn to Activation
03=Update l3=Canectlon to Update (1)Never Mauled (4)Widowed
0l-Inactivate 14=Cenedlon to inactivation (2)MrrMd (5)Divorced
05=Discherge
Y 15=Corredlon to Discharge (3)Mamled Separated(Legal a isco
Mahal Drd)
E
PLACE OF RESIDENCE Tr
I REDS ONLY CLIENT 43 (1)Correctional Faclly/Jal
(1)Yes (2)No (2)Indeed
(3)Nursing Horne
ADMISSION STATUS 44 (4)Residential Fealty-Mental Health
(1) (5)Raide 'sl Fealty-Nam-Meld Health
(2)Readmission From This Fiscal Year (6)Boarding Ho
rne
Shelter
(3)Readmission From Prior Fiscal Year (T)H In
(8)Hamden-On the Street
PERMANENT HMIpCAPAMPARRMENT 45-41 (9)Other independent UrA g Arrangement
(Cod. ),5 Barra Using I Yea 2 No) CURRENT LIVING ARRANGEMENT n
(1)Mental Retardation I
(2)Deafness or Severe Hearing Loss (I)Lives Wilh lath Pawls
(2)Lives WRIT One Parent
(3)Blindness or Severe Visual Impairment (3)Lies WRh Spouse and or Other Relative(s)
(4)Speech Impairment (4)Lives Atone
(5)Non-Ambulatory or Assisted Ambulation (5)Lives Wt1 Unrelated Person(s)
LEGAL STATUS CURRENT EMPLOYMENT STATUS n I
(1)Employed-Full Time
(1)Voluntary
(2)Court-Directed Voluntary (3)Employed-Pet Time
Otherwise
(3)Formic Involuntary (3)Sheltered
Employment-Not OMervtise Employed
(4)72-Hour Evaluation and Treatment(MH-HOLD) (4)Not Rend e
(5)Shod-Term Certified (5)Not in loyedr Face
(6)Long-Term Certified (6)7 Unemployed For Less Months
hsn 3 Months
(7)Voluntary Hospitalization of Minas (7)ArmedUnemployedrcs(ActiveFor 3 or Marc
(B)Chldreml Cafe C.R.S.19-1-101
(8)Armed Faces May Duty)
(9)Einem/ha.Alcoholism/Drug Commitment ANNUAL FAMILY HOUSEHOLD INCOME 46.4
REFERRAL SOURCE 6142 I I I
PRIMARY DIAGNOSIS SECOND GNOSIS r so kJ e3 y� NUMBER OF PERSONS SUPPORTED BY as I
I I I II I I THIS INCOME(Include Client)
•
PRESENTING PROBLEM HAS EXISTED ere (2)2(dent (7)7)7
(1)1 Yearor Longer (2)Less Than 1 Year (3)3 (B)8
(4)4 (9)9 or More
PREVIOUS MENTAL HEALTH SERVICES arc (5)5
(Cods ALL Fa`Banco Using 1 Ye`2 No) HIGHEST EDUCATION LEVEL-IN YEARS scar 7
inpatient Care
(less Than Feel Oracle Cods as CO)
Caber 224-Hour Care
1
Partial Care DUE TO MENTAL HEALTH REASONS, N
OutpatientCare
CLIENT IS CURRENTLY RECEIVING:
(1)SSI (3)Both
I COUNTY OF RESIDENCE 4444 (2)SSDI (4)Nether
DATE OF BIRTH es-n FIRST 3 LETTERS OF CEMENTS LAST NAMF_aei I 1 I
y.n..':'i. .....i
ZIP CODE n.r n•1m
MONTH DAY ` YEAR 4 1 1 I
MI SEX n Triage Denver Health e,Medical Ceder Only 101 I
(1)Male (2)Female
White—Billing Yellow—Chart SHADED BOXES ARE NOT PROCESSED ON UPDATE
Fn.m soar. m 11/97
•
I COLORADO CLIENT ASSESSMENT RECORD 2
client I.D. Name Admit Date
HISTORY tea-toe Check ALL that Apply CURRENT P-SEV Check ALL Problems that Apply
Vlct:Sexual Abuse Hist:Suicide Akenpt _Hit:Unstable Employrn
n AGGRESSIVENESS 141-197
_Via:Physical Abuse H erl
t:Family M -IN
VM:Neglect Mist:Family Sub Abuse _Atka Out�M _Defiant _
—
Threatening
SPECIAL PROBLEMS/ISSUES lost is Check ALL that Apply _Hostile _Intimidating
ANTISOCIAL 194.203
_Learning Disability CNS Disorder Language ssues
_Loss/Grief Wetting/Soiling Cultural/Belief IssuesDisrespect Disregards Rules lheslCona Others
—Eating Disorder _Fire SM/Dwlroy Properly _Disobedient _Dishonest
PROBLEM SEVERITY Il LEGAL 204-210
Legal Problems Probations/Parole Offences:Property
•
RATE the CURRENT P-SEV(PROBLEM SEVERITY) —_Charges Pending —Offenses:Substances —Offenses Persons
for area In the boxes provided. ratesing the following scale: n VIOLENCE/DANGER TO OTHERS x11217
None Slight Moderate Severe Extreme
..1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 Violet Homicidal Ideation
Assaullive —Homicidal ThreaVAtlenpt
CURRENT P-SEV Check ALL Problems that Apply Phys Serial Abuse Danger bailers "o-5;,: ,Q„M
7 §MOTIONAL WITHDRAWAL In-In I''�� —
Underative Passive _Doesn't Verbalize Feelings 1 I FAMILY ISSUES alst2a
_Distal Subdued_ nted Meet No Family/No Contact Family Legal Domestic Violence
DEPRESSION —Out of Home Placement _Parenting _Unstable Home/Film/24130 —SW�fionICUtody
_Depressed Lonely Hope10ss n FAMILY PROBLEMS WITH 224231
WcMless _Sad _Dejected
-1 wiryPafe t —Padner —Relative
tat./33 —Sroling _Child
Adous Nervous Panic
_ I INTERPERSONAL PROBLEMS 232-236
_Tense Flashbacks Phobic
_Feadt _Nightmares/7errors w/Friend Establishing Relationships
—1 HYPER AFFECT —Social Skills _MakdaIning Relationships
/a0.1K
_Overactive _Pressured Speech _Elevated Mood ROLE PERFORMANCE(Work/Schooll 237243
Mood Swings _ _
Accelerated Speech Mania
Absenteeism Performance _Behavior
ATTENTION PROBLEMS 147-153 _SucpensiorvProbalion _ _
Termination Limited Employability
_Agitated Distractible Mention Span I SUBSTANCE ABUSE 244243
Restless _Impulsive Concentration
Problem w Alcohol DependenUAddicted In Recovery
SUICIDE/DANGER TO SELF 1x/so _ _
Problem w Drugs Responsibilitiessres with Responsibilities
_suicide Ideation sere-InjuryeMutllalion I MEDICAL/PHYSICAL 250250-214a
Suicide Plan Reckless Self-Endangerment
_
_Suicide Attempt —Danger toSelf (C{.t$Ayt:Ip} . Acute Illness _Medical Care Needed Physical Handicap
—
Chronic Illness InjuryByAbuse/Assaut Permanent Disability
THOUGHT PROCESSES 141-Isa
I SECURITY/MANAGEMENT ISSUES Mai
_Bizarre Though!
Suspicious _Repealed
_Delusions _Paranoid Obsessive Seclusbr✓iime Out Walkaway/Escape _behavior Manapeml
—
Hallucinations _Close Supervision Security Suicide Watch
Medication Compliance Inadequate Adult Supervision
COGNITIVE PROBLEMS 14417e — —
_ sorganzed Confused Loose Associations Lacks Self Awareness OVERALL DEGREE OF PROBLEM SEVERITY 254
_Disoriented _Dii _impaired Judgement Check ONE Response
—1 SELF-CARE/BASIC NEEDS 174Ip None Slight Moderate Severe Extreme
Hygiene DoesnV.hnage Money _Doesn't Provide Food 1 2 3 4 5 6 7 a 9
_Self Care Problems _Doesn't the Resources Doesnl Provide Housing
—Gram Disabled (ORS2T1Nr UPDATE.ACTIVATE.INACTIVATE 6 DISCHARGE ONLY
CHANGE IN OVERALL PROBLEM SEVERITY 297
—1 RESISTIVENESS 184-100 Check ONE Response
Resistive Evasive Wary Much Much
_Uncooperative Guarded _Denies Problems Better No Change Worse Worse
1 2 3 4 5 6 7 8 9
White— Billing Yellow—Chart
c....... eonn 0 4/07
I. ' COLORADO CLIENT ASSESSMENT RECORD - - 3 I
Client I.D. Name Admit Date
STRENGTHS/RESOURCES LEVEL-OF-FUNCTIONING (LOF)
Cheek ALL CURRENT STRENGTHS!RESOURCES Individual has: Check ONE Response for Each LOF Ares
ECONOMIC RESOURCES 244771 SOCIETAL/ROLE FUNCTIONING 304
9654151454.10522574 nEmplo ent _Transportation Very High Moder High Average Moder Low Very Low
Other Medical incur —Housing Function Function Function Function Function
—Oher Public Assist _FkwnWl
EDUCATION/SKILL RESOURCES 275-ins 1 2 3 5 6 7 e 9
_Language Malls lla Intelligence mll s gerpersonal Sld INTERPERSONAL FUNCTIONING 205
_Eduon Job Skills — Very High Moder High Average Moder Low Very Low
Function Function Function Function Function
PERSON RESOURCES 200-207
_Parsrd(s) Penner Professional Caregiver I 2 3 4 5 6 7 a 9
_SIMrg(s) _Ched(ren) Other Supportive Relationship DAILY LIVING/PERSONAL CARE FUNCTIONING 305
Relative(— ') _Friend(*) Very High Moder High Average Moder Low Very Low
PERSONAL STRENGTHS 1BF39/ Function Function Function Function Function
_Laasklen°" Emotional Stability Adaptability 1 2 3 4 5 6 7 8 9
AppserMros —Health TAM Panty PHYSICAL FUNCTIONING 2m
Csoeadence Hopefulness Resourcefulness
Judgement Responsibility —Tolerance Very High Moder High Average Moder Low Very Low
Empathy —iny9M — Function Function Function Function Function
1 2 3 4 5 6 7 a 9
COGNITIVE/INTELLECTUAL FUNCTIONING 3a
Very Hipp Moder High Average Moder Low Very Low
Function Function Function function Function
1 2 3 4 5 6 7 a 9
CURRENT OVERALL STRENGTHS/RESOURCES 302 OVERALL LEVEL OF FUNCTIONING Check ONE Response 303
Check ONE Response
Very High Moder High Average Moder Low Very Low
Very High High Moderate Some Very Low Function Function Function Function Function
1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 a 9
UPDATE.ACTIVATE.INACTIVATE&DISCHARGE ONLY UPDATE.ACTIVATE.INACTIVATE&DISCHARGE ONLY
CHANGE IN OVERALL STRENGTHS/RESOURCES 203 CHANGE IN LEVEL OF FUNCTIONING Check ONE Response 310
Check ONE Response Much Much
Much Much Better Better No Change Worse Worse
Better Better No Change Worse Worse
1 2 3 4 5 6 7 e 9
1 2 3 4 5 6 7 8 9 •
I I I I I I I I I STAFF ID meta STAFF SIGNATURE
-1 DISCIPLINE: 1=none 2=mh worker 3=nursing *social work 5=psychology 6=psychiatry 7=other 325
—I DEGREE: 1=none 2=associate 3=bachelors 4-masters 5=PhD/PsyD/EdD 6=MD 7-other 321
COMPLETE THIS BOX ONLY FOR COMPLETE THIS BOX ONLY AT DISCHARGE
UPDATE,ACTIVATE AND INACTIVATE STATUS
I PATE FORM COMPLETED
MONTH DAY YEAR 330337
I I (LAST CONTACT DATE
MONTH DAY YEAR 335445
I I I I I EFFECTIVE DATE 322-329 1 I I I I I DISCHARGE DATE
MONTH DAY YEAR MONTH DAY YEAR 345453
I TYPE OF TERMINATION. 334
SPECIAL STUDIES 1'DiaclurgeNrransferred 5-From Inactive
2-TX Compleled/No Referral 6-ParierrI/CIient Died
I I I I I I I I I 337440 3-TX Cenlpleledoll Fow-up 7-PalienkChw l rerminaled
1-Evaluation Only
I I I I I I I I I I 35747. 1 TERMINATION REFERRAL' 355434
NOTE:Use 61 'Selr if no Referral
White— Billing Yellow—Chart Form 0270 R 5/97
INTEGRATED ASSESSMENTS FOR GOAL DEVELOPMENT
Client Name: Client# DOB:
Admission Date: Clinician:
AGGRESSIVENESS/SELF OR OTHERS (Homicidal/SuicidaVSelf-destructive)
ASSESSMENT:
_ History Clinical Assessment
Intake Assessment _ Other
Psych. Assessment To Be Assessed
Findings/Assessment Results:
_ STRENGTH: Not A Treatment Issue At This Time
Focus Of Treatment (Refer To Goal Sheet)
Defer Presently: Provide Clinical Rationale
FUNCTIONAL
COMMUNICATION/PROCESSING ISSUES
ASSESSMENT:
History Psych. Assessment
Intake Assessment Clinical Assessment
Speech/Language Assessment To Be Assessed
Other
Findings/Assessment Results:
STRENGTH: Not A Treatment Issue At This Time
Focus Of Treatment(Refer To Goal Sheet)
Defer Presently: Provide Clinical Rationale:
DAILY LIVNG SKILLS:
ASSESSMENT:
dory Psych Assessment
Observation Other
Clinical Assessment To Be Assessed
Findings/Assessment Results:
•
STRENGTH:Not A Treatment Issue At This Time
Focus of Treatment: (Refer to Goal Sheet)
Defer Presently: Clinical Rationale:
EDUCATION
ASSESSMENT:
Academic Testing Other
History _ To Be Assessed
Observation
Findings/Assessment Results:
2
STRENGTH:Not a Treatment Issue At This Time
Focus of Treatment:(Refer to Goal Sheet)
Defer Presently: Clinical Rationale:
PHYSICAL/NEUROLOGICAL
ASSESSMENTS:
History _OT/PT Assessment
Clinical Assessment _Other
Psych Assessment To Be Assessed
Findings/Assessment Results:
STRENGTH: Not A Treatment Issue At This Time
Focus of Treatment(Refer to Goal Sheet)
Defer Priestly: Clinical Rationale
SOCIAL SKILLS:
ASSESSMENT:
__ History Other
Clinical Assessment Intake Assessment
Psych Assessment To Be Assessed
Findings/Assessment Results:
3
STRENGTH: Not a Treatment Issue At This Time
_ Focus of Treatment(Refer to Goal Sheet)
Defer Presently: Clinical Rationale
MENTAL STATUS
THOUGHT PERCEPTION OR JUDGEMENT ISSUES
ASSESSMENT:
History Other
Psych Assessment Intake Assessment
Clinical Assessment To Be Assessed
Findings/Assessment Results:
STRENGTH:Not a Treatment Issue At This Time
Focus of Treatment(Refer to Goal Sheet)
Defer Presently: Clinical Rationale
•
MOOD/AFFECT
ASSESSMENT:
History Other
Psych Assessment Intake Assessment
_._ Clinical Assessment To Be Assessed
4
Findings/Assessment Results:
_STRENGTH:Not a Treatment Issue
_ Focus of Treatment(Refer to Goal Sheet)
Defer Presently: Clinical Rationale:
SEXUAL REACTIVE OR PERPITRATION ISSUES:
ASSESSMENT:
History/Physical M.D. Assessment
Medical Illness Other
Psych Assessment To Be Assessed •
Intake Assessment
Findings/Assessment Results:
STRENGTH: Not a Treatment Issue:
Focus of Treatment(Refer to Goal Sheet)
Defer Presently: Clinical Rationale:
5
TRAUMA RELATED ISSUES: (Abuse/neglect/attachment issues)
ASSESSMENT:
won' _ Clinical Assessment
Intake Assessment Other
Psych. Assessment
Finding/Assessment Results:
_ STRENGTH: Not A Treatment Issue At This Time
Focus Of Treatment(Refer To Goal Sheet)
Defer Presently: Provide Clinical Rationale
OTHER CHALLENGING BEHAVIORS:
ASSESSMENTS:
History _ Clinical Assessment
Intake Assessment Other
Legal Involvement To Be Assessed
Psych Assessment
Findings/Assessment Results
6
STRENGTHS: Not a Treatment Issue
Focus of Treatment(Refer to Goal Sheet)
Defer Presently : Clinical Rationale
HEALTH ISSUES:
ASSESSMENTS:
History _ Clinical Assessment
Intake Assessment Other
_ Psyche Assessment To Be Assessed
Findings/Assessment Results:
STRENGTH:Not a Treatment Issue
Focus of treatment(Refer to Goal sheet)
Defer Presently Clinical Rationale:
SUBSTANCE ABUSE ISSUES:
ASSESSMENT:
History Clinical Assessment
Intake Assessment Other
Psych. Assessment To Be Assessed
Findings/ Assessment Results:
7
•
Strength: Not a Treatment Issue At This Time
Focus of Treatment(Refer To Goal Sheet)
Defer Presently: Provide Clinical Rationale
FAMILY/GUARDIAN TREATMENT ISSUES:
ASSESSMENTS:
History Pscyh Assessment
Intake Assessment _ Other
Clinical Assessment To Be Assessed
Findings/Assessment Results:
STRENGTH: Not a Treatment Issue At This Time
Focus of Treatment: (Refer to Goal Sheet)
Defer Presently: Clinical Rationale:
CASEMANAGEMENT RESPONSIBILITIES:
Describe out-side sources involved in Client's treatment and on-going responsibilities of Littler Staff in
regards to these resources. Include understanding of responsibility of out-side source discharge planning as
well.
8
•
SUMMARY OF STRENGTHS FOR THIS CLIENT TO BE USED IN
TREATMENT: •
- JUSTIFICATION FOR TREATMENT:
Decomposition of Psychiatric Illness
Medication Management/Stabilization
Continued Treatment Failures at other Placements or Less Restrictive Levels of Care
Crisis Stabilization Escalation of Behavior Problems Safety Issues
Other: (please State) _
JUSTIFICATION FOR LEVEL OF CARE:
9
DISCHARGE CRITERIA:
Absence of suicidalself destructive behavior
Management/Self Management of Aggressive Behavior
Medication Stabilization
Stabilization of Psychiatric Illness
Management/Self Management of Feelings Causing Affective or Behavioral Issues
Determination of an appropriate Discharge Placement
_ Other(please specify)
Other(please specify)
DISCHARGE PLAN/FOLLOW-UP NEEDS;
Return to Parent/Guardian Intensive Family Treatment
FosterCare Placement Medication Management
_ Group Home T Medical Treatment
Return to Public School _ OT/PT Services
_ Long Term Treatment Placement Perpetration Treatment(Group or
Individual)
_ Special Education Program _ Individual Therapy
Mentor/Community Referral(specify)
Other(specify)
Other(specify)
10
(IV(
s.\\::t
DEPARTMENT OF SOCIAL SERVICES
P.O. BOX A
GREELEY, CO. 80632
Website:www.co.weld.co.us
111 1 11 Administration and Public Assistance(970)352-1551
Child Support(970)352-6933
O
•
COLORADO MEMORANDUM
TO: David E. Long, Chair Date: April 28, 2003
Board of County Commissioners
FR: Judy Griego, Director, Social Services , C�C,i,U,/1L.
RE: Notification of Financial Assistance Aw d(N AA) under Core
Services Funds-North Range Behavioral Health.
Enclosed for Board approval is a Notification of Financial Assistance Award(NOFAA) for Core
Services Funds with North Range Behavioral Health. The Families, Youth and Children
Commission (FYC)has reviewed this proposal under a Request for Proposal process and is
recommending approval of this bid.
The major provisions of the NOFAA are as follows:
1. The period of the NOFAA is June 1, 2003, through May 31, 2004.
2. The source of funding is Core Services, which is comprised of 80% Federal/State and
20% County resources and 100% State resources. The total budget for Core Services is
projected to be$929,822.
3. North Range Behavioral Health agrees to provide services to those children and families
who are in imminent risk of placement under child welfare. The services to be provided
will be under Day Treatment.
A comprehensive, highly structured service alternative to the out-of-home placement or
the more intensive placement, that provides mental health care and education to its
student clients. Monthly average capacity of eight, 29.5 hours weekly, an average of 5.9
hours daily, for 36-52 weeks. The daily rate for service is $89.14.
If you have any questions,please telephone me at extension 6510.
2003-1059
Hello